Intracranial Aneurysm Surgery in Southeast Nigeria: Experience and Challenges from Neurosurgical Management.
Keywords:
Ruptured Intracranial Aneurysm, Subarachnoid Hemorrhage, Neurosurgery, aSAH, WFNS gradeAbstract
Background: Intracranial aneurysms (IAs) remain underreported in sub-Saharan Africa, with limited data on neurosurgical management, challenges and outcomes. This study aimed to document the clinical experience and challenges of IA management at a tertiary neurosurgical centre in Southeast Nigeria. This study presents the first institutional experience of intracranial aneurysm surgery in Southeast Nigeria. Methods: We conducted a nine-year retrospective cohort review (2015–2023) of computed tomography angiography (CTA/MRA)-confirmed intracranial aneurysms managed at our centre. Data extracted included demographics, clinical presentation, aneurysm characteristics, surgical approaches, intra- and post-operative challenges, and outcomes. Results: Fifty-eight patients with intracranial aneurysms were managed (female-male ratio 2.5:1), of whom 35 underwent surgery. The mean age was 42.3 ±12.1 years. Of the 58 patients, 32.8% were <40 years, and 55.2% had admission systolic BP >160mmHg. All presented with subarachnoid hemorrhage, predominantly from posterior communicating artery aneurysms (53.4%). World Federation of Neurosurgical Societies (WFNS) grades were 0–2 in 48.3% and 3–5 in 51.7%. CTA-based aneurysm size was <11mm in 15 (42.9%) (four of these had bigger dimension at surgery) and > 25 mm 7 (20.0%). Delay from presentation to surgery was < 3 days in 9 (25.7%), 4-7 days in 14 (40.0%), > 7 days in 12 (34.3%). Successful surgical clipping was performed in 94.3% of cases and common carotid artery ligation in 1 case. Intraoperative challenges included brain oedema (25.7%), rupture (22.9%), and vasospasm (11.4%). Postoperative complications included delayed ischemic neurologic deficit (34.3%) and hydrocephalus (31.5%). Post-operative mortality was 17.1% (6/35) while overall in-hospital mortality occurred in six patients (10.3%). Conclusion: Our experience revealed that younger patients with hypertension predominated, with posterior communicating artery aneurysms being most common. Neurosurgeons should be conscious of the study's highlighted intra- and post-operative challenges during surgical planning. High complication rates underscore the need for improved preoperative planning and postoperative monitoring in resource-limited settings.
Downloads
References
Hughes JD, Bond KM, Mekary RA, et al. Estimating the global incidence of aneurysmal subarachnoid hemorrhage: a systematic review for central nervous system vascular lesions and meta-analysis of ruptured aneurysms. World neurosurgery. 2018;115:430-447. e7.
de Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. Journal of Neurology, Neurosurgery & Psychiatry. 2007;78(12):1365-1372.
Bederson JB, Awad IA, Wiebers DO, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke. 2000;31(11):2742-2750.
Ohaegbulam SC, Ndubuisi CA, Okwuoma O, et al. Will improved neuroradiology facilities debunk the reported rarity of intracranial aneurysms in Sub-Saharan Africa? Surgical Neurology International. 2023;14
Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers JC. A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. Journal of neurology, neurosurgery, and psychiatry. 1988 Nov;51(11):1457.
Sano H, Satoh A, Murayama Y, Kato Y, Origasa H, Inamasu J, Nouri M, Cherian I, Saito N. Modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading system. World neurosurgery. 2015 May 1;83(5):801-7.
Ferreira T, Awuah WA, Tan JK, et al. The current landscape of intracranial aneurysms in Africa: management outcomes, challenges, and strategies—a narrative review. Neurosurgical review. 2023;46(1):194.
Aborode AT, Mago A, Ahmed FK, Ubechu SC, Oko C, Ahmed FA. Delay in surgical treatment in low-income and middle-income countries: an editorial. LWW; 2023. p. 3256-3257.
Loconi-Vallejos A, Jorge-Dejo C, Azurín-Peña M, Garcia-Solorzano FO. Timing of aneurysm treatment in subarachnoid hemorrhage and grade of functional capacity at discharge: a retrospective cohort study. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2023;59(1):89.
Nomura S, Kunitsugu I, Ishihara H, et al. Relationship between aging and enlargement of intracranial aneurysms. Journal of Stroke and Cerebrovascular Diseases. 2015;24(9):2049-2053.
Brinjikji W, Zhu Y-Q, Lanzino G, et al. Risk factors for growth of intracranial aneurysms: a systematic review and meta-analysis. American Journal of Neuroradiology. 2016;37(4):615-620.
Asaithambi G, Adil MM, Chaudhry SA, Qureshi AI. Incidences of unruptured intracranial aneurysms and subarachnoid hemorrhage: results of a statewide study. Journal of vascular and interventional neurology. 2014;7(3):14.
Akinlua JT, Meakin R, Umar AM, Freemantle N. Current prevalence pattern of hypertension in Nigeria: A systematic review. PloS one. 2015;10(10):e0140021.
Ogunniyi MO, Commodore-Mensah Y, Ferdinand KC. Race, ethnicity, hypertension, and heart disease: JACC focus seminar 1/9. Journal of the American College of Cardiology. 2021;78(24):2460-2470.
Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P. Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis. Hypertension. 2011;57(6):1101-1107.
Opie LH, Seedat YK. Hypertension in sub-Saharan African populations. Circulation. 2005;112(23):3562-3568.
Modesti PA, Reboldi G, Cappuccio FP, et al. Panethnic differences in blood pressure in Europe: a systematic review and meta-analysis. PloS one. 2016;11(1):e0147601.
Sandvei MS, Romundstad PlR, Müller TB, Vatten L, Vik A. Risk factors for aneurysmal subarachnoid hemorrhage in a prospective population study: the HUNT study in Norway. Stroke. 2009;40(6):1958-1962.
Williams LN, Brown RD. Management of unruptured intracranial aneurysms. Neurology: Clinical Practice. 2013;3(2):99-108.
Feigin VL, Rinkel GJ, Lawes CM, et al. Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies. Stroke. 2005;36(12):2773-2780.
Nahed BV, DiLuna ML, Morgan T, et al. Hypertension, age, and location predict rupture of small intracranial aneurysms. Neurosurgery. 2005;57(4):676-683.
Lin Q-S, Lin Y-X, Lin Z-Y, Yu L-H, Dai L-S, Kang D-Z. Systolic blood pressure variability is a novel risk factor for rebleeding in acute subarachnoid hemorrhage: a case–control study. Medicine. 2016;95(11)
Connolly Jr ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-1737.
Zhang J, Can A, Lai PMR, et al. Age and morphology of posterior communicating artery aneurysms. Scientific Reports. 2020;10(1):11545.
Chien A, Lau V, Yi Q, Chang W. Posterior communicating artery aneurysms demonstrate faster interval growth than other growing aneurysms. The Neuroradiology Journal. 2018;31(3):288-291.
Keedy A. An overview of intracranial aneurysms. McGill Journal of Medicine: MJM. 2006;9(2):141.
Kim MC, Hwang S-K. The rupture risk of aneurysm in the anterior communicating artery: a single center study. Journal of Cerebrovascular and Endovascular Neurosurgery. 2017;19(1):36-43.
Rilianto B, Prasetyo BT, Kurniawan RG, et al. Clinical and Morphological Factors for Ruptured Anterior Communicating Artery Aneurysms. Vascular Health and Risk Management. 2023:371-377.
Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome. Neurosurgery. 1996;38(1):2-11.
Huttunen T, von und zu Fraunberg M, Frösen J, et al. Saccular intracranial aneurysm disease: distribution of site, size, and age suggests different etiologies for aneurysm formation and rupture in 316 familial and 1454 sporadic eastern Finnish patients. Neurosurgery. 2010;66(4):631-638.
Yamada S, Utsunomiya M, Inoue K, et al. Genome-wide scan for Japanese familial intracranial aneurysms: linkage to several chromosomal regions. Circulation. 2004;110(24):3727-3733.
van der Voet M, Olson JM, Kuivaniemi H, et al. Intracranial aneurysms in Finnish families: confirmation of linkage and
Downloads
Published
License
Copyright (c) 2026 East African Journal of Neurological Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
