Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases

Predictors of cognitive dysfunction after subarachnoid hemorrhage

BACKGROUND

Cognitive dysfunction is a common and disabling sequela of subarachnoid hemorrhage (SAH). Although several clinical and radiographic findings have been implicated in the pathogenesis of cognitive dysfunction after SAH, few prospective studies have comprehensively and simultaneously evaluated these risk factors.

METHODS

Between July 1996 and March 2000, we prospectively evaluated 113 of 248 consecutively admitted nontraumatic SAH patients alive at 3 months with a comprehensive neuropsychological evaluation. Summary scores for 8 cognitive domains were calculated to express test performance relative to the entire study population. Clinical and radiographic variables associated with domain-specific cognitive dysfunction were identified with forward stepwise multiple regression, with control for the influence of demographic factors.

RESULTS

The study participants were younger (P=0.005), less often white (P=0.006), and had better 3-month modified Rankin scores (P=0.001) than those who did not undergo neuropsychological testing. The proportion of subjects who scored in the impaired range (>2 SD below the normative mean) on each neuropsychological test ranged from 10% to 50%. Predictors of cognitive dysfunction in 2 or more domains in the multivariate analysis included global cerebral edema (4 domains), left-sided infarction (3 domains), and lack of a posterior circulation aneurysm (2 domains). Other variables consistently associated with cognitive dysfunction in the univariate analysis included admission Hunt-Hess grade >2 and thick SAH in the anterior interhemispheric and sylvian fissures.

CONCLUSIONS

Global cerebral edema and left-sided infarction are important risk factors for cognitive dysfunction after SAH. Treatment strategies aimed at reducing neurological injury related to generalized brain swelling, infarction, and clot-related hemotoxicity hold the best promise for improving cognitive outcomes after SAH.

Outcome prediction with serum intercellular adhesion molecule-1 levels after aneurysmal subarachnoid hemorrhage

OBJECT

Although upregulated adhesion molecule expression has been demonstrated in experimental models of subarachnoid hemorrhage (SAH) and in the cerebrospinal fluid of patients with aneurysmal SAH, the clinical significance of these proinflammatory findings remains unclear. The authors hypothesize that 1) serum levels of soluble intercellular adhesion molecule-l (ICAM-1) are increased in all patients with aneurysmal SAH shortly after the hemorrhagic event, and 2) elevated soluble ICAM-1 values are associated with poor patient outcome, even when controlling for the severity of the initial hemorrhagic insult.

METHODS

One hundred one patients were prospectively enrolled and stratified according to their admission Hunt and Hess grade and functional status at discharge (modified Rankin Scale [mRS] score). Soluble ICAM-1 levels were determined every other day for 12 days post-SAH by using the enzyme-linked immunosorbent assay. Early soluble ICAM-1 levels (post-SAH Days 2-4) were increased compared with levels in control patients without SAH (p < 0.05). Patients with aneurysmal SAH who had a poor outcome (mRS Grades 4-6) had significantly higher soluble ICAM-1 levels over the first 2 weeks post-SAH compared with patients who had a good outcome (mRS Grades 0-3, p < 0.01). This association with outcome was predicted by late increases (Day 6, p = 0.07; Days 8-12, p < 0.05) rather than early increases (p = not significant) and was best seen in patients with Hunt and Hess Grades I and II. in whom only those with poor outcomes demonstrated delayed ICAM-1 elevations (p < 0.05).

CONCLUSIONS

These data demonstrate a correlation between soluble ICAM-1 levels and functional outcome following aneurysmal SAH that appears to be, at least in part, independent of the initial hemorrhage.

Blood transfusion during aneurysm surgery

INTRODUCTION

Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery.

METHODS

We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered.

RESULTS

A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1-17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 +/- 0.35 units, whereas patients who did not have a rupture required 1.9 +/- 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1-31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications.

CONCLUSION

Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.

Treatment of aneurysmal subarachnoid haemorrhage in elderly patients

Spontaneous subarachnoid haemorrhage (SAH) due to ruptured saccular aneurysm is the fourth most frequent cerebrovascular disorder following atherosclerosis, embolism, and primary intracerebral haemorrhage (1). SAH is a common and often devastating condition, which is a significant cause of world-wide morbidity and mortality (2). The aim of this article is to review the epidemiology, pathophysiology and current management of SAH.

Anticoagulation and induced hypertension after endovascular treatment for ruptured intracranial aneurysms

OBJECTIVE

Guglielmi detachable coil (GDC) embolization may be used to prevent early rebleeding after aneurysmal subarachnoid hemorrhage, but anticoagulation and induced hypertension may increase this risk. We sought to determine retrospectively the relationship between levels of induced hypertension and anticoagulation and incidence of rebleeding in GDC-treated patients.

METHODS

Twenty-five consecutive patients with acute (<14 days) subarachnoid hemorrhage who underwent GDC embolization were retrospectively analyzed with regard to percent obliteration of an aneurysm on postprocedure angiogram, the duration and intensity of anticoagulation, the duration and level of induced hypertension, and the frequency of thromboembolic and rebleeding complications.

RESULTS

Complete angiographic obliteration of the aneurysm was achieved in five cases (20%). In some cases (n = 2), only the dome of the aneurysm was coiled to allow eventual surgical clipping. Heparin was given to 23 patients (92%) for an average of 6 days (range, 8 hrs to 22 days); the mean dose was 588 units/hr, and the mean partial thromboplastin time was 37 secs. Seven patients (28%) were treated with vasopressors for symptomatic vasospasm for a mean duration of 5 days (range, 8 hrs to 9 days); mean arterial blood pressure averaged 118 mm Hg, and peak systolic blood pressures ranged from 195 to 250 mm Hg. There were no episodes of aneurysm rebleeding. Three patients (12%) suffered intraoperative thromboembolic complications, which in one instance was fatal; two of these cases were associated with subtherapeutic partial thromboplastin time values.

CONCLUSION

Induced hypertension (mean arterial blood pressure, 120 mm Hg) and heparinization do not appear to increase the risk of early rebleeding after GDC embolization. In a select group of patients, use of anticoagulation in the immediate perioperative period to prevent thromboembolic complications appears to be safe.

Clinical outcomes of aneurysmal subarachnoid hemorrhage patients treated with oral diltiazem and limited intensive care management

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) patients are frequently treated with prophylactic nimodipine and undergo invasive monitoring of blood pressure and volume status in an intensive care unit (ICU) setting to decrease the incidence of delayed ischemic neurological deficit (DIND) and improve functional outcomes. The goal of this study was to examine the incidence of DIND and poor functional outcomes in a consecutive series of SAH patients treated with a different regimen of prophylactic oral diltiazem and limited use of intensive care monitoring.

METHODS

The study involved a consecutive series of 123 aneurysmal SAH patients treated by the senior author who were admitted within 72 hours of hemorrhage and who never received nimodipine or nicardipine. Functional outcomes were graded using the Glasgow Outcome Scale (GOS).

RESULTS

Of the 123 patients identified, favorable outcomes (GOS 4 and 5) were achieved in 74.8%. The incidence of DIND was 19.5%. Hypertensive, hypervolemic, hemodilutional (HHH) therapy was used in 10 patients (8.1%) and no patients were treated for DIND by endovascular means. Seven patients (5.7%) had a poor functional outcome or death because of DIND and two of these were related to complications of HHH therapy. These results were compared to contemporary series of SAH patients managed with other treatment protocols.

CONCLUSIONS

Functional outcomes of patients treated with a regimen of oral diltiazem, limited use of ICU monitoring and HHH therapy for DIND compare favorably with other contemporary series of SAH patients.

Neurological grades of patients with poor-grade subarachnoid hemorrhage improve after short-term pretreatment

OBJECTIVE

Short-term pretreatment of patients with subarachnoid hemorrhage, but without hematomas causing mass effect, who presented in poor neurological condition at admission was evaluated as a protocol for the selection of candidates for radical surgery.

METHODS

One hundred-three patients were pretreated for 12 hours with control of blood pressure and intracranial pressure, using diuretic agents and/or ventricular drainage.

RESULTS

Neurological improvement was observed for 32 of 47 patients in Grade IV at admission and 23 of 56 patients in Grade V (P < 0.01). Hydrocephalus requiring drainage was more common (P < 0.05) and the interval between onset and admission was shorter (P < 0.01) for the improved group. Clipping surgery was performed for all patients in Grade III or better and for patients in Grade IV who were less than 75 years of age and without systemic complications, i.e., 38 of 47 patients in Grade IV and 16 of 56 patients in Grade V at admission. Good outcomes (defined as moderately disabled or better on the Glasgow Outcome Scale) were achieved by 34 of 38 patients in Grade IV and 10 of 16 patients in Grade V (P < 0.01). The proportion of patients in Grade IV after pretreatment was lower for Grade IV (2 of 38 patients) than for Grade V (9 of 16 patients) (P < 0.00001). However, none of the 49 patients who underwent nonsurgical treatment achieved good outcomes.

CONCLUSION

Our protocol may be beneficial for the selection of candidates for radical surgery among patients with subarachnoid hemorrhage but without hematomas who are in poor neurological condition at admission and for the improvement of postoperative outcomes.

Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution

OBJECT

The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy.

METHODS

The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option.

CONCLUSIONS

The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.

Initial hyperglycemia as an indicator of severity of the ictus in poor-grade patients with spontaneous subarachnoid hemorrhage

An association between hyperglycemia and outcome in spontaneous subarachnoid hemorrhage (SAH) has been sporadically reported. Our hypothesis was that hyperglycemia is a sign of central metabolic disturbance linked with specific appearances on computerized tomography (CT) scans reflecting different degrees of corresponding brain injury. The admission plasma glucose level, initial CT findings, and outcome after 6 months were analysed in a cohort of 99 patients with SAH in Hunt & Hess Grade IV or V. The CT scans were quantitatively assessed for subarachnoid blood, intracerebral hematoma, intraventricular hemorrhage, hydrocephalus, midline shift and compression of the perimesencephalic cisterns. These findings were combined to determine a three-point CT severity score. All patients showed elevated (>5.8 mmol/l) plasma glucose levels on admission. Mortality among 33 patients with glucose concentration below 9.0 mmol/l was 33.3%, 71.1% for the 45 patients with glucose level between 9.0 and 13.0 mmol/l, and 95.2% for the 21 patients with concentration above 13.0 mmol/l (P<0.0001). Glucose level was higher in Grade V than in Grade IV patients (mean+/-SD) (11.8+/-3.2 vs 9.8+/-2.9 mmol/l; P=0.0012). Patients with mild CT findings (n=10) had the lowest glucose level (8.9+/-1.8 mmol/l; P=0.0082), whereas patients with severe findings (n=56) had the highest glucose (11.4+/-3.5 mmol/l; P=0.011). Despite association with clinical grade and extent of CT findings, logistic multiple regression revealed the admission plasma glucose level to be an independent prognosticator of outcome. The prognostic potential of the initial plasma glucose level may be beneficial in management protocols of poor-grade SAH patients.

Considerations on surgical treatment for elderly patients with intracranial aneurysms

BACKGROUND

The purpose of this study was to investigate why elderly patients have poorer outcomes and to determine indications for surgery in elderly patients.

METHODS

One hundred fifty-four patients with intracranial aneurysms admitted to the Department of Neurosurgery, Showa University School of Medicine, from 1990 through 1996 were reviewed. The patients were classified by age into three groups (young group, middle-aged group, elderly group).

RESULTS

Forty-four patients (28.6%) were in the elderly group (mean age, 73 years). No difference in outcome was found between middle-aged and elderly patients if patients were stratified according to clinical grade. In addition, the main factors related to unfavorable outcomes in elderly patients were infection, organ failure, aneurysm rerupture before operation, and delayed ischemic deterioration. Elderly patients were more likely to experience rebleeding and have poor outcomes.

CONCLUSIONS

Our results suggest that elderly patients should have early surgery. Furthermore, we found that the presence of hypertension or atherosclerosis had no significant effect on outcome. We conclude that early surgical treatment of aneurysms is indicated for elderly patients with good clinical grades in the absence of organ failure.

Outcome after endovascular treatment of Hunt and Hess grade IV or V aneurysms: comparison of anterior versus posterior circulation

BACKGROUND AND PURPOSE

The most common cause of poor treatment outcome in patients suffering aneurysmal subarachnoid hemorrhage is cerebral vasospasm, especially in cases of poor Hunt and Hess grades (IV and V). A further prognostic factor in surgically treated patients is aneurysm localization. The aim of the present retrospective study is to compare the endovascular treatment outcome in such poor-grade patients according to aneurysm localization in either the anterior (AC) or posterior (PC) circulation.

METHODS

Forty poor-grade patients admitted between 1993 and July 1998 were treated by endovascular approach within 23 days after aneurysm rupture. Eighteen had aneurysms in the AC, 22 in the PC. Mean treatment delay was 4 days after rupture and median, 2 days. One patient showed multiple aneurysms. In 36 cases, aneurysms were occluded by Guglielmi detachable coils; in 4 cases, by parent vessel balloon occlusion.

RESULTS

The incidence of delayed ischemic neurological dysfunction or cerebral infarct due to vasospasm did not differ significantly between the AC and PC groups. Two procedure-related complications with clinical effect were observed in each group. At 6 months' follow-up, the result was good in 5 patients and poor in 13 in the AC group and good in 11 patients and poor in 11 in the PC group.

CONCLUSION

Given comparable incidence of vasospasm in poor-grade patients, a tendency toward better treatment outcome was found in patients with aneurysms in the posterior circulation (chi(2)=2.04; P=0.15) than in the anterior circulation. Endovascular therapy for poor-grade patients is recommended, as are further studies to determine treatment differences.

Results of early surgical evacuation of packed intraventricular hemorrhage from aneurysm rupture in patients with poor-grade subarachnoid hemorrhage

OBJECT

The goal of this study was to evaluate the results of early surgical evacuation of "packed" intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH).

METHODS

The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view.

CONCLUSIONS

Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.

Aneurysmal intracerebral hemorrhage: Clinical outcome after emergent surgical treatment

BACKGROUND

Management guidelines and recovery potentials for individuals presenting with poor clinical condition owing to an aneurysmal intracerebral hemorrhage are not well established.

METHODS

We assessed the outcome of a consecutive series of 6 patients with aneurysmal intracerebral hemorrhages presenting with Hunt and Hess clinical grade IV or V selected to undergo emergent hematoma evacuation and aneurysm clip obliteration. Their presenting clinical condition and neuroradiology were assessed, as well as early surgical results and follow-up outcome.

RESULTS

The 2 women and 4 men were 30 to 59 years old. All 6 patients had profound neurological deficits on admission, with Glasgow Coma Scale scores of 4 to 9. Aneurysmal intracerebral hemorrhage diameters measured from 6 to 8 cm and were associated with 5 to 15 mm of midline shift. Surgical intervention was initiated within 3 hours of ictus in 5 patients and within 7 hours in one patient. All 6 patients survived, demonstrated clinical improvement postoperatively, and were transferred to rehabilitation centers 19 to 30 days after presentation. The Glasgow Outcome Scores were 2 to 3 with a minimum follow-up interval of 12 months. Four patients returned home and resumed independent activities of daily living; one required partial supervision. One patient remained in a chronic care facility.

CONCLUSION

An acute management protocol, including aggressive neurosurgical intervention, with craniotomy for hematoma evacuation and aneurysm clip obliteration, can result in good neurological outcome in carefully selected, poor-grade patients with aneurysmal intracerebral hemorrhage.

Predictive clinical factors of very early in-hospital mortality in subarachnoid hemorrhage

This study was conducted to determine clinical predictors of very early in-hospital mortality (within the first 72 h) in patients with non-traumatic subarachnoid hemorrhage. Data of 184 patients with subarachnoid hemorrhage were obtained from consecutive stroke patients included in the prospective Barcelona Stroke Registry. Demographic, anamnestic, clinical, neurological and neuroimaging variables in the subgroup of patients who died within 72 h after the onset of symptoms were compared with those in the subgroup of patients that had survived this initial period. The independent predictive value of each variable on the development of very early death was assessed with a logistic regression analysis. Very early in-hospital death was observed in 18 patients (9.8%). These patients were significantly more likely to have progressive deficit, seizures, altered consciousness, limb weakness, sensory involvement and basal ganglia hematoma than patients without very early death. After multivariate analysis, only progressive deficit (odds ratio (OR) 6.90; 95% confidence interval (95% CI) 2-23.80) and limb weakness (OR 5.46; 95% CI 1.78-16.77) were independent clinical predictors of very early mortality. Progressive neurological deficit and limb weakness at the onset of stroke was independent predictive factors of very early death in patients with non-traumatic subarachnoid hemorrhage. These results further emphasize the need to establish an early etiological diagnosis and to manage these patients aggressively including early surgery in selected cases.

Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient

Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.

Functional outcome after aneurysmal subarachnoid hemorrhage

The introduction of the operating microscope, the principle of early surgery, specialized intensive care units, the calcium antagonist nimodipine, the sophisticated pre- and postoperative management and an aggressive antiischemic pharmacological management have substantially reduced morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). In spite of this progress, many patients after rupture and surgical repair of an intracranial aneurysm exhibit substantial cognitive deficits and emotional problems although their neurological outcome was rated as good according to the Glasgow Outcome Scale (GOS = I). Therefore, a comprehensive neuropsychological examination is called for in order to evaluate the factual functional outcome after SAH. Neither focal brain damage associated with aneurysm location nor surgery but the hemorrhage itself and related events can be regarded as the most important causal factors for the late result after SAH. In contrast to the mild permanent effects of aneurysm surgery, the initial bleeding itself seems to have substantial lasting adverse neurobehavioral effects after. In concordance with other authors our own data stress the strong predictive power of the bleeding pattern such as the presence of intraventricular and/or intracerebral blood on the functional outcome after aneurysmal SAH.

Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period

OBJECT

Based on the concept that unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the disease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelines, diagnostic and monitoring methods, and pharmacological and surgical treatment in a neurointensive care setting. The impact of such changes on the outcome of aneurysmal SAH over a longer period of time has not previously been studied in detail. This was the present undertaking.

METHODS

The authors analyzed all patients with SAH admitted to the neurosurgery department between 1981 and 1992. This period was divided in two parts, Period A (1981-1986) and Period B (1987-1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patients with SAH (mean age 52 years, 59% females) were admitted; an aneurysm presumably causing the SAH was found in 874 (72%). The 30-day mortality rate decreased from 29% during the first 2 years (1981-1982) to 9% during the last 2 years (1991-1992) (Period A 22%; Period B 10%; p<0.0001) and the 6-month mortality rate decreased from 34 to 15% (Period A 26%; Period B 16%; p<0.001). At follow-up review conducted 2 to 9 years (mean 5.2 years) after SAH occurred, patients were evaluated according to the Glasgow Outcome Scale. Subarachnoid hemorrhage-related poor outcome (vegetative or dead) was reduced (Period A 30%; Period B 18%; p<0.001). There was an increase both in patients with favorable outcome (good recovery and moderate disability) (Period A 61 %; Period B 66%) and in those with severe disability (Period A 9%; Period B 16%; p<0.01).

CONCLUSIONS

This study provides evidence that the prognosis for patients with aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical outcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinical outcomes of patients with Hunt and Hess Grades III to V SAH were less conspicuous, although reduced incidences of mortality were seen in some subgroups; however, few survivors subsequently appeared to attain a favorable outcome.

Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage

OBJECTIVE

To analyze the influence of extracerebral organ system dysfunction after aneurysmal subarachnoid hemorrhage (SAH) on mortality and neurologic outcome.

DESIGN

Observational study with retrospective data extraction.

SETTING

Neurosurgical intensive care unit (NICU) at a primary level university hospital, supervised and staffed by both members of the Clinic of Neurosurgery and the Clinic of Anesthesiology and General Intensive Care.

PATIENTS

Two hundred forty-two patients treated for intracranial aneurysm rupture within 7 days of the most recent SAH.

INTERVENTIONS

Routine neurosurgical interventions for obliteration of the ruptured aneurysm (microsurgery, Guglielmi Detachable Coils embolization) and for treatment of posthemorrhagic hydrocephalus (ventriculostomy, cerebrospinal fluid shunt implantation).

MEASUREMENTS AND MAIN RESULTS

Respiratory, renal, hepatic, cardiovascular, and hematologic organ system functions were evaluated both individually and in aggregate by using a modified version of the Multiple Organ Dysfunction (mMOD) score. Of 1,452 organ system functions assessed in 242 patients during their NICU stay, 714 organ system functions were intact (cerebral: 0, extracerebral: 714), 556 organ systems had mild-to-moderate dysfunctions (mMOD scoremax 1-2 for the affected organ system; cerebral: 153, extracerebral: 403), and 182 organ systems failed (mMOD scoremax 3 for the affected organ system; cerebral: 89, extracerebral: 93). Severity of extracerebral organ system dysfunctions correlated with the degree of neurologic impairment (Hunt and Hess [H&H] score) in a graded fashion. Similarly, the chance to develop systemic inflammatory response syndrome (SIRS) during the NICU stay increased with increasing admission H&H grade. The incidence of SIRS and septic shock was 29% and 10.3%, respectively. The mortality rate was 40.2% in patients with SIRS and 80% for patients suffering septic shock. Seventy-seven percent of extracerebral organ system failures (OSFs) occurred in conjunction with SIRS: 51% of respiratory OSFs, 97% of renal OSFs, 100% of hepatic OSFs, 96% of cardiovascular OSFs, and 73% of hematopoietic OSFs. Both CNS dysfunction and extracerebral organ system dysfunctions were significantly related to neurologic outcome. The probability of unfavorable neurologic outcome significantly increased with both decreasing cerebral perfusion pressure (CPP) and increasing severity of extracerebral organ dysfunction.

CONCLUSION

Aneurysmal SAH and its neurologic sequelae accounted for the principal morbidity and mortality in the current series. Development of extracerebral organ system dysfunction was associated with a higher probability of unfavorable neurologic outcome. Systemic inflammation (SIRS) and secondary organ dysfunction were the principal non-neurologic causes of death.

Complex intracranial aneurysms: combined operative and endovascular approaches

OBJECTIVE

Endovascular management of complex intracranial aneurysms is increasingly being considered as an alternative to standard surgical clipping. However, little attention has been paid to the complementary nature of surgery and endovascular therapy.

METHODS

Between September 1992 and May 1997, 12 patients with complex intracranial aneurysms were treated with combined operative and endovascular methods. Seven patients demonstrated subarachnoid hemorrhage (two of Grade II, two of Grade III, and three of Grade IV). Five patients demonstrated unruptured aneurysms, i.e., three giant aneurysms (one vertebrobasilar junction aneurysm, one middle cerebral artery bifurcation aneurysm, and one internal carotid artery-ophthalmic artery aneurysm), one large internal carotid artery-ophthalmic artery aneurysm, and one middle cerebral artery serpentine aneurysm. Management strategies involved either surgery followed by endovascular therapy (S-E; n = 5) or endovascular therapy followed by surgery (E-S; n = 7). S-E paradigms included aneurysm exploration followed by endovascular treatment (S-E1; n = 3), partial aneurysm clipping followed by endovascular aneurysm packing (S-E2; n = 1), and extracranial-to-intracranial bypass followed by endovascular parent vessel occlusion (S-E3; n = 1). E-S paradigms included superselective angiography followed by surgical clipping (E-S1; n = 2), Guglielmi detachable coil partial dome packing followed by delayed surgical clipping (E-S2; n = 2), proximal temporary vessel balloon occlusion followed by aneurysm clipping (E-S3; n = 2), and proximal permanent vessel occlusion followed by surgical aneurysm decompression for mass effect treatment (E-S4; n = 1).

RESULTS

Eleven aneurysms (92%) were completely eliminated. The remaining aneurysm was 90% obliterated and remained quiescent at the 34-month follow-up examination, despite presenting with subarachnoid hemorrhage. No patient experienced repeat bleeding (follow-up period, 23+/-28 mo). There were no deaths. One patient achieved a fair outcome (Glasgow Outcome Scale score of III); all other patients experienced excellent outcomes (Glasgow Outcome Scale score of I). In all cases, the aneurysm management paradigm chosen had a positive effect on definitive therapy.

CONCLUSION

Several factors can contribute to the complexity of intracranial aneurysms. Management strategies that combine operative and endovascular techniques in a complementary way, for the best possible outcomes for these patients, can be designed accordingly.

Risks and benefits of diagnostic angiography after aneurysm surgery: a retrospective analysis of 597 studies

INTRODUCTION

Cerebral angiography performed after aneurysm surgery can identify causes of morbidity and mortality that may be corrected. The risks and benefits of angiography that is performed after aneurysm surgery, however, have not been clearly defined. We therefore reviewed our experience with postoperative angiography to determine its dangers and benefits.

METHODS

During 10 years, 543 consecutive patients received treatment for cerebral aneurysms. A retrospective analysis of 597 diagnostic angiograms obtained after aneurysm surgery for 494 of these patients was performed.

RESULTS

Catheter-induced vessel spasm and dissection, occurring most frequently in the internal carotid artery, were observed in seven (1.2%) and six (1%) studies, respectively. No angiography-associated strokes were identified. No association between age, smoking, hypertension, blood pressure, atherosclerosis, or severe vasospasm and angiographic complications was observed. Aneurysm remnants were identified in 36 (5.7%) of the 637 aneurysms that were surgically treated. Atherosclerosis (P < 0.01) or multiple clip applications (P < 0.01) were significantly associated with aneurysm remnants. Angiographic vessel occlusion was observed in 28 (5.7%) patients and resulted in stroke in 14 of these patients. Vessel occlusion was significantly associated with increasing aneurysm size (P < 0.001), atherosclerosis (P < 0.001), temporary clips (P < 0.001), multiple clips (P=0.03), multiple clip applications (P=0.001), and a new postoperative neurological deficit (P=0.002). Severe vasospasm and newly identified aneurysms were observed in 51 and 16 patients, respectively.

CONCLUSION

Angiography after aneurysm surgery is safe and can be routinely performed. Angiography after aneurysm surgery should be particularly considered for patients with large aneurysms or cerebrovascular atherosclerosis and for those who develop new postoperative neurological deficits.

Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation

BACKGROUND AND PURPOSE

Decisions on invasive arteriovenous malformation (AVM) treatment are currently based on natural-course risk estimates of AVM bleeding and assumptions on morbidity from cerebral hemorrhage in general. However, morbidity of AVM hemorrhage has rarely been reported. We sought to assess the morbidity of intracranial hemorrhage in patients with cerebral AVMs.

METHODS

From a prospective AVM database, 119 patients were analyzed: 115 had a hemorrhage as the diagnostic event, and 27 of them suffered a second hemorrhage during follow-up; an additional 4 patients had other diagnostic symptoms but bled during follow-up. The type (parenchymal, subarachnoid, intraventricular) and location of AVM hemorrhage were determined by CT/MR brain imaging. Disability and neurological impairment were assessed with the Barthel Index, the Rankin Scale, and the National Institutes of Health Stroke Scale, with a mean follow-up time of 16.2 months.

RESULTS

Of the 115 incident hemorrhages, 34 (30%) were subarachnoid, 27 (23%) parenchymal, 18 (16%) intraventricular, and 36 (31%) in combined locations. In 54 patients (47%; 95% confidence interval [CI], 38% to 56%) the incident hemorrhage resulted in no neurological deficit, and an additional 43 patients (37%; 95% CI, 28% to 46%) were independent in their daily activities (Rankin 1). Fifteen patients (13%; 95% CI, 7% to 19%) were moderately disabled (Rankin 2 or 3), and 3 (3%; 95% CI, 0% to 6%) were severely disabled (Rankin > or =4). Parenchymal hemorrhages were most likely to result in a neurological deficit (52%). Type and morbidity of hemorrhage during follow-up were similar to incident events. Twenty (74%) of 27 patients with both incident and follow-up hemorrhages were normal or independent (Rankin 0 or 1). None of the patients with a hemorrhage during follow-up died during the observation period.

CONCLUSIONS

Hemorrhage from cerebral AVMs appears to have a lower morbidity than currently assumed. This finding encourages a reevaluation of the risks and benefits of invasive AVM treatment.

Comparison of balloon angioplasty and papaverine infusion for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage

OBJECT

The purpose of this study was to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients.

METHODS

Blood flow velocities of the involved vessels were assessed by using transcranial Doppler (TCD) monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papaverine infusion cohorts were compared based on mean pre- and posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment after balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), a decrease that was sustained.

CONCLUSIONS

Balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

Cerebral aneurysms in the elderly in Yamaguchi, Japan. Analysis of the Yamaguchi Data Bank of Cerebral Aneurysm from 1985 to 1995

BACKGROUND AND PURPOSE

The number of elderly people is markedly increasing in Japan. We have investigated the epidemiology and management outcome of cerebral aneurysms in elderly patients aged > or = 70 years.

METHODS

A total of 3100 patients were enrolled in the Yamaguchi Data Bank of Cerebral Aneurysm between 1985 and 1995. Of these, 598 with ruptured cerebral aneurysms and 120 with unruptured cerebral aneurysms were elderly (ie, aged > or = 70 years).

RESULTS

The number of elderly patients with cerebral aneurysms has markedly increased since 1991, and in 1995 approximately 30% of all patients with cerebral aneurysms were elderly. In cases of ruptured cerebral aneurysms, the proportion of patients with severe neurological grade did not change and that with an unfavourable outcome did not decrease throughout the 11 years. The proportion of patients with severe neurological grade in the elderly group was higher than in the younger group (< 70 years), and the management outcome of elderly patients for each neurological grade on admission was worse than that of younger patients (P < .01). However, the incidence rate of symptomatic cerebral vasospasm and rebleeding was the same for the two age groups. Eventually, 60.4% of all elderly patients with ruptured cerebral aneurysms had an unfavorable outcome. In cases of unruptured cerebral aneurysms, 63.3% of the selected elderly patients were surgically treated, and the surgical morbidity and mortality rates were 26.3% and 4.0%, respectively. These rates were nonsignificantly higher than those for younger patients.

CONCLUSIONS

The number of elderly patients with cerebral aneurysms has markedly increased in Yamaguchi. Because of the unsatisfactory management outcome of ruptured cerebral aneurysms and surgical outcome of unruptured cerebral aneurysms in elderly patients during the 11-year period, we propose the treatment of unruptured cerebral aneurysms at a younger age and the use of a screening system to detect these subjects.

Management of subarachnoid hemorrhage patients who presented with respiratory arrest resuscitated with bystander CPR

BACKGROUND AND PURPOSE

The sudden death rate from aneurysmal subarachnoid hemorrhage (SAH) is 10%. Since 1989, 26 SAH patients who were witnessed to collapse into coma with respiratory arrest and required cardiopulmonary resuscitation (CPR) at the scene survived to reach the hospital and be diagnosed. Although reports on hospital management of grade V SAH suggest improved outcome, no report has previously addressed the issue of respiratory arrest after acute SAH. We analyze our experience with this unique subgroup of aneurysmal SAH patients.

METHODS

This is a retrospective analysis of 26 consecutive SAH patients who collapsed at the scene and required CPR for respiratory arrest and survived to reach the hospital and be diagnosed. Statistical analysis was performed using the t test and Mann-Whitney rank-sum test.

RESULTS

All patients were grade V on arrival at the emergency department. Twenty-one patients received mouth-to-mouth resuscitation only, and 5 received chest compressions as well. The mean duration of bystander CPR was 12 to 15 minutes. CT scan showed diffuse, thick SAH in all patients, an associated subdural hemorrhage in 2, and an intraparenchymal hemorrhage in 4. After CT scan, an intracranial pressure (ICP) monitor was placed in 24, and 2 were taken to emergency surgery for subdural and intracerebral hemorrhage. ICP was elevated in 24 patients (mean, 54 mm Hg), and a ventriculostomy was placed in all 24. ICP was unresponsive in 12, and all suffered brain death. ICP lessened to < 25 mm Hg in 12, and all underwent angiography. All 12 had an aneurysm and underwent emergency surgical clipping. Time to surgery from SAH was < or = 11 hours in all 12 patients. All were managed with calcium channel blockers and hyperdynamic therapy in addition to aggressive control of ICP. The outcome at 12 months in the 14 surgical cases was normal in 3 patients (21%), good in 2 (14%), vegetative in 1 (7%), and death in 8 (57%).

CONCLUSIONS

Aneurysmal SAH patients that present with respiratory arrest present as grade V patients with elevated ICP. Bystander CPR coupled with early retrieval, diagnosis, and therapy can lead to 20% functional survival in what used to be sudden death from aneurysmal SAH.

The incidence of surgical complications is similar in good and poor grade patients undergoing repair of ruptured anterior circulation aneurysms: a retrospective review of 355 patients

To determine how clinical grade after subarachnoid hemorrhage impacts operative characteristics and the incidence of intra- and postoperative surgical complications, we retrospectively compared the surgical management of all good grade (n = 224) and poor grade (n = 131) patients who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The majority of good grade (74.2%) and poor grade (89.8%) patients underwent surgery < 3 days after subarachnoid hemorrhage. The results in this series demonstrate that severe cerebral swelling, often secondary to intracerebral hemorrhage, was significantly more frequent in poor grade patients. The incidence of complications, such as failure to occlude the aneurysm, major vessel occlusion, intraoperative aneurysm rupture, or surgical contusion, however, was similar in poor grade and good grade patients. We conclude, therefore, that except for severe cerebral swelling associated with intracerebral hemorrhage, the risk of surgical complications is similar in good and poor grade patients undergoing surgical repair of ruptured anterior circulation aneurysms.