Patients in poor neurological condition after subarachnoid hemorrhage: early management and long-term outcome

Outcomes following poor-grade aneurysmal subarachnoid haemorrhage: a prospective observational study

BACKGROUND

Up to 35% of aneurysmal subarachnoid haemorrhage (aSAH) cases may present as poor grade, defined as World Federation of Neurosurgical Societies (WFNS) grades IV and V. In this study, we evaluate functional outcomes and prognostic factors.

METHODS

This prospective study included all patients referred to a national, centralized neurosurgical service with a diagnosis of poor-grade aSAH between 01/01/2016 and 31/12/2019. Multivariable logistic regression models were used to estimate probability of poor functional outcomes, defined as a Glasgow Outcome Scale (GOS) of 1-3 at 3 months.

RESULTS

Two hundred fifty-seven patients were referred, of whom 116/257 (45.1%) underwent treatment of an aneurysm, with 97/116 (84%) treated within 48 h of referral. Median age was 62 years (IQR 51-69) with a female predominance (167/257, 65%). Untreated patients tended to be older; 123/141 (87%) had WFNS V, 60/141 (45%) unreactive pupils and 21/141 (16%) circulatory arrest. Of all referred patients, poor outcome occurred in 169/230 (73.5%). Unreactive pupils or circulatory arrest conferred a universally poor prognosis, with mortality in 55/56 (98%) and 19/19 (100%), respectively. The risk of a poor outcome was 14.1% (95% CI 4.5-23.6) higher in WFNS V compared with WFNS IV. Age was important in patients without circulatory arrest or unreactive pupils, with risk of a poor outcome increasing by 1.8% per year (95% CI 1-2.7). In patients undergoing aneurysm securement, 48/101 (47.5%) had a poor outcome, with age, rebleeding, vasospasm and cerebrospinal fluid (CSF) diversion being important prognosticators. The addition of serum markers did not add significant discrimination beyond the clinical presentation.

CONCLUSIONS

The overall outcomes of WFNS IV and V aSAH remain poor, mainly due to the devastating effects of the original haemorrhage. However, in patients selected for aneurysm securement, good outcomes can be achieved in more than half of patients. Age, pre-intervention rebleeding, vasospasm, and CSF diversion are important prognostic factors.

Optimal Glucose Target After Aneurysmal Subarachnoid Hemorrhage: A Matched Cohort Study

BACKGROUND

Hyperglycemia has been associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, there remains debate as to what optimal glucose targets should be in this patient population.

OBJECTIVE

To assess whether we could identify an optimal glucose target for patients with aSAH.

METHODS

We performed a post hoc analysis of the "clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage" trial data set. Patients had laboratory results drawn daily for the entirety of their intensive care unit stay. Maximum blood glucose levels were assessed for a relationship with unfavorable outcomes using multiple logistic regression analysis. Maximum blood glucose levels were dichotomized based on the Youden index, which identified a maximum level of <9.2 mmol/L as the optimal cut point for prediction of unfavorable outcomes. Nearest neighbor matching was used to assess the relationship between maintaining glucose levels below the cut point and unfavorable functional outcomes (defined as a modified Rankin score of >2 at 3 mo post-aSAH). The matching was performed after calculation of a propensity score based on identified predictors of outcome and glucose levels.

RESULTS

Three hundred eighty-nine patients were included in the matched analysis. Propensity scores were balanced on both the covariates and outcomes of interest. There was a significant average treatment effect (-0.143: 95% confidence interval -0.267 to -0.019) for patients who maintained glucose levels <9.2 mmol/L.

CONCLUSION

Maintaining glucose levels below the identified cut point was associated with a decreased risk for unfavorable outcomes in this retrospective matched study.

Time course of outcome in poor grade subarachnoid hemorrhage patients: a longitudinal retrospective study

Background

Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients’ characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors.

Methods

We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004–2007; 2008–2011; 2012–2015 and 2016–2018).

Results

A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008–2011 and 2016–2018 periods (HR 0.55 [0.34–0.89] and HR 0.33 [0.20–0.53], respectively, when compared to 2004–2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 [1.43–3.14]) and UO (OR 3.23 [1.67–6.25]). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 [0.43–0.84]).

Conclusions

Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02229-1.

Clinical Outcomes After Endovascular Coiling in High-Grade Aneurysmal Hemorrhage

Object:

Our experience in Calgary was reviewed to determine the safety and clinical effectiveness of coiling in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).

Methods:

Patients with Hunt-Hess grades IV and V aneurysmal subarachnoid hemorrhage who underwent endovascular coiling between January 1999 and April 2009 at Foothills Medical Centre, Calgary, Alberta, Canada were reviewed. The primary outcome measure was the Modified Rankin Score after at least six months. Secondary outcome measures included extent of aneurysm occlusion and peri-procedural complications. In patients with favourable functional outcomes, Barthel's Index (BI), Re-integration to normal living index (RINL), and Zung depression scale (ZDS) were determined.

Results:

Thirty-three patients were identified (median age of 57 years; 73% female) and 69% were Hunt-Hess grade IV subarachnoid hemorrhage and 22 % were grade V Endovascular coiling resulted in absence of residual flow into the aneurysm fundus in 91%. Only seven procedure-related complications occurred with no deaths attributed to the procedure. Vasospasm, hydrocephalus, and pneumonia were the most common non-procedural complications. Average follow-up was 27 +/- 17 months. Overall mortality was 32%, but 53% of patients had good functional outcome (mRS<3). Nine patients completed the BI, RINL, and ZDS with average BI 99 +/- 2, RINL 89 +/- 14, ZDS 33 +/-11, suggesting minimal deficits in function and mood.

Conclusions:

Endovascular coiling in patients with high-grade subarachnoid hemorrhage is safe. While the morbidity and mortality from high-grade aneurysmal subarachnoid hemorrhage remains significant, favourable radiologic and functional outcomes can be achieved in a significant proportion of these critically ill patients.

Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review

BACKGROUND AND PURPOSE

Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population.

METHODS

Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment.

RESULTS

The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter.

CONCLUSION

Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.

Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma

Spontaneous subarachnoid hemorrhage (SAH) is the most common cerebrovascular disease. The conventional treatment for SAH is usually associated with high mortality. The present study aims to assess the prognosis of microsurgical treatment for patients with poor-grade aneurysm (Hunt and Hess grades IV-V) associated with intracerebral hematoma. A total of 18 consecutive patients who were diagnosed with poor-grade aneurysm accompanied with intracerebral hematoma were retrospectively recruited. All patients underwent microsurgical treatment between April 2010 and June 2013 at The 101st Hospital of Chinese People's Liberation Army (Wuxi, China). Among them, 15 cases underwent microsurgery within 24 h of SAH, and 3 cases underwent microsurgery 24 h following SAH. All 18 cases were examined by computed tomography angiography (CTA). The outcome was assessed during a follow-up time of 6-36 months. According to the Glasgow Outcome Scale, 4 patients experienced a good recovery, 6 were dissatisfied with the outcome, 4 were in vegetative state and 4 succumbed to disease. Poor outcome occurred in patients with an aneurysm diameter >10 mm, exhibited >50 ml volume of intracerebral hematoma or presented cerebral hernia prior to the surgical operation. The outcome of ultra-early surgery (within 24 h of SAH) was improved, compared with that of surgery following 24 h of SAH (P=0.005). Among 7 patients who accepted extraventricular drainage, good outcomes were achieved in 4 of them, whereas dissatisfaction and mortality occurred in 2 and 1 patients, respectively. Therefore, ultra-early microsurgery (within 24 h of SAH) combined with extraventricular drainage may improve the prognosis of patients with poor-grade aneurysm.

Response of brain oxygen to therapy correlates with long-term outcome after subarachnoid hemorrhage

BACKGROUND

Brain oxygen (PbtO2) monitoring can help guide care of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients. The relationship between PbtO2-directed therapy and long-term outcome is unclear. We hypothesized that responsiveness to PbtO2-directed interventions is associated with outcome.

METHODS

Seventy-six aSAH patients who underwent PbtO2 monitoring were included. Long-term outcome [Glasgow Outcome Score-Extended (GOS-E) and modified Rankin Scale (mRS)] was ascertained using the social security death database and structured telephone interviews. Univariate and multivariate regression were used to identify variables that correlated with outcome.

RESULTS

Data from 64 patients were analyzed (12 were lost to follow-up). There were 530 episodes of compromised PbtO2 (<20 mmHg) during a total of 7,174 h of monitor time treated with 1,052 interventions. Forty-two patients (66 %) survived to discharge. Median follow-up was 8.5 months (range 0.1-87). At most recent follow-up 35 (55 %) patients were alive, and 28 (44 %) had a favorable outcome (mRS ≤3). In multivariate ordinal regression analysis, only age and response to PbtO2-directed intervention correlated significantly with outcome. Increased age was associated with worse outcome (coeff. 0.8, 95 % CI 0.3-1.3, p = 0.003), and response to PbtO2-directed intervention was associated with improved outcome (coeff. -2.12, 95 % CI -4.0 to -0.26, p = 0.03). Patients with favorable outcomes had a 70 % mean rate of response to PbtO2-directed interventions whereas patients with poor outcomes had a 45 % response rate (p = 0.005).

CONCLUSIONS

Response to PbtO2-directed intervention is associated with improved long-term functional outcome in aSAH patients.

Mechanisms of acute brain injury after subarachnoid hemorrhage

Brain injury after subarachnoid hemorrhage (SAH) is a biphasic event with an acute ischemic insult at the time of the initial bleed and secondary events such as cerebral vasospasm 3 to 7 days later. Although much has been learned about the delayed effects of SAH, less is known about the mechanisms of acute SAH-induced injury. Distribution of blood in the subarachnoid space, elevation of intracranial pressure, reduced cerebral perfusion and cerebral blood flow (CBF) initiates the acute injury cascade. Together they lead to direct microvascular injury, plugging of vessels and release of vasoactive substances by platelet aggregates, alterations in the nitric oxide (NO)/nitric oxide synthase (NOS) pathways and lipid peroxidation. This review will summarize some of these mechanisms that contribute to acute cerebral injury after SAH.

Risk profile of patients with poor-grade aneurysmal subarachnoid hemorrhage using early perfusion computed tomography

OBJECTIVE

To determine whether perfusion computed tomography (CT) is useful for identifying patients with poor-grade subarachnoid hemorrhage (SAH) with reversible etiologies and whether early obliteration in patients with poor-grade aneurysmal SAH leads to favorable outcomes.

METHODS

Patients with new-onset aneurysmal SAH in World Federation of Neurological Surgeons (WFNS) grade IV or V neurologic condition who had perfusion CT performed at admission were eligible for the study. The study retrospectively enrolled 38 patients seen between January 2007 and July 2009. The decision to perform an early obliteration was made by the family after a discussion with the neurosurgeons, neurointensivists, and interventional radiologists. The functional outcomes were correlated with the Glasgow Outcome Scale (GOS) at 6 months, and quantitative perfusion CT data were collected.

RESULTS

This study included 10 (26%) grade IV and 28 (74%) grade V patients. Favorable outcomes occurred in 19 (50%) patients, and 11 (29%) patients died. After a multivariate logistic regression analysis of the parameters, older age (odds ratio 1.104, P = 0.0317), bilateral prolonged mean transient time (MTT) at the thalami (odds ratio 4.155, P = 0.0362), and early obliteration (odds ratio 0.098, P = 0.003) were predictive of poor outcome.

CONCLUSIONS

Early bilateral prolonged MTT at the thalami and old age are associated with a poor outcome. Early obliteration benefits a significant portion of SAH patients.

Development of a kit to treat subarachnoid hemorrhage by intrathecal simple urokinase infusion (ITSUKI) therapy: preliminary results in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage

OBJECTIVE

To report the effectiveness of intrathecal selective administration of urokinase infusion (ITSUKI) therapy delivered via a special kit (ITSUKit), developed to prevent vasospasm in patients with ruptured aneurysms who had undergone Guglielmi detachable coil (GDC) placement, in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage (SAH).

METHODS

A study of ITSUKI therapy with or without ventricular drainage enrolled 6 patients with WFNS grade V SAH owing to ruptured intracranial aneurysms who were eligible for coil embolization. The procedures were performed within 48 hours of the occurrence of aneurysmal SAH. The incidence of symptomatic vasospasm and the clinical outcomes based on the Glasgow Outcome Scale (GOS) were assessed at 6 months after SAH onset.

RESULTS

All patients underwent complete coil embolization. There were no side effects or adverse reactions attributable to ITSUKI therapy. Symptomatic vasospasm occurred in one patient (16.7%). There were no patients with hydrocephalus. Based on the GOS, one patient had a good outcome, two manifested moderate disability, and three manifested severe disability.

CONCLUSIONS

The results showed that the ITSUKit was useful for ITSUKI therapy. Although the combination of coil embolization and ITSUKI therapy did not completely eliminate WFNS grade V SAH, it significantly improved the treatment outcome in some patients.

Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage

BACKGROUND

Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention.

OBJECTIVE

To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery.

METHODS

A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes.

RESULTS

Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes.

CONCLUSIONS

PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

Antithrombotic States and Outcomes in Patients With Angiographically Negative Subarachnoid Hemorrhage

BACKGROUND:

Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages.

OBJECTIVE:

To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions.

METHODS:

This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years. The patients were grouped into those with and those without an antithrombotic state at time of hemorrhage and were stratified according to presentation, clinical grades, outcomes, need for cerebrospinal fluid diversion, and development of vasospasm. Computed tomography of the head was assessed for bleed pattern and modified Fisher grade. Patients were excluded if a causative lesion was subsequently discovered.

RESULTS:

There is a statistically significant association between antithrombotic states and poorer presentation, higher Hunt and Hess score, increased amount of subarachnoid hemorrhage, higher modified Fisher grade, increased incidence of vasospasm, hydrocephalus, and poor outcomes as assessed by modified Rankin scale (P &lt; .001). Patients with an antithrombotic state experience worse outcomes even with adjustment for the amount of hemorrhage as assessed by modified Fisher grade (P &lt; .001).

CONCLUSION:

Patients in an antithrombotic state presenting with angiographically negative subarachnoid hemorrhage present with inferior clinical scores, diffuse hemorrhage patterns, and worse modified Fisher grades and have worse outcomes.

Placement of external ventricular drains and intracranial pressure monitors by neurointensivists

INTRODUCTION

External ventricular drains (EVDs) and intracranial pressure (ICP) monitors are widely used in the Neurological Critical Care Unit (NCCU) to measure ICP and divert cerebrospinal fluid (CSF). EVDs and ICP monitors have historically been placed by neurosurgeons; however, with recent staffing of NCCUs by neurointensivists, a growing number of EVDs and ICP monitors are being placed by these specialists.

RESULTS

Limited data are available concerning the safety or feasibility of such placements by neurointensivists. We present our experience with EVD and ICP monitor placement by a neurointensivist in the NCCU. A retrospective chart review of 29 patients with EVD placement and 7 patients with ICP monitors--all placed by a single neurointensivist--was conducted for patients admitted to the NCCU from August 2005 to January 2008.

DISCUSSION

These findings were compared to published outcomes from neurosurgeon placements. All 29 patients with EVDs remained infection-free, with CSF pleocytosis occurring in one patient (3.4%). All 7 patients receiving ICP monitors remained free from infection. Complications after drain placement occurred in 20.7% (n = 6) of patients, with all six complications being EVD tract hematoma measuring less than 5 cm(3).

CONCLUSION

Patients receiving ICP monitors had no complications. These complication rates are comparable to published rates, which suggest that placement of EVDs and ICP monitors by neurointensivists may be safe and effective. However, small sample size (n = 36) prohibits definitive safety and efficacy conclusions. For this reason, further research analyzing a larger patient sample is warranted.

Effective glycemic control with aggressive hyperglycemia management is associated with improved outcome in aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Hyperglycemia strongly predicts poor outcome in patients with aneurysmal subarachnoid hemorrhage, but the effect of hyperglycemia management on outcome is unclear. We studied the impact of glycemic control on outcome of patients with aneurysmal subarachnoid hemorrhage.

METHODS

A prospective intensive care unit database was used to identify 332 patients with hyperglycemic aneurysmal subarachnoid hemorrhage admitted between January 2000 and December 2006. Patients treated with an aggressive hyperglycemia management (AHM) protocol after 2003 (N=166) were compared with 166 patients treated using a standard hyperglycemia management before 2003. Within the AHM group, outcome was compared between patients who achieved good (mean glucose burden <1.1 mmol/L) and poor (mean glucose burden >or=1.1 mmol/L) glycemic control. Poor outcome was defined as modified Rankin scale >or=4 at 3 to 6 months. Multivariable logistic regression models correcting for temporal trend were used to quantify the effect of AHM on poor outcome.

RESULTS

Poor outcome in AHM-treated patients was lower (28.31% versus 40.36%) but was not statistically significant after correcting for temporal trend. However, good glycemic control significantly reduced the incidence of poor outcome (OR, 0.25; 95% CI, 0.08 to 0.80; P=0.02) compared with patients with poor glycemic control within the AHM group. No difference in the rate of clinical vasospasm or the development of delayed ischemic neurological deficit was seen before and after AHM protocol implementation.

CONCLUSIONS

AHM results in good glucose control and significantly reduces the odds for poor outcome after aneurysmal subarachnoid hemorrhage in glucose-controlled patients. Further studies are needed to confirm these results.

Multimodality monitoring in neurocritical care

Multimodality monitoring of cerebral physiology encompasses the application of different monitoring techniques and integration of several measured physiologic and biochemical variables into assessment of brain metabolism, structure, perfusion, and oxygenation status. Novel monitoring techniques include transcranial Doppler ultrasonography, neuroimaging, intracranial pressure, cerebral perfusion, and cerebral blood flow monitors, brain tissue oxygen tension monitoring, microdialysis, evoked potentials, and continuous electroencephalogram. Multimodality monitoring enables immediate detection and prevention of acute neurologic injury as well as appropriate intervention based on patients' individual disease states in the neurocritical care unit. Real-time analysis of cerebral physiologic, metabolic, and cardiovascular parameters simultaneously has broadened knowledge about complex brain pathophysiology and cerebral hemodynamics. Integration of this information allows for more precise diagnosis and optimization of management of patients with brain injury.

Future of brain support: multimodality monitoring

Multimodality monitoring of cerebral physiology encompasses the application of different monitoring techniques and integration of several measured physiological and biochemical variables into the assessment of brain metabolism, structure, perfusion and oxygenation status, in addition to clinical evaluation. Novel monitoring techniques include transcranial Doppler ultrasonography, neuroimaging, intracranial pressure, cerebral perfusion and cerebral blood flow monitors, brain tissue oxygen tension monitoring, microdialysis, evoked potentials and continuous electroencephalography. Multimodality monitoring enables the immediate detection and prevention of acute neurological events, as well as appropriate intervention based on a patient’s individual disease state in the neurocritical care unit. Simultaneous real-time analysis of cerebral physiological, metabolic and cardiovascular parameters has broadened knowledge regarding complex brain pathophysiology and cerebral hemodynamics. Integration of this information allows for a more precise diagnosis and optimization of management of patients with brain injury.

Treatment of ruptured intracranial aneurysms: Report from a low-volume center

BACKGROUND

The aim of this retrospective analysis was to present our experience and results in treating subarachnoid hemorrhage due to ruptured intracranial aneurysms at a neurosurgical department with a small annual number of cases (i.e. a low-volume center) and to discover which factors could influence treatment and reliably predict the outcome of hemorrhage.

METHODS

All patients with aneurysmal subarachnoid hemorrhage treated at our department between 1973 and 2003 were retrospectively analyzed. We performed 293 operations and 21 endovascular procedures. In the majority of patients we excluded the aneurysm from circulation by placing a clip on the aneurysmal neck. Relevant data were obtained on patients' performance, imaging studies, treatment and outcome.

RESULTS

According to the Hunt & Hess grade, the majority of patients were in groups 1 or 2. Perioperative mortality was 3%. Postoperative mortality due to complications related to subarachnoid hemorrhage was 10%. Vasospasm was detected in 18% of patients and was a direct cause of death in 5%. The outcome was good in 68% (grades 4 or 5 on the Glasgow outcome scale). In multivariate analysis, the Hunt & Hess grade, age and clinical vasospasm all had important predictive value for the outcome.

CONCLUSIONS

The results of treatment in our series of patients fall within reported norms and are comparable to results from other low-volume centers. For successful treatment of aneurysmal subarachnoid hemorrhage, fast diagnosis, correct surgical or endovascular treatment and proper intensive pre- and postoperative care are of utmost importance.

One-stage embolization in patients with acutely ruptured poor-grade aneurysm

BACKGROUND

Early or ultra-early surgery for patients in poor neurological condition (Hunt and Hess grade IV or V) after ictus of aneurysmal subarachnoid hemorrhage is increasingly reported to prevent early rebleeding. To prevent any rebleeding after hospital admission, we have treated patients with poor-grade aneurysm during the same session as when diagnostic angiography is performed ("one-stage embolization"). The aim of the present study is to determine whether this treatment modality is a viable management option for this group of patients.

METHODS

We retrospectively reviewed 18 consecutive patients who presented with acutely ruptured aneurysms and were in very poor neurological condition and who were treated with one-stage embolization.

RESULTS

We observed 2 complications related to the endovascular procedure: partial occlusion of the parent artery and aneurysm rupture during the procedure. According to the Glasgow Outcome Scale, good recovery occurred in 8 patients, and moderate and severe disabilities occurred in 4 and 3 patients, respectively, and 3 patients died. No rebleeding occurred after the procedure. The mean follow-up of the surviving patients (those who were alive more than 30 days after embolization) was 13.7 months (4-25 months). Three patients had surgery after endovascular procedure: 2 surgical clipping of failed or partial aneurysm embolization and 1 emergency coil removal with clipping. A permanent ventriculoperitoneal shunt was placed in 11 patients.

CONCLUSIONS

We achieved promising results by using one-stage embolization to prevent ultra-early rebleeding followed by aggressive resuscitation. The active involvement of the endovascular team from the stage of diagnostic angiogram is a prerequisite for this treatment strategy.

Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage

OBJECT

Increased intracranial pressure (ICP) is well known to affect adversely patients with head injury. In contrast, the variables associated with ICP following aneurysmal subarachnoid hemorrhage (SAH) and their impact on outcome have been less intensely studied.

METHODS

In this retrospective study the authors reviewed a prospective observational database cataloging the treatment details in 433 patients with SAH who had undergone surgical occlusion of an aneurysm as well as ICP monitoring. All 433 patients underwent postoperative ICP monitoring, whereas only 146 (33.7%) underwent both pre- and postoperative ICP monitoring. The mean maximal ICP was 24.9 +/- 17.3 mm Hg (mean +/- standard deviation). During their hospital stay, 234 patients (54%) had elevated ICP (> 20 mm Hg), including 136 of those (48.7%) with a good clinical grade (Hunt and Hess Grades I-III) and 98 (63.6%) of the 154 patients with a poor grade (Hunt and Hess Grades IV and V) on admission. An increased mean maximal ICP was associated with several admission variables: worse Hunt and Hess clinical grade (p < 0.0001), a lower Glasgow Coma Scale (GSC) motor score (p < 0.0001); worse SAH grade based on results of computerized tomography studies (p < 0.0001); intracerebral hemorrhage (p = 0.024); severity of intraventricular hemorrhage (p < 0.0001); and rebleeding (p = 0.0048). Both intraoperative cerebral swelling (p = 0.0017) and postoperative GCS score (p < 0.0001) were significantly associated with a raised ICP. Variables such as patient age, aneurysm size, symptomatic vasospasm, intraoperative aneurysm rupture, and secondary cerebral insults such as hypoxia were not associated with raised ICP. Increased ICP adversely affected outcome: 71.9% of patients with normal ICP demonstrated favorable 6-month outcomes postoperatively, whereas 63.5% of patients with ICP between 20 and 50 mm Hg and 33.3% with ICP greater than 50 mm Hg demonstrated favorable outcomes. Among 21 patients whose raised ICP did not respond to mannitol therapy, all experienced a poor outcome and 95.2% died. Among 145 patients whose elevated ICP responded to mannitol, 66.9% had a favorable outcome and only 20.7% were dead 6 months after surgery (p < 0.0001). According to results of multivariate analysis, however, ICP was not an independent outcome predictor (odds ratio 1.26, 95% confidence interval 0.28-5.68).

CONCLUSIONS

Increased ICP is common after SAH, even in patients with a good clinical grade. Elevated ICP post-SAH is associated with a worse patient outcome, particularly if ICP does not respond to treatment. This association, however, may depend more on the overall severity of the SAH than on ICP alone.

Untreated subarachnoid hemorrhage: who, why, and when?

OBJECT

When subarachnoid hemorrhage (SAH) is caused by an aneurysm or other vascular anomaly, surgery or endovascular treatment is generally indicated. Nevertheless, some patients with SAH do not receive such therapy. The objective of this study was to characterize the patients who do not receive treatment.

METHODS

The records of all patients with SAH who were admitted to a tertiary care center during a 9-year period were retrospectively reviewed. Untreated patients were classified into one of three groups based on angiographic results. Demographic, clinical, and neuroimaging findings and outcomes were compared between these three groups and between treated and untreated patients. Definitive treatment of SAH was provided in 477 patients and 166 were untreated. Untreated patients were older, had a worse neurological status on presentation, and a higher mortality rate (43.4% compared with 11.7%). Among these, 76 had normal angiographic results and a low mortality rate (6.6%). Fifty-two patients in whom no cerebral angiogram was obtained (mostly because of their neurological condition) had the highest mortality rate (92.3%). Of 38 patients with abnormal angiographic results 50% died, mostly due to rebleeding. Among elderly patients or those with a severe neurological deficit, outcome was significantly better in the ones who were treated.

CONCLUSIONS

A significant proportion of patients who were admitted with SAH did not receive definitive therapy. Major reasons for this included normal results on angiographic studies and poor clinical grade. Untreated patients with normal angiographic results had a good outcome, whereas those in whom angiography was not performed and those with abnormal angiographic results had a high mortality rate from the consequences of the initial hemorrhage in the first instance or rebleeding in the second. Although among elderly patients and those with a poor clinical grade the mortality rate was lower among those who received treatment, a definitive conclusion favoring treatment in these high-risk groups can only be drawn from a prospective randomized study.

Intracranial pressure following aneurysmal subarachnoid hemorrhage: monitoring practices and outcome data

OBJECT

Elevated intracranial pressure (ICP) is an important consequence of aneurysmal subarachnoid hemorrhage (SAH) that often results in decreased cerebral perfusion and secondary clinical decline. No definitive guidelines exist regarding methods and techniques for ICP management following aneurysm rupture. The authors describe monitoring practices and outcome data in 621 patients with aneurysmal SAH admitted to their neurological intensive care unit during an 8-year period (1996-2003).

METHODS

A fiberoptic catheter tip probe or external ventricular drain (EVD) was used to record ICP values. The percentage of monitored patients varied, as expected, according to admission Hunt and Hess grade (p < 0.0001). Intracranial pressure monitoring devices were used in 27 (10%) of 264 Grade I to II patients, 72 (38%) of 189 Grade III patients, and 134 (80%) of 168 Grade IV to V patients. There was a strong propensity to favor transduced ventricular drains over parenchymal fiberoptic bolts, with the former used in 221 (95%) of 233 cases. This tendency was particularly strong in the poor-grade cohort, in which EVDs were placed in 99% of monitored individuals. The rates of cerebrospinal fluid infection in patients in whom ICP probes (0%) and ventricular drains (12%) were placed accorded with those in the literature.

CONCLUSIONS

Following aneurysmal SAH, ICP monitoring prevalence and techniques differ with respect to admission Hunt and Hess grade and are associated with the patient's functional status at discharge.

Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome

BACKGROUND

We report the experience in managing intracranial aneurysms at our medical center.

METHODS

We retrospectively analyzed 297 intracranial aneurysms managed during a 6-year period. Risk factors were analyzed with respect to their influence on outcome after surgery as measured by Glasgow Outcome Scale score.

RESULTS

Fifty-eight patients had multiple aneurysms. Of all aneurysms, 83% were in the anterior circulation, 37% were unruptured, and 59% were larger than 10 mm in size. Good outcomewas achieved in 75% of patients, and another 16% had fair outcomes. The mortality rate was 4%, and significant morbidity occurred in 5% of patients. Significant indicators of poor outcome were worsened clinical grade, posterior aneurysm location, and large aneurysm size.

CONCLUSION

Hypertensive patients, older patients, and patients with posterior circulation aneurysms had poorer neurologic status, which significantly influenced outcome. Larger aneurysms and vertebrobasilar aneurysms were associated with poor outcomes.

Impact of early endovascular aneurysmal occlusion on outcome of patients in poor grade after subarachnoid haemorrhage: a prospective, consecutive study

Patients in poor grade (WFNS IV and V) after aneurysmal subarachnoid hemorrhage (SAH) often have a bad outcome. To evaluate early GDC embolisation on such patients a prospective observational study, with comparison to a historical cohort was performed. From January 1996 to December 1998 113 patients were admitted to the Department of Clinical Neurosciences in poor grade after SAH (45 WFNS IV and 68 WFNS V). Eighty-one patients were managed actively with endovascular occlusion of the aneurysm (n = 42) where possible and delayed clipping (n = 16) where not. On an intention to treat basis, 46% had a favourable outcome (Glasgow Outcome Score IV or V) and 48% had died by 3 months. Compared to an historical cohort managed in the same unit between 1992 and 1995 (n = 62, 52% favourable outcome) these results suggest that early GDC aneurysmal occlusion has had a minimal impact on overall outcome.

Factors influencing the outcome after the operative treatment of cerebral aneurysms of anterior circulation

BACKGROUND

The influence of various factors on the outcome after the operative occlusion of the cerebral aneurysm was to be defined through the retrospective study on 111 surgically treated patients with aneurysm of anterior cerebral circulation.

METHODS

Preoperative clinical condition was graded from 0 to V, according to Hunt & Hess. Postoperative outcome, defined as good or bad according to modified Glasgow Outcome Scale, was correlated in homogenous experimental groups with the following factors: gender, age, aneurysmal size, preoperative interval, nimodipine therapy, experience of surgical team and existence of chronic vascular diseases.

RESULTS

Surgical outcome was good in 74.4% of males and 71.4% of females (p > 0.05); in 83.3% of patients with and 41.2% of patients without chronic diseases (p < 0.01); in 71.4% of patients underwent early, 83.3% of ones underwent postponed and 85% of those underwent late surgery (p > 0.05); in 81.5% of patients treated by nimodipine and in 41.7% of those untreated by the same drug (p < 0.01); in 78.9% of patients operated by the experienced surgical team and in 40% of those operated by less experienced surgical team (p < 0.01). In patients with both good and bad outcome, the mean age was 50.6 and 47.6 years (p > 0.05), and the mean aneurysmal size was 12.3 mm and 13.3 mm, respectively (p > 0.05). Before rupture, the mean size for aneurysms on the bifurcation of the middle cerebral artery was 14.3 mm, and for posterior communicating artery aneurysms only 9.7 mm (p < 0.05).

CONCLUSION

Surgical outcome was significantly influenced by the existence of chronic diseases, nimodipine therapy and experience of surgical team, whereas gender, age, timing for surgery and aneurysmal size were not of significant influence.

[Complications and mortality in surgery of cerebral aneurysms]

AIM

To establish the risk factors for complications and fatal outcome after the operative occlusion of cerebral aneurysms.

METHODS

Retrospective study on 91 (lethality rate) and on 72 operated patients (complications). For survived and dead patients, as well as for patients with and without complications, following parameters were compared: gender, age, clinical condition, preoperative interval, use of temporary clips, vasospasm, outcome, as well as localization, size and intraoperative rupture of the aneurysm.

RESULTS

Complications existed: in 54.5% of aneurysms of middle cerebral and 13.6% of aneurysms of internal carotid artery (p < 0.01); in 18.2% of patients in the first and 45.8% of patients in the third clinical Hunt and Hess group (p < 0.05); in 57.9% of patients with and 20.5% of patients without intraoperative rupture (p < 0.01); in 50% of patients with and 18.7% of patients without vasospasm (p < 0.05). Average aneurysmal size was 18 mm in group with complications and 10.8 mm in patients with no complications (p < 0.05), while average preoperative intervals in these two groups were 20 and 8.7 days (p < 0.05). Lethality rate was 25% for the third and 83.3% for the fourth and fifth clinical group (p < 0.01), and the existence of complications significantly increased mortality (from 15.7% to 50%, p < 0.01). Good outcome existed in 19.2% of operated patients with complications and in 78.3% of those without complications (p < 0.01).

CONCLUSIONS

Incidence of complications depended significantly on preoperative clinical condition, duration of preoperative interval, size, localization and intraoperative rupture of aneurysm. Complications significantly minimized the surgical treatment outcome and increased the lethality rate mortality.

Intraoperative complications in aneurysm surgery: a prospective national study

OBJECT

With increasing use of endovascular procedures, the number of aneurysms treated surgically will decline. In this study the authors review complications related to the surgical treatment of aneurysms and address the issue of maintaining quality standards on a national level.

METHODS

A prospective, nonselected amalgamation of every aneurysm case treated in five of six neurosurgical centers in Sweden during 1 calendar year was undertaken (422 patients; 7.4 persons/100,000 population/year). The treatment protocols at these institutions were very similar. Outcome was assessed using clinical end points. In this series, 84.1% of the patients underwent surgery, and intraoperative complications occurred in 30% of these procedures. Poor outcome from technical complications was seen in 7.9% of the surgically treated patients. Intraoperative aneurysm rupture accounted for 60% and branch sacrifice for 12% of all technical difficulties. Although these complications were significantly related to aneurysm base geometry and the competence of the surgeon, problems still occurred apparently at random and also in the best of hands (17%). The temporary mean occlusion time in the patients who suffered intraoperative aneurysm rupture was twice as long as the temporary arrest of blood flow performed to aid dissection.

CONCLUSIONS

The results obtained in this series closely reflect the overall management results of this disease and support the conclusion that surgical complications causing a poor outcome can be estimated on a large population-based scale. Intraoperative aneurysm rupture was the most common and most devastating technical complication that occurred. Support was found for a more liberal use of temporary clips early during dissection, regardless of the experience of the surgeon. Temporary regional interruption of arterial blood flow should be a routine method for aneurysm surgery on an everyday basis. A random occurrence of difficult intraoperative problems was clearly shown, and this factor of unpredictability, which is present in any preoperative assessment of risk, strengthens the case for recommending neuroprotection as a routine adjunct to virtually every aneurysm operation, regardless of the surgeon's experience.

Early endovascular treatment of ruptured cerebral aneurysms in patients in very poor neurological condition

OBJECTIVE

In patients in very poor neurological condition (World Federation of Neurosurgical Societies Grade V) with aneurysmal subarachnoid hemorrhage, early surgery to prevent rebleeding and to allow appropriate treatment of complications is often difficult. The aim of the present study was to evaluate whether early endovascular treatment followed by aggressive proactive treatment of complications (prophylactic hypervolemic hemodilution, hypertensive treatment in the event of systemic hypotension, and appropriate treatment of intracranial hypertension) is an acceptable management strategy for these patients.

METHODS

We prospectively studied 11 consecutive patients who presented with acutely ruptured aneurysms and were in very poor neurological condition after resuscitation (World Federation of Neurosurgical Societies Grade V) but did not have a significant intracerebral hemorrhage. These patients received endovascular treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA). Follow-up consisted of a clinical evaluation based on the Glasgow Outcome Scale. A control angiogram was obtained after 6 months in patients with favorable outcomes to evaluate the occlusion of the aneurysm.

RESULTS

There were no deaths or complications directly related to the procedure. Two patients died as a consequence of increased intracranial pressure. The mean follow-up of the surviving patients was 12 months. Two patients had early rebleeding after the coiling and required further treatment. Four patients had good outcomes, two patients were moderately disabled, and three patients were severely disabled.

CONCLUSION

This study demonstrates that early endovascular treatment of acutely ruptured cerebral aneurysms in patients evaluated as World Federation of Neurosurgical Societies Grade V allows for aggressive treatment of intracranial hypertension and vasospasm. More than half of the patients had favorable outcomes. Therefore, early endovascular treatment seems to be a valuable alternative to early surgery in patients who present with a very poor clinical grade after subarachnoid hemorrhage. The results of this study are promising but must be interpreted with caution, because a small number of patients were studied.

[Treatment of aneurysms in the anterior cerebral circulation]

OBJECTIVES

To analyze the outcome of either surgical or conservative treatment of patients with aneurysms on cerebral arteries.

DESIGN

Retrospective study on 114 patients (89 operated and 25 not operated).

METHODS

Clinical state was graded from 0 to V, according to Hunt & Hess (HHG), and the treatment outcome was defined as favorable or poor, according to the modified Glasgow Outcome Score. The outcome was correlated with the type of treatment (operative or conservative), clinical state and aneurysmal localization.

RESULTS

Aneurysm was localized mostly on the anterior communicating (33.6%) and middle cerebral arteries (32.8%) and the patients were mostly in HHG II or III (34.4% and 25.2%). HHG after the aneurysmal rupture did not depend on the aneurysmal location (p > 0.05). Favorable treatment outcome was noted: in 74.1% of all operated and in 60% of all conservatively treated patients (p > 0.05); in 81.6% of operated and in 33.3% of not operated patients with HHG = II-III (p < 0.01); in 78.8% of aneurysms of the middle cerebral artery and in 66.7% of those of the anterior communicating artery (p > 0.05); in 73.1% of patients with HHG = III and in 25% of patients with HHG = IV (p < 0.01).

CONCLUSIONS

Clinical state after the aneurysmal rupture did not depend on its localization. Results were better after the surgical, than after the conservative treatment. Outcome after the surgery depended on the clinical state of the patient, but not on the aneurysmal localization.

Subarachnoid Hemorrhage

Patients presenting with subarachnoid hemorrhage from aneurysmal rupture benefit from early repair of the aneurysm. Recent advances in endovascular technology now allow informed discussion of the merits of surgical versus endovascular repair of the aneurysm. Patients need close observation in an intensive-care unit following subarachnoid hemorrhage to diagnose and treat the multiple complications that result. These complications include hydrocephalus, fever, neurogenic pulmonary and cardiac dysfunction, and the development of delayed cerebral ischemia from vasospasm. There exist effective medical and endovascular treatments for cerebral vasospasm.

Decreased nitric oxide availability contributes to acute cerebral ischemia after subarachnoid hemorrhage

OBJECTIVE

Disturbances of the L-arginine-nitric oxide (NO) vasodilatory pathway have been implicated as a cause of acute vasoconstriction and ischemia after subarachnoid hemorrhage (SAH). Because NO-dependent vasodilatory mechanisms are still intact in this setting, acute vasoconstriction may be the result of limited NO availability after SAH. The present study examines this hypothesis by administration of the NO synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME).

METHODS

SAH was induced by the endovascular suture method in anesthetized rats. L-NAME (30 mg/kg intravenously) was injected 20 minutes before or 15, 30, or 60 minutes after SAH. Control rats received normal saline. Arterial and intracranial pressure and cerebral blood flow (CBF) were measured continuously for 60 minutes after SAH.

RESULTS

L-NAME administration 20 minutes before SAH produced a significant decrease in resting CBF (29.4 +/- 3.4%; P < 0.05), but it had no effect on the acute decrease in CBF after SAH or on its early recovery up to 30 minutes after SAH. However, a significant decrease in CBF recovery was found in animals receiving L-NAME injections (28.7 +/- 9.4%; P < 0.05 versus controls) 60 minutes after SAH. Administration of L-NAME 15 or 30 minutes after SAH had no effect on CBF recovery, as compared with controls. However, when administered 60 minutes after SAH, L-NAME decreased CBF significantly (45.4 +/- 8.8%; P < 0.05 versus controls).

CONCLUSION

These results indicate a biphasic pattern of NO availability after SAH. NO-mediated vasodilation is limited during the first 30 minutes of SAH and is restored 60 minutes after SAH.

Endovascular treatment and neurointensive care of ruptured aneurysms

The acute management of aneurysmal SAH requires a comprehensive approach entailing acute critical care and stabilization, occlusion of the aneurysm, and intensive care management of acute neurologic complications. The development of endovascular treatment of aneurysms has added an important, less-invasive treatment to the regimen available in treating aneurysms. An integrated approach of providing critical care before, during, and after the occlusion of the aneurysm is an important concept that should be the goal. Debate and controversy remains regarding which aneurysms are best suited to endovascular treatment or to surgical treatment; an evolving experience and clinical trials will provide further guidance. Nonetheless, some aneurysms may require both surgery and endovascular treatment. Finally, close neurologic observation and directed specialized monitoring techniques are required for providing directed critical care in the acute period after SAH.