1
|
Lanzino G, Rabinstein AA. Advances and Future Trends in the Diagnosis and Management of Subarachnoid Hemorrhage. Neurol Clin 2024; 42:705-716. [PMID: 38937037 DOI: 10.1016/j.ncl.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid hemorrhage. Yet, several knowledge gaps remain widely open. Variability in practices stems from the lack of solid evidence to guide management, which recent guidelines from professional organizations aim to mitigate. In this article, the authors review some of these gaps in knowledge, highlight important messages from recent management guidelines, emphasize aspects of our practice that we consider particularly useful to optimize patient outcomes, and suggest future areas of research.
Collapse
Affiliation(s)
- Giuseppe Lanzino
- Department of Neurological Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | | |
Collapse
|
2
|
Liu J, Zhou L, Ling Y, Xiang X, Wang P. Flow Diverter Combined with Coil Embolization for Acutely Ruptured Intracranial Aneurysms: A Single Center Experience. World Neurosurg 2024; 186:e449-e455. [PMID: 38575061 DOI: 10.1016/j.wneu.2024.03.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Extensive research has confirmed the safety and effectiveness of flow diverters in the treatment of unruptured intracranial aneurysms. However, their use in cases of acute rupture remains a subject of debate. METHODS This study was conducted as a single-center retrospective investigation from January 2018 to January 2022 and included patients with acutely ruptured intracranial aneurysms (within three days of rupture) who were treated using the Pipeline Embolization Device with adjunctive coil embolization. Patient demographics, operative procedures, and outcomes were analyzed. Antiplatelet therapy included intra-arterial tirofiban and postoperative dual therapy with clopidogrel and aspirin. RESULTS A total of 21 patients (5 males, 16 females) diagnosed with acutely ruptured intracranial aneurysms were included in this study. The aneurysm types included 7 blood blister-like aneurysms (30.0%), 3 dissecting (14.3%), and 1 fusiform aneurysm (4.8%). Perioperative complications occurred in 2 patients (9.5%), and both cases involved thrombogenesis. Nineteen patients completed digital subtraction angiography during follow-up, with an average follow-up time of 8.7 months (5 - 18 months). Results showed a complete embolization rate of 94.7% (18/19), with a partial aneurysm still present in 1 patient. A total of 90.4% (19/21) of patients had a favorable prognosis (modified Rankin Scale score = 0 - 2). CONCLUSIONS The Pipeline Embolization Device with adjunctive coil embolization proved to be a viable option for managing acutely ruptured intracranial aneurysms, notwithstanding the potential for ischemic complications.
Collapse
Affiliation(s)
- Jie Liu
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Liyun Zhou
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Yuhui Ling
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Xiuzhi Xiang
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Peiming Wang
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China.
| |
Collapse
|
3
|
Dissanayake AS, Burrows E, Ho KM, Phillips TJ, Honeybul S, Hankey GJ. Rebleeding following aneurysmal subarachnoid hemorrhage before 'endovascular first' treatment: a retrospective case-control study of published scoring systems. J Neurointerv Surg 2024; 16:498-505. [PMID: 37316197 DOI: 10.1136/jnis-2023-020390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, 'endovascular first' manner. METHODS On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan-Meier (KM) survival curve analyses were performed. RESULTS The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816). CONCLUSIONS For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.
Collapse
Affiliation(s)
- Arosha S Dissanayake
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Emalee Burrows
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Graeme J Hankey
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
4
|
Yamaguchi S, Izumo T, Sato I, Morofuji Y, Kaminogo M, Anda T, Horie N, Matsuo T. Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:2855-2864. [PMID: 37434015 DOI: 10.1007/s00701-023-05705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. METHODS The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms. RESULTS Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. CONCLUSIONS Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.
Collapse
Affiliation(s)
- Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan.
| | - Izumi Sato
- Department of Clinical Epidemiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Makio Kaminogo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeo Anda
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
5
|
Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
Collapse
Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
6
|
Perrini P. Acute hydrocephalus after aneurysmal subarachnoid hemorrhage: The controversial role of lumbar puncture. J Neurol Sci 2023; 446:120567. [PMID: 36731356 DOI: 10.1016/j.jns.2023.120567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, Pisa University Hospital, Pisa, Italy.
| |
Collapse
|
7
|
Mahto N, Owodunni OP, Okakpu U, Kazim SF, Varela S, Varela Y, Garcia J, Alunday R, Schmidt MH, Bowers CA. Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions. World Neurosurg 2023; 171:41-64. [PMID: 36470560 DOI: 10.1016/j.wneu.2022.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications. METHODS We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed. RESULTS There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies. CONCLUSIONS In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.
Collapse
Affiliation(s)
- Neil Mahto
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Oluwafemi P Owodunni
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Uchenna Okakpu
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Yandry Varela
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Josiel Garcia
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Robert Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA.
| |
Collapse
|
8
|
Yang C, Zhang Z, Liao R, Li Y. Relationship between preoperative external ventricular drainage and preoperative rebleeding in aneurysmal subarachnoid hemorrhage: A meta-analysis. Clin Neurol Neurosurg 2023; 224:107563. [PMID: 36580739 DOI: 10.1016/j.clineuro.2022.107563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To analyze published evidence on the relationship between preoperative external ventricular drainage (preop-EVD) and preoperative rebleeding (preop-rebleeding) in aneurysmal subarachnoid hemorrhage (aSAH). METHOD A comprehensive search of three databases (PubMed, Ovid EMBASE, and The Cochrane Library) was conducted from their commencement to March 31, 2022. We collected studies reporting preop-EVD of rupture aneurysms while preop-rebleeding events were documented in these studies. We also extracted information on risk factors for preop-rebleeding from the studies and used Review Manager version 5.3 software to analyze. RESULTS A total of 3671 cases from 14 articles were enrolled in this meta-analysis. Preop-rebleeding rate was 11.04 % (106/960) and 9.22 % (250/2711) in preop-EVD group and control group, respectively. The study lacked power to conclude a clinically significant increase in preop-rebleeding risk (OR=1.60, 95 %CI:0.82-3.22). Fisher> 2 (OR=1.86), modified Fisher> 2 (OR=7.57), World Federation of Neurological Surgeons (WFNS)> 2 (OR=4.39) and aneurysm size > 1 cm (OR=3.01) were risk factors of preop-rebleeding. Patients with Hunt-Hess (HH)> 2 showed a higher preop-rebleeding trend compared to HH≤ 2, but the result did not reach a statistical difference (OR=6.79, P = 0.06). No difference in preop-rebleeding risk between anterior circulation aneurysms and posterior circulation aneurysms. Hydrocephalus had also been shown to be unrelated to higher preop-rebleeding rate. CONCLUSIONS Current evidence does not support that preop-EVD significantly increases the risk of rebleeding prior to aneurysm repair. Patients with poorer clinical status on admission and aneurysms size > 1 cm are at a higher risk of preop-rebleeding.
Collapse
Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Zhulin Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Rongjie Liao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Yuhong Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| |
Collapse
|
9
|
Picetti E, Barbanera A, Bernucci C, Bertuccio A, Bilotta F, Boccardi EP, Cafiero T, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Lanterna L, Menozzi R, Munari M, Panni P, Rossi S, Stocchetti N, Sturiale C, Zoerle T, Zona G, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022; 2:13. [PMCID: PMC10245531 DOI: 10.1186/s44158-022-00042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 06/16/2023]
Abstract
Abstract
Background
Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm.
Methods
A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.
Results
Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided.
Conclusions
This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.
Collapse
|
10
|
Pavesi G, Nasi D, Moriconi E, Stanzani R, Puzzolante A, Lucchesi L, Cavallo SM, Iaccarino C. Management and safety of intraoperative ventriculostomy during early surgery for ruptured intracranial aneurysms. Acta Neurochir (Wien) 2022; 164:2909-2916. [PMID: 36008637 DOI: 10.1007/s00701-022-05346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Brain edema and/or acute hydrocephalus are common features that limit working space during early surgery of aneurysmal subarachnoid hemorrhage (aSAH). Intraoperative ventriculostomy offers an immediate brain relaxation. However, management and complications related to the routine use of intraoperative external ventricular drainage (iEVD) are not well investigated. METHODS We retrospectively reviewed all patients who were treated with pterional craniotomy and clipping for ruptured anterior circulation aneurysms in our center between 2012 and 2019. We included in this study all patients submitted to iEVD using the Paine's point on the side of craniotomy. Indication for positioning of an iEVD was given in all cases whenever initial cisternal dissection was hampered by the lack of cerebrospinal fluid (CSF) circulation due to SAH and/or hydrocephalus. RESULTS In the study period, 162 patients with aSAH underwent surgical clipping. In 103 patients, an iEVD was used. The overall rate of iEVD-related complications was 6.7%, including 3 cases of catheter misplacement, one case of catheter obstruction, one case of related hemorrhage, and 2 cases of infection. The rate of shunt-dependent hydrocephalus was 16.5% (17/103 patients). CONCLUSION In our experience, iEVD is a safe technique that facilitates dissection during early surgery for intracranial ruptured aneurysms, without requiring an additional burr hole procedure.
Collapse
Affiliation(s)
- Giacomo Pavesi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Davide Nasi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy.
| | - Elisa Moriconi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Riccardo Stanzani
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Annette Puzzolante
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Lucio Lucchesi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Selene Marika Cavallo
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| |
Collapse
|
11
|
Imberti R, Picetti E, Rossi S, Capaccio E, Accetta G, Klersy C, Lafe E, Pietrobono L, Cimino F, Frattini L, Grappa E, Casagli S, Crobeddu E, Iotti GA. Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling. World Neurosurg 2021; 156:e206-e214. [PMID: 34520863 DOI: 10.1016/j.wneu.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The main objective of the present study was to analyze the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcomes for patients monitored before and after coiling. METHODS Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH; World Federation of Neurological Surgeons grade IV and V) were enrolled in our prospective observational study. For 31 patients, ICP and CPP monitoring was started immediately after the diagnosis of aSAH, and the values were recorded every 15 minutes during coiling (early ICP group). For 68 patients, ICP and CPP monitoring began after coiling (late ICP group). The outcomes were evaluated at 90 days using the modified Rankin scale. RESULTS At the beginning of coiling, the ICP was >20 mm Hg in 10 patients (35.7%). The median ICP was 18 mm Hg (range, 5-60 mm Hg). The CPP was <60 mm Hg in 6 patients (24%). The median CPP was 70 mm Hg (range, 30-101 mm Hg). Despite medical treatment and/or cerebrospinal fluid drainage, 51.6% of the patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP >20 mm Hg), and 51.6% had at least one episode of reduced CPP (defined as CPP <60 mm Hg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days, the functional recovery was better in the early ICP group (P = 0.004). CONCLUSIONS During coiling, patients with poor-grade aSAH can experience episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcomes.
Collapse
Affiliation(s)
- Roberto Imberti
- Phase I Clinical Trials Unit and Experimental Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Emanuele Capaccio
- Dipartimento di Scienze Medico-Chirurgiche, Diagnostiche e Pediatriche, Università di Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; UOC Anestesia e Rianimazione 1, Dipartimento di Medicina Intensiva, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Accetta
- Dipartimento di Scienze Medico-Chirurgiche, Diagnostiche e Pediatriche, Università di Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; UOC Anestesia e Rianimazione 1, Dipartimento di Medicina Intensiva, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Servizio di Epidemiologia Clinica e Biometria, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elvis Lafe
- UOC Radiologia, Neuroradiologia Diagnostica e Interventistica, Dipartimento di Medicina Intensiva, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigi Pietrobono
- UOC Radiologia, Neuroradiologia Diagnostica e Interventistica, Dipartimento di Medicina Intensiva, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Cimino
- Servizio di Anestesia e Rianimazione 2, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Lara Frattini
- S.C. Anestesia e Rianimazione Neurochirurgica e Generale, ASST Sette Laghi, Varese, Italy
| | - Elena Grappa
- Anestesia e Rianimazione - ASST Cremona, Cremona, Italy
| | - Sergio Casagli
- SOD Neuroanestesia e Rianimazione, AOUP Pisa, Pisa, Italy
| | - Emanuela Crobeddu
- Divisione di Neurochirugia, AOU Maggiore della Carità, Novara, Italy; Department of Neuroscience, University of Turin, Turin, Italy
| | - Giorgio Antonio Iotti
- UOC Anestesia e Rianimazione 1, Dipartimento di Medicina Intensiva, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Servizio di Epidemiologia Clinica e Biometria, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
12
|
Ohbuchi H, Hagiwara S, Arai N, Yoneyama T, Takahashi Y, Inazuka M, Kubota Y, Chernov M, Kasuya H. Optimal timing and safety of the external ventricular drainage in patients with high-grade aneurysmal subarachnoid hemorrhage treated with endovascular coiling. J Clin Neurosci 2021; 88:63-69. [PMID: 33992206 DOI: 10.1016/j.jocn.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The presented retrospective analysis has evaluated the optimal timing and safety of external ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). The study cohort comprised 102 patients, 49 of whom underwent EVD at 3-120 h (mean, 16 h) after the clinical onset of aSAH, either before (N = 27) or after (N = 22) ruptured aneurysm coiling. Among those treated with EVD, favorable and fair outcomes at discharge (modified Rankin Scale [mRS] scores 0-3) were noted in 14 (29%) and unfavorable (mRS scores 4-6) in 35 (71%). The former was more common among women (P = 0.019) and patients without chronic arterial hypertension (P = 0.028). The cut-off value for optimal timing of EVD was defined at 13 h after the onset of aSAH. Favorable and fair outcomes were more frequent after early (≤13 h; N = 30) than late (>13 h; N = 19) EVD (40% vs. 11%; P = 0.026), whereas did not differ significantly between those in whom such procedure was done before or after ruptured aneurysm coiling (19% vs. 41%; P = 0.083). In the entire study cohort, 2 patients had re-rupture of the aneurysm, and while both of them were treated with EVD, neither case of complication was directly associated with the procedure and, in fact, preceded it. In conclusion, EVD for management of acute hydrocephalus in patients with high-grade aSAH should be preferably applied within 13 h after the clinical onset of stroke, which may be considered sufficiently safe regardless whether it is performed before or after ruptured aneurysm coiling.
Collapse
Affiliation(s)
- Hidenori Ohbuchi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo.
| | - Shinji Hagiwara
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Naoyuki Arai
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Taku Yoneyama
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Takahashi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo; Department of Neurosurgery, Moriya Daiichi General Hospital, Ibaraki, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Kubota
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Mikhail Chernov
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| |
Collapse
|
13
|
Sorteberg A, Romundstad L, Sorteberg W. Timelines and rebleeds in patients admitted into neurosurgical care for aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2021; 163:771-781. [PMID: 33409740 PMCID: PMC7886745 DOI: 10.1007/s00701-020-04673-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022]
Abstract
Background Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid. Methods Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013–31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay. Results We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1–95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair. Conclusions The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-020-04673-3.
Collapse
|
14
|
Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
Collapse
Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| |
Collapse
|
15
|
Impact of COVID-19 pandemic on patients with intracranial aneurysm rupture. Clin Neurol Neurosurg 2020; 201:106425. [PMID: 33340837 PMCID: PMC7723459 DOI: 10.1016/j.clineuro.2020.106425] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/02/2020] [Accepted: 12/06/2020] [Indexed: 11/22/2022]
Abstract
We noticed higher rate of patients with ruptured aneurysm who had deteriorated neurological presentation on admission during COVID-19 pandemic. Indeed, rates of poor neurological presentation and severe radiological presentation on hospital admission were higher (p < 0.05). Likewise, the delayed hospital admission was longer (p = 0.005). Therefore, vasospasm’s rate on presentation was also higher (p = 0.04). During pandemic, patients with only sudden headache may have feared immediate hospital admission because of potential COVID-19 contamination. In case of recurrence, educating population concerning specific symptoms such as sudden headache or neurological deficit should be emphasized.
Background/objectives The present study aimed at evaluating the impact on the early outcome of patients with ruptured intracranial aneurysms. Methods Our study prospectively included 26 consecutive patients with ruptured intracranial aneurysm managed at our institution in context of COVID-19 pandemic between March 1st, 2020 and April, 26th, 2020 (2020 group). A group control included other 28 consecutive patients managed at the same institution for the same disease in 2019, during the same time frame (2019 group). On admission, poor neurological status was defined as WFNS score >3. Severe radiological status was defined by the presence of intracerebral hematoma, or/and acute hydrocephalus requiring further EVD or/and the presence of vasospasm on presentation. Statistical analysis was performed to compare the 2 distinct groups. Results Rates of poor neurological presentation and severe radiological presentation on hospital admission were higher in the 2020 group (p = 0.01 and p = 0.02, respectively). The delayed hospital admission was 2.7 days in 2020 group and 0.75 days in 2019 group (p = 0.005). Therefore, vasospasm’s rate on presentation was also higher in the 2020 group (p = 0.04). Conclusion To our knowledge, this is one of the first studies demonstrating influence of the COVID-19 pandemic on patients with urgent and severe intracranial aneurysmal disease. In case of recurrent COVID-19 pandemic, educating the population concerning specific symptoms such as sudden headache, neurological deficit or even sudden chest pain should be emphasized.
Collapse
|
16
|
Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
Collapse
|
17
|
Bsat S, Bsat A, Tamim H, Chanbour H, Alomari SO, Houshiemy MNE, Moussalem C, Omeis I. Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: A systematic literature review and meta-analysis of prevalence. Interv Neuroradiol 2020; 26:547-556. [PMID: 32741229 DOI: 10.1177/1591019920945059] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality. METHODS We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation. RESULTS 24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% - 12.7%; I2 = 72.8%] and 8.7% [95% CI: 5.4 - 12.6%; I2 = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 - 28.1%; I2 = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 - 82.2%; I2 = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 - 11.6%; I2 = 76.9%]. CONCLUSION Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.
Collapse
Affiliation(s)
- Shadi Bsat
- Department of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ayman Bsat
- Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Chanbour
- Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Safwan Omar Alomari
- Department of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Charbel Moussalem
- Department of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Omeis
- Department of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
18
|
Thenier-Villa JL, Riveiro Rodríguez A, González-Vargas PM, Martínez-Rolán RM, Gelabert-González M, Badaoui Fernández A, Pou J, Conde Alonso C. Effects of external ventricular drainage decompression of intracranial hypertension on rebleeding of brain aneurysms: A fluid structure interaction study. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
19
|
The accuracy of aneurysm size in predicting rebleeding after subarachnoid hemorrhage: a meta-analysis. Neurol Sci 2020; 41:1843-1850. [DOI: 10.1007/s10072-020-04297-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/13/2020] [Indexed: 10/25/2022]
|
20
|
Deora H, Martinez-Perez R, Agrawal A, Moscote-Salazar LR. Commentary to: External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications. Neurointervention 2020; 15:49-51. [PMID: 32036642 PMCID: PMC7105092 DOI: 10.5469/neuroint.2019.00171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/08/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Rafael Martinez-Perez
- Department of Neurological Sciences, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Amit Agrawal
- Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, India
| | | |
Collapse
|
21
|
Rouanet C, Silva GS. Aneurysmal subarachnoid hemorrhage: current concepts and updates. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:806-814. [DOI: 10.1590/0004-282x20190112] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022]
Abstract
ABSTRACT Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.
Collapse
|
22
|
Gritti P, Lorini FL, Lanterna LA, Bilotta F. Periprocedural management of patients with subarachnoid hemorrhage. Curr Opin Anaesthesiol 2019; 31:511-519. [PMID: 30020154 DOI: 10.1097/aco.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anesthesiologists and intensivists may be involved in the management of aneurysmal subarachnoid hemorrhage (aSAH) patients at various stages of care. This article will review the recent advances in the periprocedural management of aSAH patients. RECENT FINDINGS New scoring systems to assess gravity and prognosis of aSAH patients have been evaluated and proposed. Rebleeding still remains, with early aneurysmal treatment, a major challenge in the first hours of aSAH management. In the last decades, the treatment of the aSAH has shifted from clipping to coiling and more recently, the use of flow diversion technique has been introduced in selected patients. Although these improvements allow treatment of more complex aneurysms, they have implications for the anesthesiologist, including requiring the management of anticoagulation with its inherent risks. Even though knowledge, monitoring, and management of postprocedural phase of aSAH patients has improved, vasospasm and cerebral-delayed ischemia still remain the major and devastating complications in the postoperative course of aSAH patients. SUMMARY Despite recent progress in the scoring, diagnosis, and treatment of aSAH patients, the periprocedural management of these patients is still a major challenge for anesthesiologists and intensivists, who are involved from the first phase of the aneurysm rupture through the postoperative phases and vasospasm period.
Collapse
Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Critical Care Medicine
| | | | - Luigi A Lanterna
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, 'Sapienza' University, Rome, Italy
| |
Collapse
|
23
|
Darkwah Oppong M, Gümüs M, Pierscianek D, Herten A, Kneist A, Wrede K, Barthel L, Forsting M, Sure U, Jabbarli R. Aneurysm rebleeding before therapy: a predictable disaster? J Neurosurg 2018; 131:1473-1480. [PMID: 30544356 DOI: 10.3171/2018.7.jns181119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk. METHODS All patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors. RESULTS Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction. CONCLUSIONS Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Michael Forsting
- 2Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | |
Collapse
|
24
|
Thenier-Villa JL, Riveiro Rodríguez A, Martínez-Rolán RM, Gelabert-González M, González-Vargas PM, Galarraga Campoverde RA, Díaz Molina J, De La Lama Zaragoza A, Martínez-Cueto P, Pou J, Conde Alonso C. Hemodynamic Changes in the Treatment of Multiple Intracranial Aneurysms: A Computational Fluid Dynamics Study. World Neurosurg 2018; 118:e631-e638. [DOI: 10.1016/j.wneu.2018.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 01/08/2023]
|
25
|
Cagnazzo F, Di Carlo DT, Petrella G, Perrini P. Ventriculostomy-related hemorrhage in patients on antiplatelet therapy for endovascular treatment of acutely ruptured intracranial aneurysms. A meta-analysis. Neurosurg Rev 2018; 43:397-406. [PMID: 29968172 DOI: 10.1007/s10143-018-0999-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/13/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
The risk of ventriculostomy-related hemorrhage among patients requiring antiplatelet therapy (AT) for the endovascular treatment of acutely ruptured intracranial aneurysms needed further investigation. The authors performed a systematic review and meta-analysis of the literature examining the EVD-related hemorrhage rate among patients with and without AT (controls). According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and April 2018 was carried out. The authors identified series with > 5 patients reporting the EVD-associated hemorrhage rate among the AT group and the control group. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. We included 13 studies evaluating 516 (with AT) and 647 (without AT) patients requiring ventriculostomy. EVD-related hemorrhage rates were higher among the AT group (125/516 = 20.9%, 95% CI = 11.9-30%, I2 = 90% vs 57/647 = 9%, 95% CI = 5.5-12.5%, I2 = 45.8%) (p < 0.0001). Major EVD-associated hemorrhage rates were low in both the AT and control group (25/480 = 4.4%, 95% CI = 1.7-7.7%, I2 = 53.9% vs 6/647 = 0.7%, 95% CI = 0.03-1.7%, I2 = 0%) (p < 0.0001). Ventriculostomy before embolization and intraprocedural AT were associated with lower rates of EVD-related bleeding (32/230 = 9.6%, 95% CI = 2.1-17.1%, I2 = 75.4% vs 6/24 = 25.1%, 95% CI = 8.8-41%, I2 = 0%) (p < 0.02). The rate of major hemorrhage was higher after dual AT (CP + ASA) compared to single AT (ASA or CP) used as an intraprocedural loading dose (13/173 = 7%, 95% CI = 3.3-10.7%, I2 = 0% vs 6/210 = 1.7%, 95% CI = 0.1-3.4%, I2 = 0%) (p < 0.009). AT during endovascular treatment of acutely ruptured intracranial aneurysms increases the risk of EVD-related hemorrhages, although most of them are small and asymptomatic. When ventriculostomy is performed before endovascular procedures requiring antiplatelet administration, the hemorrhagic risk is minimized. A single antiplatelet therapy is associated with a lower rate of major bleeding than a dual therapy.
Collapse
Affiliation(s)
- Federico Cagnazzo
- Department of Neurosurgery, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy.
| | | | | | - Paolo Perrini
- Department of Neurosurgery, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy
| |
Collapse
|
26
|
Ye Z, Ai X, Hu X, Fang F, You C. Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations. Medicine (Baltimore) 2017; 96:e8544. [PMID: 29137064 PMCID: PMC5690757 DOI: 10.1097/md.0000000000008544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.
Collapse
|