Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country

When microsurgery becomes the only lifesaving resource: An institutional experience treating patients from low-income backgrounds affected by posterior circulation brain aneurysms

BACKGROUND AND OBJECTIVE

Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision.

METHODS

The authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed.

RESULTS

Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0-2).

CONCLUSION

The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.

Exploring the Landscape of Intracranial Aneurysms in South America: A Comprehensive Narrative Review Intracranial Aneurysms in South America

Exploring the landscape of intracranial aneurysms in South America unravels a complex interplay of epidemiological factors, clinical manifestations, and therapeutic challenges. The study methodically conducts a comprehensive literature review spanning the years 2003 to 2023, focusing on English-language articles obtained from diverse databases to elucidate the multifaceted nature of intracranial aneurysms in the region. Results and discussions categorize outcomes into positive domains, emphasizing successful treatments, favorable recoveries, and high survival rates, while also shedding light on negative aspects such as residual aneurysms and complications. The research illuminates significant gaps in pathological typing of intracranial aneurysms and exposes challenges in healthcare accessibility, notably the disparities in neurosurgical resources. Management challenges, including constrained infrastructure access, a neurosurgeon shortage, and gender disparities, are underscored. Transitioning to future prospects, the study advocates for strategic interventions, proposing expanded neurosurgical training, multidisciplinary approaches, improved funding, enhanced access to care, and fostering international collaborations. The study concludes by emphasizing the pivotal role of collaborative efforts, intensified training programs, and global partnerships in propelling intracranial aneurysm management forward in South America, ultimately contributing to enhanced patient outcomes across the region.

Impact of Medical and Neurologic Complications on the Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage in a Middle-Income Country

OBJECTIVE

Almost two thirds of the world's aneurysmal subarachnoid hemorrhage (aSAH) are in low- and middle-income countries. Herein, we aimed to evaluate the impact of complications on the outcome of aSAH in a middle-income country.

METHODS

Baseline data (age, sex, World Federation of Neurosurgical Society, time ictus-treatment, treatment modality) and medical and neurologic complications from a cohort in Brazil (2016-2019) were evaluated: delayed cerebral ischemia; hydrocephalus; meningitis; seizures; intracranial hypertension; infections (pneumonia, bloodstream, urinary tract infection infection of undetermined source); sodium disturbances; acute kidney injury; and cardiac and pulmonary complications. The primary outcome was the modified Rankin scale (mRS) at hospital discharge. Univariate and multivariate models were employed.

RESULTS

From 212 patients (71.7% female, age 52.7 ± 12.8), 92% developed at least 1 complication (any infection-43.9%, hydrocephalus-34.4%, intracranial hypertension-33%, infection of undetermined source-20.8%, hypernatremia-20.8%, hyponatremia-19.8%, delayed cerebral ischemia-related infarction-18.7%, pneumonia-18.4%, acute kidney injury-16.5%, and seizures-11.8%). In unadjusted analysis, all but hyponatremia and urinary tract infection were associated with mRS 3-6 at discharge; however, complications explained only 12% of the variation in functional outcome (mRS). Most patients were treated by clipping (66.5%), and 15.6% (33 patients) did not receive a definitive treatment. The median time ictus-admission and ictus-treatment were 5 and 9 days, respectively.

CONCLUSIONS

While medical and neurologic complications are a recognized opportunity to improve aSAH care, low- and middle-income countries comprise 70% of the world population and still encounter difficulties concerning early definitive aneurysm treatment, rebleeding, and human and material resources.