Long-Term Outcome in Surviving Patients After Clipping of Intracranial Aneurysms

A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (> 24 hours): A 7-Year Retrospective Study of 302 Patients

Objectives  The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (> 24 hours). Methods  Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results  Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p  = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions  There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Supraorbital eyebrow keyhole approach for microsurgical management of ruptured anterior communicating artery aneurysm

The mortality and disability rate of patients with ruptured anterior communicating artery (AComA) aneurysm after bleeding is high. Even with the most advanced treatment methods, the incidence of complications remains high. The purpose of the present study was to determine the efficacy of microsurgery via supraorbital eyebrow keyhole approach (SOEK) in clipping ruptured AComA aneurysms. Between September 2010 and October 2018, 543 patients with intracranial aneurysms were admitted to the Department of Neurosurgery of the Third Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). Among them, 85 patients with ruptured AComA aneurysm and subarachnoid hemorrhage (SAH) underwent microsurgical clipping via the SOEK approach. In those patients, the clipping rate, complications and clinical efficacy of treatment were evaluated. The average age of the patients was 52.69±9.94 years (range, 28-78 years). The proportions of small, medium and large aneurysms were 83.5, 15.3 and 1.2%, respectively. Procedural complications occurred in 9 cases (10.5%). The occlusion rate of the aneurysms was 98.8%. The average follow-up period was 37.9 (±24.5) months. A total of 81.2% of the patients with SAH had a good clinical prognosisat 1 year (modified Rankin scale score, ≤2). In conclusion, for a skilled and experienced surgeon, SOEK was indicated to be a safe procedure for the treatment of ruptured AComA aneurysms; it provided sufficient intra-operative exposure and a high clipping rate.

Thick and diffuse cisternal clot independently predicts vasospasm-related morbidity and poor outcome after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. The presence of thick, diffuse subarachnoid blood may portend a worse clinical course and outcome, independently of other known prognostic factors such as age, aneurysm size, and initial clinical grade.

METHODS

In this post hoc analysis, patients with aSAH undergoing surgical clipping (n = 383) or endovascular coiling (n = 189) were pooled from the placebo arms of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS)-2 and CONSCIOUS-3 randomized, double-blind, placebo-controlled phase 3 studies, respectively. Patients without and with thick, diffuse SAH (≥ 4 mm thick and involving ≥ 3 basal cisterns) on admission CT scans were compared. Clot size was centrally adjudicated. All-cause mortality and vasospasm-related morbidity at 6 weeks and Glasgow Outcome Scale-Extended (GOSE) scores at 12 weeks after aSAH were assessed. The effect of the thick and diffuse cisternal aSAH on vasospasm-related morbidity and mortality, and on poor clinical outcome at 12 weeks, was evaluated using logistic regression models.

RESULTS

Overall, 294 patients (51.4%) had thick and diffuse aSAH. Compared to patients with less hemorrhage burden, these patients were older (median age 55 vs 50 years) and more often had World Federation of Neurosurgical Societies (WFNS) grade III-V SAH at admission (24.1% vs 16.5%). At 6 weeks, all-cause mortality and vasospasm-related morbidity occurred in 36.1% (95% CI 30.6%-41.8%) of patients with thick, diffuse SAH and in 14.7% (95% CI 10.8%-19.5%) of those without thick, diffuse SAH. Individual event rates were 7.5% versus 2.5% for all-cause death, 19.4% versus 6.8% for new cerebral infarct, 28.2% versus 9.4% for delayed ischemic neurological deficit, and 24.8% versus 10.8% for rescue therapy due to cerebral vasospasm, respectively. Poor clinical outcome (GOSE score ≥ 4) was observed in 32.7% (95% CI 27.3%-38.3%) and 16.2% (95% CI 12.1%-21.1%) of patients with and without thick, diffuse SAH, respectively.

CONCLUSIONS

In a large, centrally adjudicated population of patients with aSAH, WFNS grade at admission and thick, diffuse SAH independently predicted vasospasm-related morbidity and poor 12-week clinical outcome. Patients with thick, diffuse cisternal SAH may be an important cohort to target in future clinical trials of treatment for vasospasm.

Bypass and Deconstructive Technique for Hunt and Hess Grade 3-5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping

BACKGROUND

Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt and Hess (H & H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison with more traditional open surgical techniques. This study investigated outcomes in patients with H & H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for stand-alone endovascular treatment managed with bypass compared with direct surgical clipping.

METHODS

A prospective database of patients treated for aSAH with H & H grade 3-5 between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients who underwent bypass surgery versus direct clipping.

RESULTS

Twenty-three patients underwent revascularization, and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15% vs. 16%; P = 0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median 8-month follow-up (P > 0.67). There was a higher overall stroke rate with revascularization (P = 0.004), specifically endovascular treatment-related stroke (P = 0.049), with no difference in surgical (P = 0.47) or vasospasm-related stroke (P = 0.53). There were no differences in overall complications, medical complications, seizures, reruptures, hydrocephalus, or perioperative death (P > 0.05).

CONCLUSIONS

Bypass is a viable option for patients presenting with higher H & H grade aSAH deemed unfavorable for stand-alone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable with clipping in this high-risk patient cohort.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BACKGROUND

Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment.

METHODS

This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge.

RESULTS

The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi² test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment.

CONCLUSION

Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Cognitive Impairment, Functional Outcome, and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Measures such as modified Rankin Scale (mRS) may not reflect cognitive outcome following aneurysmal subarachnoid hemorrhage. The aim of this study was to assess the relationship between functional outcome, measured by mRS, and cognition, measured by mini-mental state examination (MMSE), after aSAH. A secondary analysis evaluated the impact of delayed cerebral ischemia (DCI) on the proportion of patients who had cognitive impairment.

METHODS

We performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data. MMSE and mRS scores were compared using Kruskal-Wallis equality-of-populations rank test with pairwise comparison post hoc analysis. Cognitive impairment was defined as MMSE score <27. A stepwise logistic regression model evaluated whether DCI was a predictor of cognitive impairment.

RESULTS

CONSCIOUS-1 comprised 413 patients. Of these, 337 took an MMSE at their 12-week follow-up. Mean MMSE score was 27 with a median of 29 (range, 0-30; SD 5.4). There were no significant differences between MMSE scores of patients who had 12-week mRS scores of 0-2. On multivariate analysis, DCI was independently associated with cognitive impairment after aSAH.

CONCLUSIONS

Patients considered to have a good outcome on mRS had varying degrees of cognitive function on MMSE, whereas development of DCI was an independent predictor of cognitive impairment after aSAH. MMSE may not be sensitive enough to discern subtle defects in cognition, as the median score was 29 out of 30.

Risk Factor Analysis for Poor Outcomes in Supraorbital Keyhole Aneurysm Clipping for Ruptured Anterior Circulation Aneurysms

BACKGROUND

The transciliary keyhole approach has been actively employed for unruptured intracranial aneurysms in many institutions, although applying this technique to ruptured aneurysms remains controversial. We investigated risk factors related to poor surgical outcomes in ruptured aneurysms and attempted to clarify the differences between conventional craniotomy and keyhole surgery.

METHODS

A retrospective review was performed at a single institution of medical records and images from surgeries of 188 patients who underwent keyhole surgery for ruptured anterior circulation aneurysms between July 2007 and February 2015.

RESULTS

The study included 116 (62%) female and 72 (38%) male patients; age range was 23-86 years. Preoperative clinical grades were good in almost all patients except for a few patients with poor clinical grades. Mean aneurysm size was 5.5 mm, and the most common aneurysm location was the anterior communicating artery (n = 82). Most patients (n = 158; 91.5%) showed good clinical outcomes. Univariate analysis of risk factors associated with poor-grade outcomes after 3 months was performed. Hunt and Hess grade (odds ratio [OR] 13.50, P < 0.0001), World Federation of Neurosurgical Societies scale (OR 7.69, P < 0.0001), aneurysm size (OR 1.21, P = 0.019), and vasospasm (OR 6.43, P = 0.0003) were statistically significant, whereas Fisher grade, skin-to-skin time (operation time), rebleeding, and ventricle puncture were not statistically significant.

CONCLUSIONS

Because incidence of poor surgical outcome of keyhole surgery is not different from known conventional craniotomy, this approach is an acceptable treatment option in a good-grade ruptured anterior circulation aneurysm.

Hypothesis on the Role of Cryptochromes in Inflammation and Subarachnoid Hemorrhage Outcome

We have recently found that the temperature variability (TV) in the day-night cycle may predict the mean intracranial pressure in the following 24 h (ICP₂₄) in subarachnoid hemorrhage (SAH) patients under multimodality monitoring, sedation, and hypothermia (<35°C). Specifically, we found that ICP₂₄ = 6 (4 - TV) mmHg. TV is the ratio between the coefficient of variation of temperature during the nocturnal and the preceding diurnal periods. This result suggests that the circadian clock reflects brain plasticity mechanisms and its malfunctioning leads to deterioration of the neurologic status. The sleep-wake cycle is absent in these patients and their circadian clock can function properly only by environment light-independent mechanisms. One mechanism involves the circadian clock proteins named cryptochromes (CRYs). CRYs are highly preserved and widespread in the evolutionary tree, are expressed in different cell types in humans [type II CRYs, in two forms: human cryptochrome 1 and 2 (hCRY1 and hCRY2)], and in certain species, respond to blue light and play role in magnetoreception. Interestingly, SAH outcome seems to correlate with inflammation, and CRYs decrease inflammatory activity. Our hypothesis derived from these observations is that CRYs modulate the circadian oscillation of temperature even during therapeutic hypothermia and improve outcome in SAH through decrease in inflammation. A strategy to test this hypothesis is to measure periodically during the acute phase of high-grade SAH the level of CRYs in cerebrospinal fluid (CSF) and circulating white blood cells, and to correlate these levels with outcome, TV, ICP₂₄, and pro- and anti-inflammatory markers in CSF and blood. If this hypothesis is true, the development of therapies targeting inflammation in SAH could take advantage of cryptochrome properties. It has been shown that blue light phototherapy increases the expression of CRYs in blood mononuclear cells in jaundiced neonates. Likewise, visual stimulus with flashing light improves Alzheimer's disease features in experimental model and there is a prominent expression of CRYs in the retina. Remarkably, recent evidence showed that hCRY2 responds to electromagnetic fields, which could be one elusive mechanism of action of transcranial magnetic stimulation and a reason for its use in SAH.

Development of contrast-induced nephropathy in subarachnoid hemorrhage: a single center perspective

BACKGROUND AND PURPOSE

The use of iodinated contrast-enhanced imaging studies is increasing in acute cerebrovascular diseases, especially in subarachnoid hemorrhage (SAH). In SAH, such studies are essential for both diagnosis and treatment of the cause and sequela of hemorrhage. These patients are often subjected to multiple contrast studies such as computed tomographic angiography, computed tomographic perfusion, and cerebral angiography. They are also predisposed to intravascular volume depletion as a part of the disease process from cerebral salt wasting (CSW) and as a result of multiple contrast exposure can develop contrast-induced nephropathy (CIN). Data regarding CIN in this population are scarce. We aimed to examine the incidence of CIN in SAH and identify potential associative risk factors.

METHODS

We analyzed data from a prospectively collected patient database of patients with SAH admitted to the neurocritical intensive care unit in a single center over a period of 1 year. CIN was defined as an increase in serum creatinine by >1.5 times or >0.3 mg/dl greater than the admission value, or urine output <0.5 ml/kg/h during one 6-h block.

RESULTS

In this cohort of 75 patients with SAH who had undergone at least one contrast study, the mean age was 57.3 ± 15.6 years and 70.7% were women. Four percent developed CIN which resolved within 72 h and none required renal replacement therapy or dialysis. Patients older than 75 years (20%, p < 0.05), those with borderline renal function (14.3%, p = 0.26), diabetics (11.1%, p = 0.32), and those with lower recommended "maximum contrast dose" volume (33.3%, p = 0.12) had a trend toward development of CIN, although most were not statistically significant. Twenty-seven patients (36 %) were on 3% hypertonic saline (HTS) for CSW during the contrasted study but none developed CIN.

CONCLUSIONS

The incidence of CIN in SAH patients is comparable to previously published reports on non-neurological cohorts. No definite association was noted with any predisposing factors postulated to be responsible for CIN, except for advanced age. Concurrent use of 3% HTS was not associated with CIN in this population.