Aneurysmal Surgery in the Presence of Angiographic Vasospasm: An Outcome Assessment

Management of patients with aneurismal subarachnoid hemorrhage and associated symptomatic vasospasm on presentation

Rebleeding and symptomatic vasospasm (VS) are the major causes of subsequent morbidity and mortality in patients surviving a subarachnoid hemorrhage (SAH). Although most patients present rapidly after the bleed, some may seek medical attention in a delayed fashion due to non-resolving or worsening headaches or new neurological deficits, requiring treatment during the period at risk for VS. Such patients may either present asymptomatic radiological VS on their diagnostic angiogram or present symptomatic VS confirmed on angiogram. A similar situation may occur in patients presenting within the first 48 hours after SAH with very early angiographic VS. Deciding on the optimal timing and modality of treatment in such patients with SAH and symptomatic VS on presentation is controversial. Only six observational studies that specifically assessed aneurysm treatment in the presence of symptomatic VS have been published to date. We reviewed the published literature on the management of ruptured intracranial aneurysms in the presence of symptomatic VS and suggest avenues for future studies.

Patients with supratentorial aneurysmal subarachnoid hemorrhage during the intermediate period: waiting or actively treating

Perhaps the most difficult practical decision for neurosurgeons these days is whether to secure aneurysms during the intermediate period (4-10 days) after aneurysmal subarachnoid hemorrhage (SAH). We retrospectively reviewed a series of 115 patients with a Hunt-Hess grade I-III upon admission who were admitted 4-10 days after initial supratentorial aneurysmal SAH. Patients who underwent active treatment in the intermediate period were assigned to the intermediate group (n = 49) while those who accepted delayed obliteration of a ruptured aneurysm (11-30 days) were assigned to the late group (n = 66). The demographic characteristics, size and site of aneurysms, and clinical conditions were well balanced in the two groups. There was no difference in outcome between the two groups according to the Glasgow Outcome Scale (GOS) at discharge or a six-month follow-up. Rebleeding before aneurysms obliteration was the leading factor resulting in poor outcome. In conclusion, for patients with supratentorial aneurysmal SAH who were in good clinical condition upon admission, active treatment during the intermediate period offered a good chance of a favorable outcome. An even larger number of patients from randomized clinical trials might be necessary to draw more reliable conclusions.

[Secondary superficial siderosis of the central nervous system: report of three cases]

BACKGROUND

Superficial siderosis (SS) is an under-recognized entity. It is due to repeated microhemorrhages in the subarachnoid spaces resulting in a deposit of hemosiderin at the surface of the central nervous system and/or the cranial nerves. The origin of microhemorrhages remains unknown in almost one third of cases and therefore no treatment can be recommended. Through a literature review and new observations, our goal is to detail the outcome of patients with a recognized etiology of SS and treated surgically.

METHODS

Series of three cases and review of the literature.

RESULTS

We present three patients with symptomatic SS for whom the origin of microhemorrhages was found. The first two patients complained of longstanding ataxia and neurosensory deafness while the third patient presented with urinary retention, vertigo, diplopia and facial paresis. Neuroradiological explorations revealed a left temporoparietal cavernoma, a fronto-orbital arterio-venous malformation and a cauda equina myxopapillary ependymoma respectively. Surgical resection of the source of hemorrhage was performed in all cases. All outcomes were good with improvement of their SS-related symptoms. These cases are discussed and the current literature is reviewed.

CONCLUSION

It is important to recognize SS since the treatment of the bleeding source may prevent further deterioration and may even in some cases improve the clinical condition.

Peri-operative measures for treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high early mortality rates. Cerebral vasospasm remains the major source of morbidity after aSAH. Angiographic evidence of vasospasm is apparent in 70% of patients, while clinical manifestation of vasospasm is present in one third of patients. Early or existing vasospasm at the time of presentation poses an additional challenge in the management of the patient, and forms the basis for this review.

METHODS

Treatment modalities for management of ruptured aneurysms in the setting of vasospasm, including timing of aneurysm surgery and peri-operative management, are reviewed. Intraoperative measures aimed at treatment of existing vasospasm and at the prevention of vasopasm are discussed.

RESULTS

Operative/endovascular means to secure the ruptured aneurysm should be performed as soon as possible to facilitate treatment of the vasospasm. Surgery performed in the presence of angiographic/symptomatic vasospasm can be associated with good outcome. Operative measures to decrease the incidence of vasospasm include clot removal, intracisternal injection of thrombolytics, fenestration of the lamina terminalis and local application of vasodilatory agents. Post-operative measures include early intra-arterial injection of vasodilators (verapamil or nicardipine), percutaneous angioplasty, triple-H therapy and CSF drainage.

DISCUSSION

The utilization of a multimodality approach to treat patients with aneurysmal subarachnoid hemorrhage presenting with existing vasospasm can result in good outcome.