Ruptured intracranial aneurysms: the overall effect of treatment and the influence of patient selection and data presentation on the reported outcome

Lessons learned by personal failures in aneurysm surgery: what went wrong, and why?

PURPOSE

To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided.

METHODS

All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively.

RESULTS

A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided.

CONCLUSIONS

It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.

Ruptured intracranial aneurysms: the outcome of surgical treatment in experienced hands in the period prior to the advent of endovascular coiling

OBJECTIVES

To evaluate the results of treatment of patients with a ruptured intracranial aneurysm treated by a single experienced vascular neurosurgeon in the period prior to the introduction of endovascular coiling.

METHODS

Over a mean (SD) period of 9 (2) years, between January 1990 and June 1999, 245 consecutive patients with ruptured intracranial aneurysms were treated. Patients' details were obtained from a database that had been constructed prospectively. The patients consisted of all those patients treated by the senior author (Mr Maurice-Williams) over this period-that is, every third day on call at his unit. During this period, all patients under the age of 75 years with a diagnosis of subarachnoid haemorrhage were admitted to the neurosurgical unit as soon as was practicable regardless of clinical grade.

RESULTS

Of 245 patients, 190 (77.6%) underwent treatment by open surgery using standard microsurgical techniques. At 1 year, the mortality of the operated patients was 2.6%, while 89.5% of the patients had a Glasgow Outcome Score (GOS) of 4 and 5. The overall management outcome (all patients treated, including operated and non-operated cases) at 1 year was: 17.1 % dead while 74.3% had GOS 4 and 5. Of the 190 patients who underwent surgery, 38 (20%) required additional operations, totalling 72 operations in all. Of these, 32 were for hydrocephalus and 17 for the evacuation of intracranial haematomas/collections. Complications of surgery occurred in 56 patients (29.5%).

CONCLUSION

Open surgery, despite good eventual results, is associated with a significant rate of re-operations and complications that would probably be largely avoided with endovascular treatment. Nevertheless, although endovascular coiling has these immediate advantages over surgery it is still not certain that the long term results will be superior to surgery which leads to permanent obliteration of the aneurysm. There may still be a need for open surgery in the future.

Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient

Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.

Improved outcome after rupture of anterior circulation aneurysms: a retrospective 10-year review of 224 good-grade patients

Several significant diagnostic and therapeutic advances in the management of subarachnoid hemorrhage have emerged during the last 10 years. The present study was undertaken to determine whether these advances have improved overall outcome in patients of low surgical risk and what factors predict outcome. The authors retrospectively reviewed the management of good-grade patients seen at the Harborview Medical Center at the University of Washington, who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The results in this series demonstrate that favorable outcomes occurred in 96.8% of patients designated Hunt and Hess Grade I, 88.3% of those assigned Grade II, and 81.3% of those deemed Grade III after rupture of anterior circulation aneurysms. On the basis of clinical and radiographic factors present at admission, correct prediction can be made about all favorable, but only 17% of unfavorable outcomes. During the decade under investigation, the authors observed a significant (p = 0.002) increase in the number of favorable outcomes: 74.5% of patients treated during the first management period (1983-1987); 87% of patients treated during the second period (1987-1990); and 93.5% of patients treated during the third management period (1990-1993) experienced favorable outcomes. Improvements in critical-care techniques and the management of vasospasm may be associated with the improved outcome observed during this series.

Management results attained by predominantly late surgery for intracranial aneurysms

In contrast to previous studies conducted by various authors, who recommended early surgery for all patients admitted to the hospital within 72 hours of an aneurysmal subarachnoid hemorrhage, several more recent studies have declined to advise early surgery for the treatment of patients with impaired consciousness. In our series, early surgery was undertaken for patients who were rated at Grades 1 to 2 (Hunt and Hess) at admission and who did not exhibit any additional risk factors (e.g., evidence of incipient vasospasm, giant aneurysm, unfavorable aneurysm location, or a severe concomitant disease). Only three patients rated Grade 3 at admission with a favorable aneurysm location and shape underwent early surgery. The management results attained in this series (n = 131), in which the early surgery rate was 17%, have been analyzed. The management mortality rate of patients with aneurysmal subarachnoid hemorrhage was 13%, and it was 7.7% for patients admitted at Grades 1 to 3 on the Hunt and Hess scale. Good results (Glasgow Outcome Scale, 1 or 2) were attained in 75% of the entire study population, in 85% of patients admitted at Grades 1 to 3, and in 53% of those patients who were admitted at Grades 4 to 5 and who underwent late surgery after their condition had improved to Grades 1 to 3. At an average interval of 3 years after the operation, 83% of the patients discharged with Glasgow Outcome Scale ratings of 1 or 2 reported no significant restriction of their "stress resistance."(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured intracranial aneurysms--learning from experience

The outcome of treatment of 400 consecutive patients with ruptured intracranial aneurysms was assessed at 1 year. The patients were treated by a single surgeon over a period of 13 years. Data sheets completed as each patient was treated included a contemporary analysis of the reasons for any unsatisfactory outcome. Surgery was usually delayed for over 10 days from the last haemorrhage. Over the four successive 100-patient cohorts, in which the composition of the patient population remained unaltered, 1 year overall management mortality fell steadily from 38 to 24%. One year surgical mortality fell from 19 to 3%. The population of those operated on who were in Glasgow Outcome Score 5 at 1 year rose from 73 to 90% (from 51 to 71% for all patients). Of the 123 deaths, 89 occurred prior to operation, 24 after it. Thirty-five patients died from rebleeding prior to operation, but only eight of these occurred in patients judged fit for surgery at the time. All but one of the postoperative deaths resulted from technical problems related to the surgery. Over the successive cohorts, several factors indicated an improvement in operative efficiency, notably a fall in the proportion of cases with technical problems from 15 to 1%. We have demonstrated a steady improvement in management results, resulting largely from increasing operative experience. We do not believe that changes in overall management strategy, such as early surgery, would have any effect on overall outcome.

The management outcome of patients with a ruptured posterior circulation aneurysm

From 1979-1986 121 patients with a vertebro basilar aneurysm were admitted to the Institute of Neurological Sciences, Glasgow. Of the 121 patients, 97 presented with a subarachnoid haemorrhage. In these patients the management mortality was 30% and the operative mortality 13%. Sixteen patients rebled and 16 developed delayed ischaemia. The prognosis of a patient with a ruptured vertebro basilar aneurysm admitted to our Institute is similar to that of a patient with aneurysmal subarachnoid haemorrhage from an anterior circulation aneurysm.

A simple scoring system for accurate prediction of outcome within four days of a subarachnoid haemorrhage

This study was designed to examine the consistency of a number of easily identifiable predictive factors in assessing outcome within four days of a subarachnoid haemorrhage. Patients with a proven subarachnoid haemorrhage, aged between 15-65, of any neurological grade who had bled within 72 hours of admission, and who had undergone a CT scan within 96 hours of the ictus, were included. Three groups of patients were studied prospectively. The studies were separated in time and place. The series were similar overall but there were some variations between the three groups of patients because of alterations in referral patterns and management strategies between the series. There were significant differences in the patients' ages, grades on admission, timing of angiography, negative angiography rate and timing of operation. This did not affect overall outcome; 57%, 61% and 59% of the patients in series 1, 2 and 3 respectively making a good recovery. The proportion of patients with a poor outcome was also similar. To identify the level of risk of an individual patient within the first few days of haemorrhage, we considered a number of early predictive factors. Two emerged as strong predictors of outcome; the early neurological grade and the distribution of blood on the CT scan. We developed a simple scoring system from the first series, based on these findings, designed to predict outcome at three months. The scoring system was calculated on the basis of the distribution of blood seen on the CT scan and the patients' neurological grade on admission. Two points each were scored for interhemispheric, intraventricular, basal or intracerebral blood (excluding blood in the sylvian fissures). Patients in grade 1-3 scored -1, grade 4 scored 0, grades 5 & 6 scored +5. The scan score and grade score were summated to give the overall score. Patients were placed in risk groups (low, score -1; medium, score 0-2; high, score 3+). The scoring system was then applied prospectively to the two subsequent groups of patients. In each of the three series there was a clear correlation between the patients' scores and their outcomes but more importantly the probability of each outcome for each risk group was considered. In both the second and third series the probability of a full recovery in the low risk group was very likely--P = 0.000.(ABSTRACT TRUNCATED AT 400 WORDS)

Factors affecting outcome after surgery for intracranial aneurysm in Glasgow

Two-hundred and ninety-five patients with angiographically demonstrated intracranial aneurysms presented to the Institute of Neurological Sciences, Glasgow over a 3-year period (1986-88). We have reviewed this group to assess the effect of changing patterns of management upon outcome. The overall mortality rate was 9.4%, and the surgical mortality rate was 4% in this selected series. Factors significantly associated with a poor outcome were: WFNS grades III-V on admission, presence of a haematoma on the first CT scan, delayed ischaemic deficit, and development of a post-operative haematoma. Seventy-six per cent of the patients who developed a delayed ischaemic deficit (nearly a third of those with recent subarachnoid haemorrhage) made a good recovery, in contrast to previous studies, and over two-thirds of those accepted in grades IV and V (28 patients) made a good recovery after surgery. Active management of patients in grades IV and V, and those with delayed ischaemia, together with prophylactic Nimodipine therapy and selective early surgery, offers the best prospect for further improvement in outcome after aneurysmal subarachnoid haemorrhage.

Ruptured intracranial arterial aneurysms of children and adolescents. Surgical and total management results

Sixteen children and adolescents under 20 years of age were treated at the Neurosurgical Department of Helsinki University Central Hospital between 1977 and 1986. These children represent 1.2% of the total 1,346 patients with aneurysm. Fourteen patients with Hunt and Hess grades I-III were operated on without surgical mortality or morbidity. Eight aneurysms were at the carotid bifurcation and six at the anterior communicating artery. One patient was grade IV and one grade V. Both died before operation. The hospital management mortality was 2 out of 16 or 12.5%. Seven patients of that age group within our area of responsibility died of a ruptured aneurysm during the years before patients were referred for neurosurgical treatment. Thus, the total mortality was 9 of 23 patients or 39%. Assuming transfer without delay to the neurosurgical clinic, operation within the first few days of bleeding, and no surgical mortality, the theoretical minimum mortality would be 22%.

Subarachnoid haemorrhage: prognostic factors as related to working capacity

Seventy-two adult patients suffering spontaneous subarachnoid haemorrhage (SAH) were investigated concerning early mortality. Five patients died within 3 weeks after the onset of clinical symptoms. A demonstrable bleeding source and a Hunt-Hess score greater than 2 were found to be powerful predictive factors for early mortality. Sixty-seven survivors of SAH were examined at an average of 85 months after their first bleeding with regard to working capacity. Various clinical variables and different rating scales during the acute and subacute stage of SAH were identified retrospectively, and their prognostic value for working capacity was investigated. We found that all clinical features at the acute stage of SAH were not predictive of limited working capacity. At the time of discharge, however, organic brain syndrome, focal neurological deficits and a low Barthel Index proved to be significantly related to impaired working capacity. A Hunt-Hess score greater than 2 on admission, and a demonstrable bleeding source, were powerful predictors for early death, but not for impaired working capacity of survivors of SAH.

Management of elderly patients with aneurysmal subarachnoid hemorrhage

A total of 299 patients with aneurysmal subarachnoid hemorrhage (SAH) were classified into three age groups, that is, those aged 59 years or younger (Group 1: 159 patients, 53%), those aged 60 to 69 years (Group 2: 85 patients, 28%), and those aged 70 years or older (Group 3: 55 patients, 18%). A comparison was made of the surgical indications and their overall management outcome in these age groups. The overall outcome at 1 year after SAH of Group 3 was significantly poorer than that of Group 1 (p less than 0.01) or Group 2 (p less than 0.01), but no significant difference could be demonstrated between Groups 1 and 2. Overall, 104 of the 299 patients died, for a mortality rate of 35%. The mortality rate by age group was 29% for Group 1, 33% for Group 2, and 55% for Group 3. Surgery was performed on 122 patients (77%) in Group 1, 56 (66%) in Group 2, and 25 (45%) in Group 3. The overall operative outcome at 1 year after SAH in Group 3 was significantly poorer than that of Group 1 (p less than 0.01), but no significant difference was observed in this regard between Groups 1 and 2. The operative mortality rate of the patients in Groups 1, 2, and 3 who were preoperatively in Hunt and Hess Grades I and II was 1%, 7%, and 22%, respectively (no significant difference). By life-table analysis the 5-year survival probability was 65% for Group 1, 60% for Group 2, and 37% for Group 3. The rate of patients surviving in good condition or in a disabled but independent condition at 1 year after SAH was 93% and no statistically significant difference in survival probability was observed among the three age groups.

Significance of "ultra-early" rebleeding in subarachnoid hemorrhage

Knowledge of the local incidence of aneurysm rupture permits the conclusion that almost every patient in the population of 933,800 persons served by the authors' institution who was stricken by this catastrophe and survived long enough to be transported was treated at this center (121 patients during 34 months). Of these, 9.1% were admitted late (greater than 72 hours after subarachnoid hemorrhage (SAH]; of the remaining cases, 94.5% were seen within 24 hours and 50% within 6 hours post-SAH. Of the 121 patients, 10% were neurologically devastated on arrival, a late operation was planned for 19%, and the earliest possible surgery and nimodipine administration was selected for 71%. In this latter group, 50% of the operations were begun within 24 hours and 76% within 48 hours post-SAH. Sixty percent of all mortality and morbidity could be linked to the initial aneurysm bleed. The remaining 40% could be ascribed to potentially avoidable causes of unfavorable outcome. No less than 9.6% of all patients admitted within 24 hours after SAH suffered from "ultra-early" rebleeding during transportation or preparation for operation. The mortality rate from such rebleeding was 7.4%, compared with the 9.1% combined mortality rate from complications and late ischemia.

Results of treatment for cerebral saccular aneurysms in a small neurosurgical unit--evaluation of early operation and nimodipine treatment

91 patients in Hunt and Hess grade I to III directly after aneurysm rupture in the anterior circulation were treated by earliest possible surgery in conjunction with parenteral Nimodipine. 96% of the cases were seen in this centre within 24 hours from bleeding and surgery was commenced in 78% within 48 hours post haemorrhage. 8% suffered from "ultra early" rebleds six of which proved fatal. 12% of the cases had medical and surgical complications whereas only 3% had permanent late ischaemic sequelae. This low incidence of ischaemia may suggest a beneficial effect from Nimodipine treatment. The need for an aggressive surgical approach to aneurysms in order to minimize the omnious impact of rebleedings is stressed, although the importance of complications and technical misadventures must also be taken into consideration.

A review of 102 consecutive patients with intracranial aneurysms in a community hospital in Japan

One hundred and two consecutive non selected patients with intracranial aneurysms were reviewed. The incidence of ruptured aneurysm was 17.5 per population of 100,000 per year. The patients were divided into two groups, according to a change of policy that reversed the timing of operations from delayed to early surgery. The overall mortality and occurrence rate of neurological deficits due to vasospasm in patients in Hunt and Kosnik grades I through III were found to be lower during the period with a policy of early surgery. Elderly patients over 70 years old constituted 19% of the cases and those in poor condition (grade IV and V) 31%. These figures in this study are high, which may reflect the fact that these are common problems inherent in the treatment of ruptured aneurysms without patient selection at most community hospitals in the forefront of primary medical care.

Differences in the management of ruptured intracranial aneurysms: a survey of practice amongst British neurosurgeons

British consultant neurosurgeons in post for at least one year were sent a postal questionnaire about the way in which they managed patients with ruptured aneurysms; 87% replied. Wide differences were evident in almost all aspects of treatment, before, during and after surgery. A consensus of opinion appeared in only a few areas: the employment of magnification during surgery, the use of clipping as the preferred method of surgical treatment, and a general reluctance to operate on patients with a depressed conscious level within a week of haemorrhage.