Effect of clot removal and the different incidence of vasospasm between clipping and GDC

Predictors of Postoperative Cerebral Ischemia in Patients with Ruptured Anterior Communicating Artery Aneurysms

OBJECTIVE

Cerebral ischemia is a major contributor to poor outcome after ruptured anterior communicating artery aneurysms (ACoAs), and is not well classified. In this article, we develop a classification and identify risk factors of cerebral ischemia after ruptured ACoAs.

METHODS

Three hundred sixty patients with ruptured ACoAs undergoing microsurgical clipping were collected. Sex, age, smoking status, Hunt-Hess grade, Fisher grade, hospital stay, surgical timing, hypertension, diabetes, postoperative cerebral ischemia, and postoperative modified Rankin Scale score were collected. Postoperative ischemic changes are classified according to a novel grade (ischemic grade I-IV).

RESULTS

Predictive factors of postoperative ischemia (grade I-IV) included sex (odds ratio [OR], 1.956; 95% confidence interval [CI], 1.262-3.032; P = 0.003) and Fisher grade (OR, 1.813; 95% CI, 1.144-2.871; P = 0.011). Male sex had a tendency to develop postoperative cerebral ischemia (61.3% in the ischemia group vs. 45.7% in the nonischemia group), while surgical timing did not. However, in patients with postoperative ischemia, early surgery within 3 days (OR, 3.334; 95% CI, 1.411-7.879; P = 0.006) and advanced age greater than 55 years (OR, 2.783; 95% CI, 1.214-6.382; P = 0.016) were risk factors for postoperative neurologic deficits (grade III-IV).

CONCLUSIONS

Male sex and higher Fisher grade predict postoperative ischemia (grade I-IV), whereas surgical timing does not. However, in patients with postoperative cerebral ischemia, early surgery within 3 days and age greater than 55 years can increase the frequency of postoperative neurological deficits (grade III-IV). Older male patients undergoing early microsurgery had a tendency to develop neurologic deficits.

Fate of clots in patients with subarachnoid hemorrhage after different surgical treatment modality: a comparison between surgical clipping and Guglielmi detachable coil embolization

BACKGROUND

Subarachnoid clot is important in the development of delayed vasospasm after subarachnoid hemorrhage (SAH).

OBJECTIVE

To compare the clearance of subarachnoid clot and the incidence of symptomatic vasospasm in surgical clipping and embolization with Guglielmi detachable coils for aneurysmal SAH.

METHODS

The subjects were 115 patients with Fisher group 3 aneurysmal SAH on computed tomography scan at admission whose aneurysm was treated by surgical clipping (clip group; n = 86) or Guglielmi detachable coil embolization (coil group; n = 29) within 72 hours of ictus. Software-based volumetric quantification of the subarachnoid clot was performed, and the amount of hemoglobin in drained cerebrospinal fluid was measured.

RESULTS

Clearance of the subarachnoid clot on the computed tomography scan was rapid in the clip group until the day after the operation but slow in the coil group (58.9% removed vs 27.8% removed; P = .008). However, postoperative clearance of the clot occurred more rapidly in the coil group. Reduction of the clot until days 3 through 5 did not differ significantly between the 2 groups (72.9% removed vs 75.2% removed). The amount of hemoglobin in the clip group was > 0.8 g/d until day 3 and then gradually decreased (n = 15), but hemoglobin in the coil group remained at > 0.8 g/d until day 5 (n = 17). The incidence of symptomatic vasospasm did not differ between the groups.

CONCLUSION

Subarachnoid clot can be removed directly during surgical clipping, which is not possible with endovascular treatment. However, the percentage reduction of the clot on days 3 through 5 did not differ between the 2 groups.