Management results attained by predominantly late surgery for intracranial aneurysms

Vasospasm: A friend or foe - initial experience

Background

The optimal time to operate on an intracranial aneurysm eludes a satisfactory answer. While most surgeons would agree to operate early in young and neurologically intact patients, the ideal timing in older and neurologically impaired patients is debatable. In India, the majority of centers operate on patients in Hunt and Hess grades I-III, but is circumspect about grades IV and V.

Purpose

The following study was carried out to check the effect of vasospasm on mortality rates and time of surgery being performed on the patient after having the same in patients coming under criteria of Hunt and Hess grades IV and V

Methods

We undertook a prospective evaluation of 171 consecutive patients of aneurysms operated during the last 9 years irrespective of their age, neurological grade, and time of presentation or vasospasm in an attempt to resolve this issue. The influence of vasospasm on each neurological grade was examined.

Results

It appears that concomitant presence of vasospasm in grade III, IV and V patients indicates a possible “reversible” cause of the poor neurological status, while its absence may indicate an irreversible or more extensive primary insult.

Conclusion

The presence of vasospasm in poor grade patients appears to be a better prognostic indicator.

Fusiform aneurysms of the anterior communicating artery: illustrative series of 5 cases with operative techniques

BACKGROUND

Fusiform anterior communicating artery (ACoA) aneurysms (ACoAAs) are rare, and a series of these aneurysms has not been reported. Large fusiform ACoAA are easily identifiable, whereas smaller ones can coexist with a saccular component.

OBJECTIVE

To provide a clear-cut definition, report the incidence of these aneurysms, present a series with follow-up data, and discuss operative nuances and clip application techniques.

METHODS

Review of a single-surgeon operative series of all ACoAAs to identify fusiform types. When A1 or A2 vessels entered or arose from the ACoAA, it was classified as fusiform. Follow-up imaging and clinical progress were noted.

RESULTS

Five fusiform ACoAAs were identified. Patient age ranged from 19 to 68 years. Anatomy varied from very obvious large fusiform, to identifiable fusiform nature with a saccular component, to an irregularly shaped aneurysm with a fusiform element of the ACoA. A large fusiform aneurysm reconstructed in 1 patient recurred 11 years later as a ruptured fusiform ACoAA that was reconstructed again. One patient had a giant thrombosed aneurysm with thrombosed vessels in which A2 reconstruction was attempted with sacrifice of the ACoA. In others, simple clipping achieved obliteration of the aneurysm together with creating a normal dimension ACoA. There were no operative deaths; other than rupture intraoperatively, no other complications occurred. Postoperatively, no patient had new neurological deficits, 3 had short-term memory loss, and all were ambulatory with good speech function.

CONCLUSION

Review of angiograms and 3-dimensional computed tomography angiography reconstruction images can identify the complex and fusiform entity of ACoAA, which is important for preoperative planning. Experience in operative techniques and thorough knowledge of the ACoA anatomy are cornerstones to obliterate the aneurysm, maintain flow in all vessels, and surgically create an ACoA of normal caliber.

One-stage embolization in patients with acutely ruptured poor-grade aneurysm

BACKGROUND

Early or ultra-early surgery for patients in poor neurological condition (Hunt and Hess grade IV or V) after ictus of aneurysmal subarachnoid hemorrhage is increasingly reported to prevent early rebleeding. To prevent any rebleeding after hospital admission, we have treated patients with poor-grade aneurysm during the same session as when diagnostic angiography is performed ("one-stage embolization"). The aim of the present study is to determine whether this treatment modality is a viable management option for this group of patients.

METHODS

We retrospectively reviewed 18 consecutive patients who presented with acutely ruptured aneurysms and were in very poor neurological condition and who were treated with one-stage embolization.

RESULTS

We observed 2 complications related to the endovascular procedure: partial occlusion of the parent artery and aneurysm rupture during the procedure. According to the Glasgow Outcome Scale, good recovery occurred in 8 patients, and moderate and severe disabilities occurred in 4 and 3 patients, respectively, and 3 patients died. No rebleeding occurred after the procedure. The mean follow-up of the surviving patients (those who were alive more than 30 days after embolization) was 13.7 months (4-25 months). Three patients had surgery after endovascular procedure: 2 surgical clipping of failed or partial aneurysm embolization and 1 emergency coil removal with clipping. A permanent ventriculoperitoneal shunt was placed in 11 patients.

CONCLUSIONS

We achieved promising results by using one-stage embolization to prevent ultra-early rebleeding followed by aggressive resuscitation. The active involvement of the endovascular team from the stage of diagnostic angiogram is a prerequisite for this treatment strategy.

Anévrismes rompus de l’artère communicante antérieure

BACKGROUND AND PURPOSE

The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed.

PATIENTS AND METHODS

Our prospective study included 119 patients: 89 treated by microsurgery and 30 undergoing embolization with Guglielmi Detachable Coils (GDC). When the aneurysm had an anterior direction (fundus of the aneurysm in front of the pericallosal arteries), we attempted microsurgery. If the fundus of the aneurysm was behind the pericallosal arteries, we selected the most adapted procedure after discussion with the neurovascular team, taking into account the physiological status, treatment risk and neck size. Preoperative status of the patients was assessed according to the Hunt and Hess (HH) classification. Cerebral CT-scan and angiograms were routinely performed after treatment to determine causes of unfavorable outcome (GOS>1) and the morphological results.

RESULT

Overall clinical outcome was excellent (GOS1) for 63.0% of patients, good (GOS2) for 10.1%, fair (GOS3) for 13.4%, poor (GOS4) for 2.5%. The mortality rate was 10.9%. Among the 82 patients in good preoperative grade (HH<or=III), the outcome was excellent in 67 (81.7%); the permanent morbidity (GOS 2-4) and mortality (GOS 5) rate was 18.3%. Among the 37 patients in poor preoperative grade (HH>III), 8 (21.6%) achieved an excellent outcome. However permanent morbidity or death occurred in 15 patients (78.4%). Permanent disability and death were related to initial subarachnoid hemorrhage and were observed 21.3% of patients in the microsurgical group and 30.0% in the endovascular group [Fisher's Exact Test; p=0.33]. Procedure-related permanent disability and death rates were 9.0% for the microsurgical group and 23.3% for the endovascular group (p=0.06) respectively. In the microsurgical group, the only morphologic characteristic which significantly correlated with the occurrence of vessel occlusion was the fundus direction (p=0.03). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (p=0.04).

CONCLUSION

In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.

Timing of surgery for aneurysmal subarachnoid haemorrhage

BACKGROUND

The timing of surgery to secure a ruptured aneurysm after a subarachnoid haemorrhage is an important issue. Early clipping of an aneurysm prevents rebleeding, a major cause of death after a subarachnoid haemorrhage. However, concerns about the possible deleterious effects of early surgery raise questions about the safety and efficacy of this approach. This review examines the randomised controlled evidence addressing the effect of surgery at different time intervals on the outcome after a subarachnoid haemorrhage.

OBJECTIVES

To determine whether the timing of surgery after a subarachnoid haemorrhage significantly influences overall management outcome.

SEARCH STRATEGY

We searched the Cochrane Stroke Review Group Trials Register and in addition searched MEDLINE, EMBASE and the Cochrane Controlled Trials Register (CENTRAL/CCTR). Colleagues were contacted to identify further studies and unpublished trials.

SELECTION CRITERIA

All completed, unconfounded, truly randomised trials comparing "best medical treatment plus early surgery" with "best medical treatment plus delayed surgery".

DATA COLLECTION AND ANALYSIS

The authors selected trials for inclusion, or exclusion, according to the above criteria. An "intention to treat" analysis strategy was utilised.

MAIN RESULTS

Only one randomised controlled trial addressing the timing of surgery after aneurysmal subarachnoid haemorrhage was identified. Patients undergoing early surgery tended to fare better than those undergoing late surgery (death or dependency at 3 months OR 0.37 95% CI 0.13,1.02). Patients undergoing surgery in the intermediate time period appeared to fare worse than those undergoing early surgery although confidence intervals were wide (death or dependency at 3 months OR 0.34 95% CI 0.12, 0.93).

REVIEWER'S CONCLUSIONS

Based upon the limited randomised controlled evidence available, the timing of surgery was not a critical factor in determining outcome following a subarachnoid haemorrhage. Since the publication of the only randomised controlled study in 1989, techniques for the treatment of subarachnoid haemorrhage have progressed, questioning the validity of the conclusions in the modern era. Currently, most neurovascular surgeons elect to operate within 3 or 4 days of the bleed in good grade patients to minimise the chances of a devastating rebleed. However, the treatment of patients in poorer grades warrants further scrutiny in a randomised controlled trial.

Surgical treatment of anterior circulation aneurysms

The purpose of this paper is to present the results, assessed by an independent observer, of surgical treatment of 428 consecutive patients harbouring aneurysms of the anterior circulation, together with a review of relevant anatomy and operative strategy. At follow-up (mean 5.6 years) 89.3% lived at home and were independent, 5.1% lived at home but needed some kind of assistance, 2.0% lived in institution, whereas information was unavailable in 3.6% of living patients. Two hundred and fifty-three patients (64.5%) had unchanged employment status, 0.3% worked in sheltered environment, whereas 30.9% went out of work due to their subarachnoid hemorrhage (SAH). Information about employment status was unavailable in 4.3%. For aneurysms of the internal carotid, anterior communicating and middle cerebral artery, respectively, mortality was 3.2, 3.9 and 5.6%, whereas 92.0, 88.1 and 89.0% of surviving patients lived at home and were independent and 67.0, 63.6 and 63.0% had unchanged employment status. Three-months mortality of all causes was 4.2%. In the postoperative period 53 (12.4%) patients developed clinical signs of vasospasms, 6 (1.4%) had cardiac infarction, 4 (0.9%) lung oedema, 4 (0.9%) deep vein thrombosis, and 7 patients (1.6%) infection. During the follow-up period shunt-dependent hydrocephalus developed in 4.2% and 0.2% had a subsequent SAH from the same aneurysm. Forty-three patients were on anticonvulsive therapy.

Outcome of 337 intracranial aneurysms patients operated in a public hospital

Many recent series of surgery for intracranial aneurysms have been based on experience of developed countries with great resources and a state of art health care. The purpose of the current study is to correlate the outcome of patients operated for intracranial aneurysms, reported from intensive high technology neurosurgical centers with the results of low technology, environment, where we practice. Between January 1986 and December 1996, 337 patients with intracranial aneurysms were operated on at the Servidores do Estado Hospital. We retrospectively reviewed the medical and radiologic records and compared the outcome of this group with other series derived from developed countries. The overall mortality of this series was 6.9%. Of the 313 good grades surgical patients, the mortality was 4.7% and the successful results were obtained in 88.8% individuals. We conclude that patients harboring intracranial aneurysms can be satisfactory handled in less developed nations, if a meticulous intraoperative technique is employed, even though sophisticated technology and equipment are not available.

Neuropsychological outcome of operated cerebral aneurysms: prognostic factors on 148 patients

OBJECTIVES

To analyse prognostic factors in patients operated upon for cerebral aneurysms. A previous investigation by our group showed that patients operated later than 10 days after bleeding have a worse neuropsychological prognosis, but the number of patients operated upon within 3 days was not sufficient. Here, a new sample of patients with early surgery is included in the analyses.

MATERIAL AND METHODS

Patients numbered 148 (65 with ACoA, 39 with MCA, and 44 with PCoA aneurysms): 56 were operated within 3 days, 44 within 4-10 days, and 48 after at least 10 days from bleeding. A standardized battery of 13 neuropsychological tests was adopted: we considered both the number of defective scores and the average performance.

RESULTS

Patients operated later than 10 days after bleeding had a worse prognosis than the 2 groups with early and intermediate surgery, which were not different. Aneurysm site was not relevant. Old age and low education were associated with a worse prognosis. Hunt and Hess scores at operation and post operation were also predictive of the outcome.

CONCLUSION

On the whole, patients operated upon later than 10 days after bleeding have a less favourable prognosis than those with earlier operation timing.

Impact of medical treatment on the outcome of patients after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The rationale behind early aneurysm surgery in patients with subarachnoid hemorrhage (SAH) is the prevention of rebleeding as early as possible after SAH. In addition, by clipping the aneurysm as early as possible, one can apply treatment for cerebral ischemia more vigorously (induced hypertension) without the risk of rebleeding. Hypervolemic hemodilution is now a well-accepted treatment for delayed cerebral ischemia. We compared the prospectively collected clinical data and outcome of patients admitted to the intensive care unit in the period 1977 to 1982 with those of patients admitted in the period 1989 to 1992 to measure the effect of the change in medical management procedures on patients admitted in our hospital with SAH.

METHODS

We studied 348 patients admitted within 72 hours after aneurysmal SAH. Patients with negative angiography results and those in whom death appeared imminent on admission were excluded. The first group (group A) consisted of 176 consecutive patients admitted from 1977 through 1982. Maximum daily fluid intake was 1.5 to 2 L. Hyponatremia was treated with fluid restriction (<1 L/24 h). Antihypertensive treatment with diuretic agents was given if diastolic blood pressure was >110 mm Hg. Patients in the second group (172 consecutive patients; group B) were admitted from 1989 through 1992. Daily fluid intake was at least 3 L, unless cardiac failure occurred. Diuretic agents and antihypertensive medications were avoided. Cerebral ischemia was treated with vigorous plasma volume expansion under intermittent monitoring of pulmonary wedge pressure, cardiac output, and arterial blood pressure, aiming for a hematocrit of 0.29 to 0.33. Aneurysm surgery was planned for day 12.

RESULTS

Patients admitted in group B had less favorable characteristics for the development of cerebral ischemia and for good outcome when compared with patients in group A. Despite this, we found a significant decrease in the frequency of delayed cerebral ischemia in patients of group B treated with tranexamic acid (P=0.00005 by log rank test) and significantly improved outcomes among patients with delayed cerebral ischemia (P=0.006 by chi2 test) and among patients with deterioration from hydrocephalus (P=0.001 by chi2 test). This resulted in a significant improvement of the overall outcome of patients in group B when compared with those in group A (P=0.006 by chi2 test). The major cause of death in group B was rebleeding (P=0.011 by chi2 test).

CONCLUSIONS

We conclude that the outcome in our patients with aneurysmal SAH was improved but that rebleeding remains a major cause of death. Patient outcome can be further improved if we can increase the efficacy of preventive measures against rebleeding by performing early aneurysm surgery.

Therapeutic management of grade IV aneurysm patients

BACKGROUND

The timing of surgery in patients suffering from subarachnoid hemorrhage grade IV and V according to Hunt and Hess, is still controversial. Several authors advocate early surgery for patients in poor clinical condition. Improved outcome and decreased mortality rates were reported. Others exclude patients in poor condition from early aneurysm surgery.

METHODS

Forty grade IV aneurysm patients were admitted to our department. After ventriculostomy and cerebral angiography, 28 of them were operated on within 72 hours. The postoperative treatment included hypertensive, hypervolemic, hemodilutional therapy (triple-H therapy) and intensive monitoring (intracerebral pressure, blood pressure, hemodynamic parameters). The mean follow-up time was 6 months.

RESULTS

Out of the 28 patients who underwent early surgery, 64% were in good health, 11% in poor health, 25% died; there were no survivors in a vegetative state. Twelve patients were treated conservatively; 50% died from infarction and rebleeding, before the operation was performed. Six underwent delayed aneurysm surgery after clinical improvement. In this group, 25% had good clinical outcome.

CONCLUSIONS

Our results favor an aggressive treatment of grade IV aneurysm patients by means of ventricular drainage, early surgery and triple-H therapy.

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.