Factors affecting outcome after surgery for intracranial aneurysm in Glasgow

Incidence of intra-procedural complications according to the timing of endovascular treatment in ruptured intracranial aneurysms

Background

Although endovascular treatment of ruptured intracranial aneurysms is well-established, some critical issues have not yet been clarified, such as the effects of timing on safety and effectiveness of the procedure. The aim of our study was to analyze the incidence of intra-procedural complications according to the timing of treatment, as they can affect morbidity and mortality.

Materials and methods

We retrospectively analyzed all patients who underwent endovascular treatment for ruptured intracranial aneurysms at three high flow center. For all patients, imaging and clinical data, aneurysm's type, mean dimension and different treatment techniques were analyzed. Intra-procedural complications were defined as thrombus formation at the aneurysm's neck, thromboembolic events, and rupture of the aneurysm. Patients were divided into three groups according to time between subarachnoid hemorrhage and treatment (<12 h hyper-early, 12-36 h early, and >36 h delayed).

Results

The final study population included 215 patients. In total, 84 patients (39%) underwent hyper-early, 104 (48%) early, and 27 (13%) delayed endovascular treatment. Overall, 69% of the patients were treated with simple coiling, 23% with balloon-assisted coiling, 1% with stent-assisted coiling, 3% with a flow-diverter stent, 3% with an intrasaccular flow disruptor device, and 0.5% with parent vessel occlusion. Delayed endovascular treatment was associated with an increased risk of total intra-procedural complications compared to both hyper-early (p = 0.009) and early (p = 0.004) treatments with a rate of complications of 56% (vs. 29% in hyper-early and 26% in early treated group-p = 0.011 and p = 0.008). The delayed treatment group showed a higher rate of thrombus formation and thromboembolic events. The increased risk of total intra-procedural complications in delayed treatment was confirmed, also considering only the patients treated with simple coiling and balloon-assisted coiling (p = 0.005 and p = 0.003, respectively, compared to hyper-early and early group) with a rate of complications of 62% (vs. 28% in hyper-early and 26% in early treatments-p = 0.007 and p = 0.003). Also in this subpopulation, delayed treated patients showed a higher incidence of thrombus formation and thromboembolic events.

Conclusions

Endovascular treatment of ruptured intracranial aneurysms more than 36 h after SAH seems to be associated with a higher risk of intra-procedural complications, especially thrombotic and thromboembolic events.

Assessment of cardiac function in rat endovascular perforation model of subarachnoid hemorrhage; A model of subarachnoid hemorrhage-induced cardiac dysfunction

Although the association between cardiac dysfunction and subarachnoid hemorrhage (SAH) has been recognized, its precise underlying mechanism remains unknown. Furthermore, no suitable animal models are available to study this association. Here, we established an appropriate animal model of SAH-induced cardiac dysfunction and elucidated its mechanism. In this rat model, contrast-enhanced computed tomography of the brain confirmed successful induction of SAH. Electrocardiography detected abnormalities in 55% of the experimental animals, while echocardiography indicated cardiac dysfunction in 30% of them. Further evaluation of left ventriculography confirmed cardiac dysfunction, which was transient and recovered over time. Additionally, in this SAH model, the expression of the acute phase reaction protein, proto-oncogene c-Fos increased in the paraventricular hypothalamic nucleus (PVN), the sympathetic nerve center of the brain. Polymerase chain reaction analysis revealed that the SAH model with cardiac dysfunction had higher levels of the macrophage-associated chemokine (C-X-C motif) ligand 1 (CXCL-1) and chemokine (C-C motif) ligand 2 (CCL-2) than the SAH model without cardiac dysfunction. Our results suggested that SAH caused inflammation and macrophage activation in the PVN, leading to sympathetic hyperexcitability that might cause cardiac dysfunction directly and indirectly. This animal model may represent a powerful tool to investigate the mechanisms of the brain-heart pathway.

Time course of outcome in poor grade subarachnoid hemorrhage patients: a longitudinal retrospective study

Background

Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients’ characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors.

Methods

We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004–2007; 2008–2011; 2012–2015 and 2016–2018).

Results

A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008–2011 and 2016–2018 periods (HR 0.55 [0.34–0.89] and HR 0.33 [0.20–0.53], respectively, when compared to 2004–2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 [1.43–3.14]) and UO (OR 3.23 [1.67–6.25]). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 [0.43–0.84]).

Conclusions

Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02229-1.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience

BACKGROUND

It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping.

MATERIAL AND METHODS

In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors.

RESULTS

Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15^th and the 60^th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival.

CONCLUSIONS

Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review

BACKGROUND AND PURPOSE

Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population.

METHODS

Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment.

RESULTS

The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter.

CONCLUSION

Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.

Unchanged safety outcomes in deep brain stimulation surgery for Parkinson disease despite a decentralization of care

OBJECT

Early work on deep brain stimulation (DBS) surgery, when procedures were mostly carried out in a small number of high-volume centers, demonstrated a relationship between surgical volume and procedural safety. However, over the past decade, DBS has become more widely available in the community rather than solely at academic medical centers. The authors examined the Nationwide Inpatient Sample (NIS) to study the safety of DBS surgery for Parkinson disease (PD) in association with this change in practice patterns.

METHODS

The NIS is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified patients with a primary diagnosis of PD (332.0) and a primary procedure code for implantation/replacement of intracranial neurostimulator leads (02.93) who underwent surgery between 2002 and 2009. They analyzed outcomes using univariate and hierarchical, logistic regression analyses.

RESULTS

The total number of DBS cases remained stable from 2002 through 2009. Despite older and sicker patients undergoing DBS, procedural safety (rates of non-home discharges, complications) remained stable. Patients at low-volume hospitals were virtually indistinguishable from those at high-volume hospitals, except that patients at low-volume hospitals had slightly higher comorbidity scores (0.90 vs 0.75, p < 0.01). Complications, non-home discharges, length of hospital stay, and mortality rates did not significantly differ between low- and high-volume hospitals when accounting for hospital-related variables (caseload, teaching status, location).

CONCLUSIONS

Prior investigations have demonstrated a robust volume-outcome relationship for a variety of surgical procedures. However, the present study supports safety of DBS at smaller-volume centers. Prospective studies are required to determine whether low-volume centers and higher-volume centers have similar DBS efficacy, a critical factor in determining whether DBS is comparable between centers.

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

OBJECT

Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement.

METHODS

The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval.

RESULTS

The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6-12 months and 12-36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11-18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02-7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89-14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17-26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10-15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65-30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46-14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55-37.30, p < 0.01).

CONCLUSIONS

A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

Effects of hyper-early (<12 hours) endovascular treatment of ruptured intracranial aneurysms on clinical outcome

Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12-48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intra-procedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intra-procedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis

INTRODUCTION

The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described.

METHODS

Fifty-nine poor grade patients had an EVD placed preoperatively and underwent definitive aneurysm treatment between September 1996 and March 2002. Patients improving > or = one Hunt and Hess grade were considered responders. Case-control comparisons were completed for each responder, based on clinical grade; the pre-EVD grade and the post-EVD (response) grade were used to generate two independent control cohorts. Logistic regression was used to evaluate the relationship of 12-month modified Rankin disability score (mRS) to clinical grade.

RESULTS

Nineteen (32%) responders were identified, and were less likely Grade V (p < 0.05), and more often had smaller (<13 mm, p < 0.01) and posterior circulation (p < 0.03) aneurysms. The frequency of favorable outcome (mRS < or= 3) was greater in responders than non-responders (68% vs. 28%, p < 0.001). Responders had a similar incidence of favorable outcome as response-grade controls (74%), and a higher incidence of favorable outcome than pre-EVD controls (47%). Regression analysis identified the post-EVD grade, but not the pre-EVD grade, as significantly predictive of long-term outcome (p < 0.04).

CONCLUSION

Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.

Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage

OBJECTIVE

To evaluate which presentation indices, demographics, and clinical information predict 12-month outcome in poor-grade aneurysmal subarachnoid hemorrhage (SAH), and to provide a preoperative index of prognosis.

METHODS

Data were obtained on all patients with poor-grade (Hunt and Hess Grades IV and V) aneurysmal SAH from a prospectively maintained SAH database and health outcomes project. Demographics, medical history, presenting clinical condition, and health outcomes were analyzed. Survival analysis was performed and Kaplan-Meier curves were generated. Multivariable logistic regression analysis was used to identify significant predictors of poor outcome at 12 months after hemorrhage, as measured by the modified Rankin disability scale.

RESULTS

Survival curves for open surgery and endovascular treatment did not differ significantly. Overall, 40% of the 98 definitively treated patients had a favorable outcome at 12 months. Multivariable analysis identified patient age older than 65 years (P < 0.001), hyperglycemia (P < 0.03), worst preoperative Hunt and Hess Grade V (P < 0.0001), and aneurysm size of at least 13 mm (P < 0.002) as significant predictors of poor outcome. These variables were weighted and used to compute a poor-grade aneurysmal SAH Prognosis Score (hereafter, Prognosis Score) for each patient. A Prognosis Score of 0 was associated with a 90% favorable outcome; Prognosis Score of 1 with 83%; Prognosis Score of 2 with 43%; Prognosis Score of 3 with 8%; Prognosis Score of 4 with 7%; and a Prognosis Score of 5 with 0%.

CONCLUSION

Outcome in poor-grade aneurysmal SAH is strongly predicted by patient age, worst preoperative Hunt and Hess clinical grade, and aneurysm size. Hyperglycemia on admission after poor-grade aneurysmal SAH increases the likelihood of poor outcome, and is a potentially modifiable risk factor. The Prognosis Score is a useful tool for preoperatively assessing the likelihood of a favorable outcome for poor-grade aneurysmal SAH patients.

Can angiographic vasospasm be used as a surrogate marker in evaluating therapeutic interventions for cerebral vasospasm?

✓ The authors tested the null hypothesis that published literature with a high level of evidence does not support the assertion that subarachnoid hemorrhage (SAH) causes cerebral vasospasm, which in turn causes cerebral infarction and poor outcome after aneurysmal SAH. The medical literature on SAH was searched in MEDLINE. The author's personal files of all published literature on SAH were reviewed. References cited in Cochrane reviews as well as the published papers that were reviewed were also retrieved.

There is no question that SAH causes what the authors have chosen to call “angiographic vasospasm.” However, the incidence and severity of vasospasm in recent series of patients is not well defined. There is reasonable evidence that vasospasm causes infarction, but again, accurate data on how severe and how diffuse vasospasm has to be to cause infarction and how often vasospasm is the primary cause of infarction are not available. There are good data on the incidence of cerebral infarction after SAH, and these data indicate that it is highly associated with poor outcome. The link between angiographic vasospasm and poor outcome is particularly poorly described in terms of what would be considered data of a high level of evidence.

The question as to whether there is a clear pathway from SAH to vasospasm to cerebral infarction to poor outcome seems so obvious to neurosurgeons as to make it one not worth asking. Nevertheless, the obvious is not always true or accurate, so it is important to note that published literature only weakly supports the causative association of vasospasm with infarction and poor outcome after SAH. It behooves neurosurgeons to document this seemingly straightforward pathway with high-quality evidence acceptable to the proponents of evidence-based medicine.

Spontaneous subarachnoid haemorrhage in the era of transition from surgery to embolization. A study of the overall outcome

The aim of the investigation was to evaluate the outcome of spontaneous subarachnoid haemorrhage, in the era of new techniques, patient centralization and subspecialization, by taking into account the local conditions in Greece. A prospective observational study was conducted during a 4-year period. All patients with a first-ever spontaneous subarachnoid haemorrhage were enrolled. Clinical, management and outcome data were recorded. Two-hundred-and-eighteen consecutive patients with an 81% good, medium clinical grade (Hunt & Hess I-III) were identified. Rebleed and rebleed leading to death rates were 22 and 11%, respectively. Permanent deficit or death from vasospasm was 15%. Twenty-eight per cent of the study population died early, were unsuitable for further management (poor clinical status, advanced age) or declined angiography or treatment, and another 22% had a negative angiogram. The remaining 50% underwent intervention (neurosurgical/endovascular), for obliteration of an aneurysm. The overall favourable 6-month outcome was 59%, whereas the favourable outcome of the intervention group was 70%. Our results confirm the findings of previous series. The relatively worse results are due to delayed referral, and lack of availability of surgical or endovascular management in the early post-haemorrhage period (28% of the patients), particularly in potentially salvageable cases. On the basis of these observations, we recommend early intervention (surgery or embolization) and centralization/subspecialization, in order to improve the outcome.

Incidence and risk factors for the growth of unruptured cerebral aneurysms: observation using serial computerized tomography angiography

OBJECT

The goal of this study was to examine the growth of unruptured intracranial aneurysms with the focus on the risk factors and incidence of these lesions.

METHODS

One hundred sixty-six untreated cerebral saccular aneurysms were analyzed in 140 patients. The age of the patients ranged from 29 to 82 years (mean 62.8 years), the female/male ratio was 94:46, and the mean follow-up period was 17.7 months. Aneurysms were located at the internal carotid artery (ICA) in 68 patients, the middle cerebral artery (MCA) in 43, the anterior cerebral artery in 38, the basilar artery (BA) in 13, and the vertebral artery in four patients. The maximum diameter of the lesions ranged from 2 to 20 mm (mean 4.1 mm). All patients were examined using serial computerized tomography angiography to evaluate signs of aneurysm growth. Although growth was identified in 10 aneurysms (nine patients 16.4%]), no bleeding occurred. Growth-related changes were significantly associated with the size of the aneurysm and occurred in three (2.4%) of 125 aneurysms measuring 2 to 4 mm, three (9.1%) of 33 lesions measuring 5 to 9 mm, and four (50%) of eight lesions measuring 10 to 20 mm. These changes were more frequently found in aneurysms located at the BA bifurcation (two [40%] of five lesions) and the ICA (six [8.8%] of 68 lesions) than in those located at the MCA (zero of 43 lesions, p < 0.05). The 1-, 2-, and 3-year cumulative growth rates calculated using the Kaplan-Meier method were 2.5, 8, and 17.6%, respectively.

CONCLUSIONS

A diameter of at least 10 mm and a location at the BA bifurcation or the ICA were significant risk factors for aneurysm growth. The incidence of growth was 2.5% in the 1st year and this risk increased yearly. Computerized tomography angiography is useful for follow up of patients with aneurysms because it allows the detection of even subtle morphological changes.

Effectiveness of the head-shaking method combined with cisternal irrigation with urokinase in preventing cerebral vasospasm after subarachnoid hemorrhage

OBJECT

The head-shaking method combined with cisternal irrigation has been proposed to be effective in preventing cerebral vasospasm after subarachnoid hemorrhage (SAH) by facilitating rapid washout of the clot from the subarachnoid space. This study was conducted to evaluate the effectiveness of this method.

METHODS

The inclusion criteria included the following: 1) Fisher Grade 3 SAH on admission computerized tomography (CT) scans; 2) aneurysm secured within 48 hours of SAH onset; and 3) no focal deficit and ability to obey commands within 24 hours postsurgery. Two hundred thirty patients treated between 1994 and 2002 fulfilled the criteria. Because only one machine was available and it required I month of maintenance every other month, 114 patients underwent irrigation combined with the head-shaking method (head-shaking group), whereas the remaining 116 patients received cisternal irrigation alone (control group). There were no significant differences in sex, age, site of aneurysm, or preoperative grade between the two groups. The incidence of symptomatic vasospasm with or without infarction, cerebral infarction on CT scans, and permanent ischemic neurological deficit was 25.7, 17.7, and 8.8%, respectively, in the control group and 15.2, 4.5, and 2.7% in the head-shaking group. The difference was statistically significant for symptomatic vasospasm, cerebral infarction, and permanent ischemic neurological deficit (p < 0.05). In a multivariate backward stepwise logistic regression analysis, absence of head shaking was the only variable that was predictive of permanent ischemic neurological deficit (p = 0.061). The outcomes evaluated using the modified Rankin Scale were better in the head-shaking group (p = 0.051).

CONCLUSIONS

The head-shaking method significantly reduced the incidence of symptomatic vasospasm, cerebral infarction, and permanent ischemic neurological deficit and improved the clinical outcomes in patients who underwent cisternal irrigation therapy after aneurysmal SAH.

Anxiety and Depression after Spontaneous Subarachnoid Hemorrhage

OBJECTIVE

Relatively little attention has been paid to emotional outcome after subarachnoid hemorrhage (SAH). This study assessed levels of anxiety and depression among SAH survivors and related these to clinical indices.

METHODS

Seventy SAH patients from a consecutive series of neurosurgical admissions participated in semistructured assessments of functional outcome; 52 of the patients also returned standardized measures of emotional outcome. These data were compared with clinical indices collected during the initial hospital admission.

RESULTS

Moderate to severe levels of anxiety were present in approximately 40% of patients 16 months after hemorrhage, with approximately 20% experiencing moderate to severe levels of depression. Although anxiety was more likely to be reported at interview by those with an SAH of Fisher Grade 4, the standardized measures of anxiety and depression were not associated with severity of hemorrhage or any other clinical variables. Both anxiety and depression were significantly associated with outcome indices such as return to work and engagement in social activities.

CONCLUSION

Anxiety is a significant and lasting problem for approximately 40% of survivors of SAH. It is suggested that measures taken to prevent or treat such anxiety among survivors of SAH may serve to significantly improve functional outcome.

Surgery for Parkinson disease in the United States, 1996 to 2000: practice patterns, short-term outcomes, and hospital charges in a nationwide sample

Object. The surgical treatment of Parkinson disease (PD) has undergone a dramatic shift, from stereotactic ablative procedures toward deep brain stimulaion (DBS). The authors studied this process by investigating practice patterns, mortality and morbidity rates, and hospital charges as reflected in the records of a representative sample of US hospitals between 1996 and 2000.

Methods. The authors conducted a retrospective cohort study by using the Nationwide Inpatient Sample database; 1761 operations at 71 hospitals were studied. Projected to the US population, there were 1650 inpatient procedures performed for PD per year (pallidotomies, thalamotomies, and DBS), with no significant change in the annual number of procedures during the study period. The in-hospital mortality rate was 0.2%, discharge other than to home was 8.1%, and the rate of neurological complications was 1.8%, with no significant differences between procedures. In multivariate analyses, hospitals with larger annual caseloads had lower mortality rates (p = 0.002) and better outcomes at hospital discharge (p = 0.007).

Placement of deep brain stimulators comprised 0% of operations in 1996 and 88% in 2000. Factors predicting placement of these devices in analyses adjusted for year of surgery included younger age, Caucasian race, private insurance, residence in higher-income areas, hospital teaching status, and smaller annual hospital caseload. In multivariate analysis, total hospital charges were 2.2 times higher for DBS (median $36,000 compared with $12,000, p < 0.001), whereas charges were lower at higher-volume hospitals (p < 0.001).

Conclusions. Surgical treatment of PD in the US changed significantly between 1996 and 2000. Larger-volume hospitals had superior short-term outcomes and lower charges. Future studies should address long-term functional end points, cost/benefit comparisons, and inequities in access to care.

In-hospital Mortality and Morbidity after Surgical Treatment of Unruptured Intracranial Aneurysms in the United States, 1996–2000: The Effect of Hospital and Surgeon Volume

OBJECTIVE

We sought to determine the risk of adverse outcome after contemporary surgical treatment of patients with unruptured intracranial aneurysms in the United States. Patient, surgeon, and hospital characteristics were tested as potential outcome predictors, with particular attention to the surgeon's and hospital's volume of care.

METHODS

We performed a retrospective cohort study with the Nationwide Inpatient Sample, 1996 to 2000. Multivariate logistic and ordinal regression analyses were performed with endpoints of mortality, discharge other than to home, length of stay, and total hospital charges.

RESULTS

We identified 3498 patients who were treated at 463 hospitals, and we identified 585 surgeons in the database. Of all patients, 2.1% died, 3.3% were discharged to skilled-nursing facilities, and 12.8% were discharged to other facilities. The analysis adjusted for age, sex, race, primary payer, four variables measuring acuity of treatment and medical comorbidity, and five variables indicating symptoms and signs. The statistics for median annual number of unruptured aneurysms treated were eight per hospital and three per surgeon. High-volume hospitals had fewer adverse outcomes than hospitals that handled comparatively fewer unruptured aneurysms: discharge other than to home occurred after 15.6% of operations at high-volume hospitals (20 or more cases/yr) compared with 23.8% at low-volume hospitals (fewer than 4 cases/yr) (P = 0.002). High surgeon volume had a similar effect (15.3 versus 20.6%, P = 0.004). Mortality was lower at high-volume hospitals (1.6 versus 2.2%) than at hospitals that handled comparatively fewer unruptured aneurysms, but not significantly so. Patients treated by high-volume surgeons had fewer postoperative neurological complications (P = 0.04). Length of stay was not related to hospital volume. Charges were slightly higher at high-volume hospitals, partly because arteriography was performed more frequently than at hospitals that handled comparatively fewer unruptured aneurysms.

CONCLUSION

For patients with unruptured aneurysms who were treated in the United States between 1996 and 2000, surgery performed at high-volume institutions or by high-volume surgeons was associated with significantly lower morbidity and modestly lower mortality.

Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age

OBJECT

This study was undertaken to determine the outcomes in an unselected group of patients treated with semiurgent surgical clipping of aneurysms following subarachnoid hemorrhage (SAH).

METHODS

A clinical management outcome audit was conducted to determine outcomes in a group of 391 consecutive patients who were treated with a consistent policy of ultra-early surgery (all patients treated within 24 hours after SAH and 85% of them within 12 hours). All neurological grades were included, with 45% of patients having poor grades (World Federation of Neurosurgical Societies [WFNS] Grades IV and V). Patients were not selected on the basis of age; their ages ranged between 15 and 93 years and 19% were older than 70 years. The series included aneurysms located in both anterior and posterior circulations. Eighty-eight percent of all patients underwent surgery and only 2.5% of the series were selectively withdrawn (by family request) from the prescribed surgical treatment. In patients with good grades (WFNS Grades I-III) the 3-month postoperative outcomes were independence (good outcome) in 84% of cases, dependence (poor outcome) in 8% of cases, and death in 9%. In patients with poor grades the outcomes were independence in 40% of cases, dependence in 15% of cases, and death in 45%. There was a 12% rate of rebleeding with all cases of rebleeding occurring within the first 12 hours after SAH; however, outcomes of independence were achieved in 46% of cases in which rebleeding occurred (43% mortality rate). Rebleeding was more common in patients with poor grades (20% experienced rebleeding, whereas only 5% of patients with good grades experienced rebleeding).

CONCLUSIONS

The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early rebleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.

Effects of Timing of Coil Embolization after Aneurysmal Subarachnoid Hemorrhage on Procedural Morbidity and Outcomes

OBJECTIVE

To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization.

METHODS

A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH.

RESULTS

The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables.

CONCLUSION

The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.

Neurological grades of patients with poor-grade subarachnoid hemorrhage improve after short-term pretreatment

OBJECTIVE

Short-term pretreatment of patients with subarachnoid hemorrhage, but without hematomas causing mass effect, who presented in poor neurological condition at admission was evaluated as a protocol for the selection of candidates for radical surgery.

METHODS

One hundred-three patients were pretreated for 12 hours with control of blood pressure and intracranial pressure, using diuretic agents and/or ventricular drainage.

RESULTS

Neurological improvement was observed for 32 of 47 patients in Grade IV at admission and 23 of 56 patients in Grade V (P < 0.01). Hydrocephalus requiring drainage was more common (P < 0.05) and the interval between onset and admission was shorter (P < 0.01) for the improved group. Clipping surgery was performed for all patients in Grade III or better and for patients in Grade IV who were less than 75 years of age and without systemic complications, i.e., 38 of 47 patients in Grade IV and 16 of 56 patients in Grade V at admission. Good outcomes (defined as moderately disabled or better on the Glasgow Outcome Scale) were achieved by 34 of 38 patients in Grade IV and 10 of 16 patients in Grade V (P < 0.01). The proportion of patients in Grade IV after pretreatment was lower for Grade IV (2 of 38 patients) than for Grade V (9 of 16 patients) (P < 0.00001). However, none of the 49 patients who underwent nonsurgical treatment achieved good outcomes.

CONCLUSION

Our protocol may be beneficial for the selection of candidates for radical surgery among patients with subarachnoid hemorrhage but without hematomas who are in poor neurological condition at admission and for the improvement of postoperative outcomes.

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.

Resumption of work after aneurysmal subarachnoid hemorrhage in middle-aged Japanese patients

OBJECT

Previous reports on the results of treatment for aneurysmal subarachnoid hemorrhage (SAH) have been based only on activities of daily living after discharge, whereas resumption of work has received insufficient attention. Most Japanese work under a lifetime employment system, and it is best for those who have recovered from SAH to return to work for their previous employer. The present study was conducted to determine the extent to which discharged patients who have suffered an SAH resume their former occupations in Japan, focusing on those between 40 and 49 years of age, who usually have a strong desire to return to work.

METHODS

The participants consisted of 193 patients with SAH. Based on the results of telephone interviews or written questionnaires, their work status at 1 year after onset was analyzed. The work resumption rates for patients with Hunt and Kosnik neurological Grades 1 or 2 on admission were higher than for those with Grades 3 or 4 (p = 0.015) and lower for patients with basilar artery aneurysms than for those with aneurysms at other sites (p = 0.028). With regard to premorbid occupation, the work resumption rates were high (80%) for professionals and engineers, many of whom were public servants, or teachers at junior or senior high schools. The resumption rates were also high for primary industry workers (80%), but lowest (20%) for professional drivers (p = 0.04-0.001). The work resumption rate was lower for women than for men (p = 0.01).

CONCLUSIONS

These findings indicate that resumption of work is determined not only by medical factors, but also by social factors including gender, type of occupation, employment system, and socioeconomic background.

Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis

BACKGROUND AND PURPOSE

Greater availability and improvement of neuroradiological techniques have resulted in more frequent detection of unruptured aneurysms. Because prognosis of subarachnoid hemorrhage is still poor, preventive surgery is increasingly considered as a therapeutic option. Elective surgery requires reliable data on its risks. Therefore, we performed a meta-analysis on the mortality and morbidity of surgery for unruptured intracranial aneurysms.

METHODS

Through Medline and additional searches by hand, we retrieved studies on clipping of unruptured (additional, symptomatic, or incidental) aneurysms published from 1966 through June 1996. Two authors independently extracted data. We used weighted linear regression for data analysis.

RESULTS

We included 61 studies that involved 2460 patients (57% female; mean age, 50 years) and at least 2568 unruptured aneurysms (27% >25 mm, 30% located in the posterior circulation). Mortality was 2.6% (95% confidence interval [CI], 2.0% to 3.3%). Permanent morbidity occurred in 10.9% (95% CI, 9.6% to 12.2%) of patients. Postoperative mortality was significantly lower in more recent years for nongiant aneurysms and aneurysms with an anterior location; the last 2 characteristics were also associated with a significantly lower morbidity.

CONCLUSIONS

In studies published between 1966 and 1996 on clipping of unruptured aneurysms, mortality was 2.6% and morbidity was 10.9%. In calculating the pros and cons of preventive surgery, these proportions should be taken into account.

Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases

During a six-year (1986-1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery. Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8%) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2%). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6%). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%). We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.

Predicting length of hospital stay and cost by aneurysm grade on admission

To determine the relationship between clinical grade on admission and treatment cost after aneurysm rupture, the authors retrospectively examined the length of hospital stay (LOS) and total hospitalization costs (excluding professional fees) for 543 patients admitted for aneurysm surgery between 1983 and 1993. The overall median LOS was 18 days, with a range of 1 to 165 days. Increased median LOS correlated with Hunt and Hess Grades 0 to IV on admission (p < 0.001). Median LOS for Grade V patients was reduced, in part, because of early mortality. Increased treatment cost also correlated with worse admission clinical grade (p < 0.001). A significant proportion of total expenditures occurred early in the hospitalization for patients in all clinical grades. Identification of additional factors affecting the cost of aneurysm treatment is indicated to complement treatment outcome studies.

Ruptured cerebral aneurysm: influence of specialist and trainee-performed operations on outcome

The results of a series of 160 consecutive patients operated on for ruptured cerebral aneurysm in relation to the surgeon's seniority were studied. The outcome, as measured by the Glasgow Outcome Scale at six months, shows a difference between specialist-neurosurgeon and resident-performed ruptured cerebral aneurysm obliterations, although this difference does not reach statistical significance.

The incidence of surgical complications is similar in good and poor grade patients undergoing repair of ruptured anterior circulation aneurysms: a retrospective review of 355 patients

To determine how clinical grade after subarachnoid hemorrhage impacts operative characteristics and the incidence of intra- and postoperative surgical complications, we retrospectively compared the surgical management of all good grade (n = 224) and poor grade (n = 131) patients who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The majority of good grade (74.2%) and poor grade (89.8%) patients underwent surgery < 3 days after subarachnoid hemorrhage. The results in this series demonstrate that severe cerebral swelling, often secondary to intracerebral hemorrhage, was significantly more frequent in poor grade patients. The incidence of complications, such as failure to occlude the aneurysm, major vessel occlusion, intraoperative aneurysm rupture, or surgical contusion, however, was similar in poor grade and good grade patients. We conclude, therefore, that except for severe cerebral swelling associated with intracerebral hemorrhage, the risk of surgical complications is similar in good and poor grade patients undergoing surgical repair of ruptured anterior circulation aneurysms.

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.

Timing of operation for ruptured cerebral aneurysm and long-term recovery of cognitive functions

Advantage and disadvantages of early and late operation for ruptured cerebral aneurysm are controversially evaluated with regard to peri-operative operation outcome and long-term cognitive recovery. In this retrospective analysis 22 patients with early surgery (ES) within three days after subarachnoid haemorrhage (SAH) and 22 patients with late surgery (LS) at least 14 days after SAH were studied. Patients were pair-wise matched by degree of SAH localisation of aneurysm and age at SAH. On average three years after SAH both groups were examined individually with a comprehensive neuropsychological test battery including tests of premorbid intelligence, concept formation, memory, visuomotor speed, aphasia screening, and mood. ES and LS patients were well comparable in terms of years of education and level of premorbid intelligence. There was a clear influence of patients age on fluid intelligence tests, indicating a general change-sensitivity of tests. No influence of degree of SAH and localisation of aneurysm could be detected. There were also no differences between ES and LS patients in neuropsychological tests sensitive to brain damage, suggesting that the decision for early or late surgery for ruptured cerebral aneurysm can be based upon surgical reasons at the time of the SAH.

Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care

This study records the incidence and timing of postoperative hematomas in neurosurgical patients and analyzes the best use of neurosurgical intensive care. In 2305 patients undergoing freehand or stereotactic biopsy, elective or emergency craniotomy, or posterior fossa surgery, 50 (2.2%) developed a hematoma. Clinical deterioration as a result of postoperative hematoma occurred within 6 hours of surgery in 44 patients and more than 24 hours after surgery in six patients. Although patients undergoing posterior fossa surgery or emergency craniotomy warrant longer periods of intensive-care observation, patients having elective supratentorial operations can safely be transferred to a neurosurgical ward for observation, provided they have regained their preoperative neurological status by 6 hours postsurgery.

Which are the major determinants for outcome in aneurysmal subarachnoid hemorrhage? A prospective total management study from a strictly unselected series

In this prospective study we report the outcome for all patients with a verified aneurysmal SAH managed at the Department of Neurosurgery at the University Hospital in Lund, Sweden during the four-year span from June 1, 1989 to May 31, 1993. A total of 275 patients were admitted during the study period. The vast majority of patients (196 individuals, i.e. 71%) was admitted within 24 h after the bleed. Mean age was 54.3 years and the female/male ratio 1.8/1. Nimodipine was administered in 231 (84%) of the 275 patients. We clipped the ruptured aneurysm in 199 patients. At follow-up 3 months after the bleed 161 patients were classified as having made a good neurological recovery (59%). The morbidity was 20% and 59 patients (21%) had died. The overwhelming cause for morbidity and mortality was damage from the initial bleed (62 patients, 23%). Notably, considering morbidity and mortality, delayed ischemia was less frequent than both surgical complications and rebleeding, respectively. Of the 275 patients, 13 (5%) patients made an unfavorable outcome due to delayed ischemic deterioration. There was a strict correlation between the initial clinical condition and final outcome. Of 51 grade V patients, only 2 made a good recovery. There was also a strict correlation between the amount of extravasated blood and outcome. There was no difference in clinical outcome between patients with arterial hypertension versus normotensive individuals. The mortality rate was worse for posterior circulation aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Aneurysmal bleeding. A plea for early surgery in good-risk patients

From 1985 onwards we have aimed at operating on good-risk patients, i.e., those graded I-III on the WFNS SAH Scale, within 3 days after the aneurysmal bleed. We report on a series of 100 consecutive operations for saccular aneurysm, covering a period of 5 1/2 years. Early operations (in the above sense) were done in 57 good-risk but otherwise unselected patients. After a one year follow-up, 47 of them (82%) were found to have made a good recovery (Glasgow Outcome Score I). The outcome of (mostly early) surgery in 15 selected poor-risk patients (WFNS SAH Scale IV and V) was much less favourable. Late surgery (4 or more days after SAH) was performed in 28 good-risk patients, most of whom had been admitted several days or weeks after the bleeding. Almost all of these patients had a good outcome. It is argued that the known management results of delayed surgery, which during the deliberately chosen interval exposes the patient to the risk of rebleeding and vasospasm, have by now been surpassed by those of early surgery. However excellent the surgical results of delayed operations may be, early operation should become the treatment of choice in good-risk patients.

The prognostic significance of intracerebral haematoma as shown on CT scanning after aneurysmal subarachnoid haemorrhage

In a prospective study of 1076 consecutive patients with aneurysmal subarachnoid haemorrhage (SAH), CT was carried out in 815 patients. CT visible intracerebral haematoma (ICH) was found in 42.6% of the 815 patients. There were no differences in age, pre-existing hypertension or sex between patients with or without ICH. Patients with ICH were in poorer clinical condition on admission, and had a poorer mental outcome and a higher mortality at the 2-year follow-up examination compared with patients without ICH. Of the 491 operated patients, there were in every group according to the clinical condition on admission fewer patients with a normal mental outcome and more fatal cases if an ICH was present after aneurysm rupture. This indicates that the acute brain dysfunction from SAH complicated by ICH is more likely to be followed by permanent cerebral damage compared to the corresponding acute cerebral dysfunction from SAH without ICH.

Management and long-term outcome following subarachnoid haemorrhage and intracranial aneurysm surgery in elderly patients: an audit of 199 consecutive cases

To address the question of managing subarachnoid haemorrhage (SAH) in the older patient, the management and outcome of 199 consecutive patients aged > or = 60 years with a confirmed diagnosis of subarachnoid haemorrhage (n = 186) or an unruptured intracranial aneurysm (n = 13) were reviewed. In seven patients, the cause of the SAH was an arterio-venous malformation and these were excluded from further analysis. Angiography was performed in 141 patients with a complication rate of 2.1%. Angiography was not performed in 51 patients and, in this cohort, the in-patient mortality rate was 68.6% and only 27.5% had a favourable outcome at discharge. Operation was not performed in 21 patients with demonstrated aneurysms for a variety of reasons. In this group, the in-patient mortality rate was 47.6% and 38.1% had a favourable outcome at discharge. Eighty-one patients in good neurological grade underwent surgery for a ruptured aneurysm and six patients underwent surgery for a symptomatic unruptured aneurysm. The surgical mortality was 1.1% and a favourable outcome at discharge was achieved in 83.9% of patients. Thirty-three patients were angiographic negative and there was a favourable outcome in 97% of this group. The management mortality in these selected patients admitted to the Department of Clinical Neurosciences was 24.4% and a favourable outcome was recorded in 66.2% of patients. Long-term follow-up (median 40 months, range 3-120 months) was obtained in 97% of discharged patients. The probability of survival at 60 months for patients in good condition at discharge was 0.826 (95% confidence interval 0.722-0.894).(ABSTRACT TRUNCATED AT 250 WORDS)

Subgaleal haematoma resulting in extradural compression following craniotomy. Report of two cases

We describe two patients who underwent intracranial aneurysm surgery and developed postoperative subgaleal haematomas which, in the presence of an unfixed bone flap, resulted in significant extradural compression and a marked clinical deterioration. The application of a pressure dressing to tamponade a developing scalp haematoma is unwise unless the bone flap has been rigidly fixed in place.

Ischaemic deterioration following aneurysmal subarachnoid haemorrhage: definition by clinical criteria

Ischaemia following surgery for aneurysmal subarachnoid haemorrhage (SAH) was defined by clinical criteria. Two distinct groups of patient developing ischaemia were identified: (1) patients recovering from anaesthesia with a new deficit or (2) patients developing 'true' delayed ischaemia. The only significant difference between the groups was an excess of pre-existing vascular disease in the former group. The eventual outcome for patients developing an immediate postoperative deficit was not significantly different from the delayed ischaemia group. The 6-month outcome for patients without clinical ischaemia in the first 10 postoperative days was excellent. The potentially different aetiology of ischaemia in the two subgroups with clinical ischaemia identified in this study should be considered during the planning and in particular the statistical design of trials testing new treatments for clinical ischaemia following aneurysmal SAH.

Prediction of symptomatic vasospasm after subarachnoid hemorrhage by rapidly increasing transcranial Doppler velocity and cerebral blood flow changes

BACKGROUND AND PURPOSE

Increased transcranial Doppler velocities and regional cerebral perfusion defects have been well demonstrated in patients with subarachnoid hemorrhage, but the clinical significance of these changes has not been clearly defined, particularly in the presymptomatic stage of cerebral vasospasm. We have tested the hypothesis that a rapid, massive rise in Doppler velocity denotes progressive vasospasm by relating Doppler velocity increases to regional cerebral blood flow changes and to the subsequent clinical course.

METHODS

Serial transcranial Doppler sonography was performed in 121 patients; 20 of these patients were selected for blood flow mapping on the basis of rapid increases (greater than 50 cm/sec/24 hr) in blood flow velocity. Cerebral blood flow was mapped by single-photon emission computed tomography using technetium-99m hexamethylpropyleneamine oxime.

RESULTS

Ten of 15 patients studied before the onset of any deficit subsequently developed a focal neurological abnormality. In 14 of these 15 patients, and in a further five in which single-photon emission computed tomography was performed after the onset of a delayed neurological deficit, perfusion patterns were abnormal and correlated with sites of increased Doppler velocities. Four patients had zones of cerebral hypoperfusion but did not develop neurological deficit.

CONCLUSIONS

Transcranial Doppler measurements can assist in identifying patients at risk of delayed ischemic deficit. Selection of patients for regional cerebral blood flow mapping studies and for prophylactic anti-ischemic therapy may be considered on this basis.