Total overall management and surgical outcome after aneurysmal subarachnoid haemorrhage in a defined population

Assessment of the ECG T-Wave in Patients With Subarachnoid Hemorrhage

BACKGROUND

Prolongation of the interval from the peak to the end of the T wave (Tp-Te) on a 12-lead electrocardiogram (ECG) is associated with ventricular arrhythmias. The aim of this study was to clarify associations between Tp-Te, Tp-Te/QT, and Tp-Te/rate-corrected QT (QTc) with clinical severity of subarachnoid hemorrhage (SAH) and clinical outcomes.

METHODS

This retrospective study included 222 patients with acute SAH (group S) and 306 patients with unruptured cerebral aneurysms (group U). Tp-Te, Tp-Te/QT, and Tp-Te/QTc were manually measured in standard 12-lead ECG recordings on admission and comparisons made between patients in groups S and U. The relationships of these ECG parameters with Hunt and Hess grade and Glasgow outcome scale were analyzed using multiple logistic regression analysis after adjustment for confounding factors.

RESULTS

Tp-Te, Tp-Te/QT, and Tp-Te/QTc were significantly greater in group S than in group U (group S: 109±30, 0.26±0.07, and 0.24±0.06 ms; group U: 84±12, 0.22±0.03, and 0.21±0.03 ms, respectively; P < 0.0001). In addition, in the multiple logistic regression analyses these variables were positively correlated with the Hunt and Hess grade (Tp-Te odds ratio [95% confidence interval], 2.414 [1.375-4.238], P=0.002; Tp-Te/QT, 1.886 [1.085-3.277], P = 0.024; Tp-Te/QTc, 1.873 [1.07-3.278], P=0.028, and negatively correlated with Glasgow outcome scale Tp-Te odds ratio [95% confidence interval], 4.168 [2.409-7.209], P<0.001; Tp-Te/QT, 2.434 [1.413-4.192], P=0.001; Tp-Te/QTc 2.953 [1.703-5.123], P<0.001).

CONCLUSIONS

Tp-Te, Tp-Te/QT, and Tp-Te/QTc are associated with disease severity and clinical outcome in patients with SAH.

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

Background and Purpose:

The timing of aneurysmal surgery for patients presenting within the period at risk for vasospasm (VS) is controversial. The goal of this study is to review our experience of surgically treated patients in the presence of angiographic VS.

Materials and Methods:

From 1990-2004, 894 consecutive patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with a policy of early surgery. We retrospectively analyzed the patients that had pre-operative angiographic VS. In this study, symptomatic VS was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic VS without confounding factors. Functional outcome was assessed three months after SAH using the Glasgow Outcome Scale.

Results:

Of the 40 patients studied, 62.5% were in good clinical grade Hunt & Hess (H&H 1-2) on admission; 25%, intermediate grade (H&H 3); 12.5%, poor grade (H&H 4-5). Surgery was performed 24 hours or less after initial angiography in 87.5% of patients and less than 48 hours in 97.5%. Pre-operative symptomatic VS was diagnosed in 25%. Postoperatively, angiographic VS was documented in 87.2%. Of the 30% of patients that presented post-operative symptomatic VS, 66.7% also demonstrated pre-operative symptomatic VS. The functional outcome was favorable in 92.5% of the studied patients. Two deaths occurred in patients presenting pre-operative early radiological and symptomatic VS.

Conclusion:

Aneurysmal surgery, especially between 3-12 days following SAH, in the presence of asymptomatic pre-operative angiographic VS can be associated with a good outcome. Early surgery is not contra-indicated and might enable optimal treatment of VS.

LPS Pretreatment Provides Neuroprotective Roles in Rats with Subarachnoid Hemorrhage by Downregulating MMP9 and Caspase3 Associated with TLR4 Signaling Activation

Subarachnoid hemorrhage (SAH), as a severe brain disease, has high morbidity and mortality. SAH usually induced neurological dysfunction or death and the treatment is far from satisfaction. Here, we investigated the effect of low dose of LPS pretreatment and underlying molecular mechanism in rat SAH model. Firstly, SAH model was induced by prechiasmal cistern injection method (SAH1) and common carotid artery-prechiasmal cistern shunt method (SAH2), respectively, to select the more suitable SAH model. At 6, 12, 24, 48, and 72 h after SAH, brain injury including neurological dysfunction, blood-brain barrier disruption, brain edema, and cell apoptosis were detected. And the expression of MMP9, HMGB1/TLR4, and caspase3 in cortex were also explored. Then, SB-3CT, an inhibitor of MMP9, was administrated to investigate the exact function of MMP9 in the brain injury at 24 h after SAH. Moreover, low dose of LPS was used to verify whether it had nerve protection after SAH and the mechanism involving in MMP9 and caspase 3 was investigated. Our results showed SAH1 seems to be the most suitable SAH model. In addition, MMP9 activated by HMGB1/TLR4 may promote or aggravate brain injury, while inhibiting MMP9 via SB-3CT exerted a neuroprotective effect. Moreover, LPS improved the neurological dysfunction, reduced Evans blue extravasation and brain edema, and inhibited cell apoptosis of cortex in rats with brain injury induced by SAH. Importantly, LPS pretreatment increased the expression level of TLR4, and decreased the level of MMP9 and caspase3. Therefore, the present study revealed that low dose of LPS pretreatment could provide neuroprotective effects on brain injury caused by SAH via downregulating MMP9 and caspase3 and activating TLR4 signal pathway.

Factors for Achieving Safe and Complete Treatment for Unruptured Saccular Aneurysm Smaller Than 10 mm by Simple Clipping or Simple Coil Embolization

OBJECTIVE

Reducing complications from unruptured aneurysms (UAs) treatment is important. We clarify the criteria for achieving safe and complete treatment for UAs ≤10 mm by clipping or coil embolization.

METHODS

This study included 59 newly treated UAs in the past 2 years. We prospectively decided on criteria to recommend active treatment. UAs ≤10 mm and in ≤75 year-olds, located at in the internal carotid artery at the paraclinoid portion and the posterior circulation aneurysms except for a vertebral artery-inferior posterior cerebellar artery aneurysm were mainly treated by coil embolization, and those in the internal carotid artery except at the paraclinoid portion, in the anterior or middle cerebral artery, and in the vertebral artery-inferior posterior cerebellar artery were treated preferably by clipping. UAs with a height/neck ratio or a dome/neck ratio ≤1.4 were treated preferentially by clipping. Specific preoperative imaging and careful manipulation were adopted for clipping.

RESULTS

Fifty-seven (96.6%) achieved modified Rankin scale (mRS) 0-1, 2 (3.4%) mRS 2-5, and 0 had mRS 6. Fifty-three UAs (89.8%) achieved complete occlusion (CO) and 7 (10.1%) had neck remnants (NR). Forty-one UAs (100%) within the criteria achieved mRS 0-1, 40 (98%) achieved CO, and 1 (2%) NR. The odds ratio of NR for those outside the criteria was 18.5 (95% confidence interval, 1.83-186.6) (P < 0.05). CO treated within the criteria was 39 and NR was 1. CO treated outside the criteria was 14 and NR was 5 (P < 0.05). The mRS 0-1 with age ≤75 years was 55 and the mRS 2-6 was 0. The mRS 0-1 with age ≥76 years was 2 and the mRS 2-6 was 2 (P < 0.01).

CONCLUSIONS

The treatment for UAs within the criteria, with the most recent points of concern, can lead to safe and complete results.

Assessment of cerebral circulation in the acute phase of subarachnoid hemorrhage using perfusion computed tomography

BACKGROUND AND PURPOSE

Primary brain damage, caused by acute ischemic changes during initial hemorrhage, is an important cause of death and disability following subarachnoid hemorrhage (SAH). However, the mechanism underlying the reduction in cerebral circulation in patients in the acute stage of SAH remains unclear. The goal of this study was to clarify this mechanism with the aid of perfusion computed tomography (CT).

METHODS

We prospectively evaluated 21 patients who had been undergone perfusion CT within 3 hours of SAH onset. Mean transit time (MTT) was estimated. Forty circular regions of interest 5 mm in diameter were delineated in the cortical region of the bilateral hemispheres on perfusion CT images. Neurological condition was graded with the Hunt and Hess scale, and initial CT findings were graded with the Fisher scale. We defined a good outcome as a modified Rankin scale (mRs) score of ≤2 at 3 months after SAH onset.

RESULTS

Global MTT was an independent predictor of outcome. The global MTT of patients with poor outcomes was longer than that of patients with good outcome. Furthermore, global MTT correlated significantly with Hunt & Hess grades, and disturbances in higher cerebral function.

CONCLUSION

Hemodynamic disturbances frequently occur after SAH. These abnormalities probably reflect the primary brain damage caused by initial hemorrhage. Perfusion CT is valuable for detecting hemodynamic changes in the acute stages of SAH.

Prognostic value of biochemical markers of brain damage and oxidative stress in post-surgical aneurysmal subarachnoid hemorrhage patients

The aim of this study is to determine effective biochemical markers and optimal sampling timing for prediction of neurological prognosis in post-surgical aneurysmal subarachnoid hemorrhage (SAH) patients. Subjects were a sequential group of SAH patients admitted to our centre who underwent aneurysm clipping before Day 3 and who received a cerebrospinal fluid (CSF) drain. CSF samples from 32 patients were collected on Days 3, 7, and 14. Neurological outcome was assessed by neurosurgeons using the Glasgow outcome scale (GOS) at 6 months after onset. CSF levels of neuron-specific enolase (NSE), S100B, and glial fibrillary acidic protein (GFAP) were determined using enzyme-linked immunosorbent assay, and the CSF concentrations of malondialdehyde (MDA) were determined using spectrophotometric assay. In univariate analysis, S100B on Days 3 and 14, GFAP on Days 3 and 7, and MDA on Day 14 were significantly higher in the poor outcome group (GOS 1-4) than in the good outcome group (GOS 5). In multivariate analysis, only MDA on Day 14 was identified as a significant predictor of poor neurological outcome at 6 months after onset. The area under the receiver-operating characteristic (ROC) curve for MDA on Day 14 was 0.841. For a threshold of 0.3 microM, sensitivity and specificity were 0.875 and 0.750, respectively. Our findings suggest that these biochemical markers, especially MDA, show significant promise as predictors of neurological outcome in clinical practice.

THE STOCKHOLM 20-YEAR FOLLOW-UP OF ANEURYSMAL SUBARACHNOID HEMORRHAGE OUTCOME

OBJECTIVE

To assess the clinical and radiological long-term outcome after aneurysmal subarachnoid hemorrhage (SAH) in a defined referral area regarding recurrent SAH and de novo aneurysm formation.

METHODS

One hundred and two 1-year survivors after aneurysmal SAH, who were treated at the Neurosurgical Clinic, South Hospital, Stockholm, Sweden, between 1983 and 1985, were followed for 20 years. Forty-nine surviving patients were reevaluated. Hospital records and death certificates were scrutinized for all 53 nonsurviving patients. Clinical history penetration, Mini Mental Status, Rankin Disability Score, and Barthel Index were used to evaluate the outcome. Computed tomographic angiography was used to investigate the cerebral arteries.

RESULTS

One hundred and two patients were traced. Fifty-three patients were deceased. One patient had a hospital record of sustaining an aneurysmal SAH from a known but not clipped aneurysm. Three patients had nonaneurysmal intracerebral hemorrhage and two sustained traumatic SAH. There were 49 surviving patients. Six refused follow-up. None of these patients had hospital records of intracranial disease. Three of the 43 remaining patients could not be tested. None of the survivors had experienced a new SAH. Aneurysm base remnants were observed in 1% (eight patients, 790 person-years of follow-up) and de novo aneurysms were observed in 0.9% (seven patients, 790 person-years of follow-up).

CONCLUSION

From this epidemiological survey of patients with aneurysmal SAH, it was found that none of the patients experienced a recurrent subarachnoid bleed from the treated aneurysm during a 20-year follow-up period. Thus, a routine extreme long-term follow-up period is not necessary. De novo aneurysm formation and possible enlargements of aneurysm base remnants were observed in almost 2% of patients per person year and should, therefore, be subject of a routine, long-term follow-up.

The prognostic value of serum S-100B protein in spontaneous subarachnoid haemorrhage

BACKGROUND

Despite the major progress in neurophysiological monitoring, there are still difficulties in the early identification and quantification of cerebral damage after a stroke. In this prospective study we examined the associations between serum S-100B protein, a serum marker of brain injury, and initial neurological-neuroimaging severity, secondary deterioration, external ventricular drainage (EVD: therapeutic intervention) and outcome in patients with subarachnoid haemorrhage (SAH).

METHOD

We recorded all pertinent clinical data of 52 patients with SAH and measured S-100B serum levels on admission and every 24 h for a maximum of 9 consecutive days. Mann-Whitney U-test and Kruskal Wallis analysis were employed to assess the association of S-100B levels with all variables of interest. Log-rank test was used to evaluate survival and Cox's proportional hazard regression analysis to define the significant predictors of survival rate.

FINDINGS

Admission S-100B was statistically significantly associated with initial neurological status, neuroimaging severity, and one-year outcome (p = 0.0002, 0.001, and 0.017, Kruskal Wallis analysis). Admission S-100B above 0.3 microg/L predicted unfavourable outcome (p < 0.0001, log rank test) and constituted an independent predictor of short-term survival (p = 0.035 Cox's proportional hazard regression analysis) with a hazard ratio of 2.2 (95% C.I.: 1.06-4.6) indicating a more than doubling of death probability. Secondary neurological deterioration associated with S-100B increase (p < 0.0001) and external ventricular drainage (EVD) with S-100B reduction (p = 0.003, Wilcoxon signed rank test).

CONCLUSIONS

Serum S-100B protein seems to be a useful biochemical indicator of neurological - neuroimaging severity, secondary deterioration, EVD (therapeutic intervention), and outcome in patients with SAH.

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.

Magnetic resonance angiography in the selection of patients suitable for neurosurgical intervention of ruptured intracranial aneurysms

This study was aimed at establishing whether magnetic resonance angiography (MRA) can be applied to planning and performing surgery on ruptured intracranial aneurysms, especially in the early phase, without recourse to intra-arterial digital subtraction angiography (IA-DSA). From February 1998 to August 2001, in all patients presenting with a subarachnoid hemorrhage, MRA was performed first. A three-dimensional time-of-flight MRA protocol with T2-weighted coronal and axial images was used. If MRA demonstrated an aneurysm, surgery was undertaken. IA-DSA was limited to patients with negative or inconclusive MRA findings. We compared MRA images with operative findings in positive patients and with IA-DSA in negatives. IA-DSA was considered the gold standard when MRA findings were inconclusive. In this study, 205 consecutive patients (mean age 52.7 years, 69% women) were included. In 133 patients (64.9%) MRA demonstrated an aneurysm, directly followed by neurosurgical intervention. In 33 patients (16.1%) MRA findings were categorized as inconclusive. In 39 patients (19.0%) MRA results were negative. No false-negative ruptured aneurysms were selected by MRA. In only one patient surgical intervention was performed based on false-positive MRA findings. MRA can replace IA-DSA as a first diagnostic modality in the selection of patients suitable for surgical treatment of ruptured intracranial aneurysms.

Early surgery-related complications after aneurysm clip placement: an analysis of causes and patient outcomes

Object. Most reports of series on ruptured intracranial aneurysms contain information on select intraoperative complications. An understanding of all surgical complications, however, may guide us toward improved surgical procedures and enrich discussions concerning alternative management strategies, such as endovascular treatment, which are not exempt from complications and aneurysm recurrence.

Methods. The study consists of a retrospective review of the charts, images, and notes from follow-up visits of 143 consecutive patients with subarachnoid hemorrhage (SAH) who were surgically treated during a 3-year period by one neurosurgeon. A surgical complication was determined based on findings of a clinical and/or radiological study in the absence of confounding factors such as the initial SAH ictus, vasospasm, hydrocephalus, and septic status. Functional outcome was assessed between 2 and 3 months post-SAH by using the Glasgow Outcome Scale (GOS). A procedure-related surgical complication was diagnosed in 29 (20.3%) of 143 patients studied. A brain tissue injury, including cerebral edema and hemorrhagic contusions, was diagnosed in 6.3% of patients, an unpredicted residual aneurysm neck in 5.3% of patients, and a cranial nerve deficit in 2.8% of patients. Functional outcome was good in 22 (75.9%) of the 29 patients with surgical complications. Death due to a surgical complication occurred in one (0.7%) of 143 patients.

Conclusions. Surgical complications are more prevalent than previously thought. They may have been overlooked previously because of the high percentage of good functional outcomes and low mortality rates in this group. The identification of surgical complications may encourage the search for solutions to improve surgical treatment of aneurysmal SAH.

Experimental Subarachnoid Hemorrhage: Cerebral Blood Flow and Brain Metabolism during the Acute Phase in Three Different Models in the Rat

OBJECTIVE

To study the cerebral metabolism and its relationship to cerebral blood flow (CBF) acutely after subarachnoid hemorrhage (SAH).

METHODS

SAH was induced in rats by endovascular perforation of the internal carotid artery, blood injection into the prechiasmatic cistern or the cisterna magna. CBF (measured by laser Doppler flowmetry), cerebral perfusion pressure, O(2) tension, and extracellular levels of glucose, lactate, and pyruvate were monitored during 90 minutes after SAH. CBF (assessed by (125)I-antipyrine autoradiography), arteriovenous O(2) difference, and cerebral metabolic rate of O(2) were calculated at 15 or 90 minutes after SAH.

RESULTS

After a transient reduction, cerebral perfusion pressure normalized within 5 minutes after SAH in all groups. There was a transient global decrease in CBF after SAH: its duration depended on the severity of the hemorrhage. CBF of less than 20% of baseline was observed for at least 15 minutes in 25% and 14% of the animals after perforation and prechiasmatic SAH, respectively. In all SAH groups, O(2) tension was suddenly reduced to approximately 40% of baseline and gradually increased, reaching 70 to 90% of baseline 90 minutes after SAH. The cerebral metabolic rate of O(2) was reduced only at 15 minutes after perforation and prechiasmatic SAH, but arteriovenous O(2) difference was normal in all groups. During 30 minutes after perforation SAH, a 50% decrease in glucose and a threefold increase in lactate and pyruvate levels were observed.

CONCLUSION

The data suggest that SAH induced an acute global decrease in CBF together with a depression in the cerebral metabolism. The degree of the changes was related to the severity of the hemorrhage. The metabolic derangements were not always explained by ischemic episodes.

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.

Experimental subarachnoid hemorrhage: subarachnoid blood volume, mortality rate, neuronal death, cerebral blood flow, and perfusion pressure in three different rat models

OBJECTIVE

To investigate which of three subarachnoid hemorrhage (SAH) models is the most suitable for studies of pathological and pathophysiological processes after SAH.

METHODS

SAH was induced in rats via intracranial endovascular perforation (perforation model), blood injection into the cisterna magna (300 microl), or blood injection into the prechiasmatic cistern (200 microl). The subarachnoid blood volume was quantitatively measured. Cerebral blood flow (CBF) (as assessed with laser Doppler flowmetry), intracranial pressure, and mean arterial blood pressure were recorded for 90 minutes after SAH. Mortality was recorded, and neuronal death was assessed in animals that survived 7 days after SAH.

RESULTS

The subarachnoid blood volume was close to the injected amount after prechiasmatic SAH. In the other models, the volume varied between 40 and 480 microl. The mortality rates were 44% in the perforation SAH group, 25% in the prechiasmatic SAH group, and 0% in the cisterna magna SAH group; the corresponding values for neuronal death were 11, 44, and 28%. Cerebral perfusion pressure approached baseline values within 5 minutes after SAH in all three models. CBF decreased to approximately 35% of baseline values immediately after SAH in all groups; it gradually increased to normal values 15 minutes after SAH in the cisterna magna SAH group and to 60 and 89% of baseline values 90 minutes post-SAH in the perforation and prechiasmatic SAH groups. CBF was significantly correlated with the subarachnoid blood volume.

CONCLUSION

The prechiasmatic SAH model seems to be the most suitable for study of the sequelae after SAH; it produces a significant decrease in CBF, an acceptable mortality rate, and substantial pathological lesions, with high reproducibility. The CBF reduction is predominantly dependent on the amount of subarachnoid blood.

The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis

OBJECTIVE

To estimate the proportion of patients with aneurysmal subarachnoid hemorrhage (SAH) who die before receiving medical attention.

METHODS

We performed a systematic literature review.

RESULTS

Eighteen population-based studies between 1965 and 2001 described the incidence of death from SAH before the patients received medical attention. The combined overall risk of sudden death was 12.4% (95% confidence interval, 11-14%). Patient level analysis was possible for two studies. No significant association between age and sudden death was identified. Aneurysms in the posterior circulation had an estimated probability of sudden death of 44.7% (95% confidence interval, 7.4-86%). Statistical sensitivity analysis was performed to examine some possible causes for the heterogeneity between the studies. Study factors statistically associated with a higher rate of sudden death include origin in England, computed tomographic scans not available for diagnosis, inclusion of patients with SAH from arteriovenous malformations, lower or not stated rate of autopsy for deaths in the community, and a higher rate of patients with confirmed aneurysms.

CONCLUSION

The combined overall estimated risk of sudden death was 12.4% for aneurysmal SAH and 44.7% for posterior circulation aneurysms. However, there are several sources of heterogeneity or possible bias in the reported studies. Further information on patient and aneurysm characteristics is required.

Intraoperative complications in aneurysm surgery: a prospective national study

OBJECT

With increasing use of endovascular procedures, the number of aneurysms treated surgically will decline. In this study the authors review complications related to the surgical treatment of aneurysms and address the issue of maintaining quality standards on a national level.

METHODS

A prospective, nonselected amalgamation of every aneurysm case treated in five of six neurosurgical centers in Sweden during 1 calendar year was undertaken (422 patients; 7.4 persons/100,000 population/year). The treatment protocols at these institutions were very similar. Outcome was assessed using clinical end points. In this series, 84.1% of the patients underwent surgery, and intraoperative complications occurred in 30% of these procedures. Poor outcome from technical complications was seen in 7.9% of the surgically treated patients. Intraoperative aneurysm rupture accounted for 60% and branch sacrifice for 12% of all technical difficulties. Although these complications were significantly related to aneurysm base geometry and the competence of the surgeon, problems still occurred apparently at random and also in the best of hands (17%). The temporary mean occlusion time in the patients who suffered intraoperative aneurysm rupture was twice as long as the temporary arrest of blood flow performed to aid dissection.

CONCLUSIONS

The results obtained in this series closely reflect the overall management results of this disease and support the conclusion that surgical complications causing a poor outcome can be estimated on a large population-based scale. Intraoperative aneurysm rupture was the most common and most devastating technical complication that occurred. Support was found for a more liberal use of temporary clips early during dissection, regardless of the experience of the surgeon. Temporary regional interruption of arterial blood flow should be a routine method for aneurysm surgery on an everyday basis. A random occurrence of difficult intraoperative problems was clearly shown, and this factor of unpredictability, which is present in any preoperative assessment of risk, strengthens the case for recommending neuroprotection as a routine adjunct to virtually every aneurysm operation, regardless of the surgeon's experience.

Evidence for excess long-term mortality after treated subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The purpose of this study was to examine the long-term mortality rate of patients with aneurysmal subarachnoid hemorrhage (SAH) compared with that of the general population.

METHODS

Aneurysmal SAH patients who were treated for ruptured aneurysm from 1977 through 1998 in a tertiary referral center (n=1537) were followed up for a median of 7.5 years. Dates and causes of death were determined. Standardized mortality ratios (observed/expected deaths) according to age, sex, and Glasgow Outcome Scale at 12 months after surgery were calculated.

RESULTS

The mortality rate among patients with good recovery at 12 months was twice that of the general population. The excess mortality appeared to be most evident in younger age groups. Cerebrovascular and cardiovascular diseases were the principal causes of premature death. The result was similar among patients without preexisting cardiovascular diseases at the time of SAH.

CONCLUSIONS

Aneurysmal SAH patients have an excess mortality rate even after successful treatment of ruptured aneurysms. Therefore, aneurysmal SAH should be viewed more as one aspect of a chronic general vascular disease, and more attention should be given to treatment of risk factors and long-term follow-up of these patients.

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.

Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution

OBJECT

The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy.

METHODS

The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option.

CONCLUSIONS

The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.

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.

Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

OBJECT

During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding.

METHODS

Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography.

CONCLUSIONS

Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.

Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

Object

During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed these cases to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding.

Methods

These cases were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual postal questionnaires.

Conclusions

Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.

Mild hypothermia as a protective therapy during intracranial aneurysm surgery: a randomized prospective pilot trial

OBJECTIVE

To conduct a pilot trial of mild intraoperative hypothermia during cerebral aneurysm surgery.

METHODS

One hundred fourteen patients undergoing cerebral aneurysm clipping with (n = 52) (World Federation of Neurological Surgeons score < or =III) and without (n = 62) acute aneurysmal subarachnoid hemorrhage (SAH) were randomized to normothermic (target esophageal temperature at clip application of 36.5 degrees C) and hypothermic (target temperature of 33.5 degrees C) groups. Neurological status was prospectively evaluated before surgery, 24 and 72 hours postoperatively (National Institutes of Health Stroke Scale), and 3 to 6 months after surgery (Glasgow Outcome Scale). Secondary outcomes included postoperative critical care requirements, respiratory and cardiovascular complications, duration of hospitalization, and discharge disposition.

RESULTS

Seven hypothermic patients (12%) could not be cooled to within 1 degrees C of target temperature; three of the seven were obese. Patients randomized to the hypothermic group more frequently required intubation and rewarming for the first 2 hours after surgery. Although not achieving statistical significance, patients with SAH randomized to the hypothermic group, when compared with patients in the normothermic group, had the following: 1) a lower frequency of neurological deterioration at 24 and 72 hours after surgery (21 versus 37-41%), 2) a greater frequency of discharge to home (75 versus 57%), and 3) a greater incidence of good long-term outcomes (71 versus 57%). For patients without acute SAH, there were no outcome differences between the temperature groups. There was no suggestion that hypothermia was associated with excess morbidity or mortality.

CONCLUSION

Mild hypothermia during cerebral aneurysm surgery is feasible in nonobese patients and is well tolerated. Our results indicate that a multicenter trial enrolling 300 to 900 patients with acute aneurysmal SAH will be required to demonstrate a statistically significant benefit with mild intraoperative hypothermia.

Safety and efficacy of endovascular treatment of acutely ruptured aneurysms

OBJECTIVE

To study the safety and efficacy of endovascular treatment of acutely ruptured aneurysms with Guglielmi detachable coils.

METHODS

From August 1992 until December 1995, 75 patients were referred for endovascular treatment of acutely ruptured aneurysms. There were 49 women and 26 men, with a mean age of 55 years. Patients were classified according to the Hunt and Hess grading system. There were 18 Grade I patients (24%), 13 Grade II patients (17%), 30 Grade III patients (40%), 11 Grade IV patients (15%), and 3 Grade V patients (4%). Fifty patients (66%) were treated within 48 hours, and 64 (85%) were treated within 1 week of hemorrhage. The most frequently treated aneurysms were located at the basilar bifurcation (32%), anterior communicating artery (16%), posterior communicating artery (15%), and ophthalmic segment of the carotid artery (11%). Most of the aneurysms were smaller than 15 mm (77%). Fifty-six percent of the aneurysms had small (4 mm) necks, and 44% had wide (> 4 mm) necks. Clinical follow-up was performed at 6 months, and results were classified according to the Glasgow Outcome Scale (GOS). Control angiograms were performed immediately, at 6 months, and yearly thereafter.

RESULTS

Immediate angiographic results were considered to be satisfactory in 58 patients (77%) (complete obliteration, 40%; residual neck and dog ear, 37%). Technical failures occurred in 5 patients (7%), and 12 patients experienced some residual opacification of their aneurysms (16%). The procedure-related mortality and morbidity rate was 8%. At 6 months, the outcomes were as follows: GOS score of 1, 50 patients (66.7%); GOS score of 2, 4 patients (5.3%); GOS score of 3, 4 patients (5.3%); and GOS score of 5, 17 patients (22.7%). The main causes of death and disability at 6 months were the direct effect of the initial hemorrhage (9%), delayed ischemia (6.7%), subsequent bleeding (4%), intraprocedural rupture (4%), open surgical complications (3%), and unrelated deaths (4%). Six-month angiographic follow-up data were available for 50 patients (67%). The morphological results were considered to be satisfactory in 44 of these 50 patients (88%) (complete occlusion, 46%; residual neck or dog ear, 42%).

CONCLUSION

Endovascular treatment of acutely ruptured aneurysms was attempted without clinically significant complication in 92% of the patients. The morphological results were unsatisfactory in 23% of the patients. Complete obliteration of the sac, with or without residual neck, is essential to prevent subsequent bleeding, which occurred in 5% of the patients. The overall outcome at 6 months was similar to that of surgical series, despite a selected group of patients with negative prognostic factors.

Warning leak and management outcome in aneurysmal subarachnoid hemorrhage

The impact of warning leaks on management results in patients with aneurysmal subarachnoid hemorrhage (SAH) was evaluated in this prospective study. In a consecutive series of 422 patients with aneurysmal SAH, 84 patients (19.9%) had an episode suggesting a warning leak; 34 (40.5%) of these patients were seen by a physician without the condition being recognized. The warning leak occurred less than 2 weeks before a major SAH in 75% of the patients. A good outcome was experienced by 53.6% of patients who had a warning leak versus 63.3% of those who had no warning leak. In a subgroup of patients who had an interval of 3 days or less from warning leak to SAH, only 36.4% had a good outcome. The proportion of patients in good neurological condition (Hunt and Hess Grades I and II) who had a good outcome was 88.1% in the group with no warning leak versus 53.6% in the group whose SAH was preceded by a warning leak. A difference of 35% between these two groups reflects the impact of an undiagnosed warning leak on patient outcome, based on the assumption that patients with a warning leak had clinical conditions no worse than Hunt and Hess Grade II at the time of the episode. In the subgroup of patients with the short interval between warning leak and SAH, the difference was almost 52%. The difference in outcome also reflects the potential improvement in outcome that can be achieved by a correct diagnosis of the warning leak. If the correct diagnosis is made in patients seeking medical attention due to a warning leak, favorable outcomes in the overall management of aneurysmal SAH are estimated to increase by 2.8%. An active diagnostic attitude toward patients experiencing a sudden and severe headache is warranted as it offers a means of improving overall outcome in patients with SAH.

Overall management outcome of ruptured posterior fossa aneurysms

A study of the overall management of ruptured posterior fossa aneurysms was conducted over a 1-year period (1993) in five neurosurgical centers in Sweden, serving a population of 6.93 million people. Forty-nine cases were identified and treated. One-third of the patients were in the seventh or eighth decade of life. Good overall management outcomes at 6 months were achieved in 30 cases (61%). The overall mortality rate was 27%. Patients with Hunt and Hess Grades I and II had a good overall recovery rate of 87%. On admission, 69% of the patients were assigned Hunt and Hess Grades III to V. The impact on patient outcomes of the intraoperative difficulties encountered, especially in the basilar tip area, is stressed. The authors found that delayed operation is not warranted in most cases. Frequent devastating rebleeding was observed among patients not offered early aneurysm clipping and the operative results were not at significant variance between the early and late surgical groups. Only 50% of the patients scheduled for delayed surgery ultimately made a good recovery, whereas 72% of patients scheduled for early operation did so. The data demonstrate that overall management results with posterior fossa aneurysms, comparable to achievements with supratentorial lesions, are within the reach of modern strategies, even in centers not specializing in these problems.

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.

Patients with polycystic kidney disease would benefit from routine magnetic resonance angiographic screening for intracerebral aneurysms: a decision analysis

Autosomal dominant polycystic kidney disease (ADPKD) is associated with increased prevalence of cerebral aneurysms and increased risk of subarachnoid hemorrhage. A decision analysis by Levey et al. in 1983 demonstrated that patients with ADPKD would not significantly benefit from routine arteriographic screening for cerebral aneurysms. We reexamined this conclusion in light of new clinical data and the introduction of magnetic resonance imaging (MRI) as a screening method. We compared an MRI screening strategy with a nonscreening strategy. The screening strategy specified MRI screening and then neurosurgical management of detected aneurysms. The nonscreening strategy specified cerebrovascular care only in the event of subarachnoid hemorrhage. The decision tree incorporated estimates derived from the clinical literature for the prevalence of asymptomatic aneurysms in patients with ADPKD (15%), the annual incidence of aneurysmal rupture (1.6%), the morbidity and mortality rates associated with subarachnoid hemorrhage (70 and 56%, respectively), the risk of transfemoral arteriography (0.2%), the sensitivity and specificity of MRI, the morbidity and mortality rates associated with surgical treatment of an unruptured aneurysm (4.1 and 1.0%, respectively), and the life expectancy of patients with ADPKD. The model predicted that the screening strategy would provide 1.0 additional year of life without neurological disability to a 20-year-old patient with ADPKD. A sensitivity analysis showed that the model was most sensitive to estimates of the prevalence of aneurysms in ADPKD, the annual incidence of rupture, and the morbidity and mortality rates associated with rupture. A financial analysis showed that a screening strategy is likely to cost less than a nonscreening strategy. The model predicts that an MRI screening strategy would increase the life expectancy of young patients with ADPKD and reduce the financial impact on society of ADPKD.

Surgery of unruptured, asymptomatic aneurysms: a decision analysis

BACKGROUND

Asymptomatic cerebral aneurysms are diagnosed more frequently since the advent of computed tomography and magnetic resonance imaging. Their management is currently empirical. We have used decision analysis to place it on a more analytical basis.

METHODS

Decision analysis was used to determine the benefit in years of survival free of sequelae resulting from elective surgery of unruptured aneurysms over natural history. We took 2% as the annual rate of rupture (r), 73% as the risk of death or disability with rupture (M), and 6.5% for the average risk of elective surgery (S). Benefit was calculated from the equation L([1-(1-r)L]M/2-S) [1] for life expectancy (L) corresponding to each quinquennial age group from age 15 to 100 years. Sensitivity analysis was performed to take into account increasing risk of elective surgery based on the size, and accessibility of the aneurysm, and variable risks of rupture and outcome.

RESULTS

A gain of at least one year of survival free of neurological sequelae is achieved by surgery compared to natural history for patients whose life expectancy is 19.5 years, corresponding to age 63.5 years for males and 68 years for females. The life expectancy at which a benefit accrues is longer (the patient is younger) for larger, less accessible aneurysms, for lower rates of rupture, and for lesser risks of death or disability from rupture.

CONCLUSIONS

Elective surgery of unruptured asymptomatic aneurysms achieves an increased survival over the natural history of at least one year free of neurological sequelae in patients whose life expectancy is 19.5 years or more, using our baseline assumptions. Using equation [1], the corresponding life expectancy producing this benefit can be calculated to account for the increased surgical risk of large, poorly accessible aneurysms and for factors affecting natural history.

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)