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

Endovascular Treatment for Ruptured Intracranial Aneurysms with Intracerebral Hematoma-Clinical Propriety of Less Invasive Treatment

BACKGROUND

Endovascular treatment of ruptured intracranial aneurysms (rIAs) accompanied by intracerebral hematoma (ICH) can be challenging because the ICH can be enlarged due to intraoperative anticoagulation during the endovascular procedure. This retrospective study aimed to compare the outcomes of aneurysmal subarachnoid hemorrhage with and without ICH treated by endovascular procedures.

METHODS

We reviewed 62 patients who underwent endovascular treatment of rIAs between January 2015 and April 2023. The patients were divided into 2 groups: those with ICH (group H; n = 13) and those without ICH (group N; n = 49). The patient demographics, aneurysm characteristics, World Federation of Neurosurgical Societies (WFNS) grade, complications (e.g., symptomatic vasospasm, hydrocephalus), and outcomes were assessed stratified by the presence of ICH. In group H, age, sex, complications, WFNS grade, and hematoma volume were also analyzed in relation to the outcomes at discharge.

RESULTS

None of these patients required removal of ICH after endovascular treatment of the rIA. We found no significant differences in patient characteristics, aneurysm morphologies, WFNS grade, or overall outcomes between the 2 groups. In contrast, only a poor WFNS grade was significantly associated with poor outcomes (modified Rankin scale score ≥3) in group H (P = 0.04), and the ICH volume was not significantly different between those with good (6.2 ± 5.8 mL) and poor (14.6 ± 10.4 mL) outcomes in group H (P = 0.20).

CONCLUSIONS

Endovascular treatment without hematoma evacuation did not adversely affect the outcomes of rIAs with ICH when the clinical condition and aneurysm morphology permitted. Surgical invasion might be avoidable with this less-invasive strategy without worsening the outcomes.

Proposed imaging assessment score for aneurysmal subarachnoid hemorrhage correlated with prognosis: Shinshu Aneurysmal subarachnoid hemorrhage score

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) imaging has been shown to correlate with prognosis. However, no numerical index of bleeding severity has been established. This study aimed to propose a new simple scoring system for computed tomography imaging of aSAH and to confirm its effectiveness in retrospective and prospective studies.

METHODS

We devised an image evaluation system as an objective index. This system was established by scoring six items, with a maximum total of 19 points. Using this score, named the Shinshu Aneurysmal Subarachnoid Hemorrhage Score (S-score), we performed a retrospective study of 210 patients with aSAH at a single institution to confirm its efficacy. Age and World Federation of Neurosurgical Societies grades were adopted as other verification items, and the modified Rankin Scale was used for prognostic evaluation. A multicenter prospective study was then conducted to examine the function of the score by examining 214 patients with aSAH.

RESULTS

In the retrospective study, the threshold of the S-score between good and poor prognoses was 9/19 points. The area under the curve by receiver operating characteristic analysis of the S-score was 0.819, suggesting efficacy, with an odds ratio (OR) of 1.291 (1.077-1.547). In the prospective study, the judgment capability of the S-score was evaluated with a sensitivity of 0.674, specificity of 0.881, positive predictive value of 0.789, negative predictive value of 0.804, false-positive ratio of 0.119, false-negative ratio of 0.325, positive likelihood ratio of 6.072, and negative likelihood ratio of 1.369. S-score showed a significant difference in prognosis. The OR was 1.183 (1.009-1.388).

CONCLUSIONS

The scoring system could contribute to patient prognosis assessment. S-score and its prognostic formulas may serve as an objective source of information in the development of clinical medicine.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.

METHODS

A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC.

RESULTS

Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91).

CONCLUSIONS

Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

Factors related to intracerebral haematoma in patients with aneurysmal subarachnoid haemorrhage in Vietnam: a multicentre prospective cohort study

OBJECTIVES

To investigate the impact of intracerebral haematoma (ICH) on the outcomes and the factors related to an ICH in patients with aneurysmal subarachnoid haemorrhage (aSAH) in a low- and middle-income country.

DESIGN

A multicentre prospective cohort study.

SETTING

Three central hospitals in Hanoi, Vietnam.

PARTICIPANTS

This study included all patients (≥18 years) presenting with aSAH to the three central hospitals within 4 days of ictus, from August 2019 to June 2021, and excluded patients for whom the admission Glasgow Coma Scale was unable to be scored or patients who became lost at 90 days of follow-up during the study.

OUTCOME MEASURES

The primary outcome was ICH after aneurysm rupture, defined as ICH detected on an admission head CT scan. The secondary outcomes were 90-day poor outcomes and 90-day death.

RESULTS

Of 415 patients, 217 (52.3%) were females, and the median age was 57.0 years (IQR: 48.0-67.0). ICH was present in 20.5% (85/415) of patients with aSAH. There was a significant difference in the 90-day poor outcomes (43.5% (37/85) and 29.1% (96/330); p=0.011) and 90-day mortality (36.5% (31/85) and 20.0% (66/330); p=0.001) between patients who had ICH and patients who did not have ICH. The multivariable regression analysis showed that systolic blood pressure (SBP) ≥140 mm Hg (adjusted odds ratio (AOR): 2.674; 95% CI: 1.372 to 5.214; p=0.004), World Federation of Neurosurgical Societies (WFNS) grades II (AOR: 3.683; 95% CI: 1.250 to 10.858; p=0.018) to V (AOR: 6.912; 95% CI: 2.553 to 18.709; p<0.001) and a ruptured middle cerebral artery (MCA) aneurysm (AOR: 3.717; 95% CI: 1.848 to 7.477; p<0.001) were independently associated with ICH on admission.

CONCLUSIONS

In this study, ICH was present in a substantial proportion of patients with aSAH and contributed significantly to a high rate of poor outcomes and death. Higher SBP, worse WFNS grades and ruptured MCA aneurysms were independently associated with ICH on admission.

The location of intraparenchymal bleeding determines functional outcome after spontaneous subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Non-traumatic subarachnoid hemorrhage (SAH) is a devastating disease associated with high morbidity and mortality. A higher blood burden and the presence of intraparenchymal extension of the bleeding (intracerebral hemorrhage [ICH]) are well known predictors of poor outcome. Only few studies have addressed the role of hematoma location on patient's functional outcome. The main aims were to compare clinical and radiographic characteristics between SAH patients with and without ICH and to compare different ICH localizations in relation to long-term functional outcome.

METHODS

We prospectively collected data on 280 consecutive SAH patients (aneurysmal and non-aneurysmal) admitted to a tertiary care hospital between 2010 and 2017 and assessed the initial computed tomography scans of the brain acquired after intensive care unit admission. Poor functional outcome was defined as a modified Rankin Scale score >2, 3 months after SAH. We used multivariable logistic linear regression to investigate associations between ICH location and clinical variables as well as functional outcome.

RESULTS

Intraparenchymal extension of the hemorrhage was observed in 59/280 patients (21%). The median (interquartile range) ICH volume was 11.3 (4.9-16.2) ml and the location was supratentorial in 55/59 patients (93%). Most parenchymal hemorrhages were located in the frontal (n = 24.41%) and temporal lobes (n = 12.21%), followed by insular ICH (n = 7.12%), corpus callosum (n = 6.10%), parietal (n = 2.3%) and occipital locations (n = 2.3%). Among SAH patients with ICH, those with lesions located in the corpus callosum (n = 6/59) had a significantly higher risk of 3-month poor functional outcome in comparison to all other ICH locations, even after adjusting for Hunt and Hess grade and age (adjusted odds ratio [adjOR] 50.5, 95% confidence interval [CI] 1.3-2004.2, p = 0.034). These results remained robust when comparing the whole SAH cohort (adjOR 21.7, 95% CI 1.4-347.8, p = 0.030).  CONCLUSIONS: Intraparenchymal bleeding in patients with non-traumatic SAH, in particular that involving the corpus callosum, strongly predicts functional outcome.

Delayed Progressive Mass Effect After Secured Ruptured Middle Cerebral Artery Aneurysm: Risk Factors and Outcomes

Objective

Delayed progressive mass effect (DPME) after securing an aneurysm is uncommon following microsurgical or endovascular repair and leads to a poor clinical outcome. Patients with ruptured middle cerebral artery (MCA) aneurysms have a high risk of postoperative oedema and mass effect, which may require decompressive treatment. Because few studies have discussed the risk and predictive factors, we focused on ruptured MCA aneurysms and evaluated the outcomes of these patients and the necessity of salvage surgery when DPME presented.

Methods

Data on 891 patients with aneurysmal subarachnoid haemorrhage (aSAH) treated between January 2011 and February 2020 were extracted from the medical database of a tertiary referral centre. A total of 113 patients with aSAH resulting from at least one MCA aneurysm were identified. After excluding patients with several clinical confounders, we enrolled 80 patients with surgically treated aSAH. We examined the characteristics of aneurysms and hematomas, perioperative contrast pooling patterns, presence of distal hematomas, perisylvian low density, occlusive treatment modality, management strategies, the need for salvage surgical decompression, and postoperative 90-day outcomes to identify possible risk factors.

Results

DPME was observed in 27 of the 80 patients (33.7%). The DPME and non-DPME group differed significantly in some respects. The DPME group had a higher risk of salvage surgery (p < 0.001) and poorer outcomes (mRS at day 90; p = 0.0018). The univariate analysis indicated that the presence of hematoma, CTA spot signs, perisylvian low density, and distal hematoma were independent risk factors for DPME. We also noted that DPME remained an independent predictor of a poorer 90-day functional outcome (mRS ≤ 2).

Conclusion

DPME can lead to salvage decompression surgery and directly relates to poor outcomes for patients with a ruptured MCA aneurysm. Distal hematoma, perisylvian low density, and CTA spot signs on preoperative images can predict DPME.

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.

Surgical Intervention of Intracerebral Hematoma Caused by Ruptured Middle Cerebral Artery Aneurysm in Neurosurgery Teaching Hospital, Baghdad, Iraq

Background

The incidence of intracerebral hematoma among patients with aneurysmal subarachnoid hemorrhage is up to third of the cases (12%-35%). The presence of an aneurysm with ICH negatively influences the patient's presentation, course, and outcome, and may be associated with an increased re-hemorrhage rate, vasospasm, cerebral edema, and hydrocephalus. Aneurysm obliteration and hematoma evacuation have been associated with a favourable outcome.

Aim of Study

To explore the effectiveness and the prognostic factors for patients with middle cerebral artery aneurysm associated with intracerebral hematoma treated by early surgical clipping of the aneurysm with hematoma evacuation.

Patients and Method

We analysed 21 patients with intracerebral hematoma caused by ruptured middle cerebral artery aneurysm presented to the Neurosurgery teaching hospital from January 2017 to January 2019. Parameters included five broad categories: demographic, clinical, radiological, surgical, and outcome.

Results

We found the following factors significantly related with unfavorable patient outcome: Preoperative cranial nerves deficit, dysphasia, severe contralateral weakness, presence of dilated ventricles in CT scan, presence of IVH in CT scan, aneurysm location in the dominant (left) hemisphere, high modified-Fisher grade, duration of surgery more than six hours, occurrence of intraoperative aneurysm rupture, poor postoperative GCS, occurrence postoperative vasospasm, more severe postoperative contralateral weakness, and the presence of postoperative seizure. While the good initial GCS and early surgery significantly related to favourable patient outcome.

Conclusion

Early surgical intervention of intracerebral hematoma caused by ruptured middle cerebral artery aneurysm has a favourable outcome in general and should be supported with consideration of the significant prognostic factors for each patient before the commencement of the surgery.

Parenchymatous hematoma in patients with atraumatic subarachnoid hemorrhage: Characteristics, treatment, and clinical outcomes

BACKGROUND

Data regarding the influence of concomitant parenchymatous hematoma (PH) on long-term outcomes in patients with atraumatic subarachnoid hemorrhage (SAH) are scarce. Further, it is not established if these patients benefit from surgical intervention.

AIM

The aim of this study was to determine the influence of concomitant PH in SAH patients on functional long-term outcome, and whether these patients may benefit from surgical hematoma evacuation.

METHODS

Over a 5-year period, all consecutive patients with SAH treated at the Departments of Neurology, Neuroradiology, and Neurosurgery, at the University Hospital Erlangen (Germany) were recorded. In addition to the clinical and imaging characteristics of SAH, we documented the presence, location, and volume of PH as well as treatment parameters. Outcome assessment at 12 months included functional outcome (modified Rankin scale (mRS), favorable = 0-2), health-related quality of life, and long-term complications. For outcome analysis, a propensity score matching (ratio 1:1, caliper 0.1) was performed to compare SAH patients with and without PH. Sub-analyses were performed regarding PH treatment (surgical evacuation vs. conservative).

RESULTS

A total of 494 patients with atraumatic SAH were available. Eighty-five (17.2%) had PH on initial imaging. SAH patients with PH had a worse clinical condition on admission and had a greater extent of subarachnoid/intraventricular hemorrhage. Median PH volume was 11.0 ml (5.4-31.8) with largest volumes observed in patients with ruptured middle cerebral artery (MCA)-aneurysm (31.7 ml (16.3-43.2)). After propensity-score matching (PSM), patients with PH had worse functional outcomes at 12 months (modified Rankin scale (mRS) 0-2: PH 31.8% vs. ØPH57.7% p < 0.001), and a lower rate of self-reported health compared to patients without PH (EQ-5D VAS: PH 50(30-70) vs. ØPH 80(65-95); p < 0.001). In PH patients, surgical evacuation was associated with a higher rate of favorable outcome at 12 months compared to those treated conservatively (surgery 14/28 (50.0%) vs. conservative 14/57 (24.6%); adjusted odds-ratio (OR; 95%CI): 1.34 (1.08-1.66); p = 0.001), irrespective of aneurysm location. Subgroup-analysis revealed positive associations of surgical hematoma evacuation with outcome in subgroups with larger PH volumes (>10 ml; OR (95%CI): 1.39 (1.09-1.79)), frontal PH location (OR 1.59 (1.14-2.23)), and early surgery (within 600 min after onset; OR 1.42 (1.03-1.94)).

CONCLUSIONS

Concomitant PH occurs frequently in patients with SAH and is associated with functional impairment after 1 year. Surgical evacuation of PH may improve outcomes in these patients, irrespective of aneurysm-location.

Computed tomography angiography spot sign predicts intraprocedural aneurysm rupture in subarachnoid hemorrhage

INTRODUCTION

To analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

From a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS).

RESULTS

A total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50 ml, 13-223 ml) than in the spot sign-negative group (18 ml, 1-416; p < 0.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04-8.92, p = 0.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (p = 0.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU.

CONCLUSION

In this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.

A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase

Objective

Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase.

Materials and Methods

We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%).

Results

In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality.

Conclusion

If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms.

The Hijdra scale has significant prognostic value for the functional outcome of Fisher grade 3 patients with subarachnoid hemorrhage

PURPOSE

Despite its high prevalence among patients with aneurysmal subarachnoid hemorrhage (aSAH) and high risk of delayed cerebral ischemia (DCI), the Fisher grade 3 category remains a poorly studied subgroup. The aim of this cohort study has been to investigate the prognostic value of the Hijdra sum scoring system for the functional outcome in patients with Fisher grade 3 aSAH, in order to improve the risk stratification within this Fisher category.

METHODS

Initial CT scans of 72 prospectively enrolled patients with Fisher grade 3 aSAH were analyzed, and cisternal, ventricular, and total amount of blood were graded according to the Hijdra scale. Additionally, space-occupying subarachnoid blood clots were assessed. Outcome was evaluated after 6 months.

RESULTS

Within the subgroup of Fisher grade 3, aSAH patients with an unfavorable outcome showed a significantly larger cisternal Hijdra sum score (HSS: 21.1 ± 5.2) than patients with a favorable outcome (HSS: 17.6 ± 5.9; p = 0.009). However, both the amount of ventricular blood (p = 0.165) and space-occupying blood clots (p = 0.206) appeared to have no prognostic relevance. After adjusting for the patient's age, gender, tobacco use, clinical status at admission, and presence of intracerebral hemorrhage, the cisternal and total HSS remained the only independent parameters included in multivariate logistic regression models to predict functional outcome (p < 0.01).

CONCLUSION

The cisternal Hijdra score is fairly easy to perform and the present study indicates that it has an additional predictive value for the functional outcome within the Fisher 3 category. We suggest that the Hijdra scale is a practically useful prognostic instrument for the risk evaluation after aSAH and should be applied more often in the clinical setting.

Prediction of outcome after subarachnoid hemorrhage: timing of clinical assessment

OBJECTIVE Currently, early prediction of outcome after spontaneous subarachnoid hemorrhage (SAH) lacks accuracy despite multiple studies addressing this issue. The clinical condition of the patient on admission as assessed using the World Federation of Neurosurgical Societies (WFNS) grading scale is currently considered the gold standard. However, the timing of the clinical assessment is subject to debate, as is the contribution of additional predictors. The aim of this study was to identify either the conventional WFNS grade on admission or the WFNS grade after neurological resuscitation (rWFNS) as the most accurate predictor of outcome after SAH. METHODS This prospective observational cohort study included 1620 consecutive patients with SAH admitted between January 1998 and December 2014 at our university neurovascular center. The primary outcome measure was a poor modified Rankin Scale score at the 2-month follow-up. Clinical predictors were identified using multivariate logistic regression analyses. Area under the receiver operating characteristic curve (AUC) analysis was used to test discriminative performance of the final model. An AUC of > 0.8 was regarded as indicative of a model with good prognostic value. RESULTS Poor outcome (modified Rankin Scale Score 4-6) was observed in 25% of the patients. The rWFNS grade was a significantly stronger predictor of outcome than the admission WFNS grade. The rWFNS grade was significantly associated with poor outcome (p < 0.001) as well as increasing age (p < 0.001), higher modified Fisher grade (p < 0.001), larger aneurysm size (p < 0.001), and the presence of an intracerebral hematoma (OR 1.8, 95% CI 1.2-2.8; p = 0.002). The final model had an AUC of 0.87 (95% CI 0.85-0.89), which indicates excellent prognostic value regarding the discrimination between poor and good outcome after SAH. CONCLUSIONS In clinical practice and future research, neurological assessment and grading of patients should be performed using the rWFNS to obtain the best representation of their clinical condition.

Increased risk of delayed cerebral ischemia in subarachnoid hemorrhage patients with additional intracerebral hematoma

OBJECTIVE Delayed cerebral ischemia (DCI) has a major impact on the outcome of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to assess the influence of an additional intracerebral hematoma (ICH) on the occurrence of DCI. METHODS The authors conducted a single-center retrospective analysis of cases of SAH involving patients treated between 2006 and 2011. Patients who died or were transferred to another institution within 10 days after SAH without the occurrence of DCI were excluded from the analysis. RESULTS Additional ICH was present in 123 (24.4%) of 504 included patients (66.7% female). ICH was classified as frontal in 72 patients, temporal in 24, and perisylvian in 27. DCI occurred in 183 patients (36.3%). A total of 59 (32.2%) of these 183 patients presented with additional ICH, compared with 64 (19.9%) of the 321 without DCI (p = 0.002). In addition, DCI was detected significantly more frequently in patients with higher World Federation of Neurosurgical Societies (WFNS) grades. The authors compared the original and modified Fisher Scales with respect to the occurrence of DCI. The modified Fisher Scale (mFS) was superior to the original Fisher Scale (oFS) in predicting DCI. Furthermore, they suggest a new classification based on the mFS, which demonstrates the impact of additional ICH on the occurrence of DCI. After the different scales were corrected for age, sex, WFNS score, and aneurysm site, the oFS no longer was predictive for the occurrence of DCI, while the new scale demonstrated a superior capacity for prediction as compared with the mFS. CONCLUSIONS Additional ICH was associated with an increased risk of DCI in this study. Furthermore, adding the presence or absence of ICH to the mFS improved the identification of patients at the highest risk for the development of DCI. Thus, a simple adjustment of the mFS might help to identify patients at high risk for DCI.

Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma

OBJECTIVE Intracerebral hematoma (ICH) with subarachnoid hemorrhage (SAH) indicates a unique feature of intracranial aneurysm rupture since the aneurysm is in the subarachnoid space and separated from the brain by pia mater. Broad consensus is lacking regarding the concept that ultra-early treatment improves outcome. The aim of this study is to determine the associative factors for ICH, ascertain the prognostic value of ICH, and investigate how the timing of treatment relates to the outcome of SAH with concurrent ICH. METHODS The study data were pooled from the SAH International Trialists repository. Logistic regression was applied to study the associations of clinical and aneurysm characteristics with ICH. Proportional odds models and dominance analysis were applied to study the effect of ICH on 3-month outcome (Glasgow Outcome Scale) and investigate the effect of time from ictus to treatment on outcome. RESULTS Of the 5362 SAH patients analyzed, 1120 (21%) had concurrent ICH. In order of importance, neurological status, aneurysm location, aneurysm size, and patient ethnicity were significantly associated with ICH. Patients with ICH experienced poorer outcome than those without ICH (OR 1.58; 95% CI 1.37-1.82). Treatment within 6 hours of SAH was associated with poorer outcome than treatment thereafter (adjusted OR 1.67; 95% CI 1.04-2.69). Subgroup analysis with adjustment for ICH volume, location, and midline shift resulted in no association between time from ictus to treatment and outcome (OR 0.99; 95% CI 0.94-1.07). CONCLUSIONS The most important associative factor for ICH is neurological status on admission. The finding regarding the value of ultra-early treatment suggests the need to more robustly reevaluate the concept that hematoma evacuation of an ICH and repair of a ruptured aneurysm within 6 hours of ictus is the most optimal treatment path.

Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite

BACKGROUND

The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources.

OBJECTIVE

To report our experience with 3 cases in which a novel technique for minimally invasive evacuation of intracerebral hematomas after endovascular treatment of ruptured intracranial aneurysms was used. The Penumbra Apollo system can be used in the angiography suite in conjunction with neuroendovascular techniques to simultaneously address a symptomatic hematoma associated with a ruptured aneurysm.

METHODS

Standard preoperative computed tomography angiography was performed on arrival to the emergency department. The patients underwent diagnostic cerebral angiography followed by balloon-assisted coil embolization and then remained in the neurointerventional suite for intracerebral hematoma evacuation with the Apollo system.

RESULTS

All patients tolerated coil embolization and hematoma evacuation well. The combined procedures lasted <3 hours in both cases. Two patients were eventually discharged to acute rehabilitation facilities less than a month after their initial insult, and 1 has been cleared to return to work. The other patient was transferred to hospice care.

CONCLUSION

The Apollo aspiration system appears to be a safe and effective minimally invasive option for intracerebral hematoma evacuation, particularly when coupled with endovascular embolization of ruptured intracranial aneurysms. Future work will address which patient population is most likely to benefit from this promising technique.

Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.

Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression

Objective

In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression.

Materials and Methods

In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality.

Results

Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05).

Conclusion

In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.

Which factors influence decisions to transfer and treat patients with acute intracerebral haemorrhage and which are associated with prognosis? A retrospective cohort study

OBJECTIVES

To identify factors associated with the decision to transfer and/or operate on patients with intracerebral haemorrhage (ICH) at a UK regional neurosurgical centre and test whether these decisions were associated with patient survival.

DESIGN

Retrospective cohort study.

SETTING

14 acute and specialist hospitals served by the neurosurgical unit at Salford Royal NHS Foundation Trust, Salford, UK.

PARTICIPANTS

All patients referred acutely to neurosurgery from January 2008 to October 2010.

OUTCOME MEASURES

Primary outcome was survival and secondary outcomes were transfer to the neurosurgical centre and acute neurosurgery.

RESULTS

We obtained clinical data from 1364 consecutive spontaneous patients with ICH and 1175 cases were included in the final analysis. 140 (12%) patients were transferred and 75 (6%) had surgery. In a multifactorial analysis, the decision to transfer was more likely with younger age, women, brainstem and cerebellar location and larger haematomas. Risk of death in the following year was higher with advancing age, lower Glasgow Coma Scale, larger haematomas, brainstem ICH and intraventricular haemorrhage. The transferred patients had a lower risk of death relative to those remaining at the referring centre whether they had surgery (HR 0.46, 95% CI 0.32 to 0.67) or not (HR 0.41, 95% CI 0.22 to 0.73). Acute management decisions were included in the regression model for the 227 patients under either stroke medicine or neurosurgery at the neurosurgical centre and early do-not-resuscitate orders accounted for much of the observed difference, independently associated with an increased risk of death (HR 4.8, 95% CI 2.7 to 8.6).

CONCLUSIONS

The clear association between transfer to a specialist centre and survival, independent of established prognostic factors, suggests aggressive supportive care at a specialist centre may improve survival in ICH and warrants further investigation in prospective studies.

The clinical characteristics and treatment outcomes of patients with ruptured middle cerebral artery aneurysms associated with intracerebral hematoma

Objective

The objective of this study is to evaluate the clinical presentation and outcomes of patients with an intracerebral hematoma (ICH) associated with a ruptured middle cerebral artery (MCA) aneurysm, and the correlation factors associated with the aneurysm and characteristics of the hematoma.

Methods

A retrospective evaluation of clinical and radiologic characteristics and outcomes was conducted for 24 patients (11 men and 13 women; mean age, 53 years) with ruptured MCA aneurysms associated with ICH between September 2008 and December 2011.

Results

Thirteen (54%) of the 24 patients had a favorable outcome, four (17%) suffered from severe disability, and seven (29%) died. Based on Hunt and Hess grade, one patient was classified as Grade II, three as Grade III, 12 as Grade IV, and eight as Grade V. Patients with an unfavorable outcome had significantly larger aneurysms (p = 0.047) and ICH volumes (p = 0.002), compared with patients in the group with a favorable outcome. The most frequent rupture point of aneurysms was the lateral aspect of the aneurysm (54.2%). When the rupture point is toward the lateral direction, the distribution of ICH tended to be located at the temporal lobe and intrasylvian.

Conclusion

Results of the present study suggest an association of the initial clinical state, the size of the aneurysm, and ICH volume with outcome. Although no difference was observed between the location of the rupture point and patient outcomes, an accurate assessment of ICH patterns and the rupture point in angiography may help to ensure surgical exposure and a safe aneurysm clipping.

Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms

OBJECTIVE

Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures.

METHODS

A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10-82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome.

RESULTS

The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome.

CONCLUSIONS

Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

Aneurysmal and clinical characteristics as risk factors for intracerebral haematoma from aneurysmal rupture

Intracerebral haematoma (ICH) occurs in one-third of patients with aneurysmal subarachnoid haemorrhage (SAH) and is associated with poor prognosis. Identification of risk factors for ICH from aneurysmal rupture may help in balancing risks of treatment of unruptured aneurysms. We assessed potential clinical and aneurysmal risk factors for ICH from aneurysmal rupture. In all 310 SAH patients admitted to our service between 2005 and 2007, we compared clinical risk factors (gender, age, smoking, hypertension, history of SAH and family history) of patients with and without an ICH. From the latest admitted, 50 patients with and 50 without ICH, we compared the location, shape and direction of blood flow of the aneurysms on CT-angiography. Relative risks (RRs) of ICH were 1.2 (95% confidence interval, CI):0.7–1.8) for males, 1.0 (95%CI:0.7–1.4) for age ≥55 year, 1.0 (95%CI:0.6–1.6) for smoking, 0.9 (95%CI:0.5–1.5) for hypertension, 0.6 (95%CI:0.1–3.8) for history of SAH and 0.5 (95%CI:0.2–1.3) for family history of SAH. RRs of ICH were 1.8 (95%CI:1.2–2.5) for MCA aneurysms, 0.5 (95%CI:0.3–1.0) for ICA aneurysms, 0.4 (95%CI:0.1–1.3) for posterior circulation aneurysms, and 0.7 (95%CI:0.3–1.3) for multilobed aneurysms. The RRs of other aneurysmal characteristics varied between 0.9 and 1.2. Patients with MCA aneurysms are at a higher risk of developing ICH. The other aneurysmal or clinical factors have no or only minor influence on the risk of ICH after rupture and are, therefore, not helpful in deciding on treatment of unruptured aneurysms.

Outcome after emergency surgery without angiography in patients with intracerebral haemorrhage after aneurysm rupture

BACKGROUND

Patients with large intracerebral haematomas (ICH) from aneurysm rupture often present in a poor clinical condition and have a poor prognosis. Time delay for preoperative angiography might in some cases be unappealing. We evaluated the outcome after immediate haematoma removal and aneurysm occlusion without preoperative angiography.

METHODS

We retrospectively identified 13 consecutive patients. We recorded clinical data and evaluated mortality and morbidity with the Glasgow Outcome Score (GOS) and Telephone Interview of Cognitive Status (TICS).

FINDINGS

At follow up seven of thirteen patients had favourable outcome assessed by GOS. Three patients had severe disability and three patients died. None of the survived patients interviewed had impaired cognition.

CONCLUSIONS

In patients presented in a critical state with aneurysmal ICH, emergency haematoma removal and aneurysm clipping without the delay for diagnostic angiography may be life saving and a satisfactory outcome can be accomplished.

Treatment of ruptured anterior communicating artery aneurysm accompanying intracerebral hematomas: endovascular coiling followed by hematoma evacuation with burr hole trephination and catheterization

INTRODUCTION

The aim of this study was to evaluate the outcome of endovascular coiling of ruptured anterior communicating artery (AcomA) aneurysms followed by intracerebral hematoma (ICH) evacuation with burr hole trephination and catheterization.

METHODS

Twelve patients treated by coiling with subsequent ICH drainage with burr hole trephination and catheterization were recruited from 290 patients with ruptured AcomA aneurysm in our hospital between January 2001 and June 2007. The clinical and radiographic characteristics and outcomes of the 12 patients were retrospectively analyzed.

RESULTS

All 12 patients were male, aged from 29 to 62 years, and had ICHs with 16-ml to 45-ml volumes; nine (75%) of them had frontal ICHs on the opposite side of the dominant A1. Admission Hunt-Hess (HH) grade was 4 in eight patients, 3 in two, and 5 in two. The treatment outcomes in 8 of the 12 patients were good recovery or moderately disabled (Glasgow Outcome Scale; GOS 5 or 4), and functionally dependent (GOS 3 or 2) in the other 4 patients at the 6-month clinical follow-up. There was no rebleeding during the follow-up (mean, 22.9 months; range, 7 to 68 months).

CONCLUSION

The result of our series suggests that coiling with subsequent evacuation of the ICH with burr hole trephination and catheterization may be an alternative treatment option for ruptured AcomA aneurysm with an ICH requiring evacuation on the opposite side of the dominant A1.

SUBARACHNOID HEMORRHAGE AND INTRACEREBRAL HEMATOMA

OBJECTIVE

To analyze the incidence and impact of an intracerebral hematoma (ICH) on treatment and outcome in patients with aneurysmal subarachnoid hemorrhage.

METHODS

Data of 585 consecutive patients with subarachnoid hemorrhage from June 1999 to December 2005 were prospectively entered in a database. ICH was diagnosed and size was measured by computed tomographic scan before aneurysm occlusion. Fifty patients (8.5%) presented with an ICH larger than 50 cm3. The treatment decision (coil, clip, or hematoma evacuation) was based on an interdisciplinary approach. Patients were stratified into good (Hunt and Hess Grades I–III) versus poor (Hunt and Hess Grades IV and V) grade, and outcome was assessed according to the modified Rankin Scale at 6 months.

RESULTS

Overall, 358 patients presented in good grade, with 4 of them having ICH (1.1%); and 227 patients presented in poor grade, with 46 of them having ICH (20.3%, P &lt; 0.01). In good-grade patients with an ICH (n = 4), a favorable outcome (modified Rankin Scale score of 0–2) was achieved in 1 patient (25%), and in 246 patients (75%) without an ICH (P = 0.053; odds ratio, 0.11). A favorable outcome was achieved in 5 poor-grade patients (12.8%) with an ICH and in 40 patients (23.7%) without an ICH (P = 0.19; odds ratio, 0.47). Time to treatment was significantly shorter in patients with an ICH than without an ICH (median, 7 versus 26 h; P &lt; 0.001) and shortest in patients with favorable outcome (3.5 hours; P &lt; 0.01).

CONCLUSION

The current data confirm that the presence of an ICH is a predictor of unfavorable outcome. However, despite large ICHs, a significant number of patients have a good outcome. To achieve a favorable outcome, ultra-early treatment with hematoma evacuation and aneurysm obliteration seems to be mandatory.

A less invasive approach for ruptured aneurysm with intracranial hematoma: coil embolization followed by clot evacuation

Objective

The presence of an intracerebral hematoma from a ruptured aneurysm is a negative predictive factor and it is associated with high morbidity and mortality rates even though clot evacuation followed by the neck clipping is performed. Endovascular coil embolization is a useful alternative procedure to reduce the surgical morbidity and mortality rates. We report here on our experiences with the alternative option of endovascular coil placement followed by craniotomy for clot evacuation.

Materials and Methods

Among 312 patients who were admitted with intracerebral subarachnoid hemorrhage during the recent three years, 119 cases were treated via the endovascular approach. Nine cases were suspected to show aneurysmal intracerebral hemorrhage (ICH) on CT scan and they underwent emergency cerebral angiograms. We performed immediate coil embolization at the same session of angiographic examination, and this was followed by clot evacuation.

Results

Seven cases showed to have ruptured middle cerebral artery (MCA) aneurysms and two cases had internal carotid artery aneurysms. The clinical status on admission was Hunt-Hess grade (HHG) IV in seven patients and HHG III in two. Surgical evacuation of the clot was done immediately after the endovascular coil placement. The treatment results were a Glasgow Outcome Scale score of good recovery and moderate disability in six patients (66.7%). No mortality was recorded and no procedural morbidity was incurred by both the endovascular and direct craniotomy procedures.

Conclusion

The results indicate that the coil embolization followed by clot evacuation for the patients with aneurysmal ICH may be a less invasive and quite a valuable alternative treatment for this patient group, and this warrants further investigation.

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND

Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients.

METHODS

Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score).

RESULTS

The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome.

CONCLUSIONS

In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.

Treatment of intracerebral hematomas caused by aneurysm rupture: coil placement followed by clot evacuation

OBJECT

The aim of this study was to evaluate the efficacy of a treatment combination of coil embolization and clot evacuation in patients presenting with an intracerebral hematoma (ICH) caused by the rupture of an aneurysm.

METHODS

Twenty-seven patients were prospectively recruited in this study between 1996 and 2000. Endovascular treatment of the putative ruptured aneurysm was performed as soon as practical after diagnosis and before surgical evacuation of the ICH. The Glasgow Outcome Scale (GOS) was used during follow up. Despite admission World Federation of Neurosurgical Societies grades of IV or V in 25 patients (92%), 13 (48%) recovered well with GOS scores of 1 or 2, whereas six patients (21%) died.

CONCLUSIONS

The combined result of a favorable outcome in 48% of the patients and a mortality rate of 21% indicates that this treatment may be a valuable alternative for this patient group and warrants further study.

Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas

OBJECTIVE

As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome.

METHODS

Eight patients (mean age, 56.5 yr; age range, 42-66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30-175 ml). Patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes.

RESULTS

All of the eight patients tolerated the craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (> or = 1 yr, except for one patient who died during the hospital stay) demonstrated that the craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemicraniectomy group were five good or excellent, one fair, and two poor or dead.

CONCLUSION

The data gathered in this study demonstrate that decompressive craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.

Subarachnoid haemorrhage: diagnosis, causes and management

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

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.

Functional outcome after aneurysmal subarachnoid hemorrhage

The introduction of the operating microscope, the principle of early surgery, specialized intensive care units, the calcium antagonist nimodipine, the sophisticated pre- and postoperative management and an aggressive antiischemic pharmacological management have substantially reduced morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). In spite of this progress, many patients after rupture and surgical repair of an intracranial aneurysm exhibit substantial cognitive deficits and emotional problems although their neurological outcome was rated as good according to the Glasgow Outcome Scale (GOS = I). Therefore, a comprehensive neuropsychological examination is called for in order to evaluate the factual functional outcome after SAH. Neither focal brain damage associated with aneurysm location nor surgery but the hemorrhage itself and related events can be regarded as the most important causal factors for the late result after SAH. In contrast to the mild permanent effects of aneurysm surgery, the initial bleeding itself seems to have substantial lasting adverse neurobehavioral effects after. In concordance with other authors our own data stress the strong predictive power of the bleeding pattern such as the presence of intraventricular and/or intracerebral blood on the functional outcome after aneurysmal SAH.

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.

Does nimodipine influence sex difference in outcome after aneurysmal subarachnoid haemorrhage?

Before nimodipine was introduced as a standard treatment in patients with aneurysmal subarachnoid haemorrhage (SAH) females had a significantly poorer outcome which might be due to a higher frequency of delayed cerebral ischaemia (DCI). We evaluated the overall outcome with regard to gender in 188 consecutive patients with a verified ruptured intracranial aneurysm treated with nimodipine. The only significant differences concerning prognostic factors between the sexes were a higher frequency of SAH at the primary CT in female (p < 0.05) and a higher frequency of middle cerebral artery aneurysms in females (p < 0.01). These factors affect the outcome in females unfavourably. However, contrary to previous studies, we found no difference in overall outcome after three months between the sexes in this clinical material. Our observation can be explained by a positive effect of nimodipine on DCI.