The effect of surgery on the severity of vasospasm

Vasospasm-related complications after subarachnoid hemorrhage: the role of patients' age and sex

BACKGROUND

Outcome of aneurysmal subarachnoid hemorrhage (SAH) depends strongly on occurrence of symptomatic vasospasm (SV) leading to delayed cerebral ischemia (DCI). Various demographic, radiographic, and clinical predictors of SV have been reported so far, partially with conflicting results. The aim of this study was to analyze the role of patients' age and sex on SV/DCI risk, especially to identify age and sex-specific risk groups.

METHODS

All patients admitted with acute SAH during a 14-year-period ending in 2016 were eligible for this study. The study endpoints were the following: SV requiring spasmolysis, occurrence of DCI in follow-up computed tomography scans and unfavorable outcome at 6 months (modified Rankin scale > 2).

RESULTS

Nine hundred ninety-four patients were included in this study. The majority was female (666; 67%). SV, DCI, and unfavorable outcomes were observed in 21.5, 21.8, and 43.6% of the patients, respectively. Younger age (p < 0.001; OR = 1.03 per year decrease) and female sex (p = 0.025; OR = 1.510) were confirmed as independent predictors of SV. Regarding the sex differences, there were three age groups for SV/DCI risk ≤ 54, 55-74, and ≥ 75 years. Male patients showed earlier decrease in SV risk (at ≥ 55 vs. ≥ 75 years in females). Therefore, SAH females aged between 55 and 74 years were at the highest risk for DCI and unfavorable outcome, as compared to younger/older females (p = 0.001, OR = 1.77/p = 0.001, OR = 1.80). In contrast, their male counterparts did not show these risk alterations (p = 0.445/p = 0.822).

CONCLUSION

After acute SAH, female and male patients seem to show different age patterns for the risk of SV and DCI. Females aged between 55 and 74 years are at particular risk of vasospasm-related SAH complications, possibly due to onset of menopause.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS, Unique identifier: DRKS00008749.

The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.

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.

Risk Factors for Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature

OBJECTIVE

To examine the literature on risk factors for cerebral vasospasm (CV), one of the most serious complications following aneurysmal subarachnoid hemorrhage (SAH), with special reference to the definition of CV.

METHODS

Using standard search engines, including PubMed, the medical literature on risk factors for CV after SAH was reviewed, and the best definition representative of CV was searched.

RESULTS

Severe SAH evident on computed tomography scan was the only consistent risk factor for CV after SAH. Effects of risk factors on CV, including age, clinical grade, rebleeding, intraventricular or intracerebral hemorrhage on computed tomography scan, acute hydrocephalus, aneurysm site and size, leukocytosis, interleukin-6 level, and cardiac abnormalities, appeared to be associated with the severity of SAH rather than each having a direct effect. Cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram were associated with CV without any relationship to SAH severity. With regard to parameters representative of CV, the grade of angiographic vasospasm (i.e., the degree of arterial narrowing evident on angiography) was the most adequate. Nevertheless, few reports on the risk factors associated with angiographic vasospasm grade have been reported to date.

CONCLUSIONS

Severe SAH evident on computed tomography scan appears to be a definite risk factor for CV after SAH, followed by cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram. To understand the pathogenesis of CV, further studies on the relationships between risk factors, especially factors not related to the severity of SAH, and angiographic vasospasm grade are necessary.

Factors associated with outcomes in ruptured aneurysmal patients: Clinical Study of 80 Patients

Background: Due to insufficient data in the literature, the optimal timing for surgical intervention for ruptured intracranial aneurysms is still controversial. Some practitioners advocate early surgery, but others not. It is important to identify other factors that can be used to predict poor prognosis in ruptured intracranial aneurysm patients. Objective: To determine the influence of timing of clipping surgery, and other factors on the outcomes of ruptured intracranial aneurysms in Hunt & Hess I~III grade patients. Method: We have performed a retrospective study involving 80 patients who were surgically treated for ruptured intracranial aneurysm between 2007 and 2012. The patient population consisted of 50(62.5%) females and 30(37.5%) males, with an age range of 12 to 75 years old, mean age 52.33 ± 10.63 years. We measured association between the Glasgow Outcome Scores and Sex, timing of clipping surgery, aneurysm location and pre-operative patient's neurological condition using famous Hunt and Hess grade system. Results: We did not find any correlation between the outcomes of ruptured intracranial aneurysm patients and timing (early, intermediate, late stage) of clipping, sex, aneurysm location. Whereas there is a significant correlation between patients outcomes and pre-operative patient neurological condition (Hunt & Hess grade). Conclusion: Timing of Surgery (early, intermediate, late) does not affect outcomes in low Hunt and Hess grade patients I~III. Whereas neurological condition (Hunt & Hess) has strong impact on postoperative outcomes. Others factors like sex, Age, Aneurysm location have no effect on outcomes in ruptured intracranial aneurysms.

Extent of collateralization predicting symptomatic cerebral vasospasm among pediatric patients: correlations among angiography, transcranial Doppler ultrasonography, and clinical findings

OBJECT

Although the development and prevalence of cerebral vasospasm (CV) has been extensively investigated in adults, little data exist on the development of CV in children. The authors hypothesized that even though children have highly vasoreactive arteries, because of a robust cerebral collateral blood flow, they rarely develop symptomatic CV.

METHODS

The authors retrospectively reviewed their university hospital's neurointerventional database for children (that is, patients ≤ 18 years) who were examined or treated for aneurysmal or traumatic subarachnoid hemorrhage (SAH) during the period 1990-2013. Images from digital subtraction angiography (DSA) were analyzed for the extent of CV and collateralization of the cerebral circulation. Results from transcranial Doppler (TCD) ultrasonography were correlated with those from DSA. Cerebral vasospasm on TCD ultrasonography was defined according to criteria developed for adults. Clinical outcomes of CV were assessed with the pediatric modified Rankin Scale (mRS).

RESULTS

Among 37 children (21 boys and 16 girls ranging in age from 8 months to 18 years) showing symptoms of an aneurysmal SAH (comprising 32 aneurysms and 5 traumatic pseudoaneurysms), 17 (46%) had CV confirmed by DSA; CV was mild in 21% of these children, moderate in 50%, and severe in 29%. Only 3 children exhibited symptomatic CV, all of whom had poor collateralization of cerebral vessels. Among the 14 asymptomatic children, 10 (71%) showed some degree of vessel collateralization. Among 16 children for whom TCD data were available that could be correlated with the DSA findings, 13 (81%) had CV according to TCD criteria. The sensitivity and specificity of TCD ultrasonography for diagnosing CV were 95% and 59%, respectively. The time to CV onset detected by TCD ultrasonography was 5 ± 3 days (range 2-10 days). Twenty-five (68%) of the children had good long-term outcomes (that is, had mRS scores of 0-2).

CONCLUSIONS

Children have a relatively high incidence of angiographically detectable, moderate-to-severe CV. Children rarely develop symptomatic CV and have good long-term outcomes, perhaps due to robust cerebral collateral blood flow. Criteria developed for detecting CV with TCD ultrasonography in adults overestimate the prevalence of CV in children. Larger studies are needed to define TCD ultrasonography-based CV criteria for children.

Cerebral vasospasm in patients over 80 years treated by coil embolization for ruptured cerebral aneurysms

Object. The effect on clinical outcomes of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage (SAH) in patients over 80 years who underwent coil embolization was evaluated. Methods. Forty-four cases were reviewed and divided into two groups according to patient age: Group A, 79 years or younger, and Group B, 80 or older. Patient characteristics, prevalence of symptomatic vasospasm, modified Rankin Scale (mRS) scores at discharge and frequency of symptomatic vasospasm in patients with mRS scores of 3–6 were analyzed. Results. Thirty-two (73%) of the 44 cases were categorized as Group A and 12 (27%) as Group B. Group B had a significantly higher prevalence of symptomatic vasospasm compared to Group A (P = 0.0040). mRS scores at discharge were significantly higher in Group B than in Group A (P = 0.0494). Among cases with mRS scores of 3–6, there was a significantly higher frequency of symptomatic vasospasm in Group B than in Group A (P = 0.0223). Conclusions. In our cohort of aneurysmal SAH patients treated by coil embolization, patients over 80 years of age were more likely to suffer symptomatic vasospasm, which significantly correlated with worse clinical outcomes, than those 79 years and under.

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

The removal of subarachnoid clot has been thought to be effective for prevention of cerebral vasospasm. However, it is suggested that the incidence of cerebral vasospasm is not high in the cases where ruptured cerebral aneurysms are obliterated using Guglielmi detachable coils (GDC) without clot removal. The effect of subarachnoid clot removal on the occurrence of cerebral vasospasm and the different incidence of cerebral vasospasm between clipping cases and in GDC cases are reviewed.Surgical clot removal in experimental model indicated marked preventive effect on cerebral vasospasm. However, the clinical trials of clot removal during early aneurysm surgery had failed to show satisfactory preventive effect for vasospasm, and the cumulative incidence of symptomatic vasospasm in these trials was 29%. As fibrinolytic drug, intrathecal administration of tissue plasminogen activator showed sufficient elimination of subarachnoid clot and prevention of cerebral vasospasm in the experimental studies and in the clinical case trials and nonrandomized case-control trials. However, the multi-center, randomized case-control trial showed no statistically significant effect on symptomatic cerebral vasospasm. On the other hand, the cumulative incidence of cerebral vasospasm in GDC cases was 20%. The comparative studies of the incidence of vasospasm between GDC cases and in clipping cases also showed less incidence of symptomatic vasospasm and a more favorable outcome in GDC cases. From the results of studies reviewed, the incidence of cerebral vasospasm seems less in GDC cases than in clipping cases. It should be clarified why clipping could not be dominant in the prevention of cerebral vasospasm compared to GDC.

Type of Admission is Associated with Outcome of Spontaneous Subarachnoid Hemorrhage

Background

Admitting facility may significantly affect outcome for spontaneous subarachnoid hemorrhage patients. We assessed outcomes of patients admitted directly to a comprehensive stroke center with those initially admitted to a general hospital and subsequently transferred. The comprehensive stroke center included a neurocritical care ICU, cerebrovascular neurosurgeons and endovascular specialists.

Methods

We identified 107 consecutive spontaneous subarachnoid hemorrhage cases. Of these cases, 31 (29%) patients were admitted directly and 76 (71%) were transferred from general hospitals. Univariate and multivariate analyses evaluated differences in mortality, complications, discharge disposition, and in-hospital length of stay.

Results

Differences in baseline parameters (age, gender, admission Glasgow Coma Scale, Fisher grade, admission Hunt and Hess grade) were not statistically significant between direct-admit and transfer patients at our institution. Transferred patients developed vasospasm more frequently (58% vs. 32%; P < 0·05) and had a longer delay time to surgery (3·9-days vs. 2·4-days: P < 0·05). Multivariate analysis showed that the likelihood of vasospasm was significantly higher for transfer patients (OR 3·46, CI: 1·2–10·3, P = 0·03). In addition, longer in-hospital stays and higher odds of non-routine discharge were observed in transferred patients ( P < 0·01). No differences in outcome could be identified for surgical vs. endovascular treatment rates between direct-admit and transfer patients. An association, but no causative link, can be made between the effect of transfer and the outcomes of SAH patients due to the retrospective nature of our study.

Conclusions

Spontaneous subarachnoid hemorrhage patients admitted directly to our comprehensive stroke center showed less complications compared to those transferred from general hospitals. This improvement was independent of time to treatment. Additional research in multiple centers using prospective analysis should be conducted to confirm that preferential direct transport to a comprehensive stroke center would likely yield considerable improvements in public health.

Method of Aneurysm Treatment Does Not Affect Clot Clearance After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients undergoing neurosurgical clipping or endovascular coiling of a ruptured aneurysm may differ in their risk of vasospasm.

OBJECTIVE

Because clot clearance affects vasospasm, we tested the hypothesis that clot clearance differs in patients depending on method of aneurysm treatment.

METHODS

Exploratory analysis was performed on 413 patients from CONSCIOUS-1, a prospective randomized trial of clazosentan for the prevention of angiographic vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Clot clearance was measured by change in Hijdra score between baseline computed tomography and one performed 24 to 48 hours after aneurysm treatment. Angiographic vasospasm was assessed by the use of catheter angiography 7 to 11 days after SAH, and delayed ischemic neurological deficit (DIND) was determined clinically. Extended Glasgow Outcome Score (GOSE) was assessed 3 months after SAH, and poor outcome was defined as death, vegetative state, or severe disability. Multivariable ordinal and binary logistic regression were used.

RESULTS

There was no significant difference in the rate of clot clearance between patients undergoing clipping or coiling (P = .56). Coiling was independently associated with decreased severity of angiographic vasospasm (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.33-0.86), but not with DIND or GOSE. Greater clot clearance decreased the risk of severe angiographic vasospasm (OR 0.86, 95% CI 0.81-0.91), whereas higher baseline Hijdra score predicted increased angiographic vasospasm (OR 1.17, 95% CI 1.11-1.23) and poor GOSE (OR 1.09, 95% CI 1.04-1.14).

CONCLUSION

Aneurysm coiling and increased clot clearance were independently associated with decreased severity of angiographic vasospasm in multivariate analysis, although no differences in clot clearance were seen between coiled and clipped patients.

Early surgery of multiple versus single aneurysms after subarachnoid hemorrhage: an increased risk for cerebral vasospasm?

OBJECT

As many as 33% of patients suffering from subarachnoid hemorrhage (SAH) present with multiple intracranial aneurysms (MIAs). It is believed that aneurysm surgery has the potential to increase the risk of cerebral vasospasm due to surgical manipulations of the parent vessels and brain tissue. Consequently, 1-stage surgery of MIAs, which usually takes longer and requires more manipulation, could even further increase the risk of vasospasm. The aim of this study is to define the correlation between vasospasm and the operative treatment of single intracranial aneurysms versus MIAs in a 1-stage operation.

METHODS

The authors analyzed a database including 1016 patients with SAH, identified retrospectively between 1989 and 1996 and prospectively collected between 1997 and 2004. Exclusion criteria were endovascular treatment, surgery after SAH Day 3, and, in patients with MIAs, undergoing more than 1 operation. Cerebral vasospasm was diagnosed by transcranial Doppler (TCD) ultrasonography and was defined as a maximum mean blood flow velocity > 120 cm/second. The diagnosis of symptomatic vasospasm was made if a new neurological deficit occurred that could not be explained by concomitant complications.

RESULTS

A total of 643 patients who experienced 810 aneurysms were included. Four hundred twenty-four patients were female (65.9%) and 219 were male (34.1%) with an average age of 53.1 years. One hundred twenty-one patients (18.8%) were diagnosed with MIAs. Maximum mean flow velocities measured by TCD were 131 cm/second in patients with MIAs and 129.5 cm/second in patients with single intracranial aneurysms. The incidence of TCD vasospasm (p = 0.561) as well as of symptomatic vasospasm (p = 0.241) was not significantly different in the 2 groups.

CONCLUSIONS

Clipping of more than 1 aneurysm in a 1-stage operation within 72 hours after SAH can be performed without increasing the risk of cerebral (TCD) vasospasm and symptomatic vasospasm.

Patient Age and Vasospasm After Subarachnoid Hemorrhage

BACKGROUND:

Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm is a devastating disease with high mortality and morbidity. The incidence of SAH increases with advancing age.

OBJECTIVE:

To determine whether age is an independent predictor of angiographic vasospasm, delayed ischemic neurological deficits (DINDs), or abnormal transcranial Doppler (TCD) measurements in patients with aneurysmal subarachnoid hemorrhage.

METHODS:

Data from CONSCIOUS-1 (Clazosentan to Overcome Neurological Ischemia and Infarct Occurring After Subarachnoid Hemorrhage study), a dose-finding study of clazosentan, were used. Data on angiographic vasospasm, DINDs, and TCD abnormalities were prospectively recorded as well as baseline characteristics and treatment data. Patient age was considered in 3 ways: as a continuous variable, dichotomized at age 65 years, and categorized by decade. Age was investigated as the main variable, whereas other possible confounding variables were adjusted for in the multiple logistic regression modeling with each of 3 dichotomized vasospasm outcome measures, presence or absence of angiographic vasospasm, DINDs, and TCD abnormalities as the dependent variable.

RESULTS:

The proportions of patients with angiographic vasospasm, DINDs, and TCD abnormalities were 45%, 19%, and 81%, respectively. Age, whether considered as a continuous, dichotomous, or a categorical variable, was not significantly associated with angiographic vasospasm, DINDs, or abnormal TCD measurements.

CONCLUSION:

Age does not seem to be a significant predictor for cerebral vasospasm after subarachnoid hemorrhage.

Short-Term Antifibrinolytic Therapy Before Early Aneurysm Treatment in Subarachnoid Hemorrhage: Effects on Rehemorrhage, Cerebral Ischemia, and Hydrocephalus

BACKGROUND:

Long-term administration of the antifibrinolytic agent epsilon aminocaproic acid (EACA) reduces the rate of rehemorrhage in patients with aneurysmal subarachnoid hemorrhage (SAH), but is associated with cerebral ischemia.

OBJECTIVE:

To evaluate short-term administration of EACA before early surgery in patients with SAH.

METHODS:

Retrospective review of 356 patients admitted between June 2002 and December 2007 with a diagnosis of aneurysmal SAH. Medical records were reviewed to determine SAH risk factors, clinical grade at the time of admission, and incidence of rehemorrhage, permanent new-onset focal neurological deficits, computed tomography evidence of cerebral infarction, symptomatic vasospasm, and hydrocephalus.

RESULTS:

Patients underwent treatment of the ruptured aneurysm an average of 47.4 hours after admission and received an average total dose of 40.6 g of EACA. The mean length of time of administration of EACA was 35.6 hours. There was a total of 5 rehemorrhages, for an overall rebleeding rate of 1.4% and a rate of rehemorrhage per 24-hour period of 0.71%. Overall, the rates of symptomatic vasospasm and permanent neurological deficits attributable to ischemic stroke were 11.5% and 7.2%, respectively, and the incidence of shunt-dependent hydrocephalus was 42.3%. Patients who were treated with coiling had higher rates of symptomatic vasospasm and ischemic complications than patients who had surgery.

CONCLUSION:

Short-term administration of EACA is associated with rates of rehemorrhage, ischemic stroke, and symptomatic vasospasm that compare favorably with historical controls. The rate of hydrocephalus is relatively high and may be attributable to EACA treatment.

Association of a younger age with an increased risk of angiographic and symptomatic vasospasms following subarachnoid hemorrhage

Object

Vasospasm is a leading cause of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). It is important to predict which patients are at risk for vasospasm so that interventions can be made. There are several potential risk factors for vasospasm, one of which is age. However, the effect of age on vasospasm, particularly symptomatic vasospasm, remains controversial.

Methods

Three hundred ninety-one patients were retrospectively identified from a prospective observational database of patients with SAH who had been admitted to a single center. Demographic and clinical data were recorded, and cerebral angiograms obtained at admission and between 5 and 10 days later were compared. The relationship between age and angiographic and symptomatic vasospasms was examined using logistic regression techniques.

Results

Mild (86 patients), moderate (69 patients), severe (56 patients), and no angiographic vasospasms (180 patients) were documented by comparing admission and follow-up angiograms in each patient. Symptomatic vasospasm was identified in 69 patients (17.6%). Angiographic vasospasm was more frequent as age decreased. Except in patients < 30 years old, the frequency of symptomatic vasospasm also increased with decreasing age (p = 0.0001). After adjusting for variables known to be associated with vasospasm, an advanced age was associated with a reduced incidence of any angiographic vasospasm (OR 0.96, 95% CI 0.94–0.97), severe angiographic vasospasm (OR 0.96, 95% CI 0.95–0.98), and symptomatic vasospasm (OR 0.98, 95% CI 0.96–0.99).

Conclusions

Results in this study show that a younger age is associated with an increased incidence of angiographic and symptomatic vasospasm.

Treatment of Intracranial Aneurysms

The management of intracranial aneurysms (IAs) remarkably improved due to the development of diagnostic and surgical procedures. Subarachnoid hemorrhage (SAH) from IA rupture constitutes a devastating event, whose prognosis remains unsatisfactory. At present, several researchs are targeted to individuate subjects harboring unruptured IAs and those presenting a higher risk for rupture. Numerous risk factors for the rupture of lAs have been individuated. The prevalence of intracranial saccular aneurysms in the general population is estimated from 0.2% to 6.8%, with an incidence of SAH at 10/100,000/year. The most relevant morbidity and mortality rates after SAH are related to rebleeding and vasospasm. The primary therapeutic target consists in prevention of rebleeding. At present, therapeutic opportunities for intracranial aneurysms are microsurgery and endovascular treatment.

Effects of temporary clipping during aneurysm surgery

OBJECTIVE

Intraoperative aneurysm rupture is associated with a high morbidity and mortality. Temporary vessel occlusion is an integral part of aneurysm clipping to avoid intraoperative hemorrhage. The information concerning the role of temporary occlusion regarding the development of cerebral vasospasm is sparse. The aim of this study was to provide more information in this field.

METHODS

We operated on 292 patients suffering from cerebral aneurysms. The data were reviewed from a prospectively collected databank, which includes information about the severity of subarachnoid hemorrhage, as well as transcranial Doppler data and surgical data such as temporary occlusion.

RESULTS

In 50% of our patients, temporary occlusion was performed during surgery. Twenty-nine percent showed an ischemic lesion in the CCT post-operatively, and in 58% of these patients, temporary occlusion was performed (versus 47% without temporary occlusion, p = 0.09). The mean occlusion time was longer in patients with radiologic signs of infarction. Furthermore, patients having unfavorable outcome showed a longer temporary occlusion time. Thirty-four percent of patients who underwent temporary vessel occlusion developed vasospasm postoperatively (versus 20% without temporary occlusion, p < 0.006). Temporary occlusion time correlated to the development of vasospasm as defined by transcranial Doppler flow velocity. Forty-eight percent of the patients treated using temporary occlusion suffered from middle cerebral artery aneurysm (versus 22% without temporary occlusion, p < 0.0001). An increased blood flow velocity was mostly seen in this region (p < 0.003).

CONCLUSION

According to our results, it seems to be the possible that temporary vessel occlusion is an additional factor in aggravating vasospasm after aneurysmatic subarachnoid hemorrhage.

Peri-operative measures for treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high early mortality rates. Cerebral vasospasm remains the major source of morbidity after aSAH. Angiographic evidence of vasospasm is apparent in 70% of patients, while clinical manifestation of vasospasm is present in one third of patients. Early or existing vasospasm at the time of presentation poses an additional challenge in the management of the patient, and forms the basis for this review.

METHODS

Treatment modalities for management of ruptured aneurysms in the setting of vasospasm, including timing of aneurysm surgery and peri-operative management, are reviewed. Intraoperative measures aimed at treatment of existing vasospasm and at the prevention of vasopasm are discussed.

RESULTS

Operative/endovascular means to secure the ruptured aneurysm should be performed as soon as possible to facilitate treatment of the vasospasm. Surgery performed in the presence of angiographic/symptomatic vasospasm can be associated with good outcome. Operative measures to decrease the incidence of vasospasm include clot removal, intracisternal injection of thrombolytics, fenestration of the lamina terminalis and local application of vasodilatory agents. Post-operative measures include early intra-arterial injection of vasodilators (verapamil or nicardipine), percutaneous angioplasty, triple-H therapy and CSF drainage.

DISCUSSION

The utilization of a multimodality approach to treat patients with aneurysmal subarachnoid hemorrhage presenting with existing vasospasm can result in good outcome.

Coil Embolization of Aneurysm Followed by Stereotactic Aspiration of Hematoma in a Patient with Anterior Communicating Artery Aneurysm Presenting with SAH and ICH

Even though intracerebral hematoma (ICH) due to ruptured cerebral aneurysm has been treated by aneurysm clipping at the same time of removal of ICH through craniotomy, such management strategy is controversial in an aged patients with poor clinical grade. In this regards, stereotactic aspiration of hematoma following coil embolization can be an alternative treatment modality. Thus, the authors report a case of an aged patient who underwent stereotactic aspiration of ICH following coil embolization for the ruptured aneurysm with a brief review of literature.

Monocyte chemoattractant protein–1 predicts outcome and vasospasm following aneurysmal subarachnoid hemorrhage

Object

Despite efforts to elucidate both the molecular mechanism and the clinical predictors of vasospasm after aneurysmal subarachnoid hemorrhage (ASAH), its pathogenesis remains unclear. Monocyte chemoattractant protein–1 (MCP-1) is a chemokine that has been firmly implicated in the pathophysiology of vasospasm and in neural tissue injury following focal ischemia in both animal models and human studies. The authors hypothesized that MCP-1 would be found in increased concentrations in the blood and cerebrospinal fluid (CSF) of patients with ASAH and would correlate with both outcome and the occurrence of vasospasm.

Methods

Seventy-seven patients who presented with ASAH were prospectively enrolled in this study between July 2001 and May 2002. Using an enzyme-linked immunosorbent assay, MCP-1 levels were measured in serum daily and in CSF when available. The mean serum and CSF MCP-1 concentrations were calculated for each patient throughout the entire hospital stay. Neurological outcome was evaluated at discharge or 14 days posthemorrhage using the modified Rankin Scale. Vasospasm was evaluated on angiography.

Results

The serum MCP-1 concentrations correlated with negative outcome such that a 10% increase in concentration predicted a 25% increase in the probability of a poor outcome, whereas the serum MCP-1 levels did not correlate with vasospasm. Concentrations of MCP-1 in the CSF, however, proved to be significantly higher in patients with angiographically demonstrated vasospasm.

Conclusions

These findings suggest a role for MCP-1 in neurological injury and imply that it may act as a biomarker of poor outcome in the serum and of vasospasm in the CSF.

Transcranial Doppler monitoring and clinical decision-making after subarachnoid hemorrhage

Our objective was to examine the impact of transcranial Doppler ultrasound (TCD) vasospasm monitoring on clinical decision-making following subarachnoid hemorrhage (SAH). The records of 50 randomly selected patients undergoing serial TCD monitoring following SAH were reviewed. Dates and results of TCDs and cerebral angiograms, the use of hypertensive hemodilution (HH) therapy, and the development of new neurological deficits were recorded. The independent effects of TCD-defined vasospasm and new neurological deficits on patient management were determined with multiple logistical regression. Results were validated in a second randomly selected, 50 patient cohort. Mild or moderate TCD-defined vasospasm developed in 76% of patients 5.8 +/- 0.5 days after SAH; 38% developed severe TCD-defined vasospasm after 7.9 +/- 0.7 days. Focal neurological deficits occurred in 50% after 5.7 +/- 0.6 days with TCD abnormalities preceding the deficit by 2.5 +/- 0.7 days in 64%. TCD-defined vasospasm or a new neurological deficit explained 60% of the variance in the use of HH therapy (P = .005). New neurological deficits increased the odds of HH therapy 33-fold (P = .004) whereas there was no independent effect of TCD-defined vasospasm. These variables explained 64% of the variance in the performance of angiography (P = .0002). An abnormal TCD did not increase the odds of angiography whereas its use increased 28-fold (P = .01) after a neurological deficit developed. These results were confirmed in an independent cohort. We concluded that TCD-defined vasospasm did not independently influence the use of HH therapy or angiography with both decisions associated with the development of new neurological deficits. As TCD-defined vasospasm preceded the neurological deficit in 64%, earlier intervention might reduce the incidence of vasospasm-related stroke in institutions with similar practice patterns.

Bilirubin oxidation products (BOXes) and their role in cerebral vasospasm after subarachnoid hemorrhage

Many factors have been postulated to cause delayed subarachnoid hemorrhage (SAH)-induced vasospasm, including hemoglobin, nitric oxide, endothelin, and free radicals. We propose that free radicals (because of the high levels that are produced in the blood clots surrounding blood vessels after SAH) act on bilirubin, biliverdin, and possibly heme to produce BOXes (Bilirubin OXidized Products). Bilirubin oxidation products act on vascular smooth muscle cells to produce chronic vasoconstriction and vasospasm combined with a vasculopathy because of smooth muscle cell injury. This review summarizes recent evidence that BOXes play a role in SAH-induced vasospasm. The data supporting a role for BOXes includes (1) identification of molecules in cerebrospinal fluid (CSF) of patients with vasospasm after SAH that have structures consistent with BOXes; (2) BOXes are vasoactive in vitro and mimic the biochemical actions of CSF of patients with vasospasm; (3) BOXes are vasoactive in vivo, constricting rat cerebral vessels; and (4) there is a correlation between clinical occurrence of vasospasm and BOXes concentration in our preliminary study of patients with SAH. Since oxidation of bilirubin, biliverdin, and perhaps heme is proposed to produce BOXes that contribute to vasospasm, either blocking bilirubin formation, inactivating bilirubin or BOXes, or removing all of the blood clot before vasospasm are potential treatment targets.

Impact of Coil Embolization on Overall Management and Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE:

We report on the consequences of introducing coil embolization for the total management of and outcome in patients with subarachnoid hemorrhage (SAH).

METHODS:

In southern Sweden, a prospective analysis of all patients with SAH of verified aneurysmal origin was conducted during the 3 years when coiling was gradually being introduced. The incidence of acute or chronic hydrocephalus, vasospasm, delayed ischemic deterioration, and outcome at 3 to 6 months after bleeding was analyzed.

RESULTS:

Coiling of aneurysms was used progressively more compared with clipping during the study period. The number of patients subjected to coiling was 26 (36%) of 73 patients during calendar year 1997, 43 (53%) of 81 patients in 1999, and 55 (74%) of 74 patients in 2001 (P &lt; 0.0001). Gradually, more elderly patients were admitted during the study period. Virtually all aneurysms located in the posterior circulation were treated by coil embolization, even at the start of the study, whereas aneurysms at all other locations were progressively more likely to be treated similarly. The incidence of hydrocephalus in the acute (average for all 3 yr, 39%) or chronic (16%) phase, vasospasm as measured by Doppler sonography (33%), and delayed ischemic deterioration (29%), as well as outcome at 3 to 6 months (61% good recovery, 13% deceased), did not change significantly during the study. The main cause of unfavorable outcome was the severity of the SAH.

CONCLUSION:

The increasing use of coil embolization for ruptured aneurysms in the anterior circulation did not have any significant impact on the overall incidence of SAH-related complications or outcome. The main determinant for outcome after SAH is still the severity of the SAH.

Clot volume and clearance rate as independent predictors of vasospasm after aneurysmal subarachnoid hemorrhage

OBJECT

This study was conducted for two purposes. The first was to determine whether a combination of measurements of subarachnoid clot volume, clearance rate, and density could improve prediction of which patients experience vasospasm. The second was to determine if each of these three measures could be used independently to predict vasospasm.

METHODS

Digital files of the cranial computerized tomography (CT) scans obtained in 75 consecutive patients admitted within 24 hours of subarachnoid hemorrhage (SAH) were analyzed in a blinded fashion by an observer who used quantitative imaging software to measure the volume of SAH and its density. Clot clearance rates were measured by quantifying SAH volume on subsequent CT scans. Vasospasm was defined as new onset of a focal neurological deficit or altered consciousness 5 to 12 days after SAH in the absence of other causes of deterioration, diagnosed with the aid of or exclusively by confirmatory transcranial Doppler ultrasonography and/or cerebral angiography. Univariate analysis showed that vasospasm was significantly associated with the SAH grade as classified on the Fisher scale, the initial clot volume, initial clot density, and percentage of clot cleared per day (p < 0.05). In multivariate analysis, initial clot volume and percentage of clot cleared per day were significant predictors of vasospasm (p < 0.05), whereas Fisher grade and initial clot density were not.

CONCLUSIONS

Quantitative analysis of subarachnoid clot shows that vasospasm is best predicted by initial subarachnoid clot volume and the percentage of clot cleared per day.

Reduction of ischemic sequelae following spontaneous subarachnoid hemorrhage: a double-blind, randomized comparison of enoxaparin versus placebo

BACKGROUND

Cerebral vasospasm, including its ischemic sequelae, remains a leading cause of death and disability following subarachnoid hemorrhage (SAH). This study was designed to evaluate whether the low-molecular-weight heparin (LMWH) enoxaparin reduces the occurrence of cerebral vasospasm and ischemia following spontaneous SAH.

METHODS

A prospective, double-blind, randomized study was conducted in 120 consecutive patients with SAH (Hunt Hess Scale (HHS) I-III). Patients received one subcutaneous injection per day of either 20mg enoxaparin or placebo for 3 weeks following SAH. Efficacy endpoints were the occurrence of cerebral vasospasm, delayed ischemic deficit (DID), cerebral infarction, and overall outcome at 1 year following SAH.

RESULTS

At 1-year follow-up, enoxaparin significantly reduced DID and cerebral infarction. Delayed ischemic deficit occurred in 8.8% of the enoxaparin group versus 66.7% of the placebo group (P<0.001), while 3.5% of vasospasm-related cerebral infarctions occurred in enoxaparin-treated patients and 28.3% in placebo-treated patients (P<0.001). Severe shunt-dependent hydrocephalus was significantly lower in the enoxaparin group (1.8% versus 16.7%; P=0.019). Compared with the placebo group, the enoxaparin group had fewer intracranial bleeding events and better overall outcomes at 1-year follow-up. Although there was potential bias as a result of patients in the placebo group being more severely affected (in terms of HHS), treatment with enoxaparin for 3 weeks improved long-term outcome following SAH.

CONCLUSIONS

Enoxaparin is safe and effective in reducing cerebral vasospasm and ischemia following SAH (Hunt Hess grades I-III), resulting in a better long-term outcome for the patient.

Angioplasty and coiling of ruptured aneurysm with symptomatic vasospasm: technical case report

BACKGROUND

Treating a ruptured cerebral aneurysm during symptomatic vasospasm is very difficult. We describe the successful endovascular treatment of such a case and discuss its efficacy.

CASE PRESENTATION

A 34-year-old man had a sudden onset of severe headache. One week later, he was referred to our institute with gradually progressing right hemiparesis and global aphasia. Cerebral angiography demonstrated severe vasospasm of the left internal carotid artery system and an anterior communicating artery aneurysm. With the patient under general anesthesia, 90% occlusion of the aneurysm was achieved with detachable coils after successful dilatation of the spastic vessels. The patient had an uneventful postoperative course and his neurologic symptoms were improved. Seven months after the endovascular treatment, the enlarged neck remnant of the aneurysm was successfully clipped without difficulty.

CONCLUSION

The simultaneous treatment of a ruptured aneurysm and vasospasm with percutaneous transluminal angioplasty and coils can produce a better outcome for the patient.

Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion

OBJECT

The authors studied patients with aneurysmal subarachnoid hemorrhage (SAH) to determine whether the incidence of symptomatic vasospasm or overall clinical outcomes differed between patients treated with craniotomy and clip application and those treated by endovascular coil occlusion.

METHODS

The authors reviewed 415 consecutive patients with aneurysmal SAH who had been treated with either craniotomy and clip application or endovascular coil occlusion at a single institution between 1990 and 2000. Three hundred thirty-nine patients underwent surgical clip application procedures, whereas 76 patients underwent endovascular coil occlusion. Symptomatic vasospasm occurred in 39% of patients treated with clip application, 30% of patients treated with endovascular coil occlusion, and 37% of patients overall. Compared with patients treated with clip application, patients treated with endovascular coil occlusion were more likely to suffer acute hydrocephalus (50 compared with 34%, p = 0.008) and were more likely to harbor aneurysms in the posterior circulation (53 compared with 20%, p < 0.001). Logistic regression models controlling for patient age, admission World Federation of Neurosurgical Societies (WFNS) grade, acute hydrocephalus, aneurysm location, and day of treatment revealed that, among patients with an admission WFNS grade of I to III, endovascular coil occlusion carried a lower risk of symptomatic vasospasm (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.8) and death or permanent neurological deficit due to vasospasm (OR 0.28, 95% CI 0.08-1) compared with craniotomy and clip application. Similar models revealed no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less at the longest follow-up review (median 6 months) between treatment groups (OR 0.58, 95% CI 0.28-1.21).

CONCLUSIONS

Patients with better clinical grades (WFNS Grades I-III) at hospital admission were less likely to suffer symptomatic vasospasm when treated by endovascular coil occlusion, compared with craniotomy and clip application. Nevertheless, there was no significant difference in overall outcome at the longest follow-up examination between the two treatment groups.

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

OBJECT

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

METHODS

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

CONCLUSIONS

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

Aggressive surgical treatment of elderly patients following subarachnoid haemorrhage: management outcome results

This report presents 74 consecutive cases of subarachnoid haemorrhage (SAH) in patients aged 70 years or older, compared with the 317 consecutive younger patients treated during the same period. An ultra-early surgical strategy for all SAH cases was used throughout the study period. Management outcome for all grades of elderly patients was independent in 38%, dependent in 14% and death in 49%. Surgical 3-month outcome of good grade elderly patients was independent 53%, dependent 19% and death 28%; and for poor grades was independent 35%, dependent 15% and death 50%. Elderly poor grade patients had similar outcome to younger patients, although good grade patients had better outcome in the younger group than the elderly group. Despite ultra-early surgery, rebleeding (<12 h of SAH) occurred in 9% of the elderly series. Aggressive, ultra-early treatment is likely to benefit elderly SAH patients, the potential benefit being greater for poor grade elderly patients.

Intracranial vascular surgery

The management of patients for intracranial vascular surgery is very challenging, requiring an aggressive multidisciplinary approach to provide care and improve outcome. This ensures early identification and treatment of the disease, resuscitation when indicated, and continuous and intensive perioperative monitoring to identify and treat potential complications. With advances in neuroimaging, interventional, and surgical techniques, we are increasingly involved in providing neuroanesthetic skills and insightful care to facilitate the successful management of these high-risk patients.

Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study

OBJECTIVES

The debate on the timing of aneurysm surgery after subarachnoid haemorrhage (SAH) pivots on the balance of the temporal risk for fatal rebleeding versus the risk of surgical morbidity when operating early on an acutely injured brain. By following a strict management protocol for SAH, the hypothesis has been tested that in the modern arena of treatment for aneurysmal SAH the timing of surgery to secure supratentorial aneurysms does not affect surgical outcome.

METHODS

Over a 6 year period, patients admitted with a diagnosis of SAH to a regional neurosurgical unit have been prospectively studied. All have been on a management protocol in which early transfer and resuscitation has been followed regardless of age and clinical condition. Angiographic investigation and surgery have been pursued in those who have been able to at least flex to pain. A total of 1168 patients (60.7% female, mean age 54.3) with proved SAH were received on median day 1 (86.4% arrived within 3 days) of the ictus. Of these, 784 (67.1%) showed aneurysms on angiography and were prepared for surgery. Those who received surgery for a supratentorial aneurysm within 21 days of the ictus were included in the final analysis (n=550). Patients with an initial negative angiogram, with posterior circulation aneurysms, or aneurysms treated by endovascular means, with aneurysms requiring emergency surgery for space occupying haematomas, with aneurysms which re-bled before surgery, and those who received very late surgery (after 21 days from ictus) were excluded. Surgical outcomes at hospital discharge and after 6 months were assessed using the Glasgow outcome score (GOS). Discharge destination and duration of stay in a neurosurgical ward were also documented. The influence of the timing of surgery (early group day 1-3 postictus, intermediate group day 4-10, or late group day 11-21) was analysed prospectively.

RESULTS

60.2% of cases fell into the early surgery group, 32.4% into the intermediate group, and 7.5% into the late operated group. Late surgery was due to delays in diagnosis, transfer, and logistic factors, but not clinical decision. The demographic characteristics, site of aneurysm, and clinical condition of the patients at the time of initial medical assessment were balanced in the three surgical timing groups. There was no significant difference in GOS between the surgical timing groups at 6 months (favourable GOS score 4 and 5: 83.2%, 80.5%, and 83.8% respectively; p=0.47, Kruskal-Wallis test). Outcome was favourable in 84% of patients under 65 years, and 70% in those over 65. The discharge destinations (home, referring hospital, nursing home, rehabilitation centre) showed no significant difference between surgical timing groups. There was no significant difference in mean time to discharge after admission to this hospital from the referring hospital (16.2, 16.2, and 14.6 days for early, intermediate, and late groups respectively; p=0.789, Analysis of variance (ANOVA)). As a result, there was reduction in the mean duration of total hospital inpatient stay in favour of the earliest operated patients (mean time 18.1, 22.0, and 28.3 days respectively; p=0.001. ANOVA showed that besides age, the only determinant of surgical outcome and duration of stay was presenting clinical grade (p<0.0005).

CONCLUSION

The current management of patients presenting with SAH from anterior circulation aneurysms allows early surgery to be followed safely regardless of age. The only independent variables affecting outcome are age and clinical grade at presentation. The timing of surgery did not significantly affect surgical outcome, promoting a policy for early surgery that avoids the known risks of rebleeding and reduces inpatient stay.

Effects of aging on cerebral vasospasm after subarachnoid hemorrhage in rabbits

BACKGROUND AND PURPOSE

The effects of aging on cerebral vasospasm after subarachnoid hemorrhage (SAH) remain to be elucidated. The aim of this study was to clarify age-related differences of vasospasm and of papaverine reactivity in the responses of basilar arteries after SAH in rabbits.

METHODS

Rabbits receiving a single injection of arterial blood into the cisterna magna were divided into 3 groups: young (2 to 3 months old), adult (6 to 9 months old), and old (20 to 40 months old). Vertebrobasilar angiograms were obtained before SAH and 1, 2, 4, and 7 days after SAH. Papaverine was administrated selectively via the vertebral artery on day 2, and serial angiography was performed for up to 2 hours. Vessel structures were assessed with light microscopy on days 1, 2, 4, and 7 after SAH and at 10, 30, and 60 minutes after papaverine infusion.

RESULTS

Mortality from SAH in old rabbits was 40%, whereas that of young and adult rabbits was 0%. Angiograms revealed that SAH induced maximal constriction of the basilar arteries on day 2 in all age groups, and the constrictions were significantly increased with age at all time points investigated. The degree of dilatation of spastic basilar arteries after intra-arterial papaverine administration significantly decreased with age. Duration of the efficacy of papaverine became significantly shorter with age. Vessel diameter returned to the preinfusion value approximately 120, 60, and 30 minutes after infusion in young, adult, and old rabbits, respectively. Light microscopy in old rabbits showed luminal narrowing and corrugation of the internal elastic lamina not only in the basilar arteries but also in small arteries and intraparenchymal arterioles.

CONCLUSIONS

This study suggests that aging increases the degree of vasospasm in rabbits. The impaired reactivity to papaverine with aging might imply the early transition of the aged vessel to the papaverine-resistant chronic stage.

Predicting delayed ischemic deficits after aneurysmal subarachnoid hemorrhage using a transient hyperemic response test of cerebral autoregulation

OBJECTIVE

To assess whether the development of delayed ischemic deficits (DIDs) after aneurysmal subarachnoid hemorrhage can be predicted using transcranial Doppler ultrasonography and the transient hyperemic response test (THRT).

METHODS

An increase in the middle cerebral artery peak flow velocity (FV) of more than 9% of baseline values after 5 to 9 seconds of carotid artery compression was defined as a normal THRT result, indicating good autoregulatory reserve. The transcranial Doppler criteria for vasospasm were a FV of more than 120 cm/s and a Lindegaard ratio of more than 3. Twenty patients with no immediate postoperative neurological deficits were studied. The FVs at all of the major cerebral arteries were measured daily after surgery, and the THRT results were assessed bilaterally.

RESULTS

Five of six patients with abnormal THRT results in the first examination after surgery (primary THRT impairment) developed DIDs; none of the remaining patients developed DIDs (Fisher exact test, P = 0.0004). All five patients with DIDs initially exhibited low FVs but all subsequently developed increases in FVs to values of more than 150 cm/s and four exhibited FVs of more than 200 cm/s. The time of onset of DIDs corresponded to the time of onset of moderate vasospasm (FV > 150 cm/s). None of the patients with initially normal THRT results developed DIDs, although four patients did exhibit late (secondary) THRT impairment, which was associated with FVs of more than 120 cm/s.

CONCLUSION

When the effects of primarily impaired (after surgery) autoregulation are magnified by vasospasm, the risk of DIDs seems to be very high. Vasospasm alone does not seem to cause DIDs. The development of DIDs could therefore be predicted using the THRT for patients after aneurysm clipping.

The presence of an extractable substance in the CSF of humans with cerebral vasospasm after subarachnoid haemorrhage that correlates with phosphatase inhibition

The cellular events leading to cerebral vasospasm after subarachnoid haemorrhage are poorly understood, although an increase in smooth muscle myosin light chain phosphorylation has been observed. This study set out to determine if phosphatase inhibition may be involved in the pathological maintenance of tension observed during vasospasm. We found that 1 nM okadaic acid, a type 2A protein phosphatase inhibitor, elicited an increase in rate of O(2) consumption in the porcine carotid artery similar to that by cerebrospinal fluid (CSF) from vasospastic patients (CSF(V), n=5) (control 0.23+/-0.03, CSF(V) 0.84+/-0.16 and okadaic acid 0.85+/-0.02 micromol min(-1) g dwt(-1)). It was also observed that phosphatase inhibition with 1 nM okadaic acid significantly slowed relaxation after a stretch in a similar fashion to CSF(V) haemorrhage. CSF from vasospastic subarachnoid haemorrhage patients, but not from those without vasospasm, contains an extractable substance which modulates myosin light chain phosphorylation in vitro. A phosphatase preparation obtained from the porcine carotid artery dephosphorylated 63+/-2% of the phosphorylated (MLC(20)) substrate in vitro, and non-vasospastic CSF treated enzyme dephosphorylated 60+/-2.6%. Okadaic acid inhibited phosphatase dephosphorylated only 7.5+/-1% of the substrate where CSF(V) treated enzyme dephosphorylated 22+/-2.8% of the substrate. We conclude that inhibition of smooth muscle phosphatase may be involved in the mechanisms associated with cerebral vasospasm after subarachnoid haemorrhage.

Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH were studied as well.

METHODS

Symptomatic vasospasm was defined as the association of deterioration in a patient's neurological condition between 3 and 14 days after SAH with no other explanation and an increase in mean transcranial Doppler velocities of >120 cm/s. The prognostic factors were registered on admission and during the intensive care stay.

RESULTS

Symptomatic vasospasm occurred in 22.2% surgical patients compared with 17.2% endovascular treatment patients (P=0.37). Multivariate analysis revealed that the probability of occurrence of symptomatic vasospasm decreased with age >50 years (relative risk [RR], 0.47 [0.25 to 0.88]) and severe World Federation of Neurological Surgeons (WFNS) grade measured on admission (RR, 0.43 [0.20 to 0.90]) and increased with hyperglycemia occurring during the intensive care stay (RR, 1.94 [1.04 to 3.63]). No difference in risk of symptomatic vasospasm could be identified between surgical and endovascular treatment. Symptomatic vasospasm (OR, 4.73 [CI, 1. 77 to 12.6]) as well as WFNS grade of >2 (OR, 8.95 [3.46 to 23.2]), treatment complications (OR, 8.39 [3.16 to 22.3]), and secondary brain insults were associated with an increased risk of 6-month sequelae.

CONCLUSIONS

Age <50 years, good neurological grade, and hyperglycemia were all associated with an increased risk of cerebral vasospasm whereas treatment was not. This provides a basis for future clinical prospective randomized trials comparing both treatments.

Prognostic value and determinants of ultraearly angiographic vasospasm after aneurysmal subarachnoid hemorrhage

OBJECTIVE

A small number of patients with aneurysmal subarachnoid hemorrhage have angiographic evidence of cerebral vasospasm within 48 hours of the onset of hemorrhage. The present study analyzes the prognostic value and determinants of this ultraearly angiographic finding.

METHODS

We analyzed prospectively collected data from the placebo-treated group in a multicenter clinical trial conducted at 54 neurosurgical centers in North America. The presence and severity of ultraearly angiographic vasospasm (UEAV) was determined by a blinded review of the admission angiograms. Using logistic regression analysis, we identified independent determinants of UEAV from demographic, clinical, laboratory, and neuroimaging characteristics of the patients. The impact of UEAV on the risk of symptomatic vasospasm and 3-month outcome was analyzed after adjusting for potential confounding factors.

RESULTS

Of 296 patients in the analysis, 37 (13%) had angiographic evidence of vasospasm at admission. An initial Glasgow Coma Scale score of less than 14 (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.1-6.0), and serum sodium greater than 138 mmol/L (OR, 3.4; 95% CI, 1.5-8.3) were associated with UEAV. UEAV was associated with increased risk of symptomatic vasospasm (OR, 2.5; 95% CI, 1.2-5.4) and poor outcome at 3 months (OR, 2.8; 95% CI, 1.2-6.3), after adjusting for other variables. This risk of symptomatic vasospasm was not influenced by early surgery (within 48 h of hemorrhage onset). Poor outcome was more likely to occur in patients with UEAV who did not undergo early surgery (P = 0.03).

CONCLUSION

Our analysis suggests that patients with angiographic evidence of vasospasm at admission are at high risk for both symptomatic vasospasm and poor outcome. We also found that early surgery did not aggravate this risk.

A prospective study on the effects of early surgery on vasospasm after subarachnoid hemorrhage

BACKGROUND

To test the hypothesis that early surgery prevents vasospasm, a prospective analysis used strictly selected cases of anterior communicating artery aneurysms with symmetric distribution of subarachnoid hemorrhage.

METHODS

Seven patients underwent early surgery (9-29 hours after ictus) through a standard pterional approach. Subarachnoid blood clots surrounding the ipsilateral major cerebral arteries were meticulously irrigated and suctioned. Comparison was made between the hemispheres with surgical intervention and those without, in terms of incidence of delayed ischemic neurologic deficits and cerebral infarction on computed tomographic scans, degree of angiographic vasospasm, and cerebral blood flow (CBF).

RESULT

The degree of angiographic vasospasm, quantified by measuring the alterations in the ratio of the diameters of the intracranial arteries (C1, M1) to the extracranial internal carotid artery (C5), did not differ significantly between the surgical and nonsurgical sides. The mean CBF was also comparable between both sides in the chronic spasm phase (Day 6-9) as well as in the early postoperative period (Day 1-3). A significant reduction of CBF was observed during the early postoperative period in the basal frontal lobe of the surgical side. This CBF reduction seems to correspond to brain retraction.

CONCLUSIONS

The results suggest that the effect of clot removal may be offset by the negative aspect of early surgery, and early surgery per se seems to have little effect on the course of the chronic vasospasm.

Incidence of cerebral vasospasm after endovascular treatment of acutely ruptured aneurysms: report on 69 cases

Cerebral vasospasm is the most common cause of morbidity and mortality in patients admitted to the hospital after suffering aneurysmal subarachnoid hemorrhage (SAH). The early surgical removal of subarachnoid clots and irrigation of the basal cisterns have been reported to reduce the incidence of vasospasm. In contrast to surgery, the endovascular treatment of aneurysms does not allow removal of subarachnoid clots. In this study the authors measured the incidence of symptomatic vasospasm after early endovascular treatment of acutely ruptured aneurysms with Guglielmi detachable coils (GDCs). Sixty-nine patients classified as Hunt and Hess Grades I to III underwent occlusion of intracranial aneurysms via GDCs within 72 hours of rupture. The amount of blood on the initial computerized tomography (CT) scan was classified by means of Fisher's scale. Symptomatic vasospasm was defined as the onset of neurological deterioration verified with angiographic or transcranial Doppler studies. Hypertensive, hypervolemic, hemodilution therapy, with or without intracranial angioplasty, was used to treat vasospasm after GDC placement. Symptomatic vasospasm occurred in 16 (23%) of 69 patients. The clinical grade at admission and the amount of blood on the initial CT were both associated with the incidence of subsequent vasospasm. At 6-month clinical follow-up examination, 12 of these 16 patients experienced a good recovery, two were moderately disabled, and two patients had died of vasospasm. In conclusion, the 23% incidence of symptomatic vasospasm in this series compares favorably with that found in conventional surgical series of patients with acute aneurysmal SAH. These results indicate that endovascular therapy does not have an unfavorable impact on cerebral vasospasm.

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.

Reducing the risk of rebleeding before early aneurysm surgery: a possible role for antifibrinolytic therapy

Previous studies on the initial nonoperative management of aneurysmal subarachnoid hemorrhage (SAH) demonstrated that antifibrinolytic therapy reduced the risk of rebleeding by approximately 50%; however, prolonged antifibrinolytic treatment was associated with an increase in the incidence of hydrocephalus and delayed ischemic deficit. When early surgical intervention became routine for ruptured aneurysms, the use of antifibrinolytic therapy diminished. However, early surgery is generally performed in the first several days after SAH and the risk of rebleeding remains until the aneurysm is obliterated. Based on a review of the literature, the authors formed two hypotheses: 1) the high-dose intravenous administration of epsilon-aminocaproic acid (EACA), an antifibrinolytic agent, might reduce the risk of recurrent hemorrhage in the interval between SAH and early surgical intervention, and 2) a short course of EACA might not produce the increase in complications previously associated with its prolonged administration. The use of preoperative high-dose EACA therapy was evaluated in 307 patients to determine its safety and efficacy in reducing the incidence of rebleeding before early aneurysm surgery. All patients were admitted within 3 days of their SAH and were classified as Hunt and Hess Grades I to III. Only four patients (1.3%) suffered a recurrent hemorrhage. This compares favorably to the rebleeding rate of 5.7% reported for the early surgery group in the International Cooperative Study on the Timing of Aneurysm Surgery. The incidence of hydrocephalus or symptomatic vasospasm was not unduly elevated in patients receiving preoperative EACA. Thirty-five patients (11.4%) needed temporary cerebrospinal fluid drainage during their hospitalization and, overall, 8.8% required a ventriculoperitoneal shunt. The mean age of the patients who required a shunt was nearly 10 years older than the general study population. Seventy-one patients (23%) developed symptomatic vasospasm and 8.1% suffered a stroke. This study indicates that a brief course of high-dose EACA is safe and may be beneficial in diminishing the risk of rebleeding in good-grade patients prior to early surgical intervention. Further investigation is planned based on these promising results.

Age-related multifactorial causes of neurological deterioration after early surgery for aneurysmal subarachnoid hemorrhage

The factors contributing to neurological deterioration after early surgery for aneurysmal subarachnoid hemorrhage (SAH) were investigated. One hundred forty-two patients who underwent surgery within 3 days after SAH and recovered consciousness were divided into three age groups: 49 years of age or younger (Group A), 50 to 64 years old (Group B), and 65 years of age or older (Group C). Among these, 40 patients (28%) overall showed neurological deterioration; these cases were analyzed in detail. Although the highest incidence of deterioration was noted in patients in Group C (42%), angiographic vasospasm, quantified by measuring the change in the ratio of the diameters of the intracranial arteries to the extracranial internal carotid artery, was negatively correlated with age. In elderly patients, the severity of angiographic vasospasm was not related to the reversibility of symptoms or the outcome. At the time of aggravation, associated systemic complications such as cardiac decompensation, hypoxia, and electrolyte imbalance were noted in two (18%) of 11 patients in Group A, five (38%) of 13 in Group B, and eight (50%) of 16 in Group C, and these complications were significantly correlated with poor outcome in Group C. Although arterial narrowing is a leading cause of neurological deterioration after early aneurysmal surgery, the etiology is often multifactorial, especially in elderly patients, suggesting that hypervolemic therapy, which might provoke various complications, should be performed carefully under intensive monitoring.

Amount of subarachnoid blood and vasospasm: current aspects. A transcranial Doppler study

Subsequent to admission after aneurysmal subarachnoid haemorrhage (SAH), 120 patients (74 women and 46 men) underwent microsurgical clipping of a total of 158 cerebral aneurysms within 96 hours after the bleed. Their mean age was 46 (20-91) years. Computed tomography (CT) findings were graded according to the modified Fisher scale and all patients had daily transcranial doppler (TCD) recordings of their basal cerebral arteries. In 19% of SAH was grade I on CT, in 44% grade II and in 37% grade III. The rate of patients who developed severe vasospasm as documented by TCD (mean blood flow velocities exceeding 160 cm/s on 2 or more consecutive days) was 39% for grade I patients, 26% for grade II patients and 34% for patients with SAH grade III on the initial CT. There was no difference in the rate of occurrence of severe vasospasm, when the patients were split into 2 groups according to the time of performance of the initial CT scan-within 24 hours, and 48-80 hours after SAH, respectively. It is concluded that the amount of subarachnoid blood on the initial CT scan should no longer be used as the indicator for occurrence and severity of the multifactorial entity vasospasm.

Management outcome for multiple intracranial aneurysms

The management outcome of 302 patients with multiple intracranial aneurysms (MIA) from a series of 1314 patients with cerebral aneurysms was assessed using the Glasgow Outcome Scale 1 year after diagnosis and/or treatment. The outcome was significantly poorer for patients with MIA than for those with single intracranial aneurysms (SIA). The difference in the frequencies of poor outcome (Glasgow Outcome Scale Grades 3-5) was most evident in patients with Hunt and Hess Grades 2 or 3 (MIA, 29%; SIA, 19%). The management mortality in all grades attributable to all causes was 24% in patients with MIA and 20% in those with SIA and 16 and 11%, respectively, after surgery. At the 1-year follow-up point, 66% of the patients with MIA were independent (SIA, 72%); after surgery, 74% (SIA, 81%); after subarachnoid hemorrhage, 65% (SIA, 71%); and after subarachnoid hemorrhage and surgery, 73% (SIA, 80%). Patients with aneurysms at the vertebrobasilar arteries fared badly; otherwise, the sites of the aneurysms and their different combinations had no effect on outcome, nor did the timing of surgery. In this study, again, only two-thirds of the detected aneurysms could be secured. The aneurysms left without treatment were mostly in patients with very poor grade (n, 55) and/or old (n, 23) patients or were intracavernous (n, 26). The results seemed to be more unsatisfactory as the number of aneurysms increased. In multivariate analysis, delayed neurological deficit had the most significant independent contribution to outcome in patients with MIA, far more than in patients with SIA. This can be explained by the increased manipulation of cerebral arteries during multiple aneurysm surgery.