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Akimoto T, Ohtake M, Kawasaki T, Fushimi S, Shimohigoshi W, Manaka H, Kawasaki T, Sakata K, Takeuchi I, Yamamoto T. Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:47-55. [PMID: 37502127 PMCID: PMC10370525 DOI: 10.5797/jnet.oa.2022-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/09/2022] [Indexed: 07/29/2023]
Abstract
Objective To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Methods We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis. Results Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration. Conclusion Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.
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Affiliation(s)
- Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Makoto Ohtake
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takafumi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shuto Fushimi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takashi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Ichiro Takeuchi
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Hanalioglu S, Sahin B, Sayyahmelli S, Ozaydin B, Erginoglu U, Aycan A, Baskaya MK. The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era. Acta Neurochir (Wien) 2022; 164:781-793. [PMID: 35133482 DOI: 10.1007/s00701-022-05112-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era. METHODS We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical (n = 80) or endovascular (n = 61) treatment for PGASAH. RESULTS Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0-2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991-6.981], p = 0.052). CONCLUSIONS Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.
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Abstract
Abstract:Object:Our experience in Calgary was reviewed to determine the safety and clinical effectiveness of coiling in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).Methods:Patients with Hunt-Hess grades IV and V aneurysmal subarachnoid hemorrhage who underwent endovascular coiling between January 1999 and April 2009 at Foothills Medical Centre, Calgary, Alberta, Canada were reviewed. The primary outcome measure was the Modified Rankin Score after at least six months. Secondary outcome measures included extent of aneurysm occlusion and peri-procedural complications. In patients with favourable functional outcomes, Barthel's Index (BI), Re-integration to normal living index (RINL), and Zung depression scale (ZDS) were determined.Results:Thirty-three patients were identified (median age of 57 years; 73% female) and 69% were Hunt-Hess grade IV subarachnoid hemorrhage and 22 % were grade V Endovascular coiling resulted in absence of residual flow into the aneurysm fundus in 91%. Only seven procedure-related complications occurred with no deaths attributed to the procedure. Vasospasm, hydrocephalus, and pneumonia were the most common non-procedural complications. Average follow-up was 27 +/- 17 months. Overall mortality was 32%, but 53% of patients had good functional outcome (mRS<3). Nine patients completed the BI, RINL, and ZDS with average BI 99 +/- 2, RINL 89 +/- 14, ZDS 33 +/-11, suggesting minimal deficits in function and mood.Conclusions:Endovascular coiling in patients with high-grade subarachnoid hemorrhage is safe. While the morbidity and mortality from high-grade aneurysmal subarachnoid hemorrhage remains significant, favourable radiologic and functional outcomes can be achieved in a significant proportion of these critically ill patients.
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Hoogmoed J, van den Berg R, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. A strategy to expeditious invasive treatment improves clinical outcome in comatose patients with aneurysmal subarachnoid haemorrhage. Eur J Neurol 2016; 24:82-89. [PMID: 27670264 DOI: 10.1111/ene.13134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with poor clinical condition after aneurysmal subarachnoid haemorrhage (aSAH), treatment is often deferred until patients show signs of improvement. Early external ventricular drainage and aneurysm occlusion may improve prognosis also in poor grade patients. The clinical outcome of an expeditious approach was compared with that of a conservative approach. METHODS In all, 285 consecutive World Federation of Neurological Surgeons (WFNS) grade V aSAH patients admitted to three university hospitals between January 2000 and June 2007 were included. Two hospitals followed an expeditious approach, one a more conservative approach. Groups were compared with respect to demographic and clinical characteristics and outcome. Univariable and multivariable analyses were performed to determine the associations with good outcome (Glasgow Outcome Scale scores 4-5), using logistic regression models. RESULTS Good outcome was seen more often in expeditiously treated patients [22% vs. 11%; odds ratio (OR) 2.24, 95% confidence interval (CI) 1.17-4.27]. Expeditiously treated patients more often underwent aneurysm occlusion than conservatively treated patients (64% vs. 27%; OR 4.86, 95% CI 2.93-8.05) and placement of an external ventricular catheter (82% vs. 31%; OR 10.05, CI 5.72-10.66). There was no significant difference in rebleeding between patient groups. Occlusion of the aneurysm was the only variable that remained significant in the multivariable model with an OR of 43.73 (95% CI 10.34-184.97). CONCLUSIONS An expeditious invasive treatment strategy in WFNS grade V aSAH patients can lead to a better outcome. Hesitance in the early stages seems a self-fulfilling prophecy for a poor outcome.
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Affiliation(s)
- J Hoogmoed
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - R van den Berg
- Department of Neuroradiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B A Coert
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G J E Rinkel
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - W P Vandertop
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - D Verbaan
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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Zhao B, Tan X, Zhao Y, Cao Y, Wu J, Zhong M, Wang S. Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:224-31. [PMID: 26421588 DOI: 10.1227/neu.0000000000001038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. OBJECTIVE To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. METHODS Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. RESULTS Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. CONCLUSION Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.
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Affiliation(s)
- Bing Zhao
- *Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; ‡Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; §Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Zhao B, Yang H, Zheng K, Li Z, Xiong Y, Tan X, Zhong M. Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 126:1764-1771. [PMID: 27367238 DOI: 10.3171/2016.4.jns152587] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE An increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH. METHODS A Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration. RESULTS At 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80-0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81-0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively). CONCLUSIONS Older age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms. ▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kuang Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zequn Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Zhao B, Tan X, Yang H, Li Z, Zheng K, Xiong Y, Zhong M. Endovascular Coiling versus Surgical Clipping for Poor-Grade Ruptured Intracranial Aneurysms: Postoperative Complications and Clinical Outcome in a Multicenter Poor-Grade Aneurysm Study. AJNR Am J Neuroradiol 2015; 37:873-8. [PMID: 26721769 DOI: 10.3174/ajnr.a4649] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular coiling is an alternative to surgical clipping for ruptured intracranial aneurysms. However, no large multicenter prospective study has compared coiling and clipping in patients with poor-grade ruptured aneurysms. We aimed to determine differences in postoperative complications and clinical outcome between the 2 treatments in this group of patients. MATERIALS AND METHODS A Multicenter Poor-Grade Aneurysm Study was a prospective, multicenter, observational registry of consecutive patients who presented with poor-grade ruptured aneurysms. Three hundred sixty-six patients were enrolled from October 2010 to March 2012. "Poor-grade aneurysm" was defined as a World Federation of Neurosurgical Societies grade of IV or V at the time of aneurysm treatment. Two hundred sixty-two patients received aneurysm treatment within 21 days and were included. Clinical outcomes were assessed at discharge and at 6 and 12 months by the modified Rankin Scale. RESULTS One hundred thirty-three (50.8%) patients underwent endovascular coiling. Unadjusted analysis showed that the outcome rate (mRS 0-1 or mRS 0-2) at 6 and 12 months in patients undergoing coiling was higher than that in patients undergoing clipping. In adjusted analyses, there was no statistically significant difference in outcomes at 6 and 12 months between the 2 groups. The risk of radiologic hydrocephalus was higher in patients treated with coiling than that in those treated with clipping (adjusted OR, 3.36; 95% CI, 1.13-10.01; P = .030). CONCLUSIONS The long-term outcome in selected patients was similar between endovascular coiling and clipping for poor-grade ruptured aneurysms. The risk of radiologic hydrocephalus was higher after endovascular treatment of poor-grade aneurysms.
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Affiliation(s)
- B Zhao
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China Department of Neurosurgery (B.Z.), Mayo Clinic, Rochester, Minnesota
| | - X Tan
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - H Yang
- Department of Neurosurgery (H.Y.), The First Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Z Li
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - K Zheng
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Y Xiong
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - M Zhong
- From the Department of Neurosurgery (B.Z., X.T., Z.L., K.Z., Y.X., M.Z.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Anxionnat R, Tonnelet R, Derelle AL, Liao L, Barbier C, Bracard S. Endovascular treatment of ruptured intracranial aneurysms: Indications, techniques and results. Diagn Interv Imaging 2015; 96:667-75. [PMID: 26160704 DOI: 10.1016/j.diii.2015.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/10/2015] [Indexed: 11/30/2022]
Affiliation(s)
- R Anxionnat
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France.
| | - R Tonnelet
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - A L Derelle
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - L Liao
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - C Barbier
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - S Bracard
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
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Lagares A, Munarriz PM, Ibáñez J, Arikán F, Sarabia R, Morera J, Gabarrós A, Horcajadas Á. Variabilidad en el manejo de la hemorragia subaracnoidea aneurismática en España: análisis de la base de datos multicéntrica del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía. Neurocirugia (Astur) 2015; 26:167-79. [DOI: 10.1016/j.neucir.2014.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/04/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Tkachev VV, Shagal LV, Muzlaev GG. [The use of transcallosal ventriculostomy to treat complicated forms of aneurismal intracranial hemorrhages]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:48-57. [PMID: 25909745 DOI: 10.17116/neiro201579148-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The present paper reports two cases of successful use of the anterior interhemispheric transcallosal approach during ultra-early surgery in patients in decompensated condition with severe intraventricular hemorrhage caused by rupture of cerebral aneurysms.
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Affiliation(s)
- V V Tkachev
- Regional Clinical Hospital #1, Krasnodar Region, Russia
| | - L V Shagal
- Regional Clinical Hospital #1, Krasnodar Region, Russia
| | - G G Muzlaev
- Regional Clinical Hospital #1, Krasnodar Region, Russia
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Zhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, Wang S. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis. BMJ Open 2015; 5:e007410. [PMID: 25877280 PMCID: PMC4401840 DOI: 10.1136/bmjopen-2014-007410] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH). DESIGN A multicentre retrospective analysis, observational study. SETTING High-volume teaching hospitals (more than 150 aSAH cases per year). PARTICIPANTS 118 patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V underwent surgical treatment. Ultra-early surgery was defined as surgery performed within 24 h of aSAH, and delayed surgery as surgery performed after 24 h. Outcome was assessed by modified Rankin Scale (mRS). The mean time of follow-up was 12.5±3.4 months (range 6-28 months). RESULTS 47 (40%) patients underwent ultra-early surgery, and 71 (60%) patients underwent delayed surgery. Patients with WFNS grade V (p=0.011) and brain herniation (p=0.004) more often underwent ultra-early surgery. Postoperative complications were similar in ultra-early and delayed surgery groups. Adjusted multivariate analysis showed the outcomes were similar between the two groups. Multivariate analysis of predictors of poor outcome, ultraearly surgery was not an independent predictor of poor outcome, while advanced age, postresuscitation WFNS V grade, intraventricular haemorrhage, brain herniation and non-middle cerebral artery (MCA) aneurysms were associated with poor outcome. CONCLUSIONS Although patients with WFNS grade V and brain herniation more often undergo ultra-early surgery, postoperative complications and outcomes in selected patients were similar in the two groups. Patients of younger age, WFNS grade IV, absence of intraventricular haemorrhage, absence of brain herniation and MCA aneurysms are more likely to have a good outcome. Ultra-early surgery could improve outcomes in carefully selected patients with poor-grade aSAH.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Xianxi Tan
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Ming Zhong
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
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Mitra D, Gregson B, Jayakrishnan V, Gholkar A, Vincent A, White P, Mitchell P. Treatment of poor-grade subarachnoid hemorrhage trial. AJNR Am J Neuroradiol 2015; 36:116-20. [PMID: 25059694 PMCID: PMC7965936 DOI: 10.3174/ajnr.a4061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/19/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Management of poor-grade subarachnoid hemorrhage is based on limited evidence from small single-center retrospective observational studies. The purpose of this study was to undertake a single-center randomized controlled feasibility trial comparing a strategy of early endovascular aneurysm treatment with treatment after neurologic recovery in this group of patients. MATERIALS AND METHODS Patients with poor-grade SAH were randomized within 24 hours of admission to early treatment or treatment after neurologic recovery. If a patient was randomized to early treatment, the aneurysm was treated endovascularly within 24 hours of randomization. Recruitment rate, safety profile, and functional outcome at the time of discharge and at 6 months were assessed. RESULTS Fourteen of 51 patients screened were eligible for the trial. Of these 14, 8 patients were randomized (57%). All patients in the early coiling arm received treatment within 24 hours of randomization. There was no treatment-related complication. Overall, good outcome occurred in 25% of patients; the mortality rate was 75%. Patients in the early treatment arm (n = 5) had a good outcome rate of 20%, while those in treatment after neurologic recovery arm (n = 3) had a good outcome rate of 33.3%. CONCLUSIONS This was a feasibility study that demonstrated that recruitment and randomization for comparing management strategies in poor-grade SAH are feasible. The recruitment rate among eligible patients was encouraging (57%), though a number of patients had to be excluded due to ineligibility. A multicenter study is necessary to recruit the numbers required to compare the clinical outcomes of these management strategies.
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Affiliation(s)
- D Mitra
- From the Departments of Neuroradiology (D.M., V.J., A.G.)
| | - B Gregson
- Neurosciences (B.G.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - V Jayakrishnan
- From the Departments of Neuroradiology (D.M., V.J., A.G.)
| | - A Gholkar
- From the Departments of Neuroradiology (D.M., V.J., A.G.)
| | - A Vincent
- Anesthesiology and Intensive Care (A.V.), Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - P White
- Institutes of Aging and Health (P.W.)
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Carvi y Nievas MN, Hattingen J, Hoellerhage HG. Interdisciplinary treatment selection in admitted patients with acute subarachnoid hemorrhage. Neurol Res 2013; 31:582-92. [DOI: 10.1179/174313209x382250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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14
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Iwaasa M, Ueba T, Nonaka M, Okawa M, Abe H, Higashi T, Inoue T. Safety and feasibility of combined coiling and neuroendoscopy for better outcomes in the treatment of severe subarachnoid hemorrhage accompanied by massive intraventricular hemorrhage. J Clin Neurosci 2013; 20:1264-8. [PMID: 23830690 DOI: 10.1016/j.jocn.2012.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/18/2012] [Accepted: 09/26/2012] [Indexed: 10/26/2022]
Abstract
Subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) is associated with poor outcomes. The aim of this study was to evaluate the safety and feasibility of combined coiling and neuroendoscopy for treating severe SAH with massive IVH. Between April 2008 and June 2011, 49 patients with a severe SAH were treated at the Department of Neurosurgery, Fukuoka University, Japan; 10 of these patients had a massive IVH with a ruptured aneurysm. All 10 patients (three men and seven women; mean age, 63.1±8.5 years) were treated with coiling and neuroendoscopic removal of the IVH within 2 days of onset. Coiling was successfully performed at a mean volume embolization ratio of 21.8±5.5%. Neuroendoscopic removal of the IVH reduced the mean Graeb score from 10.5±2.0 to 4.8±2.5 (p=0.005). All external drains were removed on day 3. No rebleeding or acute hydrocephalus was noted. The Glasgow Outcome Scale scores at discharge indicated two patients with good recovery, three with moderate disability, four in a vegetative state, and one dead. A good modified Rankin Scale (mRS) score (0-2) at least 6 months later (mean follow-up period, 15.4±9.2 months) was observed for five patients (50%), and a poor mRS score (3-6) was observed for the remaining four patients. Neuroendoscopically removing the IVH from all of the ventricles between the lateral and the fourth ventricle and coiling the ruptured aneurysm is a safe, feasible approach for treating severe SAH with massive IVH.
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Affiliation(s)
- Mitsutoshi Iwaasa
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jounan-ku, Fukuoka City, Fukuoka 814-0180, Japan
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Egashira Y, Yoshimura S, Enomoto Y, Ishiguro M, Asano T, Iwama T. Ultra-early endovascular embolization of ruptured cerebral aneurysm and the increased risk of hematoma growth unrelated to aneurysmal rebleeding. J Neurosurg 2013; 118:1003-8. [DOI: 10.3171/2012.11.jns12610] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Hematoma growth unrelated to aneurysmal rebleeding is recognized as a somewhat common complication following endovascular embolization of ruptured aneurysms, but it is scarcely studied. The aim of this study is to elucidate the possible risk factors for this phenomenon.
Methods
Included in this study were 101 consecutive patients with subarachnoid hemorrhage (SAH) who underwent endovascular embolization for saccular aneurysms at the authors' institution within 72 hours of symptom onset. All endovascular procedures were conducted under intraprocedural systemic anticoagulation. Age, sex, hypertension, type 2 diabetes, preoperative antiplatelet or anticoagulation use, neurological grade, Fisher grade, location and size of the aneurysm, grade of aneurysm occlusion, and timing of the endovascular procedure were retrospectively analyzed to determine the risk factors for hematoma growth unrelated to aneurysmal rebleeding. To determine the clinical significance of this complication, the authors also investigated the risk factors for poor clinical outcome (modified Rankin Scale Scores 3–6 at 30 days after onset).
Results
This series included 32 men (31.7%) and 69 women (68.3%) with a mean age ± SD of 65.5 ± 14.0 years. The mean time from onset to endovascular procedure was 12.1 ± 14.0 hours. After the procedure, hematoma growth unrelated to aneurysmal rebleeding occurred in 14 patients (13.9%), 10 of whom required surgical removal of the hematoma and/or ventriculostomy to control intracranial pressure. All 14 patients had an anterior circulation aneurysm and had Fisher Grade 3 or 4 SAH. Ultra-early embolization (conducted within 6 hours after onset), female sex, history of hypertension, and poor neurological grade (World Federation of Neurosurgical Societies Grades IV and V) were significant risk factors for hematoma growth (p < 0.05 for all, univariate logistic analysis). In multivariate analysis, ultra-early embolization (OR 18.0 [95% CI 3.26–338], p < 0.001) and female sex (OR 9.83 [95% CI 1.73–187], p = 0.007) were independent risk factors for this phenomenon. Anterior circulation aneurysms and Fisher Grade 3 or 4 SAH were also revealed to be significant risk factors (p = 0.02 for each, chi-square test). Furthermore, hematoma growth without aneurysmal rebleeding was determined as an independent risk factor for poor clinical outcome by multivariate logistic analysis (OR 11.8 [95% CI 2.31–87.1], p = 0.002).
Conclusions
Ultra-early endovascular embolization for ruptured cerebral aneurysms under systemic anticoagulation increases the risk of growth of hematomas unrelated to aneurysmal rebleeding. It is important to recognize the risk of this complication and to either reduce the amount of heparin or to refer the patient for direct clipping if appropriate.
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Affiliation(s)
| | | | | | | | - Takahiko Asano
- 2Radiology, Gifu University Graduate School of Medicine, Gifu-city, Gifu, Japan
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Shirao S, Yoneda H, Kunitsugu I, Suehiro E, Koizumi H, Suzuki M. Age limit for surgical treatment of poor-grade patients with subarachnoid hemorrhage: A project of the Chugoku-Shikoku division of the Japan neurosurgical society. Surg Neurol Int 2012; 3:143. [PMID: 23230524 PMCID: PMC3515927 DOI: 10.4103/2152-7806.103886] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 11/30/2022] Open
Abstract
Objective: Management of elderly patients with poor-grade subarachnoid hemorrhage (SAH) remains controversial. The objective of this study was to investigate whether there is an age-dependent difference in the outcome of poor-grade SAH after surgical obliteration of the aneurysm. Methods: Data were reviewed retrospectively for 156 patients with poor-grade aneurysmal SAH at multiple centers in Chugoku and Shikoku, Japan. Patients were divided into age groups of 65-74 and ≥75 years old. Factors influencing a favorable outcome at discharge (Glasgow Outcome Scale, good recovery or moderately disabled) were determined using multivariate logistic regression analyses. Results: A favorable outcome at discharge was achieved in 37 of the 156 patients (23.7%). Advanced age (≥75 years old, P < 0.01), improvement of World Federation of Neurosurgical Societies (WFNS) Grade after admission (P = 0.02), Fisher grade (P < 0.001), and a low density area (LDA) associated with vasospasm on computed tomography (CT) (P < 0.01) were significantly associated with outcome. Multivariate analysis identified advanced age (≥75 years old, P = 0.01), Fisher group 4 (P = 0.002), and a new LDA associated with vasospasm on CT (P = 0.007) as predictors of a poor outcome in elderly patients with poor-grade SAH after surgical obliteration of the aneurysm. WFNS Grade V at admission (P = 0.052) was weakly associated with a poor outcome. Conclusions: Advanced age (≥75 years old), Fisher group 4, and LDA associated with vasospasm on CT were independent predictors of clinical outcome in elderly patients with poor-grade SAH. A favorable outcome in these patients occurred more frequently after Guglielmi detachable coil embolization than after surgical clipping, but without a significant difference.
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Affiliation(s)
- Satoshi Shirao
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Ube, Japan
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Abstract
Outcome from trauma, surgery, and a variety of other medical conditions has been shown to be positively affected by providing treatment at facilities experiencing a high volume of patients with those conditions. An electronic literature search was made to identify English-language articles available through March 2011, addressing the effect of patient treatment volume on outcome for patients with subarachnoid hemorrhage. Limited data were identified, with 16 citations included in the current review. Over 60% of hospitals fall into the lowest case-volume quartile. Outcome is influenced by patient volume, with better outcome occurring in high-volume centers treating >60 cases per year. Patients treated at low-volume hospitals are less likely to experience definitive treatment. Furthermore, transfer to high-volume centers may be inadequately arranged. Several factors may influence the better outcome at high-volume centers, including the availability of neurointensivists and interventional neuroradiologists.
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Affiliation(s)
- P Vespa
- Division of Neurosurgery, David Geffen School of Medicine at UCLA, University of California, Room 6236A Ronald Reagan UCLA Medical Center, 750 Westwood Blvd, Los Angeles, CA 90095, USA.
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Qahwash OM, Alaraj A, Aletich V, Charbel FT, Amin-Hanjani S. Safety of early endovascular catheterization and intervention through extracranial-intracranial bypass grafts. J Neurosurg 2012; 116:201-7. [DOI: 10.3171/2011.8.jns11747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal of this study was to demonstrate feasibility and evaluate technical aspects of early endovascular access through extracranial-intracranial (EC-IC) bypass grafts.
Methods
Patients undergoing endovascular interventions through the graft in the acute postoperative period following EC-IC bypass are presented. Results, complications, and technical nuances are reviewed.
Results
Fourteen endovascular procedures were performed in 5 patients after EC-IC bypass for ruptured aneurysms in 4 patients and posterior circulation ischemia in 1 patient. In 2 patients, a saphenous vein graft (SVG) was used to bypass the common carotid artery (CCA) to the middle cerebral artery (MCA). One patient underwent a superficial temporal artery (STA)–MCA bypass, and in 2 other patients the STA stump was connected to the intracranial circulation via an interposition SVG. The interval from surgery to endovascular intervention spanned 2–18 days; the indication was intracranial vasospasm in all patients. One case involved angioplasty of the proximal anastomosis on postoperative Day 14. All other interventions entailed proximal access through the bypass conduit for intraarterial infusion of vasodilators. Significant vasospasm of the STA itself was encountered in 2 patients during endovascular manipulation, and it was treated with intraarterial nitroglycerin. There were no cases of anastomotic disruption.
Conclusions
Endovascular catheterization and intervention involving a recent EC-IC bypass is feasible. The main limitation in this series was catheter-induced vasospasm involving the STA. A vein graft may be the more appropriate option in patients with subarachnoid hemorrhage who may require subsequent endovascular intervention for vasospasm.
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Egashira Y, Yoshimura S, Funatsu N, Tanaka Y, Yamada K, Enomoto Y, Iwama T. Continuous growth of remote intracerebral haematoma following angiographically successful endovascular embolisation of ruptured cerebral aneurysms. J Clin Neurosci 2011; 19:170-3. [PMID: 22153825 DOI: 10.1016/j.jocn.2011.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/28/2011] [Accepted: 03/29/2011] [Indexed: 10/14/2022]
Abstract
We describe a poorly recognised and rare complication following the endovascular embolisation of ruptured cerebral aneurysms. Three patients with dense focal subarachnoid haemorrhage (SAH) developed continuous growth of remote intracerebral haematoma (ICH) following endovascular embolisation of a ruptured aneurysm. All endovascular procedures were conducted within less than 6 hours after the onset of SAH with systemic anticoagulation and were completed uneventfully; external ventricular drainage was subsequently inserted. Repeated CT scans revealed continuous growth of ICH remote from the aneurysm without aneurysmal rebleeding. The authors suggest that endovascular embolisation for a ruptured aneurysm under systemic anticoagulation within 6 hours after SAH onset may increase the risk of expanding haematomas, especially in patients with dense focal SAH.
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Affiliation(s)
- Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-city, Gifu 501-1194, Japan.
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Huang APH, Arora S, Wintermark M, Ko N, Tu YK, Lawton MT. Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery 2011; 67:964-74; discussion 975. [PMID: 20881562 DOI: 10.1227/neu.0b013e3181ee359c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention. OBJECTIVE To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery. METHODS A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes. RESULTS Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes. CONCLUSIONS PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.
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Affiliation(s)
- Abel Po-Hao Huang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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21
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Surgical Management of Posterior Circulation Aneurysms. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Suzuki S, Tateshima S, Jahan R, Duckwiler GR, Murayama Y, Gonzalez NR, Viñuela F. Endovascular treatment of middle cerebral artery aneurysms with detachable coils: angiographic and clinical outcomes in 115 consecutive patients. Neurosurgery 2009; 64:876-88; discussion 888-9. [PMID: 19287326 DOI: 10.1227/01.neu.0000343534.05655.37] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Because of their anatomic configuration, middle cerebral artery (MCA) aneurysms are most often treated with surgical clipping. However, endovascular coil embolization of these aneurysms is an increasingly used alternative. We retrospectively reviewed the anatomic and clinical outcomes of patients with MCA aneurysms who underwent endovascular treatment at our institution. METHODS One hundred fifteen MCA aneurysms in 115 patients (mean age, 55.1 years) were treated by an endovascular technique from April 1990 to March 2007. Forty-eight patients (42%) presented with acute subarachnoid hemorrhage, and 67 patients (58%) had unruptured aneurysms. Fifty-three aneurysms (46%) were small with a small neck, 28 (24%) were small with a wide neck, 22 (19%) were large, and 12 (11%) were giant. RESULTS Angiographic results immediately after embolization showed complete occlusion in 53 aneurysms (46%), a neck remnant in 51 (44%), and incomplete occlusion in 3 (3%). Because of anatomic difficulties, we could not embolize 8 aneurysms (7%). Thirteen patients underwent combined treatment that included endovascular and extracranial-intracranial bypass surgery. Morbidity and mortality rates were 6.9% (8 patients) and 3% (3 patients), respectively. Procedure-related complications were encountered in 10 patients (9%). Seventy patients had long-term follow- up angiograms. Seven aneurysms (10%) were recanalized; all were large or giant. One partially embolized large aneurysm ruptured 13 months after embolization. CONCLUSION In this series, endovascular coil embolization of MCA aneurysms has morbidity and mortality rates comparable to those of conventional surgical clipping. Combined treatment of endovascular and bypass surgery can successfully treat large or giant complex fusiform MCA aneurysms.
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Affiliation(s)
- Shuichi Suzuki
- Division of Interventional Neuroradiology, Department of Radiological Sciences, University of California, Los Angeles School of Medicine, Los Angeles, California 90095-1721, USA.
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Ferns SP, Sprengers MES, van Rooij WJ, Rinkel GJE, van Rijn JC, Bipat S, Sluzewski M, Majoie CBLM. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates. Stroke 2009; 40:e523-9. [PMID: 19520984 DOI: 10.1161/strokeaha.109.553099] [Citation(s) in RCA: 323] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups. METHODS We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment. RESULTS Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used. CONCLUSIONS At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.
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Affiliation(s)
- Sandra P Ferns
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Abstract
OBJECTIVE Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications. DATA SOURCES Source data were obtained from a PubMed search of the medical literature. DATA SYNTHESIS AND CONCLUSION The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means. During the first 1-2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
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Hagiwara S, Tanaka N, Tani S, Nakamura S, Ohbuchi H, Hirota K, Iwabuchi S, Kasuya H. Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage. Interv Neuroradiol 2009; 15:45-51. [PMID: 20465928 DOI: 10.1177/159101990901500107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 10/27/2008] [Indexed: 11/15/2022] Open
Abstract
SUMMARY This study evaluated the clinical and angiographic outcome of large aneurysms treated with coil embolization at an acute stage in patients with poor-grade subarachnoid hemorrhage (SAH). Between July 1, 2001 and June 30, 2004, eight consecutive WFNS grade 5 patients with large aneurysms (15~23 mm) were treated with endovascular coil embolization within two days and followed for at least 30 months. There were three middle cerebral and five internal carotid artery aneurysms. No patients were treated by craniotomy and none survived without treatment. Two patients died of primary brain damage or cerebral vasospasm within one month. One patient died of pneumonia at 24 months. Four patients were alive with good recovery or moderate disability at the time of final follow-up (30~66 months). Angiography immediately after the procedure showed complete occlusion in three, neck remnant in four, and body filling in one patient. No complication was seen related to the procedure. Three aneurysms that were initially neck remnant developed body filling due to coil compaction. Two were re-treated with coils at six and 12 months and resulted in neck remnant. One patient refused re-treatment and died of re-bleeding. Endovascular coil embolization can be selected at an acute stage for the treatment of aneurysms in patients with poor-grade SAH without intraparenchymal hematoma even if the aneur-ysm is large. Serial follow up by MRA/angiography is necessary for at least 12 months.
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Affiliation(s)
- S Hagiwara
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University; Tokyo, Japan -
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Kim SR, Vora N, Jovin TG, Gupta R, Thomas A, Kassam A, Lee K, Gologorsky Y, Jankowitz B, Panapitiya N, Aleu A, Sandhu E, Crago E, Hricik A, Gallek M, Horowitz MB. Anatomic results and complications of stent-assisted coil embolization of intracranial aneurysms. Interv Neuroradiol 2008; 14:267-84. [PMID: 20557724 PMCID: PMC3396013 DOI: 10.1177/159101990801400307] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2008] [Accepted: 07/23/2008] [Indexed: 11/16/2022] Open
Abstract
SUMMARY The purpose of this study was to evaluate and report our anatomic results and complications associated with stent-assisted coil embolization of intracranial aneurysms using the Neuroform stent. From September 2003 to August 2007, 127 consecutive patients (ruptured 50, 39.4%; unruptured 77, 60.6%) underwent 129 stent-assisted coil embolization procedures to treat 136 aneurysms at our institution. Anatomic results at follow-up, procedure-related complications, and morbidity/mortality were retrospectively reviewed. Stent deployment was successful in 128 out of 129 procedures (99.2%). Forty-seven patients presented with 53 procedure-related complications (37.0%, 47/127). Thromboembolic events (n=17, 13.4%) were the most common complications, followed by intraoperative rupture (n=8, 6.3%), coil herniation (n=5, 3.9%), and postoperative rupture (n=4, 3.1%). For thromboembolic events, acute intra-procedural instent thromboses were observed in two patients and subacute or delayed in-stent thromboses in three patients. Overall mortality rate was 16.5% (21/127) and procedure-related morbidity and mortality rates were 5.5% (7/127) and 8.7% (11/127) retrospectively. Patients with poor grade subarachnoid hemorrhage (Hunt and Hess grade IV or V; 25/127, 19.7%) exhibited 56% (14/25) overall mortality rate and 24% (6/25) procedure-related mortality rate. Immediate angiographic results showed complete occlusion in 31.7% of aneurysms, near-complete occlusion in 45.5%, and partial occlusion in 22.8%. Sixty nine patients in 70 procedures with 77 aneurysms underwent angiographic followup at six months or later. Mean follow-up period was 13.7 months (6 to 45 months). Complete occlusion was observed in 57 aneurysms (74.0%) and significant in-stent stenosis was not found. Thromboembolism and intra/postoperative aneurysm ruptures were the most common complications and the main causes of procedure-related morbidity and mortality. Patients with poor grade subarachnoid hemorrhage showed poor clinical outcomes. Since most complications were induced by stent manipulation and deployment, it is mandatory to utilize these devices selectively and cautiously. While the follow- up angiographic results are promising, further studies are essential to evaluate safety, efficacy, and durability of the Neuroform stent.
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Affiliation(s)
- S R Kim
- Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Department of Neurosurgery,Minimally Invasive Endo-Neurosurgery Center, Presbyterian Hospital,University of Pittsburgh Medical Center, U.S.A -
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Oran I, Cinar C. Continuous intra-arterial infusion of nimodipine during embolization of cerebral aneurysms associated with vasospasm. AJNR Am J Neuroradiol 2007; 29:291-5. [PMID: 17989369 DOI: 10.3174/ajnr.a0830] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Despite rigorous efforts, cerebral vasospasm remains an important cause of morbidity and mortality in patients who survive their initial subarachnoid hemorrhage. In cases of intracranial ruptured aneurysm associated with vasospasm, we evaluated the effectiveness of combined embolization of an aneurysm and intra-arterial infusion of nimodipine, which continued during the entire procedure. MATERIALS AND METHODS Ten patients with ruptured aneurysms associated with vasospasm who were treated in a single session were reviewed retrospectively. After initial intra-arterial infusion of nimodipine (1-2 mg within 10-15 minutes), they underwent occlusion of the aneurysm with coils under continuous intra-arterial infusion of nimodipine at a dose of 1 mg per hour. RESULTS Angiography showed severe proximal vasospasm in 1 patient, proximal and distal in 3 patients, and distal in 3 patients. There was also moderate proximal vasospasm in 4 patients, proximal and distal in 1 patient, and distal in 1 patient. Complete occlusion of the aneurysm was achieved in 5 patients, incomplete occlusion in 3 patients, and a small neck remnant in 2 patients. Final angiograms also demonstrated complete clearance of a proximal spasm in 4 patients, and complete clearance of proximal and distal spasms in another 4 patients. Mean initial dose of nimodipine was 1.375 mg, and mean continuous infusion dose was 1.275 mg (mean total dose, 2.65 mg). No medical complications related to extended infusion of nimodipine occurred. CONCLUSION In this small series, extended intra-arterial infusion of nimodipine up to the end of the embolization procedure was effective and safe in patients with a ruptured aneurysm and associated vasospasm. This technique seems to increase the security of the procedure as well as force further vasorelaxation when the endovascular route is used to treat both the aneurysm and vasospasm in a single step.
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Affiliation(s)
- I Oran
- Ege University Medical School Department of Radiology, Izmir, Turkey.
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