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Cai J, He C, Xu J, He Q, Su J, Wu Z, Xu Y. Ruptured Anterior Communicating Artery Aneurysms Concomitant with Small Intracranial Hematoma: Evacuating Hematoma or Not? Neuropsychiatr Dis Treat 2023; 19:1833-1840. [PMID: 37641587 PMCID: PMC10460576 DOI: 10.2147/ndt.s422692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
Objective To identify whether intracranial hematoma (ICH) evacuation improves the prognosis of patients with ruptured anterior communicating artery (AcomA) aneurysms concomitant with small ICHs (≥10 mL and <25 mL). Methods Data on patients diagnosed with small ICHs secondary to ruptured AcomA aneurysms who underwent surgery in our department between January 2010 and February 2018 was retrospectively analyzed. The patients were divided into two groups based on whether the hematoma was evacuated. The modified Rankin Scale (mRS) was used to assess prognosis six months after onset. Results The study recruited 58 patients, 19 of whom underwent aneurysm clipping and ICH evacuation. While 33 patients underwent aneurysm clipping, 6 patients underwent coiling embolism without ICH evacuation. The average ICH volume was 15.27±4.07 mL. In the hematoma-evacuated group, 13 (68.4%) patients had unfavorable outcomes (mRS scores of 4 to 6). In the non-evacuated hematoma group, 13 (33.3%) patients had unfavorable outcomes (P = 0.001), postoperative infarction occurred in 11 (57.9%) patients in the hematoma evacuation group and 9 (23.1%) patients in the other group (P = 0.009). Conclusion ICH evacuation was associated with unfavorable outcomes and postoperative infarction in ruptured AcomA aneurysms with concomitant small hematomas (<25 mL). Aneurysm clipping or coiling without ICH evacuation may be a safe and effective choice; however, further investigation is needed.
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Affiliation(s)
- Jiawei Cai
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Chao He
- Department of Neurosurgery, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji, Zhejiang, People’s Republic of China
| | - Jiaheng Xu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Qiu He
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Jinye Su
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Zanyi Wu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Yawen Xu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, First Affiliated Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
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Li YC, Chen CC, Chen CT, Tu PH, Yeap MC, Wu YM, Liu ZH, Chang TW, Lin YJ, Wu TWE, Hsieh PC. Delayed Progressive Mass Effect After Secured Ruptured Middle Cerebral Artery Aneurysm: Risk Factors and Outcomes. Front Surg 2022; 9:852576. [PMID: 35586508 PMCID: PMC9108715 DOI: 10.3389/fsurg.2022.852576] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/14/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Delayed progressive mass effect (DPME) after securing an aneurysm is uncommon following microsurgical or endovascular repair and leads to a poor clinical outcome. Patients with ruptured middle cerebral artery (MCA) aneurysms have a high risk of postoperative oedema and mass effect, which may require decompressive treatment. Because few studies have discussed the risk and predictive factors, we focused on ruptured MCA aneurysms and evaluated the outcomes of these patients and the necessity of salvage surgery when DPME presented. Methods Data on 891 patients with aneurysmal subarachnoid haemorrhage (aSAH) treated between January 2011 and February 2020 were extracted from the medical database of a tertiary referral centre. A total of 113 patients with aSAH resulting from at least one MCA aneurysm were identified. After excluding patients with several clinical confounders, we enrolled 80 patients with surgically treated aSAH. We examined the characteristics of aneurysms and hematomas, perioperative contrast pooling patterns, presence of distal hematomas, perisylvian low density, occlusive treatment modality, management strategies, the need for salvage surgical decompression, and postoperative 90-day outcomes to identify possible risk factors. Results DPME was observed in 27 of the 80 patients (33.7%). The DPME and non-DPME group differed significantly in some respects. The DPME group had a higher risk of salvage surgery (p < 0.001) and poorer outcomes (mRS at day 90; p = 0.0018). The univariate analysis indicated that the presence of hematoma, CTA spot signs, perisylvian low density, and distal hematoma were independent risk factors for DPME. We also noted that DPME remained an independent predictor of a poorer 90-day functional outcome (mRS ≤ 2). Conclusion DPME can lead to salvage decompression surgery and directly relates to poor outcomes for patients with a ruptured MCA aneurysm. Distal hematoma, perisylvian low density, and CTA spot signs on preoperative images can predict DPME.
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Affiliation(s)
- Ying-Ching Li
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Po-Hsun Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Yi-Ming Wu
- Department of Radiology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Ting-Wei Chang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan
| | - Ya-Jui Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Tai-Wei Erich Wu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taoyuan, Taiwan
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan
- Correspondence: Po-Chuan Hsieh
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Prognostic models for neurological functional outcomes in aneurysmal subarachnoid hemorrhage patients with intracranial hematoma. Clin Neurol Neurosurg 2020; 191:105691. [DOI: 10.1016/j.clineuro.2020.105691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/12/2020] [Accepted: 01/20/2020] [Indexed: 11/20/2022]
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Neyazi B, Siblini A, Frantsev R, Özkan N, Sandalcioglu IE, Sure U, Maslehaty H. The role of the Sylvian fissure configuration and the vascular anatomy on different bleeding patterns in ruptured middle cerebral artery aneurysms. Clin Neurol Neurosurg 2019; 189:105572. [PMID: 31786430 DOI: 10.1016/j.clineuro.2019.105572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/20/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Ruptured middle cerebral artery (MCA) aneurysms are one of the causes of subarachnoid (SAH) or intracerebral hemorrhage (ICH) but the factors associated with the bleeding type are unknown. The aim of the study was to analyze the association of the morphological variations of the Sylvian fissure (SF) and vascular parameters on occurrence of different bleeding patterns in patients with ruptured MCA aneurysms. PATIENTS AND METHODS The data of consecutive 202 patients with ruptured MCA aneurysm of two centers were included for analysis. Patients were divided into three groups: Group 1 with SAH, Group 2 with accompanying ICH and Group 3 with intrasylvian hemorrhage (ISH). The SF was divided into five types according to the previously described classification. Analyzed vascular parameters were aneurysm size, localization, presence of a daughter aneurysm, shape, and angulation of the aneurysm sac. RESULTS A total of 202 patients (141 female, 61 male, mean age 52.4 yr) were included in this study. 67 patients (33.2%) had a SAH, 122 (60.4%) an ICH and 13 (6.4%) presented with ISH. Statistical analysis showed a significant association of narrow and twisted SF types 4 and 5 (p < 0.001) and temporal angulation of the aneurysm (p = 0.030) for occurrence of ICH. All other vascular parameters showed no significant association for any kind of hemorrhage. CONCLUSION Our results allow the conclusion that the complex SF types 4 and 5, as well as the temporal angulation of the aneurysm sac are associated with the occurrence of ICH in ruptured MCA aneurysms.
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Affiliation(s)
- Belal Neyazi
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany.
| | - Ali Siblini
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Roman Frantsev
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Homajoun Maslehaty
- Department of Neurosurgery, University Hospital Essen, Essen, Germany; Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany.
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Zijlstra IA, van der Steen WE, Verbaan D, Majoie CB, Marquering HA, Coert BA, Vandertop WP, van den Berg R. Ruptured middle cerebral artery aneurysms with a concomitant intraparenchymal hematoma: the role of hematoma volume. Neuroradiology 2018; 60:335-342. [PMID: 29356856 PMCID: PMC5799354 DOI: 10.1007/s00234-018-1978-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/09/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To study whether clinical outcome data from our patient cohort could give support to the new recommendation in the AHA/ASA guidelines for the management of aneurysmal subarachnoid hemorrhage that states "that microsurgical clipping may receive increased consideration in patients with ruptured middle cerebral artery (MCA) aneurysms and large (>50 mL) intraparenchymal hematomas", while clinical outcome data supporting this recommendation are sparse. METHODS We reviewed the clinical and radiological data of 81 consecutive patients with MCA aneurysms and concomitant hematomas admitted between January 2006 and December 2015. The relation between (semi-automatically quantified) hematoma volume (< or > 50 ml), neurological condition on admission (poor: GCS < 8 or non-reactive pupils), treatment strategies (no treatment, coiling, or clipping with or without decompression and/or clot removal), and outcome (favorable: mRS score 0-3) was evaluated. RESULTS Clinical outcome data were available for 76 patients. A significant difference in favorable outcome (17 vs 68%) was seen when comparing patients with poor and good neurological condition on admission (p < 0.01). Patients with hematomas > 50 ml had similar outcomes for coiling and clipping, all underwent decompression. Patients with hematomas < 50 ml did not show differences in favorable outcome when comparing coiling and clipping with (33 and 31%) or without decompression (90 and 88%). CONCLUSION Poor neurological condition on admission, and not large intraparenchymal hematoma volume, was associated with poor clinical outcome. Therefore, even in patients with large hematomas, the neurological condition on admission and the aneurysm configuration seem to be equally important factors to determine the most appropriate treatment strategy.
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Affiliation(s)
- I A Zijlstra
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - W E van der Steen
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - D Verbaan
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - C B Majoie
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - H A Marquering
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - B A Coert
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - W P Vandertop
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - R van den Berg
- Department of Radiology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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Intrasylvian/Intracerebral Hematomas Associated with Ruptured Middle Cerebral Artery Aneurysms: A Single-Center Series and Literature Review. World Neurosurg 2016; 98:432-437. [PMID: 27847269 DOI: 10.1016/j.wneu.2016.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. METHODS The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. RESULTS In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). CONCLUSIONS In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH.
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Life-Threatening Cerebral Hematoma Owing to Aneurysm Rupture. World Neurosurg 2015; 85:215-27. [PMID: 26361325 DOI: 10.1016/j.wneu.2015.08.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To refine the surgical indications of surgery for life-threatening cerebral hematomas caused by aneurysm rupture, through the analysis of possible outcome predictors. METHODS Forty-nine consecutive patients requiring prompt clot evacuation were retrospectively reviewed. In all cases, the hematoma was equal to or greater than 60 mL. The bleeding aneurysm was located on the middle cerebral artery in 26 cases, on the internal carotid artery in 10 cases, and on the anterior cerebral artery in 13 cases; four aneurysms were giant. Six patients underwent aneurysm coiling followed by clot removal, whereas 43 patients were managed by concomitant clot evacuation and aneurysm clipping. The main clinical and radiologic features, the management paths and the treatment modalities were correlated with the outcomes. A statistical analysis was conducted. RESULTS Overall mortality was 32.6%, severe morbidity was 22.4% and 22 patients (44.8%) achieved favorable results. The short-term results were more significantly influenced by the radiological parameters than by the initial clinical conditions. The prognostic weight of the radiologic findings was partially lost for six-month results, whereby management factors gained in importance. CONCLUSIONS The bleeding severity was strongly determinant for early mortality. However, if patients can survive the initial crucial phase, their chances of a favorable outcome are not negligible. Further improvement may be possible through better patient selection and the identification of nonsalvageable subjects.
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Gong J, Sun H, Shi XY, Liu WX, Shen Z. Pure subdural haematoma caused by rupture of middle cerebral artery aneurysm: Case report and literature review. J Int Med Res 2014; 42:870-8. [PMID: 24691457 DOI: 10.1177/0300060514524929] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/30/2014] [Indexed: 11/15/2022] Open
Abstract
Pure subdural haematoma (occurring without detectable subarachnoid haemorrhage) caused by intracranial aneurysm rupture is uncommon and is usually associated with delayed diagnosis and treatment. We describe the case of a 43-year-old man who presented with ongoing headache. Computed tomography and magnetic resonance imaging of the brain revealed subdural haematoma in the left fronto–temporo–parietal region, without subarachnoid haemorrhage. Digital subtraction angiography showed an aneurysm measuring ≤5 mm in diameter, arising from the distal region of the left middle cerebral artery. During hospitalization, an acute change in mental status accompanied by slurred speech and narcolepsy prompted an emergency CT scan. This revealed an enlargement of the subdural haematoma. The patient underwent an emergency craniotomy, during which a large amount of bloody fluid was evacuated, and the aneurysm was coagulated and resected. The patient had a good outcome without neurological deficit. The incidence, mechanisms and treatment of this condition are discussed.
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Affiliation(s)
- Jie Gong
- Department of Neurosurgery, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Hu Sun
- Department of Neurosurgery, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Xiao-Yong Shi
- Department of Neurosurgery, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Wei-Xian Liu
- Department of Neurosurgery, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Zheng Shen
- Department of Neurosurgery, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
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