Relation of cerebral vasospasm to operative findings of subarachnoid blood around ruptured aneurysms

Summary An investigation was carried out in 28 patients in order to evaluate the relationship between angiographically documented vasospasm, amount of subarachnoid blood found at surgery around ruptured intracranial aneurysms, and delayed ischaemic deficits. Angiography was performed at time intervals ranging between 5 and 17 days, and surgery not later than 21 days following subarachnoid haemorrhage. The absence of subarachnoid clots was associated in ten patients, with no or minor vasospasm and no or mild neurological deficits. Thin clots were found in eight patients; one of them had no vasospasm, six had minor vasospasm, and one showed severe vessel narrowing. Major clinical signs were absent in these cases. All ten patients with thick clots developed severe vasospasm, and eight of them severe neurological signs.The important aetiological role of local subarachnoid clots in determining vasospasm is emphasized in view of surgical timing.     

Shunt-dependent hydrocephalus after subarachnoid haemorrhage and aneurysm surgery: Timing of surgery is not a risk factor

Summary Early hydrocephalus is a risk factor of shunt-dependent late hydrocephalus (SDHC). In the CT era 1980–1990 we had 835 consecutive patients operated on because of aneurysm and subarachnoid haemorrhage (SAH); 294 had an early hydrocephalus and 67 finally required a shunt. There were 14 patients with normal early CT and SDHC, in all 81 patients needed a shunt (10%). Patients with shunt did worse, they were older (53 vs 49) than the non-shunted group and there was a female preponderance.Pre-operative Grade correlated significantly with the need for a shunt operation; no one in Grade I developed SDHC, incidence in Grades III and IV was high (18% and 10%, respectively). Location was important; in vertebrobasilar area 28% and in anterior communicating area 14% but in middle cerebral area only 4% of the patients had SDHC.The amount of cisternal bleeding correlated significantly with SDHC; in 155 patients with non detectible or minimal cisternal blood only one developed SDHC, with severe cisternal bleeding the incidence was 16%. Ventricular bleeding increased the risk of SDHC, but intracerebral haematoma did not.Timing of surgery had no correlation with the risk of SDHC. Postoperative complications, haematomas and infections increased the risk of late SDHC. Delayed ischaemia correlated with the risk, but so did the treatment with nimodipine. Severe bleeding was the common predictor for the risk of SDHC. Location of the bleeding and postoperative problems are the other major causes. Outcome is, however, not so gloomy; 54% of patients with SDHC are independent one year later.     

Results of direct surgery for aneurysmal subarachnoid haemorrhage: outcome of 2055 patients who underwent direct aneurysm surgery and profile of ruptured intracranial aneurysms

Summary  Background and Purpose. The purpose of this study is to evaluate the therapeutic value of our surgical treatment of subarachnoid haemorrhage in a large series with standardized surgical principles.  Methods. Results of 2055 direct operations on ruptured intracranial aneurysms, treated in our institutions, where surgical indications, instruments and techniques were standardized, between 1988 and 1998, were retrospectively evaluated and outcome of the patients was discussed; cases treated by intravascular procedures were excluded.  Results. According to the evaluation at discharge, 1083 (52.7%) patients were excellent, 324 (15.8%) good and 223 (10.9%) fair. There were 160 (7.8%) patients of poor outcome and the remaining 265 (12.9%) died. There were no differences in the outcome between pre-operative Hunt & Kosnik grade I and II, Fisher Scale 1 and 2, anterior circulation aneurysms and posterior circulation aneurysms except those at and around the basilar bifurcation, men and women, and those clipped and not clipped.  Conclusions. The factors related to poor outcomes were, age of 60 years or over, pre-operative Hunt & Kosnik grade II or more, Fisher Scale 3 or more, aneurysm size over 15 mm in diameter, and location at and around the basilar artery bifurcation. The results presented in this study show the status of our direct surgical management of subarachnoid haemorrhage in a large series with standardized surgical principles and procedures.     

MRI in multiple vascular lesions: Identification of the ruptured malformation

Summary 4 patients were recently admitted for subarachnoid haemorrhage with multiple vascular lesions. 3 of them presented with multiple aneurysms, and one with an aneurysm associated with an arterio-venous malformation. In these 4 cases identification of the ruptured lesion was difficult in spite of clinical examination, CT scan, and complete panangiography; on magnetic resonance imaging (MRI) was found a signal hyperintensity, mainly on T2 weighted views, corresponding to blood clots around the ruptured aneurysm. This signal hyperintensity was completely absent in the vicinity of the associated vascular lesion, which appeared only as a signal void corresponding to the blood flow inside the unruptured lesion. Therefore MRI can be used in such cases to identify the ruptured lesion, so permitting the choice of the best approach and strategy of treatment.     

One-year outcome in early aneurysm surgery: Prediction of outcome

Summary Predictors of one-year outcome were studied in patients treated for ruptured intracranial aneurysm. A total of 929 patients, who were treated conservatively or surgically, and 839 patients as a part of this population who were surgically treated, were randomly divided into two groups in order to create predictive models by logistic regression and to validate them. The models were derived from two-thirds of these two patient groups and the remaining one-thirds were used for validation.The pre-operative variables of both conservatively and surgically treated patients were studied byModel A. The pre-operative Grade (Hunt and Hess), age, and the presence of vasospasm on angiography were the three most important predictors of the one-year outcome (Glasgow Outcome Scale 1-2/3-5). Model B consisted of preand per-operative, andModel C pre-per-, and post-operative variables collected from the surgically treated group. The pre-operative Grade, ligation of a major vessel and age were the three most powerful determinants of outcome inModel B. In Model C high Grade, post-operative CT-hypodensities and ligation of a major vessel were most closely associated with poor outcome.Model A, based on pre-operative data, most accurately predicted good outcome. All the 59 patients in the validation sample (n=310) who were predicted to have a less than 5% probability of poor outcome had a favourable outcome (positive and negativ predictive value 100%). Model C determined that 22 of 280 patients would have a more than 80% probability of poor outcome. Only three patients made a good recovery (positive predictive value 86.4%).These models predicted the outcome one year following surgery accurately and may aid decision making in the selection of these patients for surgery and intensive care.This study was supported, in part, by the Finnish Medical Foundation, the North Savo Regional Fund of the Finnish Cultural Foundation, and the Helena Vuorenmies Foundation, Kuopio, Finland.     

Posterior circulation aneurysms. Results of direct operations

Twenty-eight patients with aneurysms of the posterior circulation were managed by direct operations, 53.6% of these being done within 14 days of a subarachnoid hemorrhage. Transvenous cardiac pacing was used in 4 of the 13 patients with aneurysms of the basilar bifurcation in order to produce a short period of profound hypotension while final dissection and clip application was performed. There were nine patients with posterior-inferior cerebellar artery/vertebral-junction aneurysms, the only one dying having a large aneurysm. The operative technique used in the majority of the 13 patients with basilar bifurcation aneurysms involved subtotal temporal lobectomy, and the operative exposure so obtained was excellent. Five patients died, one of whom rebled from an aneurysm of the basilar artery origin that could only be wrapped, the total mortality being 17.9%. Seventeen (74%) of the 23 survivors were assessed as showing good results; 5 (22%) as showing fair results, and only 1 (4%) as showing a poor result.     

The impact of rebleeding on the life time probabilities of different outcomes in patients with ruptured intracranial aneurysms

Summary In order to strengthen patient-information a theoretical evaluation of the impact of rebleeding on the life time probabilities of different outcomes in patients with an aneurysmal subarachnoid haemorrhage (SAH) has been made using a life table method. The calculations were performed for SAH-presenting ages from 20 to 70 years assuming a rate of rebleeding of 50% in the first 6 months after the initial bleeding with a mortality rate of 70%, and the following years an annual rate of rebleeding of 3%, and with a mortality rate of 60%. A survey of the life time probabilities of the 4 different outcomes after an aneurysmal SAH shows the great life time reducing effect of rebleedings in all SAH-presenting ages.     

Significance of ST segment elevation in electrocardiograms in patients with ruptured cerebral aneurysms

Summary Twenty-three patients with aneurysmal subarachnoid haemorrhage (SAH), who showed an ST segment elevation in their electrocardiograms (ECG), were examined.There were 12 males and 11 females, with a mean age of 61 years. The clinical condition on admission was Hunt and Kosnik grade II in four, III in seven, IV in one, and V in 11 patients. Computerized tomography (CT) also revealed many cases of diffuse, thick SAH or intracerebral or intraventricular haematoma. Laboratory examinations including serum electrolyte, pH, and PaO₂ revealed no abnormalities that might have influenced the ECG. Elevation in the levels of myocardial enzymes in serum was observed in two of the nine patients examined, although the elevation was only slight in one of them. Echocardiography, which was performed on several occasions on all patients, and cardiac catheterization, which was performed on eight patients, revealed a reduction in the motion of the left ventricular apex that was synchronous with ST segment elevation. This is the first report about these phenomena. No abnormalities were observed in the coronary artery. The elevated ST segment was normalized within one week in all patients, accompanied by normalization of the apical wall motion recorded on echocardiograms. In four patients, however, T wave inversion accompanied the improvement of the ST segment and was normalized within three months after the onset.These results suggest that ST segment elevation in the acute stage of SAH reflects transient cardiac dysfunction rather than myocardial injury. In some patients, however, the elevated serum levels of myocardial enzymes or T wave inversion suggested the presence of myocardial injury. Close follow-up seems to be necessary in such cases     

The role of antifibrinolytic therapy in the preoperative management of recently ruptured intracranial aneurysms

In a retrospective study of the use of antifibrinolytic therapy in a series of patients with recently ruptured intracranial aneurysms, 131 patients were selected based on the following criteria: commencement of therapy within 3 days of the last subarachnoid hemorrhage (SAH); continuation of therapy for at least 6 days; and apparently uncomplicated surgery. Two main modalities of antifibrinolytic therapy were used: Group A, tranexamic acid (AMCA) 3 gm daily plus aprotinin k.i.u. (kallikrein inactivating units) daily (82 cases); Group B, AMCA 6 gm daily (41 cases). The remaining 8 patients were treated with epsilon-aminocaproic acid alone or in combination with aprotinin and were not considered to constitute a large enough group for statistical comparison. The rest of the preoperative treatment consisted of bed rest; mild sedation; antihypertensives, if the blood pressure exceeded 160 mm Hg; and osmotic diuretics as needed. The mean interval between last SAH and operation was about 13 days in both groups. The rates of rebleeding and thromboembolism were similar in the two groups but the rates of ischemic complications and post-SAH hydrocephalus were higher in Group B. The difference in the rate of severe cerebral ischemic complications was statistically significant (11 of 82 in Group A versus 12 of 41 in Group B, p less than 0.02), and in the main they were present preoperatively. The rates of rebleeding (approximately 10%) and of death from rebleeding (approximately 5%) are lower than in other published series on the natural history of this condition. In cases in which antifibrinolytics are indicated, present evidence indicates that low-dose AMCA plus aprotinin seems to be a rational combination for lowering the rebleeding, ischemic complication, and post-SAH hydrocephalus rates.     

How often is a perimesencephalic subarachnoid haemorrhage CT pattern caused by ruptured aneurysms?

SummaryBackground Angiography is usually recomended in perimesencephalic subarachnoid haemorrhage (PM SAH) to rule out a basilar artery aneurysm. However it is not known how often aneurysms are found among patients with a CT pattern of PM haemorrhage or the frequency of this CT pattern after rupture of posterior circulation aneurysms.Method CTs of all SAH caused by posterior circulation aneurysms admited from 1/85 to 12/92 where reviewed by two examiners. Late (>72 h) examinations were excluded. The remaining CTs were classified in perimesencephalic (PM) or non PM.Results 81 posterior circulation aneurysms were collected. Only one PM-like CT pattern was found, due to ruptured posterior communicating artery aneurysm (1.3%; 95% Cl (confidence intervals)=.03–6.7%). During the same period 37 PM SAH with negative angiographic results were admited. The likehood of finding an aneurysm in a patient with an early CT showing a PM distribution of haematic densities was 2.7% (95% Cl=.07–14%).Conclusion Although the probability of finding an aneurysm in a SAH patient with a PM CT pattern is low, a complete 4-vessel angiogram must be obtained.     

Giant calcified aneurysm on the posterior cerebral artery in a nine-year-old child

We report the case of a 9-year-old child in whom, after a plain x-ray examination of the skull was performed for a suppurating otitis in the left ear, a calcified lesion was discovered in the left temporal region. Angiographic study showed it to be an aneurysm of the left posterior cerebral artery. The rarity of these lesions is discussed, as well as the successful surgical treatment in this case.     

SPECT with technetium-99m-HMPAO in relation to late cognitive outcome after surgery for ruptured cerebral aneurysms

Summary Fifteen patients with a good neurological outcome after aneurysmal SAH and surgery were collected prospectively. Six months after surgery neurological examination and a SPECT study for evaluation of the three dimensional CBF distribution as well as an extensive neuropsychological test were performed. In all patients with pathological SPECT findings the location of the reduced regional CBF correlated with the location of the ruptured aneurysm and/or side of surgical approach. The volume of the brain tissue with reduced rCBF showed a great variety, from 9–112 cm³ (mean: 33 cm³). Similarly, the maximum flow reduction in the affected areas also varied considerably from 17–95% (mean: 39%). In general, the neuropsychological functioning of the patients post SAH was favourable. Seven individuals had a presumably normal neuropsychological appearance with respect to estimates of premorbid levels of functioning. Another four patients were slightly impaired and the remaining four were moderately affected. Only in five cases did the location of SPECT pathology and the site of neuropsychological impairment appear to coincide, whereas this was not the case in the remaining 10 patients. In general, the extent of SPECT pathology did not differ in the three neuropsychological outcome groups (normal, slight and moderate disability).     

One-year outcome in early aneurysm surgery: a 14 years experience

Summary In a consecutive series of 1150 patients with cerebral aneurysms diagnosed in our department by angiography or autopsy between the years 1977–1990, 1007 patients underwent definitive operative treatment of their aneurysms mainly by early surgery. More than half (55%) were operated on during the first three days after subarachnoid haemorrhage (SAH), and more than three quarters (77%) during the first week. The surgical mortality at 30 days was 9%; at one-yearfollow-up 13% had died. The total management mortality was 22%. The 618 patients presenting in Hunt and Hess Grades I–II had a 4% mortality, and 90% had an independent life at follow-up; 270 Grade III patients hat a 19% mortality and 68% were independent. There were 99 patients operated on in Grades IV–V with a 46% mortality and 30% were independent. Age of the patient and size of the aneurysm were strongly related to outcome; however, many of the giant aneurysms were operated on as an emergency because of large intracerebral haematomas. Best results were obtained in the anterior communicating artery (ACA) area; the lowest rate of useful recoveries was in the vertebro-basilar artery (VBA) area (71%). Early surgery did not prevent delayed ischaemic deficits.During the first 72 hours patients in Grades I–III can be operated on safely with good results. The results in Grades IV–V are poor, and we suggest that only cases with large haematomas or considerable hydrocephalus or those improving should be operated on in the first days after SAH, with limited hopes of functional recovery.     

Early aneurysm surgery and dehydration therapy in patients with severe subarachnoid haemorrhage without ICH

Summary We prospectively analysed treatment results in patients with severe subarachnoid haemorrhage (SAH) who underwent early aneurysm surgery, and were managed by dehydration therapy. We studied a total of 31 patients with poor-grade SAH including 18 in grade IV, and 13 in grade V according to the WFNS classification system. Patients who were older than 70 years of age, or those with an intracerebral haemorrhage or absent brainstem response were excluded from this study. At surgery, clot evacuation from the peribrainstem cisterns with/without external decompression was performed following obliteration of the aneurysmal neck. In the early postoperative period, patients were maintained in negative water balance using osmotic diuretics. When delayed ischaemic deficits had manifested themselves, the pulmonary wedge pressure and/or central venous pressure was immediately increased by the rapid injection of albumin until hypovolaemia reverted to normovolaemia with the continuous administration of dobutamine. The outcome at 3 months was good recovery in 16 (52%) patients, moderate disability in 3 (10%), severe disability in 5 (16%), a vegetative state in 1 (3%), and death in 6 (19%). We thought that early aneurysm surgery and postoperative dehydration therapy in the acute stages of brain oedema resulting from primary brain damage are effective in the treatment of patients with severe SAH but reversilbe primary brain damage.     

Surgical management of ruptured aneurysms in the eighth and ninth decades

Summary ?Background. The surgical management of elderly patients with aneurysmal subarachnoid haemorrhage (SAH) is controversial. The present study was performed to more clearly define issues facing elderly SAH patients undergoing surgical repair of their aneurysms. Method. Between 1990 and 2000, 100 patients, aged 70 years or older, were managed consecutively with aneurysmal surgical repair at Verona City Hospital. Ninety-seven of these were analysed with regard to age, clinical grade on admission, radiological features, and specific management components (3 patients were excluded from further analysis because of inadequate follow up data). Surviving patients were followed up for a minimum of 6 months and clinical outcome was assessed. Findings. Hydrocephalus requiring permanent CSF diversion occurred in 44% of cases surviving beyond 10 days from their SAH. The development of hydrocephalus requiring shunting was delayed more than 6 weeks in 7% of these cases. Medical complications occurred in 22% of cases. Clinical grade of haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.03) were significantly associated with poor outcome. Clinical vasospasm was not a major determinant of outcome in this group. The need for permanent CSF diversion was significantly associated with increasing age (p=0.03), intraventricular haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.05). Interpretation. Elderly patients experience a different range of complications following aneurysmal subarachnoid haemorrhage than their younger counterparts. Clinicians should remain alert to the development of hydrocephalus, especially of delayed onset. Published online June 11, 2003     

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms

Summary One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances.More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage then a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p<0.04); the reverse was true for the placebo patient (p<0.05).     

Medical management of patients following a ruptured cerebral aneurysm,with ϵ-aminocaproic acid,kanamycin, and reserpine

Patients suffering from a subarachnoid hemorrhage who were admitted to the Neurosurgical Unit of the Royal Perth Hospital during the period 1971 to 1979 were assessed with regard to the effectiveness of preoperative treatment with ?-aminocaproic acid, kanamycin, and reserpine. Forty-two patients who were treated with ?-aminocaproic acid had a rebleed rate of 2.3% compared to a 9.7% rebleed rate in appropriately selected controls. Patients treated with kanamycin and reserpine had a preoperative cerebral vasospasm rate of 32% compared to a 26% rate in controls; however, kanamycin and reserpine were found useful for decreasing the postoperative complications of cerebral vasospasm.     

Is eyebrow approach suitable for ruptured anterior circulation aneurysms on early stage: a prospective study at a single institute

Objective  A prospective study was underway to evaluate the outcome of eyebrow keyhole approach for ruptured anterior circulation aneurysms on early stage. Methods  In the past 4 years, 88 patients with ruptured anterior circulation aneurysms, were operated on early stage by an experienced neurosurgical team through eyebrow craniotomy. The clinical data were analyzed. Results  Patients with Hunt and Hess Grade I–II (85.2%) or III (14.8%) were selected for eyebrow approach on early stage. All aneurysms were small (20.5%) or middle (79.5%) in size. All but seven (92.0%) aneurysms were clipped successfully. The opening of frontal sinus occurred in 11(12.5%) cases through eyebrow approach. Of all, 78 (88.6%) patients achieved favorable outcomes. Conclusions  Eyebrow keyhole approach for ruptured anterior circulation aneurysms on early stage might be in particular selected according to the Hunt and Hess Scale, the projection of aneurysm, the length of M1 segment, the location of cerebral hematoma, the size and complexity of aneurysm, as well as the preference and experience of the neurosurgical team.     

Value of the quantity and distribution of subarachnoid haemorrhage on CT in the localization of a ruptured cerebral aneurysm

Summary ¶Background. Computed tomography (CT) is the gold standard for detecting subarachnoid haemorrhage (SAH) and digital subtraction angiography (DSA) for visualising the vascular pathology. We studied retrospectively 180 patients with subarachnoid haemorrhage (SAH) who underwent first non-enhanced computed tomography (CT), then digital subtraction angiography (DSA) and finally operative aneurysm clipping. Our aim was to assess if the location of the ruptured aneurysm could be predicted on the basis of the quantity and distribution of haemorrhage on the initial CT scan. Methods. 180 patients with SAH were retrospectively studied. All the CT and DSA examinations were performed at the same hospital. CT was performed within 24 hours after the initial haemorrhage. DSA was performed after the CT, within 48 hours after the initial haemorrhage. Two neuroradiologists, blind to the DSA results, analysed and scored independently the quantity and distribution of the haemorrhage and predicted the site of the ruptured aneurysm on the basis of the non-enhanced CT. DSA provided the location of the ruptured aneurysm. All the patients were operated upon, and the location of the ruptured aneurysm was determined. Findings. The overall reliability value (-value) between the two neuroradiologists for locating all ruptured aneurysms was 0.780. The corresponding value for the right MCA was 0.911, that for the left MCA 0.877 and that for the AcoA 0.736. Not all of the -values were calculated, either because the location of the rupture was constant or because the number of ruptures in the vessel was too small. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of the ruptured aneurysm with a statistical significance of p=0.003. Interpretation. The quantity and pattern of the blood clot on CT within the day of onset of SAH is a reliable and quick tool for locating a ruptured MCA or AcoA aneurysm. It is not, however, reliable for locating other ruptured aneurysms. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of a ruptured aneurysm.Published online July 23, 2003