Predictors of in-hospital shunt-dependent hydrocephalus following rupture of cerebral aneurysms

The development of shunt-dependent hydrocephalus is a well-recognised complication after aneurysmal subarachnoid haemorrhage, and negatively impacts on outcomes among survivors. This study aimed to identify early predictors of shunt dependency in a large administrative dataset of aneurysmal subarachnoid haemorrhage patients. We reviewed the National Hospital Morbidity Database in Australia for the years 1998 to 2008 and investigated the incidence of ventricular shunt placement following aneurysmal subarachnoid haemorrhage admissions. Putative risk factors were evaluated with univariate and multivariate logistic regression analysis to identify independent predictors of outcome. The following variables were considered: poor admission neurological grade; aneurysm location; intracerebral haemorrhage; intraventricular haemorrhage; acute hydrocephalus requiring the insertion of an external ventricular drain; surgical clipping; endovascular coiling; meningitis; and prolonged period of external ventricular drainage. A total of 10 807 patients hospitalised for aneurysmal subarachnoid haemorrhage were identified. Among them, 701 (6.5%) required a permanent cerebrospinal fluid diversion procedure during the same admission as the aneurysmal subarachnoid haemorrhage. On multivariate analysis, poor admission neurological grade, acute hydrocephalus, the presence of intraventricular haemorrhage, ruptured vertebral artery aneurysm, surgical clipping, endovascular coiling, meningitis, and a prolonged period of external ventricular drainage were significant predictors of shunt dependency. A patient with a ruptured middle cerebral artery aneurysm was unlikely to develop shunt dependency (odds ratio 0.58; 95% confidence interval 0.46–0.73; p < 0.001).     

Arterial fenestrations and their association with cerebral aneurysms

Fenestrations of intracranial arteries and associated aneurysms are rare. The significance of these fenestrations in relation to aneurysms remains unclear. We present four patients with fenestration-associated aneurysms and a comprehensive review of associations with aneurysms and other vascular lesions. A PubMed search of the literature was conducted from 1970–2012 reporting cases of intracranial aneurysms associated with arterial fenestration or duplications. Data were collected on patient presentation, sex, age, aneurysm and fenestration location, aneurysm treatment, and presence of other vascular lesions. We performed a retrospective review of four patients with intracranial fenestrations associated with aneurysms at our institution from 2012–2013. There were 59 cases of fenestrations and associated aneurysms in the literature. Aneurysms were reported as either arising from (n = 50) or adjacent to but distinct from (n = 13) fenestrations. The most common single fenestration location was at the basilar artery (n = 23, 36.5%); however the majority of fenestrations were in the carotid circulation (n = 34, 54.0%). The majority of patients with aneurysms and fenestrations at all locations except those at the anterior communicating artery (70.5%) presented with subarachnoid hemorrhage. Patients with aneurysms arising from a fenestration or adjacent to a fenestration presented with an additional intracranial vascular lesion in 38% and 31% of cases, respectively. The majority of all aneurysms were treated with microsurgical clipping. Aneurysms associated with cerebral arterial fenestrations are most commonly discovered after subarachnoid hemorrhage and are most often located in the carotid circulation. A high index of suspicion must be maintained for an associated vascular lesion if an intracranial fenestration is discovered.     

Changing paradigm in the management of elderly patients with intracranial aneurysms: An institutional review

Optimal treatment of intracranial aneurysms (IAs) in elderly patients has not yet been well established. We have investigated the clinical and radiological outcomes and predictors of unfavorable outcome of IAs in elderly patients. Radiological and clinical data of 85 elderly patients from 2010 through 2015 were retrospectively reviewed. Significant differences between the groups were determined by a chi-square test. Regression analysis was performed to identify the predictors of unfavorable outcome. Among the 85 patients with IAs, the number of patients with >7 mm size aneurysm (p = 0.01), diabetes mellitus (DM) (p = 0.02), smoking (0.009) and Hunt and Hess grade 4–5 (p = 0.003) was significantly higher in the ruptured group compared to the unruptured group. Similarly, the number of patients who underwent clipping was higher in the ruptured aneurysm group (p = 0.01). The overall clinical outcome was comparatively better in the unruptured group (p = 0.03); however, microsurgical clipping of aneurysms provides a significantly higher rate of complete aneurysmal occlusion (p = 0.008). Overall, there was no significant difference in outcome in respect to treatment approach. In regression analysis, hypertension (HTN), obstructive sleep apnea (OSA), prior stroke, ruptured aneurysms and partial occlusion of aneurysms were identified as predictors of unfavorable outcome of IAs. Intracranial aneurysms in elderly patients reveals that endovascular treatment provides better clinical outcome; however, microsurgical clipping yields higher complete occlusion. Retreatment of residual aneurysms was comparatively more in the coiling group. Practice pattern has shifted from clipping to coiling for aneurysms in posterior circulation but not for aneurysms in anterior circulation.     

Results of clipping surgery for aneurysmal subarachnoid hemorrhage in the ninth and tenth decades of life

This study investigated the outcome of clipping surgery for ruptured aneurysms in patients older than 80 years of age. From 1988 to 2011 data were retrospectively reviewed, and 196 patients treated with clipping obliteration for aneurysmal subarachnoid hemorrhage were identified. Patients were divided into two age groups of 80–84 and ⩾85 years old. The Glasgow Outcome Scale score was assessed at discharge and classified as favorable (good recovery or moderate recovery) or unfavorable (severe disability, vegetative state, or dead). Radiological and clinical characteristics were compared between the two groups. A favorable outcome was achieved in 106 (54.1%) of the 196 patients. Preoperative grade and Fisher grade were significantly associated with unfavorable outcome, but age was not. Based on logistic regression analysis, poor preoperative grade and ruptured anterior cerebral artery aneurysm were the predictors of unfavorable outcome, but advanced age (⩾85 years old) was not. Advanced age itself did not affect the outcome of the elderly patients who underwent clipping surgery for aneurysmal subarachnoid hemorrhage.     

Clinical outcomes after craniotomy for unruptured intracranial aneurysm in patients with coronary artery disease

BackgroundCoronary artery disease (CAD) patients receiving antiplatelet agents occasionally undergo craniotomy. We aimed to clarify clinical outcomes after craniotomy for unruptured intracranial aneurysm (UIA) in patients with CAD. We also aimed to identify the possible predictive factors for morbidity and surgical complications in patients on antiplatelet treatment.MethodsWe retrospectively analyzed 401 consecutive patients who had undergone craniotomy for UIA at our institution between January 2006 and December 2016. Forty-three patients (10.7%) received antiplatelet agents during the perioperative period. The underlying reasons for antiplatelet treatment were CAD in 12 patients and other diseases in 31 patients.ResultsSevere morbidity and intracranial hemorrhage occurred more commonly and symptomatic brain infarction occurred less frequently in patients with CAD compared to patients with other underlying diseases (16.7% versus 3.2%, 16.7% versus 9.7%, and 8.3% versus 16.1%, respectively), though differences between the two groups were not significant. Univariate analysis revealed that a low preoperative baseline platelet count was significantly correlated with the occurrence of intracranial hemorrhage (cutoff value, 16.5 × 10⁴/µL; odds ratio (OR), 46.67; 95% confidence interval (CI), 3.88–561.95; p = 0.0005), and a high baseline platelet count tended to correlate with severe morbidity (cutoff value, 29.8 × 10⁴/µL; OR, 11.33; 95% CI, 0.88–145.52; p = 0.0550).ConclusionsOur results suggest that surgical complications and clinical outcomes after craniotomy may depend on the underlying reason for antiplatelet treatment. Moreover, a preoperative platelet count can be useful in predicting the occurrence of intracranial hemorrhage and severe morbidity after craniotomy in patients receiving antiplatelet agents.     

Unilateral craniotomy for bilateral cerebral aneurysms

Multiple intracranial aneurysms located bilaterally in the anterior circulation are usually clipped sequentially by separate craniotomies or a bilateral craniotomy. However, in selected patients, bilateral aneurysms can be clipped on both sides in a single sitting through a unilateral approach and unilateral craniotomy without causing morbidity. We present our technique and results of bilateral aneurysms clipped through a unilateral craniotomy from the ruptured aneurysm side. Ten patients (between 2006 and 2008) aged 20 years to 67 years with bilateral supratentorial anterior circulation saccular aneurysms, World Federation of Neurological Surgeons Scale (WFNS) score subarachnoid hemorrhage (SAH) grades 1 and 3, Fisher grades 2 and 3, were operated with unilateral orbito–pterional craniotomy and clipping of bilateral aneurysms. A total of 23 aneurysms, 12 located contralaterally, were successfully clipped with a good outcome in nine patients and no mortality at all. We therefore conclude that the unilateral orbito–pterional approach can be safely employed in selected patients harboring bilateral supratentorial saccular aneurysms and presenting with SAH, having WFNS grade 1 to 3, Fisher grade up to grade 3. The brain must be lax intra-operatively. Wide opening of the basal cisterns, 3rd ventriculostomy, and clipping of ruptured aneurysms are the important steps to be performed first before clipping the contralateral aneurysm thus avoiding a second craniotomy.     

Somatosensory evoked potentials in carotid artery stenting: Effectiveness in ascertaining cerebral ischemic events

Somatosensory evoked potentials (SSEP) have been used in various endovascular procedures and carotid endarterectomy, but to our knowledge no literature deals exclusively with the utility of SSEP in carotid artery stenting (CAS). The purpose of this study was to evaluate the efficacy of SSEP in detecting cerebral ischemic events during CAS. We conducted a prospective study in 35 CAS procedures in 31 patients during an 18 month period. Thirty-three patients without near occlusion underwent stenting using dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration, while two patients with near occlusion underwent stenting without dual protection. All 35 patients underwent SSEP monitoring. SSEP were generated by stimulating median and/or tibial nerves and recorded by scalp electrodes. During the aspiration phase post-dilation, seven patients (20%) exhibited SSEP changes with a mean duration of 11.3 ± 8.5 minutes (range: 3–25 minutes), three of whom later developed minor stroke/transient ischemic attack. Diffusion-weighted imaging showed new lesions in 10 patients (28.6%). Change in SSEP exhibited mean sensitivity of 100% (95% confidence interval, 0.29–1.0) and specificity of 88% (95% confidence interval, 0.71–0.96) in predicting clinical stroke post-CAS. Intra-procedural SSEP change was predictive of post-procedural complications (p = 0.005, Fisher’s exact test). Longer span of SSEP change was positively correlated with complications (p = 0.032, Mann–Whitney test). Intra-procedural SSEP changes are highly sensitive in predicting neurological outcome following CAS. Chances of complications are increased with prolongation of such changes. SSEP allows for prompt intra-procedural ischemia prevention measures and stratification to pursue an aggressive peri-procedural protocol for high risk patients to mitigate neurological deficits.     

Whole-brain CT perfusion combined with CT angiography for ischemic complications following microsurgical clipping and endovascular coiling of ruptured intracranial aneurysms

Ischemic complications associated with microsurgical clipping and endovascular coiling affects the outcome of patients with intracranial aneurysms. We prospectively evaluated 58 intracranial aneurysm patients who had neurological deterioration or presented with poor grade (Hunt-Hess grades III and IV), aneurysm size >13 mm and multiple aneurysms after clipping or coiling. Thirty patients had ischemic complications (52%) as demonstrated by whole-brain CT perfusion (WB-CTP) combined with CT angiography (CTA). Half of these 30 patients had treatment-associated reduction in the diameter of the parent vessels (n = 6), ligation of the parent vessels or perforating arteries (n = 2), and unexplained or indistinguishable vascular injury (n = 7); seven of these 15 (73%) patients suffered infarction. The remaining 15 patients had disease-associated cerebral ischemia caused by generalized vasospasm (n = 6) and focal vessel vasospasm (n = 9); six of these 15 (40%) patients developed infarction. Three hemodynamic patterns of ischemic complications were found on WB-CTP, of which increased time to peak, time to delay and mean transit time associated with decreased cerebral blood flow and cerebral blood volume were the main predictors of irreversible ischemic lesions. In conclusion, WB-CTP combined with CTA can accurately determine the cause of neurological deterioration and classify ischemic complications. This combined approach may be helpful in assessing hemodynamic patterns and monitoring operative outcomes.     

Endovascular treatment of ruptured tiny (⩽3 mm) intracranial aneurysms in the setting of subarachnoid hemorrhage: A case series of 20 patients and literature review

Successful endovascular coiling of ruptured tiny saccular intracranial aneurysms (⩽3 mm) is technically challenging and traditionally has been associated with technical failures, as well as morbidity related to thromboembolic events and high intraoperative rupture rates. This study analyzes the feasibility, technical efficacy, and clinical outcomes of coil embolization of ruptured tiny intracranial aneurysms using current coil and microcatheter technology and techniques. We performed a retrospective review of 20 patients with 20 ruptured tiny aneurysms treated with endovascular coil embolization from 2013 to 2016 at a single high-volume academic tertiary care practice. The mean aneurysm size was 2.4 mm (median 2.5 mm, 1–3). Complete occlusion was achieved in 12 of 20 patients (60%), the remaining 7 of 20 patients (35%) had a small neck remnant, and there was 1 failure (5%) converted to microsurgical clipping. Two patients had a failed attempted surgical clip reconstruction and were subsequently coiled. There was 1 intraprocedural rupture (5%) and 1 severe parent artery vasospasm (5%) during coiling. At discharge, 60% of patients were living independently. At follow-up three patients were deceased. Mean angiographic follow-up was 139 days (SD 120). There were no aneurysm recurrences among occluded patients and there were no retreatments among those with neck remnants. Coiling of ruptured aneurysms ⩽3 mm is feasible with high occlusion rates and low complication rates. The availability of softer coils with flexible detachment zones has led to safe and effective endovascular treatment of tiny ruptured aneurysms.     

Carotid artery disease and perioperative stroke risk after surgical aortic valve replacement: A nationwide inpatient sample analysis

To study the role of carotid stenosis (CS) and cerebrovascular disease as independent risk factors for perioperative stroke following surgical aortic valve replacement (SAVR). The National Inpatient Sample (NIS) database was used for our study. All patients who underwent SAVR from 1999 to 2011 were identified using ICD-9 codes. Univariate and multivariate analysis of baseline characteristics, Elixhauser comorbidities and other covariates were examined to identify independent predictors of perioperative strokes following SAVR. Data on 50,979 patients who underwent SAVR from 1999 to 2011 was obtained. The mean age of the study cohort was 60.5. The study patients were predominantly Caucasian (79.3%) and males (60.01%). The incidence of perioperative stroke was 2.48%. CS (OR 1.8, 95%CI 1.1–2.8, p = 0.009) and cerebral arterial occlusion (OR 3.4, 95% CI 1.3–8.9) significantly increased perioperative stroke risk following SAVR. Infective endocarditis (OR 4.6, 95%CI 3.8–5.6, p = 0.00) and neurological disorders (OR 4.8, 95% CI 4–5.8, p = 0.00) appeared to be the strongest risk factors for strokes. Other risk factors found to be significant predictors of perioperative strokes (p < 0.05) were – age, higher VWR scores, CS, cerebral arterial occlusion, infective endocarditis, DM, HTN, renal failure, neurological disorders, coagulopathy and hypothyroidsm. In conclusion, perioperative stroke risk has remained more or less constant despite advancements in surgical techniques with risk having gone up in patients <65 years of age. CS and cerebral arterial occlusion significantly increase stroke risk following SAVR. Improved patient selection with pre-operative risk stratification and institution of preventive strategies are necessary to improve operative outcomes following SAVR.     

Decreased serum sodium levels predict symptomatic vasospasm in patients with subarachnoid hemorrhage

Background: Symptomatic vasospasm is a major cause of morbidity and mortality in subarachnoid hemorrhage patients. Hyponatremia and dehydration due to natriuresis after subarachnoid hemorrhage are related to symptomatic vasospasm. Therefore, most institutions are currently targeting euvolemia and eunatremia in subarachnoid hemorrhage patients to avoid complications. We retrospectively investigated the predictors of symptomatic vasospasm with respect to water and sodium homeostasis, while maintaining euvolemia and eunatremia after subarachnoid hemorrhage. Methods: We monitored changes in serum sodium levels, serum osmolarity, daily sodium intake, daily urine volume, and daily water balance for 14 days after subarachnoid hemorrhage. Outcomes were assessed using the modified Rankin scale at 1 month after subarachnoid hemorrhage. Results: Among 97 patients, 27 (27.8%) had symptomatic vasospasm. Patients with symptomatic vasospasm were older than those without symptomatic vasospasm; the occurrence of symptomatic vasospasm affected outcomes. Serum sodium levels were sequentially significantly decreased, but within the normal range from 1 day before the occurrence of symptomatic vasospasm. Serum osmolarity of the spasm group was lower than that of the non-spasm group. Conclusions: Symptomatic vasospasm occurs more often in older patients and affects outcomes. A decrease in serum sodium levels occurs a day before symptomatic vasospasm. This observation may help predict symptomatic vasospasm.     

The relationship of blunt head trauma, subarachnoid hemorrhage, and rupture of pre-existing intracranial saccular aneurysms

Patients with a history of closed head trauma and subarachnoid hemorrhage are uncommonly diagnosed with an intracranial saccular aneurysm. This study presents a group of patients in whom a pre-existing aneurysm was discovered during work-up for traumatic subarachnoid hemorrhage. Without an accurate pre-trauma clinical history, it is difficult to define the relationship between trauma and the rupture of a pre-existing intracranial saccular aneurysm. We retrospectively reviewed 130 patients who presented to Detroit Receiving Hospital between 1993 and 1997 with a diagnosis of subarachnoid hemorrhage (SAH). Of these 130 patients, 70 were spontaneous, and 60 had a history of trauma. Mechanisms of trauma include motor vehicle accident, assault, or fall from a height. Of the 60 patients with subarachnoid hemorrhage and a history of trauma, 51 (86%) did not undergo conventional four-vessel angiography, and had no further neurological sequelae. Nine patients (14%) had a suspicious quantity of blood within the basal cisterns or Sylvian fissure and had a four-vessel angiogram. Five patients (8%) were diagnosed with a saccular intracranial aneurysm, and all underwent surgical clipping of the aneurysm. We conclude that the majority of patients (92%), with post-traumatic SAH do not harbor intracranial aneurysms. However, during initial evaluation, a high level of suspicion must be entertained when post-traumatic subarachnoid hemorrhage is encountered in the basal cisterns or Sylvian fissure, as 8% of our population were diagnosed with aneurysms.     

Safety and effectiveness of CATCH+ as a first-line device for revascularization in the treatment of acute ischemic stroke

PurposeMechanical thrombectomy devices and stent retrievers have recently been advocated for use as first-line therapy in acute ischemic stroke. Here we evaluate the safety and effectiveness of the CATCH+ stent retriever as a percutaneous thrombectomy device.MethodsA retrospective analysis was performed on 101 consecutive patients who presented with anterior or posterior intracranial vessel occlusion and were treated with the CATCH+ intracranial system, either alone or in combination with intravenous tissue plasminogen activator, at a single treatment center. The primary outcome measure was successful post-procedural reperfusion as classified by the mTICI score. Secondary endpoints included mortality rate, incidence of adverse events, and functional outcomes evaluated at discharge using the mRS score.ResultsSixty-nine (68.3%) patients received thrombolysis prior to mechanical thrombectomy. Successful reperfusion (mTICI ≥ 2b) was achieved in 73.3% of patients at the end of the procedure, and good functional outcomes (mRS ≤ 2) were observed in 32.7% of patients at discharge. Three patients developed asymptomatic subarachnoid hemorrhage, two developed asymptomatic dissections of the internal carotid artery, and one patient developed a symptomatic intracranial hemorrhage. Seventeen patients died (mortality rate 16.8%).ConclusionsThe CATCH+ device is a safe and effective mechanical thrombectomy device for the first-line treatment of acute ischemic stroke.     

3D Slicer三维影像重建在颅内动脉瘤夹闭术中的应用

目的 探讨3D Slicer三维影像重建技术在颅内动脉瘤开颅夹闭术中的应用价值。方法 回顾性分析2020年7～9月经翼点入路开颅夹闭术治疗的12例颅内动脉瘤的临床资料。术前利用3D Slicer软件三维重建动脉瘤模型及其周围血管和部分骨性结构,并模拟手术入路,显示手术视野下动脉瘤与毗邻结构的位置关系;术中参考立体模型,寻找动脉瘤并根据解剖结构实时定位,实现精准夹闭。结果 12例均顺利完成三维影像重建,将三维模型与术中所见进行对比,9例正确反映术中真实解剖情况,3例术中对比效果欠佳,小动脉瘤（直径<5 mm）以及小血管重建效果相对较差,但是动脉瘤周围主要血管结构对比一致。12例动脉瘤均顺利实施开颅夹闭术,术中没有出现动脉瘤破裂。术后次日复查颅脑CTA示载瘤动脉通畅,未见新增出血,动脉瘤夹闭良好。术后3个月,复查CTA未见动脉瘤复发;GOS评分5分8例,4分3例,3分1例。结论 3D Slicer三维影像重建制作的颅内动脉瘤三维立体模型,可获得更多的立体解剖信息,加深对病变局部解剖的认识,指导制定手术计划,减少术中动脉瘤破裂的风险,提高手术效果。     

Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment

Acute subdural hematoma is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up, or were collected over a long period during which treatment evolved. To evaluate prognostic factors, we analyzed a large modern series of aneurysmal subdural hematoma (aSDH) with long-term follow-up. A prospectively maintained database was queried for patients presenting with aSDH from 2001–2013. Thirty patients met the study criteria. Statistical analysis was performed with unpaired t-test or Fisher’s exact test. Aneurysm treatment involved open clipping (n = 18), endosaccular coiling (n = 8), both (n = 1), or no treatment (n = 3). Good Glasgow Outcome Scale score at discharge was present in 20% and increased to 40% at 6–12 months postoperatively. Good clinical presentation was associated with good final outcome in 75%, whereas poor clinical presentation correlated with good outcome in 30%. Good outcome correlated with younger age (p = 0.04), smaller aneurysm (p = 0.04), and lower Hunt-Hess score (HH) at intervention (p = 0.04). Favorable outcome did not correlate with sex, race, presence of subarachnoid or intraparenchymal hemorrhage, size or laterality of hemorrhage, midline shift, aneurysm treatment modality, or HH at admission (p > 0.15). There was no difference between good and poor outcomes in terms of time to treatment or hematoma evacuation. Poor clinical presentation may be exaggerated by mass effect of hematoma; aggressive treatment is not futile. Presenting neurological status, age, and aneurysm size are predictors of outcome, while laterality and size of hematoma and extent of midline shift are not, suggesting that clinical status is more important than radiographic findings.     

Tibial somatosensory evoked potential can prognosticate for ambulatory function in subacute hemiplegic stroke

Early prediction of expected recovery in stroke can help in planning appropriate medical and rehabilitation interventions. Recovery of ambulation is one of the essential endpoints in stroke rehabilitation. However, the correlation of somatosensory evoked potentials (SSEP) with clinical parameters and their predictive significance are not clearly defined. We aimed to examine the association between tibial nerve SSEP and ambulatory outcomes in subacute hemiplegic stroke patients. We reviewed medical records for hemiplegic patients with first-ever stroke who received inpatient rehabilitation from January 2009 to May 2013. We excluded patients with diabetes mellitus, quadriplegia, bilateral lesions, brainstem lesions, those aged over 80 years, and those with severe musculoskeletal problems. Tibial nerve SSEP were performed when they were transferred to the rehabilitation department. SSEP findings were divided into three groups; normal, abnormal and absent response. Berg balance scale and functional ambulation category (FAC) at discharge were compared with initial tibial SSEP findings using one-way analysis of variance. Thirty-one hemiplegic patients were included. Berg balance scale and FAC were significantly different according to the SSEP (P < 0.001). Post hoc analysis showed a significant difference between normal and absent response in Berg balance scale (P < 0.001) and FAC (P < 0.001), and between abnormal and absent response in Berg balance scale (P = 0.012) and FAC (P = 0.019). Functional outcomes of the normal response group were better than the abnormal response group, but there was no statistical significance. These findings suggest that initial tibial nerve SSEP may be a useful biomarker for prognosticating functional outcomes in hemiplegic patients.     

Microsurgical clipping of large and giant cerebral aneurysms: A single-center contemporary experience

Several treatment strategies are available to manage large and giant cerebral aneurysms, including surgical, endovascular and combined approaches. We present our experience with microsurgical clipping of large and giant aneurysms. A total of 138 patients with 139 aneurysms of which 128 were large (⩾10 mm) and 11 were giant (⩾25 mm) were treated at our institution between 2004 and 2011. Data were collected from a prospectively maintained neurovascular database. Of 138 patients, 53 (38.4%) patients presented with subarachnoid hemorrhage (SAH). Peri-operative complications occurred in 16.7% of patients causing permanent morbidity in 4.4% and death in 0.7%. Complete occlusion, as evident on intra-operative angiography, was achieved in all clipped aneurysms (100%). Long-term follow-up angiography showed no recurrence (mean follow-up time, 43.9 months; range: 1–72 months). Favorable outcomes at discharge (Glasgow Outcome Scale score 4 or 5) were noted in 64.1% of SAH patients and 93% of non-SAH patients. Favorable outcomes at follow-up (mean follow up time, 42.5 months) were seen in 96% of patients. In our experience, microsurgical clipping of large and giant aneurysms carries low rates of morbidity and mortality with high rates of favorable outcomes. The excellent durability of surgical treatment stands in stark contrast with the high recurrence rates observed with coiling for this subset of aneurysms. These data suggest that microsurgical clipping continues to be a viable option that can be offered for patients with large and giant aneurysms.     

Chronic basilar artery dissection with an associated symptomatic aneurysm presenting with massive subarachnoid hemorrhage

Basilar artery dissection (BAD) is a rare condition with a worse prognosis than a dissection limited to the vertebral artery. We report a rare case of chronic BAD with an associated symptomatic aneurysm presenting with massive subarachnoid hemorrhage (SAH) in a 54-year-old woman. The diagnosis of acute BAD could only be made retrospectively, based on clinical and neuroradiological studies from a hospital admission 10 months earlier. Angiography performed after her SAH showed unequivocal signs of imperfect healing; she was either post-recanalization of a complete occlusion or post-dissection. Residual multi-channel intraluminal defects led to the development of a small aneurysm, which was responsible for the massive hemorrhage. The occurrence of an associated aneurysm, and wall disease, but not an intraluminal process, reinforces the diagnosis of dissection. The patient was fully recovered at 90 day follow-up. This case reinforces the need for long-term neuroradiological surveillance after non-hemorrhagic intracranial dissections to detect the development of de novo aneurysms.     

Perioperative Use of Recombinant Factor VII to Prevent Intraoperative Aneurysm Rupture in High Risk Patients: A Preliminary Safety Evaluation

Object  The authors present a safety evaluation of the perioperative use of recombinant activated factor VII (rFVIIa) in a series of subarachnoid hemorrhage patients undergoing microsurgical aneurysm clipping. Methods  We performed a retrospective chart review of the records of 18 consecutive subarachnoid hemorrhage patients who underwent craniotomy for aneurysm clipping and received an intraoperative dose of rFVIIa. In each case, the aneurysm was felt to be a “high risk” lesion for intraoperative rupture either because it had bled multiple times prior to surgery or based on anatomical considerations. All complications were recorded whether or not they were attributed to the use of rFVIIa. Results  Eighteen patients, 7 men and 11 women, ranging in age from 42 to 85 years were included in this review. Nine patients (50%) were either Hunt/Hess Grades IV or V. Six patients developed clinically significant cerebral vasospasm. Fifteen patients required ventricular drainage on admission, and seven patients ultimately required a ventriculoperitoneal shunt. One lower extremity deep venous thrombosis and seven upper extremity venous thromboses in association with peripherally inserted central catheter (PICC) lines were identified on screening Doppler evaluations. There were no associated pulmonary emboli. No aneurysm ruptured intraoperatively. Conclusion  We describe our experience with the use of a single dose of rFVIIa administered perioperatively in an attempt to decrease the rate of intraoperative aneurysm rupture in patients undergoing microsurgical aneurysm clipping. There were no significant immediate or long-term adverse effects attributable to the use of rFVIIa in this group, and we encountered no intraoperative ruptures in this relatively small series.     

颅内动脉瘤破裂合并颅脑损伤5例分析

目的探讨颅内动脉瘤破裂合并颅脑损伤的临床特征,以此鉴别创伤性蛛网膜下腔出血。方法对我院近三年来收治的5例颅内动脉瘤破裂合并颅脑损伤患者的临床资料进行回顾性研究,总结其临床特征。结果 4例患者入院后急诊经CTA检查证实为颅内动脉瘤破裂出血,其中前交通动脉瘤2例,大脑中动脉瘤1例,颈内动脉-后交通动脉瘤l例;1例患者为动脉瘤再次破裂后行CTA检查示颈内动脉-后交通动脉瘤。急诊开颅血肿清除及动脉瘤夹闭术2例,动脉瘤夹闭术1例,血管内介入栓塞治疗术1例,药物保守治疗1例。恢复良好3例,重残1例,死亡l例。结论对伴有颅脑外伤史的蛛网膜下腔出血应注意考虑颅内动脉瘤破裂的可能,以便采取积极合理的治疗方案。