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

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

Grading of subarachnoid hemorrhage: modification of the world World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients

OBJECTIVE: The goals of this study were to use a large, prospectively collected, multicenter database for patients with aneurysmal subarachnoid hemorrhage (SAH) who were treated between 1991 and 1997 to determine the prognostic significance of clinical and radiological factors for outcomes and to use those factors to develop a grading scale to predict outcomes. METHODS: A total of 3567 patients with SAH who were entered into four randomized clinical trials of tirilazad were studied. Outcomes were assessed 3 months after SAH, with the Glasgow Outcome Scale. Twenty clinical and radiological factors were entered into univariate and multivariate analyses, to determine factors prognostic for outcomes. Grading scales based on the most powerful prognostic parameters were statistically derived and validated and were compared with the World Federation of Neurosurgical Societies (WFNS) grading scale. RESULTS: Factors predictive of outcomes included age, WFNS grade, history of hypertension, systolic blood pressure at admission, ruptured aneurysm location and size, blood clot thickness on computed tomographic scans, and angiographic vasospasm at admission. A grading scale using these factors could be derived; it predicted outcomes more accurately than did the WFNS scale, although it would be more complex to use. CONCLUSION: Outcome prediction after SAH can be improved by adding additional clinical and radiological factors to the WFNS scale, albeit with added complexity.     

Deteriorating factors on the outcome in patients with fair grade of subarachnoid hemorrhage (WFNS grade I and II)

BACKGROUND AND PURPOSE: Although, the overall treatment results in aneurysmal subarachnoid hemorrhage (SAH) has been improving in recent years, more than 10% of the patients with WFNS grade I and II we have sought to determine the clinical variables for predicting poor functional outcome and symptomatic vasospasm (VS) in patients with individual WFNS grades. MEASUREMENTS: The eligible patient fulfilled the following conditions; (1) ruptured aneurysm located in the anterior part of the circle of Willis, (2) surgically clipped followed by craniotomy under microscope, (3) early surgery within 72 hours, (4) classified to WFNS grade I or II. The medical records were retrospectively reviewed in 119 patients (63 of grade I and 56 of grade II). Sex, age, Fisher's CT group, intraventricular hemorrhage (IVH), site of aneurysm, VS, hydrocephalus, premature bleeding and complications of various kinds were selected as the dependent variables. The contributions of these factors to outcome (Glasgow Outcome Scale, GOS) as well as VS were analyzed using the logistic regression method. MAIN RESULTS: Outcome was better in WFNS grade I (p=0.039), and VS occurred less often and responded well to various interventional techniques and drug delivery. No significant variables contributed to the poor outcome or VS in WFNS grade I. In WFNS grade II, logistic regression analysis showed that VS (OR 34.6, 95% CI, 30.8-38.9, p =0.012) and the complications (OR 52.4, 95% CI, 46.5-59.1, p=0.004) were significant predictors for a poor outcome. Fisher's group 3 was also the only significant factors in VS (OR 3.78, 95% CI, 3.35-4.28, p =0.039). The cause for the difference in outcome and VS were discussed in detail. CONCLUSION: The vasospasm and various kinds of complications were the predictive factors of poor clinical outcome, in patient of WFNS garde II. Therefore, careful management and meticulous/pertinent surgical maneuvers are mandatory to obtain better results in aneurysmal SAH, even in better WFNS grades.     

Pulmonary complications of aneurysmal subarachnoid hemorrhage

OBJECTIVE: Pulmonary complications challenge the medical management of patients who have sustained aneurysmal subarachnoid hemorrhage (SAH). We assessed the frequency and types of pulmonary complications after aneurysmal SAH and analyzed the impact of pulmonary complications on patient outcome. METHODS: We reviewed the records of all patients with acute SAH treated at our institution between 1990 and 1997. Three hundred five consecutive patients with an aneurysmal hemorrhage source documented by angiography and treated within 7 days of ictus were analyzed. Outcomes at longest follow-up (mean, 16 mo) were measured by use of the Glasgow Outcome Scale. RESULTS: Pulmonary complications were documented in 66 patients (22%). The pulmonary complications were nosocomial pneumonia in 26 patients (9%), congestive heart failure in 23 (8%), aspiration pneumonia in 17 (6%), neurogenic pulmonary edema in 5 (2%), pulmonary embolus in 2 (<1%), and other pulmonary disorders in 4 (1%); 11 patients had two pulmonary complications. The incidence of symptomatic vasospasm was greater in patients with pulmonary complications (63%) than in patients without pulmonary complications (31%) (P = 0.001), and this association was independent of age and clinical grade at admission (odds ratio, 3.68; P < 0.001). Overall clinical outcomes were worse in patients with pulmonary complications (mean Glasgow Outcome Scale score, 3.3) than in patients without pulmonary complications (mean Glasgow Outcome Scale score, 4.0; P = 0.0001), but pulmonary complications were not an independent predictor of worse outcome when adjusted for age and clinical grade at admission (odds ratio, 1.38; P = 0.315). CONCLUSION: Patients who experience pulmonary complications after aneurysmal SAH have a higher incidence of symptomatic vasospasm than do patients without pulmonary complications. This most likely reflects both the failure to maintain aggressive hypervolemic and hyperdynamic therapy in patients with pulmonary compromise and the possible precipitation of congestive heart failure by hypervolemic therapy in patients with preexisting delayed ischemic neurological deficit. Although patients with pulmonary complications have worse overall clinical outcomes than do patients without pulmonary complications, this is attributable to older age and worse clinical grades at admission.     

Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage

BACKGROUND AND OBJECTIVE: Factors related to prognosis after subarachnoid haemorrhage (SAH) have been mainly extracted from surgical series, and only few authors have considered these factors in total management or population series. Though the level of consciousness is a major determinant of outcome after subarachnoid haemorrhage, there is not a consensus about which classification should be used to define it. The objective of this study was twofold. Firstly to find which factors recorded on hospital admission relate to outcome determining their relative importance in a non-selected series of patients suffering from aneurysmal SAH admitted to our centre, and secondly to assess the validity of the WFNS clinical scale for predicting the final result. METHODS: A series of 294 patients consecutively admitted to Hospital 12 de Octubre Madrid between January 1990 and June 2000 with the diagnosis of aneurysmal SAH were retrospectively reviewed. All factors possibly related to prognosis were recorded on hospital admission. Outcome was measured by means of the Glasgow Outcome Scale measured one month after hospital discharge. Relationship between factors and outcome was evaluated by univariate and logistic regression multivariate analysis. RESULTS: Although several factors, appeared related to prognosis in the univariate analysis, only the age. the level of consciousness defined by the WFNS scale and the presence of global brain hypodensity on the initial CT scan had a significant prognostic influence in the logistic regression model. Global brain hypodensity was strongly related to mortality. Since a number of factors associated with poor outcome in the univariate analysis are related to age, their influence could be explained by the difficulty of recovery of the ageing brain. The WFNS grading scale failed to predict significant differences in outcome between some of its grades. CONCLUSIONS: Age and clinical grade on admission are the most important factors influencing the final outcome of patients suffering aneurysmal SAH. A reappraisal of the WFNS grading scale should be considered as no significant differences in outcome were found between some of its grades.     

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

OBJECT: This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms. METHODS: In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization. CONCLUSIONS: Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.     

Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies

OBJECT: The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. METHODS: One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome--indicated by mRS scores of 0 to 2 after at least 6 months--was achieved in 71% of patients. CONCLUSIONS: Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.     

Endovascular surgery using stents for vertebral artery dissecting aneurysms and a review of the literature

The treatment of dissecting aneurysms of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA) or presenting with hypoplasia of the contralateral VA is controversial. We describe our experience with 4 ruptured and 2 unruptured VA dissecting aneurysms and discuss the efficacy of endovascular surgery using stents. All patients were male; their mean age was 50.7 years. According to World Federation of Neurological Surgeons (WFNS) grading, 3 of the ruptured aneurysms were grade V, the other was grade I. All patients were successfully treated using stents; in 5 we also coil-embolized the aneurysmal lumen. One aneurysm was treated by the placement of 2 stents covering the dissection site; there was a danger of aneurysmal rupture during coil embolization. No technical complications were encountered although one patient suffered minor rebleeding 5 days post-treatment. Delayed vasospasm occurred in 4 cases. According to the Glasgow Outcome Scale (GOS), at 3 months after treatment 2 patients had made a good recovery, one was moderately disabled, one suffered severe disability, and 2 had died. One death each was due to acute myocardial and brain stem infarction. Endovascular surgery using stents may be a useful treatment in patients in poor condition who manifest dissecting VA aneurysms involving the PICA or hypoplasia of the contralateral VA, especially in the acute period after rupture.     

Effectiveness of combining continuous cerebrospinal drainage and intermittent intrathecal urokinase injection therapy in preventing symptomatic vasospasm following aneurysmal subarachnoid haemorrhage

The effect of cisternal drainage and intrathecal urokinase (UK) injections in preventing symptomatic vasospasm after aneurysmal subarachnoid haemorrhage was retrospectively studied in 69 patients with uniform backgrounds with regard to subarachnoid haemorrhage (SAH; WFNS grade I to IV, Fisher's group 3, undergoing surgery or coil embolization within 72 h of the onset). With regard to the selection of patients, 34 patients belonging to the control group (no UK injection group) underwent the treatment during the 3-year period from 2001 to 2003, while 35 patients belonging to the UK group underwent the treatment during the 3-year period from 2004 to 2006. The incidence of symptomatic vasospasm was 5/35 with the UK group, but 12/34 with a control group. The UK injection significantly reduced the incidence of symptomatic vasospasm (p = 0.042, Pearson chi-square test), resulting in an improvement shown by the Glasgow Outcome Scale (GOS; p = 0.030, Mann-Whitney U test; Table V). The distribution on the angiographic grading scales for cerebral vasospasm significantly shifted in a positive direction for the UK group (mild 0, moderate 5, severe 0) in comparison with the control group (mild 0, moderate 4, severe 8; p = 0.014, Mann-Whitney U test). This study suggests that combining continuous cerebrospinal drainage and intermittent intrathecal UK injection therapy is a relatively simple and effective method for symptomatic vasospasm prophylaxis in patients with aneurysmal SAH.     

Apolipoprotein E epsilon4 and the risk of unfavorable outcome after aneurysmal subarachnoid hemorrhage

BACKGROUND: The APOE-E4 allele has been identified as a risk factor for Alzheimer's disease and unfavorable outcomes after brain injuries. The purpose of this study was to confirm that APOE allele polymorphism also represents a risk factor for unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH). METHODS: A total of 104 patients with aneurysmal SAH were studied. Computed tomography (CT) scan findings of SAH were assessed by Fisher's grade and clinical neurologic assessment was performed using the Hunt and Hess (H&H)grading system. Serum lipids were also analyzed. Outcomes at 3 months after SAH were determined using the Glasgow Outcome Scale. RESULTS: The distributions of APOE genotypes and alleles of patients were matched with those of control subjects. That 5 of 18 patients with APOE-E4 allele (28%) had an unfavorable outcome was significantly different from those without APOE-E4 (8%, chi2, p = 0.032; OR = 4.34, 95% CI 1.20-15.75). However, the presence or absence of E2 or E3 alleles had no significant difference. The relative hazard of APOE-E4 for unfavorable outcome exited after adjustment for clinical assessment (OR = 6.95, 95% CI 1.21-39.75). Total serum cholesterol, low-density lipoprotein and apolipoprotein B were elevated in patients with unfavorable rather than favorable outcomes. CONCLUSION: Our findings confirmed that the patients with APOE-E4 allele were predisposed to unfavorable outcomes after aneurysmal SAH even though an association between APOE and incidence of the SAH may not exist. The effect of APOE on neurobiology and lipoprotein metabolism seems to partially explain the difference in outcomes and deserves further study.     

A comparison of different grading scales for predicting outcome after subarachnoid haemorrhage

Summary Background. Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale.Method. A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by ² statistics. ROC curves were plotted for the different scales and their areas compared.Findings. Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH.Interpretation. Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.     

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

OBJECT: This study was undertaken to determine the outcomes in an unselected group of patients treated with semiurgent surgical clipping of aneurysms following subarachnoid hemorrhage (SAH). METHODS: A clinical management outcome audit was conducted to determine outcomes in a group of 391 consecutive patients who were treated with a consistent policy of ultra-early surgery (all patients treated within 24 hours after SAH and 85% of them within 12 hours). All neurological grades were included, with 45% of patients having poor grades (World Federation of Neurosurgical Societies [WFNS] Grades IV and V). Patients were not selected on the basis of age; their ages ranged between 15 and 93 years and 19% were older than 70 years. The series included aneurysms located in both anterior and posterior circulations. Eighty-eight percent of all patients underwent surgery and only 2.5% of the series were selectively withdrawn (by family request) from the prescribed surgical treatment. In patients with good grades (WFNS Grades I-III) the 3-month postoperative outcomes were independence (good outcome) in 84% of cases, dependence (poor outcome) in 8% of cases, and death in 9%. In patients with poor grades the outcomes were independence in 40% of cases, dependence in 15% of cases, and death in 45%. There was a 12% rate of rebleeding with all cases of rebleeding occurring within the first 12 hours after SAH; however, outcomes of independence were achieved in 46% of cases in which rebleeding occurred (43% mortality rate). Rebleeding was more common in patients with poor grades (20% experienced rebleeding, whereas only 5% of patients with good grades experienced rebleeding). CONCLUSIONS: The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early rebleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.     

Role of coil embolization and arterial injection in elderly subarachnoid hemorrhage patients: preliminary report

With the recent advanced aging seen in society, the number of elderly patients with aneurismal subarachnoid hemorrhage (SAH) is increasing. We focused on current management of SAH in patients who were over 75 years old. From January 1st, 2004 to the end of June, 2007, we had treated 170 SAH patients including 39 who were over 75 years old. We divided the patients into three groups : Coiling Group, Clipping Group, and conservative treatment group (Conservative Group). We analyzed the Hunt-Kosnik grade (H-K), the rate of symptomatic vasospasm, the rate of shunting operation, the Glasgow Outcome Scale (GOS) at 30 days after the onset of SAH, bed rest periods and rate of shunt operation retrospectively. The Conservative Group included many H-K poor grade cases. Symptomatic vasospasm occurred significantly less in the Coiling Group. Rates of shunting operation did not have any significant change. GOS of the Coiling Group and Clipping Group had no significant change, due to the effectiveness of arterial injection for vasospasm. Patients in the Coiling Group started walking significantly earlier than members of other groups. Twenty-five percent of the Clipping Group needed a shunt operation but no patients of the Coiling Group needed a shunt. For elderly SAH patients, we recommend doing coil embolization or clipping and maintaining the patients' activity in daily life. Interventional treatment is necessary to improve results for elderly SAH patients.     

Multiple interstitial substances measured by microdialysis in patients with subarachnoid hemorrhage

OBJECTIVE: Intracerebral microdialysis is a tool to monitor metabolic disturbances in the brains of patients with severe head injuries or subarachnoid hemorrhage (SAH). In the search for putative indicators of primary and secondary brain damage, we measured multiple metabolites in the dialysates of patients with SAH, to elucidate their significance for the outcomes of the patients as well as their temporal profiles of liberation after the insult. METHODS: Microdialysis probes were placed, with a ventriculostomy catheter for drainage of cerebrospinal fluid, into a frontal lobe of 10 patients with aneurysmal SAH, for 4.6 +/- 0.5 days. Amino acids, metabolites of glycolysis, purines, catecholamines, and nitric oxide oxidation byproducts were measured by high-performance liquid chromatography. Spearman's correlation coefficient and Student's t test were used to compare the levels of the metabolites with the outcomes of the patients, as assessed using the Glasgow Outcome Scale, 3 months after the ictus. RESULTS: For patients with unfavorable outcomes (Glasgow Outcome Scale scores of 1-3), which were primarily associated with the development of large infarctions, dialysate levels of excitatory amino acids increased up to 30-fold, those of lactate up to 10-fold, and those of nitrite up to 5-fold, compared with normal levels observed for patients with favorable outcomes (Glasgow Outcome Scale scores of 4 or 5). When average peak concentrations in the dialysates of patients with favorable and unfavorable outcomes were compared, significantly higher levels of excitatory amino acids, taurine, lactate, and nitrite, but not of purines and catecholamines, were observed for those with poor outcomes (P < 0.05). With respect to the temporal profiles of the average metabolite concentrations, the significantly increased levels of amino acids observed for patients with poor outcomes followed a biphasic course, with maximal concentrations on the first and second days or the seventh day after the insult (P < 0.01). CONCLUSION: These data confirm the usefulness of excitatory amino acids and lactate as major parameters for neurochemical monitoring for patients threatened by acute cerebral disorders. Other substances, such as taurine and nitrite, were also demonstrated to be potentially predictive. Release of these substances into the extracellular fluid of the brain might be particularly relevant for the development of secondary brain damage after SAH, e.g., infarction or brain swelling.     

Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage

ABSTRACT: BACKGROUND: Hydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital. METHODS: One hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score. RESULTS: Hydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 +/- 1.40 for patients with shunt-dependent hydrocephalus and 4.21 +/- 1.19 for those without. CONCLUSIONS: The presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.     

Acute subdural haematoma due to ruptured intracranial aneurysms

Acute spontaneous subdural haematoma (SDH) is rarely associated with rupture of intracranial saccular aneurysm. We report our experience with four cases of non-traumatic SDHs secondary to rupture of an intracranial aneurysm and discuss the diagnosis and management of this condition. We retrospectively reviewed of four cases of acute SDH due to cerebral aneurysm rupture confirmed by cerebral angiography and surgery. Patients were evaluated using the Glasgow Coma Scale (GCS) and subarachnoid grade of the World Federation of Neurosurgical Societies (WFNS) and outcome with the Glasgow Outcome Scale (GOS). Of the 232 patients with non-traumatic subarachnoid haemorrhage (SAH) treated between 1993 and 2002, only four patients (1.72%) presented SDH due to aneurysmal rupture. The SAH grade on admission was grade IV in one patient and V in the other three. In all cases the aneurysm was located in the posterior communicating artery. Spontaneous acute SDH secondary to aneurysm rupture has been rarely reported. We suggested that timely SDH removal and aneurysmal clipping surgery should be performed in such patients, including those in poor neurological condition.     

Aneurysmal rupture during embolization with Guglielmi detachable coils

OBJECTIVE: The purpose of this study is to determinate the frequency, causes, management and outcome of aneurysmal rupture occurring during embolization. We present our experience with this severe and feared complication. METHODS: We retrospectively reviewed 314 acute cerebral aneurysms that were treated with endovascular coiling. These patients were identified and the management and outcomes were recorded. The literature was reviewed. RESULTS: Six patients had an intraprocedural aneurysmal rupture. This complication occurred sporadically. Prevalence was 1.9%. Of these six, four were women and two were men. The mean age was 68 years (range: 43-74 years). Four aneurysms were located in the anterior circulation and two in the posterior circulation. Perforation occurred during microcatheterization of the aneurysm in one case and during coil deposition in five cases. In these five patients, aneurysmal rupture resulted from detachment of the first coil in three patients and detachment of the third and last coil in two patients. Hemodynamic changes were noted for one patient. The Glasgow Outcome Scale score at last follow-up examination was 1 in three patients and 3 in one patient (fair recovery). Mortality was 33% and morbidity was 16.7%. CONCLUSION: Aneurysmal perforation during embolization is a rare event (1.8 to 4.4%). When perforation is recognized, embolization can be completed immediately with further coil deposition and reversal of anticoagulation therapy.     

Analysis of subarachnoid hemorrhage according to the Japanese Standard Stroke Registry Study--incidence, outcome, and comparison with the International Subarachnoid Aneurysm Trial

The data for subarachnoid hemorrhage (SAH) from the Japanese Standard Stroke Registry Study (JSSRS) were analyzed to evaluate the incidence of SAH according to age, neurological grading and outcome, and outcome of surgical clipping, for comparison with the International Subarachnoid Aneurysm Trial (ISAT). From the ISSRS data, the peak incidence of SAH was the sixth decade in males and the eighth decade in females. The overall mortality was 22%, and good outcome, better than 2 on the modified Rankin Scale (mRS), at discharge was achieved in 58% of cases. Radical treatment was performed in 62.6% of all SAH cases, 58.7% with surgical clipping and 3.2% with endovascular coiling. Poor outcome, worse than 3 on the mRS, occurred in 26.6% of patients under 60 years, 47.3% between 60-69 years, 54.2% between 70-79 years, and 72.9% 80 years or over. From the ISAT data, 88% of patients were in grades 1-2 of the World Federation of Neurological Surgeons (WFNS) grading system in both surgical clipping and endovascular coiling groups, 94% in grades 1-3, and 98% in grades 1-4. Poor outcome, worse than 3 on the mRS, at 2 months occurred in 25.4% and 36.4% of patients with endovascular coiling and surgical clipping, respectively. Limiting the patients in the JSSRS to WFNS grades 1-2 showed poor outcome, worse than 3 on the mRS, occurred in 12.8%, and in grades 1-3 and 1-4 occurred in only 16.3% and 23.0%, respectively.     

Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage

OBJECT: Previous studies have indicated an increased incidence of death in patients with subarachnoid hemorrhage (SAH) who are currently receiving anticoagulation therapy. The significance of previous aspirin use in patients with SAH is unknown. The authors analyzed the effects of prior aspirin use on clinical course and outcomes following aneurysmal SAH. METHODS: The medical records of 305 patients with angiogram-confirmed aneurysmal SAH who consecutively presented to our institution between 1990 and 1997 within 7 days of ictus were analyzed. Twenty-nine (9.5%) of these patients had a history of regular aspirin use before onset of the SAH. The Glasgow Outcome Scale (GOS) was used to measure patient outcome at the longest available follow up. Aspirin users were older on average than nonusers (59 years of age compared with 53 years; p = 0.018). The mean admission Hunt and Hess grades of patients with and without aspirin use were similar (2 compared with 2.3; p = 0.51). Two trends, which did not reach statistical significance, were observed. 1) The rebleeding rate in aspirin users was 14.3%, compared with a 4.7% rebleeding rate in nonusers (p = 0.06). 2) Permanent disability from vasospasm was less common among aspirin users (23% compared with 50%; p = 0.069). Outcomes did not differ between aspirin users and nonusers (mean GOS Score 3.83 compared with GOS Score 3.86, respectively; p = 0.82). CONCLUSIONS: Despite trends indicating increased rebleeding rates and a lower incidence of permanent disability due to delayed ischemic neurological deficits, there was no significant effect of previous aspirin use on overall outcome following aneurysmal SAH. Based on these preliminary data, the presence of an intracranial aneurysm is not a strict contraindication to aspirin use.