Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases

During a six-year period (1986–1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery, Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8 %) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2 %). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6 %). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%).We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.     

Characteristics and management of ruptured distal middle cerebral artery aneurysms

Summary Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.     

无蛛网膜下腔出血的大脑中动脉动脉瘤破裂

目的总结无蛛网膜下腔出血（SAH）的大脑中动脉（MCA）动脉瘤破裂的临床特点。方法对6例在首次CT扫描上表现为脑内出血（ICH），或壁内出血（IMH）而无SAH的MCA动脉瘤破裂患者的临床表现、影像学检查、治疗方法和预后进行回顾性总结。结果本组首次CT扫描时间为起病后0—2d，表现为单纯ICH者4例，IMH者2例。DSA和手术证实为MCA动脉瘤破裂。开颅动脉瘤切除1例，夹闭5例，其中4例同时行血肿清除术。术后无死亡。结论MCA动脉瘤破裂首次CT扫描可仅表现为ICH或IMH而无SAH，与动脉瘤的部位、出血量以及CT扫描时间相关。     

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.     

Intracranial aneurysm due to metastatic choriocarcinoma

The case of a woman with an episode of subarachnoid hemorrhage 2 days after delivery is presented. An emergency operation was performed, and an intracerebral clot from a ruptured aneurysm was removed. Histologic examination of the resected aneurysm showed metastasis from a choriocarcinoma to the aneurysmal wall. Six cases of intracranial aneurysm due to metastasis of choriocarcinoma are reviewed.     

Diagnostic cerebral angiography in spontaneous intracranial haemorrhage: a guide for developing countries

OBJECTIVE: Spontaneous intracranial haemorrhage constitutes 18-40% of all stroke cases. Indications for cerebral angiography to find underlying potentially treatable vascular abnormalities are not clear. This study determined which intracranial haemorrhage patients need cerebral angiography by correlating computed tomography (CT) findings, age and hypertension history with cerebral angiography findings. METHODS: A total of 54 patients (8-79 years) with intracranial haemorrhage who underwent both CT examination and six-vessel cerebral angiography were studied over a 2-year period. Cerebral angiography was repeated within 6 weeks if the first angiogram was negative. RESULTS: Angiography detected vascular lesions in 50% of cases (aneurysm 38.9% and arteriovenous malformation, AVM, 11.1%). In the aneurysm group, angiographic yield was 34.3% whereas in the AVM group, it was 37.9%. Subarachnoid haemorrhage (SAH) combined with other types of haemorrhage (such as intracerebral haemorrhage, ICH) was not significantly correlated with the likelihood of finding a vascular lesion, both aneurysm and AVM (p = 0.157). Age less than 50 years had significant correlation (p = 0.021) in the AVM group as well as in the aneurysm group (p < 0.001). A history of hypertension was associated with both aneurysm (p = 0.039) and AVM (p = 0.008). No patients with deep intracerebral haematoma had vascular lesions. The presence of an intravascular haemorrhage (IVH) had significant correlation with aneurysm (p = 0.008) but not AVM. There was no significant difference in mean age between patients with and without a vascular lesion (p = 0.134). CONCLUSION: Cerebral angiography is justified in patients with ICH accompanied by pure SAH (p = 0.001). Other factors associated with finding a vascular lesion were a history of hypertension and the presence of IVH. Diagnostic cerebral angiography is indicated for patients with ICH and SAH and IVH with a history of hypertension, regardless of age.     

False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage

OBJECTIVE: Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms. METHOD: We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information. RESULTS: The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding. CONCLUSION: In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.     

Computed tomography in the diagnosis of hemorrhage secondary to intracranial aneurysm. (author's transl)

In 168 patients with ruptured intracranial aneurysms, the pathology of intracranial hemorrhage visualized on CT was analyzed. Blood in the subarachnoid space could be visualized in 95% of cases within three days after SAH and 75% of 106 cases within two weeks after SAH. In one case blood clot in the subarachnoid space visible up to 13 days after SAH. Concerning the cases within two weeks after the bleeding, intracerebral hematomas were observed in 36% of anterior cerebral aneurysms and middle cerebral aneurysms, 16% of internal carotid aneurysms and none of vetebro-basilar aneurysms. The incidence of the intraventricular hemorrhage was as follows; vertebro-basilar, 44%; anterior cerebral, 38%; internal carotid, 28%; middle cerebral, 12%. On the basis of the pattern of distribution of extravasated blood the location of the ruptured aneurysm was properly predicted in 58% of anterior cerebral, 81% of middle cerebral, 58% of internal carotid and 30% of vertebro-basilar. Especially CT could contribute to predict which aneurysm has ruptured in patients with multiple aneurysms. It was possible to localize the site of bleeding in 11 out of 12 CT positive cases. The development of intracranial hemorrhage demonstrated by CT well correlated with the clinical grading of the patients and the clinical outcome. Patients merely showing subarachnoid hemorrhage were more likely to have good neurological grades, but ones showing complicated intracerebral hematomas and intraventricular hemorrhage had poor neurological grades at the time of the scan. The findings of extensive subarachnoid clot, which were followed by severe vasospasm, and marked intraventricular hemorrhage, usually correlated with poor prognosis. These pathology recognizable on CT was very helpful in determination of the timing of surgery and management of such patients. In conclusion CT is of great value in the examination of SAH when performed in the acute stage and should be the initial examination followed by angiography.     

Emergency surgery for haematoma-forming aneurysmal haemorrhage

Patients with intracerebral haematomas (ICH) secondary to aneurysmal bleeds usually have a poor prognosis or die if treated conservatively. Younger patients with rupture of a middle cerebral artery (MCA) aneurysm and temporal haematomas have the potential to return to useful life. They should be assessed separately from other subarachnoid haemorrhage (SAH) patients and considered for emergency surgery. Seven such cases are presented, five made an acceptable recovery. The experience of other units as represented in the literature is considered.     

Current updates in perioperative management of intracerebral hemorrhage

Spontaneous intracerebral hemorrhages (ICH) account for 10% to 30% of all strokes and are a result of acute bleeding into the brain by rupturing of small penetrating arteries. Despite major advancements during the past several decades in the management of ischemic strokes and other causes of hemorrhagic strokes, such as ruptured aneurysm, arteriovenous malformations (AVMs), or cavernous angioma, there has been limited progress made in the treatment of ICH. The prognosis for patients who suffer intracerebral hemorrhage remains poor. The societal impact of these hemorrhagic strokes is magnified by the fact that affected patients typically are a decade younger than those afflicted with ischemic strokes.     

Current treatment of active infective endocarditis with brain complications

We describe the optimal timing of surgery in active infective endocarditis patients with brain complications. (1) Non-hemorrhagic infarction: elective surgery has been recommended in patients with non-hemorrhagic infarction. However, the timing is changing to an earlier phase. Recent studies have shown that silent brain embolism and small-size infarction (15–20 mm) without coma can be operated safely without delay. On the other hand, in patients with large non-hemorrhagic infarction with impaired consciousness, early surgery is not recommended. (2) Non-ruptured infectious intracranial aneurysm: treatment strategies for patients with infectious aneurysms without rupture remain controversial. However, the treatments are generally as follows. If the intracranial aneurysm without rupture decreases in size by administration of effective antibiotics, neurosurgery will not be required and cardiac surgery can be prioritized without delay. When the aneurysm without rupture enlarges and changes its morphology, neurosurgery or endovascular surgery should be prioritized to prevent its rupture. (3) Hemorrhagic stroke: this type is classified into primary intra-cerebral hemorrhage due to simple necrotic arteritis, hemorrhagic transformation of ischemic infarcts, and rupture of intracranial infectious aneurysms. Among these, primary intracerebral hemorrhage is the most frequently observed. In patients with the primary intracerebral hemorrhage, surgery must be postponed for at least 4 weeks to prevent exacerbation of bleeding. In patients with ruptured infectious aneurysm, neurosurgery or endovascular surgery is performed initially and cardiac surgery should be postponed at least 2–3 weeks.     

Intracerebral haemorrhage after internal carotid endarterectomy

This paper reports three fatal cases of intracerebral haemorrhage after internal carotid artery thrombendarterectomy, one in a patient operated on four weeks after a cerebral infarction and two in patients operated after a transient ischemic attack. Two other late intracerebral haemorrhagic events are reported in patients submitted to internal carotid artery surgery, one from a ruptured intracerebral aneurysm and another probably due to anticoagulation medication. It is emphasized to make a clear distinction between haemorrhagic and ischemic events when reporting stroke frequency in patient materials after internal carotid artery surgery.     

Management strategy for infectious cerebral aneurysms: report of four cases

The surgical and/or endovascular treatment of four patients with infectious cerebral aneurysm associated with infective endocarditis was reported. Two patients presented with intracerebral hemorrhage. One of them, with large hematoma, was treated surgically and the other, with small hematoma, was treated by endovascular surgery. The third patient, with unruptured aneurysm of the distal anterior cerebral artery, was treated by endovascular parent-artery occlusion without neurological deterioration. The fourth patient, with unruptured aneurysm of the distal middle cerebral artery, was initially treated with antibiotics, resulting in stabilization of the aneurysm. However, three weeks after open heart surgery, the aneurysm ruptured, causing a large cerebral hematoma. Despite prompt evacuation of the hematoma and surgical resection of the aneurysm, this patient remained in a vegetative state. Management strategy of intracranial infective aneurysms is discussed.     

Safety of intracranial aneurysm surgery performed in a postgraduate training program: implications for training

OBJECT: Patient care and educational experience have long formed a dichotomy in modem surgical training. In neurosurgery, achieving a delicate balance between these two factors has been challenged by recent trends in the field including increased subspecialization, emerging technologies, and decreased resident work hours. In this study the authors evaluated the experience profiles of neurosurgical trainees at a large Canadian academic center and the safety of their practice on patient care. METHODS: Two hundred ninety-three patients who underwent surgery for intracranial aneurysm clipping between 1993 and 1996 were selected. Prospective data were available in 167 cases, allowing the operating surgeon to be identified. Postoperative data and follow-up data were gathered retrospectively to measure patient outcomes. In 167 cases, a total of 183 aneurysms were clipped, the majority (91%) by neurosurgical trainees. Trainees performed dissections on aneurysms that were predominantly small (< 1.5 cm in diameter; 77% of patients) and ruptured (64% of patients). Overall mortality rates for the patients treated by the trainee group were 4% (two of 52 patients) and 9% (nine of 100 patients) for unruptured and ruptured aneurysm cases, respectively. Patient outcomes were comparable to those reported in historical data. Staff members appeared to be primary surgeons in a select subset of cases. CONCLUSIONS: Neurosurgical trainees at this institution are exposed to a broad spectrum of intracranial aneurysms, although some case selection does occur. With careful supervision, intracranial aneurysm surgery can be safely delegated to trainees without compromising patient outcomes. Current trends in practice patterns in neurosurgery mandate ongoing monitoring of residents' operative experience while ensuring continued excellence in patient care.     

Acute communicating hydrocephalus due to rupture of cerebral aneurysm (author's transl)]

That direct intracranial operation in indicated in ruptured intracranial aneurysm which has passed the acute stage is an accepted procedure today. However, regarding the pros and cons of direct intracranial operation during the acute stage, settlement has yet to be made. This arises from the fact that various combined aggravated pathological states of cerebral vasospasm, brain edema, intracerebral hematoma, hydrocephalus etc. are present. The authors had attended to the acute hydrocephalus in the cases of ruptured aneurysm and conducted ventriculoatrial shunt for hydrocephalus actively. As a result, it was found that ventriculoatrial shunt brought about considable improvement of the patients condition to such an extent that an early operation became possible. The results are following: (1) The authors conducted cerebral angiography in the acute stage in 51 cases of ruptured intracranial aneurysm. Of this 51 cases as a result of angiographic findings, 12 cases, 23.5% showed ventricular dilation and accompanied lowering of consciousness level and increased intracranial pressure. (2) The largest number of acute hydrocephalus among our cases appeared in patients in the age level of 30-39, amounting to 44.4%. While this seemed to indicate the importance of the age factor, no correlation was seen with the localization of ruptured intracranial aneurysm or the number of experienced ruptures. (3) Of 12 cases of acute hydrocephalus 7 cases were subjected to ventriculoatrial shunt operations. Of 7 cases, after operation 6 cases showed an improvement in consciousness remarkably, thus making it possible to conduct an early intracranial operation of aneurysm. Ventricular drainage, V-A shunt for the following reasons: 1. Possibility of infection is very few. 2. The site of burr hole for V-A shunt located in parietal area. So craniotomy area, for example bifrontal craniotomy is apart from the site of V-A shunt. 3. The control of intracranial pressure is also easy after intracranial operation for aneurysm. 4. Normal pressure hydrocephalus can be prevented. 5. This method is useful for decreasing the brain bulk during the direct operation.     

Spontaneous Intracranial Haematomas Caused by Neoplasms

We report about 50 patients with spontaneous intracerebral haematomas (ICH) caused by intracranial neoplasms to assess the underlying histological condition, their presentation on admission, diagnostic work-up, treatment, histological diagnosis, and clinical outcome. These patients were identified in a prospective series of 2041 patients with intracranial neoplasms and 692 patients with spontaneous ICH, which were both consecutively collected over a nine-year-period. The frequency of ICH in patients with intracranial neoplasms was 2.4%. The frequency of tumour related ICH in the ICH group was 7.2%. The leading cause of tumour related ICH were metastases of extracranial origin (n = 18; 36%), followed by glioblastoma multiforme (n = 15; 30%). Nine patients (18%) had benign primary intracranial neoplasms. On admission 18 patients were somnolent (36%) and 14 patients (28%) were comatose. In 29 cases (58%) ICH was the first clinical sign of neoplastic disease, while in 21 patients (42%) a malignant tumour was already known. We operated on 45 patients (90%), four patients (8%) were not operated on because of poor clinical condition and died, one patient refused surgical treatment. Six patients (12%) died despite surgery. This series confirms the importance of a proper neuroradiological and clinical work-up of patients with suspected tumour related ICH followed by operative treatment and histological confirmation of the diagnosis. This is supported by the fact that 18% of patients had prognostically favourable intracranial tumours which would not otherwise have been adequately treated.     

Arteriovenous malformation and a ruptured giant aneurysm cured by emergency operation in a child

An arteriovenous malformation with a giant aneurysm and an intracerebral hemorrhage in a 3-year-old girl is reported. The malformation, the ruptured giant aneurysm, and the hematoma were totally and successfully removed during an emergency operation with temporary occlusion of the feeding artery and administration of 20% mannitol to prolong the permissive occlusion time of the cerebral arteries.     

A ruptured mycotic aneurysm,simultaneously associated with acute subdural hematoma and intracerebral hemorrhage: case report and review of the literature

A case is reported of a patient with simultaneous subdural hematoma and intracerebral hemorrhage associated with a ruptured intracranial mycotic aneurysm. A 65-year-old woman, with a history of low grade fever for over a month, presented with disturbance of consciousness. A CT showed bilateral acute subdural hematomas and parenchymal hematomas in the occipital lobes. Cerebral angiography demonstrated a distal middle cerebral aneurysm. Cardiac ultrasonography showed a verruca at the mitral valve. The incidence of ruptured mycotic aneurysm presenting with acute subdural hematoma is extremely rare. To our knowledge, there have been only seven cases. The present case is discussed with reference to a review of the literature.     

Treatment of ruptured anterior communicating artery aneurysm accompanying intracerebral hematomas: endovascular coiling followed by hematoma evacuation with burr hole trephination and catheterization

Introduction  The aim of this study was to evaluate the outcome of endovascular coiling of ruptured anterior communicating artery (AcomA) aneurysms followed by intracerebral hematoma (ICH) evacuation with burr hole trephination and catheterization. Methods  Twelve patients treated by coiling with subsequent ICH drainage with burr hole trephination and catheterization were recruited from 290 patients with ruptured AcomA aneurysm in our hospital between January 2001 and June 2007. The clinical and radiographic characteristics and outcomes of the 12 patients were retrospectively analyzed. Results  All 12 patients were male, aged from 29 to 62 years, and had ICHs with 16-ml to 45-ml volumes; nine (75%) of them had frontal ICHs on the opposite side of the dominant A1. Admission Hunt-Hess (HH) grade was 4 in eight patients, 3 in two, and 5 in two. The treatment outcomes in 8 of the 12 patients were good recovery or moderately disabled (Glasgow Outcome Scale; GOS 5 or 4), and functionally dependent (GOS 3 or 2) in the other 4 patients at the 6-month clinical follow-up. There was no rebleeding during the follow-up (mean, 22.9 months; range, 7 to 68 months). Conclusion  The result of our series suggests that coiling with subsequent evacuation of the ICH with burr hole trephination and catheterization may be an alternative treatment option for ruptured AcomA aneurysm with an ICH requiring evacuation on the opposite side of the dominant A1.     

Ruptured middle cerebral artery aneurysm with intracerebral hemorrhage in younger patients appearing moribund: emergency operation?

Four women, aged 39 to 46 years, were urgently admitted to our neurosurgical unit after strokes. On admission, all appeared moribund, presenting with deep coma, pupils bilaterally dilated and fixed, decerebrate posture, and markedly abnormal respiratory patterns. Computed tomography revealed subarachnoid hemorrhage with an associated large intracerebral hematoma and pronounced shift of midline structures in all four cases. Because of the clinical appearance, the patients were given urea and were operated without preceding angiography. The origin of the hemorrhage was identified as a middle cerebral artery (MCA) bifurcation berry aneurysm in one patient and giant MCA aneurysms in the other three. The hematomas were evacuated, and the aneurysms were occluded. All four patients received intravenous nimodipine, none showed any sign of delayed ischemic deterioration, and all regained full consciousness within a few days. One patient died 3 weeks later from a pulmonary embolus. Three patients are presently at home with moderate focal neurological deficits and moderate to marked cognitive impairment. The psychosocial readjustment was very good in a patient with a left giant aneurysm, satisfactory in a patient with a right giant aneurysm, and unsatisfactory in a patient with a right berry aneurysm. The indications, ethical considerations, and technical aspects of operating on seemingly moribund patients who probably harbor a ruptured MCA aneurysm are discussed.