Late epilepsy following open surgery for aneurysmal subarachnoid haemorrhage

OBJECTIVE: To determine the risk for late epilepsy (>2 weeks postoperatively) following aneurysmal subarachnoid haemorrhage (SAH) treated by early aneurysm clipping. DESIGN: Subgroup analysis of the East Anglian regional audit of SAH (1994-2000; n = 872) with 12 month follow up. Prophylactic anticonvulsants were not routinely prescribed unless there was a perioperative seizure. SUBJECTS: 472 patients with aneurysmal SAH undergoing surgical clipping of the aneurysm were studied. Patients presenting in WFNS grade V, with space occupying haematomas requiring emergency surgery, or with posterior circulation aneurysms, rebleeds, and surgery after 21 days were excluded. RESULTS: Late epilepsy occurred in 23 patients (4.9%). There was a correlation between the incidence of late epilepsy and both the presenting WFNS grade (p<0.05) (grade 1, 1.4%; grade 2, 3.8%; grade 3, 9.6%; grade 4, 12.5%) and the Glasgow outcome score at discharge (p<0.01) (good recovery, 2.2%; moderate disability, 5.0%; severe disability, 15.5%). There was no relation between the incidence of late epilepsy and sex or the site of the aneurysm. CONCLUSIONS: The low incidence of late epilepsy following open surgery for aneurysmal SAH supports the withholding of prophylactic anticonvulsants. Patients with poor WFNS grade and poor recovery after surgery are at increased risk and should be closely monitored.     

Risk factors and outcome in 100 patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE: Clinical and surgical outcome of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm were assessed in comparison to pre-operative data and risk factors such as previous medical history, clinical presenting condition, CT findings and site of bleeding. METHODS: We evaluated 100 consecutive patients with aneurysmal SAH. Gender, color, history of hypertension, smoking habit, site and size of aneurysm, admittance and before surgery Hunt Hess scale, need for cerebro-spinal fluid shunt, presence of complications during the surgical procedure, Glasgow Outcome Scale, presence of vasospasm and of rebleeding were assessed and these data matched to outcome. For statistical analysis, we applied the chi-squared test or Fisher's test using the pondered kappa coefficient. Kruskal-Wallis test was used for comparison of continue variables. Tendency of proportion was analyzed through Cochran-Armitage test. Significance level adopted was 5%. RESULTS: Patients studied were mainly white, female, without previous history of hypertension and non-smokers. Upon hospital admittance, grade 2 of Hunt-Hess scale was most frequently observed (34%), while grade 3 of Fisher scale was the most prevalent. Single aneurysms were most frequent at anterior circulation, between 12 and 24 mm. The most frequent Glasgow Outcome Scale observed was 5 (60%). Hunt Hess upon the moment of surgery and presence of complications during surgical procedure showed positive correlation with clinical outcome (p=0.00002 and p=0.001, respectively). Other variables were not significantly correlated to prognosis. Tendency of proportion was observed between Hunt-Hess scale and Fisher scale. CONCLUSION: Among variables such as epidemiological data, previous medical history and presenting conditions of patients with ruptured aneurysms, the Hunt-Hess scale upon the moment of surgery and the presence of surgical adversities are statistically related to degree of disability.     

Comparison of prognosis and complications after warning leaks in subarachnoidal hemorrhage--experience with 214 patients following aneurysm clipping

OBJECTIVES: The 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs before an acute massive subarachnoidal hemorrhage (SAH), was first described in 1967. The present study was performed to compare the complications and prognosis for 214 patients with and without a warning leak; aneurysm clipping had been performed in all.METHODS: The interval between the warning headache and the actual SAH was calculated. The following complications were examined: preoperative hemorrhage, intra-operative rupture of the aneurysm, postoperative re-bleeding, symptomatic vasospasm, shunt-requiring hydrocephalus, ventriculitis, postoperative wound infection, and outcome according to the Glasgow Outcome Scale (GOS).RESULTS: Sixty-seven (31%) out of the 214 patients had a warning leak with a median distance of 11 days before suffering from major SAH. Preoperative angiographic vasospasms occurred more frequently in the group with a warning bleeding (22.4 versus 6.1%; p<0.05), which means that the warning leaks induce vascular reactions similar to SAH. The outcome of both groups after a mean follow-up time of 22 months did not show any difference. But 30 out of the 67 patients with a warning leak were graded H&H III-V at admission to hospital after a major SAH. The overall outcome for patients graded H&H I and II was in 92% favorable, compared with only a 54% favorable outcome for H&H III-V patients. Long-term outcome in the warning leak group was not impaired by angiographically proven vasospasm.DISCUSSION: To give patients the chance to start their treatment in a better clinical condition it is important to recognize the early warning signs.     

Trends in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage in Izumo city, Japan, between 1980-1989 and 1990-1998

BACKGROUND AND PURPOSE: The purpose of this community-based study was to evaluate temporal changes in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: The subjects were 358 patients with aneurysmal SAH who were treated during the 19-year period from 1980 to 1998 in Izumo City, Japan. We compared data during the 9-year period 1990-1998 (period B; 188 patients) with those during the 10-year period 1980-1989 (period A; 170 patients). RESULTS: The proportion of patients 80 years of age or older or those with World Federation of Neurosurgical Societies grade V increased significantly (period A, 5 and 25%; period B, 18 and 35%, respectively). The operability rate did not change for patients 69 years of age or younger, whereas it increased significantly for those 70-79 years of age (period A, 48%; period B, 72%). The 6-month and 2-year case fatality rates in surgically treated patients decreased significantly (period A, 12 and 20%; period B, 2 and 8%, respectively), whereas they were virtually unchanged for overall management (period A, 41 and 46%; period B, 38 and 42%, respectively). In patients who underwent surgery, the incidence of permanent symptomatic vasospasm decreased from 21% during period A to 11% during period B, and there was no death from vasospasm in the later period. However, no significant difference was found in the functional outcome between the two periods, regardless of whether surgery was performed. The most important determinants of 6-month and 2-year survival rates were grade on admission, rebleeding and the site of the ruptured aneurysms. Age was also a significant predictor of the 6-month case fatality rate. CONCLUSIONS: For patients with SAH who underwent surgery, there were trends towards decreases in the case fatality rate and in the incidence of permanent symptomatic vasospasm. Nevertheless, the overall management outcome was still unsatisfactory, mainly because of increasing numbers of very elderly and/or high-risk patients. .     

Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area

OBJECTIVES: This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway. MATERIAL AND METHODS: A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery. RESULTS: Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001). CONCLUSIONS: Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.     

Computed tomography in aneurysmal subarachnoid haemorrhage.

The initial CT scans of 76 patients with aneurysmal subarachnoid haemorrhage were reviewed, and the amount of blood visible in the basal CSF cisterns was quantified. The outcome of surgery was found to correlate significantly with the quantity of blood seen on the scan, as did the pre-operative grade of the patient, a history of pre-existing hypertension, and the presence of angiographic vasospasm.     

Assessment of the haemostatic system in patients surgically treated for ruptured cerebral aneurysm

BACKGROUND AND PURPOSE: The aim of the study was to evaluate selected markers of thrombin generation and subsequent fibrinolysis in patients with aneurysmal subarachnoid haemorrhage (SAH) and to assess the relationship between thrombin generation/fibrinolysis and clinical course and outcome. MATERIAL AND METHODS: This prospective study included 72 patients after aneurysmal SAH who underwent surgery within 72 hours after onset of symptoms. The results were compared with 84 control patients without SAH. Selected markers of thrombin generation (thrombin-antithrombin complexes, TAT), fibrinolysis (D-dimer) and fibrinogen level were examined in blood just after admission and on day 7 after surgery. The relationship between levels of those markers and selected clinical and radiological data, and outcome at 3-6 months after surgery, were assessed. RESULTS: On admission, patients with SAH had higher levels of TAT (p<0.001), D-dimer (p=0.048), and fibrinogen than the control group (p<0.001). Also, patients with severe bleeding demonstrated higher TAT (p<0.001) and D-dimer (p=0.04) levels. The admission level of TAT (higher than 24 g/l; odds ratio = 10.8) and the elevated blood fibrinogen level (odds ratio = 1.2) showed a strong correlation with mortality. Furthermore, a level of TAT higher than 24 g/l (odds ratio = 9.98) and the level of fibrinogen (odds ratio = 1.3) strongly correlated with poor outcome. There was no significant correlation between markers of coagulation on the 7th day after surgery for SAH and the outcome. CONCLUSIONS: Activation of blood coagulation as well as the fibrinolytic system occurred early in the course of SAH. Such activation was associated with poor clinical status of patients on admission, greater amount of subarachnoid blood, and poor clinical outcome. Thus, blood levels of TAT and fibrinogen are independent factors associated with mortality and morbidity after aneurysmal SAH.     

Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage

Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. However, the correlation between the timing, modality of intervention (clipping or coiling) and the clinical outcome is not clear. This study aims to examine this correlation. Patients presenting with WFNS grades IV and V aneurysmal SAH between 1997 and 2008 to a single centre were studied. An aggressive policy of early intervention was followed, and the selection of endovascular versus microsurgical intervention was made according to angiographic rather than clinical features. Clinical outcomes were graded using the modified Rankin scale (mRS) at 6 month follow-up. One hundred and forty-three poor-grade patients (23.9% of all 598 aneurysmal SAH patients) were studied. Treatment was microsurgical in 83 (58.0%) and endovascular in 60 (42%) patients. Twenty patients (14.0%) were lost to follow-up. Good outcome (mRS 0-2) at 6 months was found in 45 microsurgical patients (63.3%) and 24 endovascular patients (46.1%). This trend towards better clinical outcomes in the microsurgical group was not statistically significant. With an aggressive early treatment policy more than half of the poor-grade SAH patients demonstrated a good clinical outcome. Microsurgery and endovascular treatment, when selected primarily according to angiographic features, were equally likely to achieve good outcome.     

Clinical outcome of spontaneous non-aneurysmal subarachnoid hemorrhage in 108 patients

Background: The cause of spontaneous subarachnoid hemorrhage (SAH) is unknown in 15% of cases; idiopathic SAH has a better prognosis than aneurysmal SAH. When bleeding is confined to the perimesencephalic cisterns, SAH has an especially benign course. Methods: We retrospectively studied 108 patients admitted for spontaneous non‐aneurysmal SAH between 1991 and 2004. We divided patients into two groups according to the bleeding pattern at cranial CT: perimesencephalic pattern (n = 60) and aneurysmal pattern (n = 48). We included only patients in whom no source of bleeding was detected at angiography; patients with aneurysmal pattern underwent at least two angiographic examinations. Mean follow‐up was 5.5 years; follow‐up consisted of telephone interview in 84.7% of patients. Results: All but one patient with perimesencephalic pattern were classified as grade I or II on the Hunt and Hess scale; the exception was the only patient in this group with a complication (hydrocephalus), who was classified as grade IV. Three‐quarters of the patients with aneurysmal pattern were classified as grade I or II on the Hunt and Hess scale; 5 patients presented with hydrocephalus that required drainage and 2 with vasospasms without repercussions. No rebleeding or long‐term complications were observed in either group. Conclusions: Non‐aneurysmal SAH with a perimesencephalic pattern of bleeding has a benign course and excellent short‐term and long‐term prognosis. Patients with non‐aneurysmal SAH with an aneurysmal pattern of bleeding have more complications, and the initial clinical situation has a significant impact on their prognosis.     

Metaanalysis of Tirilazad Mesylate in Patients with Aneurysmal Subarachnoid Hemorrhage

Background  Tirilazad is a non-glucocorticoid, 21-aminosteriod that inhibits lipid peroxidation. It had neuroprotective effects in experimental ischemic stroke and reduced angiographic vasospasm after experimental subarachnoid hemorrhage (SAH). Five randomized clinical trials of tirilazad were conducted in patients with SAH. We performed a meta-analysis of these trials to assess the effect of tirilazad on unfavorable outcome, symptomatic vasospasm, and cerebral infarction after SAH. Methods  Data from 3,797 patients were analyzed and modeled using random effect and Mantel-Haenszel meta-analyses and multivariable logistic regression to determine the effect of tirilazad on clinical outcome, symptomatic vasospasm, and cerebral infarction. Clinical outcome was assessed 3 months after SAH using the Glasgow outcome scale, and symptomatic vasospasm was defined by clinical criteria with laboratory and radiological exclusion of other causes of neurological deterioration. Results  The five trials were randomized, double-blind, and placebo-controlled. Tirilazad did not significantly decrease unfavorable clinical outcome on the GOS (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.89–1.20) or cerebral infarction (OR 1.04, 95% CI 0.89–1.22). There was a significant reduction in symptomatic vasospasm in patients treated with tirilazad (OR 0.80, 95% CI 0.69–0.93). There was no heterogeneity across the five trials. Conclusion  Tirilazad had no effect on clinical outcome but did decrease symptomatic vasospasm in five trials of aneurysmal SAH. The dissociation between clinical outcome and symptomatic vasospasm deserves further investigation.     

Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution

Background: Although many studies evaluated independent prognosis factors of functional outcome in patients with subarachnoid hemorrhage (SAH) at a suitable time point, some patients take a long time to get functional improvement. The purpose of this study is to evaluate predictors for functional outcome in SAH patients who underwent surgical clipping and in-hospital rehabilitation in our single institution using Modified Rankin Scale (MRS) and Barthel Index (BI). Methods: Two-hundred fifty-one SAH patients were admitted to our hospital from January 2008 to December 2017. Of them, 144 patients who diagnosed aneurysmal SAH, underwent surgical clipping within 72 hours, and completed subsequent in-hospital rehabilitation were included in this study. We explored their clinical variables and evaluated the relationships between those factors and functional outcome using MRS and BI. Results: In multivariate analysis, independent prognostic factors of both MRS and BI were age, World Federation of Neurologic Surgeons grade, and symptomatic vasospasm. Conclusions: We suggest that age, SAH severity, and symptomatic vasospasm are associated with functional outcome in patients with aneurysmal SAH who completed surgical clipping and in-hospital rehabilitation.     

Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH were studied as well. METHODS: Symptomatic vasospasm was defined as the association of deterioration in a patient's neurological condition between 3 and 14 days after SAH with no other explanation and an increase in mean transcranial Doppler velocities of >120 cm/s. The prognostic factors were registered on admission and during the intensive care stay. RESULTS: Symptomatic vasospasm occurred in 22.2% surgical patients compared with 17.2% endovascular treatment patients (P=0.37). Multivariate analysis revealed that the probability of occurrence of symptomatic vasospasm decreased with age >50 years (relative risk [RR], 0.47 [0.25 to 0.88]) and severe World Federation of Neurological Surgeons (WFNS) grade measured on admission (RR, 0.43 [0.20 to 0.90]) and increased with hyperglycemia occurring during the intensive care stay (RR, 1.94 [1.04 to 3.63]). No difference in risk of symptomatic vasospasm could be identified between surgical and endovascular treatment. Symptomatic vasospasm (OR, 4.73 [CI, 1. 77 to 12.6]) as well as WFNS grade of >2 (OR, 8.95 [3.46 to 23.2]), treatment complications (OR, 8.39 [3.16 to 22.3]), and secondary brain insults were associated with an increased risk of 6-month sequelae. CONCLUSIONS: Age <50 years, good neurological grade, and hyperglycemia were all associated with an increased risk of cerebral vasospasm whereas treatment was not. This provides a basis for future clinical prospective randomized trials comparing both treatments.     

Predictors and outcome of acute symptomatic cerebral infarctions following aneurysmal subarachnoid hemorrhage

The leading cause of unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH) is cerebral infarction. In this 3-year retrospective study, we have retrospectively evaluated 172 hospitalized patients with aneurysmal SAH, and compared those who developed a complicated cerebral infarction with those who did not. In this study, acute symptomatic cerebral infarctions accounted for 22.6% (39/172) of all episodes. Significant statistical analysis between the two patient groups included age at onset, hypertension as the underlying disease, presence of symptomatic vasospasm, mean hospitalization days and Glasgow Outcome Score at the time of discharge. After a minimum 1.5-year follow-up period, the median (interquantile range) Barthel index score was 75 (6–85) for those patients who had cerebral infarctions, and 80 (0–90) for those who had no cerebral infarctions. Multiple logistic regression analysis demonstrated that the presence of symptomatic vasospasm was independently associated with the presence of acute symptomatic cerebral infarctions. The presence of symptomatic vasospasm implies the danger of acute symptomatic cerebral events after aneurysmal SAH. Although our study demonstrates a worse short-term outcome and longer duration of hospitalization in this special group of patients, the functional outcome for patients with cerebral infarction was not inferior to those patients without cerebral infarction after a follow-up of at least 1.5-years.     

High-Dose Simvastatin Is Effective in Preventing Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study in Korean Patients

ObjectiveThe goal of this study was to assess the effect of high-dose simvastatin on cerebral vasospasm and its clinical outcome after aneurysmal subarachnoid hemorrhage (SAH) in Korean patients.MethodsThis study was designed as a prospective observational cohort study. Its subjects were aneurysmal SAH patients who had undergone aneurysm clipping or coiling. They were assigned to 1 of 3 groups : the 20 mg, 40 mg, and 80 mg simvastatin groups. The primary end-point was the occurrence of symptomatic vasospasm. The clinical outcome was assessed with the modified Rankin Scale (mRS) score after 1 month and 3 months. The risk factors of the development of vasospasm were assessed by logistic regression analysis.ResultsNinety nine patients with aneurysmal SAH were treated and screened. They were sequentially assigned to the 20 mg (n=22), 40 mg (n=34), and 80 mg (n=31) simvastatin groups. Symptomatic vasospasm occurred in 36.4% of the 20 mg group, 8.8% of the 40 mg group, and 3.2% of the 80 mg group (p=0.003). The multiple logistic regression analysis showed that poor Hunt-Hess grades (OR=5.4 and 95% CI=1.09-26.62) and high-dose (80 mg) simvastatin (OR=0.09 and 95% CI=0.1-0.85) were independent factors of symptomatic vasospasm. The clinical outcomes did not show a significant difference among the three groups.ConclusionThis study demonstrated that 80 mg simvastatin treatment was effective in preventing cerebral vasospasm after aneurysmal SAH, but did not improve the clinical outcome in Korean patients.     

Angiographic vasospasm in a contemporary series of patients with aneurysmal subarachnoid haemorrhage

Over the last decade there have been significant changes in the management of patients with aneurysmal subarachnoid haemorrhage (SAH). Many of these changes, such as haemodilutional, hypervolaemic, hypertensive therapy and the use of calcium channel blockers, have been directed at the prevention and treatment of vasospasm. The angiograms of a contemporary series of 56 consecutive surgically treated patients with aneurysmal SAH were examined to compare angiographic vasospasm with that seen in historical studies. The time course of angiographic vasospasm was found to be broadly similar to that reported in previous studies, with onset after day 3 following SAH, maximal narrowing during the second week, and resolution after day 16. The times of peak narrowing and resolution were slightly earlier in previous studies. 30% of patients had clinical vasospasm (delayed neurological deficit for which other causes had been excluded), and these patients had a trend to more severe angiographic narrowing than those without clinical vasospasm, particularly in the second week following SAH. 44 angiograms were performed between days 1-3 post SAH and repeated between days 4-16. 95% of these showed arterial narrowing at the second angiogram. Patients not achieving an independent outcome tended to have had both more clinical vasospasm and more severe angiographic spasm than those achieving independence. It is concluded that angiographic vasospasm remains a common occurrence in the modern era, and continues to be associated with clinical events and a poor outcome.     

Safety of intrathecal sodium nitroprusside for the treatment and prevention of refractory cerebral vasospasm and ischemia in humans.

BACKGROUND AND PURPOSE: The delayed type of cerebral vasoconstriction known as cerebral vasospasm (DCV) remains an important cause of permanent neurological injury and death following aneurysmal subarachnoid hemorrhage despite best current medical therapy. The mechanism of DCV remains unknown. A new treatment for refractory DCV using intrathecally delivered sodium nitroprusside and results in 21 patients is reported. METHODS: Candidates for treatment were patients with secured cerebral aneurysms presenting with clinical or radiographic SAH of grade 3 or higher. Patients with and without established DCV were treated. In 57% (12/21 patients) the diagnosis of severe DCV refractory to conventional treatment (HHH therapy and nimodipine) was established before treatment. Ten patients received ITSNP prophylactically. All patients with established DCV were in grave neurological condition before treatment. Procedures for vasospasm reversal were performed under simultaneous angiographic control with extensive hemodynamic and neurophysiologic monitoring. ITSNP was delivered by intraventricular or subdural catheter or by direct intraoperative suffusion. End points of intervention for established DCV were (1) durable angiographic reversal of vasoconstriction, (2) failure to effect reversal within 30 minutes, and (3) adverse effect. End points for DCV prevention were (1) post-SAH day 10 without evidence of vasoconstriction and (2) adverse effect. Cerebral angioplasty was used concomitantly in 9 treatments. The total number of treatments recorded was 171. RESULTS: The overall neurological outcome was good or excellent in 76% of patients (16/21) overall and in 88.9% of patients (16/18) having at least a 1-month follow-up. Of the 5 patients with less-than-good outcome, 4 had presented initially with severe neurological injury (clinical SAH grade 4). Angiography demonstrated reversal or amelioration of vasoconstriction in 83% (5/6 cases) of established DCV treated by ITSNP alone. Among patients treated prophylactically, none developed clinical DCV. CONCLUSIONS: These results suggest that ITSNP is a safe and potentially effective treatment for established DCV and cerebral ischemia refractory to conventional treatment. The preliminary results of prophylactic treatment are also favorable with regard to safety.     

Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus

Background  Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. Methods  Hospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated. Results  One hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients (p=0.5), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p=0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24±14 versus 15±8, 20.5±9 versus 11±7, and 30±13 versus 16±11 days, respectively; p≤0.01). In a logistic regression model, VS was independently associated with rebleeding, external ventricular drain placement, coiling, and UHC-expected LOS (odds ratios, 95% confidence interval 12.1, 2.3–62.6, 6.9, 1.6–30, 6.25, 1.3–29, and 1.1, 1.02–1.14, respectively). Conclusions  One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.     

Does treatment modality of intracranial ruptured aneurysms influence the incidence of cerebral vasospasm and clinical outcome?

BACKGROUND: Cerebral vasospasm is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). This study is designed to determine whether the incidence of symptomatic vasospasm and the overall clinical outcome differ between patients treated with surgical clipping compared with endovascular obliteration of aneurysms. METHODS: In this prospective study, 98 patients with aneurysmal SAH were treated. Seventy-two patients underwent surgery and clipping and 26 had coil embolization. The incidence of symptomatic vasospasm, permanent neurologic deficit due to vasospasm and clinical outcome were analyzed. Patients with better clinical and radiological grades (World Federation of Neurological Surgeons grades I-III and Fisher grades I-III) were analyzed separately. RESULTS: Symptomatic vasospasm occurred in 22% of the patients; 25% in the surgical group and 15% in the endovascular group. Nine percent of the patients in the surgical group and 7% in the endovascular group suffered ischemic infarction with permanent neurological deficit. These differences did not reach statistical significance (p = 0.42). For patients with better clinical and radiological grades, no significant difference was found for the rate of symptomatic vasospasm; 23% in the surgical and 12% in the endovascular group (p = 0.49). The overall clinical outcome was comparable in both groups, with no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less (15% in the surgical and 16% in the endovascular group; p = 0.87). The same results for outcome were obtained for the subgroup of patients with better clinical grades on admission. CONCLUSION: Symptomatic vasospasm and ischemic infarction rate seem comparable in both groups, even for patients with better clinical and radiological admission grades. There is no significant difference in the overall clinical outcome at the long-term follow-up between both groups.     

Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study

OBJECTIVES: The debate on the timing of aneurysm surgery after subarachnoid haemorrhage (SAH) pivots on the balance of the temporal risk for fatal rebleeding versus the risk of surgical morbidity when operating early on an acutely injured brain. By following a strict management protocol for SAH, the hypothesis has been tested that in the modern arena of treatment for aneurysmal SAH the timing of surgery to secure supratentorial aneurysms does not affect surgical outcome. METHODS: Over a 6 year period, patients admitted with a diagnosis of SAH to a regional neurosurgical unit have been prospectively studied. All have been on a management protocol in which early transfer and resuscitation has been followed regardless of age and clinical condition. Angiographic investigation and surgery have been pursued in those who have been able to at least flex to pain. A total of 1168 patients (60.7% female, mean age 54.3) with proved SAH were received on median day 1 (86.4% arrived within 3 days) of the ictus. Of these, 784 (67.1%) showed aneurysms on angiography and were prepared for surgery. Those who received surgery for a supratentorial aneurysm within 21 days of the ictus were included in the final analysis (n=550). Patients with an initial negative angiogram, with posterior circulation aneurysms, or aneurysms treated by endovascular means, with aneurysms requiring emergency surgery for space occupying haematomas, with aneurysms which re-bled before surgery, and those who received very late surgery (after 21 days from ictus) were excluded. Surgical outcomes at hospital discharge and after 6 months were assessed using the Glasgow outcome score (GOS). Discharge destination and duration of stay in a neurosurgical ward were also documented. The influence of the timing of surgery (early group day 1-3 postictus, intermediate group day 4-10, or late group day 11-21) was analysed prospectively. RESULTS: 60.2% of cases fell into the early surgery group, 32.4% into the intermediate group, and 7.5% into the late operated group. Late surgery was due to delays in diagnosis, transfer, and logistic factors, but not clinical decision. The demographic characteristics, site of aneurysm, and clinical condition of the patients at the time of initial medical assessment were balanced in the three surgical timing groups. There was no significant difference in GOS between the surgical timing groups at 6 months (favourable GOS score 4 and 5: 83.2%, 80.5%, and 83.8% respectively; p=0.47, Kruskal-Wallis test). Outcome was favourable in 84% of patients under 65 years, and 70% in those over 65. The discharge destinations (home, referring hospital, nursing home, rehabilitation centre) showed no significant difference between surgical timing groups. There was no significant difference in mean time to discharge after admission to this hospital from the referring hospital (16.2, 16.2, and 14.6 days for early, intermediate, and late groups respectively; p=0.789, Analysis of variance (ANOVA)). As a result, there was reduction in the mean duration of total hospital inpatient stay in favour of the earliest operated patients (mean time 18.1, 22.0, and 28.3 days respectively; p=0.001. ANOVA showed that besides age, the only determinant of surgical outcome and duration of stay was presenting clinical grade (p<0.0005). CONCLUSION: The current management of patients presenting with SAH from anterior circulation aneurysms allows early surgery to be followed safely regardless of age. The only independent variables affecting outcome are age and clinical grade at presentation. The timing of surgery did not significantly affect surgical outcome, promoting a policy for early surgery that avoids the known risks of rebleeding and reduces inpatient stay.     

Familial subarachnoid hemorrhage. Outcome study

BACKGROUND AND PURPOSE: The aim of our study was to compare outcome and its determinants in familial subarachnoid hemorrhage and in sporadic subarachnoid hemorrhage in a large and well-documented patient population. METHODS: Patients with aneurysmal subarachnoid hemorrhage (SAH) treated at the Department of Neurosurgery, Kuopio University Hospital, from 1977 to 1995 were included. Patients with polycystic kidney disease were excluded. The Glasgow Outcome Scale (GOS) score at 12 months was studied. RESULTS: There were 120 patients (97 first-, 15 second-, and 8 third-degree family connections) in 96 different families with familial SAH and 1237 patients with sporadic SAH. Age, gender, and admission grade on the Hunt and Hess scale did not differ between these 2 groups. In both groups >80% of patients were in relatively good condition at admission. The outcome was good (GOS score of 1 to 2) in 87 patients (73%) with familial SAH and in 874 patients (71%) with sporadic SAH. Analysis of 20 variables, including presence of coexisting diseases, aneurysm site and size, amount of blood shown on CT scan, intraventricular bleeding, preoperative intracerebral hematoma and hydrocephalus, as well as postoperative bleeding and vasospasm, revealed no significant differences between study groups. The degree of family connection (first-, second-, and third-degree) did not have any statistically important effect on outcome in the familial group in the Finnish study population. In multivariate analysis the knowledge of familial SAH was not an independent prognostic factor. CONCLUSIONS: Admission status, postoperative course, and outcome were similar in the familial and sporadic SAH groups in this Finnish population, in contrast to previous results. Familial SAH may not be a significant risk factor for poor outcome.