Contribution of endovascular therapy to the management of poor-grade aneurysmal subarachnoid hemorrhage: Clinical and angiographic outcomes

OBJECT: Treatment of patients presenting with poor-grade (Hunt and Hess Grade IV or V) subarachnoid hemorrhage (SAH) is controversial. Endovascular coil embolization has been considered a valuable therapeutic alternative to surgical clip placement for this kind of patient. The aim of the present study was to evaluate immediate and long-term angiographic and clinical outcomes in patients with poor-grade SAH treated by endovascular embolization. METHODS: One hundred eleven patients with Hunt and Hess Grade IV or V SAH were treated with endovascular embolization at the University of California at Los Angeles Medical Center between October 1990 and December 2004. Eighty patients harbored Grade IV hemorrhages and 31 patients had Grade V ones. Immediate and long-term anatomical and clinical outcomes were evaluated in all patients. Long-term clinical outcome assessments were based on follow-up data obtained over an average of 32 months posttherapy. Technical complications occurred in 15 patients (13.5%). Immediate complete aneurysm occlusion was observed in 51.4% of aneurysms. Angiographic, long-term follow-up review revealed aneurysm recanalization in 16.2% of cases. Thirty-nine patients (35.1%) demonstrated a favorable long-term clinical outcome. The overall mortality rate in this patient series was 32.4%. The mortality rate associated with vasospasm was significantly higher in patients with Grade IV SAHs than in those with Grade V hemorrhages. CONCLUSIONS: The results of this study demonstrate a valuable contribution of endovascular therapy of ruptured intracranial aneurysms in patients with Hunt and Hess Grade IV or V SAH. This technique was successful in decreasing repeated aneurysm rupture and in enabling aggressive medical management during the acute phase of SAH. This is particularly important in patients with Grade IV SAH because of their potential for obtaining higher physical and functional recoveries.     

Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms

OBJECT: Patients with fusiform aneurysms can present with subarachnoid hemorrhage (SAH), mass effect, ischemia, or unrelated symptoms. The absence of an aneurysm neck impedes the direct application of a clip and endovascular coil deployment. To evaluate the effects of their treatments, the authors retrospectively analyzed a consecutive series of patients with posterior circulation fusiform aneurysms treated at Stanford University Medical Center between 1991 and 2005. METHODS: Forty-nine patients (mean age 53 years, male/female ratio 1.2:1) treated at the authors' medical center form the basis of the analysis. Twenty-nine patients presented with an SAH. The patients presenting without SAH had cranial nerve dysfunction (five patients), symptoms of mass effect (eight patients), ischemia (six patients), or unrelated symptoms (one patient). The aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) (21 patients); vertebrobasilar junction (VBJ) or basilar artery (BA) (18 patients); and posterior cerebral artery (PCA) (10 patients). Pretreatment clinical grades were determined using the Hunt and Hess scale; for patients with unruptured aneurysms (Hunt and Hess Grade 0) functional subgrades were added. Outcome was evaluated using the Glasgow Outcome Scale (GOS) score during a mean follow-up period of 33 months. Overall long-term outcome was good (GOS Score 4 or 5) in 59%, poor (GOS Score 2 or 3) in 16%, and fatal (GOS Score 1) in 24% of the patients. In a univariate analysis, poor outcome was predicted by age greater than 55 years, VBJ location, pretreatment Hunt and Hess grade in patients presenting with SAH, and incomplete aneurysm thrombosis after endovascular treatment. In a multivariate analysis, age greater than 55 years was the confounding factor predicting poor outcome. Stratification by aneurysm location removed the effect of age. Of 13 patients with residual aneurysm after treatment, five (38%) subsequently died of SAH (three patients) or progressive mass effect/brainstem ischemia (two patients). CONCLUSIONS: Certain posterior circulation aneurysm locations (PCA, VA-PICA, and BA-VBJ) represent separate disease entities affecting patients at different ages with distinct patterns of presentation, treatment options, and outcomes. Favorable overall long-term outcome can be achieved in 90% of patients with PCA aneurysms, in 60% of those with VA-PICA aneurysms, and in 39% of those with BA-VBJ aneurysms when using endovascular and surgical techniques. The natural history of the disease was poor in patients with incomplete aneurysm thrombosis after treatment.     

Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils.

In a multicenter study, 120 patients with intracranial aneurysms presenting a high surgical risk were treated using electrolytically detachable coils and electrothrombosis via an endovascular approach. The results of treatment in patients with posterior fossa aneurysms (42 patients with 43 aneurysms) are presented. The most frequent clinical presentation was subarachnoid hemorrhage (24 cases). The clinical follow-up periods ranged from 1 week to 18 months. Complete aneurysm occlusion was obtained in 13 of 16 aneurysms with a small neck and in four of 26 wide-necked aneurysms. A 70% to 98% thrombosis of the aneurysm was achieved in 22 of 26 aneurysms with a wide neck and in three of 16 small-necked aneurysms. One aneurysm could not be treated due to a technical complication. Two cases required postprocedural surgical clipping of a residual aneurysm. One patient (originally in Hunt and Hess Grade V) experienced procedural rupture of the aneurysm requiring an emergency parent artery occlusion. He eventually died 5 days later. Another patient (originally in Grade IV) had coil migration and posterior cerebral artery territory ischemia. A third patient developed a permanent neurological deficit (hemianopsia) after complete occlusion of a wide-necked basilar bifurcation aneurysm. One patient, harboring an inoperable giant basilar bifurcation aneurysm, died from aneurysm bleeding 18 months after partial occlusion. Overall morbidity and mortality rates related to treatment were 4.8% (two cases) and 2.4% (one case), respectively (2.6% and 0% if considering only patients in Hunt and Hess Grades I, II, and III). It is suggested that this technique is a viable alternative in the management of patients with posterior fossa aneurysms associated with high surgical risk. Longer angiographic and clinical follow-up study is necessary to determine the long-term efficacy of this recently developed endovascular occlusion technique. Close postoperative angiographic and clinical monitoring of patients with wide-necked subtotally occluded aneurysms is mandatory to check for potential aneurysmal recanalization, regrowth, and rupture.     

Pediatric cerebral aneurysms

OBJECT: The exceptional pediatric aneurysm can be distinguished from its adult counterpart by its location and size; however, patient outcomes remain difficult to evaluate based on the published literature. METHODS: Twenty-two children, all consecutively treated in three neurosurgery departments, were included in this study. Each patient's preoperative status was determined according to the Hunt and Hess classification. Routine computerized tomography scanning and angiography were performed in all children on the 10th postoperative day. Each patient's clinical status was evaluated 2 to 10 years postoperatively by applying the Glasgow Outcome Scale (GOS). Twenty-one children presented with a subarachnoid hemorrhage (SAH) and one child harbored an asymptomatic giant aneurysm. Thirteen patients were in good preoperative grade (Hunt and Hess Grades I to III) and eight in poor preoperative grade (Hunt and Hess Grade IV or V). The symptomatic aneurysms were located on the internal carotid artery bifurcation (36.4%); middle cerebral artery (36.4%), half of which were found on the distal portion; anterior communicating artery (18.2%); and within the vertebrobasilar system (9.1%). A giant aneurysm was observed in 14% of patients. Overall outcome was favorable (GOS Score 5) in 14 children (63.6%) and death occurred in five (22.7%). Causes of unfavorable outcome included the initial SAH in four children, a complication in procedure in three children, and edema in one child. CONCLUSIONS: Pediatric aneurysms have a specific distribution unlike that of aneurysms in the adult population. The incidence of giant aneurysms and outcomes were similar to those in the adult population. The major cause of poor outcome was the initial SAH, in particular, the high proportion of rebleeding possibly due to a delay in diagnosis.     

Case of spontaneous bilateral VA dissecting aneurysm presenting with SAH

We report a case of bilateral vertebral artery (VA) dissecting aneurysm presenting subarachnoid hemorrhage (SAH). It was difficult to decide which side was responsible for SAH because the patient's symptom and head CT suggested that the left VA aneurysm had ruptured, but angiography and MRA showed an irregular pearl and string sign on the right side. He was successfully treated by trapping of the right VA dissecting aneurysm and we confirmed by intraoperative evaluation that the right VA dissecting aneurysm had ruptured. The left unruptured aneurysm decreased its size spontaneously. In the treatment of the bilateral VA dissecting aneurysms, angiography needs to be performed over and over again because contralateral unruptured aneurysm may grow or rupture due to increased hemodynamic stress. Various combinations of direct sugery with or without arterial reconstruction and endovascular treatment should be considered when treating bilateral VA dissecting aneurysms.     

Dissecting aneurysms of the vertebral artery: a management strategy

OBJECT: The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA). METHODS: Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)-PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA-PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%. CONCLUSIONS: Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.     

Endovascular coil trapping for ruptured vertebral artery dissecting aneurysms by using double microcatheters technique in the acute stage

Summary ?Background. In the treatment of vertebral artery (VA) dissecting aneurysms, only proximal occlusion of the VA does not necessarily prevent rerupture. We evaluated the efficacy of coil trapping for the ruptured VA dissecting aneurysms using the double microcatheters technique. Methods. We treated 11 patients who presented with subarachnoid haemorrhage (SAH) due to rupture of a VA dissecting aneurysm which did not involve the posterior inferior cerebellar artery at the site of dissection. All patients tolerated the balloon occlusion test. Within 3 days of the SAH, the dissection site was trapped with a Guglielmi detachable coil (GDC) using the double microcatheters technique. The proximal and distal sites of the dissecting aneurysm were embolized simultaneously. Findings. GDC trapping at the affected site was successful in all 11 patients. Radiographic findings showed complete occlusion of the dissection site and patency of the unaffected artery. Although one patient experienced transient dysphagia, there were no major complications. Interpretation. The double microcatheters technique is effective for coil trapping of ruptured VA dissecting aneurysms in selected patients. The risks posed by this simple technique are minimal, even in the acute stage. Published online May 26, 2003     

Relation among aneurysm size, amount of subarachnoid blood, and clinical outcome

OBJECT: The authors of recent reports have suggested that smaller aneurysms are associated with more extensive subarachnoid hemorrhage (SAH), which could potentially presage poor outcome in patients harboring these lesions. The authors reviewed their clinical experience to determine if this theory has a basis in truth. METHODS: The authors undertook a retrospective review of a consecutive series of patients with aneurysmal SAH. Computed tomography scans and angiograms were studied to establish SAH scores and aneurysm size. RESULTS: One hundred thirty-three patients were treated during a 2-year period (January 2003-December 2004). There were 101 female and 32 male patients whose mean age was 56.7 years. The location distribution of aneurysms that bled was as follows: anterior communicating artery (56 cases), posterior communicating artery (34 cases), middle cerebral artery (21 cases), posterior circulation (16 cases), and paraclinoid region (six cases). The mean aneurysm size was 6.2 mm (range 2-26 mm). The mean SAH score was 18.3 (not normally distributed, p < 0.01, D'Agostino-Pearson test). One hundred three patients underwent surgical exploration and placement of an aneurysm clip, 21 underwent deployment of a coil, and two underwent both therapies; seven patients died prior to intervention. No correlation was found between aneurysm size and SAH score (r(s) = -0.023, p = 0.8) or between small aneurysm size and poor Glasgow Outcome Scale score (p = 0.13). In fact, the trend was the opposite. The SAH score did, however, correspond strongly with the admission Hunt and Hess grade (p < 0.0001), indicating the strong correlation between grade and volume of intracranial blood. Outcome was best explained in the multivariate analysis by the following factors: admission Hunt and Hess grade, age, and clinical vasospasm (p < 0.0001) with the proportion of cases correctly classified as 79.7%. CONCLUSIONS: Evaluation of the results in the present clinical series suggests that there is no relation between aneurysm size and volume of subarachnoid blood. The volume of cisternal blood correlates with Hunt and Hess grade but is not an independent determinant of outcome. Outcome is related to the following triad of well-established clinical factors: Hunt and Hess grade, age, and clinical vasospasm.     

Subarachnoid hemorrhage in the presence of both intracranial dissecting and saccular aneurysms--two case reports

Two patients presented with subarachnoid hemorrhage (SAH) associated with both intracranial dissecting and saccular aneurysms. Case 1, a 48-year-old woman, had a saccular aneurysm of the right internal carotid artery and dissecting aneurysms of the bilateral vertebral arteries. Case 2, a 52-year-old man, had three saccular aneurysms in the anterior circulation and a dissecting aneurysm of the unilateral vertebral artery. A saccular aneurysm was responsible for the SAH in both patients. Ruptured saccular aneurysms were treated with surgical clipping and unruptured dissecting aneurysms remained untreated. SAH recurred due to bleeding from an untreated dissecting aneurysm 4 days after the initial SAH in Case 1. Triple-H therapy, which causes increased hemodynamic stress, was not administered for symptomatic cerebral vasospasm after SAH in Case 2, because of the risk of bleeding from the untreated dissecting aneurysm, and the patient suffered cerebral infarction. The risk factors for this rare association are unclear, but both patients were smokers and had hypocholesterolemia including low apolipoprotein E levels. The clinical management of patients with SAH and both dissection and saccular aneurysms is complicated. Asymptomatic dissecting aneurysm has a benign clinical course in general, but hemodynamic stress related to stroke may induce abrupt development of dissecting aneurysms. Prophylactic obliteration during the acute stage of SAH may provide better outcomes if the unruptured dissecting lesion appears as obvious aneurysmal dilatation or pearl-and-string sign and is safely treatable with endovascular trapping.     

Management-Related Morbidity and Mortality in Unselected Aneurysms of the Basilar Trunk and Vertebrobasilar Junction

Summary  Objects. To analyze the management-related morbidity and mortality in unselected aneurysms of the basilar trunk and vertebrobasilar junction. The secondary objective was to investigate the factors associated with favourable or unfavourable surgical outcome in order to define subgroups for surgical and endovascular treatment.  Methods. 24 consecutive patients with aneurysms of the basilar trunk and vertebrobasilar junction were included in this study. They comprised 2.7% of all aneurysms treated during the study period between 1990 and 1997. 22 patients presented with acute subarachnoid hemorrhage (SAH) and 2 patients with symptoms of brainstem compresssion. All patients were managed using a standard protocol including surgery at the earliest possible moment, aggressive tripe-H therapy in patients with symptomatic vasospasm and mandatory follow-up angiography. 23 patients underwent surgical clipping and one patient endovascular coiling of the aneurysm. 12 patients had an excellent outcome. 6 patients had a good outcome, resulting in a total of satisfactory outcomes in 18 patients (75%). 4 patients (17%) had moderate to severe deficits. Two patients died (8%). Both patients had fusiform basilar trunk aneurysms. Good or excellent outcome was observed in 7 of 8 patients with aneurysms of the vertebrobasilar junction, 13 of 14 patients with moderate or minor SAH or without SAH (Fisher grade 0 to 2) and all patients with small sized aneurysm (n=6). Factors mostly associated with poor outcome or death after surgical treatment were aneurysm location at the basilar trunk, large aneurysm size or fusiforme aneurysm type and severe SAH.  Conclusions. Location, aneurysm size and the severity of SAH may help to predict the subgroup which highly benefits from surgical clipping of these rare vascular lesions.     

Dissecting aneurysms of the bilateral vertebral arteries with subarachnoid hemorrhage: report of three cases

OBJECTIVE AND IMPORTANCE: Treatment of one side in cases of dissecting aneurysms of the bilateral vertebral arteries (VAs) with subarachnoid hemorrhage may result in dissection or rupture on the contralateral side. CLINICAL PRESENTATION: Three patients presented with dissecting aneurysms of the bilateral VAs with subarachnoid hemorrhage. INTERVENTION: Two patients underwent trapping of the ruptured VA, with side-to-side anastomosis between the bilateral posteroinferior cerebellar arteries. One patient underwent resection of the ruptured VA, with interposition of a saphenous vein graft. Two patients died as a result of rupture of the contralateral VA dissecting aneurysm after surgery. One patient demonstrated development of an unruptured dissecting aneurysm in the contralateral VA 1 month after surgery. CONCLUSION: Surgical intervention to treat dissecting aneurysms of the bilateral VAs on one side carries the risk of rupture of the contralateral lesion. Increased hemodynamic stress may be important in the development and rupture of dissections in the contralateral VA.     

Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome

OBJECT: The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) trunk. METHODS: The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up. RESULTS: A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9-67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001). CONCLUSIONS: Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.     

Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases

Summary Introduction. Haemorrhagic intracranial vertebrobasilar dissection is an uncommon cause of nontraumatic subarachnoid haemorrhage (SAH) and accounts for only 1–10% of non-traumatic SAH. Treatment in the acute phase is considered to be essential because of the high risk of rebleeding and the consequent unfavourable outcome. However, the location, the potential for involvement of eloquent vessels and the histopathological characteristics of the vessel wall make treatment demanding from both a technical and anatomical point of view. We report our experience in the management of this disease. Patients and treatments. From 1989 to June 2006, we managed 21 patients with spontaneous haemorrhagic dissection located in the intracranial vertebrobasilar system, 13 patients were treated using an endovascular approach, 1 by surgical clipping, and 7 were managed conservatively. Results. Among the 13 patients treated endovascularly, 7 underwent proximal occlusion, 4 underwent parent artery embolization at the site of dissection, and 2 underwent endovascular trapping. Severe, treatment-related complications due to dislodgement of the thrombus during the procedure occurred in 1 patient, who then died from brainstem ischaemia. One patient died from severe pneumonia and one patient was left disabled from vasospastic ischaemia resulting from severe initial SAH. The remaining 10 patients had satisfactory outcomes: none rebled after treatment and when discharged they had Karnovsky scores of 80–100. Of the 7 conservatively treated patients, three died of rebleeding and four were discharged with Karnovsky scores of 50–100. One patient, who was treated surgically, was discharged with a Karnovsky of 90. Conclusion. The high rate of rebleeding and consequent mortality among the patients treated conservatively argues for treatment in the acute phase. Treatment should be guided by each patient’s angiomorphology, clinical condition and the experience of the neurosurgical/neuroradiological team. Options include endovascular or surgical trapping of the dissection and proximal occlusion and embolisation of the parent artery at the site of the dissection.     

Leukocytosis as an independent risk factor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

OBJECT: The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. METHODS: A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 +/- 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5-15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02-1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01-0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04-0.45). A serum leukocyte count greater than 15 x 10(9)/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74-6.38). CONCLUSIONS: During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 x 10(9)/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.     

Prophylactic hypervolemia without calcium channel blockers in early aneurysm surgery.

Delayed ischemic neurological deficit (DIND) remains a major unsolved problem in the management of aneurysmal subarachnoid hemorrhage (SAH). For many years, the complications reported with acute aneurysm surgery caused surgeons to operate late after SAH. In a 42-month-period, we managed 146 patients with aneurysm and/or SAH. Forty-seven patients were characterized by the following: Hunt and Hess Grades I through III after an aneurysmal SAH; 2) clipping of their aneurysm within 72 hours of their SAH; and (3) prophylactic hypervolemia with a pulmonary artery catheter to optimize their fluid management. Forty of 47 (85%) had an excellent or good outcome, and 3 of 47 (6%) died. All of those who died had DIND. Nine of 47 (19%) patients developed DIND. There were 20 complications, primarily pulmonary edema, in 16 patients and one death related to prophylactic hypervolemia. It is not clear from our experience, when compared with results from other series, that hypervolemia provides any additional benefit to the patient as measured by a reduction in the risk of DIND or improved outcome. Despite aggressive volume expansion to the point of cardiovascular compromise, as evidenced by our high rate of pulmonary edema, we had no appreciable decrease in neurological morbidity and mortality when compared with results from recent reports.     

New clinical grading in ruptured cerebral aneurysm

A new clinical grading of subarachnoid hemorrhage (SAH) due to ruptured aneurysm, classified by the presence or absence of vomiting, and by the duration of initial unconciousness at the time of bleeding, is proposed. Grade I: headache without vomiting, Grade II: headache, vomiting, and/or loss of consciousness lasting less than one hour, Grade III: loss of consciouness for over one hour. Grade IV: permanent unconsciousness or cerebral herniation signs. Based on the clinical records, 142 cases of ruptured cerebral aneurysms directly operated on in phases varying from peracute phase (within 72 hours) to delayed phase (22 days or over) were retrospectively analyzed. They included 99 cases which were operated on under microscope. The Hunt & Hess grading was applied just before surgery. Outcome at the 6 month to 1 year follow-up was rated as good, fair, poor and dead. Correlations between the severity and the outcome were calculated using the chi-square test and the levels of significance were compared with those between the recent Hunt and Hess grading and the outcome. In the total of 142 cases, correlation between the clinical severity and the outcome was significant (P less than 0.0005), whereas correlation between the Hunt & Hess grading and the outcome was not significant. In the analysis of cases classified by the operative timing, the clinical severity showed good correlation in the peracute (within 72 hours after SAH) (P less than 0.05) alone, while Hunt & Hess grading showed correlation in delayed phase alone. Neither of the gradings was significant in the acute phase or subacute phase.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison between endovascular and surgical management of basilar artery apex aneurysms

OBJECT: The goal of this retrospective study was to evaluate endovascular treatment by means of Guglielmi detachable coils (GDCs) compared with surgical management for basilar artery (BA) apex aneurysms. METHODS: Forty-one patients presented with saccular BA apex aneurysms with angiographically definable necks that were judged suitable for either treatment. Of 20 patients who underwent surgery and 21 who underwent GDC embolization, 15 (75%) and 11 (52%), respectively, were treated in the acute phase after subarachnoid hemorrhage (SAH). Twenty-four (92%) of the 26 patients presenting with an SAH had a Hunt and Hess Grade III or better. Fifteen patients with unruptured or ruptured aneurysms more than 14 days post-SAH were treated electively. Patients in the endovascular and surgical treatment groups had aneurysms with comparable dimensions and configurations. Overall, 15 (75%) of the surgical patients and 20 (95%) of the patients in whom GDC embolization was performed had a good outcome (Glasgow Outcome Scale score of 4 or 5). Among those patients treated in the acute stage post-SAH, 11 (73%) of the surgical group and 10 (91%) of the endovascular group did well. Fourteen patients treated electively (93%) had good outcomes. There were two deaths (10%) in the surgical group and none in the endovascular group. Patients treated surgically were hospitalized twice as long and incurred twice the expenses of patients who underwent endovascular treatment (p<0.001). CONCLUSIONS: Endovascular GDC embolization of select BA apex aneurysms may be a competitive alternative to direct surgical clipping. Long-term follow up is needed to better define the natural history of the endovascularly treated aneurysm and to further evaluate the accuracy of these preliminary results.     

Ruptured intracranial dissecting aneurysms: management considerations with a focus on surgical and endovascular techniques to preserve arterial continuity

Background. The present retrospective analysis was undertaken to review an institutional experience with 13 intracranial dissecting aneurysms as source of subarachnoid haemorrhage (SAH) among a total of 585 ruptured intracranial aneurysms. Methods and results. In 6 patients the vertebral artery (VA) was affected, in 2 patients the basilar artery (BA), in 3 the internal carotid (ICA), in 1 the middle cerebral (MCA) and in 1 the postcommunicating (A2) segment of the anterior cerebral artery (ACA). Maintaining arterial patency was aimed at in all patients. Tangential clipping or circumferential wrapping were used as surgical methods. Endovascular stenting and/or coiling was applied in 2 instances. Four of the 6 VA dissecting aneurysms underwent surgical exploration between 1 and 22 days after haemorrhage. Two patients were in WFNS grade V and died subsequently with the aneurysms untreated, one after rehaemorrhage. In the patients with secured VA aneurysms the postoperative course was uncomplicated with the exception of additional caudal cranial nerve injury in 1 instance. Both BA aneurysms were initially treated by endovascular methods. In the first patient incomplete packing with Gugliemi detachable (GDC) coils was achieved. Follow-up angiography 6 months later showed growth and coil compaction and subsequent wrapping with Teflon fibres resulting in angiographic stabilization. The other BA aneurysm was treated by a combination of a coronary stent and GDC coils. The 3 dissecting ICA aneurysms were all explored surgically. In only 1 instance ICA continuity could be preserved by wrapping, in the other 2 cases a major portion of the vessel wall disintegrated upon removal of the surrounding clot. The only ACA dissecting aneurysm, on A2, was successfully treated with a Dacron cuff. In the single patient with a MCA aneurysm, a decision for conservative management was taken, because neither a surgical nor an endovascular solution was seen as a possibility that did not risk occlusion of lenticulostriate branches. The patient suffered a fatal rehaemorrhage 4 weeks later at her home. Conclusions. The reported experience suggests that in Western countries also dissecting aneurysms are an occasional source of SAH. The outcome in our conservatively managed patients confirms the poor prognosis of conservative management. Wrapping and endovascular stent based methods can achieve stabilization of the dissected artery without sacrificing the artery. Results of treatment appear to depend largely on the location of the dissecting aneurysm.     

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.     

Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia

A consecutive series of 145 patients with acute aneurysmal subarachnoid hemorrhage (SAH) were operated on within 7 days of SAH and were prospectively evaluated over a 4-year period to determine if the timing of aneurysm surgery influenced the development of delayed cerebral ischemia. All patients were managed with a standardized policy of urgent surgical clipping and treatment with aggressive prophylactic postoperative volume expansion. Patients with delayed ischemic symptoms were additionally treated with induced hypertension. Forty-nine patients underwent surgery on Day 0 or 1 (Group 1) post-SAH, 60 patients on Day 2 or 3 (Group 2), and 36 patients on Days 4 through 7 (Group 3). Postoperative delayed cerebral ischemia developed in 16% of (Group 1) patients, in 22% of Group 2 patients, and in 28% of Group 3 patients. Cerebral infarction resulting from delayed cerebral ischemia developed in only 4% of Group 1 patients, 10% of Group 2 patients, and 11% of Group 3 patients. A bad clinical outcome as a result of delayed cerebral ischemia occurred in one Group 1 patient (2%), two Group 2 patients (3%), and one Group 3 patient (3%). Preoperative grade was not significantly correlated with the incidence or severity of delayed cerebral ischemia at any time interval except that patients in modified Hunt and Hess Grade I or II who underwent surgery on Day 0 or 1 after SAH had no strokes or bad outcomes from delayed cerebral ischemia. This study demonstrates that there is no rationale for delaying aneurysm surgery based on the time interval between SAH and patient evaluation.