Tag: Rebleeding

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Predictors of aneurysmal rebleed before definitive surgical or endovascular management

A Simple and Quantitative Method to Predict Symptomatic Vasospasm After Subarachnoid Hemorrhage Based on Computed Tomography- Beyond the Fisher Scale

Acta Neurochir (2016) 158:1037–1044

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

Method: A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

Results: Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p=0.023), diastolic blood pressure of >90 mmHg on admission (p=0.008); presence of loss of consciousness (p= 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p=0.005); higher Fisher grade (p<0.001); presence of multiple aneurysms (p= 0.021); irregular aneurysm surface (0.002).

Conclusions: Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

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Suboptimal interventional conditions for the occlusion of ruptured intracranial aneurysms do not increase periprocedural complications and poor clinical outcomes


 aneurysms of the middle cerebral artery

Acta Neurochir (2014) 156:1267–1272

Occluding a ruptured intracranial aneurysm as early as possible may entail certain periprocedural conditions that compromise the outcome. The aim of the present study was to evaluate the effectiveness, safety, and clinical outcome of endovascular coiling procedures performed on an emergency basis under potentially suboptimal conditions, and to compare results with those from scheduled procedures under potentially optimal conditions.

Methods Interventions performed on 66 SAH patients were retrospectively analysed by classifying them into two groups: under emergency (within three hours fromdiagnosis or during non–standard working hours) or scheduled conditions. A binary logistic regression analysis was also performed to identify characteristics associated with poor outcomes.

Results No differences in effectiveness, periprocedural complications, or clinical outcomes were found between the two groups. Rebleeding was detected in 4.8 % of the emergency interventions and 2.2 % of the scheduled interventions. Multivariate analysis identified age and Hunt and Hess grade, but no conditions of treatment, as the factors associated to poor outcome.

Conclusion Suboptimal interventional conditions for occluding ruptured intracranial aneurysms, such as performing procedures outside of standard working hours or within three hours of diagnosis, do not result in increased periprocedural complications and poor clinical outcomes compared with scheduled procedures under potentially optimal conditions. These results suggest the need for treatment to be provided as soon as possible.

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Surgery of brainstem cavernous malformations

Brainstem cavernoma

Acta Neurochir (2013) 155:2079–2083

Cavernomas are vascular hamartomas made up of thin-walled, grossly dilated blood vessels lined with endothelium. Between 4 and 35 % (mean 15 %) of cerebral cavernomas are located in the brainstem making resection of these lesions one of the most challenging tasks in neurosurgery.

Methods Patients with cavernomas within the brainstem or deep supratentorial structures were chosen from our prospectively collected database of operated patients with brain cavernomas. The timespan of treatment was between January 1998 and June 2012. Primary outcome was defined as percentage of patients with favourable outcome (Glasgow Outcome Scale (GOS) 4 or 5) at 1 year. Secondary outcome was defined as operation-related morbidity and mortality (drop at least 1 point on GOS at 1 year).

Results A total of 37 patients underwent surgery. The mean age was 34.7±11.7 years. The male to female ratio was 19:16. Thirty-two patients had a solitary lesion and 12 patients harboured multiple lesions. The Glasgow outcome score 4 or 5 was achieved after 34 operations (89.5 %). The mean follow-up was 39 months.We experienced two early post-operative deaths (5.3 %) and decrease in the Glasgow outcome scale postoperatively in 4 patients (10.5 %).

Conclusions • Favourable outcome was achieved in 89.5 % of cases. • Although M&M appears to be relatively high, surgery is method of choice for surgically accessible lesion which has bled for the first time due to reported high rebleed rate and high probability of poor outcome after cavernoma rebleed. • Radiosurgery should be reserved for those lesions which are deemed unresectable and where surgical intervention is considered favourable to observation alone.

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Early recurrent hemorrhage after coil embolization in ruptured intracranial aneurysms

Neuroradiology (2012) 54:719–726 DOI 10.1007/s00234-011-0950-3

The authors present a series of patients in whom early rebleeding occurred after coiling for ruptured aneurysms. We investigated the incidence and possible mechanisms of early rebleeding.

Methods This study consisted of 1,167 consecutive patients who underwent coiling for a ruptured saccular aneurysm. Clinical and radiological data were collected retrospectively from three institutions. Early rebleeding was defined as occurrence of further bleeding within 30 days after coiling with worsening of the patient’s condition. We divided early rebleeding into hyperacute, subacute, and delay groups depending on the timing of rebleeding after coil embolization.

Results Incidence of early rebleeding after coiling of a ruptured saccular aneurysm was 1.1% (13 of 1,167), and mortality was 31% (4 of 13) in our series. Out of ten patients in hyperacute group, three (30%) had incomplete occlusion result and six patients (60%) underwent intraarterial (IA) infusion of abciximab or tirofiban during the procedures. Seven patients (70%) had an intracerebral hemorrhage (ICH) on initial computed tomography. Four patients died, another four sustained severe disabilities, and the others had good recovery. All three patients in subacute and delay group showed recanalization on post-rebleeding angiography and made an excellent recovery.

Conclusion Early rebleeding was associated with high mortality and morbidity. IA abciximab infusion or thrombolytic interventions during the procedure, maintenance of anticoagulation after the procedure, incomplete treatment of the aneurysms, and presence of ICH seemed to be related to hyperacute early rebleeding after coiling. Increased aneurysmal size and coil compaction could induce subacute and delayed early rebleeding.

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Acute serious rebleeding after angiographically successful coil embolization of ruptured cerebral aneurysms

Acta Neurochir (2010) 152:771–781. DOI 10.1007/s00701-009-0593-x

The present study investigated the incidence of acute rebleeding after successful coil embolization of a ruptured cerebral aneurysm, including clinical outcomes, and possible mechanisms of the events other than coil compaction and/or incomplete embolization.

Materials and methods. This study included 591 consecutive patients who presented with aneurysmal subarachnoid hemorrhage, were treated with coil embolization, and whose post-procedural angiography revealed successful embolization. Data were collected retrospectively from six patients who showed acute rebleeding despite that angiographically successful coil embolization was achieved. All clinical, radiological data and intraoperative videos were reviewed to identify causative factors which could have contributed to the occurrence of rebleeding.

Results. Incidence of acute rebleeding after successful coil embolization of ruptured cerebral aneurysm was 1.0% (6/591). In all of these six patients, complete angiographic occlusion was achieved except in one case where a small residual neck was intentionally left to avoid compromise of the parent artery. Four of the six patients showed poor clinical courses, either died or recovered with severe disability. Whenever possible, we performed an immediate craniotomy for exploration and additional clipping. Based on intraoperative findings, we hypothesized that uneven distribution of the coil masses and spontaneous resolution of thrombus among the strands of coil (inter-coil-loop thrombolysis) could be possible mechanisms of rebleeding.

Conclusion. Acute rebleeding is extremely rare, but is possible as a complication of coil embolization of a ruptured cerebral aneurysm even when a case is angiographically successful. The higher degree of morbidity and mortality is a major concern. Therefore, further investigation to discover risk factors and causative mechanisms for such a complication is sorely needed.

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