Tag: Subarachnoid hemorrhage

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Basilar artery perforator rupture as the cause of perimesencephalic subarachnoid hemorrhage

J Neurosurg 144:1271–1277, 2026

This clinical study evaluates the etiology of perimesencephalic subarachnoid hemorrhage (pmSAH) by applying high-resolution cone-beam CT (CBCT) during catheter angiography to detect basilar artery perforator outpouchings. The retrospective analysis of 22 pmSAH patients found that CBCT identified basilar perforator pseudoaneurysms in a substantial subset, with conservative management yielding excellent outcomes.

The authors argue that many pmSAHs may be arterial rather than venous in origin when imaged with modern high-resolution CBCT protocols. They recommend heightened suspicion for an arterial source and detailed angiographic CBCT acquisition, while acknowledging limits of retrospective design, variable imaging quality, and unresolved management questions.

Objective High-resolution CBCT performed during catheter angiography was used to better identify the etiology of perimesencephalic SAH (pmSAH), challenging the historical assumption of a venous source.

Methods Retrospective review of pmSAH cases (Jan 2023–Dec 2024) requiring catheter angiography with available, diagnostic-quality CBCT; images were interpreted by two experienced neuroangiographers to consensus.

Cohort Of 152 spontaneous SAH presentations, 22 met Rinkel criteria for pmSAH; after exclusions (alternative causes found, missing/low-quality CBCT), 13 patients remained for CBCT-based imaging analysis.

Key finding In 8/13 (61.5%) analyzed pmSAH cases, CBCT showed a basilar artery perforator focal outpouching consistent with a rupture site (submillimeter, 0.4–0.8 mm).

Anatomy distribution Among the 8 identified perforator lesions, 6 were rostral basilar perforators, with 1 midbasilar and 1 caudal perforator involvement.

Outcomes All pmSAH patients—including those with identified basilar perforator outpouchings—had excellent recovery, with no re-rupture events and no clinically significant vasospasm reported in the series.

Follow-up imaging In patients who underwent follow-up DSA with CBCT, the basilar perforator finding resolved on follow-up imaging.

Conclusion/implication pmSAH should be approached with high suspicion for an arterial etiology (basilar perforator pseudoaneurysm frequently detectable with high-resolution CBCT), and conservative management was associated with excellent outcomes in this cohort.

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Clinical Outcomes of Subarachnoid Hemorrhage in Patients With Nicotine Dependence

Neurosurgery 98:1095–1102, 2026

This retrospective, population-based study analyzes clinical outcomes after nontraumatic subarachnoid hemorrhage (SAH) among 43,315 patients with documented nicotine dependence versus patients without substance use disorders. Using the TriNetX network with propensity score matching, primary endpoints included mortality, vasospasm, hydrocephalus, and delayed cerebral ischemia (DCI), with nicotine dependence associated with significantly higher hazards for all outcomes.

The manuscript details methods, matching variables, statistical analyses, mechanistic discussion of nicotine’s vascular effects, and limitations inherent to large electronic health record databases. Conclusions emphasize that nicotine dependence predicts worse SAH outcomes and support prioritizing smoking cessation counseling as part of long-term patient management.

Study focus: Clinical outcomes after nontraumatic subarachnoid hemorrhage (SAH) in adults with nicotine dependence versus those with no substance use disorder diagnoses.

Data source & cohort: TriNetX electronic medical record network analysis of adults (≥18) with ICD-10 I60 (nontraumatic SAH) from 2004–2024; 43,315 had nicotine dependence (F17) out of ~210k+ SAH patients.

Methods: Used 1:1 propensity score matching to balance demographics, comorbidities, lab/substance testing, and SAH severity (NIS-SAH Severity Score elements), then applied Cox proportional hazards and Kaplan–Meier survival analyses.

Mortality risk: Nicotine dependence associated with higher post-SAH mortality hazard (HR ≈ 1.24–1.25, statistically significant).

Vasospasm risk: Nicotine dependence associated with higher hazard of vasospasm (HR ≈ 1.47–1.49, statistically significant).

DCI risk: Nicotine dependence associated with higher hazard of delayed cerebral ischemia (DCI) (HR reported ≈ 1.30–1.35, statistically significant).

Hydrocephalus risk: Nicotine dependence associated with higher hazard of newly diagnosed hydrocephalus (HR ≈ 1.27, statistically significant).

Clinical implication: Elevated risks linked to nicotine dependence underscore the importance of smoking cessation counseling for long-term management after SAH.

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Neuropsychological profile and risk factors for poor cognitive outcomes in survivors of aneurysmal subarachnoid hemorrhage

J Neurosurg 144:517–525, 2026

This clinical study characterizes long-term neuropsychological outcomes in 156 survivors of aneurysmal subarachnoid hemorrhage (aSAH), using MoCA-22, digit span, and verbal fluency tests. Findings show that 34% scored below the 25th percentile despite largely favorable functional recovery, with deficits concentrated in executive function, working memory, and language.

Multivariable analysis identified modified Fisher grade 4 on admission and new radiological infarction during hospitalization as independent predictors of poor cognitive outcomes. Secondary assessments revealed frequent depressive symptoms and acquired personality disturbances, implicating impacts on work productivity and social relationships.

Objective Characterize neuropsychological deficits in aneurysmal subarachnoid hemorrhage (aSAH) survivors and identify clinical variables linked to poor cognitive outcomes.

Design/assessments Retrospective cohort (2009–2024) with cognitive testing ≥6 months post-aSAH using MoCA-22, Digit Span Forward/Backward, and Verbal Fluency; poor outcome defined as MoCA-22 <25th percentile (norm-adjusted).

Prevalence 34% (53/156) had MoCA-22 <25th percentile despite most having good functional recovery at discharge (mRS ≤2 in 79% of those with poor MoCA-22).

Cognitive profile Moderate/severe deficits (z-score >1 SD below norms) occurred in 11% on DST-F, 27% on DST-B, and 9% on VFT, highlighting prominent working-memory/executive-function vulnerability.

Key risk factors Modified Fisher grade 4 on admission and new radiological infarction during hospitalization were independently associated with poor MoCA-22 outcomes (aOR 2.43 and 2.71, respectively).

Quality of life impact Radiological infarction was associated with worse work productivity (OR 0.69) and social relationships (OR 0.72).

Behavioral sequelae Among those assessed, 27% reported at least mild depressive symptoms and 64% showed acquired personality disturbance.

Bottom line Cognitive/behavioral deficits can persist long after aSAH even with favorable mRS; higher hemorrhage burden (modified Fisher 4) and in-hospital infarction signal higher risk.

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Role of surgical treatment of intracranial aneurysms in the era of endovascular therapy: a review

Neurosurg Focus 59(6):E2, 2025

This review evaluates the contemporary role of microsurgical clipping versus endovascular treatment (EVT) for intracranial aneurysms, comparing long-term durability, complication profiles, and anatomical or patient factors that guide modality selection. It synthesizes trial data (ISAT, BRAT), meta-analyses, and location-specific outcomes to highlight differences in occlusion, retreatment, and morbidity.

The article also outlines practical considerations—hybrid strategies, cerebral bypass, training needs, economics, and global disparities—arguing for individualized, multidisciplinary decision-making and preserving microsurgical expertise despite growing EVT adoption.

Treatment Goals: Exclusion of intracranial aneurysms from circulation while preserving parent vessels and neural function remains the primary objective; both endovascular treatment (EVT) and microsurgical clipping are core modalities.

Long-term Outcomes: Microsurgical clipping offers greater durability and lower rates of recurrence, rebleeding, and retreatment compared to EVT, which has higher retreatment rates despite lower short-term morbidity.

Procedure Selection: EVT is generally preferred for older patients and posterior circulation aneurysms, while microsurgery is favored in younger patients, those with hematomas, mass effect, and aneurysms of the middle cerebral and pericallosal arteries.

Aneurysm Location: Surgical clipping achieves higher occlusion and lower recurrence, especially for anterior circulation, middle cerebral artery, and complex aneurysms; EVT is more suitable for posterior circulation and anatomically challenging cases.

Complications and Adjuncts: Microsurgery allows for evacuation of hematomas and cisternal blood (reducing vasospasm and hydrocephalus), while EVT avoids craniotomy risks but may induce mechanical vasospasm and requires antiplatelet therapy.

Hybrid and Advanced Techniques: Hybrid approaches (combining EVT and surgery) and cerebral bypass remain essential for complex, giant, or recurrent aneurysms not amenable to standard treatments.

Cost and Access: Microsurgical treatment incurs lower overall healthcare costs than EVT; global disparities exist, with surgical clipping dominating in low-resource settings due to limited endovascular infrastructure.

Decision-Making: Optimal management requires individualized, multidisciplinary evaluation considering patient factors, aneurysm characteristics, and resource availability; no single factor should solely dictate treatment choice

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Lumbar Puncture or External Ventricular Drainage as Initial Treatment for Acute Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 97:1308–1315, 2025

This two-center cohort study compares lumbar puncture (LP) versus external ventricular drainage (EVD) as initial treatments for acute hydrocephalus after aneurysmal subarachnoid hemorrhage, analyzing rates of permanent ventriculoperitoneal shunts (VPS), procedure-related complications, and 3-month functional outcomes. Patients eligible for LP had similar admission severity, and outcomes were adjusted for baseline predictors to compare strategies across centers.

Results show markedly fewer permanent VPS implantations (10% vs 68%) and lower short-term complication rates with LP, while unfavorable functional outcomes at 3 months did not differ significantly. The authors conclude LP is a viable initial option for selected patients, recommending future studies on cognitive and quality-of-life effects.

Initial Treatment: Lumbar puncture (LP) as initial treatment for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) resulted in significantly fewer patients requiring permanent ventriculoperitoneal shunt (VPS) implantation compared to external ventricular drainage (EVD) (10% vs 68%).

Complication Rates: LP was associated with lower short-term complication rates than EVD (21% vs 38%), including lower rates of intracerebral hemorrhage and infection, especially when LP alone was sufficient.

Functional Outcomes: No statistically significant difference was observed in unfavorable functional outcomes (Glasgow Outcome Scale 1-3 at 3 months) between LP and EVD groups, though the trend favored LP (40% vs 49%).

Patient Selection: LP is suitable as first-line treatment only for selected patients (e.g., GCS ≥7, no space-occupying hematoma, no intraventricular obstruction), while EVD remains necessary for those with contraindications to LP or requiring intracranial pressure monitoring.

Volume of CSF Drainage: Lower cerebrospinal fluid (CSF) volumes drained with LP (typically 25-30 mL per procedure) compared to EVD (hundreds of mL over days) may contribute to reduced VPS dependency.

Study Limitations: Differences in overall management strategies, patient selection, and treatment protocols between centers limit the ability to attribute outcomes solely to the initial hydrocephalus treatment modality; results should not be interpreted as definitive evidence that LP is superior to EVD.

Implications for Practice: LP can be considered as an initial treatment for acute hydrocephalus after SAH in eligible patients, but there is currently no evidence that it improves long-term functional outcomes; further research is needed to assess effects on cognition and quality of life.

Research Needs: More robust, prospective studies are required to clarify optimal patient selection, CSF drainage strategies, and comparative benefits of LP versus EVD in post-SAH hydrocephalus management.

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Decreasing delayed cerebral infarction after aneurysmal subarachnoid hemorrhage using active blood clearance and prevention of delayed cerebral ischemia: results of a 16-year patient registry

J Neurosurg 143:928–938, 2025

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) after aneurysmal subarachnoid hemorrhage significantly reduced delayed cerebral infarction rates and improved outcomes in high-risk patients, using methods like intrathecal irrigation, urokinase, and nimodipine, according to a 16-year registry study.

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) was introduced for patients with aneurysmal subarachnoid hemorrhage (aSAH) to reduce delayed cerebral infarction (DCI) using methods like intrathecal irrigation, fibrinolysis with urokinase, and intrathecal nimodipine.

• Four ABCD methods were developed: stereotactic catheter ventriculocisternostomy (STX-VCS), intraoperative cisternoventricular catheter (CVC), ventriculolumbar irrigation (VLI), and lumbo-lumbar irrigation (LLI).

• Implementation of ABCD in high-risk patients led to a significant reduction in DCI rates from 21.2% to 7.7% and a 70% decrease in per-patient DCI burden.

• Patients selected for ABCD had higher initial blood load and worse clinical status, but still showed improved outcomes, especially those with high Hijdra scores (≥30).

• Pressure-controlled VLI and intraoperative CVC emerged as the most practical and widely applicable ABCD techniques.

• Complication rates were low and ABCD was considered safe, with rare adverse events and no increase in infection rates.

• The study suggests ABCD outperforms previous DCI prevention strategies and recommends multicenter trials for further validation.

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Microsurgical management of 883 previously coiled intracranial aneurysms

J Neurosurg 143:654–667, 2025

This systematic review and meta-analysis found that microsurgical management of previously coiled intracranial aneurysms is effective and safe in well-selected patients, achieving high complete occlusion and good functional outcomes, especially with delayed direct clipping, small aneurysm size, and anterior location.

• Microsurgical management of previously coiled intracranial aneurysms (IAs) is effective and safe in well-selected patients.

• Meta-analysis included 874 patients with 883 previously coiled IAs; most underwent direct clipping.

• Complete occlusion rate was 97.2%, good functional outcome 82.9%, and perioperative mortality 3.7%.

• Direct clipping had the best safety and efficacy, with the lowest rates of complications and highest rates of good outcomes.

• Smaller, anteriorly located, and unruptured aneurysms were associated with the most favorable outcomes.

• Early microsurgery (within 1 month of coiling) and Gurian group C IAs had higher perioperative death rates.

• Key management factors: IA size, location, rupture status, indication, and timing/type of microsurgery.

• Most studies were retrospective case series, limiting subgroup analysis and introducing some heterogeneity.

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Has a fast treatment transition from surgical to endovascular operations improved the survival of aneurysmal subarachnoid hemorrhage?

Acta Neurochirurgica (2025) 167:34

The study examines the impact of transitioning from surgical to endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH) at Helsinki University Hospital. Findings suggest that case fatality rate (CFR) reductions may be more attributable to other factors than the treatment shift.

• The study investigates the effects of a rapid transition from surgical to endovascular treatment on case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (aSAH) at Helsinki University Hospital (HUH).

• The transition to endovascular treatment occurred in 2015, with two treatment eras defined: surgical (2012–2014) and endovascular (2015–2017).

• Results showed a significant increase in endovascular treatment for non-MCA cases and a consistent surgical treatment for MCA cases, with similar decreases in 1-year CFRs for both groups.

• The study concludes that the independent effect of endovascular treatment on decreasing CFRs is small, suggesting improvements in other factors such as diagnostic modalities and acute care may have contributed more.

• The study highlights the need for a case-specific approach in treating aSAH, as different aneurysm locations may benefit differently from surgical or endovascular treatments.

• The research emphasizes the importance of considering other outcome-related factors in addition to treatment modality when analyzing CFR trends.

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Aneurysm Wall Enhancement Can Predict Rupture Point in Intracranial Aneurysms With Multiple Blebs

Neurosurgery 96:593–599, 2025

• Aneurysm Wall Enhancement (AWE) can predict rupture points in intracranial aneurysms with multiple blebs.

• Vessel Wall MRI (VW-MRI) is used to visualize ruptured aneurysms, showing characteristic AWE.

• Higher AWE is associated with ruptured blebs, while lower wall shear stress (WSS) is observed in ruptured versus unruptured blebs.

• CRstalk (contrast ratio of the aneurysm wall against the stalk) is a significant predictor of rupture status, with higher values indicating ruptured blebs.

• AWE is independent of WSS in predicting rupture status and can guide treatment strategies.

• Study limitations include its retrospective nature and small sample size; future studies with high-resolution MRI are suggested.

• Clinical value: AWE helps determine which aneurysm to treat first, especially in cases with multiple aneurysms, improving surgical safety.

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Association of Global Ultraviolet Radiation With the Incidence of Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 96:396–401, 2025

• Study Focus: The research investigates the association between global ultraviolet (UV) radiation and the incidence of aneurysmal subarachnoid hemorrhage (SAH).

• Inverse Correlation: A significant inverse correlation between UV radiation and SAH incidence was found, suggesting higher UV exposure is linked to lower SAH rates.

• Methodology: Data from 32 countries were analyzed using UV indices from the Tropospheric Emission Monitoring Internet Service, with statistical analyses performed using R and Excel.

• Geographic Variations: The study found significant regional differences, with higher UV indices in Europe associated with lower SAH incidences, but this was not significant in non-European countries.

• Biological Implications: UV radiation may reduce inflammation, potentially decreasing the risk of aneurysm rupture, and may also boost vitamin D synthesis, which is linked to improved immune response.

• Limitations: The study faced limitations, including lack of data from some countries and inability to assess seasonal influences due to variability in study periods.

• Conclusion: The findings suggest that environmental factors like UV exposure may influence SAH incidence, warranting further investigation into potential therapeutic implications.

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Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes

Neurosurgery 96:78–86, 2025

Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes.

METHODS: This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 PM and 7 AM, with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 PM and 7 AM, with other times classified as on-hours.

RESULTS: This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes.

CONCLUSION: Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.

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Three-Dimensional Morphological Change of Intracranial Aneurysms Before and Around Rupture

Neurosurgery 94:1211–1217, 2024

Patients with an unruptured intracranial aneurysm often undergo periodic imaging to detect potential aneurysm growth, which is associated with an increased rupture risk. Because prediction of rupture based on growth is moderate, morphological changes have gained interest as a risk factor for rupture. We studied 3-dimensionalquantified morphological changes over time during radiological monitoring before rupture and around rupture.

METHODS: In this retrospective observational study, we identified aneurysms that ruptured during follow-up, with imaging available for at least 2 time points before rupture and one after rupture. For each time point, we obtained 8 morphological parameters: 2-dimensional size, volume, surface area, compactness 1 and 2, sphericity, elongation, and flatness. Morphological changes before rupture and around rupture were log-transformed, scaled, and analyzed with linear mixed-effects models.

RESULTS: We included 16 aneurysms in 16 patients who were imaged between 2004 and 2021. In the time period before rupture (median follow-up duration 1200 days, IQR 736-1340), 3 size-related morphological parameters increased: 2-dimensional size (estimated mean change 0.44, 95% CI 0.24-0.65), volume (estimated mean change 0.34, 95% CI 0.12-0.56), and surface area (0.33, 95% CI 0.11-0.54). In the period around rupture (median follow-up duration 407 days, IQR 148-719), these parameters further increased. In addition, 5 morphological parameters (compactness 1 and 2, sphericity, elongation, and flatness) decreased around rupture but not before rupture.

CONCLUSION: Change in aneurysm volume and surface area may be novel risk factors for rupture. Because most morphological parameters changed around but not before rupture, morphological changes during these 2 periods should be regarded as different processes. This implies that postrupture morphology should not be used as a surrogate for prerupture morphology in rupture prediction models.

 

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HummingFlow: novel single twist-drill access for ventricular drainage, irrigation, monitoring, and automated local drug delivery in subarachnoid hemorrhage

J Neurosurg 139:1036–1041, 2023

The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH.

METHODS The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy.

RESULTS Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm.

CONCLUSIONS Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.

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Cisternal Score: A Radiographic Score to Predict Ventriculoperitoneal Shunt Requirement in Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 93:75–83, 2023

Persistent hydrocephalus requiring a ventriculoperitoneal shunt (VPS) can complicate the management of aneurysmal subarachnoid hemorrhage (aSAH). Identification of high-risk patients may guide external ventricular drain management.

OBJECTIVE: To identify early radiographic predictors for persistent hydrocephalus requiring VPS placement. METHODS: In a 2-center retrospective study, we compared radiographic features on admission noncontrast head computed tomography scans of patients with aSAH requiring a VPS to those who did not, at 2 referral academic centers from 2016 through 2021. We quantified blood clot thickness in the basal cisterns including interpeduncular, ambient, crural, prepontine, interhemispheric cisterns, and bilateral Sylvian fissures. We then created the cisternal score (CISCO) using features that were significantly different between groups.

RESULTS: We included 229 survivors (mean age 55.6 years [SD 13.1]; 63% female) of whom 50 (22%) required VPS. CISCO was greater in patients who required a VPS than those who did not (median 4, IQR 3-6 vs 2, IQR 1-4; P < .001). Higher CISCO was associated with higher odds of developing persistent hydrocephalus with VPS requirement (odds ratio 1.6 per point increase, 95% CI 1.34-1.9; P < .001), independent of age, Hunt and Hess grades, and modified GRAEB scores. CISCO had higher accuracy in predicting VPS requirement (area under the curve 0.75, 95% CI 0.68-0.82) compared with other predictors present on admission.

CONCLUSION: Cisternal blood clot quantification on admission noncontrast head computed tomography scan is feasible and can be used in predicting persistent hydrocephalus with VPS requirement in patients with aSAH. Future prospective studies are recommended to further validate this tool.

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A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology

J Neurosurg 138:165–172, 2023

OBJECTIVE Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes.

METHODS The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model.

RESULTS Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98–1.00; OR per point increase 10; 95% CI 2.18–46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92–1.00) of this model.

CONCLUSIONS A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.

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Microsurgical treatment of ruptured aneurysms beyond 72 hours after rupture: implications for advanced management

Acta Neurochirurgica (2022) 164:2431–2439

Aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to primary stroke centers are often transferred to neurosurgical and endovascular services at tertiary centers. The effect on microsurgical outcomes of the resultant delay in treatment is unknown. We evaluated microsurgical aSAH treatment > 72 h after the ictus.

Methods All aSAH patients treated at a single tertiary center between August 1, 2007, and July 31, 2019, were retrospectively reviewed. The additional inclusion criterion was the availability of treatment data relative to time of bleed. Patients were grouped based on bleed-to-treatment time as having acute treatment (on or before postbleed day [PBD] 3) or delayed treatment (on or after PBD 4). Propensity adjustments were used to correct for statistically significant confounding covariables.

Results Among 956 aSAH patients, 92 (10%) received delayed surgical treatment (delayed group), and 864 (90%) received acute endovascular or surgical treatment (acute group). Reruptures occurred in 3% (26/864) of the acute group and 1% (1/92) of the delayed group (p = 0.51). After propensity adjustments, the odds of residual aneurysm (OR = 0.09; 95% CI = 0.04–0.17; p < 0.001) or retreatment (OR = 0.14; 95% CI = 0.06–0.29; p < 0.001) was significantly lower among the delayed group. The OR was 0.50 for rerupture, after propensity adjustments, in the delayed setting (p = 0.03). Mean Glasgow Coma Scale scores at admission in the acute and delayed groups were 11.5 and 13.2, respectively (p < 0.001).

Conclusions Delayed microsurgical management of aSAH, if required for definitive treatment, appeared to be noninferior with respect to retreatment, residual, and rerupture events in our cohort after adjusting for initial disease severity and significant confounding variables.

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Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage—justifiable in light of long‑term outcome?

Acta Neurochirurgica (2022) 164:1815–1826

Decompressive hemicraniectomy (DHC) is a potentially lifesaving procedure in refractory intracranial hypertension, which can prevent death from brainstem herniation but may cause survival in a disabled state. The spectrum of indications is expanding, and we present long-term results in a series of patients suffering from aneurysmal subarachnoid hemorrhage (SAH).

Methods We performed a retrospective analysis of previously registered data including all patients treated for SAH between 2010 and 2018 in a single institution. Patients treated with decompressive hemicraniectomy due to refractory intracranial hypertension were identified. Clinical outcome was assessed by means of the Glasgow outcome scale after 12 months.

Results Of all 341 SAH cases, a total of 82 (24.0%) developed intracranial hypertension. Of those, 63 (18.5%) patients progressed into refractory ICP elevation and were treated with DHC. Younger age (OR 0.959, 95% CI 0.933 to 0.984; p = 0.002), anterior aneurysm location (OR 0.253, 95% CI 0.080 to 0.799; 0.019; p = 0.019), larger aneurysm size (OR 1.106, 95% CI 1.025 to 1.194; p = 0.010), and higher Hunt and Hess grading (OR 1.944, 95% CI 1.431 to 2.641; p < 0.001) were independently associated with the need for DHC. After 1 year, 10 (15.9%) patients after DHC were categorized as favorable outcome. Only younger age was independently associated with favorable outcome (OR 0.968 95% CI 0.951 to 0.986; p = 0.001).

Conclusions Decompressive hemicraniectomy, though lifesaving, has only a limited probability of survival in a clinically favorable condition. We identified young age to be the sole independent predictor of favorable outcome after DHC in SAH.

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Solid vs. cystic predominance in posterior fossa hemangioblastomas: implications for cerebrovascular risks and patient outcome

Acta Neurochirurgica (2022) 164:1357–1364

Hemangioblastomas (HGBs) are highly vascular benign tumors, commonly located in the posterior fossa, and 80% of them are sporadic. Patients usually present with features of raised intracranial pressure and cerebellar symptoms. HGB can be classified as either mostly cystic or solids. Although the solid component is highly vascularized, aneurysm or hemorrhagic presentation is rarely described, having catastrophic results.

Methods We identified 32 consecutive patients with posterior fossa HBG who underwent surgery from 2008 through 2020 at our medical center. Tumors were classified as predominantly cystic or solid according to radiological features. Resection was defined as gross total (GTR) or subtotal (STR).

Results During the study period, 32 posterior fossa HGBs were resected. There were 26 cerebellar lesions and 4 medullar lesions, and in 2 patients, both structures were affected. Predominant cystic tumors were seen in 15 patients and solids in 17. Preoperative digital subtraction angiography (DSA) was performed in 8 patients with solid tumors, and 4 showed tumor-related aneurysms. Embolization of the tumors was performed in 6 patients, including the four tumor-related aneurysms. GTR was achieved in 29 tumors (91%), and subtotal resection in 3 (9%). Three patients had postoperative lower cranial nerve palsy. Functional status was stable in 5 patients (16%), improved in 24 (75%), and 3 patients (9%) deteriorated. One patient died 2 months after the surgery. Two tumors recurred and underwent a second surgery achieving GTR. The mean follow-up was 42.7 months (SD ± 51.0 months).

Conclusions Predominant cystic HGB is usually easily treated as the surgery is straightforward. Those with a solid predominance present a more complex challenge sharing features similar to arteriovenous malformations. Given the important vascular association of solid predominance HGB with these added risk factors, the preoperative assessment should include DSA, as in arteriovenous malformations, and endovascular intervention should be considered before surgery.

Keywords

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The added value of cerebrospinal fluid analysis in patients with subarachnoid hemorrhage after negative noncontrast CT

J Neurosurg 136:1024–1028, 2022

In patients presenting within 6 hours after signs and symptoms of suspected subarachnoid hemorrhage (SAH), CSF examination is judged to be no longer necessary if a noncontrast CT (NCCT) scan rules out SAH. In this study, the authors evaluated the performance of NCCT to rule out SAH in patients with positive CSF findings.

METHODS Between January 2006 and April 2018, 1657 patients were admitted with a nontraumatic SAH. Of these patients, 1546 had positive SAH findings on the initial NCCT and 111 patients had an NCCT scan that was reported as negative in the acute setting, but with positive CSF examination for subarachnoid blood. Demographic data, World Federation of Neurosurgical Societies grade, and SAH time points (ictus, time of NCCT, and time of lumbar puncture) were collected. All 111 NCCT scans were reevaluated by an experienced neuroradiologist.

RESULTS Of the 111 patients with positive CSF findings, SAH was initially missed on NCCT in 25 patients (23%). Reevaluation of 21 patients presenting within 6 hours of symptom onset confirmed NCCT negative findings in 12 (5 aneurysms), an aneurysmal SAH (aSAH) pattern in 8 (7 aneurysms), and a perimesencephalic pattern in 1 patient. Reevaluation of 90 patients presenting after 6 hours confirmed negative NCCT findings in 74 patients (37 aneurysms), aSAH pattern in 10 (4 aneurysms), and a perimesencephalic pattern in 6 (2 aneurysms).

CONCLUSIONS CSF examination is still mandatory to rule out SAH as NCCT can fail to show blood, even within 6 hours after symptom onset. In addition, the diagnosis SAH was frequently missed during initial reporting.

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The influence of aneurysm morphology on the volume of hemorrhage after rupture

J Neurosurg 136:1015–1023, 2022

Factors determining the risk of rupture of intracranial aneurysms have been extensively studied; however, little attention is paid to variables influencing the volume of bleeding after rupture. In this study the authors aimed to evaluate the impact of aneurysm morphological variables on the amount of hemorrhage.

METHODS This was a retrospective cohort analysis of a prospectively collected data set of 116 patients presenting at a single center with subarachnoid hemorrhage due to aneurysmal rupture. A volumetric assessment of the total hemorrhage volume was performed from the initial noncontrast CT. Aneurysms were segmented and reproduced from the initial CT angiography study, and morphology indexes were calculated with a computer-assisted approach. Clinical and demographic characteristics of the patients were included in the study. Factors influencing the volume of hemorrhage were explored with univariate correlations, multiple linear regression analysis, and graphical probabilistic modeling.

RESULTS The univariate analysis demonstrated that several of the morphological variables but only the patient’s age from the clinical-demographic variables correlated (p < 0.05) with the volume of bleeding. Nine morphological variables correlated positively (absolute height, perpendicular height, maximum width, sac surface area, sac volume, size ratio, bottleneck factor, neck-to-vessel ratio, and width-to-vessel ratio) and two correlated negatively (parent vessel average diameter and the aneurysm angle). After multivariate analysis, only the aneurysm size ratio (p < 0.001) and the patient’s age (p = 0.023) remained statistically significant. The graphical probabilistic model confirmed the size ratio and the patient’s age as the variables most related to the total hemorrhage volume.

CONCLUSIONS A greater aneurysm size ratio and an older patient age are likely to entail a greater volume of bleeding after subarachnoid hemorrhage.

 

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