Tag: Subarachnoid hemorrhage

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Oculomotor nerve palsy due to posterior communicating artery aneurysm: Clipping vs coiling

Neurochirurgie 68 (2022) 86–93 

Posterior communicating artery aneurysms (PCoAA) usually present with brain hemorrhage, but they might present with oculomotor nerve palsy (ONP) in about one out of five patients. Treatment options include endovascular coiling and surgical clipping. The present analysis aims to compare the two treatment options for ONP due to PCoAA in terms of complete recovery and related parameters.

Methods. – A comprehensive literature search was performed for studies published between 2000 and2019 on ONP due to PCoAA. The included studies were divided into two categories—surgical clipping (group A) and endovascular coiling (group B). The collected data were statistically processed with SPSSversion 25.

Results. – There was a significant difference between the two treatment groups regarding complete recovery of ONP (P < 0.001), suggesting superiority of the surgical clipping. The correlation analysis showed no correlations for group A. Group B had negative and positive correlations, showing that endovascular coiling results in higher rates of complete ONP recovery for elderly patients.

Conclusion. – Surgical clipping is superior to endovascular coiling in terms of complete recovery among patients with ONP due to PCoAAs. Endovascular coiling seems to benefit older patients. While no recommendations exist for the treatment of ONP due to intracranial aneurysms, an increasing number of studies imply the superiority of operative clipping

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Spontaneous angiogram-negative subarachnoid hemorrhage

Acta Neurochirurgica (2022) 164:129–140

Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH.

Methods We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis.

Results Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode.

Conclusion SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

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Low-Dose Intravenous Heparin Infusion After Aneurysmal Subarachnoid Hemorrhage is Associated With Decreased Risk of Delayed Neurological Deficit and Cerebral Infarction

Neurosurgery 88 (3)2021: 523–530

Patients who survive aneurysmal subarachnoid hemorrhage (aSAH) are at risk for delayed neurological deficits (DND) and cerebral infarction. In this exploratory cohort comparison analysis, we compared in-hospital outcomes of aSAH patients administered a low-dose intravenous heparin (LDIVH) infusion (12 U/kg/h) vs those administered standard subcutaneous heparin (SQH) prophylaxis for deep vein thrombosis (DVT; 5000 U, 3 × daily).

OBJECTIVE: To assess the safety and efficacy of LDIVH in aSAH patients.

METHODS: We retrospectively analyzed 556 consecutive cases of aSAH patients whose aneurysm was secured by clipping or coiling at a single institution over a 10-yr period, including 233 administered the LDIVH protocol and 323 administered the SQH protocol. Radiological and outcome datawere compared between the 2 cohorts using multivariable logistic regression and propensity score-based inverse probability of treatment weighting (IPTW).

RESULTS: The unadjusted rate of cerebral infarction in the LDIVH cohort was half that in SQH cohort (9 vs 18%; P = .004). Multivariable logistic regression showed that patients in the LDIVH cohort were significantly less likely than those in the SQH cohort to have DND (odds ratio (OR) 0.53 [95% CI: 0.33, 0.85]) or cerebral infarction (OR 0.40 [95% CI: 0.23, 0.71]). Analysis following IPTWshowed similar results. Rates of hemorrhagic complications, heparin-induced thrombocytopenia and DVT were not different between cohorts.

CONCLUSION: This cohort comparison analysis suggests that LDIVH infusion may favorably influence the outcome of patients after aSAH. Prospective studies are required to further assess the benefit of LDIVH infusion in patients with aSAH.

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Vitamin D—A New Perspective in Treatment of Cerebral Vasospasm

Neurosurgery 88 (3) 2021: 674–685

Cerebral vasospasm (CVS) is a frequent complication after subarachnoid hemorrhage (SAH), with no sufficient therapy and a complex pathophysiology.

OBJECTIVE: To explore the vitamin D system as a potential treatment for CVS.

METHODS: 25-vitamin D3 levels tested between 2007 and 2015 and data of SAH patients admitted during themonthswith a peak vs nadir of VitD3 valueswere analyzed, retrospectively. We prospectively correlated VitD3 and vasospasm/outcome data in SAH patients admitted in 2017. An experimental mice SAH model and cell culture model were used to investigate the effect of 1,25-dihydroxyvitamin D3 (1,25-VitD3). Additionally, the mediators acting in the VitD mechanism were researched and detected.

RESULTS: Based on the retrospective analysis demonstrating an increased frequency of vasospasm in SAH patients during the low vitamin D period in winter, we started basic research experiments. Active 1,25-VitD3 hormone attenuated CVS, neurological deficit, and inflammation after intrathecal blood injection inmice. Deletion of the vitaminDreceptor in the endothelium or in myeloid cells decreased the protective 1,25-VitD3 effect. Co-culture experiments ofmyeloid and endothelial cells with blood confirmed the anti-inflammatory 1,25-VitD3 effect but also revealed an induction of stroma-cell-derived factor 1α (SDF1α), vascular endothelial growth factor, and endothelial nitric oxide synthase by 1,25-VitD3. In mice, SDF1α mimicked the protective effect of 1,25-VitD3 against CVS. From bench to bedside, CVS severity was inversely correlated with vitamin D plasma level, prospectively. Patients with more severe CVS exhibited attenuated expression of SDF1α and 1,25-VitD3- responsive genes on circulating myeloid cells.

CONCLUSION: 1,25-VitD3 attenuates CVS after SAH by inducing SDF1α. However, VitD administration should be tested as optional treatment to prevent CVS.

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Survival, Dependency, and Health-Related Quality of Life in Patients With Ruptured Intracranial Aneurysm

Neurosurgery 88:252–260, 2021

Previous analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on clinical outcomes after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or endovascular coiling.

OBJECTIVE: To evaluate the long-term quality-adjusted life years (QALYs) gained of endovascular coiling compare to neurosurgical clipping in the UK cohort of ISAT.

METHODS: Between September 12, 1994 and May 1, 2002, patients with ruptured intracranial aneurysms who were assumed treatment equipoise were randomly allocated to either neurosurgical clipping or endovascular coiling. We followed-up 1644 patients in 22 UK neurosurgical centers for a minimum of 10 yr. Health-related quality of life (HRQoL) was collected through yearly questionnaires,measured by utilities calculated from the EQ- 5D-3L. We compared HRQoL between the 2 treatment groups over a period of 10 yr. In all, 1-yr, 5-yr, and 10-yr QALYs were estimated by combining utility and survival information.

RESULTS: Higher average utility values were found in the endovascular group throughout the follow-up period, with mean differences between groups statistically significant in most years. The 10-yr QALYs were estimated to be 6.68 (95% CI: 6.45-6.90) in the coiling group and 6.32 (95% CI: 6.10-6.55) in the clipping group, respectively, a significant mean difference of 0.36 (95% CI: 0.04-0.66). A third of this mean QALYs gain was estimated to derive solely from HRQoL differences.

CONCLUSION: HRQoL after treatment of a ruptured intracranial aneurysm was better after endovascular coiling compared to neurosurgical clipping, which contributed significantly to the QALYs gained over a 10-yr period.

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Lateral transorbital approach: an alternative microsurgical route for supratentorial cerebral aneurysms

J Neurosurg 134:72–83, 2021

Transorbital approaches for neurosurgery have recently attracted attention and several anatomical studies have aimed to improve these techniques, but significant deficiencies in clinical practice remain, especially for aneurysm surgery. The authors present an alternative microsurgical route and the results of an analysis of patients with intracranial aneurysms who underwent a lateral transorbital approach (LTOA) using lateral orbito-zygoma-sphenotomy (LOZYGS).

METHODS The clinical and surgical results of a series of 54 consecutive patients with 1 or more aneurysms who underwent surgery via LTOA are reported. A lateral orbitotomy was performed after making a 3-cm skin incision parallel to the lateral orbital rim. A second bone flap, which included the zygoma and sphenoid bones that form the lateral orbital wall, was removed. The lesser sphenoid wing, including the anterior clinoid process, was fully drilled, except in cases of middle cerebral artery (MCA) aneurysms. Cisternal dissection was performed using the classic microsurgical technique starting from the proximal Sylvian fissure and carotid cistern. After the aneurysm was clipped following microsurgical principles, the dura mater was closed in a watertight fashion and 2-piece bone reconstruction was achieved.

RESULTS Sixty aneurysms in 54 patients were clipped using the LOZYGS route. Twenty-one aneurysms were located on the MCA, 30 on the anterior communicating artery, 8 on the internal carotid artery, and 1 at the apex of the basilar artery. The unruptured-to-ruptured aneurysm ratio was 17:43. The operative field was moved to the orbit using the LTOA to avoid interference by bone and muscle tissues. Early proximal control was achieved using a short working distance and direct exposure of the base of the cerebrum, without any requirement for retraction. Because different view angles and surgical corridors were used, no segment of the aneurysm or the parent artery remained unexposed. Therefore, the introduction of additional tools was not required.

CONCLUSIONS The LTOA allowed enhanced broad-perspective exposure of the operative field, early proximal control, and satisfactory surgical freedom. This alternative surgical approach safely exposed the target area and the operative field. The LOZYGS route is safe and effective for the LTOA and microsurgical clipping of anterior circulation aneurysms. According to the authors’ surgical experience and clinical experience, the LTOA can be considered an alternative surgical route to supratentorial aneurysm surgery.

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Giant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment

J Neurosurg 134:49–57, 2021

Clinical evidence on giant intracranial aneurysms (GIAs), intracranial aneurysms with a diameter of at least 25 mm, is limited. The authors aimed to investigate the natural history, case fatality, and treatment outcomes of ruptured and unruptured GIAs.

METHODS In this international observational registry study, patients with a ruptured or unruptured GIA received conservative management (CM), surgical management (SM), or endovascular management (EM). The authors investigated rupture rates and case fatality.

RESULTS The retrospective cohort comprised 219 patients with GIAs (21.9% ruptured GIAs and 78.1% unruptured GIAs) whose index hospitalization occurred between January 2006 and November 2016. The index hospitalization in the prospective cohort (362 patients with GIAs [17.1% ruptured and 82.9% unruptured]) occurred between December 2008 and February 2017. In the retrospective cohort, the risk ratio for death at a mean follow-up of 4.8 years (SD 2.2 years) after CM, compared with EM and SM, was 1.63 (95% CI 1.23–2.16) in ruptured GIAs and 3.96 (95% CI 2.57–6.11) in unruptured GIAs. In the prospective cohort, the 1-year case fatality in ruptured GIAs/unruptured GIAs was 100%/22.0% during CM, 36.0%/3.0% after SM, and 39.0%/12.0% after EM. Corresponding 1-year rupture rates in unruptured GIAs were 25.0% during CM, 1.2% after SM, and 2.5% after EM. In unruptured GIAs, the HR for death within the 1st year in patients with posterior circulation GIAs was 6.7 (95% CI 1.5–30.4, p < 0.01), with patients with a GIA at the supraclinoid internal carotid artery as reference. Different sizes of unruptured GIAs were not associated with 1-year case fatality.

CONCLUSIONS Rupture rates for unruptured GIAs were high, and the natural history and treatment outcomes for ruptured GIAs were poor. Patients undergoing SM or EM showed lower case fatality and rupture rates than those undergoing CM. This difference in outcome may in part be influenced by patients in the CM group having been found poor candidates for SM or EM.

Clinical trial registration no.: NCT02066493 (clinicaltrials.gov)

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Lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms

Acta Neurochirurgica (2020) 162:2767–2772

P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe.

We describe the technique for treating such aneurysms via a lateral supra-cerebellar infratentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe.

Method Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach.

Conclusion LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.

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Aspirin associated with decreased rate of intracranial aneurysm growth

J Neurosurg 133:1478–1485, 2020

Aspirin has emerged as a potential agent in the prevention of rupture of intracranial aneurysms (IAs). In this study, the authors’ goal was to test if aspirin is protective against aneurysm growth in patients harboring multiple IAs ≤ 5 mm.

METHODS The authors performed a retrospective review of a prospectively maintained database covering the period July 2009 through January 2019. Patients’ data were included if the following criteria were met: 1) the patient harbored multiple IAs; 2) designated primary aneurysms were treated by surgical/endovascular means; 3) the remaining aneurysms were observed for growth; and 4) a follow-up period of at least 5 years after the initial treatment was available. Demographics, earlier medical history, the rupture status of designated primary aneurysms, aneurysms’ angiographic features, and treatment modalities were gathered.

RESULTS The authors identified 146 patients harboring a total of 375 IAs. At the initial encounter, 146 aneurysms were treated and the remaining 229 aneurysms (2–5 mm) were observed. During the follow-up period, 24 (10.48%) of 229 aneurysms grew. All aneurysms observed to grow later underwent treatment. None of the observed aneurysms ruptured. Multivariate analysis showed that aspirin was significantly associated with a decreased rate of growth (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.05–0.63). Variables associated with an increased rate of growth included hypertension (OR 14.38, 95% CI 3.83–53.94), drug abuse (OR 11.26, 95% CI 1.21–104.65), history of polycystic kidney disease (OR 9.48, 95% CI 1.51–59.35), and subarachnoid hemorrhage at presentation (OR 5.91, 95% CI 1.83–19.09).

CONCLUSIONS In patients with multiple IAs, aspirin significantly decreased the rate of aneurysm growth over time. Additional prospective interventional studies are needed to validate these findings.

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Ventriculostomy with subsequent ventriculoperitoneal shunt placement after subarachnoid hemorrhage: the effect of implantation site on postoperative complications

Acta Neurochirurgica (2020) 162:1831–1836

Patients suffering from aneurysmal subarachnoid hemorrhage (SAH) with shunt-dependent hydrocephalus require subsequent placement of a ventriculoperitoneal shunt (VPS) after ventriculostomy. However, in patients with previous ventriculostomy, the site for proximal VPS catheter placement is still controversial.We investigated the effect of catheter placement on postoperative complications by analyzing patients with ventriculostomy and subsequent VPS placement after SAH.

Methods From January 2004 to December 2018, 164 of 1128 patients suffering from SAH underwent subsequent VPS placement after ventriculostomy in the authors’ institution. Patients were divided into two groups according to the position of the ventriculostomy and the site of the proximal VPS catheter (“same site” group versus “contralateral site” group). VPS-related infectious and bleeding complications following VPS placement were assessed and analyzed.

Results Overall, VPS-related infections occurred in 11 of the 164 patients (7%). Furthermore, five of the 164 patients (3%) suffered from VPS-related hemorrhage. However, VPS infection rate was lower 5% (6/115) in the same site compared to 10% (5/49) in the contralateral site group, although without reaching statistical significance (OR = 0.48 (0.14, 1.67) 95% confidence interval, p = 0.3). VPS-related hemorrhage rate did not differ significantly between patients in the same site group (3.5%, 4/115) and the contralateral site group (2.0%, 1/49; OR = 1.73 (0.18, 15.9), p = 1.0).

Conclusions Our study suggests that the use of the ventriculostomy site for VPS placement does not significantly increase the risk of either VPS-related infections or VPS-related hemorrhages.

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Impact of temperature decline from the previous day as a trigger of spontaneous subarachnoid hemorrhage

J Neurosurg 133:374–382, 2020

Several environmental factors have been reported to correlate with incidence of spontaneous subarachnoid hemorrhage (SAH). However, because of different patient selection and study designs among these studies, meteorological factors that trigger the incidence of SAH in a short hazard period remain unknown. Among meteorological factors, daily temperature changes may disrupt and violate homeostasis and predispose to cerebrovascular circulatory disturbances and strokes. The authors aimed to investigate whether a decline in the temperature from the highest of the previous day to the lowest of the event day (temperature decline from the previous day [TDP]) triggers SAH in the prefecture-wide stroke database.

METHODS All 28 participating institutions with primary or comprehensive stroke centers located throughout Kochi Prefecture, Japan, were included in the study. Data collected between January 2012 and December 2016 were analyzed, and 715 consecutive SAH patients with a defined date of onset were enrolled. Meteorological data in this period were obtained from the Kochi Local Meteorological Observatory. A case-crossover study was performed to investigate association of TDP and other environmental factors with onset of SAH.

RESULTS The increasing TDP in 1°C on the day of the SAH event was associated with an increased incidence of SAH (OR 1.041, 95% CI 1.007–1.077) after adjustment for other environmental factors. According to the stratified analysis, a significant association between TDP and SAH was observed in women, patients < 65 years old, and patients with weekday onset. Among these factors, increasing TDP had a great impact on SAH onset in patients < 65 years old (p = 0.028, Mann-Whitney U-test).

CONCLUSIONS TDP, temperature decline from the highest of the previous day to the lowest of the day, was correlated with the incidence of spontaneous SAH, particularly in younger patients < 65 years old.

 

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Anatomical triangles defining routes to anterior communicating artery aneurysms: the junctional and precommunicating triangles and the role of dome projection

J Neurosurg 132:1517–1528, 2020

Anterior communicating artery (ACoA) aneurysms are common intracranial aneurysms. Despite advances in endovascular therapy, microsurgical clipping remains an important treatment for aneurysms with broad necks, large size, intraluminal thrombus, complex branches, or previous coiling. Anatomical triangles identify safe corridors for aneurysm access. The authors introduce the A1-A2 junctional triangle and the A1-A1 precommunicating triangle and examine relationships between dome projection, triangular corridors of access, and surgical outcomes.

METHODS Preoperative catheter and CT angiograms were evaluated to characterize aneurysm dome projection. Aneurysm projection was categorized into quadrants and octants. Preoperative, intraoperative, and postoperative factors were correlated to aneurysm dome projection and patient outcomes using univariate and multivariate analyses.

RESULTS A total of 513 patients with microsurgically treated ACoA aneurysms were identified over a 13-year period, and 400 had adequate imaging and follow-up data for inclusion. Surgical clipping was performed on 271 ruptured and 129 unruptured aneurysms. Good outcomes were observed in 91% of patients with unruptured aneurysms and 86% of those with ruptured aneurysms, with a mortality rate < 1% among patients with unruptured aneurysms. Increasing age (p < 0.01), larger aneurysm size (p = 0.03), and worse preoperative modified Rankin Scale score (p < 0.01) affected outcomes adversely. Aneurysms projecting superiorly and posteriorly required dissection in the junctional triangle, and multivariate analysis demonstrated worse clinical outcomes in these patients (p < 0.01).

CONCLUSIONS Anteriorly and inferiorly projecting aneurysms involve only the precommunicating triangle, are simpler to treat microsurgically, and have more favorable outcomes. Superior and posterior dome projections make ACoA aneurysms more difficult to visualize and require opening the junctional triangle. Added visualization through the junctional triangle is recommended for these aneurysms in order to facilitate dissection of efferent branch arteries, careful clip application, and perforator preservation. Dome projection can be determined preoperatively from images and can help anticipate dissection routes through the junctional triangle.

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How definitive treatment affects the rupture rate of unruptured cerebral aneurysms: a competing risk survival analysis

J Neurosurg 132:1062–1067, 2020

To investigate the risk of bleeding from unruptured cerebral aneurysms (UCAs), previous studies have used Kaplan-Meier analyses without treating the definitive treatment as a competing risk event, which may underestimate the rupture rate. The authors analyzed the survival of patients with UCAs alongside the occurrence of aneurysm bleeding and its competing risk events.

METHODS A retrospective analysis was conducted on 722 patients diagnosed with UCAs in the period from 2000 to 2009 using an institution’s electronic medical records and telephone interviews. The cumulative incidence of aneurysm rupture was examined, and factors contributing to rupture were assessed using regression analyses.

RESULTS By 2014, 19 patients had experienced aneurysm rupture, with an overall rupture rate of 0.57% per year over 3320.8 person-years. However, cumulative incidence analysis indicated that 1.3% of all patients had a rupture within 2 years after aneurysm identification, and 38.4% of the patients underwent definitive treatment in the same period. Among the patients who experienced rupture, regression analysis revealed that an aneurysm size greater than 5 mm, a location in the anterior or posterior communicating arteries, and an irregular shape contributed to aneurysm rupture, with HRs of 4.4 (95% CI 1.2–15.7), 3.5 (95% CI 1.4–8.7), and 2.1 (95% CI 0.7–6.0), respectively.

CONCLUSIONS Rupture rate analyses using the person-year or standard Kaplan-Meier method are not as informative without consideration of the competing risks. The incidence of aneurysm rupture should be presented clearly with those of competing risks.

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Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

J Neurosurg 132:771–776, 2020

The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm.

METHODS In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.

RESULTS There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip-assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time.

CONCLUSIONS There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

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Outcomes of Retreatment for Intracranial Aneurysms—A Meta-Analysis

Neurosurgery. 2019 Dec 1;85(6):750-761

Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.

OBJECTIVE: To evaluate retreatment related outcomes.

METHODS: A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.

RESULTS: Twenty-five articles that met the inclusion criteria were included in the metaanalysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1- 19.9). All pooled incidence rates were produced using random-effect models.

CONCLUSION: Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate.

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Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms

J Neurosurg 131:1269–1277, 2019

Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.

METHODS In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.

RESULTS Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0–2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4–5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment–related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.

CONCLUSIONS Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment–related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

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Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study

Neurosurgery, Volume 85, Issue 2, August 2019, Pages 223–230

Induced hypertension (IH) remains the mainstay of medicalmanagement for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized.

OBJECTIVE: To ascertain the frequency and predisposing factors for PRES during IH therapy.

METHODS: We identified 68 patients treated with IH from 345 SAH patients over a 3- yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls.

RESULTS: Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, bothMAP immediately prior to IH (112 vs 90) and highestMAP targetedwere greater (140 vs 120mmHg, both P<.01).Magnitude ofMAP elevation was greater (54 vs 34 above baseline, P = .004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation.

CONCLUSION: PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most oftenwhenMAP was raisedwell above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.

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Morphological Variables Associated With Ruptured Middle Cerebral Artery Aneurysms

Neurosurgery, Volume 85, Issue 1, July 2019, Pages 75–83

Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce.

OBJECTIVE: To investigate the morphological characteristics associated with ruptured middle cerebral artery (MCA) aneurysms.

METHODS: Five hundred sixty-one patients with 638 MCA aneurysms diagnosed between 1990 and 2016 who had available computed tomography angiography (CTA) were included in this study. CTAs were evaluated using the Vitrea Advanced Visualization software for 3-dimensional (3D) reconstruction. Morphological parameters examined in each model included aneurysm projection, wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal posterior communicating arteries (PCoA), aneurysm height and width, neck diameter, bottleneck factor, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological characteristics with rupture of MCA aneurysms. Logistic regression was used to build a predictive MCA score.

RESULTS: Greater bottleneck and size ratio, and irregular, multilobed, temporally projecting MCA aneurysms are associated with higher rupture risk, whereas higher M1/M2 ratio, larger width, and the presence of an ipsilateral or bilateral hypoplastic PCoA were inversely associated with rupture. The MCA score had good predictive capacity with area under the receiver operating curve = 0.88.
CONCLUSION: These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.

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Clipping aneurysms improves outcomes for patients undergoing coiling

J Neurosurg 130:1491–1497, 2019

Most intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.

METHODS The Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group’s (BNVG) National Subarachnoid Haemorrhage Database.

RESULTS Increasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.

CONCLUSIONS There is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

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Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia

Neurosurgery 84:1019–1027, 2019

Within randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE: To study the association of coiling and clipping with outcome after aSAH in daily clinical practice.

METHODS: In this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006- 2016) of 1501 patients.

RESULTS: In the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d casefatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality ratewas 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%- 11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1–2.7), for 90-d case-fatality 1.28 (95% CI 0.91–1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6–1.01).

CONCLUSION: In clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.

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