Tag: Subarachnoid hemorrhage

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Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients

J Neurosurg 112:1200–1207, 2010. DOI: 10.3171/2009.10.JNS08754

The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context.

Methods. This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997–June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score ≤ 2) and unfavorable (mRS score > 2).

Results. Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001).

Conclusions. The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.

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Trends in Case-Fatality Rates in Hospitalized Nontraumatic Subarachnoid Hemorrhage: Results of a Population-Based Study in Dijon, France, From 1985 to 2006

Neurosurgery 66:1039-1043, 2010 DOI: 10.1227/01.NEU.0000369512.58898.99

Subarachnoid hemorrhage accounts for 2% to 5% of all strokes and is associated with high morbidity and mortality rates. Reports in the literature show that case-fatality rates vary with time and according to geographical area.

OBJECTIVE: The objective of the study was to evaluate the case-fatality rates in subarachnoid hemorrhage at 1 and 6 months and to determine trends in these rates over 22 years using a population-based registry.

METHODS: The Dijon Stroke Registry has enabled us to perform a comprehensive analysis of subarachnoid hemorrhage diagnosed in a population of >150 000 inhabitants hospitalized between 1985 and 2006 in the Dijon University Hospital, which has both a neurosurgery unit and a neuroradiology unit. Diagnosis was based on clinical and neuroimaging features and, when necessary, on lumbar puncture.

RESULTS: Case-fatality rates for hospitalized subarachnoid hemorrhages at 1 and 6 months were 15.59% (95% confidence interval [CI], 9.37-25.34) and 16.84% (95% CI, 10.33-26.78), respectively. From 1985 to 1995, case-fatality rates for SAH at 1 and 6 months were 17.1% (95% CI, 8.1-34.2) and 17.7% (95% CI, 9.6-31.3), whereas from 1996 to 2006, they were 20.2% (95% CI, 10.2-37.8) and 19.7% (95% CI, 11.1-33.6), respectively.

CONCLUSION: Case-fatality rates for hospitalized subarachnoid hemorrhages in this population- based study remained stable over 22 years, suggesting that this stroke subtype is still a very severe disease despite early management. Most deaths occurred during the first 30 days. Further work is necessary to evaluate levels of prehospital case-fatality in our population-based registry.

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Early Ventriculoperitoneal Shunt Placement After Severe Aneurysmal Subarachnoid Hemorrhage: Role of Intraventricular Hemorrhage and Shunt Function

Neurosurgery 66:904-909, 2010 DOI: 10.1227/01.NEU.0000368385.74625.96

This study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance. METHODS:This study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF. RESULTS: The mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection. CONCLUSION: Based on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage–induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

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Which Variables Help Explain the Poor Health-Related Quality of Life After Subarachnoid Hemorrhage? A Meta-analysis

Neurosurgery 66:772-783, 2010. DOI: 10.1227/01.NEU.0000367548.63164.B2
Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.
METHODS: Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.
RESULTS: Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.
CONCLUSION: Studies need to turn to new factors to account for poor patient outcome.

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Saccular Intracranial Aneurysm Disease: Distribution of Site, Size, and Age Suggests Different Etiologies for Aneurysm Formation and Rupture in 316 Familial and 1454 Sporadic Eastern Finnish Patients

Neurosurgery 66:631-638, 2010. DOI: 10.1227/01.NEU.0000367634.89384.4B

Finnish saccular intracranial aneurysm (sIA) disease associates to 2q33, 8q11, and 9p21 loci and links to 19q13, Xp22, and kallikrein cluster in sIA families. Detailed phenotyping of familial and sporadic sIA disease is required for fine mapping of the Finnish sIA disease.

METHODS: Eastern Finland, which is particularly isolated genetically, is served by Kuopio University Hospital’s Department of Neurosurgery. We studied the site and size distribution of unruptured and ruptured sIAs in correlation to age and sex in 316 familial and 1454 sporadic sIA patients on first admission from 1993 to 2007.

RESULTS: The familial and sporadic aneurysmic subarachnoid hemorrhage patients had slightly different median ages (46 vs 51 years in men; 50 vs 57 years in women), different proportion of males (50% vs 42%), equal median diameter of ruptured sIAs (7 mm vs 7 mm) with no correlation to age, and equally unruptured sIAs (30% vs 28%). The unruptured sIAs were most frequent at the middle cerebral artery (MCA) bifurcation (44% vs 39%) and the anterior communicating artery (12% vs 13%), in contrast to the ruptured sIAs at the anterior communicating artery (37% vs 29%) and MCA bifurcation (29% vs 29%). The size of unruptured sIAs increased by age in the sporadic group.

CONCLUSION: The MCA bifurcation was most prone to develop unruptured sIAs, suggesting that MCA branching during the embryonic period might be involved. The different site distribution of ruptured and unruptured sIAs suggests different etiologies for sIA formation and rupture. The lack of correlation of size and age at rupture (exposure to risk factors) suggests that the size at rupture is more dependent on hemodynamic stress.

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Randomized, double-blind, placebo-controlled, pilot trial of high-dose methylprednisolone in aneurysmal subarachnoid hemorrhage

J Neurosurg 112:681–688, 2010. DOI: 10.3171/2009.4.JNS081377

The object of this study was to determine the efficacy of methylprednisolone in reducing symptomatic vasospasm and poor outcomes after subarachnoid hemorrhage (SAH).

Methods. Ninety-five patients with proven SAH were recruited into a double-blind, placebo-controlled, random- ized trial. Starting within 6 hours after angiographic diagnosis of aneurysm rupture, placebo or methylprednisolone, 16 mg/kg, was administered intravenously every day for 3 days to 46 and 49 patients, respectively. Deterioration, defined as development of a focal sign or decrease of more than 1 point on the Glasgow Coma Scale for more than 6 hours, was investigated by using clinical criteria and transcranial Doppler ultrasonography, cerebral angiography, or CT when appropriate. The end points were incidence of symptomatic vasospasm (delayed ischemic neurological deficits associated with angiographic arterial narrowing or accelerated flow on Doppler ultrasonography, or both) and outcome 1 year after entry into the study according to a simplified Rankin scale (Functional Outcome Scale [FOS]) in living patients and the Glasgow Outcome Scale in all patients included.

Results. All episodes of deterioration and all living patients with a 1-year outcome were assessed by a review committee. In patients treated with methylprednisolone, the incidence of symptomatic vasospasm was 26.5% com- pared with 26.0% in those given placebo. Poor outcomes according to FOS were significantly reduced in the Meth- ylprednisolone Group at 1 year of follow-up; the risk difference was 19.3% (95% CI 0.5–37.9%). The outcome was poor in 15% (6/40) of patients in the Methylprednisolone Group versus 34% (13/38) in the Placebo Group.

Conclusions. A safe and simple treatment with methylprednisolone did not reduce the incidence of symptomatic vasospasm but improved ability and functional outcome at 1 year after SAH.

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Outcome correlates with blood distribution in subarachnoid hemorrhage of unknown origin

Acta Neurochir (2010) 152:417–42.DOI10.1007/s00701-009-0525-9

Between 15 and 30 % of patients with subarachnoid hemorrhage (SAH) have no bleeding source and usually have a benign clinical course and outcome. The objectives of this study were to classify the pattern of blood distribution on initial computed tomography (CT) and to correlate it with clinical outcome in aneurysmal (ASAH) and SAH of unknown origin (SAHuO).

Methods We reviewed 112 CTs of SAHuO and 104 CTs of ASAH patients. Blood distribution was classified according to a new grading system (type 0–4) and correlated to Hunt and Hess (H&H) grade and modified Rankin scores (MRS) at short- and long-term follow-up.

Results Fifty percent of 112 SAHuO patients were classified as type 0 (no visible blood on CT) or 1 (blood restricted to prepontine cisterns). Most ASAH patients presented with bleeding into the lateral Sylvian fissure (66%; type 3) or with intracerebral hemorrhage (27%; type 4) whereas types 0 and 1 were not observed. SAHuO patients were in better clinical condition on admission than ASAH patients (p<0.0001). H&H grades of SAHuO patients correlated with the amount of subarachnoid blood according to the new classification (p=0.004). Short-term outcome was obtained from 100% and long-term outcome from 95% patients (follow-up 29±31 months). Short- and long-term MRS correlated with blood distribution in SAHuO patients (p=0.012) and was significantly better than in ASAH patients (p<0.0001). No correlation was observed between blood distribution, H&H grade, and short- and long-term outcome in aneurysmal patients.

Conclusions In SAH of unknown origin, a new classification allows to predict outcome based on the extent of blood on CT.

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Intracranial infectious aneurysms: a comprehensive review

Neurosurg Rev (2010) 33:37–46 DOI 10.1007/s10143-009-0233-1

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950–2009) using the following keywords (singly and in combination): “infectious,” “mycotic,” “cerebral aneurysm,” and “intracranial aneurysm.” We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.

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The effect of coiling vs clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the University of Florida

Neurosurgery 64:614–621, 2009 DOI: 10.1227/01.NEU.0000340784.75352.A4

There are few studies comparing the economic costs and reimbursements for aneurysm clipping versus coiling, and none are from the United States. Our hypothesis predicted that coiling would result in shorter lengths of hospitalization than clipping in patients with unruptured aneurysms and would therefore result in lower hospital charges. However, because of the severity of subarachnoid hemorrhage, there would be no difference in length of hospitalization or hospital charges in patients with ruptured aneurysms.

Methods: We compared aneurysm coiling with aneurysm clipping in patients with unruptured and ruptured aneurysms treated at the University of Florida from January 2005 to June 2007 for differences in length of hospitalization, hospital costs, hospital collections, and surgeon collections. Patient demographic and aneurysm characteristic data were obtained from a clinical database. Length of hospitalization, cost, billing, and collection data were obtained from the hospital cost accounting database. Multivariate statistical analyses of length of hospitalization, hospital costs, hospital collections, and surgeon collections were performed using factors including patient age, sex, aneurysm size, aneurysm location, aneurysm treatment, presence of subarachnoid hemorrhage, clinical grade, payor, hospital billing, and surgeon billing.

Results: There were 565 patients with cerebral aneurysms treated either surgically (306 patients, 54%) or endovascularly (259 patients, 46%). In patients without subarachnoid hemorrhage (unruptured aneurysms) (n=367), surgery, compared with endovascular treatment, was associated with longer hospitalization (P<0.001), but lower hospital costs (P<0.001), higher surgeon collections (P<0.003), and similar hospital collections. In patients with subarachnoid hemorrhage (ruptured aneurysms) (n=198), surgery was associated with lower hospital costs (P<0.011), but similar length of stay, surgeon collections, and hospital collections. Larger aneurysm size was significantly associated with longer hospitalization in the patients with unruptured aneurysms (P<0.001) and higher hospital costs for both patients with unruptured (P<0.001) and ruptured (P<0.015) aneurysms. The payor was significantly associated with hospital costs in patients with ruptured aneurysms (P<0.034) and length of stay (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001), hospital collections (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001), and surgeon collections (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001) in both patients with unruptured and ruptured aneurysms. A worse clinical grade was significantly associated with higher hospital costs (P<0.001).

Conclusion: Despite a shorter length of hospitalization in patients with unruptured aneurysms, coiling was associated with higher hospital costs in both patients with unruptured and ruptured aneurysms. This is likely attributable to the higher device cost of coils than clips. The advantages of coiling over clipping would be better realized if the cost of coils could be comparably reduced to that of clips.

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Shunt­dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

J Neurosurg 111:1029–1035, 2009. DOI: 10.3171/2008.9.JNS08881

Chronic shunt­dependent hydrocephalus is a recognized complication of aneurysmal subarachnoid hem­ orrhage. While its incidence and risk factors have been well described, the long­term performance of shunts in this setting has not been not widely reported.

Methods. Using administrative databases, the authors derived a retrospective cohort of patients undergoing treat­ ment of a ruptured aneurysm in Ontario, Canada, between 1995 and 2005. The authors determined the incidence of shunt­dependent hydrocephalus and analyzed putative risk factors. Mortality rates and indicators of morbidity were recorded. Patients were followed up for the occurrence of shunt failure over time.

Results. Of 3120 patients in the cohort, 585 (18.75%) developed shunt-dependent hydrocephalus. On multivari­ ate analysis, age, acute hydrocephalus, ventilation on admission, aneurysms in the posterior circulation and giant aneurysms were all significant predictors of shunt-dependent hydrocephalus. The mortality rate was not increased in patients with chronic hydrocephalus (hazard ratio 1.04, p = 0.63); however, indicators of morbidity were increased in these patients. Of the 585 patients with shunt-dependent hydrocephalus, only 173 (29.6%) underwent a subsequent revision procedure. Ninety-eight percent of these revisions were completed within 6 months. Subsequent revisions occurred more frequently. On multivariate analysis, significant predictors of shunt revision included aneurysm loca­ tion in the posterior circulation and endovascular treatment of the initial ruptured aneurysm.

Conclusions. Shunt-dependent hydrocephalus affects a significant proportion of subarachnoid hemorrhage sur­ vivors, contributing to additional morbidity among these patients. Shunt failures occur less frequently in patients who underwent treatment for a ruptured aneurysm than with other forms of hydrocephalus. Most failures occur within 6 months, suggesting that shunt dependency may be transient in the majority of patients.

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Intracranial infectious aneurysms: a comprehensive review

Neurosurg Rev DOI 10.1007/s10143-009-0233-1

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950–2009) using the following keywords (singly and in combination): “infectious,” “mycotic,” “cerebral aneurysm,” and “intracranial aneurysm.” We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.


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Aneurysmal subarachnoid hemorrhage diagnosis with computed tomographic angiography and OsiriX

Acta Neurochir DOI 10.1007/s00701-009-0508-x

Purpose Recent advances in computed tomographic angiography (CTA) have resulted in its replacing digital subtraction angiography (DSA). However, CTA requires a powerful workstation and experienced technicians for image postprocessing. OsiriX, a free open-source medical imaging software with powerful three-dimensional (3D) capability, enables neurosurgeons to perform 3D rendering without extensive training. In this study, we examined the sensitivity and specificity of CTA with OsiriX as the primary diagnostic tool for intracranial aneurysms.

Method From May 2006 to March 2009, 121 patients with spontaneous subarachnoid hemorrhage (SAH) underwent CTA. The CTA source images were 3D rendered by neurosurgeons using OsiriX. All the possible locations for aneurysms were carefully reviewed. DSA was performed on every patient in any of the following conditions: for negative CTA findings, after surgical clipping of aneurysms or before transarterial embolization of aneurysms.

Results Of the 121 patients, 8 were excluded because DSA data were not available. In the remaining 113 patients, 20 patients had negative CTA findings. CTA with OsiriX detected 106 aneurysms in 93 patients, of which 103 were confirmed by DSA or postoperative DSA; 3 infundibular dilated pouches of small arteries were mistaken for aneurysms. Two anterior communicating artery aneurysms (1.5 mm and 1 mm) were missed by CTA from among all 113 patients. The sensitivity and specificity of CTA for detecting aneurysms on a per-patient basis were 98.9% and 100%, respectively. The sensitivity and specificity of CTA for detecting aneurysms on a per-aneurysm basis for detecting aneurysms were 98.1% and 86.3%, respectively.

Conclusion CTA with OsiriX enables accurate detection of intracranial aneurysms. Cerebral DSA should be reserved for those patients with negative CTA findings.

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