Effect of Clipping, Craniotomy, or Intravascular Coiling on Cerebral Vasospasm and Patient Outcome after Aneurysmal Subarachnoid Hemorrhage

Abstract OBJECTIVE: Although several recent studies have suggested that the incidence of vasospasm after aneurysmal subarachnoid hemorrhage is lower in patients undergoing aneurysmal coiling as compared with clipping, other studies have had conflicting results. We reviewed our experience over 8 years and assessed whether clipping, craniotomy, or coiling affects patient outcomes or the risk for vasospasm. METHODS: We included 515 patients with aneurysmal subarachnoid hemorrhage, identified prospectively from November 2000 to February 2003 (243 patients) and retrospectively from November 1995 to October 2000 (272 patients), by using International Classification of Diseases, 9th Revision, codes for subarachnoid hemorrhage. We classified patients as follows: clipping (413 patients), coiling (79 patients), and craniotomy (436 patients, including all 413 patients who underwent clipping plus 23 who underwent coiling as well as craniotomy for various reasons). We studied four outcome measures: total vasospasm, symptomatic vasospasm, poor outcome (modified Rankin score 3–6), and in-hospital mortality. To assess the risk of total vasospasm and symptomatic vasospasm, we performed multivariate regression analyses adjusting for age, Fisher grade, Hunt and Hess grade, aneurysm location (anterior versus posterior circulation), and aneurysm treatment modality. To assess the risk for poor outcome and in-hospital mortality, we adjusted for all the above variables as well as for total and symptomatic vasospasm. RESULTS: In the clipping group there was 63% total vasospasm and 28% symptomatic vasospasm; in the coiling group there was 54% total vasospasm and 33% symptomatic vasospasm; and in the craniotomy group there was 64% total vasospasm and 28% symptomatic vasospasm. In the multivariate analysis, age <50 years (P = 0.0099) and Fisher Grade 3 (P < 0.00001) predicted total vasospasm, and Fisher Grade 3 (P < 0.000001) and Hunt and Hess Grade IV or V (P = 0.018) predicted symptomatic vasospasm. Predictors of poor outcome were age ≥50 years (P < 0.0001), Fisher Grade 3 (P = 0.0072), Hunt and Hess Grade IV or V (P < 0.00001), symptomatic vasospasm (P < 0.0001), and coiling (P = 0.0314 versus clipping and P = 0.045 versus craniotomy). Predictors of in-hospital mortality were age ≥ 50 years (P = 0.0030), Hunt and Hess Grade IV or V (P = 0.0001), symptomatic vasospasm (P < 0.00001), and coiling (P = 0.008 versus clipping and P = 0.0013 versus craniotomy). There was no significant difference in total vasospasm or symptomatic vasospasm when patients who underwent clipping or craniotomy were compared with patients who underwent coiling. In patients with Hunt and Hess Grade I to III (“good grade”), clipping and craniotomy were associated with better outcome and less in-hospital mortality, but there was no difference in total vasospasm or symptomatic vasospasm versus coiling. In patients with Hunt and Hess Grade IV or V (“poor grade”), there was no difference in any outcome measure among the treatment groups. CONCLUSION: In a single-center, retrospective, nonrandomized study, performance of clipping and/or craniotomy had significantly better outcome and lower mortality at discharge than coiling in good-grade patients but had no effect on total vasospasm or symptomatic vasospasm in good- or poor-grade patients.

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Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/neu.0000000000000963 ◽

2015 ◽

Vol 77 (5) ◽

pp. 786-793 ◽

Cited By ~ 22

Author(s):

◽

Carole L. Turner ◽

Karol Budohoski ◽

Christopher Smith ◽

Peter J. Hutchinson ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

White Blood Cells ◽

Cerebral Injury ◽

World Federation ◽

C Reactive Protein ◽

Reactive Protein ◽

Poor Outcome ◽

Fisher Grade ◽

Good Grade

Abstract BACKGROUND: There remains a proportion of patients with unfavorable outcomes after aneurysmal subarachnoid hemorrhage, of particular relevance in those who present with a good clinical grade. A forewarning of those at risk provides an opportunity towards more intensive monitoring, investigation, and prophylactic treatment prior to the clinical manifestation of advancing cerebral injury. OBJECTIVE: To assess whether biochemical markers sampled in the first days after the initial hemorrhage can predict poor outcome. METHODS: All patients recruited to the multicenter Simvastatin in Aneurysmal Hemorrhage Trial (STASH) were included. Baseline biochemical profiles were taken between time of ictus and day 4 post ictus. The t-test compared outcomes, and a backwards stepwise binary logistic regression was used to determine the factors providing independent prediction of an unfavorable outcome. RESULTS: Baseline biochemical data were obtained in approximately 91% of cases from 803 patients. On admission, 73% of patients were good grade (World Federation of Neurological Surgeons grades 1 or 2); however, 84% had a Fisher grade 3 or 4 on computed tomographic scan. For patients presenting with good grade on admission, higher levels of C-reactive protein, glucose, and white blood cells and lower levels of hematocrit, albumin, and hemoglobin were associated with poor outcome at discharge. C-reactive protein was found to be an independent predictor of outcome for patients presenting in good grade. CONCLUSION: Early recording of C-reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome.

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

Journal of Neurosurgery ◽

10.3171/jns.2003.98.6.1222 ◽

2003 ◽

Vol 98 (6) ◽

pp. 1222-1226 ◽

Cited By ~ 89

Author(s):

Matthew J. McGirt ◽

John C. Mavropoulos ◽

Laura Y. McGirt ◽

Michael J. Alexander ◽

Allan H. Friedman ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Leukocyte Count ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Content Type ◽

Symptomatic Vasospasm ◽

Fisher Grade ◽

Increased Risk ◽

Grade 3 ◽

Fine Print

Object. The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. Methods. A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 ± 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5–15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02–1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01–0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04–0.45). A serum leukocyte count greater than 15 × 109/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74–6.38). Conclusions. During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 × 109/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.

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Magnesium infusion for vasospasm prophylaxis after subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2006.105.5.723 ◽

2006 ◽

Vol 105 (5) ◽

pp. 723-729 ◽

Cited By ~ 46

Author(s):

Martina Stippler ◽

Elizabeth Crago ◽

Elad I. Levy ◽

Mary E. Kerr ◽

Howard Yonas ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Doppler Ultrasonography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Treated Group ◽

Aneurysm Rupture ◽

Current Standard ◽

Ruptured Aneurysms ◽

Symptomatic Vasospasm ◽

Fisher Grade ◽

Significant Difference

Object Despite the application of current standard therapies, vasospasm continues to result in death or major disability in patients treated for ruptured aneurysms. The authors investigated the effectiveness of continous MgSO4 infusion for vasospasm prophylaxis. Methods Seventy-six adults (mean age 54.6 years; 71% women; 92% Caucasian) were included in this comparative matched-cohort study of patients with aneurysmal subarachnoid hemorrhage on the basis of computed tomography (CT) findings. Thirty-eight patients who received continuous MgSO4 infusion were matched for age, race, sex, treatment option, Fisher grade, and Hunt and Hess grade to 38 historical control individuals who did not receive MgSO4 infusion. Twelve grams of MgSO4 in 500 ml normal saline was given intravenously daily for 12 days if the patient presented within 48 hours of aneurysm rupture. Vasospasm was diagnosed on the basis of digital substraction angiography, CT angiography, and transcranial Doppler ultrasonography, and evidence of neurological deterioration. Symptomatic vasospasm was present at a significantly lower frequency in patients who received MgSO4 infusion (18%) compared with patients who did not receive MgSO4 (42%) (p = 0.025). There was no significant difference in mortality rate at discharge (p = 0.328). A trend toward improved outcome as measured by the modifed Rankin Scale (p = 0.084), but not the Glasgow Outcome Scale (p = 1.0), was seen in the MgSO4-treated group. Conclusions Analysis of the results suggests that MgSO4 infusion may have a role in cerebral vasospasm prophylaxis if therapy is initiated within 48 hours of aneurysm rupture.

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Cigarette smoking—induced increase in the risk of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1997.87.3.0381 ◽

1997 ◽

Vol 87 (3) ◽

pp. 381-384 ◽

Cited By ~ 83

Author(s):

Todd M. Lasner ◽

Robert J. Weil ◽

Howard A. Riina ◽

Joseph T. King ◽

Eric L. Zager ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Alcohol Abuse ◽

Cigarette Smoking ◽

Cerebral Vasospasm ◽

Odds Ratio ◽

Aneurysmal Subarachnoid Hemorrhage ◽

World Federation ◽

Symptomatic Vasospasm ◽

Fisher Grade ◽

Grade 3

✓ Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is correlated with the thickness of blood within the basal cisterns on the initial computerized tomography (CT) scan. To identify additional risk factors for symptomatic vasospasm, the authors performed a prospective analysis of 75 consecutively admitted patients who were treated for aneurysmal SAH. Five patients who died before treatment or were comatose postoperatively were excluded from the study. Of the remaining 70 patients, demographic (age, gender, and race) and clinical (hypertension, diabetes, coronary artery disease, smoking, alcohol abuse, illicit drug use, sentinel headache, Fisher grade, Hunt and Hess grade, World Federation of Neurological Surgeons grade, and ruptured aneurysm location) parameters were evaluated using multivariate logistic regression to determine factors independently associated with cerebral vasospasm. All patients were treated with hypervolemic therapy and administration of nimodipine as prophylaxis for vasospasm. Cerebral vasospasm was suspected in cases that exhibited (by elevation of transcranial Doppler velocities) neurological deterioration 3 to 14 days after SAH with no other explanation and was confirmed either by clinical improvement in response to induced hypertension or by cerebral angiography. The mean age of the patients was 50 years. Sixty-three percent of the patients were women, 74% were white, 64% were cigarette smokers, and 46% were hypertensive. Ten percent of the patients suffered from alcohol abuse, 19% from sentinel bleed, and 49% had a Fisher Grade 3 SAH. Twenty-nine percent of the patients developed symptomatic vasospasm. Multivariate analysis demonstrated that cigarette smoking (p = 0.033; odds ratio 4.7, 95% confidence interval [CI] 2.4–8.9) and Fisher Grade 3, that is, thick subarachnoid clot (p = 0.008; odds ratio 5.1, 95% CI 2–13.1), were independent predictors of symptomatic vasospasm. The authors make the novel observation that cigarette smoking increases the risk of symptomatic vasospasm after aneurysmal SAH, independent of Fisher grade.

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Poor-grade Aneurysmal Subarachnoid Hemorrhage: Outcome after Treatment with Urgent Surgery

Neurosurgery ◽

10.1227/01.neu.0000093199.74960.ff ◽

2003 ◽

Vol 53 (6) ◽

pp. 1275-1282 ◽

Cited By ~ 79

Author(s):

John D. Laidlaw ◽

Kevin H. Siu

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Management Policy ◽

Surgical Patients ◽

World Federation ◽

Selective Treatment ◽

Poor Grade ◽

Significant Difference ◽

Rebleeding Rate ◽

Good Grade

Abstract OBJECTIVE We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results. METHODS A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months. RESULTS Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05). CONCLUSION The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.

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Simvastatin for the prevention of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a single-institution prospective cohort study

Journal of Neurosurgery ◽

10.3171/2008.10.jns08901 ◽

2009 ◽

Vol 110 (5) ◽

pp. 968-974 ◽

Cited By ~ 48

Author(s):

Matthew J. McGirt ◽

Giannina L. Garces Ambrossi ◽

Judy Huang ◽

Rafael J. Tamargo

Keyword(s):

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Hospital Mortality ◽

Cerebral Vasospasm ◽

Glasgow Outcome Scale ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Poor Outcome ◽

Symptomatic Vasospasm ◽

Scale Scores ◽

Length Of Hospitalization

Object Vasospasm is the major cause of disability and death after aneurysmal subarachnoid hemorrhage (aSAH). Although the results of 2 randomized clinical trials demonstrated that statin decreases the incidence of symptomatic cerebral vasospasm after aSAH, retrospective studies have failed to confirm this. The authors conducted a prospective observational study to determine whether a standardized regimen of simvastatin would reduce the incidence of cerebral vasospasm and improve neurological outcomes in patients with aSAH. Methods Since 1991, all patients with aSAH admitted to the authors' institution have been prospectively followed up with standardized outcomes recording. Starting in September 2005, all patients admitted with aSAH were given enteral simvastatin (80 mg/day for 14 days) in addition to the standard care. The incidence of symptomatic cerebral vasospasm, length of hospitalization, in-hospital mortality rate, and discharge Glasgow Outcome Scale scores in these 170 patients were compared to data obtained in 170 consecutive patients who underwent treatment in our unit prior to the introduction of statin therapy. Results The 5-year study period included 340 consecutively treated patients (170 who received statins and 170 who did not). Patients who received simvastatin therapy were more frequently male (29 vs 20%) and had a smaller median aneurysm diameter (6 vs 7 mm). Baseline characteristics were otherwise similar between the cohorts. There were no differences in the incidence of symptomatic vasospasm (25.3 vs 30.5%; p = 0.277), in-hospital mortality rate (18 vs 15%; p = 0.468), length of hospitalization (21 ± 15 vs 19 ± 12 days; p = 0.281), or poor outcome at discharge (Glasgow Outcome Scale Scores 1–2: 21.7 vs 18.2%; p = 0.416) between the simvastatin and nonstatin cohorts. There were no statin-related complications. Conclusions The uniform introduction of simvastatin did not reduce the incidence of symptomatic cerebral vasospasm, death, or poor outcome in patients with aSAH. Simvastatin was well tolerated, but its benefit may be less than has been previously reported.

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302 Validation of the Barrow Neurological Institute Scale for Symptomatic Vasospasm Prediction Following Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1093/neuros/nyx417.302 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 263-263

Author(s):

Christopher J Stapleton ◽

Brian Patrick Walcott ◽

Seunggu Jude Han ◽

Matthew Koch ◽

Arjun Khanna ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

San Francisco ◽

Massachusetts General Hospital ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Observer Agreement ◽

Chi Square ◽

Symptomatic Vasospasm ◽

Fisher Grade ◽

Grade 3 ◽

The University

Abstract INTRODUCTION The Barrow Neurological Institute (BNI) scale was introduced in 2012 as a simple and quantitative method for symptomatic vasospasm prediction following aneurysmal subarachnoid hemorrhage (SAH). The scale was developed from data collected from 218 patients from the Barrow Ruptured Aneurysm Trial (BRAT). Validation of this scale in a large, multicenter aneurysmal SAH cohort may encourage its use in broader clinical neurovascular practice. METHODS The records of 474 patients with aneurysmal SAH were studied to evaluate the predictive capacities of the BNI and original Fisher scales. The study sample included 241 patients from Massachusetts General Hospital (MGH) and 233 patients from the University of California, San Francisco (UCSF). RESULTS >Within this external cohort, the mean age at the time of presentation was 55.7 years and there were 353 (74.5%) female patients. Of the 474 total patients, 108 (22.8%) developed symptomatic vasospasm, which occurred in 44% and 42.4% of patients with BNI grade 4 and 5 SAH, respectively, and 26.7% of patients with Fisher grade 3 SAH. Chi-square for trend analysis demonstrated that the BNI scale (Chi-square 40.9, P < 0.0001) performed better than the Fisher scale (Chi-square 7.9, P = 0.0048) with respect to symptomatic vasospasm prediction in the combined cohort. Mean intra- and inter-observer agreement was greater for the BNI scale (kappa 0.83 and kappa 0.76, respectively) than the Fisher scale (kappa 0.62 and kappa 0.52, respectively). CONCLUSION The present study demonstrates that the BNI scale reliably predicts symptomatic vasospasm in a large, multicenter cohort of 474 patients. The quantitative nature of the BNI scale circumvents the potential subjectivity associated with Fisher scale assessments, which may result in more reliable SAH measurements and predictions regarding symptomatic vasospasm development.

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Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2016.4.jns152587 ◽

2016 ◽

Vol 126 (6) ◽

pp. 1764-1771 ◽

Cited By ~ 14

Author(s):

Bing Zhao ◽

Hua Yang ◽

Kuang Zheng ◽

Zequn Li ◽

Ye Xiong ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Endovascular Treatment ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Prognostic Models ◽

Term Outcome ◽

Long Term Outcome ◽

Poor Grade ◽

Poor Outcome ◽

Fisher Grade

OBJECTIVEAn increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH.METHODSA Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration.RESULTSAt 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80–0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81–0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively).CONCLUSIONSOlder age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms.▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.

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The venous delay phenomenon in computed tomography angiography: a novel imaging outcome predictor for poor cerebral perfusion after severe aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2017.5.jns17794 ◽

2018 ◽

Vol 129 (4) ◽

pp. 876-882 ◽

Cited By ~ 1

Author(s):

Po-Chuan Hsieh ◽

Yi-Ming Wu ◽

Alvin Yi-Chou Wang ◽

Ching-Chang Chen ◽

Chien-Hung Chang ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Perfusion ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariable Analysis ◽

Outcome Predictor ◽

Treatment Results ◽

Tertiary Referral Center ◽

Poor Grade ◽

Poor Outcome ◽

Delay Phenomenon

OBJECTIVEDiverse treatment results are observed in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Significant initial perfusion compromise is thought to predict a worse treatment outcome, but this has scant support in the literature. In this cohort study, the authors correlate the treatment outcomes with a novel poor-outcome imaging predictor representing impaired cerebral perfusion on initial CT angiography (CTA).METHODSThe authors reviewed the treatment results of 148 patients with poor-grade aSAH treated at a single tertiary referral center between 2007 and 2016. Patients with the “venous delay” phenomenon on initial CTA were identified. The outcome assessments used the modified Rankin Scale (mRS) at the 3rd month after aSAH. Factors that may have had an impact on outcome were retrospectively analyzed.RESULTSCompared with previously identified outcome predictors, the venous delay phenomenon on initial CTA was found to have the strongest correlation with posttreatment outcomes on both univariable (p < 0.0001) and multivariable analysis (OR 4.480, 95% CI 1.565–12.826; p = 0.0052). Older age and a higher Hunt and Hess grade at presentation were other factors that were associated with poor outcome, defined as an mRS score of 3 to 6.CONCLUSIONSThe venous delay phenomenon on initial CTA can serve as an imaging predictor for worse functional outcome and may aid in decision making when treating patients with poor-grade aSAH.

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STATIN USE WAS NOT ASSOCIATED WITH LESS VASOSPASM OR IMPROVED OUTCOME AFTER SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000316009.19012.e3 ◽

2008 ◽

Vol 62 (2) ◽

pp. 422-430 ◽

Cited By ~ 67

Author(s):

Andreas H. Kramer ◽

Matthew J. Gurka ◽

Bart Nathan ◽

Aaron S. Dumont ◽

Neal F. Kassell ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Vegetative State ◽

Treatment Protocol ◽

Poor Outcome ◽

Reductase Inhibitors ◽

Symptomatic Vasospasm ◽

Endovascular Coil Embolization ◽

Baseline Characteristics ◽

Statin Use

Abstract OBJECTIVE The development of delayed ischemia caused by cerebral vasospasm remains a common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Preliminary studies suggest that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) may decrease the risk of vasospasm, but additional study is required. METHODS Beginning in May 2006, our treatment protocol for patients presenting with subarachnoid hemorrhage was altered to routinely include the use of 80 mg of simvastatin per day for 14 days. Before this time, only patients with other indications for statins were treated. The charts of 203 consecutive patients over a period of 27 months were retrospectively reviewed, and 150 patients were included in the analysis, of whom 71 patients received statins. These patients were compared with 79 untreated patients to determine whether or not the use of statins was associated with a reduction in the occurrence of vasospasm, delayed infarction, or poor outcome (death, vegetative state, or severe disability). RESULTS Patients who were treated with statins and those who were not had similar baseline characteristics, although more patients in the former group were managed with endovascular coil embolization. There were no statistically significant differences in the proportion of patients developing at least moderate radiographic vasospasm (41% with statins versus 42% without, P = 0.91), symptomatic vasospasm (32% with statins versus 25% without, P = 0.34), delayed infarction (23% with statins versus 28% without, P = 0.46), or poor outcome (39% with statins versus 35% without, P = 0.61). After adjustment for differences in baseline characteristics, including the method of aneurysm treatment, statins were still not significantly protective. CONCLUSION The addition of statins to standard care was not associated with any reduction in the development of vasospasm or improvement in outcomes after aneurysmal subarachnoid hemorrhage. If there is a benefit to statin use, it may be smaller than suggested by previous studies. However, further randomized controlled trials are awaited.

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