Method of Aneurysm Treatment Does Not Affect Clot Clearance After Aneurysmal Subarachnoid Hemorrhage

Abstract BACKGROUND Patients undergoing neurosurgical clipping or endovascular coiling of a ruptured aneurysm may differ in their risk of vasospasm. OBJECTIVE Because clot clearance affects vasospasm, we tested the hypothesis that clot clearance differs in patients depending on method of aneurysm treatment. METHODS Exploratory analysis was performed on 413 patients from CONSCIOUS-1, a prospective randomized trial of clazosentan for the prevention of angiographic vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Clot clearance was measured by change in Hijdra score between baseline computed tomography and one performed 24 to 48 hours after aneurysm treatment. Angiographic vasospasm was assessed by the use of catheter angiography 7 to 11 days after SAH, and delayed ischemic neurological deficit (DIND) was determined clinically. Extended Glasgow Outcome Score (GOSE) was assessed 3 months after SAH, and poor outcome was defined as death, vegetative state, or severe disability. Multivariable ordinal and binary logistic regression were used. RESULTS There was no significant difference in the rate of clot clearance between patients undergoing clipping or coiling (P = .56). Coiling was independently associated with decreased severity of angiographic vasospasm (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.33-0.86), but not with DIND or GOSE. Greater clot clearance decreased the risk of severe angiographic vasospasm (OR 0.86, 95% CI 0.81-0.91), whereas higher baseline Hijdra score predicted increased angiographic vasospasm (OR 1.17, 95% CI 1.11-1.23) and poor GOSE (OR 1.09, 95% CI 1.04-1.14). CONCLUSION Aneurysm coiling and increased clot clearance were independently associated with decreased severity of angiographic vasospasm in multivariate analysis, although no differences in clot clearance were seen between coiled and clipped patients.

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High-Dose Nadroparin Following Endovascular Aneurysm Treatment Benefits Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1093/neuros/nyx381 ◽

2017 ◽

Vol 83 (2) ◽

pp. 281-287 ◽

Cited By ~ 1

Author(s):

Rene Post ◽

IJsbrand A.J Zijlstra ◽

Rene van den Berg ◽

Bert A Coert ◽

Dagmar Verbaan ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Dose Group ◽

Low Dose ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Controlled Trial ◽

Delayed Cerebral Ischemia ◽

Neurological Status ◽

High Dose ◽

Aneurysm Treatment ◽

Significant Difference

Abstract BACKGROUND Delayed cerebral ischemia (DCI) is one of the major causes of delayed morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To evaluate the effect of high-dose nadroparin treatment following endovascular aneurysm treatment on the occurrence of DCI and clinical outcome. METHODS Medical records of 158 adult patients with an aSAH were retrospectively analyzed. Those patients treated endovascularly for their ruptured aneurysm were included in this study. They received either high-dose (twice daily 5700 AxaIE) or low-dose (once daily 2850 AxaIE) nadroparin treatment after occlusion of the aneurysm. Medical charts were reviewed and imaging was scored by 2 independent neuroradiologists. Data with respect to in-hospital complications, peri-procedural complications, discharge location, and mortality were collected. RESULTS Ninety-three patients had received high-dose nadroparin, and 65 patients prophylactic low-dose nadroparin. There was no significant difference in clinical DCI occurrence between patients treated with high-dose (34%) and low-dose (31%) nadroparin. More patients were discharged to home in patients who received high-dose nadroparin (40%) compared to low-dose (17%; odds ratio [OR] 3.13, 95% confidence interval [95% CI]: 1.36-7.24). Furthermore, mortality was lower in the high-dose group (5%) compared to the low-dose group (23%; OR 0.19, 95% CI: 0.07-0.55), also after adjusting for neurological status on admission (OR 0.21, 95% CI: 0.07-0.63). CONCLUSION Patients who were treated with high-dose nadroparin after endovascular treatment for aneurysmal SAH were more often discharged to home and showed lower mortality. High-dose nadroparin did not, however, show a decrease in the occurrence of clinical DCI after aSAH. A randomized controlled trial seems warranted.

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COILING VERSUS CLIPPING FOR THE TREATMENT OF ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000255335.72662.25 ◽

2007 ◽

Vol 60 (3) ◽

pp. 434-442 ◽

Cited By ~ 46

Author(s):

Duncan Frazer ◽

Abha Ahuja ◽

Laurence Watkins ◽

Lisa Cipolotti

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Intellectual Functioning ◽

Acute Stage ◽

Cognitive Outcome ◽

Endovascular Coiling ◽

Surgical Clipping ◽

Significant Difference ◽

Prospective Longitudinal

Abstract OBJECTIVE Endovascular coiling has been used increasingly as an alternative to neurosurgical clipping for treating subarachnoid hemorrhage secondary to aneurysm rupture. The aim of the present study was to provide a prospective, longitudinal investigation into cognitive function in patients with aneurysmal subarachnoid hemorrhage treated with either neurosurgical clipping or endovascular coiling. METHODS Twenty-three patients who were treated for aneurysmal subarachnoid hemorrhage at the National Hospital for Neurology and Neurosurgery in London, England, were recruited prospectively. Twelve patients who underwent surgical clipping were compared with a group of 11 patients who underwent endovascular coiling. All patients underwent a comprehensive, standardized neuropsychological assessment using the same battery of tests at the acute stage (within 2 wk after treatment). All patients who underwent coiling and 11 of the 12 patients who underwent clipping were reassessed at the post-acute long-term follow-up (6 mo) stage. RESULTS Group comparisons at the acute assessment revealed a significant difference favoring coiling patients on only one measure of verbal recall. However, there were no other significant differences between the groups at this stage. At the post-acute assessment, the clipped group performed better than the coiled group on measures of intellectual functioning (P < 0.05), although no other differences were found on a range of cognitive tests. Intragroup comparisons between the acute and post-acute assessments found equivocal, significant improvements in measures of intellectual functioning, memory, executive functions, and speed of information processing in both groups of patients. CONCLUSION We argue that there are minimal differences in the long-term cognitive outcome between endovascular coiling and surgical clipping. In the acute phase after treatment, we suggest that coiled patients, having been spared neurosurgical intervention, may have a slightly better cognitive outcome than clipped patients. However, these differences level off and both groups of patients ultimately experience widespread improvement in cognitive functioning by the post-acute stage of recovery.

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Evaluation of time to aneurysm treatment following subarachnoid hemorrhage: comparison of patients treated with clipping versus coiling

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2014-011642 ◽

2015 ◽

Vol 8 (4) ◽

pp. 373-377 ◽

Cited By ~ 9

Author(s):

Frank J Attenello ◽

Patrick Reid ◽

Timothy Wen ◽

Steven Cen ◽

May Kim-Tenser ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Nationwide Inpatient Sample ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Teaching Hospitals ◽

Endovascular Coiling ◽

Teaching Institution ◽

Aneurysm Clipping ◽

Aneurysm Treatment ◽

Teaching Status ◽

Delayed Time

IntroductionPrior studies of aneurysmal subarachnoid hemorrhage (SAH) have shown that treatment at teaching institutions and decreased time to surgery are factors that correlate with improved patient outcome. We aimed to individually evaluate the effect of teaching institution treatment on rates of surgical clipping or endovascular coiling.MethodsPatients with SAH treated by either aneurysm clipping or coiling between 2002 and 2010 in the Nationwide Inpatient Sample were analyzed. Time to aneurysm treatment was dichotomized to >3 days or ≤3 days and evaluated by multivariable logistic regression modeling, controlling for patient and hospital covariates. Identified predictors for prolonged time to procedure were compared between the clipping and coiling populations.ResultsBetween 2002 and 2010 there were 90 684 SAH admissions with subsequent clipping and coiling procedures. Treatment at teaching hospitals was associated with faster time to clipping (OR 0.60, 95% CI 0.44 to 0.80, p=0.001) but not coiling procedures (p=0.66). Likewise, older age (≥80 years) was associated with delays to clipping (p<0.05) but not coiling procedures (p>0.05). Patients with delayed time to treatment were associated with increased rates of moderate to severe neurological disability.ConclusionsOlder patients with SAH and those treated at non-teaching hospitals were more likely to have delays to aneurysm clipping procedures. These associations were unique to open surgery as age and hospital teaching status did not affect time to coiling procedures.

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Effects of cilostazol on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a multicenter prospective, randomized, open-label blinded end point trial

Journal of Neurosurgery ◽

10.3171/2012.9.jns12492 ◽

2013 ◽

Vol 118 (1) ◽

pp. 121-130 ◽

Cited By ~ 50

Author(s):

Nobuo Senbokuya ◽

Hiroyuki Kinouchi ◽

Kazuya Kanemaru ◽

Yasuhiro Ohashi ◽

Akira Fukamachi ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Control Group ◽

Fisher Exact Test ◽

Exact Test ◽

Symptomatic Vasospasm ◽

Angiographic Vasospasm ◽

Significant Difference ◽

Length Of Hospitalization

Object Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of subsequent morbidity and mortality. Cilostazol, a selective inhibitor of phosphodiesterase 3, may attenuate cerebral vasospasm because of its antiplatelet and vasodilatory effects. A multicenter prospective randomized trial was conducted to investigate the effect of cilostazol on cerebral vasospasm. Methods Patients admitted with SAH caused by a ruptured anterior circulation aneurysm who were in Hunt and Kosnik Grades I to IV and were treated by clipping within 72 hours of SAH onset were enrolled at 7 neurosurgical sites in Japan. These patients were assigned to one of 2 groups: the usual therapy group (control group) or the add-on 100 mg cilostazol twice daily group (cilostazol group). The group assignments were done by a computer-generated randomization sequence. The primary study end point was the onset of symptomatic vasospasm. Secondary end points were the onset of angiographic vasospasm and new cerebral infarctions related to cerebral vasospasm, clinical outcome as assessed by the modified Rankin scale, and length of hospitalization. All end points were assessed for the intention-to-treat population. Results Between November 2009 and December 2010, 114 patients with SAH were treated by clipping within 72 hours from the onset of SAH and were screened. Five patients were excluded because no consent was given. Thus, 109 patients were randomly assigned to the cilostazol group (n = 54) or the control group (n = 55). Symptomatic vasospasm occurred in 13% (n = 7) of the cilostazol group and in 40% (n = 22) of the control group (p = 0.0021, Fisher exact test). The incidence of angiographic vasospasm was significantly lower in the cilostazol group than in the control group (50% vs 77%; p = 0.0055, Fisher exact test). Multiple logistic analyses demonstrated that nonuse of cilostazol is an independent factor for symptomatic and angiographic vasospasm. The incidence of new cerebral infarctions was also significantly lower in the cilostazol group than in the control group (11% vs 29%; p = 0.0304, Fisher exact test). Clinical outcomes at 1, 3, and 6 months after SAH in the cilostazol group were better than those in the control group, although a significant difference was not shown. There was also no significant difference in the length of hospitalization between the groups. No severe adverse event occurred during the study period. Conclusions Oral administration of cilostazol is effective in preventing cerebral vasospasm with a low risk of severe adverse events. Clinical trial registration no. UMIN000004347, University Hospital Medical Information Network Clinical Trials Registry.

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Evidence for a conditioning effect of inhalational anesthetics on angiographic vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.3.jns183512 ◽

2020 ◽

Vol 133 (1) ◽

pp. 152-158 ◽

Cited By ~ 1

Author(s):

Umeshkumar Athiraman ◽

Diane Aum ◽

Ananth K. Vellimana ◽

Joshua W. Osbun ◽

Rajat Dhar ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariate Logistic Regression Analysis ◽

Secondary Brain Injury ◽

Large Artery ◽

Inhalational Anesthetics ◽

Angiographic Vasospasm ◽

Inhalational Anesthetic

OBJECTIVEDelayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is characterized by large-artery vasospasm, distal autoregulatory dysfunction, cortical spreading depression, and microvessel thrombi. Large-artery vasospasm has been identified as an independent predictor of poor outcome in numerous studies. Recently, several animal studies have identified a strong protective role for inhalational anesthetics against secondary brain injury after SAH including DCI—a phenomenon referred to as anesthetic conditioning. The aim of the present study was to assess the potential role of inhalational anesthetics against cerebral vasospasm and DCI in patients suffering from an SAH.METHODSAfter IRB approval, data were collected retrospectively for all SAH patients admitted to the authors’ hospital between January 1, 2010, and December 31, 2013, who received general anesthesia with either inhalational anesthetics only (sevoflurane or desflurane) or combined inhalational (sevoflurane or desflurane) and intravenous (propofol) anesthetics during aneurysm treatment. The primary outcomes were development of angiographic vasospasm and development of DCI during hospitalization. Univariate and logistic regression analyses were performed to identify independent predictors of these endpoints.RESULTSThe cohort included 157 SAH patients whose mean age was 56 ± 14 (± SD). An inhalational anesthetic–only technique was employed in 119 patients (76%), while a combination of inhalational and intravenous anesthetics was employed in 34 patients (22%). As expected, patients in the inhalational anesthetic–only group were exposed to significantly more inhalational agent than patients in the combination anesthetic group (p < 0.05). Multivariate logistic regression analysis identified inhalational anesthetic–only technique (OR 0.35, 95% CI 0.14–0.89), Hunt and Hess grade (OR 1.51, 95% CI 1.03–2.22), and diabetes (OR 0.19, 95% CI 0.06–0.55) as significant predictors of angiographic vasospasm. In contradistinction, the inhalational anesthetic–only technique had no significant impact on the incidence of DCI or functional outcome at discharge, though greater exposure to desflurane (as measured by end-tidal concentration) was associated with a lower incidence of DCI.CONCLUSIONSThese data represent the first evidence in humans that inhalational anesthetics may exert a conditioning protective effect against angiographic vasospasm in SAH patients. Future studies will be needed to determine whether optimized inhalational anesthetic paradigms produce definitive protection against angiographic vasospasm; whether they protect against other events leading to secondary brain injury after SAH, including microvascular thrombi, autoregulatory dysfunction, blood-brain barrier breakdown, neuroinflammation, and neuronal cell death; and, if so, whether this protection ultimately improves patient outcome.

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Correlation between angiographic transit times and neurological status on admission in patients with aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2015.4.jns15134 ◽

2016 ◽

Vol 124 (4) ◽

pp. 1093-1099 ◽

Cited By ~ 9

Author(s):

Alexander Ivanov ◽

Andreas Linninger ◽

Chih-Yang Hsu ◽

Sepideh Amin-Hanjani ◽

Victor A. Aletich ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Clinical Information ◽

Control Group ◽

Angiography Suite ◽

Transit Times ◽

Significant Difference ◽

Group A ◽

Group B

OBJECT The use of digital subtraction angiography (DSA) for semiquantitative cerebral blood flow(CBF) assessment is a new technique. The aim of this study was to determine whether patients with aneurysmal subarachnoid hemorrhage (aSAH) with higher Hunt and Hess grades also had higher angiographic contrast transit times (TTs) than patients with lower grades. METHODS A cohort of 30 patients with aSAH and 10 patients without aSAH was included. Relevant clinical information was collected. A method to measure DSA TTs by color-coding reconstructions from DSA contrast-intensity images was applied. Regions of interest (ROIs) were chosen over major cerebral vessels. The estimated TTs included time-to-peak from 0% to 100% (TTP0–100), TTP from 25% to 100% (TTP25–100), and TT from 100% to 10% (TT100–10) contrast intensities. Statistical analysis was used to compare TTs between Group A (Hunt and Hess Grade I-II), Group B (Hunt and Hess Grade III-IV), and the control group. The correlation coefficient was calculated between different ROIs in aSAH groups. RESULTS There was no difference in demographic factors between Group A (n = 10), Group B (n = 20), and the control group (n = 10). There was a strong correlation in all TTs between ROIs in the middle cerebral artery (M1, M2) and anterior cerebral artery (A1, A2). There was a statistically significant difference between Groups A and B in all TT parameters for ROIs. TT100–10 values in the control group were significantly lower than the values in Group B. CONCLUSIONS The DSA TTs showed significant correlation with Hunt and Hess grades. TT delays appear to be independent of increased intracranial pressure and may be an indicator of decreased CBF in patients with a higher Hunt and Hess grade. This method may serve as an indirect technique to assess relative CBF in the angiography suite.

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Cerebrospinal fluid macrophage migration inhibitory factor: a potential predictor of cerebral vasospasm and clinical outcome after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.6.jns19613 ◽

2020 ◽

Vol 133 (6) ◽

pp. 1786-1791 ◽

Cited By ~ 1

Author(s):

Kevin Kwan ◽

Orseola Arapi ◽

Katherine E. Wagner ◽

Julia Schneider ◽

Heustein L. Sy ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Cerebral Vasospasm ◽

Migration Inhibitory Factor ◽

Macrophage Migration Inhibitory Factor ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Inhibitory Factor ◽

Macrophage Migration ◽

Significant Difference

OBJECTIVEIn patients with aneurysmal subarachnoid hemorrhage (aSAH), poor outcomes have been shown to be correlated with subsequent cerebral vasospasm (CV) and delayed cerebral ischemia (DCI). The identification of novel biomarkers may aid in the prediction of which patients are vulnerable to developing vasospasm, cerebral ischemia, and neurological deterioration.METHODSIn this prospective clinical study at North Shore University Hospital, patients with aSAH or normal pressure hydrocephalus (NPH) with external ventricular drains were enrolled. The concentration of macrophage migration inhibitory factor (MIF) in CSF was assessed for correlation with CV or DCI, the primary outcome measures.RESULTSTwenty-five patients were enrolled in the aSAH group and 9 were enrolled in the NPH group. There was a significant increase in aggregate CSF MIF concentration in patients with aSAH versus those with NPH (24.4 ± 19.2 vs 2.3 ± 1.1 ng/ml, p < 0.0002). Incidence of the day of peak MIF concentration significantly correlated with the onset of clinical vasospasm (rho = 0.778, p < 0.0010). MIF concentrations were significantly elevated in patients with versus those without evidence of DCI (18.7 ± 4.93 vs 8.86 ± 1.28 ng/ml, respectively, p < 0.0025). There was a significant difference in MIF concentrations between patients with infection versus those without infection (16.43 ± 4.21 vs 8.5 ± 1.22 ng/ml, respectively, p < 0.0119).CONCLUSIONSPreliminary evidence from this study suggests that CSF concentrations of MIF are correlated with CV and DCI. These results, however, could be confounded in the presence of clinical infection. A study with a larger patient sample size is necessary to corroborate these findings.

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Bilateral subdural hygromas after endovascular coiling for ruptured aneurysmal subarachnoid hemorrhage: an unusual and rare complication

Oxford Medical Case Reports ◽

10.1093/omcr/omab062 ◽

2021 ◽

Vol 2021 (8) ◽

Author(s):

Walid O Ahmed ◽

Shady N Mashhour ◽

Marwa E Abdelfattah

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Rare Complication ◽

Mass Effect ◽

Contralateral Side ◽

Endovascular Coiling ◽

Neurological Assessment ◽

Ruptured Intracranial Aneurysm ◽

Significant Mass Effect

ABSTRACT Subarachnoid hemorrhage (SAH) with subdural hygroma (SH) was rarely reported after endovascular coiling. A 60-year-old male presented with impaired consciousness and convulsions due to SAH from a ruptured aneurysm. It was managed by endovascular coiling 20 h after the onset of symptoms. Serial brain imaging for 2 weeks revealed progressive bilateral SHs, more on contralateral side of leaking aneurysm. Management of SH was discussed in a multidisciplinary setting to be conservative as there was neither significant mass effect nor hydrocephalus. The patient recovered neurologically except for mild dysarthria. The SH persisted for 2 months and then cleared gradually. We concluded that SH may arise and become symptomatic as an unusual sequela of post-coiling of a ruptured intracranial aneurysm, in which the SH can complicate the clinical course of SAH. However, the symptomatic SH may resolve spontaneously and completely without any intervention, but needs meticulous neurological assessment and follow-up.

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