Impact of early surgery after aneurysmal subarachnoid haemorrhage

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Hyperacute versus Subacute Coiling of Aneurysmal Subarachnoid Hemorrhage a Short-term Outcome and Single-Center Experience, Pilot Study

BACKGROUND

After the initial subarachnoid hemorrhage (SAH), rebleeding is the major cause of morbidity and poor outcome, which is maximal in the first 24 h. We supposed that the coiling of ruptured intracranial aneurysms within 24 h of SAH is related to the improved clinical outcome compared with coiling 24 h after aneurysmal SAH.

OBJECTIVE

We examined whether coiling ruptured aneurysms within 24 h of aneurysmal SAH is associated with better early 24 h and late 30 days outcome.

METHOD

This prospective study was carried on 30 patients with aneurysmal SAH presenting to the Alexandria University Hospital and Insurance Main Hospital during the period from February 2013 to May 2014. They were divided into two groups: Group I (10 patients treated within 24 h of presentation) and Group II (20 patients treated after 24 h of presentation). Time interval from presentation to treatment were 78.60 and 10.60 h for subacute and hyperacute group, respectively. All patients were treated with endovascular coiling. Change between admission and immediate postoperative World Federation of Neurosurgeons classification Scale was measured for early outcome, while remote outcome was measured by modified Rankin Scale at 30 days follow-up.

RESULTS

There was a clinical improvement regarding early 24 h outcome (weighted by postoperative WFNS grade) and on late 30 days outcome (weighted by Modified Rankin Scale Score) in the group managed within 24 h versus who were treated after 24 h (P = 0.049 and P = 0.024, respectively). There was a significant decrease in the incidence of clinical rebleeding detected by postoperative computed tomography (CT) of the brain in patients undergoing aneurysm treatment within 24 h (P = 0.029).

CONCLUSION

The study affirms evidence that the management of ruptured intracranial aneurysms within 24 h of SAH is associated with better immediate and short-term clinical outcome.

Does Treatment of Ruptured Intracranial Aneurysms Within 24 Hours Improve Clinical Outcome?

Background and Purpose—

The purpose of this study was to analyze whether treating ruptured intracranial aneurysms within 24 hours of subarachnoid hemorrhage improves clinical outcome.

Methods—

An 11-year database of consecutive ruptured intracranial aneurysms treated with endovascular coiling or craniotomy and clipping was analyzed. Outcome was measured by the modified Rankin Scale at 6 months. Our policy is to treat all cases within 24 hours of subarachnoid hemorrhage. Treatment delays are due to nonclinical logistical factors.

Results—

Two hundred thirty cases were coiled or clipped within 24 hours of subarachnoid hemorrhage and 229 at >24 hours. No difference in age, gender, smoking, family history of subarachnoid hemorrhage, aneurysm size, or aneurysm location was found between the groups. Poor World Federation of Neurological Surgeons clinical grade patients were overrepresented in the ultra-early group. Increasing age and higher World Federation of Neurological Surgeons clinical grade were predictors of poor outcome. Eight point zero percent of cases treated within 24 hours of subarachnoid hemorrhage (ultra-early) were dependent or dead at 6 months compared with 14.4% of those treated at >24 hours (delayed), a 44.0% relative risk reduction and a 6.4% absolute risk reduction (χ 2 , P =0.044). A total of 3.5% of cases coiled within 24 hours were dependent or dead at 6 months compared with 12.5% of cases coiled at 1 to 3 days, an 82% relative risk reduction and a 10.2% absolute risk reduction (χ 2 , P =0.040). These groups did not differ in age, World Federation of Neurological Surgeons clinical grade, aneurysm size, or aneurysm location.

Conclusions—

Treatment of ruptured aneurysms within 24 hours is associated with improved clinical outcomes compared with treatment at >24 hours. The benefit is more pronounced for coiling than clipping.

Epidemiology of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a form of hemorrhagic stroke that affects up to 30,000 individuals per year in the United States. The incidence of aSAH has been shown to be associated with numerous nonmodifiable (age, gender, ethnicity, family history, aneurysm location, size) and modifiable (hypertension, body mass index, tobacco and illicit drug use) risk factors. Although early repair of ruptured aneurysms and aggressive postoperative management has improved overall outcomes, it remains a devastating disease, with mortality approaching 50% and less than 60% of survivors returning to functional independence. As treatment modalities change and the percentage of minority and elderly populations increase, it is critical to maintain an up-to-date understanding of the epidemiology of SAH.

Cerebrospinal fluid opening pressure measurements in acute headache patients and in patients with either chronic or no pain

OBJECTIVE

To observe cerebrospinal fluid opening pressure (CSFOP) in different clinical settings and in patients with acute, chronic and no pain and to observe possible differences because of age and sex.

METHOD

In this prospective study, CSFOP was measured in lumbar puncture in three different settings of clinical investigations; patients with acute headache investigated for subarachnoidal haemorrhage (n = 222), patients with sciatica undergoing myelography (n = 61), and patients in an outpatient neurological clinic (n = 65).

RESULTS

The mean CSFOP in cm H(2)O was 17.3 for the myelography patients, 19.1 for the outpatients, 19.3 for the primary headache patients and 22.4 for the patients with secondary headache. Large proportions of patients in all groups had CSFOP above 20 cm H(2)O. The female patients in all groups had lower mean CSFOP than the male patients.

CONCLUSION

The CSFOP levels found in clinical practice among patients without intracranial lesions or infectious conditions were broader than expected. Measurement of CSFOP is of limited value as diagnostic procedure if not closely linked to clinical symptoms and finds.