1
|
Muacevic A, Adler JR, Perez Vega C, Brown N, Gendreau JL, Al Shaikh RH, Jeevaratnam S, Freeman WD. Management of Poor-Grade Aneurysmal Subarachnoid Hemorrhage and Key Pearls for Achieving Favorable Outcomes: An Illustrative Case. Cureus 2023; 15:e33217. [PMID: 36733562 PMCID: PMC9888499 DOI: 10.7759/cureus.33217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/03/2023] Open
Abstract
Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high patient mortality. Despite recent advances in management strategies, the prognosis for poor-grade aSAH remains dismal. We present a challenging case of a patient presenting with poor-grade aSAH. A 46-year-old female presented to the emergency department after losing consciousness following a sudden headache. The examination showed a dilated left pupil and a Glasgow Coma Scale of 4. Imaging revealed a ruptured anterior communicating artery (ACoM) aneurysm, after which the patient was subsequently taken to the neuro-interventional radiology suite. We showed that carefully managing blood pressure and intracranial pressure (ICP) makes it possible to achieve a favorable outcome and reduce the risk of secondary brain injury in aSAH, regardless of patient presentation. We propose maintaining blood pressure at <160 mmHg prior to intervention, after which it can be permitted to increase to 160-240 mmHg for the purpose of preventing vasospasm. Additionally, transcranial doppler (TCD) is essential to detect vasospasm due to the subtility of symptoms in patients with aSAH. Once identified, vasospasm can be successfully treated with balloon angioplasty. Finally, targeted temperature management (TTM), mannitol, hypertonic saline, and neuromuscular paralysis are essential for the postoperative management of ICP levels.
Collapse
|
2
|
Arikan F, Errando N, Lagares A, Gándara D, Gabarros A, López-Ojeda P, Ibáñez J, Brell M, Gómez PA, Fernández-Alén JA, Morera J, Horcajadas A, Vanaclocha V, Llácer JL, Baño-Ruiz E, Gonçalves-Estella JM, Torné R, Hoyos JA, Sarabia R, Arrese I, Rodríguez-Boto G, de la Lama A, Domínguez J, Martín-Láez R, Santamarta-Gómez D, Delgado-López PD, Ley-Urzaiz L, Mateo O, Iza B, Orduna-Martínez J, de Asís Lorente-Muñoz F, Muñoz-Hernández F, Iglesias J, Vilalta J. Variability of Clinical and Angiographic Results Based on the Treatment Preference (Endovascular or Surgical) of Centers Participating in the Subarachnoid Hemorrhage Database of the Working Group of the Spanish Society of Neurosurgery. World Neurosurg 2019; 135:e339-e349. [PMID: 31811967 DOI: 10.1016/j.wneu.2019.11.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Since the introduction of endovascular treatment for cerebral aneurysms, hospitals in which subarachnoid hemorrhage is treated show different availability and/or preferences towards both treatment modalities. The main aim is to evaluate the clinical and angiographic results according to the hospital's treatment preferences applied. METHODS This study was conducted based on use of the subarachnoid hemorrhage database of the Vascular Pathology Group of the Spanish Neurosurgery Society. Centers were classified into 3 subtypes according to an index in the relationship between endovascular and surgical treatment as: endovascular preference, high endovascular preference, and elevated surgical preference. The clinical results and angiographic results were evaluated among the 3 treatment strategies. RESULTS From November 2004 to December 2017, 4282 subarachnoid hemorrhage patients were selected for the study: 630 (14.7%) patients from centers with surgical preference, 2766 (64.6%) from centers with endovascular preference, and 886 (20.7%) from centers with high endovascular preference. The surgical preference group obtained the best angiographic results associated with a greater complete exclusion (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). The surgical preference subgroup obtained the best outcome at discharge (65.45%), followed by the high endovascular preference group (61.5%) and the endovascular preference group (57.8%) (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). CONCLUSIONS In Spain, there is significant variability in aneurysm exclusion treatment in aneurysmal subarachnoid hemorrhage. Surgical centers offer better results for both surgical and endovascular patients. A multidisciplinary approach and the maintenance of an elevated quality of surgical competence could be responsible for these results.
Collapse
Affiliation(s)
- Fuat Arikan
- Neurosurgery Department, University Hospital Vall d'Hebron, Barcelona, Spain; Neurotraumatology-Neurosurgery Research Unit (UNINN), Research Institute Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | - Alfonso Lagares
- Neurosurgery Department, Hospital 12 de Octubre, Imas12, Universidad Complutense de Madrid, Spain
| | - Darío Gándara
- Neurosurgery Department, University Hospital Vall d'Hebron, Barcelona, Spain; Neurotraumatology-Neurosurgery Research Unit (UNINN), Research Institute Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andreu Gabarros
- Neurosurgery Department, University Hospital of Bellvitge and University of Barcelona, Barcelona, Spain
| | - Pablo López-Ojeda
- Neurosurgery Department, University Hospital of Bellvitge and University of Barcelona, Barcelona, Spain
| | - Javier Ibáñez
- Neurosurgery Department, University Hospital of Son Espases, Palma de Mallorca, Spain
| | - Marta Brell
- Neurosurgery Department, University Hospital of Son Espases, Palma de Mallorca, Spain
| | - Pedro A Gómez
- Neurosurgery Department, Hospital 12 de Octubre, Imas12, Universidad Complutense de Madrid, Spain
| | - Jose A Fernández-Alén
- Neurosurgery Department, Hospital 12 de Octubre, Imas12, Universidad Complutense de Madrid, Spain
| | - Jesús Morera
- Neurosurgery Department, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Spain
| | - Angel Horcajadas
- Neurosurgery Department, Virgen de las Nieves University Hospital, Granada, Spain
| | - Vicente Vanaclocha
- Neurosurgery Department, General University Hospital Consortium of Valencia, Spain
| | - José L Llácer
- Neurosurgery Department, Hospital Ribera, Alzira, Spain
| | - Elena Baño-Ruiz
- Neurosurgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Ramon Torné
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain; Augusti Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jhon A Hoyos
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Rosario Sarabia
- Neurovascular Unit UNVRH, Neurosurgery Department, University Hospital Rio Hortega, Valladolid, Spain
| | - Ignacio Arrese
- Neurovascular Unit UNVRH, Neurosurgery Department, University Hospital Rio Hortega, Valladolid, Spain
| | - Gregorio Rodríguez-Boto
- Neurosurgery Department, University Hospital Clínico San Carlos, Complutense University, Madrid, Spain; Neurosurgery Department, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | | | - Jaime Domínguez
- Neurosurgery Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Rubén Martín-Láez
- Department of Neurosurgery and Surgical Spine Unit, University Hospital Marqués de Valdecilla, Santander, Spain
| | | | | | - Luís Ley-Urzaiz
- Neurosurgery Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - Olga Mateo
- Neurosurgery Department, University Hospital Gregorio Marañon, Madrid, Spain
| | - Begoña Iza
- Neurosurgery Department, University Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | - Jone Iglesias
- Neurosurgery Department, University Hospital of Cruces, Barakaldo, Spain
| | - Jordi Vilalta
- Neurosurgery Department, University Hospital Vall d'Hebron, Barcelona, Spain; Neurotraumatology-Neurosurgery Research Unit (UNINN), Research Institute Vall d'Hebron, Barcelona, Spain
| |
Collapse
|
4
|
Liu Y, Soppi V, Mustonen T, Könönen M, Koivisto T, Koskela A, Rinne J, Vanninen RL. Subarachnoid hemorrhage in the subacute stage: elevated apparent diffusion coefficient in normal-appearing brain tissue after treatment. Radiology 2006; 242:518-25. [PMID: 17179395 DOI: 10.1148/radiol.2422051698] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively evaluate whether subarachnoid hemorrhage (SAH) is associated with a change in the apparent diffusion coefficient (ADC) in normal-appearing brain parenchyma. MATERIALS AND METHODS Institutional review board approval and informed consent were obtained for all patient and volunteer studies. One hundred patients (48 men, 52 women; mean age, 52 years +/- 12 [standard deviation]) with aneurysmal SAH underwent conventional and diffusion-weighted magnetic resonance (MR) imaging at a mean of 9 days +/- 3 after SAH to evaluate possible lesions caused by SAH, treatment of SAH, and vasospasm. Aneurysms were treated surgically (n = 70) or endovascularly (n = 30) before MR imaging. Diffusion-weighted MR imaging was performed at 1-year follow-up in 30 patients (10 men, 20 women; mean age, 51 years +/- 11). Thirty healthy age-matched volunteers (11 men, 19 women; mean age, 54 years +/- 16) underwent MR imaging with an identical protocol. ADC values were measured bilaterally in the gray and white matter (parietal, frontal, temporal, occipital lobes; cerebellum; caudate nucleus; lentiform nucleus; thalamus; and pons) that appeared normal on T2-weighted and diffusion-weighted MR images. Linear mixed model was used for comparison of ADC values of supratentorial gray matter and white matter; general linear regression analysis was used for comparison of ADC values of cerebellum and pons. RESULTS In patients with SAH, the ADC values in normal-appearing white matter, with a single exception in the frontal lobe (P = .091), were significantly higher than they were in healthy volunteers (P </= .011). The differences disappeared by 1 year, except in parietal white matter (P = .045). The ADC values of cortical gray matter did not significantly differ between patients and volunteers (P >/= .121). CONCLUSION SAH and its treatment may cause global mild vasogenic edema in white matter and deep gray matter that is undetectable on T2-weighted and diffusion-weighted MR images but is detectable by measuring the ADC value in the subacute stage of SAH.
Collapse
Affiliation(s)
- Yawu Liu
- Department of Clinical Radiology, Kuopio University Hospital, PO Box 1777, FIN-70211 Kuopio, Finland.
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Miranda P, Lagares A, Alen J, Perez-Nuñez A, Arrese I, Lobato RD. Early transcranial Doppler after subarachnoid hemorrhage: clinical and radiological correlations. ACTA ACUST UNITED AC 2006; 65:247-52; discussion 252. [PMID: 16488242 DOI: 10.1016/j.surneu.2005.06.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Accepted: 06/13/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The initial decrease in the level of consciousness after subarachnoid hemorrhage (SAH) is commonly considered secondary to cerebral hypoperfusion and metabolic depression. Age, intracranial pressure, and the amount of cisternal blood are closely related to the clinical grade on admission after SAH. Transcranial Doppler (TCD) may partially and indirectly estimate cerebral blood flow through analysis of flow velocity in the middle cerebral artery (MCA). Besides, pulsatility index (PI) can also be considered an indirect estimator of cerebrovascular resistance. The objective of this study was to determine the TCD parameters in the early stage after SAH and to analyze their correlation with the main clinical and radiological variables on admission. METHODS A series of 52 consecutive patients diagnosed with SAH, with an abnormal computed tomography (CT) scan on admission and a TCD performed in the first 24 hours from the onset of the hemorrhage, were retrospectively reviewed. Age, sex, clinical grade, presence of cisternal blood or hydrocephalus on initial CT scan, and parameters of TCD examination were recorded for every patient. The relationship between sonographic and clinical and radiological variables was evaluated by partial correlation test, Kruskal-Wallis, and Student t test for paired samples. RESULTS There were no significant differences in blood flow velocities or PIs between the left and right sides. Lower velocities and higher PIs correlated with a worse clinical condition at admission. Lower velocities also correlated with larger amounts of cisternal blood on the initial CT scan. No significant correlation was observed between PI and the amount of blood in the initial CT scan. CONCLUSIONS A global decrease in blood velocity in the MCA along with a rise in PI is present in the first 24 hours after SAH. These changes correlate with the clinical deterioration and partially with the amount of blood in the initial CT scan. These findings support the hypothesis that low cerebral perfusion caused by high intracranial pressure leads to diffuse ischemic changes in the early phase of SAH.
Collapse
Affiliation(s)
- Pablo Miranda
- Department of Neurosurgery, Hospital 12 de Octubre, 28041 Madrid, Spain.
| | | | | | | | | | | |
Collapse
|