Lower Incidence of Symptomatic Vasospasm after Subarachnoid Hemorrhage owing to Ruptured Vertebrobasilar Aneurysms

Sex-Related Differences in Mortality, Delayed Cerebral Ischemia, and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Background/Objective: Sex-related differences among patients with aneurysmal subarachnoid hemorrhage (aSAH) and their potential clinical implications have been insufficiently investigated. To address this knowledge gap, we conduct a comprehensive systematic review and meta-analysis. Methods: Sex-specific differences in patients with aSAH, including mortality, delayed cerebral ischemia (DCI), and functional outcomes were assessed. The functional outcome was dichotomized into favorable or unfavorable based on the modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Glasgow Outcome Scale Extended (GOSE). Results: Overall, 2823 studies were identified in EMBASE, MEDLINE, PubMed, and by manual search on 14 February 2024. After an initial assessment, 74 studies were included in the meta-analysis. In the analysis of mortality, including 18,534 aSAH patients, no statistically significant differences could be detected (risk ratio (RR) 0.99; 95% CI, 0.90-1.09; p = 0.91). In contrast, the risk analysis for DCI, including 23,864 aSAH patients, showed an 11% relative risk reduction in DCI in males versus females (RR, 0.89; 95% CI, 0.81-0.97; p = 0.01). The functional outcome analysis (favorable vs. unfavorable), including 7739 aSAH patients, showed a tendency towards better functional outcomes in men than women; however, this did not reach statistical significance (RR, 1.02; 95% CI, 0.98-1.07; p = 0.34). Conclusions: In conclusion, the available data suggest that sex/gender may play a significant role in the risk of DCI in patients with aSAH, emphasizing the need for sex-specific management strategies.

Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients

BACKGROUND

The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS.

METHODS

Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale.

RESULTS

We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS.

CONCLUSIONS

Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.

Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol

INTRODUCTION

Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH.

METHODS AND ANALYSIS

This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone.

ETHICS AND DISSEMINATION

Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04148105.

Vasospasm-related complications after subarachnoid hemorrhage: the role of patients' age and sex

BACKGROUND

Outcome of aneurysmal subarachnoid hemorrhage (SAH) depends strongly on occurrence of symptomatic vasospasm (SV) leading to delayed cerebral ischemia (DCI). Various demographic, radiographic, and clinical predictors of SV have been reported so far, partially with conflicting results. The aim of this study was to analyze the role of patients' age and sex on SV/DCI risk, especially to identify age and sex-specific risk groups.

METHODS

All patients admitted with acute SAH during a 14-year-period ending in 2016 were eligible for this study. The study endpoints were the following: SV requiring spasmolysis, occurrence of DCI in follow-up computed tomography scans and unfavorable outcome at 6 months (modified Rankin scale > 2).

RESULTS

Nine hundred ninety-four patients were included in this study. The majority was female (666; 67%). SV, DCI, and unfavorable outcomes were observed in 21.5, 21.8, and 43.6% of the patients, respectively. Younger age (p < 0.001; OR = 1.03 per year decrease) and female sex (p = 0.025; OR = 1.510) were confirmed as independent predictors of SV. Regarding the sex differences, there were three age groups for SV/DCI risk ≤ 54, 55-74, and ≥ 75 years. Male patients showed earlier decrease in SV risk (at ≥ 55 vs. ≥ 75 years in females). Therefore, SAH females aged between 55 and 74 years were at the highest risk for DCI and unfavorable outcome, as compared to younger/older females (p = 0.001, OR = 1.77/p = 0.001, OR = 1.80). In contrast, their male counterparts did not show these risk alterations (p = 0.445/p = 0.822).

CONCLUSION

After acute SAH, female and male patients seem to show different age patterns for the risk of SV and DCI. Females aged between 55 and 74 years are at particular risk of vasospasm-related SAH complications, possibly due to onset of menopause.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS, Unique identifier: DRKS00008749.

A Comparison of Computed Tomography-Based Scales with and without Consideration of the Presence or Absence of Intraventricular Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

There has been controversy as to whether intraventricular hemorrhage (IVH) after aneurysmal subarachnoid hemorrhage (SAH) contributes to angiographic cerebral vasospasm (aCV) and delayed cerebral ischemia (DCI). Computed tomography-based SAH scales that did and did not consider IVH were compared in terms of ability to predict aCV, DCI, and outcome.

METHODS

We reviewed 390 patients with ruptured aneurysms who had been treated surgically by day 3 by the same surgeon (T.I.). aCV was graded as 0-4. Outcome at 6 months was classified using the Glasgow Outcome Scale. Inagawa SAH grades and scores, for which only SAH was evaluated, were compared with scales that evaluated both SAH and IVH (Fisher, Claassen, and Frontera grades, and Hijdra score). The area under the receiver operating characteristic curve was calculated to compare severe aCV (grade 3-4), DCI, or poor outcome (Glasgow Outcome Scale score 1-3).

RESULTS

The Inagawa grade showed constant and significant intergrade differences in both aCV and DCI. The Inagawa grade area under the receiver operating characteristic curve values were highest among the scales examined. In the Fisher, Claassen, and Frontera grades, IVH was unlikely to be related to aCV and DCI. There was no significant difference in aCV grade or DCI occurrence between the Inagawa and Hijdra scores. In contrast, the presence of IVH was significantly associated with poor outcome.

CONCLUSIONS

In patients with aneurysmal SAH, IVH is an important factor affecting patient outcome, whereas computed tomography-based SAH scales that do not consider IVH are superior to scales that do consider it for prediction of aCV or DCI.

Risk Factors for Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature

OBJECTIVE

To examine the literature on risk factors for cerebral vasospasm (CV), one of the most serious complications following aneurysmal subarachnoid hemorrhage (SAH), with special reference to the definition of CV.

METHODS

Using standard search engines, including PubMed, the medical literature on risk factors for CV after SAH was reviewed, and the best definition representative of CV was searched.

RESULTS

Severe SAH evident on computed tomography scan was the only consistent risk factor for CV after SAH. Effects of risk factors on CV, including age, clinical grade, rebleeding, intraventricular or intracerebral hemorrhage on computed tomography scan, acute hydrocephalus, aneurysm site and size, leukocytosis, interleukin-6 level, and cardiac abnormalities, appeared to be associated with the severity of SAH rather than each having a direct effect. Cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram were associated with CV without any relationship to SAH severity. With regard to parameters representative of CV, the grade of angiographic vasospasm (i.e., the degree of arterial narrowing evident on angiography) was the most adequate. Nevertheless, few reports on the risk factors associated with angiographic vasospasm grade have been reported to date.

CONCLUSIONS

Severe SAH evident on computed tomography scan appears to be a definite risk factor for CV after SAH, followed by cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram. To understand the pathogenesis of CV, further studies on the relationships between risk factors, especially factors not related to the severity of SAH, and angiographic vasospasm grade are necessary.

Tenascin-C induces prolonged constriction of cerebral arteries in rats

Tenascin-C (TNC), a matricellular protein, is induced in association with cerebral vasospasm after subarachnoid hemorrhage. The aim of this study was to assess the vasoconstrictive effects of TNC and its mechanisms of action on cerebral arteries in vivo. Two dosages (1 and 10μg) of TNC were administered intracisternally to healthy rats, and the effects were evaluated by neurobehavioral tests and India-ink angiography at 24, 48, and 72h after the administration. Western blotting and immunohistochemistry were performed to explore the underlying mechanisms on constricted cerebral arteries after 24h. The effects of toll-like receptor 4 (TLR4) antagonists (LPS-RS), c-Jun N-terminal kinase (JNK), and p38 inhibitors (SP600125 and SB203580) on TNC-induced vasoconstriction were evaluated at 24h. Higher dosages of TNC induced more severe cerebral arterial constriction, which continued for more than 72h. TNC administration also upregulated TLR4, and activated JNK and p38 in the smooth muscle cell layer of the constricted cerebral artery. LPS-RS blocked TNC-induced TLR4 upregulation, JNK and p38 activation, and vasoconstrictive effects. SP600125 and SB203580 abolished TNC-induced TLR4 upregulation and vasoconstrictive effects. TNC may cause prolonged cerebral arterial constriction via TLR4 and activation of JNK and p38, which may upregulate TLR4. These findings suggest that TNC causes cerebral vasospasm and provides a novel therapeutic approach against it.

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Background and Purpose—

Established predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage are large amounts of extravasated blood and poor clinical condition on admission. The predictive value of other factors is uncertain.

Methods—

We searched MEDLINE (1960–2012) for clinical, laboratory, and radiological predictors routinely available within 72 hours after subarachnoid hemorrhage. The studies were categorized according to methodological quality. Crude data and effect estimates (odds ratio [OR], hazard ratios, and risk ratio) with 95% CI were extracted, (re-)calculated and pooled if possible. For every potential predictor we assessed all effect estimates on consistency (point estimates in equal direction) and clinical relevance (size and 95% CI).

Results—

Fifty-two studies on 33 potential predictors were included. There was strong evidence (≥3 high-quality studies) for a higher risk of delayed cerebral ischemia in smokers (pooled OR, 1.2; 95% CI, 1.1–1.4), and moderate evidence (2 high-quality studies) for an increased risk in patients with hyperglycemia (OR, 3.2; 1.8–5.8 and hazard ratios, 1.7; 1.1–2.5), hydrocephalus (OR, 1.3; 1.1–1.5 and OR, 2.6; 1.2–5.5), history of diabetes mellitus (pooled OR, 6.7; 1.7–26), and early systemic inflammatory response syndrome (pooled OR, 2.1; 1.4–3.3). Evidence was limited for increased risk in women (pooled OR, 1.3; 1.1–1.6) and in patients with history of hypertension (pooled OR, 1.5; 1.3–1.7). The evidence on initial loss of consciousness, history of migraine, previous use of selective serotonin reuptake inhibitors, hypomagnesemia, low hemoglobin, or high blood flow on early transcranial Doppler was also limited.

Conclusions—

There is strong evidence that smoking is a predictor of delayed cerebral ischemia. For several other potential predictions the evidence is moderate, limited, or inconsistent.

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

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.

Risk Factors Affecting Clinical Outcome of Ruptured Vertebrobasilar Saccular Aneurysms

Objective

Ruptured vertebrobasilar (VB) saccular aneurysm is a difficult lesion to treat, and is associated with high rates of morbidity and mortality. The aim of this study is to investigate the risk factors associated with the clinical outcome of ruptured VB aneurysms.

Methods

A retrospective review of 29 patients with ruptured VB saccular aneurysms between 2002 and 2010 was conducted between Jan 2002 and Dec 2010. Univariate and multivariate analyses were performed for determination of the statistical significance of the Glasgow Outcome Scale (GOS) at three months, according to age, initial Hunt-Hess grade, the presence of acute hydrocephalus, and treatment modality.

Results

The study included 24 (82.7%) females and five (17.3%) males, with a mean age of 59 years (range, 22-78 years). Seventeen patients were treated with surgical clipping and 12 patients were treated with endovascular coil embolization. No statistical significance was observed between clinical outcome and treatment modalities (clipping or coiling; p = 0.803). Seventeen (58.6%) patients achieved favorable outcome, defined as GOS score of 4-5, at 3 months. Procedure-related complications occurred in seven patients (24.1%). Results of multivariate analysis indicated that initial Hunt-Hess grade and the presence of acute hydrocephalus were independent predictors of unfavorable outcome, defined as GOS score of 1-3 (Odds ratio (OR) = 8.63, Confidence interval (CI) [95%] 1.11-66.84, p = 0.039 and OR = 36.64, CI [95%] 2.23-599.54, p = 0.012, respectively).

Conclusion

The present study suggests that the clinical outcomes are related to the initial Hunt-Hess grade and the presence of acute hydrocephalus in ruptured saccular VB aneurysms.

The use of nicardipine prolonged release implants (NPRI) in microsurgical clipping after aneurysmal subarachnoid haemorrhage: comparison with endovascular treatment

BACKGROUND

Nicardipine prolonged release implants (NPRI) have been shown to decrease the incidence of cerebral vasospasm and infarcts significantly in patients after aneurysmal subarachnoid haemorrhage (SAH) following microsurgical clipping. Yet, the comparison with results after endovascular coiling is lacking. This study was conducted to determine the differences in the incidence of cerebral vasospasm and infarctions between those two treatment modalities

METHODS

The design of this investigation reflects a case-control study; 27 patients suffering from acute SAH were treated by microsurgical clipping and received an intracisternal implantation of NPRI. Twenty-seven matching consecutive patients after microsurgical treatment without implantation of NPRI or endovascular treatment, respectively, served as controls. The incidence of angiographic vasospasm and cerebral infarctions were documented.

RESULTS

All groups were comparable concerning demographics and severity of SAH. Twenty-four of 81 patients developed angiographic vasospasm (>33% constriction). The incidence of vasospasm was 48%, 44% and 11% for patients after endovascular treatment, microsurgical clipping without NPRI and microsurgical clipping with NPRI, respectively. New cerebral infarctions occurred in 28%, 22% and 7% of the treated patients, respectively. A good clinical recovery 1 year after the initial bleeding (modified Rankin scale 0-2) was seen in 48%, 50% and 77% of the treated patients, respectively.

CONCLUSION

The use of NPRI during microsurgical clipping was confirmed to be safe and effective. Patients who received intracisternally implanted NPRI during clipping after aneurysmal SAH yielded significantly lower vasospasm and infarction rates, and showed a better clinical outcome when compared with clipping without NPRI and also when compared with endovascular coiling.

Predictors analysis of symptomatic cerebral vasospasm after subarachnoid hemorrhage

PURPOSE

symptomatic cerebral vasospasm (SCVS) is still lacking in reliable early warning methods and often diagnosed after clinical deterioration of neurological function, making prevention and treatment extremely passive. This study investigates the risk factors relevant to SCVS after subarachnoid hemorrhage (SAH) in order to provide useful information for clinical work.

MATERIALS AND METHODS

clinical data of 211 patients with SAH was reviewed in this study. 16 risk factors relevant to SCVS were retrospectively analyzed, including univariate analysis and logistic analysis.

RESULTS

of 211 patients, 81 were found to have SCVS (38.4%). Univariate analysis showed that age, history of hypertension, Hunt-Hess grade at admission, modified Fisher grade, aneurysm location, fever and intraventricular blood clot reached statistical significance (P < 0.05), suggesting that they might be risk factors to SCVS. However, logistic analysis showed that only age (OR=1.027, 95% CI=1.002-1.053, P < 0.05) and modified Fisher grade (OR=2.985, 95% CI=2.048-4.352, P < 0.05) entered the regression equation, suggesting both were independent risk factors.

CONCLUSIONS

SCVS is the final result of multiple factors acting together. Age and modified Fisher grades are independent risk factors to SCVS.

The correlation between COMT gene polymorphism and early cerebral vasospasm after subarachnoid hemorrhage

BACKGROUND

The individual difference of cerebral vasospasm (CVS) degree after subarachnoid hemorrhage (SAH) is common in clinic observation. Numerous studies have found that early CVS after SAH is associated with derangements in catecholamine (CA) metabolism. Catechol-O-methyltransferase (COMT) is a key rate-limiting enzyme in the degradation of CA. In this study, we investigate the correlation between COMT gene polymorphism of patients and early CVS after SAH.

METHODS

One hundred and sixty-seven patients with spontaneous SAH in early stage were selected in this study. COMT genotyping was performed by means of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The degree of CVS was identified by TCD. Hunt-Hess classification was used to evaluate the severity of the patients' condition. The bleeding amount was evaluated by means of Fisher classification of head CT. χ2 test (SPSS13.0 software) and logistic regression were adopted to analyze the correlation of COMT gene polymorphism and other clinical data of patients with early CVS after SAH.

RESULTS

The distribution of each allele matched Hardy-Weinberg law and research samples were heredity equilibrium population. Early CVS incidence of patients with COMT-A allele was much higher than those with COMT-G allele (P<0.01). Early CVS incidence of patients with COMT A/A genotype was obviously higher than those with COMT G/G genotype (P<0.05). Univariate logistic regression demonstrated that COMT-A allele, A/A genotype and Grade 3-5 of Hunt-Hess classification were all associated with early CVS. After adjustment of general information, further multivariate logistic regression demonstrated that COMT-A allele, A/A genotype were risk factors of early CVS after SAH.

CONCLUSION

COMT-A allele, A/A genotype were risk factors of early CVS after SAH.

Management of distal anterior cerebral artery aneurysms: a single institution retrospective analysis (1997-2005)

OBJECTIVE

Our goal was to assess the clinical and angiographic outcomes among patients undergoing treatment for distal anterior cerebral artery aneurysms at the Jefferson Hospital for Neuroscience (1997-2005).

METHODS

Forty-one patients (1.5% of all aneurysms treated) with distal anterior cerebral artery aneurysms had undergone treatment. The clinical and angiographic outcomes of these patients were studied retrospectively using chart reviews, operative reports, and angiographic reports. The mean clinical and angiographic follow-up periods were 16 months (range, 3-74 mo) and 16.5 months (range, 6-81 mo), respectively.

RESULTS

Twenty-eight (68%) patients had undergone endovascular embolization (22 women, six men; mean age, 58.2 yr), whereas 13 (32%) had undergone microsurgery for clip ligation (six men, seven women; mean age, 47.4 yr). Within the coiled group, 50% of the patients belonged in the Hunt and Hess (HH) III and IV groups, whereas 46.2% of the patients in the clipped group were elective patients (HH Grade 0). The mean aneurysmal sizes among the clipped and coiled groups were 4.9 and 5.5 mm, respectively. Among the clipped patient population, 100% of the patients had successful clip ligation as evidenced by intraoperative cerebral angiography, there was a 0% recurrence rate among the two patients who have had long-term follow-up, 0% recurrent subarachnoid hemorrhage, and 92% patients achieved a modified Glasgow Outcome Scale score of I to II. Among the coiled patient population, there was an 89% rate of successful embolization, 18% recurrence rate, 0% recurrent subarachnoid hemorrhage, and 64% achieved a modified Glasgow Outcome Scale score of I to II. None of the patients had clinically symptomatic vasospasm. A strong correlation existed between having a ventriculostomy and requiring a shunt in patients with HH Grade IV compared with patients in HH Grades I through III.

CONCLUSION

In our analysis, clinical outcomes were better in the clipped group; however, the differences are not statistically significant (P = 0.3675) and are explained by the selection bias. Statistically significant predictors of outcomes were age (<60 yr), size of the aneurysm (>5 mm), absence of ventriculostomy, and presenting HH grade.

ENDOVASCULAR COIL EMBOLIZATION OF RUPTURED AND UNRUPTURED POSTERIOR CIRCULATION ANEURYSMS

OBJECTIVE

Treatment of posterior circulation aneurysms poses a great technical challenge for the practicing neurosurgeon. The advent of endovascular techniques has made such treatment more feasible. We report our experience with the endovascular management of ruptured and unruptured posterior circulation aneurysms during the past 10 years.

METHODS

A retrospective analysis was performed on all patients with posterior circulation aneurysms undergoing endovascular treatment at Jefferson Hospital for Neuroscience between July 1995 and December 2005. This yielded 275 patients (67 men and 208 women). The degree of aneurysm occlusion was determined by the operating endovascular neurosurgeon at the time of the procedure. Successful embolization was defined as greater than 95% occlusion of the dome without any coil prolapsing into the parent vessel. Clinical outcome was evaluated using the modified Glasgow Outcome Scale. Clinical follow-up data was obtained for 262 patients (95.3%); the follow-up period ranged from 1 to 94 months (mean, 31.8 mo for procedures performed before 2004 and 13.3 mo for procedures performed during 2004 and 2005). Angiographic follow-up data was obtained for 224 patients (84.8%) for periods ranging from 6 to 94 months (mean, 31.3 mo for procedures performed before 2004 and 13.7 mo for procedures performed during 2004 and 2005).

RESULTS

Based on the Hunt and Hess grading scale, the patient population included 106 patients (38.5%) with unruptured aneurysms, 43 patients (15.6%) with Grade I aneurysms, 16 patients (5.8%) with Grade II aneurysms, 56 patients (20.5%) with Grade III aneurysms, and 54 patients (19.6%) with Grade IV aneurysms. The locations of the posterior circulation aneurysms included 189 (68.7%) in the basilar apex or posterior cerebral artery, 23 (8.4%) in the basilar trunk/anterior inferior cerebellar artery, 22 (8%) in the superior cerebellar artery, and 41 (14.9%) in the vertebral artery or posterior inferior cerebellar artery. Of the 275 patients, 208 (76%) were women and 67 (24%) were men. The mean age at the time of treatment was 53.9 years (range, 7–90 yr). Of all patients treated, 237 patients (87.8%) had successful embolization (&gt;95% occlusion of the dome). On angiographic follow-up, 55 patients (24.5%) developed recanalization of at least 5%. Retreatment was required in 11 patients (4.9%; 0.01%/patient yr) and rehemorrhage occurred in three patients (1.1%; 0.003%/patient yr). Clinical follow-up was graded using the modified Glasgow Outcome Scale (mGOS) and revealed 229 patients (87.4%) in the mGOS I category, 12 patients (4.6%) in the mGOS II category, eight patients (3%) in the mGOS III category, two patients (0.8%) in the mGOS IV category, and 11 patients (4.2%) were deceased (mGOS V). Clinically significant vasospasm requiring angioplasty occurred in 11 patients (6.5%) with subarachnoid hemorrhage, and 120 patients (71%) with subarachnoid hemorrhage required ventricular shunts. Complications causing clinical morbidity occurred in 14 patients (5.1%) and ranged from postoperative ischemia to recurrent subarachnoid hemorrhage. Of all clinical factors evaluated, Hunt and Hess grade was the strongest predictor of good clinical outcome (P &lt; 0.0001).

CONCLUSION

Endovascular coil embolization of posterior circulation aneurysms is an effective treatment in the short term but is associated with recurrence, which requires close surveillance, possible retreatment, and can, albeit very rarely, lead to rehemorrhage. Future technological advancements such as the development of biologically active coils will be essential in the permanent obliteration of aneurysms.