Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-02T18:56:45.422Z Has data issue: false hasContentIssue false
  • English
  • Français

Aneurysmal Surgery in the Presence of Angiographic Vasospasm: An Outcome Assessment

Published online by Cambridge University Press:  10 January 2017

Nancy McLaughlin  and
Michel W. Bojanowski
Nancy McLaughlin
Affiliation:
Division of Neurosurgery, Department of Surgery, Centre Hospitalier de, l'Université de Montréal - Hôpital Notre-Dame, Montreal, Quebec, Canada
Michel W. Bojanowski*
Affiliation:
Division of Neurosurgery, Department of Surgery, Centre Hospitalier de, l'Université de Montréal - Hôpital Notre-Dame, Montreal, Quebec, Canada
*
Division of Neurosurgery, Department of Surgery, CHUM-Hôpital Notre-Dame, 1560 Sherbrooke Est, Montreal, Quebec, H2L 4M1, Canada.
Rights & Permissions [Opens in a new window]

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background and Purpose:

The timing of aneurysmal surgery for patients presenting within the period at risk for vasospasm (VS) is controversial. The goal of this study is to review our experience of surgically treated patients in the presence of angiographic VS.

Materials and Methods:

From 1990-2004, 894 consecutive patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with a policy of early surgery. We retrospectively analyzed the patients that had pre-operative angiographic VS. In this study, symptomatic VS was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic VS without confounding factors. Functional outcome was assessed three months after SAH using the Glasgow Outcome Scale.

Results:

Of the 40 patients studied, 62.5% were in good clinical grade Hunt & Hess (H&H 1-2) on admission; 25%, intermediate grade (H&H 3); 12.5%, poor grade (H&H 4-5). Surgery was performed 24 hours or less after initial angiography in 87.5% of patients and less than 48 hours in 97.5%. Pre-operative symptomatic VS was diagnosed in 25%. Postoperatively, angiographic VS was documented in 87.2%. Of the 30% of patients that presented post-operative symptomatic VS, 66.7% also demonstrated pre-operative symptomatic VS. The functional outcome was favorable in 92.5% of the studied patients. Two deaths occurred in patients presenting pre-operative early radiological and symptomatic VS.

Conclusion:

Aneurysmal surgery, especially between 3-12 days following SAH, in the presence of asymptomatic pre-operative angiographic VS can be associated with a good outcome. Early surgery is not contra-indicated and might enable optimal treatment of VS.

Résumé:

RÉSUMÉ: Contexte et objectif:

Chez les patients qui consultent pour une hémorragie sous-arachnoïdienne (HSA) due à un anévrisme pendant la période à risque de vasospasme (VS), le moment de la ligature de l’anévrisme demeurecontroversé. Le but de cetteétude est de réviser notreexpérience chez des patients traités chirurgicalement en presence de VS angiographique.

Matériel et Méthode:

De 1990 à 2004, 894 patients consécutifs ontété admis pour une HSA due à un anévrisme et ontété traité par unechirurgieprécoce. Nous avonsanalysé de façon rétrospective les patients présentant du VS angiographiquepré-opératoire. Danscetteétude, un diagnostic de VS symptomatiqueétait posé en présence d’une altération de la conscience ou d’un déficit focal survenantaprès une HSA en presence de VS angiographique et en l’absence de facteursconfondants. Le pronosticfonctionnelfutévalué selon l’échelle de Glasgow (GOS) 3 moissuivant l’HSA.

Résultats:

Parmi les 40 patients étudiés, 62,5% étaient en bon grade clinique de Hunt&Hess (H&H 1-2) à l’admission; 25% en grade intermédiaire (H&H 3); 12,5% en mauvais grade (H&H4-5).La chirurgieétait réalisée 24 heuresoumoinsaprès l’angiographie initiale chez 87,5% des patients et 48 heuresoumoins chez 97,5% des patients.Un VS symptomatiquepré-opératoire futdiagnostiqué dans 25% des cas. En post-opératoire, un VS angiographiquefut documenté dans 87,2% des cas. Parmi les 30% qui présentaient un vasospasmesymptomatique post-opératoire, 66,7% avaientégalement présenté un VS symptomatiqueavant la chirurgie. Le pronosticfonctionnelétait favorable chez 92,5% des patients étudiés. Deux décès sontsurvenus chez des patients qui présentaient un VS radiologique et symptomatiqueprécoce.

Conclusion:

La ligature d’un anévrisme rompu, particulièrement entre le 3e et 12e jourssuivantune HSA, en présence de vasospasmeangiographiqueasymptomatiquepré-opératoire, peutêtre associé à un pronostic favorable. La chirurgieprécoce n’est pas contre-indiquée et pourraitfavoriser un traitement optimal du VS.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 33 , Issue 2 , May 2006 , pp. 181 - 188
Copyright
Copyright © The Canadian Journal of Neurological 2006

References

1. Chyatte, D, Fode, NC, Sundt, TM Jr. Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg. 1988;69:326–31.Google Scholar
2. Kassell, NF, Torner, JC, Jane, JA, Halley, EC Jr, Adams, HP. The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. J Neurosurg. 1990;73:37–47.CrossRefGoogle Scholar
3. de Gans, K, Nieuwkamp, DJ, Rinkel, GJ, Algra, A. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery. 2002;50:336–40.Google Scholar
4. Haley, EC Jr, Kassell, NF, Torner, JC. The international cooperative study on the timing of aneurysm surgery. The North American experience. Stroke. 1992;23:205–14.CrossRefGoogle Scholar
5. Ohman, J, Heiskanen, O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg. 1989;70:55–60.Google Scholar
6. Heros, RC, Morcos, JJ. Cerebrovascular surgery: past, present, and future. Neurosurgery. 2000;47:1007–33.Google Scholar
7. Kassell, NF, Torner, JC, Haley, EC Jr, Jane, JA, Adams, HP, Kongable, GL. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg. 1990;73:18–36.Google Scholar
8. Solomon, RA, Onesti, ST, Klebanoff, L. Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia. J Neurosurg. 1991;75:56–61.Google Scholar
9. Suzuki, J, Onuma, T, Yoshimoto, T. Results of early operations on cerebral aneurysms. Surg Neurol. 1979;11:407–12.Google Scholar
10. Grandin, CB, Cosnard, G, Hammer, F, Duprez, TP, Stoobandt, G, Mathurin, P. Vasospasm after subarachnoid hemorrhage: diagnosis with MR angiography. Am J Neuroradiol. 2000;21:1611–17.Google Scholar
11. Anderson, GB, Ashforth, R, Steinke, DE, Findlay, JM. CT angiography for the detection of cerebral vasospasm in patients with acute subarachnoid hemorrhage. Am J Neuroradiol. 2000;21:1011–15.Google ScholarPubMed
12. Kassell, NF, Sasaki, T, Colohan, ART, Nazar, G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke. 1985; 16:562–72.Google Scholar
13. Sandham, JD, Hull, RD, Brant, RF, Knox, L, Pineo, GF, Doig, CJ, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.Google Scholar
14. Corsten, L, Raja, A, Guppy, K, Roitberg, B, Misra, M, Alp, MS, et al. Contemporary management of subarachnoid hemorrhage and vasospasm: the UIC experience. Surg Neurol. 2001;56:140–48.Google Scholar
15. Sen, J, Belli, A, Albon, H, Morgan, L, Petzold, A, Kitchen, N. Triple-H therapy in the management of aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2003;2:614–21.Google Scholar
16. Hudak, ML, Koehler, RC, Rosenberg, AA, Traystman, RJ, Jones, MD Jr. Effect of hematocrit on cerebral blood flow. Am J Physiol. 1986;251:63–70.Google Scholar
17. Sano, K, Saito, I. Timing and indication of surgery for ruptured intracranial aneurysms with regard to cerebral vasospasm. Acta Neurochir (Wien). 1978;4:49–60.Google Scholar
18. Findlay, JM, Macdonald, RL, Weir, BK, Grace, MG. Surgical manipulation of primate cerebral arteries in established vasospasm. J Neurosurg. 1991;75:425–32.Google Scholar
19. Flamm, ES. Parasurgical treatment of aneurysms. Clin Neurosurg. 1977;24:240–7.CrossRefGoogle ScholarPubMed
20. Sundt, TM Jr. Cerebral vasospasm following subarachnoid hemorrhage: evolution, management, and relationship to timing of surgery. Clin Neurosurg. 1977;24:228–39.Google Scholar
21. Macdonald, RL, Wallace, MC, Coyne, TJ. The effect of surgery on the severity of vasospasm. J Neurosurg. 1994;80:433–9.Google Scholar
22. Qureshi, AI, Sung, GY, Suri, MA, Straw, RN, Guterman, LR, Hopkins, LN. Prognostic value and determinants of ultraearly angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery. 1999; 44:967–73.CrossRefGoogle ScholarPubMed
23. Saito, I, Ueda, Y, Sano, K. Significance of vasospasm in the treatment of ruptured intracranial aneurysm. J Neurosurg. 1977;47:412–29.Google Scholar
24. Findlay, JM, Deagle, GM. Causes of morbidity and mortality following intracranial aneurysm rupture. Can J Neurol Sci. 1998;25:209–15.CrossRefGoogle ScholarPubMed
25. Fridriksson, S, Saveland, H, Jakobsson, KE, Edner, G, Zygmunt, S, Brandt, L, et al. Intraoperative complications in aneurysm surgery: a prospective national study. J Neurosurg. 2002; 96:515–22.Google Scholar
26. Göran, E, Kågström, E, Wallstedt, L. Total overall management and surgical outcome after aneurysmal subarachnoid hemorrhage in a defined population. Br J Neurosurg. 1992;6:409–20.Google Scholar
27. Le Roux, PD, Elliot, JP, Newell, DW, Grady, MS, Winn, HR. The incidence of surgical complications is similar in good and poor grade patients undergoing repair of ruptured anterior circulation aneurysms: a retrospective review of 355 patients. Neurosurg. 1996;38:887–95.Google Scholar
28. McLaughlin, N, Bojanowski, MW. Early surgery-related complications after aneurysm clip placement: an analysis of causes and patient outcomes. J Neurosurg. 2004;101:600–6.Google Scholar
29. Proust, F, Hannequin, D, Langlois, O, Freger, P, Creissard, P. Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography. Stroke. 1995;9:1553–7.Google Scholar
30. Wilkins, RH. The role of intracranial arterial spasm in the timing of operations for aneurysm. Clin Neurosurg. 1977;24:185–207.Google Scholar
31. Frykholm, P, Andersson, JL, Langstrom, B, Persson, L, Enblad, P. Haemodynamic and metabolic disturbances in the acute stage of subarachnoid haemorrhage demonstrated by PET. Acta Neurol Scand. 2004;109:25–32.Google Scholar
32. Hayashi, T, Suzuki, A, Hatazawa, J, Kanno, I, Shirane, R, Yoshimoto, T, et al. Cerebral circulation and Metabolism in the acute stage of subarachnoid hemorrhage. J Neurosurg. 2000;93:1014–8.Google Scholar
33. Kawamura, S, Sayama, I, Yasui, N, Uemura, K. Sequential changes in cerebral blood flow and metabolism in patients with subarachnoid haemorrhage. Acta Neurochir (Wien). 1992; 114:12–5.Google Scholar
34. Meyer, CH, Lowe, D, Meyer, M, Richardson, PL, Neil-Dwyer, G. Progressive change in cerebral blood flow during the first three weeks after subarachnoid hemorrhage. Neurosurgery. 1983; 12:5858–76.Google Scholar
35. Prunell, GF, Mathiesen, T, Svendgaard, NA. Experimental subarachnoid hemorrhage: cerebral blood flow and brain metabolism during the acute phase in three different models in the rat. Neurosurgery. 2004;54:426–36.Google Scholar
36. Merory, J, Thomas, DJ, Humphrey, PR, DuBoulay, GH, Marshall, J, Russell, RW, et al. Cerebral blood flow after surgery for recent subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1980;43:214–21.Google Scholar
37. Mountz, JM, McGillicuddy, JE, Wilson, MW, Bartold, SP, Siegal, EM. Pre- and post-operative cerebral blood flow changes in subarachnoid haemorrhage. Acta Neurochir (Wien). 1991; 109:30–3.Google Scholar
38. Rosenstein, J, Wang, AD, Symon, L, Susuki, M. Relationship between hemispheric cerebral blood flow, central conduction time, and clinical grade in aneurysmal subarachnoid hemorrhage. J Neurosurg. 1985;62:25–30.Google Scholar
39. Lang, EW, Diehl, RR, Mehdorn, HM. Cerebral autoregulation testing after aneurysmal subarachnoid hemorrhage: the phase relationship between arterial blood pressure and cerebral blood flow velocity. Crit Care Med. 2001;29:158–63.Google Scholar
40. Soehle, M, Czosnyka, M, Pickard, JD, Kirkpatrick, PJ. Continuous assessment of cerebral autoregulation in subarachnoid hemorrhage. Anesth Analg. 2004;98:1133–9.Google Scholar
41. Yundt, KD, Grubb, RL Jr, Diringer, MN, Powers, WJ. Autoregulatory vasodilation of parenchymal vessels is impaired during cerebral vasospasm. J Cereb Blood Flow Metab. 1998;18:419–24.Google Scholar
42. Baldwin, ME, Macdonald, RL, Huo, D, Novakovic, RL, Goldenberg, FD, Frank, JI, et al. Early vasospasm on admission angiography in patients with aneurysmal subarachnoid hemorrhage is a predictor for in-hospital complications and poor outcome. Stroke. 2004;35:2506–11.Google Scholar
43. Dehdashti, AR, Mermillod, B, Rufenacht, DA, Reverdin, A, de Tribolet, N. Does treatment modality of intracranial ruptured aneurysms influence the incidence of cerebral vasospasm and clinical outcome? Cerebrovasc Dis. 2004;17:53–60.Google Scholar
44. Goddard, AJ, Raju, PP, Gholkar, A. Does the method of treatment of acutely ruptured intracranial aneurysms influence the incidence and duration of cerebral vasospasm and clinical outcome? J Neurol Neurosurg Psychiatry. 2004;75:868–72.Google Scholar
45. Hoh, BL, Topcuoglu, MA, Singhal, AB, Pryor, JC, Rabinov, JD, Rordorf, GA, et al. Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2004;55:779–86.Google Scholar
46. Rabinstein, AA, Pichelmann, MA, Friedman, JA, Piepgras, DG, Nichols, DA, McIver, JI. Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion. J Neurosurg. 2003;98:319–25.Google Scholar
47. Sugiu, K, Katsumata, A, Ono, Y, Tamiya, T, Ohmoto, T. Angioplasty and coiling of ruptured aneurysm with symptomatic vasospasm: technical case report. Surg Neurol. 2003;59:413–7.Google Scholar
48. Murayama, Y, Song, JK, Uda, K, Gobin, YP, Duckwiler, GR, Tateshima, S. Combined endovascular treatment for both intracranial aneurysm and symptomatic vasospasm. Am J Neuroradiol. 2003;24:133–9.Google Scholar