Recurrent Subarachnoid Hemorrhage Research Articles

Study of the effectiveness factors of microsurgical treatment of cerebral arterial aneurysms

BACKGROUND: Despite improvements in diagnostic methods and microsurgical techniques for treating arterial aneurysms of the cerebral vessels, there remains a high probability of mortality and persistent disability among the working population. AIM: To determine the factors influencing the effectiveness of surgical interventions in patients with cerebral arterial aneurysms. MATERIALS AND METHODS: This scientific work presents the results of examination and surgical treatment of 86 patients operated on from 2017 to 2023 y. at the Neurosurgery Clinic of the National Hospital. The age of the patients ranged from 23 to 78 years (average age - 47±1.7 years), among them there were 48 (55.8%) men, 38 (44.2%) women. All patients underwent MRI or CT angiography of cerebral vessels; in 47 (54.6%) patients, cerebral aneurysm was confirmed by selective cerebral angiography. The size of the aneurysms ranged from miliary (3.0 mm to giant sizes 25.0-30.0 mm). RESULTS: The clinical picture of patients with ruptured arterial aneurysms was associated with the prevalence of subarachnoid hemorrhage, the location and volume of formed intracerebral hematomas in patients in the pre-hemorrhagic period with unruptured aneurysms - with the location and size of arterial aneurysms. One of the serious complications that arose during operations was intraoperative rupture (15.1%) of the aneurysmal sac at different stages of operations. The worst results with mortality up to 4.17% were observed in patients with ruptured arterial aneurysms, on the HH scale III, IV and 7-8, 9-10 points on the Glasgow scale. In cases where direct access to the aneurysm is difficult, it is advisable to perform subpial microresection of the altered medulla around the aneurysm. This allows you to avoid traumatic damage to the walls of the aneurysm and the development of spasm of arterial vessels. In order to avoid aneurysm rupture when isolating the aneurysm neck, it is advisable to temporarily apply special removable (temporary) clips to the proximal and distal segments of the supporting vessel of the aneurysm. After it was possible to isolate the neck of the aneurysm, a special clip was applied and, if possible, the patency and integrity of the vessel carrying the aneurysm and its branches were preserved. To determine the absence of blood flow in the aneurysm and assess the patency of arterial vessels, it is recommended to use intraoperative microvascular doplefography. CONCLUSION: The results of surgical treatment for ruptured aneurysms depended on the preoperative condition of the patients. Microsurgical clipping of arterial aneurysms effectively prevents the risk of recurrent subarachnoid hemorrhage. The absence of complications in patients during surgery and the early postoperative period does not guarantee the possibility of developing delayed complications that may require repeated operations.

Isolated spinal artery aneurysm: etiology, clinical characteristics, and outcomes.

Isolated spinal aneurysms (ISAs) are rare causes of subarachnoid hemorrhage (SAH), which encompass a highly heterogeneous group of clinical entities with multifarious pathogeneses, clinical characteristics, and treatment strategies. Therefore, knowledge about the ISAs remains inadequate. In this study, the authors present a comprehensive analysis of clinical data associated with ISAs at their institutions to enhance the understanding of this disease. Patients with ISAs confirmed by spinal angiography or surgery at the authors' institutions between 2015 and 2022 were included. Data regarding clinical presentation, lesion location, aneurysm morphology, comorbidities, treatment results, and clinical outcomes were reviewed. Seven patients with ISAs were included in the study. Among them, 4 patients (57.1%) experienced severe headache, and 3 patients (42.9%) reported sudden-onset back pain. Additionally, lower-extremity weakness and urinary retention were observed in 2 of these patients (28.6%). Four of the aneurysms exhibited fusiform morphology, whereas the remaining were saccular. All saccular aneurysms in this series were attributed to hemodynamic factors. Conservative treatment was administered to 3 patients, 2 of whom underwent follow-up digital subtraction angiography, which showed spontaneous occlusion of both aneurysms. Four patients ultimately underwent invasive treatments, including 2 who underwent microsurgery and 2 who received endovascular embolization. One patient died of recurrent SAH, while the remaining 6 patients had a favorable prognosis at the latest follow-up assessment. The morphology of aneurysms may be associated with their etiology. Saccular ISAs are usually caused by pressure due to abnormally increased blood flow, whereas fusiform lesions may be more likely to be secondary to vessel wall damage. The authors found that a saccular spinal aneurysm in young patients with a significant dilated parent artery may be a vestige of spinal cord arteriovenous shunts. ISAs can be managed by surgical, endovascular, or conservative procedures, and the clinical outcome is generally favorable. However, the heterogeneous nature of the disease necessitates personalized treatment decision-making based on specific clinical features of each patient.

Subarachnoid Hemorrhage Because of Ruptured Multiple Peripheral Fusiform Aneurysms Associated With Systemic Lupus Erythematosus: A Case Report

BACKGROUND AND IMPORTANCE: In rare cases, systemic lupus erythematosus (SLE) can cause subarachnoid hemorrhage (SAH) because of aneurysm rupture. Such aneurysms are most commonly located in the posterior circulatory system, but can occur extremely rarely in the spinal vascular territory. CLINICAL PRESENTATION: We describe a patient with SLE who had a sudden onset of posterior neck pain. Cranial computed tomography and MRI showed SAH, but no aneurysm could be identified on computed tomography angiography or magnetic resonance angiography. Digital subtraction angiography (DSA) revealed multiple small fusiform aneurysms in the spinal vascular territory, which were treated conservatively without rebleeding. One year later, the patient suffered from recurrent SAH. On DSA, the fusiform aneurysms seen at the previous admission had disappeared and a de novo small fusiform aneurysm was observed in the anterior spinal artery. Conservative treatment was performed, and rebleeding was not observed thereafter. On follow-up DSA performed 2 weeks later, the aneurysm had decreased in size. CONCLUSION: In SLE, spinal arteriography should be performed to evaluate the possible development of peripheral fusiform aneurysms in the spinal vascular territory associated with vasculitis, and careful follow-up is necessary considering the risk of rebleeding because of de novo aneurysms.

P.128 Recurrent subarachnoid hemorrhage secondary to Chiari 1 malformation

Background: We describe a patient with recurrent subarachnoid hemorrhage (SAH) secondary to Chiari 1 malformation. Methods: A retrospective review of the clinical chart was performed. Results: A previously healthy female in her 70’s presented with worst headache of life. CT demonstrated 4th ventricular hemorrhage with SAH extending into the bilateral cerebellomedullary fissures. CTA did not show a vascular etiology and patient was discharged home. Incidental note was made of a right persistent trigeminal artery. The patient then represented 2 weeks later with worst headache of life and decreased level of consciousness. CT demonstrated extensive SAH extending into the 3rd and 4th ventricles. CTA and diagnostic cerebral angiogram did not show a vascular etiology. MRI brain/C-spine revealed Chiari 1 malformation. An external ventricular drain was placed but could not be weaned. She underwent suboccipital craniectomy with C1 laminectomy. Intraoperatively, there was a prominent dorsal spinal vein that appeared under tension as it pierced the arachnoid membrane and subsequently entering the dura as a rudimentary occipital sinus. This vein was coagulated and divided. The patient recovered well and was at neurological baseline at 6 month follow-up. Conclusions: This is the first reported case of recurrent SAH secondary to Chiari 1 malformation.

СЛУЧАЙ УСПЕШНОГО ОТКРЫТОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ГИГАНТСКОЙ АНЕВРИЗМЫ СУПРАКЛИНОИДНОГО ОТДЕЛА ВНУТРЕННЕЙ СОННОЙ АРТЕРИИ

Methods: Despite the progress in developing high-tech methods for neurosurgical patient treatment, managing giant internal carotid artery (ICA) aneurysms remains challenging. We report a case of the successful surgical treatment of a patient with a highly complex clinical problem – a giant aneurysm (GA) at the right supraclinoid ICA. First, the extent of an open surgical intervention was as follows: the ICA was exposed using a linear neck incision and mobilized. Then, osteoplastic skull trepanation in the pterional region and the aneurysmal portion of supraclinoid ICA was performed. The chosen surgical tactics prevented recurrent subarachnoid and intracerebral hemorrhage, ischemia, edema, and brain compression, which are closely related to death and disability. Based on the above, the treatment method has been considered a practical option for treating this cohort of patients. Keywords: Internal carotid artery, aneurysm, clipping, intracranial hemorrhage, intraventricular hemorrhage.

Abstract WP136: Recurrent Intracerebral Hemorrhage In Patients With Cerebral Amyloid Angiopathy

Background: Studies suggest an increased risk of recurrent intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA). In this study, we sought to compare the rates of recurrent cerebrovascular events in patients admitted for ICH with and without CAA. Methods: We utilized the National Readmissions Database 2016-2018 to identify hospitalizations with the primary discharge diagnosis of ICH with and without a concomitant diagnosis of CAA. Hospitalizations with age >55 years, survival to discharge, and known discharge disposition were included for further analysis. Propensity score matching was used to match for the differences in demographics, comorbidities, and disease severity between the CAA and no CAA groups. Survival analysis was performed to evaluate the rates of recurrent ICH, subarachnoid hemorrhage (SAH), and acute ischemic stroke (AIS) in the propensity-matched groups. Results: A total of 194,290 patients with ICH met the study inclusion criteria; 8,247 with CAA and 186,043 without CAA. After propensity score matching, we identified 7,857 hospitalizations with CAA and 7,874 without CAA. Patients with CAA were more likely to be readmitted due to ICH [hazards ratio (HR): 3.4, 95% confidence interval (CI): 2.6-4.6, P <0.001] and SAH (HR: 2.5, 95% CI: 1.2-5.4, P 0.007) during the mean follow-up period of 6 months. However, there was no statistically significant difference in readmissions due to AIS (HR: 0.7, 95% CI: 0.5-1.0, P 0.061) [Figure 1]. Age (HR: 0.96 per year increase in age, 95% CI: 0.95-0.98, P <0.001) and Medicare payer (HR: 3.23; 95% CI: 1.92-5.41, P <0.001) were independently associated with readmissions due to ICH. Conclusions: Patients admitted for ICH with a secondary diagnosis of CAA are three times more likely to have readmissions for recurrent ICH compared to patients without CAA.

The Potential Value of 320-Row Computed Tomography Angiography in Digital Subtraction Angiography–Negative Spontaneous Subarachnoid Hemorrhage Patients

ObjectiveThis study aimed to investigate the clinical value of multiphase and multiparametric 320-row computed tomography (CT) in the long-term follow-up of spontaneous subarachnoid hemorrhage (SAH) with initially negative CT angiography (CTA) and digital subtraction angiography (DSA) results.MethodsWe retrospectively analyzed the clinical data of 35 patients with nontraumatic angiographically negative SAH results from February 2012 to December 2015. Regular follow-up was performed with 320-row CTA, CT venography, and CT perfusion.ResultsAll patients received 320-row CT follow-up for 0.5 to 4 years. The diagnostic yield of the follow-up examinations was 4 of 35 (11.4%), 3 of 31 (9.7%), and 1 of 28 (3.6%) for the first, second, and third time points, respectively. Two patients were admitted to the hospital because of recurrent subarachnoid hemorrhage during the follow-up period and diagnosed with ruptured aneurysms.ConclusionsPatients with SAH with negative findings in the first DSA examination require to follow up. Follow-up using 320-row CTA, CT venography, and CT perfusion allows for a noninvasive diagnostic test for cerebrovascular diseases with higher compliance and fewer complications when compared with follow-up using DSA.

Recurrent intracerebral hemorrhage in patients with cerebral amyloid angiopathy: a propensity-matched case-control study.

Cerebral amyloid angiopathy (CAA) can present with intracerebral hemorrhage (ICH), convexity subarachnoid hemorrhage (SAH), and rarely acute ischemic stroke (AIS). The objective of our study was to compare the readmission rates for recurrent ICH, SAH, and AIS among patients admitted for ICH with and without CAA. Using the National Readmissions Database 2016-2018 we identified patients admitted for ICH with and without a concomitant diagnosis of CAA. Primary outcome of the study was readmission due to ICH. Secondary outcomes included readmissions due to AIS and SAH. Survival analysis was performed, and Kaplan-Meier curves were created to assess for readmissions. The study consisted of 194,290 patients with ICH, 8247 with CAA and 186,043 without CAA as a concomitant diagnosis. After propensity matching, we identified 7857 hospitalizations with CAA and 7874 without CAA. Patients with CAA had higher risk of readmission due to ICH as compared to those without CAA [hazards ratio (HR) 3.44, 95% confidence interval (CI) 2.55-4.64, P < 0.001] during the mean follow-up period of 181.4 (SD ± 106.4) days. Patients with CAA were also more likely to be readmitted due to SAH (HR 2.52, 95% CI 1.18-5.37, P 0.017) but not due to AIS (HR 0.74, 95% CI 0.54-1.01, P 0.061). Age (HR 0.96 per year increase in age, 95% CI 0.94-0.98, P < 0.001) and Medicare payer (HR 3.31; 95% CI 1.89-5.78, P < 0.001) were independently associated with readmissions due to ICH. Patients admitted for ICH with a concomitant diagnosis of CAA are three times more likely to have readmissions for recurrent ICH compared to patients without CAA.

Risk of intracranial haemorrhage and ischaemic stroke after convexity subarachnoid haemorrhage in cerebral amyloid angiopathy: international individual patient data pooled analysis

ObjectiveTo investigate the frequency, time-course and predictors of intracerebral haemorrhage (ICH), recurrent convexity subarachnoid haemorrhage (cSAH), and ischemic stroke after cSAH associated with cerebral amyloid angiopathy (CAA).MethodsWe performed a systematic review and international individual patient-data pooled analysis in patients with cSAH associated with probable or possible CAA diagnosed on baseline MRI using the modified Boston criteria. We used Cox proportional hazards models with a frailty term to account for between-cohort differences.ResultsWe included 190 patients (mean age 74.5 years; 45.3% female) from 13 centers with 385 patient-years of follow-up (median 1.4 years). The risks of each outcome (per patient-year) were: ICH 13.2% (95% CI 9.9–17.4); recurrent cSAH 11.1% (95% CI 7.9–15.2); combined ICH, cSAH, or both 21.4% (95% CI 16.7–26.9), ischemic stroke 5.1% (95% CI 3.1–8) and death 8.3% (95% CI 5.6–11.8). In multivariable models, there is evidence that patients with probable CAA (compared to possible CAA) had a higher risk of ICH (HR 8.45, 95% CI 1.13–75.5, p = 0.02) and cSAH (HR 3.66, 95% CI 0.84–15.9, p = 0.08) but not ischemic stroke (HR 0.56, 95% CI 0.17–1.82, p = 0.33) or mortality (HR 0.54, 95% CI 0.16–1.78, p = 0.31).ConclusionsPatients with cSAH associated with probable or possible CAA have high risk of future ICH and recurrent cSAH. Convexity SAH associated with probable (vs possible) CAA is associated with increased risk of ICH, and cSAH but not ischemic stroke. Our data provide precise risk estimates for key vascular events after cSAH associated with CAA which can inform management decisions.

Coaxial Access for Microcatheter Stabilization During Aneurysm Coiling: 2-Dimensional Operative Video.

Coaxial support is a fundamental technique utilized by neurointerventionalists to optimize distal catheter control within the intracranial circulation. Here we present a 41-yr-old woman with a previously coiled ruptured anterior communicating artery aneurysm with progressive recurrence harboring tortuous internal carotid anatomy to demonstrate the utility of coaxial support. Raymond-Roy classification of initial aneurysm coiling of class 1 resulted as class 3b over the 21 mo from initial treatment.1 The patient consented to stent-assisted coiling for retreatment of this aneurysm. Coaxial support was advanced as distally as possible in the proximal vasculature to improve catheter control, reducing dead space within which the microcatheter could move, decreasing angulations within proximal vasculature, limiting the movement of the native vessels, and providing a surface of lower friction than the endothelium. As the risk of recurrent subarachnoid hemorrhage in previously treated coiled aneurysms approaches 3%, retreatment occurs in 16.4% within 6 yr2 and in 17.4% of patients within 10 yr.3 Rerupture is slightly higher in patients who underwent coiling vs clipping, with the rerupture risk inversely proportional to the degree of aneurysm occlusion,4 further substantiating that coaxial support provides technical advantage in selected patients where additional microcatheter control is necessary for optimal occlusion. Pitfalls of this technique include vasospasm and vascular injury, which can be ameliorated by pretreatment of the circulation with vasodilators to prevent catheter-induced vasospasm. This case and model demonstration illustrates the technique of coaxial access in the stent-assisted coiling of a recurrent anterior communicating artery aneurysm and identification and management of catheter-induced vasospasm.

A Rare Treatable and Under Recognized Cause of Recurrent Convexity Subarachnoid Hemorrhage: Lupus Anticoagulant Hypoprothombinemia Syndrome.

A Rare Treatable and Under Recognized Cause of Recurrent Convexity Subarachnoid Hemorrhage: Lupus Anticoagulant Hypoprothombinemia Syndrome.

An unusual cause of superficial siderosis of central nervous system: A case report of a vestibular schwannoma

Vestibular schwannomas are relatively common benign tumors that account for 7-8% of all intracranial tumors. There is a limited number of cases of subarachnoid hemorrhage associated with vestibular schwannoma in the literature. The incidence of symptomatic tumor bleeding is historically reported less than 1%. Susceptibility-weighted imaging (SWI) is a relatively new Magnetic Resonance Imaging (MRI) sequence that is highly sensitive to compounds which distort the local magnetic field such as blood products and hemorrhage. We herein report the rare MRI findings of a 53-year-old man with unilateral vestibular schwannoma and hearing loss who was followed for 4 years. Initial diagnosis of the vestibular schwannoma was made on prior conventional MRI. We included SWI sequence in routine brain MRI protocol. During follow-up, SWI demonstrated focal superficial siderosis due to recurrent subarachnoid hemorrhage seen as hypointense blooming artifacts on the middle cerebellar peduncle-pons junction adjacent to the mass. We think that including SWI in routine MRI protocol will contribute to the initial diagnosis of acoustic schwannoma and detection of its complications such as subarachnoid hemorrhage and subsequent superficial siderosis.

Coil embolization of saccular frontopolar artery aneurysm.

In this case report, a distal anterior cerebral artery aneurysm was presented. While most distal anterior aneurysms occur at the bifurcation of the pericallosal and callosomarginal arteries, this particular aneurysm occurred at the frontopolar artery, a case rarely reported in published literature. The aneurysm had a recurrent subarachnoid haemorrhage due to the rupture of a saccular aneurysm and was treated through endovascular coiling.

Focused Neuro-Otological Review of Superficial Siderosis of the Central Nervous System.

Infratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge. We reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS. The epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips. iSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.

Treatment of Intracranial Aneurysms With the SILK Embolization Device in a Multicenter Study. A Retrospective Data Analysis.

BACKGROUNDFlow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device.OBJECTIVETo evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology.METHODSWe retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively.RESULTSA total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively.CONCLUSIONSThe SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.

Erratum to: Thrombectomy for ischemic stroke: meta-analyses of recurrent strokes, vasospasms, and subarachnoid hemorrhages.

Mechanical thrombectomy with stent retrievers is an effective treatment for patients with ischemic stroke. Results of recent meta-analyses report that the treatment is safe. However, the endpoints recurrent stroke, vasospasms, and subarachnoid hemorrhage have not been evaluated sufficiently. Hence, we extracted data on these outcomes from the five recent thrombectomy trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA published in 2015). Subsequently, we conducted meta-analyses for each outcome. We report the results of the fixed, as well as the random effects model. Three studies reported data on recurrent strokes. While the results did not reach statistical significance in the random effects model (despite a three times elevated risk), the fixed effects model revealed a significantly higher rate of recurrent strokes after thrombectomy. Four studies reported data on subarachnoid hemorrhage. The higher pooled rates in the intervention groups were statistically significant in both, the fixed and the random effects model. One study reported on vasospasms. We recorded 14 events in the intervention group and none in the control group. The efficacy of mechanical thrombectomy is not questioned, yet our results indicate an increased risk for recurrent strokes, subarachnoid hemorrhage, and vasospasms post-treatment. Therefore, we strongly recommend a thoroughly surveillance, concerning these adverse events in future clinical trials and routine registries.

Thrombectomy for ischemic stroke: meta-analyses of recurrent strokes, vasospasms, and subarachnoid hemorrhages.

Mechanical thrombectomy with stent retrievers is an effective treatment for patients with ischemic stroke. Results of recent meta-analyses report that the treatment is safe. However, the endpoints recurrent stroke, vasospasms, and subarachnoid hemorrhage have not been evaluated sufficiently. Hence, we extracted data on these outcomes from the five recent thrombectomy trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA published in 2015). Subsequently, we conducted meta-analyses for each outcome. We report the results of the fixed, as well as the random effects model. Three studies reported data on recurrent strokes. While the results did not reach statistical significance in the random effects model (despite a three times elevated risk), the fixed effects model revealed a significantly higher rate of recurrent strokes after thrombectomy. Four studies reported data on subarachnoid hemorrhage. The higher pooled rates in the intervention groups were statistically significant in both, the fixed and the random effects model. One study reported on vasospasms. We recorded 14 events in the intervention group and none in the control group. The efficacy of mechanical thrombectomy is not questioned, yet our results indicate an increased risk for recurrent strokes, subarachnoid hemorrhage, and vasospasms post-treatment. Therefore, we strongly recommend a thoroughly surveillance, concerning these adverse events in future clinical trials and routine registries.

Early prediction and outcome of septic encephalopathy in acute stroke patients with nosocomial coma.

BackgroundSeptic encephalopathy (SE) is the most common acute encephalopathy in ICU; however, little attention has been focused on risk of SE in the course of acute stroke. Our aim is to investigate the early prediction and outcome of SE in stroke patients with nosocomial coma (NC).MethodsA retrospective cohort study was conducted in an ICU of the tertiary teaching hospital in China from January 2006 to December 2009. Ninety-four acute stroke patients with NC were grouped according to with or without SE. Risk factors for patients with SE were compared with those without SE by univariate and multivariate analysis.ResultsOf 94 stroke patients with NC, 46 (49%) had NC with SE and 48 (51%) had NC without SE. The onset-to-NC time was significant later in stroke patients with SE than those without SE (P < 0.01). There was a significant difference in body temperature, heart rate, respiratory rate, white blood cell (WBC), systolic blood pressure (SBP), diastolic blood pressure (DBP), systemic inflammatory response syndrome (SIRS), acute respiratory failure, septic shock, hypernatremia, and sequential organ failure assessment (SOFA) score between the SE and non-SE group (P < 0.05). On a repeat head imaging, vasogenic edema (P = 0.023) and subcortical white matter lesions (P = 0.011) were significantly higher in patients with SE than those without SE, while hematoma growth (P = 0.000), infarction progress (P = 0.003), and recurrent subarachnoid hemorrhage (SAH) (P = 0.011) were significantly lower in patients with SE than those without SE. Patients with SE had higher adjusted rates of fever ≥ 39 °C (odds ratio (OR): 2.753; 95% confidence interval (CI): 1.116 - 6.794; P = 0.028) and SIRS ≥ 3 items (OR: 6.459; 95% CI: 2.050 - 20.351; P = 0.001). The 30-day mortality in stroke patients with SE was higher than those without SE (76.1% vs. 45.8%, P = 0.003).ConclusionHigh fever and severe SIRS are two early predictors of stroke patients with SE, and survival rates were worse in stroke patients with SE than those without SE.

Long-Term Angiographic Findings in Patients Treated With Microsurgical Clipping of Intracranial Aneurysms

Microsurgical clipping remains a durable treatment for intracranial aneurysms. Despite the low rate of re-treatment, recurrence of subarachnoid hemorrhage is 3% within the first 10 years. This may be caused by rupture of a recurrent or residual aneurysm at the clip site or by rupture of another untreated aneurysm. We investigated the natural history of aneurysms treated with microsurgical clipping at our institution over a 10-year period. A secondary objective was to analyze our compliance rate with follow-up angiograms at three and 10 years and to investigate a role for less-invasive imaging modalities to manage microsurgical clipping patients. Ruptured and/or unruptured aneurysm patients treated with microsurgical clipping from 2000–2008 who had angiographic follow-up were included. Data were analyzed with respect to formation of de novo aneurysms, presence of residual aneurysm after clipping, and the rate of recurrence after complete clipping. There were 24 residual aneurysms (13%), two de novo aneurysms (1%) and one recurrent aneurysm (0.5%). The size of the aneurysm was significantly associated with having a residual aneurysm. Patient sex was also significantly associated with having a residual aneurysm. Compliance with angiographic follow-up occurred in 31% of patients treated with the majority only having one study at three years. Microsurgical clipping of aneurysms is durable with a low rate of recurrence and rebleeding. Residuals do not show angiographic progression and rarely require re-treatment. Compliance with angiographic follow-up is poor and this suggests that less invasive and expensive imaging modalities should be evaluated. Categories: Neurosurgery

The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT)

SummaryBackgroundPrevious analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on the risks of recurrent subarachnoid haemorrhage and death or dependency for a minimum of 5 years and up to a maximum of 14 years after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or endovascular coiling. At 1 year there was a 7% absolute and a 24% relative risk reduction of death and dependency in the coiling group compared with the clipping group, but the medium-term results showed the increased need for re-treatment of the target aneurysm in the patients given coiling. We report the long-term follow-up of patients in this UK cohort.MethodsIn ISAT, patients were randomly allocated to either neurosurgical clipping or endovascular coiling after a subarachnoid haemorrhage, assuming treatment equipoise, between Sept 12, 1994, and May 1, 2002. We followed up 1644 patients in 22 UK neurosurgical centres for death and clinical outcomes for 10·0–18·5 years. We assessed dependency as self-reported modified Rankin scale score obtained through yearly questionnaires. Data for recurrent aneurysms and rebleeding events were collected from questionnaires and from hospital and general practitioner records. The Office for National Statistics supplied data on deaths. This study is registered, number ISRCTN49866681.FindingsAt 10 years, 674 (83%) of 809 patients allocated endovascular coiling and 657 (79%) of 835 patients allocated neurosurgical clipping were alive (odds ratio [OR] 1·35, 95% CI 1·06–1·73). Of 1003 individuals who returned a questionnaire at 10 years, 435 (82%) patients treated with endovascular coiling and 370 (78%) patients treated with neurosurgical clipping were independent (modified Rankin scale score 0–2; OR 1·25; 95% CI 0·92–1·71). Patients in the endovascular treatment group were more likely to be alive and independent at 10 years than were patients in the neurosurgery group (OR 1·34, 95% CI 1·07–1·67). 33 patients had a recurrent subarachnoid haemorrhage more than 1 year after their initial haemorrhage (17 from the target aneurysm).InterpretationAlthough rates of increased dependency alone did not differ between groups, the probability of death or dependency was significantly greater in the neurosurgical group than in the endovascular group. Rebleeding was more likely after endovascular coiling than after neurosurgical clipping, but the risk was small and the probability of disability-free survival was significantly greater in the endovascular group than in the neurosurgical group at 10 years.FundingUK Medical Research Council.