Surgery For Ruptured Aneurysm Research Articles

Understanding the importance of the primary trial hypothesis: The randomized trial on the timing of ruptured aneurysm surgery

Background and purposeThe primary hypothesis of a trial must be explicitly formulated. The primary hypothesis is essential for the proper interpretation of trial results. MethodsWe review the seminal Finnish randomized trial on the timing of aneurysm surgery, and re-examine how trial results could have been interpreted at the time had a precise primary hypothesis been pre-specified. Finally, we compare the power of this single center randomized trial with the multicenter International Cooperative (observational) Study that examined the same clinical problem. ResultsHad the Finnish authors worked under a pragmatic hypothesis in favor of early surgery (within 3days) versus delayed surgery, the trial results could have been interpreted as conclusive. The randomized trial was more appropriate, more ethical, and more efficient than the inconclusive International Cooperative study. ConclusionThe randomized trial on the timing of aneurysm surgery was a landmark in neurovascular research. A precise pragmatic primary hypothesis is a crucial step in trial design and interpretation.

Clinical Efficacy of Shenmai Injection in the Treatment of Cerebral Vasospasm after Ruptured Aneurysm Surgery

Objective: To investigate the therapeutic effect of Shenmai Injection on postoperative cerebral vasospasm in patients with ruptured aneurysms. Methods: Seventy patients undergoing craniotomy for ruptured aneurysms in our hospital were selected as study subjects and randomly divided into control (n = 33) and research (n = 37) groups, they were treated with nimodipine and nimodipine combined with Shenmai injection after operation. The blood flow velocity in the middle cerebral artery (MCA) before and at 1, 3, 7, 11 and 14 days after surgery and the incidence of cerebral vasospasm during these days were compared, and the GCS scores at 14 days postoperatively and GOS scores at 6 months postoperatively were compared between the two groups. Results: There were no statistically significant differences in the occurrence of cerebral vasospasm, GCS or GOS scores between the two groups (P > 0.05), but the period of postoperative cerebral vasospasm in the study group was significantly shorter than that in the control group. Conclusion: Shenmai injection has the effect of shortening the cycle of occurrence of cerebral vasospasm after the operation of ruptured aneurysms, promoting patients to recover as early as possible and reducing their physical and mental burden.

Prediction of Outcomes for Ruptured Aneurysm Surgery.

Background and Purpose- Predicting long-term functional outcomes after intracranial aneurysmal rupture can be challenging. We developed and validated a scoring system-the Southwestern Aneurysm Severity Index-that would predict functional outcomes at 1 year after clipping of ruptured aneurysms. Methods- Ruptured aneurysms treated microsurgically between 2000 and 2014 were included. Outcome was defined as Glasgow Outcome Score (ranging from 1, death, to 5, good recovery) at 1 year. The Southwestern Aneurysm Severity Index is composed of multiple prospectively recorded patient demographic, clinical, radiographic, and aneurysm-specific variables. Multivariable analyses were used to construct the best predictive models for patient outcomes in a random 50% of the cohort and validated in the remaining 50%. A scoring system was created using the best model. Results- We identified 527 eligible patients. The Glasgow Outcome Score at 1 year was 4 to 5 in 375 patients (71.2%). In the multivariable logistic regression, the best predictive model for unfavorable outcome included intracerebral hemorrhage (odds ratio [OR], 2.53; 95% CI, 1.55-4.13), aneurysmal size ≥20 mm (OR, 6.07; 95% CI, 1.92-19.2), intraventricular hemorrhage (OR, 2.56; 95% CI, 1.15-5.67), age >64 (OR, 3.53; 95% CI, 1.70-7.35), location (OR, 1.82; 95% CI, 1.10-3.03), and hydrocephalus (OR, 2.39; 95% CI, 1.07-5.35). The Southwestern Aneurysm Severity Index predicts Glasgow Outcome Score at 1 year with good discrimination (area under the receiver operating characteristic curve, derivation: 0.816, 95% CI, 0.759-0.873; validation: 0.803, 95% CI, 0.746-0.861) and accurate calibration ( R2=0.939). Conclusions- The Southwestern Aneurysm Severity Index has been internally validated to predict 1 year Glasgow Outcome Scores at initial presentation, thus optimizing patient or family counseling and possibly guiding therapeutic efforts.

Microsurgical Vascular Manipulation in Aneurysm Surgery and Delayed Ischemic Injury.

The role of aggressive surgical manipulation with clot evacuation, arachnoid dissection, and papaverine-guided adventitial dissection of large vessels during ruptured aneurysm surgery in reducing vasospasm is controversial. Here we describe a single-institution experience in aneurysm surgery outcomes with and without aggressive surgery. We performed retrospective analysis of all patients >18 years of age with subarachnoid hemorrhage (SAH) from anterior circulation aneurysms between 2008 and 2013 at the University of New Mexico Hospital. Vasospasm was characterized on days 3 through 14 after SAH based on: (1) angiography, (2) vasospasm requiring angiographic intervention, (3) development of delayed ischemic neurologic deficit (DIND), and (4) radiological appearance of new strokes. Of 159 patients, 114 (71.6%) had "aggressive" and 45 (28.3%) had standard microsurgery. More than 60% of patients presented with a Hunt and Hess score of ≥3 and a Fisher grade (FG) of 4. Compared with standard surgery, there was a statistically significant decrease in the incidence of DIND in patients undergoing aggressive surgery (18.4% vs 37.8%, p=0.01). Moreover, there was a reduction in the number of new strokes by 30% in the aggressive surgery group with moderate or higher degrees of vasospasm (46.0% vs 76.5%, p=0.06). In the same group with FG 4 SAH, however, this difference was more than 50% (30% vs 64.7%, p=0.02). We conclude that aggressive surgical manipulation during aneurysm surgery results in lower incidence of DIND and new strokes. This effect is most pronounced in patients with FG 4 SAH.

Brain stem herniation secondary to cerebrospinal fluid drainage in ruptured aneurysm surgery: a case report.

BackgroundA lumbar drainage catheter is frequently placed intra-operatively to decrease fluid pressure on the brain in aneurysmal subarachnoid cases. In rare cases, this catheter placement can lead to intracranial hypotension, resulting in brain stem herniation termed “brain sag” and it can lead to neurological injury and may prove to be fatal. We present our patient with brain sag secondary to intraoperative lumbar drainage. Case descriptionA 56-year-old woman was admitted with a sudden onset of severe headache. A computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage with ruptured anterior communicating artery aneurysm. After general anesthesia, a lumbar drainage catheter was placed intra-operatively to reduce pressure on the brain and 50 cc of CSF was removed during a 5-h period. Three to five days after operation, her neurologic symptoms became worse with an altered mental state and pupillary asymmetry. CT and magnetic resonance imaging (MRI) showed slit lateral ventricles, effacement of the cisterns and an elongated brain stem. After placing the patient in the Trendelenburg position, the patient rapidly recovered to her baseline neurologic state. DiscussionTypical complications of subarachnoid hemorrhage such as vasospasm or hydrocephalus also manifest as neurological deterioration, but their treatments differ greatly from those for brain sag. Thusly, it is important to distinguish between causes. Treatments such as lumbar or extra-ventricular drainage, induced hypertension or administration of mannitol must be stopped once brain sag is suspected. Also, care should be taken for typical imaging features of brain sag on CT or MRI scan. For brain sag, placing the patient in the Trendelenburg position can improve neurological status in a rapid fashion.ConclusionsBrain sag is a rare but serious condition and can be fatal if not rapidly diagnosed and treated. We therefore recommend including brain sag in the differential diagnosis, along with vasospasm, hydrocephalus or cerebral edema as part of possible complications following subarachnoid hemorrhage treatment. We hope our clinical and imaging data from this case study contribute to the correct diagnosis of brain sag, as its early detection is important.

Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm.

The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery. Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model. The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model. This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery.

Subfrontal Endoscopic Fenestration of Lamina Terminalis: An Anatomical Study

Different surgical approaches to and through the lamina terminalis (LT) have been proposed to treat pathologies of the anterior third ventricle. Moreover, the opening of the LT is a standard adjunct in ruptured aneurysm surgery. However, the endoscopic anatomy and approach to the LT have not been extensively described. In the following study we performed an endoscopic subfrontal approach to the LT on 10 human cadaveric specimens through a supraorbital minicraniotomy. We discuss the endoscopic anatomy of the LT region and its fenestration through such an approach. The clinical potential use of this alternative third ventriculostomy is also pointed out.

脳動脈瘤手術ｕｐｄａｔｅ 脳動脈瘤における軽度低体温麻酔下一時血行遮断の検討

To determine the efficacy of mild hypothermia in patients treated with temporary arterial occlusion during aneurysm surgery, we investigated postoperative neurological deficits relevant to the cerebral ischemia due to temporary occlusion and ischemic change on CT. There were 97 consecutive patients who underwent neck clipping with temporary occlusion under mild hypothermia (34ºC) anesthesia in the past 10 years at our hospital. Ten patients (10%) had transient neurological deficits including mainly hemiparesis and 2 patients (2%) had permanent hemiplegia. Preoperative neurological state, such as an unruptured aneurysm, mild or severe subarachnoid hemorrhage, and patient's age did not correlate with the frequency of postoperative neurological deficits. More than 20 minutes of temporary occlusion increased the frequency of ischemic neurological signs after surgery. Permanent hemiplegia occurred with occlusion times between 19 and 28 minutes. Temporary occlusion of the middle cerebral artery tended to raise the frequency of postoperative neurological deficits. Small infarction of the perforating artery territory was revealed on CT scan in 17 percent of 12 patients who presented neurological dysfunction. Temporary arterial occlusion was mainly applied to reduce dome pressure of the aneurysm and make a proper clip placement in cases of large domes and multi-dimensional neck geometry in 35 patients with unruptured aneurysm at a mean occlusion time of 6.5 minutes. In 62 patients with ruptured aneurysm, temporary arterial occlusion was used to prevent intraoperative rupture as well at a mean time of 12.9 minutes. Therefore, the option of mild hypothermia may be indicated for a complicated ruptured aneurysm surgery, which requires about 20 minutes of temporary arterial occlusion.

P-1-25 - Timing of ruptured aneurysm surgery

Yttrium 90 radioembolization is a transcatheter therapy for unresectable hepatocellular carcinoma (HCC) that delivers internal radiation to tumors. In contrast to the usual method of lobar regional delivery, catheter-directed computed tomographic (CT) angiography was investigated as a potentially useful technique to evaluate the administration of segmental90Y tumor radiation doses superselectively without significantly altering liver function or Child-Pugh classification.Fourteen patients underwent 90Y therapy for unresectable HCC. After standard angiographic placement of a 3-F microcatheter in a segmental hepatic artery supplying the tumor, each patient underwent CT angiography with use of segmental hepatic artery injection of iodinated contrast agent to confirm segmental perfusion and delineate segmental liver volume. 90Y was later injected into the same segmental artery. Target dose was calculated according to infused 90Y activity and targeted hepatic volume with standard lobar volume (before CT angiography) versus segmental liver volume (after CT angiography). The Wilcoxon signed-rank test (α0.05) was used to compare the estimated 90Y dose before CT angiography with the actual 90Y dose after CT angiography, as well as changes in serum bilirubin level and Child-Pugh classification as a result of treatment.The mean estimated tumor dose before CT angiography (SD) was 100 Gy±43 (range, 35–169 Gy). The mean actual tumor dose after CT angiography was 348 Gy±204 (range, 105–857 Gy), which was significantly greater (P < .001). The mean bilirubin level before treatment was 1.0 mg/dL ±0.97 (range, 0.2–4.0 mg/dL), whereas the mean bilirubin level after treatment was 1.3 mg/dL ±0.85 (range, 0.5–3.8 mg/dL). This difference, although statistically significant (P=.03), was not clinically important. Thirteen of 14 patients had no change in Child-Pugh class.CT angiography can be used to delineate the blood supply and volume to a targeted hepatic segment, allowing superselective90Y radioembolization. This approach significantly increases effective 90Y tumor radiation dose without clinically altering liver function or Child-Pugh class.

Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography.

The purpose of this study was to determine the causes of morbidity and mortality after surgery for ruptured aneurysms. Two hundred thirty consecutive patients were studied. Initial hemorrhage volume and vasospasm were evaluated preoperatively with CT, transcranial Doppler ultrasonography, and angiography. Nimodipine infusion was started before surgery. Preoperative clinical status was evaluated according to Hunt and Hess grading criteria. Surgery was performed early in 186 patients (81%). Control angiography, transcranial Doppler ultrasonography, and CT were performed routinely after surgery. Hypodense areas revealed by control CT were related to intracerebral initial hematoma, vasospasm, postoperative thrombosis, or spatula hyperpressure. Clinical outcome was excellent or good (Glasgow Outcome Scale [GOS] scores of 1 or 2) in 176 patients (77%), 17 (7%) were disabled (GOS score of 3), and 37 (16%) were vegetative or dead. In patients in good condition (grades I to III) preoperatively (n = 200), 38 had an unfavorable outcome (GOS score of 2, 3, 4, or 5). The major cause of complication was postoperative thrombosis (42%). In patients in poor condition (grade IV or V) (n = 30), 27 had an unfavorable outcome. The major cause of complication was initial bleeding (66%). Vasospasm was responsible for delayed ischemic deficit in 9 patients (3.9% of the total population). Systematic angiography remains by far the best means for determining the cause of a poor postoperative course.

Long-term survival and quality of life following ruptured abdominal aortic aneurysm.

To document both the long-term survival and the quality of life of patients following surgery for ruptured abdominal aortic aneurysm (AAA), the records of 65 patients with ruptured AAA resection were compared with those of 100 who underwent elective AAA resection. The actuarial survival following ruptured aneurysm surgery was 92%, 51%, and 51% at 1, 5, and 10 years, respectively, and did not differ statistically for patients after elective AAA surgery or for an age- and sex-matched sample from the general population. Based on responses to a quality of life survey, there were no discernible differences in life-style, degree of independence, or productivity following either ruptured or elective AAA surgery. Survivors of ruptured AAA have an excellent long-term prognosis and expectation for a good quality of life.