Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia

Solomon, Robert A.; Onesti, Stephen T.; Klebanoff, Louise M.

doi:10.3171/jns.1991.75.1.0056

Cited by 82 publications

(42 citation statements)

References 54 publications

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“…For example, craniotomy with brain retraction and surgical manipulation of blood vessels may exacerbate preexisting vasospasm. 24,25,27,28 Therefore, although decreasing the clot burden theoretically contributes to lowering the rates of vasospasm, this beneficial effect could be negated by other effects associated with surgery.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Treatment or Neurosurgical Clipping of Ruptured Intracranial Aneurysms

Dumont

Crowley

Monteith

et al. 2010

Stroke

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Background and Purpose-The effects of aneurysm treatment modality (clipping or coiling) on the incidence of cerebral vasospasm and infarction after subarachnoid hemorrhage have not been clearly defined. We hypothesized that there may be a difference in angiographic and clinical vasospasm, cerebral infarction, and clinical outcome between patients undergoing clipping compared to coiling. Methods-A retrospective, exploratory analysis of 413 patients randomized into the CONSCIOUS-1 trial was conducted.Patients underwent baseline and follow-up catheter angiography and computed tomography, as well as clinical assessments. Radiology end points were adjudicated by central blinded review, and angiographic vasospasm was quantified by measurements of arterial diameters on catheter angiography. The effect of method of aneurysm treatment (clipping [nϭ199] or coiling [nϭ214]) on angiographic vasospasm, delayed ischemic neurological deficit, cerebral infarction, and clinical outcome was analyzed using univariate and multivariate logistic regression. Propensity matching was used to adjust for differences in baseline risk factors between clipped and coiled patients. Results-In all patients and the propensity-matched subset, aneurysm coiling was associated with a significantly reduced risk of angiographic vasospasm and delayed ischemic neurological deficit compared to clipping. Cerebral infarction and clinical outcome were not associated with clipping or coiling. Conclusions-In this exploratory analysis, aneurysm coiling was associated with less angiographic vasospasm and delayed ischemic neurological deficit than surgical clipping, whereas no effect on cerebral infarction or clinical outcome was observed. Whether this is attributable to differences in baseline risk factors between clipped and coiled patients or a true difference cannot be proven here. (Stroke. 2010;41:2519-2524.)

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Section: Discussionmentioning

confidence: 99%

Endovascular Treatment or Neurosurgical Clipping of Ruptured Intracranial Aneurysms

Dumont

Crowley

Monteith

et al. 2010

Stroke

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“…SPSS software version 19 (SPSS Inc., Chicago, IL, USA) was used to perform statistical analysis. proach such as the timing of treatment and the differences between interventional techniques, and almost all of them referred to surgical series [3][4][5][6][7][8] . Furthermore, a prospective study on a group of patients with ruptured aneurysms treated with surgical clipping demonstrated that early treatment may reduce the risk of rebleeding 9 .…”

Section: Introductionmentioning

confidence: 99%

Effects of Hyper-Early (<12 Hours) Endovascular Treatment of Ruptured Intracranial Aneurysms on Clinical Outcome

et al. 2013

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Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12–48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intraprocedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intraprocedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

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“…More and more neurosurgeons rely on early aneurysm surgery rather than delayed surgery for the prevention of rebleeding after aneurysmal SAH. [3][4][5][6][7][8][9][10][11][12] The rationale behind early aneurysm surgery is that by clipping the aneurysm as early as possible, one can apply treatment for cerebral ischemia more vigorously (for example, induced hypertension) without the risk of a rebleed. However, in most studies early aneurysm surgery failed to improve outcome when compared with delayed surgery, probably because of an increase in the frequency of cerebral ischemia.…”

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confidence: 99%

Impact of Medical Treatment on the Outcome of Patients After Aneurysmal Subarachnoid Hemorrhage

Vermeij

Hasan

Bijvoet

et al. 1998

Stroke

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Background and Purpose-The rationale behind early aneurysm surgery in patients with subarachnoid hemorrhage (SAH) is the prevention of rebleeding as early as possible after SAH. In addition, by clipping the aneurysm as early as possible, one can apply treatment for cerebral ischemia more vigorously (induced hypertension) without the risk of rebleeding. Hypervolemic hemodilution is now a well-accepted treatment for delayed cerebral ischemia. We compared the prospectively collected clinical data and outcome of patients admitted to the intensive care unit in the period 1977 to 1982 with those of patients admitted in the period 1989 to 1992 to measure the effect of the change in medical management procedures on patients admitted in our hospital with SAH. Methods-We studied 348 patients admitted within 72 hours after aneurysmal SAH. Patients with negative angiography results and those in whom death appeared imminent on admission were excluded. The first group (group A) consisted of 176 consecutive patients admitted from 1977 through 1982. Maximum daily fluid intake was 1.5 to 2 L. Hyponatremia was treated with fluid restriction (Ͻ1 L/24 h). Antihypertensive treatment with diuretic agents was given if diastolic blood pressure was Ͼ110 mm Hg. Patients in the second group (172 consecutive patients; group B) were admitted from 1989 through 1992. Daily fluid intake was at least 3 L, unless cardiac failure occurred. Diuretic agents and antihypertensive medications were avoided. Cerebral ischemia was treated with vigorous plasma volume expansion under intermittent monitoring of pulmonary wedge pressure, cardiac output, and arterial blood pressure, aiming for a hematocrit of 0.29 to 0.33. Aneurysm surgery was planned for day 12. Results-Patients admitted in group B had less favorable characteristics for the development of cerebral ischemia and for good outcome when compared with patients in group A. Despite this, we found a significant decrease in the frequency of delayed cerebral ischemia in patients of group B treated with tranexamic acid (Pϭ0.00005 by log rank test) and significantly improved outcomes among patients with delayed cerebral ischemia (Pϭ0.006 by 2 test) and among patients with deterioration from hydrocephalus (Pϭ0.001 by 2 test). This resulted in a significant improvement of the overall outcome of patients in group B when compared with those in group A (Pϭ0.006 by 2 test). The major cause of death in group B was rebleeding (Pϭ0.011 by 2 test). Conclusions-We conclude that the outcome in our patients with aneurysmal SAH was improved but that rebleeding remains a major cause of death. Patient outcome can be further improved if we can increase the efficacy of preventive measures against rebleeding by performing early aneurysm surgery. (Stroke. 1998;29:924-930.)

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Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia

Cited by 82 publications

References 54 publications

Endovascular Treatment or Neurosurgical Clipping of Ruptured Intracranial Aneurysms

Endovascular Treatment or Neurosurgical Clipping of Ruptured Intracranial Aneurysms

Effects of Hyper-Early (<12 Hours) Endovascular Treatment of Ruptured Intracranial Aneurysms on Clinical Outcome

Impact of Medical Treatment on the Outcome of Patients After Aneurysmal Subarachnoid Hemorrhage

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