Surgical Management of Aneurysmal Hematomas in the Presence of Brain Herniation on Arrival: A Single-Center Case Series Analysis

Wang, Minqing; Xu, Zuo-Feng; Wang, Xiaofei; Han, Chongfang; Xing, Deguang; Wang, Chengwei

doi:10.1016/j.wneu.2018.03.011

Cited by 5 publications

(3 citation statements)

References 29 publications

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“…Given that up to 50% of WFNS grade V patients show a favorable outcome, various authors have proposed variations of the WFNS grading to improve outcome prediction. [8][9][10][11][12]17 According to the initial report of the World Federation of Neurological Surgeons Committee, the most important predictor of death and disability was the level of consciousness. 1 Therefore, the more precisely the level of consciousness can be described, the more precise should be the outcome prediction based on the WFNS scale.…”

Section: Discussionmentioning

confidence: 99%

“…7 Various studies have reported on the impact on outcome of aneurysmal subarachnoid hemorrhage patients in whom signs of brain stem dysfunction were identified. [8][9][10][11][12] Using a simple modification of the WFNS scale, we have previously shown an improvement in the prediction of mortality and poor outcomes in a retrospective cohort study. 13 This modification is based on the pathophysiology of brain stem dysfunction, which is the underlying event in patients with GCS grades 3 to 5.…”

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confidence: 99%

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Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Raabe

Beck

Goldberg

et al. 2022

Stroke

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BACKGROUND: Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort. METHODS: We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version—the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4–6). RESULTS: Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P <0.001) whereas the sensitivity decreased from 0.88 to 0.37 ( P <0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P <0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P <0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P <0.001). CONCLUSIONS: The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification—presence of brain stem signs is required for grade V—should be added to the WFNS classification. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Raabe

Beck

Goldberg

et al. 2022

Stroke

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“…This approach would support Personalized Acute Care. Any findings associated with the final brain outcome could be supported with the serial imaging panels [ 109 , 118 ]. Such illustrative panels—with basic animation—require user-friendly interfaces with timeline construction tools.…”

Section: Suggested Development—individual Timeline and Serial Imaging...mentioning

confidence: 99%

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage

et al. 2023

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Purpose Our review of acute brain insult articles indicated that the patients’ individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. Methods We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.–45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ($$n=25$$ n = 25 ; 56%) or 3 years ($$n=20$$ n = 20 ; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). Results The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. Conclusions The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.

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Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm—illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months

Autio,

Paavola,

Tervonen

et al. 2024

Acta Neurochir

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Purpose In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient’s individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. Methods Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient’s individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.–54.) in the pseudonymized panels, tables, results, and discussion. Results The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome. Conclusions Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.

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Surgical Management of Aneurysmal Hematomas in the Presence of Brain Herniation on Arrival: A Single-Center Case Series Analysis

Cited by 5 publications

References 29 publications

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage

Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm—illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months

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