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Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 2004 Jun;75(6):868–872. doi: 10.1136/jnnp.2003.033068

Does the method of treatment of acutely ruptured intracranial aneurysms influence the incidence and duration of cerebral vasospasm and clinical outcome?

A Goddard 1, P Raju 1, A Gholkar 1
PMCID: PMC1739081  PMID: 15146002

Abstract

Objectives: Cerebral vasospasm remains the leading cause of death and permanent disability after subarachnoid haemorrhage. This study determined whether the method of aneurysm treatment plays an important role in determining the incidence of cerebral vasospasm and its clinical consequences.

Methods: Admission data, cranial computed tomography (CT), treatment details, transcranial Doppler (TCD) results, and clinical outcomes of patients who had surgical or endovascular management of their ruptured aneurysm were recorded and subject to multivariate analysis.

Results: Between January 1995 and December 1999, 292 eligible patients (206 female, 86 male) had definitive aneurysm treatment at our unit. 212 patients were clipped, 80 coiled. There was no significant difference in patient age, pre-treatment neurological grade, Fisher grade, or timing of treatment in the two groups. 48.3% patients developed TCD detected cerebral vasospasm and 16.1% patients developed permanent ischaemic neurological deficit. At clinical follow up, 84.2% of patients were well (mGOS 1 and 2) with a cumulative death rate of 6.5% from all causes.

The only significant predictor of TCD-detected cerebral vasospasm was patient age (inversely, p = 0.004). Increased patient age, vasospasm, poor pre-treatment WFNS, and higher CT Fisher grades correlated with a poor discharge GOS. However, only poor pre-treatment WFNS grade and patient age correlated with poor GOS at follow up (p<0.001).

Conclusion: The treatment method had no influence on the incidence or duration of TCD detected vasospasm and there was no significant difference in outcome at discharge or follow up between those patients who had surgery or endovascular management of their aneurysms.

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Selected References

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  1. Adams H. P., Jr, Kassell N. F., Torner J. C., Haley E. C., Jr Predicting cerebral ischemia after aneurysmal subarachnoid hemorrhage: influences of clinical condition, CT results, and antifibrinolytic therapy. A report of the Cooperative Aneurysm Study. Neurology. 1987 Oct;37(10):1586–1591. doi: 10.1212/wnl.37.10.1586. [DOI] [PubMed] [Google Scholar]
  2. Auer L. M., Mokry M. Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery. Neurosurgery. 1990 May;26(5):804–809. doi: 10.1097/00006123-199005000-00012. [DOI] [PubMed] [Google Scholar]
  3. Biller J., Godersky J. C., Adams H. P., Jr Management of aneurysmal subarachnoid hemorrhage. Stroke. 1988 Oct;19(10):1300–1305. doi: 10.1161/01.str.19.10.1300. [DOI] [PubMed] [Google Scholar]
  4. Charpentier C., Audibert G., Guillemin F., Civit T., Ducrocq X., Bracard S., Hepner H., Picard L., Laxenaire M. C. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke. 1999 Jul;30(7):1402–1408. doi: 10.1161/01.str.30.7.1402. [DOI] [PubMed] [Google Scholar]
  5. Creissard P., Proust F., Langlois O. Vasospasm diagnosis: theoretical and real transcranial Doppler sensitivity. Acta Neurochir (Wien) 1995;136(3-4):181–185. doi: 10.1007/BF01410623. [DOI] [PubMed] [Google Scholar]
  6. Creissard P., Proust F. Vasospasm diagnosis: theoretical sensitivity of transcranial Doppler evaluated using 135 angiograms demonstrating vasospasm. Practical consequences. Acta Neurochir (Wien) 1994;131(1-2):12–18. doi: 10.1007/BF01401449. [DOI] [PubMed] [Google Scholar]
  7. Ekelund A., Säveland H., Romner B., Brandt L. Is transcranial Doppler sonography useful in detecting late cerebral ischaemia after aneurysmal subarachnoid haemorrhage? Br J Neurosurg. 1996 Feb;10(1):19–25. doi: 10.1080/bjn.10.1.19. [DOI] [PubMed] [Google Scholar]
  8. Ekelund A., Säveland H., Romner B., Brandt L. Transcranial Doppler ultrasound in hypertensive versus normotensive patients after aneurysmal subarachnoid hemorrhage. Stroke. 1995 Nov;26(11):2071–2074. doi: 10.1161/01.str.26.11.2071. [DOI] [PubMed] [Google Scholar]
  9. Grosset D. G., Straiton J., McDonald I., Cockburn M., Bullock R. Use of transcranial Doppler sonography to predict development of a delayed ischemic deficit after subarachnoid hemorrhage. J Neurosurg. 1993 Feb;78(2):183–187. doi: 10.3171/jns.1993.78.2.0183. [DOI] [PubMed] [Google Scholar]
  10. Grosset D. G., Straiton J., du Trevou M., Bullock R. Prediction of symptomatic vasospasm after subarachnoid hemorrhage by rapidly increasing transcranial Doppler velocity and cerebral blood flow changes. Stroke. 1992 May;23(5):674–679. doi: 10.1161/01.str.23.5.674. [DOI] [PubMed] [Google Scholar]
  11. Haley E. C., Jr, Kassell N. F., Torner J. C., Truskowski L. L., Germanson T. P. A randomized trial of two doses of nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. J Neurosurg. 1994 May;80(5):788–796. doi: 10.3171/jns.1994.80.5.0788. [DOI] [PubMed] [Google Scholar]
  12. Handa Y., Weir B. K., Nosko M., Mosewich R., Tsuji T., Grace M. The effect of timing of clot removal on chronic vasospasm in a primate model. J Neurosurg. 1987 Oct;67(4):558–564. doi: 10.3171/jns.1987.67.4.0558. [DOI] [PubMed] [Google Scholar]
  13. Hurst R. W., Schnee C., Raps E. C., Farber R., Flamm E. S. Role of transcranial Doppler in neuroradiological treatment of intracranial vasospasm. Stroke. 1993 Feb;24(2):299–303. doi: 10.1161/01.str.24.2.299. [DOI] [PubMed] [Google Scholar]
  14. Inagawa T., Kamiya K., Matsuda Y. Effect of continuous cisternal drainage on cerebral vasospasm. Acta Neurochir (Wien) 1991;112(1-2):28–36. doi: 10.1007/BF01402451. [DOI] [PubMed] [Google Scholar]
  15. Kassell N. F., Torner J. C., Haley E. C., Jr, Jane J. A., Adams H. P., Kongable G. L. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg. 1990 Jul;73(1):18–36. doi: 10.3171/jns.1990.73.1.0018. [DOI] [PubMed] [Google Scholar]
  16. Kassell N. F., Torner J. C., Jane J. A., Haley E. C., Jr, Adams H. P. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results. J Neurosurg. 1990 Jul;73(1):37–47. doi: 10.3171/jns.1990.73.1.0037. [DOI] [PubMed] [Google Scholar]
  17. Klingelhöfer J., Dander D., Holzgraefe M., Bischoff C., Conrad B. Cerebral vasospasm evaluated by transcranial Doppler ultrasonography at different intracranial pressures. J Neurosurg. 1991 Nov;75(5):752–758. doi: 10.3171/jns.1991.75.5.0752. [DOI] [PubMed] [Google Scholar]
  18. Langlois O., Rabehenoina C., Proust F., Freger P., Tadie M., Creissard P. Diagnostic du vasospasme: comparison artériographie-Doppler transcrânien. Une série de 112 examens comparatifs. Neurochirurgie. 1992;38(3):138–140. [PubMed] [Google Scholar]
  19. Laumer R., Steinmeier R., Gönner F., Vogtmann T., Priem R., Fahlbusch R. Cerebral hemodynamics in subarachnoid hemorrhage evaluated by transcranial Doppler sonography. Part 1. Reliability of flow velocities in clinical management. Neurosurgery. 1993 Jul;33(1):1–9. doi: 10.1227/00006123-199307000-00001. [DOI] [PubMed] [Google Scholar]
  20. Macdonald R. L., Weir B. K. A review of hemoglobin and the pathogenesis of cerebral vasospasm. Stroke. 1991 Aug;22(8):971–982. doi: 10.1161/01.str.22.8.971. [DOI] [PubMed] [Google Scholar]
  21. Manno E. M., Gress D. R., Schwamm L. H., Diringer M. N., Ogilvy C. S. Effects of induced hypertension on transcranial Doppler ultrasound velocities in patients after subarachnoid hemorrhage. Stroke. 1998 Feb;29(2):422–428. doi: 10.1161/01.str.29.2.422. [DOI] [PubMed] [Google Scholar]
  22. Minhas Pawan S., Menon David K., Smielewski Piotr, Czosnyka Marek, Kirkpatrick Peter J., Clark John C., Pickard John D. Positron emission tomographic cerebral perfusion disturbances and transcranial Doppler findings among patients with neurological deterioration after subarachnoid hemorrhage. Neurosurgery. 2003 May;52(5):1017–1024. [PubMed] [Google Scholar]
  23. Miyaoka M., Sato K., Ishii S. A clinical study of the relationship of timing to outcome of surgery for ruptured cerebral aneurysms. A retrospective analysis of 1622 cases. J Neurosurg. 1993 Sep;79(3):373–378. doi: 10.3171/jns.1993.79.3.0373. [DOI] [PubMed] [Google Scholar]
  24. Molyneux Andrew, Kerr Richard, Stratton Irene, Sandercock Peter, Clarke Mike, Shrimpton Julia, Holman Rury, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002 Oct 26;360(9342):1267–1274. doi: 10.1016/s0140-6736(02)11314-6. [DOI] [PubMed] [Google Scholar]
  25. Murayama Y., Malisch T., Guglielmi G., Mawad M. E., Viñuela F., Duckwiler G. R., Gobin Y. P., Klucznick R. P., Martin N. A., Frazee J. Incidence of cerebral vasospasm after endovascular treatment of acutely ruptured aneurysms: report on 69 cases. J Neurosurg. 1997 Dec;87(6):830–835. doi: 10.3171/jns.1997.87.6.0830. [DOI] [PubMed] [Google Scholar]
  26. Newell D. W., Winn H. R. Transcranial Doppler in cerebral vasospasm. Neurosurg Clin N Am. 1990 Apr;1(2):319–328. [PubMed] [Google Scholar]
  27. Osaka K. Prolonged vasospasm produced by the breakdown products of erythrocytes. J Neurosurg. 1977 Sep;47(3):403–411. doi: 10.3171/jns.1977.47.3.0403. [DOI] [PubMed] [Google Scholar]
  28. Rabb C. H., Tang G., Chin L. S., Giannotta S. L. A statistical analysis of factors related to symptomatic cerebral vasospasm. Acta Neurochir (Wien) 1994;127(1-2):27–31. doi: 10.1007/BF01808542. [DOI] [PubMed] [Google Scholar]
  29. Sloan M. A., Burch C. M., Wozniak M. A., Rothman M. I., Rigamonti D., Permutt T., Numaguchi Y. Transcranial Doppler detection of vertebrobasilar vasospasm following subarachnoid hemorrhage. Stroke. 1994 Nov;25(11):2187–2197. doi: 10.1161/01.str.25.11.2187. [DOI] [PubMed] [Google Scholar]
  30. Sloan M. A., Haley E. C., Jr, Kassell N. F., Henry M. L., Stewart S. R., Beskin R. R., Sevilla E. A., Torner J. C. Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology. 1989 Nov;39(11):1514–1518. doi: 10.1212/wnl.39.11.1514. [DOI] [PubMed] [Google Scholar]
  31. Solomon R. A., Onesti S. T., Klebanoff L. Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia. J Neurosurg. 1991 Jul;75(1):56–61. doi: 10.3171/jns.1991.75.1.0056. [DOI] [PubMed] [Google Scholar]
  32. Wardlaw J. M., Offin R., Teasdale G. M., Teasdale E. M. Is routine transcranial Doppler ultrasound monitoring useful in the management of subarachnoid hemorrhage? J Neurosurg. 1998 Feb;88(2):272–276. doi: 10.3171/jns.1998.88.2.0272. [DOI] [PubMed] [Google Scholar]
  33. Yalamanchili K., Rosenwasser R. H., Thomas J. E., Liebman K., McMorrow C., Gannon P. Frequency of cerebral vasospasm in patients treated with endovascular occlusion of intracranial aneurysms. AJNR Am J Neuroradiol. 1998 Mar;19(3):553–558. [PMC free article] [PubMed] [Google Scholar]
  34. Zygmunt S. C., Delgado-Zygmunt T. J. The haemodynamic effect of transcranial Doppler-guided high-dose nimodipine treatment in established vasospasm after subarachnoid haemorrhage. Acta Neurochir (Wien) 1995;135(3-4):179–185. doi: 10.1007/BF02187765. [DOI] [PubMed] [Google Scholar]

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