Elsevier

World Neurosurgery

Volume 82, Issue 6, December 2014, Pages e725-e730
World Neurosurgery

Peer-Review Report
Treatment Modality and Vasospasm After Aneurysmal Subarachnoid Hemorrhage

https://doi.org/10.1016/j.wneu.2013.08.017Get rights and content

Objective

Vasospasm is the leading source of neurological morbidity after aneurysmal subarachnoid hemorrhage. Our objective was to evaluate the impact of treatment modality on vasospasm, delayed cerebral infarction, and clinical deterioration caused by delayed cerebral ischemia (CD-DCI).

Methods

We reviewed an institutional cohort, comparing rates of vasospasm, delayed cerebral infarction, and CD-DCI between patients managed with only microsurgical clipping and those treated with only endovascular coiling within 72 hours of rupture. Age, sex, smoking status, Hunt-Hess grade, and Fisher grade were adjusted for in a multivariate regression model.

Results

Two hundred three patients were treated with clipping and 52 with coiling. There was no significant difference in patient age, sex, smoking status, aneurysm location, and presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between these two groups. Sixty-percent of patients had moderate or severe vasospasm after clipping compared with 38% after coiling (Multivariate odds ratio [OR] 2.32, 95% confidence interval [95% CI] 1.21–4.47, P = 0.01). Clipping was associated with a greater number of territories with vasospasm (mean of 3.1 vs. 2.3, P = 0.03 after multivariate analysis). Delayed radiographic cerebral infarction was more common in the clipping group (17% vs. 6%, multivariate OR 3.66, 95% CI 1.06–12.71, P = 0.04). For CD-DCI, a trend was seen as 16% of patients treated with clipping had CD-DCI compared with 6% of patients treated with coiling (multivariate OR 3.11, 95% CI 0.89–10.86, P = 0.07).

Conclusion

We demonstrate significantly lower rates of vasospasm and delayed infarction after endovascular coiling of ruptured aneurysms.

Introduction

Vasospasm is the leading cause of delayed neurological morbidity after aneurysmal subarachnoid hemorrhage (SAH) 12, 15. Known risk factors for vasospasm include younger age 2, 8, high presenting Hunt-Hess (HH) grade, and diffuse subarachnoid clot 11, 33. The impact of aneurysm treatment modality on the incidence of vasospasm and clinical deterioration caused by delayed cerebral ischemia (CD-DCI, clinical vasospasm) has been addressed in several studies 2, 4, 6, 8, 11, 12, 13, 24, 26, 28, 31, 33, although the general issue remains a matter of debate (5). In this report, we evaluated a single institutional cohort to elucidate risk factors for vasospasm, delayed radiographic infarction, and CD-DCI.

Section snippets

Methods

We reviewed the records of a consecutive series of patients with aneurysmal SAH managed at our institution from January 2007 through January 2013. Patient age, sex, smoking status, aneurysm location, presenting HH grade, and Fisher grade were noted. Patients with Fisher grade 4 hemorrhages were reclassified by the amount of SAH present into grades 1–3. We defined traditional “clinical vasospasm” and “radiographic vasospasm” as per the modern terminology proposed by Vergouwen et al. (30)—CD-DCI

Results

Our review afforded 255 patients with aneurysms treated with only microsurgical clipping or endovascular coiling within 72 hours of initial hemorrhage that survived through the vasospasm period (Table 1). Two hundred three patients were treated with microsurgical clipping (80%). Overall, 34% of patients were younger than 50 years, 61% ages 50–80 years, and 5% older than 80 years. Seventy-five percent of patients were female. Forty percent were smokers. Collectively, 85% of ruptured aneurysms

Discussion

Although early clinical studies of aneurysmal SAH and vasospasm demonstrated an association of early open surgery with worsening vasospasm 1, 27, subsequent clinical studies explored the potential benefit of open surgery as a means for cisternal irrigation and clearing of subarachnoid blood 14, 29, 32, 34. Although successful in some animal models 29, 34, results in human studies proved less promising 14, 32. Although a different vascular disease prototype, it is interesting to consider the

Conclusion

This study illustrates a statistically significant association of microsurgical clipping with the risk of vasospasm and delayed radiographic infarction. A trend was also seen for CD-DCI. Although not entirely consistent with all previous studies evaluating the impact of treatment modality on vasospasm, this is consistent with more modern studies and those that used more stringent methods (angiography) in the evaluation of vasospasm. Although yet to be proven, this finding may explain, at least

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

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