Peer-Review ReportTreatment Modality and Vasospasm After Aneurysmal Subarachnoid Hemorrhage
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