Peer-Review ReportOutcomes for Clip Ligation and Hematoma Evacuation Associated with 102 Patients with Ruptured Middle Cerebral Artery Aneurysms
Introduction
The incidence of intracranial aneurysm ranges from 0.4%–6% (22). Rupture of an intracranial aneurysm commonly results in subarachnoid hemorrhage (SAH), but may also lead to hematoma formation. Locksley (12) found that 90% of the patients who died within 3 days of the onset of an aneurysmal SAH harbored an intracerebral hematoma (ICH). Although the cause and risk factors for hematoma formation during aneurysmal rupture remain unknown, previous studies have indicated that patients with concomitant hematoma have relatively worse neurologic presentation and poorer outcome (1, 4, 27).
Middle cerebral artery (MCA) aneurysms are most likely to result in an intracerebral and intrasylvian hematoma after their rupture (17, 19). Early surgical management has been advocated, although few studies have focused on the outcome of patients with ruptured MCA aneurysms and concomitant ICH (2, 20, 25). It is important to explore different prognostic factors in this patient population to elucidate the optimal management strategy. In the present study, we investigated the influence of age, sex, and admission Hunt and Hess (HH) grade on several outcome factors. This information will be important for counseling family members regarding the ultimate outcome for patients who undergo intervention and may have potential implications for offering aggressive treatment options. The previous studies have not evaluated the influence of these factors on Glasgow outcome scale (GOS). This is the largest case series to date, specifically evaluating the outcome of hematomas associated with MCA aneurysms.
Section snippets
Methods and Materials
Clinical information relevant to patients suffering from an MCA aneurysm rupture and concomitant ICH or intrasylvian hematoma (ISH) with or without SAH who had been admitted to Methodist or Saint Vincent hospitals in Indianapolis, Indiana, between 1977 and 2008 were surveyed. The source of data was the digital clinical aneurysm database at Goodman Campbell Brain and Spine. Established in 1976 and prospectively maintained, the database includes all patients who have presented with an
Results
Between June 1977 and October 2008, 144 patients with a diagnosis of ruptured MCA aneurysm and concomitant ICH (intraparenchymal and/or intrasylvian) related to their aneurysm were admitted. The mean age of our patients was 52.5 ± 14.3 years (range, 10–82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent surgical or endovascular intervention (within 8 hours of admission). Notably, 102 underwent clip ligation of their aneurysm and evacuation of their hematoma simultaneously
Patient 1 (poor outcome)
A 30-year-old woman, who was 3 weeks postpartum, was found unresponsive by her husband. On presentation, the patient's pupils were 4 mm and reactive; deep stimulation triggered flexion posturing of both upper extremities. Head CT and CT angiogram demonstrated a large left temporal intraparenchymal hemorrhage associated with a 4-mm right MCA aneurysm (Figure 1). The patient was immediately taken to the operating room for clot evacuation and clip ligation of her aneurysm, which were conducted
Discussion
The incidence of ICH (intracerebral or intrasylvian hemorrhage) among patients with aneurysmal SAH ranges from 12%–34% (6, 17, 18, 19, 27). Autopsy series tend to report a higher incidence of 33%–60% (4, 10, 13, 21). The presence of an aneurysm with ICH negatively influences the patient's presentation, course, and outcome (1, 6, 27), and may be associated with an increased rehemorrhage rate (9, 11, 14, 26), vasospasm (19, 28), cerebral edema (16), and hydrocephalus (16). Conservative management
Conclusions
The admission HH grade is the primary prognostic factor that significantly correlated with several outcome variables including in-hospital mortality, discharge GOS, and 6-month GOS. Specifically, the outcome for patients with presenting HH grade IV-V is poor. It may be beneficial to discuss these potential prognosticating factors with the family before implementing aggressive measures. We would recommend against aggressive measures for patients with ISH or ICH associated with an aneurysm
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2020, Clinical Neurology and NeurosurgeryCitation Excerpt :Several former studies evaluated the higher rates of cerebral vasospasm, mortality and poorer clinical outcome due to aneurysmal ICH following MCA aneurysm rupture compared to patients suffering from SAH alone [6,8,9]. Although the pattern of hemorrhage is known to have a crucial impact on the outcome of patients, no common treatment guidelines have been established thus far [5–7,9–11,21,10,20]. Irrespective of the different management strategies, we aimed to evaluate which factors could be associated with the different bleeding types in ruptured MCA aneurysms.
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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.