Outcomes for Clip Ligation and Hematoma Evacuation Associated with 102 Patients with Ruptured Middle Cerebral Artery Aneurysms

Objective

Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures.

Methods

A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10–82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome.

Results

The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome.

Conclusions

Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

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.