Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has high morbidity and mortality, even when emergency treatment such as decompressive craniectomy (DC), coil embolization, or clipping is performed. The best treatment for acute aSAH, especially in poor-grade aSAH patients, has not been determined. The purpose of this study was to evaluate treatment methods in these patients in order to suggest the best treatment method.
We compared 130 patients with poor-grade aSAH who underwent DC with clipping or coiling (clipping, 102 patients; coiling, 28 patients). We compared functional outcome, mortality, and the time interval between admission and DC surgery between the clipping and coiling groups.
There was a significant difference in functional outcomes (modified Rankin score [mRS]) between the clipping and coiling groups. The mean mRS at discharge in the clipping and coil groups was 4.824 and 5.214, respectively (P=0.049). The time interval until DC surgery was also significantly different (161 and 481 minutes in the clipping and coiling groups, respectively; P=0.003). No significant difference was found in mortality between the 2 groups (P=0.301).
DC might be helpful for severe brain edema and intracranial pressure control. This procedure was more effective when performed with clipping than with coil embolization. DC with clipping showed better functional outcomes, lower mortality, and more favorable outcomes than DC with coil embolization. This demonstrates that aggressive surgical treatment can be helpful for poor-grade aSAH patients.
Aneurysmal subarachnoid hemorrhage (aSAH) is caused by rupture of an intracranial aneurysm and has high morbidity and mortality. Cases of poor grade aSAH have even higher morbidity and mortality [
Traditionally, simultaneous craniectomy with aneurysmal neck clipping has been used in poor grade ruptured cerebral aneurysm patients. However, when brain swelling is severe, the process of dissecting the subarachnoid space for ligation of the cerebral aneurysm and securing the parent artery and aneurysm can cause further brain damage. Recently, endovascular coil embolization has been developed, and its use has been increasing. This procedure attempts to control IICP by first preventing re-bleeding using a coil and then performing DC. Although there is no additional brain damage around the ruptured aneurysm during coil embolization, there is a risk of further brain damage in severe IICP cases due to brain edema during this procedure. DC can be conducted first, followed by coil embolization, but this method carries the risk of re-bleeding. The authors conducted this study to test the methods of treatment so that we might suggest a best treatment method for poor-grade patients. Our test was conducted by examining how the prognosis after surgery differed between patients who received simultaneous clipping and DC and patients who first received coil embolization and then DC.
We included patients who visited our hospital with poor grade aSAH (World Federation of Neurological Surgeons or H-H grade 3 or more) and underwent DC between April 2004 and January 2021. We excluded patients who received DC due to re-rupture during or after surgery or DC due to delayed cerebral ischemia as these patients were low grade aSAH at the time of admission. Cases in which minimal craniectomy was performed instead of general decompression (size of removed bone flap less than 12×15 cm) were also excluded (17 patients).
The number of patients who received clip and DC was 102, and the number of patients who received coil and DC was 28. We used brain computed tomography (CT) and brain CT angiography to diagnose aSAH. The treatment plan decision (clip or coil) was made by the officiating, well-experienced vascular neurosurgeon(s). The decision to perform DC was based on factors such as brain edema, herniation, presence of intracerebral hematoma (ICH), and intra-operative brain swelling [
Coil embolization performance was preceded by bi-plane digital subtraction angiography (DSA) under general anesthesia. DC was performed after coil embolization, and decompression measures to remove bone flaps larger than 12×15 cm were performed. Hematoma evacuation was performed according to the decision of the neurosurgeon, and 26 of 28 patients received both EVD insertion and DC. Clipping of the aneurysm and DC were performed simultaneously, and this also included removal of large bone flaps (12×15 cm or more).
After surgery, all patients were monitored in the intensive care unit. We designed our own aSAH treatment protocol in accordance with best medical treatment guidelines. This included treatment methods to prevent worsening of complications that can occur after aneurysm rupture [
We recorded H-H grade and modified Fisher grade of the aSAH patients, and functional outcomes of the patients were recorded in accordance with the modified Rankin score (mRS). Our goal was to test whether there was any difference in functional outcome of patients in whom coil or clip was performed. We assessed mRS at the time of admission and at the time of discharge, comparing the difference in mRS at these times. Patient characteristics included age, sex, length of hospital stay, location, and H-H and modified Fisher grades. Also, the time interval between hospital arrival and time of DC surgery was ascertained. Statistical analyses included performance of unpaired t-test, chi-square test, and Fisher exact test using IBM SPSS software ver. 20.0 (IBM Corp., Armonk, NY, USA). We calculated the 95% confidence interval (CI), and P<0.05 was considered significant.
Patient characteristics and demographics are summarized in
We found no significant difference in admission mRS, with an average value of 4.990 in the clip group and 4.890 in the coil group (P=0.117) (
A 63-year-old male patient came to emergency department of The Catholic University of Korea, Bucheon St. Mary's Hospital, he complained of sudden bursting headache and progressed to mental deterioration brain CT revealed thick SAH and ICH due to ruptured MCA aneurysm in right frontal lobe (
A 70-year-old female patient came to emergency department with stuporous mentality. Initially brain CT showed thick SAH due to ruptured MCA aneurysm on left hemisphere (
Poor-grade aSAHs generally have high morbidity and mortality. One of the most important factors associated with poor outcome after rupture of a cerebral aneurysm is an initial poor grade [
As performance of endovascular coil embolization became more popular, better results with this procedure were reported in poor-grade aSAH patients than in the surgical group patients [
The selection of DC with clipping or DC with coiling in poor-grade patients is important and should be determined based on the degree of brain swelling and the risk of re-bleeding according to aneurysm morphology. It is important to evaluate the priority between treatment to prevent re-bleeding and treatment to control IICP and to predict and determine the degree of additional brain damage that can occur in the course of treatment to prevent re-bleeding. The surgeon should first decide whether to use clipping or coiling and then decide whether to perform DC before or after.
The group in which DC and clipping were performed had lower morbidity than the group in which DC and coiling were performed together. There was no difference in mRS at the time of admission between the 2 groups, but the functional outcomes (mRS) at discharge were better in the group in which clipping was performed. While mortality was not significantly different between clipping and coiling groups, the clipping group showed a tendency toward lower mortality than the coil group. Also, a relatively large number of patients discharged with good functional outcome (mRS 0–3) were present in the clipping group. Therefore, in patients presenting with the same neurological deficit, the functional outcome was better at discharge for those in whom DC and clipping were performed simultaneously.
When DC and clipping were performed at the same time, bone flap removal and dura incision were performed more quickly; early decompression resulted in better functional outcomes. SAH evacuation through a trans-sylvian approach and cerebrospinal fluid circulation promotion through a cistern opening can be effective in regulating brain edema. In cases of subdural hematoma and ICH that have a mass effect with the SAH, the hematoma can be removed at the same time as clipping for decompression.
We divided the patients into 2 groups, those with good functional outcome (mRS 0–3) and those with poor functional outcome (mRS 4–6) and tested to determine the factors causing the difference in effects. The shorter was the time interval between admission and surgery, the better were the Fisher and H-H grades, and, therefore, the better was the functional outcome (time interval, P=0.001; Fisher, P=0.036; H-H, P=0.007). While there was no significant difference in the degree of good functional outcome in the clip and the coil groups, the functional outcome in the clip group showed a better tendency.
The difference in length of hospital stay between groups might have influenced the discharge mRS value. The longer hospital stay in the clipping group could have allowed for more rehabilitation and recovery and, therefore, a better functional outcome at discharge. Ideally, to adjust for bias created by differences in length of hospital stay, assessing the functional outcome at the same time intervals from admission, such as at 1 month, 6 months, 1 year, would be necessary. However, due to lack of medical records, we did not have the data necessary to perform such an assessment.
This study has the limitations inherent to a single institution, retrospective study with a small number of patients. Selection biases exist, and differences might be due to neurosurgeon decision-making. DC can be easier to perform in conjunction with clipping than with coil embolization; this could contribute to the difference in results. The skill level of the neurosurgeon performing the DC is likely to have an effect on the prognosis, and there might be differences in this skill level between groups.
To treat poor-grade aSAH, DC might be helpful for cases of severe brain edema and for control of IICP, especially when performed with clipping rather than coil embolization. Also, a short time interval between admission and DC surgery could result in better functional outcomes in poor-grade aSAH cases. Performing DC in conjunction with clipping had more favorable outcomes and demonstrates that aggressive surgical treatment could be helpful for poor-grade aSAH patients.
No potential conflict of interest relevant to this article was reported.
Preoperative images. (A) Brain computed tomography (CT) revealed a thick subarachnoid hemorrhage on the right sylvian fissure and intracerebral hemorrhage in the right frontal lobe. (B) Surface rendering image of CT angiography showed a saccular aneurysm (*) on the right middle cerebral artery bifurcation.
Postoperative images. (A) Right fronto-temporo-parietal craniectomy with hematoma removal observed on computed tomography (CT) with aneurysmal neck clipping (arrow). (B) Complete aneurysmal neck clipping (arrow) was observed on three-surface rendering of CT.
One-month follow-up image. Post-cranioplasty brain computed tomography showed decreased brain swelling with minimal encephalomalacic changes on the right temporal lobe.
Preoperative images. (A) Brain computed tomography revealed a subarachnoid hemorrhage with severe brain swelling. (B) Pre-coil embolization digital subtraction angiography image showed an aneurysmal dilatation on the left middle cerebral artery (arrows).
Postoperative images. (A) Post-coil embolization digital subtraction angiography image revealed complete obliteration of the aneurysmal dilatation by coils (black arrows). (B) Brain computed tomography post-craniectomy (immediately after coil embolization) showed severe brain swelling with diffuse subarachnoid hemorrhage. (C) An ischemic injury of both occipital lobes, suggesting brain herniation, was noticed at postoperative 4 hours on a magnetic resonance fluid attenuated inversion recovery image.
Patient characteristics
Characteristic | Clip (n=102) | Coil (n=28) | 95% CI | P-value |
---|---|---|---|---|
Age (yr) | 53.07±12.48 | 55.89±10.57 | –7.54 to 1.90 | 0.235 |
Sex (male:female) | 42:60 | 12:16 | 0.520 | |
Hospital stay (day) | 45.66±39.54 | 30.04±23.55 | 5.74–32.01 | 0.010 |
Location | 0.833 | |||
Anterior cerebral artery | 25 | 8 | ||
Middle cerebral artery | 61 | 15 | ||
Internal carotid artery | 16 | 5 | ||
Hunt and Hess grade | 0.413 | |||
4 | 83 | 24 | ||
5 | 2 | 4 | ||
Modified Fisher grade | 0.523 | |||
2 | 1 | |||
3 | 0 | 9 | ||
4 | 61 | 19 | ||
Time interval (min) | 161.529±169.21 | 481.821±512.44 | 119.17–521.41 | 0.003 |
Values are presented as mean±standard deviation. The time interval indicates the duration from hospital arrival to decompressive craniectomy surgery. The 95% confidence interval (CI) was calculated using the t-test.
Functional outcomes (modified Rankin score at discharge) in the clipping and coil groups
Group | Modified Rankin score |
||||||
---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | Total | |
Clipping | |||||||
Admission | 0 | 0 | 0 | 1 (1.0) | 101 (99.0) | 0 | 102 |
Discharge | 1 (1.0) | 4 (3.9) | 10 (9.8) | 15 (14.7) | 39 (38.2) | 33 (32.4) | 102 |
Coil | |||||||
Admission | 0 | 0 | 1 (3.6) | 1 (3.6) | 26 (92.9) | 0 | 28 |
Discharge | 0 | 0 | 1 (3.6) | 4 (14.3) | 11 (39.3) | 12 (42.9) | 28 |
Values are presented as number (%).
Modified Rankin score (mRS) and mortality differences between the clipping and coil groups
mRS | Clipping group | Coil group | P-value |
---|---|---|---|
Admission | 4,990 | 4,890 | 0.117 |
Discharge | 4.824 | 5.214 | 0.049 |
Mortality (%) | 33 (32.4) | 12 (42.9) | 0.301 |