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ruptured_intracranial_aneurysm

Ruptured intracranial aneurysm

Complications

1. A ruptured intracranial aneurysm, most commonly produces aneurysmal subarachnoid hemorrhage

2, Intracerebral hemorrhage occurs in 20-40 % most common middle cerebral artery aneurysm

3. Intraventricular hemorrhage occurs in 13-28 %.

4. Subdural hematomas (SDH) from ruptured aneurysm (RA) are much less common than intracerebral (ICH) hematomas or subarachnoid (SAH) or intraventricular hemorrhage (IVH). With computerized tomography, preoperative diagnosis is now made more often. The authors have collected 18 such cases from a review of 897 cases of RA admitted to eleven medical centers in 1980 and 1981. Nine (50%) of these patients died prior to discharge from hospital. Four (22%) had surgery and died postoperatively and 9 (50%) were operated upon and survived. Thirteen (72%) of the patients showed anisocoria, decreased consciousness and unilateral weakness prior to surgery. Eight (89%) of the fatalities had shown preoperative herniation as opposed to only 5 (56%) of the survivors. The overall incidence of delayed ischemia due to vasospasm was 11% (2 cases). Those who died had greater midline shift and larger SDH on the admission CT scan. Sixteen (89%) of these patients were female. Thirteen (72%) had ruptured aneurysms on the internal carotid artery. All of these hematomas were unilateral and uniformly hyperdense, and the convexity hematomas were crescentic in shape. Seventeen (94%) had evidence of blood in locations other than the subdural space. If the patient is potentially salvageable and has a midline shift, the SDH should probably be evacuated immediately and the aneurysm clipped at the same operation since the development of a tentorial herniation has such an adverse effect on outcome 1).

Treatment

Endovascular coil embolization and surgical clip occlusion are the currently accepted treatment options for patients with ruptured intracranial aneurysms. Since the publication of results from the International Subarachnoid Aneurysm Trial (ISAT) in 2002, endovascular treatment has become the mainstay in many centers, especially in Europe 2).

Surgical or endovascular treatment of ruptured cerebral aneurysms within the first 3 days of aneurysmal subarachnoid hemorrhage (aSAH) is associated with improved outcome.

Treatment has been a rapidly evolving field with numerous technical innovations, especially since 2000. Selecting the appropriate treatment can be a complex process that involves integration of information regarding the patient's clinical presentation, associated comorbidities, the aneurysm's morphological characteristics, safety and efficacy of the treatment options and skill and experience of available practitioners, amongst others 3).

Surgical clipping versus endovascular coiling

Flow diverter for ruptured intracranial aneurysm

Bibliometrics

16468 global papers were identified that were cited 273500 times until 2013-08-15. The United States accounted for 31.497% of the articles, 58.64% of the citations, and the highest h-index (127). Japan and Germany followed in frequency. China's articles ranked eighth (third in 2012) in total number, with most of the contributions occurring since 2002 (91.33%). China was at the early stage of the logic growth curve (exponential growth), with the citation frequency and h-index per year increasing. The quality of the publications was low. The main research centers were located in Beijing, Shanghai, Taiwan, and Hong Kong. The main Asian funding body was the National Natural Science Foundation of China. The number of publications and frequency of citations of papers from mainland China was greater than that of Taiwan or Hong Kong.

Global intracranial aneurysm research has been developing swiftly since 1991, with the United States making the largest contribution. Research in China started later, in 2002. Since then, China has increased its rate of publication, and became the third largest contributor by 2012 4).

Case series

2017

The outcomes at discharge for ruptured cerebral aneurysms after subarachnoid hemorrhage (SAH) were investigated using data from the Japanese stroke databank. Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients had SAH caused by ruptured saccular aneurysm. Of these, 3593 patients (1140 men and 2453 women; mean age 61.3 ± 13.7 years) were treated by surgical clipping (SC) and/or endovascular coiling (EC). The outcomes of modified Rankin scale (mRS) at discharge were compared between the SC and EC groups. There were 2666 cases in the SC group, 881 cases in the EC group, and 46 cases in the SC and EC group. The rates of poor outcome of mRS > 2 were 33.0 and 45.5% in the SC and EC groups (p < 0.05), respectively. Cases were selected using two types of criteria compatible with both treatments. Under the first compatible criteria, the rates of poor outcome of mRS > 2 were 18.9 and 24.8% in the SC and EC groups (p < 0.05), respectively. Under the second compatible criteria, the rates of poor outcome of mRS > 2 were 16.0 and 14.8% in the SC and EC groups (p = 0.22), respectively. No significant differences were found in clinical characteristics or outcomes between the two groups. Multivariate analysis of aneurysmal SAH revealed no significant risk for poor outcome associated with the treatment method. The present study was not a randomized controlled study, but no significant differences in mRS at discharge were found between SC and EC in the Japanese stroke databank 5).

2016

3210 patients underwent treatment for ruptured intracranial aneurysms. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for subarachnoid hemorrhage (SAH) were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounding factor by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663).

In this cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling 6).

1)
Weir B, Myles T, Kahn M, Maroun F, Malloy D, Benoit B, McDermott M, Cochrane D, Mohr G, Ferguson G, et al. Management of acute subdural hematomas from aneurysmal rupture. Can J Neurol Sci. 1984 Aug;11(3):371-6. PubMed PMID: 6467088.
2)
Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al.: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274, 2002
3)
Treatment of cerebral aneurysms-surgical clipping or endovascular coiling: the guiding principles. Semin Neurol. 2013 Nov;33(5):476-87. doi:10.1055/s-0033-1364217. Epub 2014 Feb 6. PubMed PMID: 24504611.
4)
Jia ZJ, Hong B, Chen DM, Huang QH, Yang ZG, Yin C, Deng XQ, Liu JM. China's Growing Contribution to Global Intracranial Aneurysm Research (1991-2012): A Bibliometric Study. PLoS One. 2014 Mar 12;9(3):e91594. doi: 10.1371/journal.pone.0091594. eCollection 2014. PubMed PMID: 24622581.
5)
Ikawa F, Abiko M, Ishii D, Ohshita J, Matsushige T, Okazaki T, Sakamoto S, Hida E, Kobayashi S, Kurisu K. Analysis of outcome at discharge after aneurysmal subarachnoid hemorrhage in Japan according to the Japanese stroke databank. Neurosurg Rev. 2017 Aug 19. doi: 10.1007/s10143-017-0894-0. [Epub ahead of print] PubMed PMID: 28821992.
6)
Bekelis K, Gottlieb DJ, Su Y, Lanzino G, Lawton MT, MacKenzie TA. Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage. J Neurosurg. 2016 May 20:1-6. [Epub ahead of print] PubMed PMID: 27203138.
ruptured_intracranial_aneurysm.txt · Last modified: 2017/08/20 17:06 by administrador