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Aneurysmal Surgery in the Presence of Angiographic Vasospasm: An Outcome Assessment

Published online by Cambridge University Press:  10 January 2017

Nancy McLaughlin
Affiliation:
Division of Neurosurgery, Department of Surgery, Centre Hospitalier de, l'Université de Montréal - Hôpital Notre-Dame, Montreal, Quebec, Canada
Michel W. Bojanowski
Affiliation:
Division of Neurosurgery, Department of Surgery, Centre Hospitalier de, l'Université de Montréal - Hôpital Notre-Dame, Montreal, Quebec, Canada
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Abstract:

Background and Purpose:

The timing of aneurysmal surgery for patients presenting within the period at risk for vasospasm (VS) is controversial. The goal of this study is to review our experience of surgically treated patients in the presence of angiographic VS.

Materials and Methods:

From 1990-2004, 894 consecutive patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with a policy of early surgery. We retrospectively analyzed the patients that had pre-operative angiographic VS. In this study, symptomatic VS was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic VS without confounding factors. Functional outcome was assessed three months after SAH using the Glasgow Outcome Scale.

Results:

Of the 40 patients studied, 62.5% were in good clinical grade Hunt & Hess (H&H 1-2) on admission; 25%, intermediate grade (H&H 3); 12.5%, poor grade (H&H 4-5). Surgery was performed 24 hours or less after initial angiography in 87.5% of patients and less than 48 hours in 97.5%. Pre-operative symptomatic VS was diagnosed in 25%. Postoperatively, angiographic VS was documented in 87.2%. Of the 30% of patients that presented post-operative symptomatic VS, 66.7% also demonstrated pre-operative symptomatic VS. The functional outcome was favorable in 92.5% of the studied patients. Two deaths occurred in patients presenting pre-operative early radiological and symptomatic VS.

Conclusion:

Aneurysmal surgery, especially between 3-12 days following SAH, in the presence of asymptomatic pre-operative angiographic VS can be associated with a good outcome. Early surgery is not contra-indicated and might enable optimal treatment of VS.

Résumé:

RÉSUMÉ: Contexte et objectif:

Chez les patients qui consultent pour une hémorragie sous-arachnoïdienne (HSA) due à un anévrisme pendant la période à risque de vasospasme (VS), le moment de la ligature de l’anévrisme demeurecontroversé. Le but de cetteétude est de réviser notreexpérience chez des patients traités chirurgicalement en presence de VS angiographique.

Matériel et Méthode:

De 1990 à 2004, 894 patients consécutifs ontété admis pour une HSA due à un anévrisme et ontété traité par unechirurgieprécoce. Nous avonsanalysé de façon rétrospective les patients présentant du VS angiographiquepré-opératoire. Danscetteétude, un diagnostic de VS symptomatiqueétait posé en présence d’une altération de la conscience ou d’un déficit focal survenantaprès une HSA en presence de VS angiographique et en l’absence de facteursconfondants. Le pronosticfonctionnelfutévalué selon l’échelle de Glasgow (GOS) 3 moissuivant l’HSA.

Résultats:

Parmi les 40 patients étudiés, 62,5% étaient en bon grade clinique de Hunt&Hess (H&H 1-2) à l’admission; 25% en grade intermédiaire (H&H 3); 12,5% en mauvais grade (H&H4-5).La chirurgieétait réalisée 24 heuresoumoinsaprès l’angiographie initiale chez 87,5% des patients et 48 heuresoumoins chez 97,5% des patients.Un VS symptomatiquepré-opératoire futdiagnostiqué dans 25% des cas. En post-opératoire, un VS angiographiquefut documenté dans 87,2% des cas. Parmi les 30% qui présentaient un vasospasmesymptomatique post-opératoire, 66,7% avaientégalement présenté un VS symptomatiqueavant la chirurgie. Le pronosticfonctionnelétait favorable chez 92,5% des patients étudiés. Deux décès sontsurvenus chez des patients qui présentaient un VS radiologique et symptomatiqueprécoce.

Conclusion:

La ligature d’un anévrisme rompu, particulièrement entre le 3e et 12e jourssuivantune HSA, en présence de vasospasmeangiographiqueasymptomatiquepré-opératoire, peutêtre associé à un pronostic favorable. La chirurgieprécoce n’est pas contre-indiquée et pourraitfavoriser un traitement optimal du VS.

Type
Original Articles
Copyright
Copyright © The Canadian Journal of Neurological 2006

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