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Microsurgical Vascular Manipulation in Aneurysm Surgery and Delayed Ischemic Injury

  • Muhammad Omar Chohan (a1), Andrew P. Carlson (a1), Cristina Murray-Krezan (a2), Christopher L. Taylor (a1) and Howard Yonas (a1)...

Abstract

Background: The role of aggressive surgical manipulation with clot evacuation, arachnoid dissection, and papaverine-guided adventitial dissection of large vessels during ruptured aneurysm surgery in reducing vasospasm is controversial. Here we describe a single-institution experience in aneurysm surgery outcomes with and without aggressive surgery. Methods: We performed retrospective analysis of all patients >18 years of age with subarachnoid hemorrhage (SAH) from anterior circulation aneurysms between 2008 and 2013 at the University of New Mexico Hospital. Vasospasm was characterized on days 3 through 14 after SAH based on: (1) angiography, (2) vasospasm requiring angiographic intervention, (3) development of delayed ischemic neurologic deficit (DIND), and (4) radiological appearance of new strokes. Results: Of 159 patients, 114 (71.6%) had “aggressive” and 45 (28.3%) had standard microsurgery. More than 60% of patients presented with a Hunt and Hess score of ≥3 and a Fisher grade (FG) of 4. Compared with standard surgery, there was a statistically significant decrease in the incidence of DIND in patients undergoing aggressive surgery (18.4% vs 37.8%, p=0.01). Moreover, there was a reduction in the number of new strokes by 30% in the aggressive surgery group with moderate or higher degrees of vasospasm (46.0% vs 76.5%, p=0.06). In the same group with FG 4 SAH, however, this difference was more than 50% (30% vs 64.7%, p=0.02). Conclusions: We conclude that aggressive surgical manipulation during aneurysm surgery results in lower incidence of DIND and new strokes. This effect is most pronounced in patients with FG 4 SAH.

Gestes microchirurgicaux vasculaires dans la chirurgie des anévrismes et dans le cas de lésions ischémiques retardées. Contexte: Lors d’interventions chirurgicales consécutives à des ruptures d’anévrismes, l’impact des gestes microchirurgicaux agressifs (évacuation de caillots ; dissection de l’arachnoïde ; sous l’effet de la papavérine, dissection sous-adventitielle d’importants vaisseaux sanguins) visant à réduire les vasospasmes demeure controversé. Nous voulons décrire ici une expérien1ce menée au sein d’un seul établissement hospitalier en ce qui concerne l’impact sur les anévrismes d’une chirurgie courante et d’une chirurgie plus agressive. Méthodes: Nous avons mené une analyse rétrospective des dossiers de tous les patients âgés de plus de 18 ans de l’Hôpital de l’Université du Nouveau-Mexique ayant été victimes, de 2008 à 2013, d’une hémorragie sous-arachnoïdienne (HSA) à la suite d’anévrismes de la circulation sanguine. À la suite d’une HSA, du jour 3 au jour 14, des vasospasmes ont été décrits en se fondant sur : (1) une angiographie ; (2) des vasospasmes nécessitant une intervention angiographique ; (3) l’apparition d’une ischémie cérébrale retardée (ICR) ; et (4) les indices radiologiques de nouveaux AVC. Résultats: Sur 159 patients, 114 (71,6 %) ont bénéficié d’une microchirurgie dite agressive et 45 autres (28,3 %) d’une microchirurgie courante. Plus de 60% des patients ont obtenu un score de ≥3 sur l’échelle de Hunt et Hess et 4 sur l’échelle de Fisher. En comparaison avec une intervention chirurgicale courante, il y a eu une diminution statistiquement significative de la fréquence d’ICR chez les patients qui avaient subi une intervention chirurgicale agressive (18,4 % contre 37,8 % ; p=0,01). De plus, on a pu noter, outre une diminution de 30% du nombre de nouveaux AVC, des degrés modérés ou plus élevés de vasospasmes au sein du groupe de patients ayant subi une chirurgie agressive (46,0 % contre 76,5 % ; p=0,06). Dans le même groupe où les individus avaient été victimes d’une HSA et obtenu 4 à l’échelle de Fisher, cette différence était toutefois de plus de 50% (30 % contre 64,7 % ; p=0,02). Conclusions: Nous concluons que des gestes microchirurgicaux agressifs lors d’une chirurgie des anévrismes ont pour conséquence une fréquence plus faible d’ICR et de nouveaux AVC. Cette conséquence est particulièrement marquée dans les cas d’HSA dont le score se situe à 4 sur l’échelle de Fisher.

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Copyright

Corresponding author

Correspondence to: Muhammad Omar Chohan, Department of Neurosurgery, MSC 10-5615, 1 University of New Mexico, Albuquerque, NM 87131. Email: mchohan@salud.unm.edu

References

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