The management of intracranial aneurysms has changed dramatically through the time. Since the introduction of microneurosurgery in the 1960s, the outcome in patients suffering SAH after rupture of aneurysms improved dramatically. The technological developments that allow the endovascular treatment of aneurysms are gaining popularity due to the associated low morbidity and feasibility of the methods. This fact is supported by approximately 1100 new cases treated each month worldwide with intracranial endovascular devices [
The incidence of subarachnoid hemorrhage-induced vasospasm (CVS) in patients undergoing endovascular treatments compared to surgical occlusion of ruptured aneurysm is still controversial [
The aim of this prospective study was to analyze and compare the incidence of CVS, influencing risk factors, outcome, and quality of life in patients undergoing either surgical or endovascular treatment of ruptured aneurysms in a single institution.
A total of 94 patients presenting with SAH were admitted in our institution during a one-year period. In 16 patients (17.1%) angiographic studies failed to demonstrate an aneurysm as cause of the SAH. Twelve (11.7%) patients who did not undergo occlusion of the aneurysm and died immediately after admission were also excluded. Finally, this prospective study included 66 (70.2%) patients with aneurysmal SAH proven on CT and angiography who underwent occlusion of ruptured aneurysms. Demographic characteristics are shown in Table
Demographic characteristics and clinical and radiological findings on admission.
Surgical treatment | Endovascular treatment | |||||
Total | Clinical CVS | No clinical CVS | Total | Clinical CVS | No clinical CVS | |
Patients | 41 | 12 | 29 | 25 | 6 | 19 |
Age (years) | ||||||
Gender (f : m) | 30 : 11 | 11 : 1 | 19 : 10 | 17 : 8 | 4 : 2 | 13 : 06 |
BMI (m2/kg) | ||||||
WFNS grading | ||||||
Grade 1–3 (%) | 82.3 | 75 | 86.2 | 72 | 83.3 | 68.4 |
Grade 4-5 (%) | 17.7 | 25 | 13.7 | 28 | 16.7 | 31.6 |
mGCS | ||||||
Hunt & Hess grading | ||||||
Grade 1–3 (%) | 97.6 | 91.7 | 100 | 84 | 83.3 | 84.2 |
Grade 4-5 (%) | 2.4 | 8.3 | 0 | 16 | 16.7 | 15.8 |
Initial mean arterial pressure (mmHg) | ||||||
Time interval SAH—admission (mean hours/range) | 21/0.4–312 | 21.5/0.4–124 | 20.8/0.5–312 | 19.5/0.5–206 | 39.4/1–206 | 12.3/0.5–159 |
Headache (%) | 97.5 | 100 | 96.6 | 92 | 100 | 89.5 |
Unconsciousness (%) | 43.9 | 50 | 41.5 | 31 | 33.3 | 36.8 |
Nausea/vomitting (%) | 65.9 | 50 | 75.9 | 76 | 83.3 | 73.7 |
Neck stiffness (%) | 61 | 50 | 65.5 | 64 | 83.3 | 57.9 |
Seizures (%) | 7.3 | 8.3 | 6.8 | 28 | 16.7 | 31.6 |
Focal neurological deficits (%) | 19.5 | 16.6 | 20.7 | 8 | 0 | 10.5 |
Hydrocephalus (%) | 26.8 | 25 | 27.6 | 32 | 33.3 | 36.8 |
CVS: cerebral vasospasm; BMI: body mass index; WFNS: World Federation of Neurosurgical Societies; mGCS: modified Glasgow Coma Score; SAH: subarachnoid hemorrhage. All data are expressed as mean ± standard deviation.
All patients were admitted at the Intensive Care (ICU) or Intermediate Care (IMC) Unit in order to assure an optimal oxygenation and adequate hemodynamic management prior and after occlusion of the aneurysm. Monitoring of blood pressure and intracranial pressure (ICP), if indicated, was performed. Hemodynamic, ICP, and cerebral perfusion pressure (CPP) were documented hourly. Fluid control was documented hourly and summarized twice a day. Initial routine laboratory examination included coagulation status, electrolytes, hematology, liver and renal function, and arterial blood gases. These parameters were controlled and documented throughout the treatment once a day. All patients underwent computerized tomography (CT) at admission, 2 days after occlusion of the aneurysm, and 6 weeks after treatment. Initial cerebral angiography was performed in all patients after admission.
The decision how to occlude the aneurysm was based on a case-by-case evaluation in which different angiographic and clinical factors were considered. Angiographic findings included location, size, and shape of the aneurysm, as well as tortuosity of the proximal vessels. Clinical data included age, initial neurological findings, and systemic comorbidities.
All patients received steroids (Prednison 150 mg p.o. or Methylprednisolone 120 mg i.v.) and oral nimodipine (90–360 mg). A total of 32 (48%) patients were additionally included in a multicentric prospective phase II study testing the effects of the endothelin receptor antagonist clazosentan [
After occlusion of the aneurysm, patients were classified according to the risk for development of CVS. The criteria to consider patients as high risk for CVS included severity of clinical findings (WFNS [
The diagnosis of symptomatic or clinical CVS was considered if deterioration of level of consciousness defined as one-point decrease in the mGCS or development of focal neurological signs occurring between days 3 and 14 after SAH could be documented. Clinical assessment in terms of mGCS and neurological examination was performed three times a day and documented prospectively. All patients included in this study underwent cerebral angiography on day 9 ± 2 after SAH. Angiographic CVS was classified in proximal or distal, and focal or diffuse. The severity of CVS was classified into mild (<33%), moderate (34–66%), and severe (67–100%). Grade of obliteration of the aneurysm was assessed in the postinterventional angiography as follows: 100%, >90%, 70–90%, and <70%. Transcranial Doppler (TCD) was performed every two days or daily if CVS was diagnosed. TCD criteria for CVS included: increase in velocities of 30%, increase in absolute values (50 cm/sec), or a Lindegaard index greater than 3. Endovascular treatment of CVS was not performed. All patients suffering CVS underwent CT scan prior to discharge in order to assess possible ischemic lesions.
Assessment of functional status was based on responses of questionnaires performed 6 and 12 weeks after admission. Computerized scoring algorithms served to classify the patients according to the Mini Mental Status Examination [
Quality of life was assessed using the quality of life questionnaire EuroQoL (EQ-5D) [
Quantitative data are expressed as mean values ± standard deviation. Differences between groups were assessed by using the Student’s
A total of 66 patients (age: 52 ± 10; female: 47, 71.2%) were included in this study. Table
The aneurysm location, size, and treatment modality are shown in Table
Location, size, and degree of obliteration of the aneurysm according to treatment modality.
Surgical treatment | Endovascular treatment | |||||
Total | Clinical CVS | No clinical CVS | Total | Clinical CVS | No clinical CVS | |
41 | 12 | 29 | 25 | 6 | 19 | |
Location of the aneurysm | ||||||
ICA | 4 | 1 | 3 | 2 | 1 | 1 |
MCA | 14 | 3 | 11 | 1 | 0 | 1 |
PComA | 10 | 3 | 7 | 5 | 2 | 3 |
AComA | 12 | 5 | 7 | 9 | 1 | 8 |
BA | 0 | 0 | 0 | 7 | 2 | 5 |
VA | 0 | 0 | 0 | 1 | 0 | 1 |
PICA | 1 | 0 | 1 | 0 | 0 | 0 |
Aneurysm size, maximal diameter (mm) | ||||||
Degree of obliteration (%)* | ||||||
100 | 82.9 | 100 | 75.9 | 52 | 33.3 | 57.9 |
>90 | 4.9 | 0 | 6.9 | 28 | 50 | 21.05 |
70–90 | 4.9 | 0 | 6.9 | 16 | 0 | 21.05 |
<70 | 7.3 | 0 | 10.3 | 4 | 16.7 | 0 |
CVS: cerebral vasospasm, MCA: middle cerebral artery; ICA: internal carotid artery, PComA: posterior communicating artery; AComA: anterior communicating artery; BA: basilar artery; VA: vertebral artery; PICA: posterior inferior cerebellar artery; *: based on postinterventional angiography at day 9 ± 2 after SAH.
The overall incidence of CVS detected clinically was 27.2% (
Risk factors for cerebral vasospasm on admission and during the treatment in patients undergoing surgical and endovascular treatment.
Surgical treatment | Endovascular treatment | ||||||
Total | Clinical CVS | No clinical CVS | endovascular | Total | Clinical CVS | no clinical CVS | |
Total patients | 41 | 12 | 29 | — | 25 | 6 | 19 |
Patients with angiographic CVS (%) | 70.7 | 91.7 | 62.1 | NS | 52 | 83.3 | 36.8 |
Patient with clinical CVS (%) | 29.2 | — | — | NS | 24 | — | — |
Platelet count (×1000/ | NS | ||||||
Lowest platelet count/admission count > 0.7 (%) | 85.4 | 83 | 86 | — | 80 | 66 | 84 |
Hematocrit (L/L) | |||||||
Mean systolic blood pressure (mmHg) | NS | ||||||
Episodes of hypotension (SBP <105 mmHg) | NS | ||||||
Maximal ICP (mmHg)* | NS | ||||||
Patients undergoing ICP monitoring (%) | 31.7 | 42 | 27 | — | 48 | 66 | 42 |
Angiographic vasospasm on admission (%) | 7.3 | 8.3 | 6.9 | — | 16 | 50 | 5.3 |
Fisher CT grading | NS | ||||||
Grade 1-2 (%) | 17.1 | 8.3 | 20.7 | — | 16 | 16.7 | 15.8 |
Grade 3-4 (%) | 82.9 | 91.7 | 79.3 | — | 86 | 83.3 | 84.2 |
Mean fluid balance (mL) | NS | ||||||
Patients with negative fluid balance (%) | 63.4 | 75 | 58.7 | — | 60 | 83.3 | 52.6 |
Episodes of negative fluid balance | NS | ||||||
Inclusion in the Clazosentan study* ( | 23 | 7 (28.1%) | 16 (69.5%) | NS | 9 | 2 (22.2%) | 7 (77.7%) |
Sodium (mmol/L) | |||||||
Glucose (mmol/L) | NS | ||||||
Cigarette use (%) | 48.8 | 75 | 38 | — | 52 | 33.3 | 57.9 |
Cigarette use (py) | NS |
CVS: cerebral vasospasm; ICP: intracranial pressure; SBP: systolic blood pressure; NS: no statistically significant; *: including all patients receiving placebo and clazosentan (1, 5, and 15 mg). All data are expressed as mean ± standard deviation.
Angiographic CVS was classified as proximal (
TCD confirmed angiographic CVS in only 51% of patients. The rest of patients presenting with angiographic CVS were not detected with TCD. Therefore, TCD did not influence the decision for CVS treatment in our series. In this series, the inclusion of patients in the endothelin receptor antagonist clazosentan study (placebo, 1, 5, or 15 mg) did not influence significantly the incidence and severity of angiographic (56.2% versus 70.5%,
The only risk factors for CVS, which differed significantly between patients undergoing clipping and coiling, were hematocrit and sodium values throughout the treatment (Table
The overall mortality due to CVS was 9.9%. The mortality of patients who underwent clipping was higher than in patients who underwent endovascular treatment (14.6% versus 4%) (Table
Outcome and quality of life after surgical and endovascular occlusion of the aneurysm.
Surgical Treatment | Endovascular treatment | |||||||
Total | clinical CVS | no clinical CVS | versus endovascular | versus CVS endovascular | Total | clinical CVS | no clinical CVS | |
Survivors/total patients | 35/41 | 7/12 | 28/29 | — | — | 24/25 | 5/6 | 19/19 |
Survivors (%) | 85.4 | 58.3 | 96.6 | — | — | 96 | 83.3 | 100 |
Mortality (%) | 14.6 | 41.6 | 3.4 | NS | NS | 4 | 16.7 | 0 |
mRS | NS | NS | ||||||
MMSE* | NS | NS | ||||||
NIHSS* | NS | NS | ||||||
Barthel-Index* | NS | NS | ||||||
51.5 | 14.3 | 61.5 | NS | 52.2 | 80 | 44.4 | ||
Mobility (%)‡ | 12.1 | 14.3 | 9.1 | 34.8 | 80 | 22.2 | ||
Self-Care (%)‡ | 12.1 | 0 | 15.4 | NS | 21.7 | 60 | 11.1 | |
Usual activities (%)‡ | 27.3 | 14.3 | 30.8 | NS | 39.1 | 80 | 27.8 | |
Pain/Discomfort (%)‡ | 30.3 | 0 | 38.5 | NS | 39.1 | 60 | 33.3 | |
Anxiety/Depression (%)‡ | 24.2 | 14.3 | 26.9 | NS | NS | 21.7 | 60 | 11.1 |
Patients’ health (VAS) | NS | NS | ||||||
PCS | 48.69 | 49.75 | 48.36 | NS | NS | 48.22 | 41.34 | 49.44 |
MCS | 43.18 | 44.23 | 42.85 | NS | NS | 45.47 | 35.46 | 47.42 |
CVS: cerebral vasospasm; mRS: modified Rankin Score; MMSE: Minimental State Examination; NIHSS: National Institutes of Health Stroke Scale; NS: no statistically significant. *: measurements in survivors. EQ-5D: EuroQoL health state; VAS: visual analog scale for patients’ health state (0–100); *: patients reporting problems in at least one of the EuroQol items. ‡: patients presenting with any limitation (level 2 or 3); SF-12: Short Form-12; PCS: physical component summary; MCS: mental component summary; †: measurements based on 30 out of 35 patients in the surgical group and 20 out of 24 in the endovascular group. All data are expressed as mean ± standard deviation.
No statistically differences of outcome parameters (mRS, Barthel Index, NIHSS, and MMSE) could be demonstrated between both groups (Figure
Barthel index at 12 weeks according to type of treatment (surgical group: 97.5 ± 7.6, endovascular group: 88.4 ± 29.6,
In terms of assessment of quality of life using the EuroQoL (EQ-5D), only mobility was demonstrated to be significantly less impaired in patients undergoing surgical treatment (12.1% versus 34.8%). In patients who survived clinical CVS, an additional statistically significant less impairment (level 2 or 3) in terms of mobility, self-care, usual activities, and pain/discomfort could be demonstrated in the surgical group compared to the endovascular group (Table
Physical and mental component summaries of the SF-12 at 6 months distributed according to treatment type (
The overall incidence of symptomatic and angiographic vasospasm in this prospective study was 27.2% and 63.6%, respectively. These data are similar to previous series reported in the literature [
New therapeutic strategies which could influence the lower incidence of CVS compared to previous series might include the introduction of CSF drainage (ventricular or lumbar) in our treatment protocol [
In our series, the only risk factor for CVS detected to be different in the two treatment groups was hematocrit and sodium values, which remained nevertheless within normal limits. Natriuresis following SAH is frequently associated with hypovolemia caused by cerebral salt wasting and may be related to increased secretion of brain natriuretic peptide [
Since the introduction of endovascular techniques for the treatment of intracranial aneurysms, very few studies comparing the outcome of patients undergoing surgical and endovascular treatment, have been reported [
The quality of life in patients treated with surgical or endovascular techniques has not been studied extensively. To our knowledge, only one report including 93 patients (clip: 56 patients, coil: 37 patients) has been published so far [
Finally, the main limitation of this study is the small population included and the lack of randomization of the type of treatment. In our study, nevertheless, the statistical analysis of the demographic and radiological features showed no differences in both treatment groups.
According to the results of this study, the incidence of symptomatic and angiographic CVS, outcome, and quality of life might not significantly differ between patients undergoing endovascular or surgical treatment if demographic and radiological features as well as parameters during intensive care management are similar. Nevertheless, a trend of lower incidence of CVS in patients undergoing endovascular treatment was observed.
This study was supported by the Cerebrovascular Research Fund from the Departments of Neurosurgery and Intensive Care Medicine from the University of Berne, Berne, Switzerland (Account no. 34-160). The authors thank the collaboration of our study nurses Jürgen Rohner, RN, Klaus Meier, RN, and Judith Kaufmann, RN.