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The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era

  • Original Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era.

Methods

We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical (n = 80) or endovascular (n = 61) treatment for PGASAH.

Results

Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0–2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991–6.981], p = 0.052).

Conclusions

Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.

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Abbreviations

ACA:

Anterior cerebral artery

AcomA:

Anterior communicating artery

aSAH:

Aneurysmal subarachnoid aneurysmal hemorrhage

BA:

Basilar artery

BBA:

Blood blister–like aneurysm

CSF:

Cerebrospinal fluid

CT:

Computed tomography

CTA:

Computed tomography angiography

CVS:

Cardiovascular system

DSA:

Digital subtraction angiography

DVT:

Deep venous thrombosis

HH:

Hunt and Hess

ICA:

Internal carotid artery

ICH:

Intracerebral hemorrhage

ICU:

Intensive care unit

ISAT:

International subarachnoid aneurysm trial

ISAT:

International subarachnoid aneurysm trial

IVH:

Intraventricular hemorrhage

MCA:

Middle cerebral artery

mRS:

Modified Rankin scale

PcomA:

Posterior communicating artery

PE:

Pulmonary embolism

PGASAH:

Poor-grade aneurysmal subarachnoid hemorrhage

PICA:

Posterior inferior cerebellar artery

RA:

Ruptured aneurysm

RR:

Raymond-Roy

SAFIRE:

Size of the aneurysm, Age, FIsher grade, REsuscitation

VPS:

Ventriculo-peritoneal shunt

WFNS:

World Federation of Neurological Surgeons

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Acknowledgements

The authors thank Steven L. Goodman, PhD for his editing assistance.

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Authors and Affiliations

  1. Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, CSC, K4/822, 600 Highland Avenue, Madison, WI, 53792, USA

    Sahin Hanalioglu, Balkan Sahin, Sima Sayyahmelli, Burak Ozaydin, Ufuk Erginoglu, Abdurrahman Aycan & Mustafa K. Baskaya

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  1. Sahin Hanalioglu
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Correspondence to Mustafa K. Baskaya.

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This study was approved by our Institutional Review Board. Patient consent was not sought due to the retrospective nature of this study.

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This article is part of the Topical Collection on Vascular Neurosurgery – Aneurysm

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Hanalioglu, S., Sahin, B., Sayyahmelli, S. et al. The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era. Acta Neurochir 164, 781–793 (2022). https://doi.org/10.1007/s00701-022-05112-1

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