Role of Multislice Computerized Tomographic Angiography in Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: We evaluate the role of multislice computerized tomographic angiography(MCTA) in the diagnosis of intracranial vasospasm following subarachnoid hemorrhage(SAH) in patients suspected of having vasospasm on clinical ground. METHODS: Between October 2003 and June 2005, patients with ruptured cerebral aneurysms of the anterior circulation clipped within 3 days of the onset were included. We performed follow-up MCTAs in patients who were suspected to have vasospasm on transcranial doppler sonography(TCD) findings and clinical grounds. Based on the clinical presentation of symptomatic vasospasm, we investigated the correlation between clinical, TCD, and MCTA signs of vasospasm and evaluated the role of MCTA in vasospasm. RESULTS: One hundred one patients met the inclusion criteria and symptomatic vasospasm developed in 25 patients (24.8%). We performed follow-up MCTAs in 28 patients. MCTA revealed spasm in the vessels of 26 patients. The sensitivity of MCTA was 100%. Among the 26 patients with MCTA evidence of vasospasm, 3 patients had TCD signs of vasospasm after symptomatic vasospasm presentation. Another 3 patients with symptomatic vasospasm had no TCD signs of vasospasm in daily serial recordings. Six other patients without symptomatic vasospasm showed MCTA evidence of vasospasm (false positive result) but these patients had also positive TCD signs of vasospasm. Volume rendering(VR) images tended to show significantly more exaggerated vasospasm than maximum intensity projection(MIP) images. The mean cerebral blood flow velocity of both proximal segment of the middle cerebral artery (M1) was significantly correlated with each reduced M1 diameter on MCTA (P<0.05). CONCLUSION: MCTA could be a useful tool for evaluation and planning management of critically ill patients suspected of having vasospasm; however, more randomized controlled trials are necessary to assess these points definitively.

Symptomatic Vasospasm and Chronic Hydrocephalus in Elderly Patients after Intracranial Aneurysm Rupture-Comparison with Younger Ones / 대한뇌혈관학회지

OBJECTIVE: The purpose of this study is to compare the incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm in elderly patients following intracranial aneurysm rupture with those of younger patients. METHODS: We retrospectively reviewed the medical records of 189 patients who were treated with open surgery between May 1994 and December 2000. They were divided into two groups; elderly (> or =60 yrs) and younger (< or =59 yrs) group. Incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm was analysed in each group during 6 months after surgery. RESULTS: Shunt-dependent chronic hydrocephalus has developed more frequently in the elderly group (27.8%) than in the younger group (7.3%). Incidence of symptomatic vasospasm was not significantly different between two groups, even though poor grade patients were more represented in the elderly group. CONCLUSION: Meticulous clinical long-term follow-up is needed to detect shunt-dependent chronic hydrocephalus as early as possble in the elderly patients with operated ruptured intracranial aneurysms and in that case, shunt operation should be undertaken.

Effect of the Intra-arterial Papaverine Infusion on the Symptomatic Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage

OBJECTIVES: To clarify the benefits and therapeutic effects of intra-arterial papaverine infusion on the symptomatic cerebral vasospasm, we analyzed the results of treatment in 32 patients retrospectively. METHODS: A total of 510 patients underwent surgical clipping or endovascular intra-aneurysmal treatment for ruptured intracranial aneurysm between May, 1996 and June, 1999. The delayed ischemic deficit(DID) was developed in 90 of 510 patients. Of these 90 patients, 32 developed symptomatic vasospasm inspite of using modest "3H therapy". The brain CT scan was taken before the intra-arterial infusion of papaverine. The 32 patients underwent 42 intra-arterial papaverine infusion. The symptomatic vasospasm was divided into three groups: deterioration of mental status(Group 1), appearance of a focal neurologic deficit(Group 2), or both(Group 3). We measured Glasgow Coma Scale(GCS), arterial diameters, and cerebral circulation time(CCT) at the time of pre- and postangioplasty. RESULTS: The number of patients in group 1, 2 and 3 were 26, 7, 9 respectively. Eighteen cases showed improvement of GCS more than 2 scores, 16 more than 1, and 8 showed no change of GCS. Average cerebral circulation time(CCT) was decreased ranging from 0.0%-67.5%, and arterial diameters were increased in 21 cases ranging from 1 to 4 folds. CONCLUSION: Intra-arterial papaverine infusion seemed to have therapeutic effects on symptomatic vasospasm by improving the neurological signs and increasing the arterial diameter. We suggest that intra-arterial papaverine infusion would be an useful adjunctive therapeutic modality in symptomatic vasospasm.

An Analysis of Factors Related to Symptomatic Vasospasm and Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

Symptomatic vasospasm is still one of the major causes of death and disability in patients who suffer an aneurysmal subarachnoid hemorrhage(SAH). To identify risk factors related to symptomatic vasospasm, to determine the outcome in patients with SAH, and to determine the differences identified risk factors between patients with good and bad outcomes, we performed this retrospective study. From a total of 279 SAH patients who were admitted to our hospital between January 1993 and December 1995, 212 were chosen for study. These were patients who had been admitted within 7 days of SAH, had undergone brain computed tomography(CT) within 3 days of SAH and had survived more than 6 days after SAH. Nine variables were examined as to their relationship to symptomatic vasospasm: age, sex, admission day after SAH, hypertension history, frequency of SAH, clinical grade, CT grade, operation day after SAH, and outcome. Data were analyzed by the univariate and multivariate logistic regression method using the Statistical Analysis System(SAS). Symptomatic vasospasm was demonstrated in 30 cases(14.2%). Univariate analysis showed that admission more than 4 days after SAH(p=0.07), clinical grades III-V(p=0.001), and CT grade III(p=0.00001) were associated with a higher risk of symptomatic vasospasm. When study cases were grouped into either good or bad outcome groups, and multivariate logistic regression analysis was performed, these factors were associated with a higher risk of symptomatic vasospasm only in the good outcome group. This suggests that there is a group of patients with a predisposition to symptomatic vasospasm that is independent of these risk factors, and that in these patients, the outcome may be worse.

Factors Affecting Development and Recovery of Symptomatic Vasoapasm in Patients with Ruptured Intracranial Aneurysm(s)

To determine the factors affecting development and recovery of symptomatic vasospasm, the author analyzed the results of patients with ruptured intracranial aneurysms treated by nimodipine and prophylactic "triple-H" therapy. From January 1991 to December 1995, 199 patients underwent surgery for ruptured intracerebral aneurysms. Combined hypervolemic hemodilution was initiated at the time of admission. Induced hypertension was added immediately after surgery(aneurysmal neck clipping). All patients received nimodipine intravenously or orally until the 14th day of SAH. Sixty patients underwent surgery on Day 0 through 2 after attackes of subarachnoid hemorrhage(Group A), 105 patients on Day 3 through 14(Group B), and 34 patients after Day 14(Group C). Of 199 patients, 76(38%) patients suffered from symptomatic vasospasm. Symptomatic vasospasm occurred in 34% of Group A patients, 33% of Group B patients, and 5% of Group C patients. Symtomatic vasospasm occurred more frequently in the older age group, the Fisher group 3, and Hunt & Hess grades 3, 4 and 5 groups. Of 76 patients who suffered from symptomatic vasospasm, 47(62%) patients recovered completely. The author analyzed the relationship between recovery rate and sex, age, Hunt & Hess grade and Fisher group among these 76 patients. Recovery rates between these groups were not significantly different. Based on this experience, the author believes that Hunt-Hess grade, Fisher group, and age are important factors affecting symptomatic vasospasm development.

Clinical Analysis of Intracranial Aneurysms(Sep. 1957-Jun. 1988)

In order to have the statistical basis of intracranial aneurysms, the authors analyzed the cases of angiographically proven intracranial aneurysms which were admitted to the department of neurosurgery, Seoul National University Hospital from Sep. 1957 to June 1988. The results of analysis were summarized as follows; 1) Total number of patients was 564 and 64 patients had multiple aneurysms, so total number of aneurysms was 647. Peak age incidence was in the 5th & 6th decades and male to female ratio was 1 : 1.2. 2) Location of aneurysms were anterior communicating artery(32%), posterior communicating artery(28.1%), middle cerebral artery(21.5%) in the order of frequency. Posterior circulation aneurysms comprised 7.1% and multiple aneurysms were 11.3%. 3) Among 647 aneurysms, 368 aneurysms were neck-clipped(56.9%), and operative mortality was 4.9%. 4) After 1983, 300 patients of 344 aneurysms were admitted to the neurosurgical department. The size of aneurysm was most frequent in 6-10 mm in diameter(49.4%) and 5 giant aneurysms were detected. 5) Among 344 aneurysms, 253 aneurysms were neck-clipped(73.5%) and operative mortality were lowered to 2.4%. 6) Among 300 patients 287 patients had ruptured aneurysm. Angiographic spasm was detected in 32.1% and symptomatic spasm was in 19.5%. 7) Hydrocephalus was detected in 36.2% during the period of admission and follow-up. 8) Anterior communicating artery aneurysms ruptured most frequently among the multiple aneurysms. 9) Clinical state on admission was an important factor for the outcome and preoperative clinical state was related to the operative outcome and mortality.

Risk Factors Contributing to Symptomatic Vasospasm in Aneurysmal Subarachnoid Hemorrhage

The prediction of possibility which patient will develop vasospasm constitutes a further advance in the management of this complication. So the possible clinical risk factors predicting ischemic complication of subarachnoid hemorrhage were retrospectively investigated in patients with ruptured intracranial aneurysm. A comparative analysis of risk factors contributing to symptomatic vasospasm was carried out between 40 patients with symptomatic vasospasm as DID(Delayed Ischemic Neurologic Deficit) group and 52 patients without symptomatic vasospasm as Non-DID group, those who were selected among 349 cases of ruptured intracranial aneurysm admitted to department of neurosurgery at Presbyterian Medical Center, Jeon Ju for 6 years from August, 1982 to July, 1988. Peripheral WBC count, clinical grade, hematocrit, blood glucose level, EKG findings, age, sex and aneurysm location of admission failed to show a prognostic value as a factor developing delayed ischemic neurologic deficit in the patients. However a statistically significant rise in peripheral WBC count was observed at the beginning of clinical deterioration and also systolic blood pressure at admission were significantly higher in DID than Non-DID group. The results suggest that the increase of peripheral WBC count observed at the time of neurological deterioration of delayed onset and high systolic blood pressure at admission might be a risk factor for developing vasospasm.