Chronological Change of the Clinical Features and Treatment Outcomes for Subarachnoid Hemorrhage in Japan: A Multicenter Retrospective Study.

Aneurysmal subarachnoid hemorrhage (SAH) treatment has progressed, and patients are rapidly aging in Japan. Consequently, dynamic changes must have emerged in the clinical practice of SAH. This study aimed to elucidate chronological changes of aneurysmal SAH and the prognostic factors in the previous quarter century in Japan. We conducted a retrospective survey regarding aneurysmal SAH in eight institutions in Japan. The study included 848, 863, and 781 patients in the first (1989-1993), second (1999-2003), and third (2009-2013) periods, respectively. The chronological changes of factors that influenced the poor outcomes and differences between the nonelderly (<75 years) and elderly patients were investigated. Mean age was significantly higher in patients in the third period (61.4 years) than in those in the other two periods (first, 57.8 years; second, 59.5 years). During these periods, the proportion of good outcomes did not change; however, the mortality rate significantly decreased from 19% in the first period to 11% and 9.2% in the second and third periods, respectively. The poor outcome was mainly caused by the significantly higher incidence of systemic complication and procedural complication in the first period and the significantly lower incidence of delayed ischemic neurological deficit in the third period. The elderly patients had significantly poorer clinical outcomes than the nonelderly ones. During the last 25 years, the age of patients with aneurysmal SAH has rapidly increased. The study results may contribute to the improvement of the treatment strategy of SAH in advanced countries with a rapidly aging population.

Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Advanced Monitoring.

BACKGROUND: Wrap-clipping is one of the recommended treatments for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). However, the long-term clinical and angiographic outcomes of this procedure have not yet been elucidated. The present study examined the long-term efficacy of wrap-clipping using a polytetrafluoroethylene membrane, an ideal wrapping material, for BBAs. METHODS: The data from 9 patients with ruptured BBAs treated at our institutes from 2007 to 2016 were retrospectively analyzed. Wrap-clipping was performed with advanced monitoring techniques, including fluorescence video angiography and endoscopy. Angiographic follow-up was achieved using 3-dimensional computed tomography angiography or digital subtraction angiography. Clinical outcomes were assessed using the modified Rankin scale. RESULTS: Wrap-clipping was performed without any permanent morbidity in all patients. Endoscopy visualized accurate margins of the aneurysmal pathological wall with high magnification and revealed the position of the clip blades and the surrounding perforators in the dead angles of the microscope. Fluorescence video angiography could confirm the blood flow of the ICA and the surrounding arteries. Regrowth of the aneurysm owing to the presence of a neck remnant occurred 1 month after treatment in 1 case that was repaired surgically. However, no other recurrence of BBAs or progression of ICA stenosis was observed by angiography with a mean follow-up period of 37 months. No repeat rupture or ischemic complications occurred, and all patients had a modified Rankin scale score of 0 with a mean follow-up period of 61 months. CONCLUSION: Wrap-clipping using a polytetrafluoroethylene membrane for ruptured BBAs is a useful and acceptable procedure with long-term effectiveness. The effectiveness of this method can be ensured using modern monitoring methods.

Effects of cilostazol on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a multicenter prospective, randomized, open-label blinded end point trial.

OBJECT: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of subsequent morbidity and mortality. Cilostazol, a selective inhibitor of phosphodiesterase 3, may attenuate cerebral vasospasm because of its antiplatelet and vasodilatory effects. A multicenter prospective randomized trial was conducted to investigate the effect of cilostazol on cerebral vasospasm. METHODS: Patients admitted with SAH caused by a ruptured anterior circulation aneurysm who were in Hunt and Kosnik Grades I to IV and were treated by clipping within 72 hours of SAH onset were enrolled at 7 neurosurgical sites in Japan. These patients were assigned to one of 2 groups: the usual therapy group (control group) or the add-on 100 mg cilostazol twice daily group (cilostazol group). The group assignments were done by a computer-generated randomization sequence. The primary study end point was the onset of symptomatic vasospasm. Secondary end points were the onset of angiographic vasospasm and new cerebral infarctions related to cerebral vasospasm, clinical outcome as assessed by the modified Rankin scale, and length of hospitalization. All end points were assessed for the intention-to-treat population. RESULTS: Between November 2009 and December 2010, 114 patients with SAH were treated by clipping within 72 hours from the onset of SAH and were screened. Five patients were excluded because no consent was given. Thus, 109 patients were randomly assigned to the cilostazol group (n = 54) or the control group (n = 55). Symptomatic vasospasm occurred in 13% (n = 7) of the cilostazol group and in 40% (n = 22) of the control group (p = 0.0021, Fisher exact test). The incidence of angiographic vasospasm was significantly lower in the cilostazol group than in the control group (50% vs 77%; p = 0.0055, Fisher exact test). Multiple logistic analyses demonstrated that nonuse of cilostazol is an independent factor for symptomatic and angiographic vasospasm. The incidence of new cerebral infarctions was also significantly lower in the cilostazol group than in the control group (11% vs 29%; p = 0.0304, Fisher exact test). Clinical outcomes at 1, 3, and 6 months after SAH in the cilostazol group were better than those in the control group, although a significant difference was not shown. There was also no significant difference in the length of hospitalization between the groups. No severe adverse event occurred during the study period. CONCLUSIONS: Oral administration of cilostazol is effective in preventing cerebral vasospasm with a low risk of severe adverse events. Clinical trial registration no. UMIN000004347, University Hospital Medical Information Network Clinical Trials Registry.

[A case of symptomatic arachnoid cyst of the occipital convexity in an adult].

Symptomatic arachnoid cyst in an adult patient is rare. We present a case of a 51-year-old female with an arachnoid cyst of the right occipital convexity who developed homonymous hemianopsia. She had complained of numbness in the limbs at the age of 47 and based on MRI was diagnosed with a cystic space-occupying lesion in the right occipital convexity. After being under observation for four and a half years, she complained of headache and visual disturbance, at which time we diagnosed growth of the cyst. On ophthalmologic examination, homonymous hemianopsia was demonstrated. She underwent membranectomy, which resulted in the disappearance of visual disturbance. This case is comparatively rare among previously reported cases of symptomatic arachnoid cyst with regard to both location and symptom. Membranectomy is one of effective methods for treating symptomatic arachnoid cyst in the occipital convexity.

[A middle cerebral artery dissecting aneurysm manifesting solely with pain, following a vertebral artery dissecting aneurysm].

A 41-year-old male had presented with severe neck pain and was diagnosed as having a left vertebral artery (VA) dissecting aneurysm. During the observation period, he suddenly suffered from a pain on his left temple. MR imaging revealed neither SAH nor cerebral infarction. MR angiography, computed tomographic (CT) angiography and cerebral angiography showed fusiform dilatation of the M1 portion of the left middle cerebral artery (MCA) which had been normal in the former study. The abnormality of the left MCA normalized on both MR and CT angiography 6 months after the second onset. Because of the chronological change of radiological findings compatible with the symptom, we diagnosed the second episode as a MCA dissecting aneurysm manifesting with isolated pain. Among the previous forty-four MCA dissecting aneurysms, all but one case presented with hemorrhagic or ischemic event. In addition, this is the only case of multiple dissecting aneurysms of VA and MCA manifesting with isolated pain.