Stroke. 1999;30:2617-2622
(Stroke. 1999;30:2617.)
© 1999 American Heart Association, Inc.
Outcome After Endovascular Treatment of Hunt and Hess Grade IV or V Aneurysms
Comparison of Anterior Versus Posterior Circulation
Christine Kremer, MD;
Christoph Groden, MD;
Hans Christian Hansen, MD;
Ulrich Grzyska, MD
Hermann Zeumer, MD
From the Departments of Neurology (C.K., H.C.H.) and Neuroradiology
(C.G., U.G., H.Z.), University Hospital Eppendorf, Hamburg, Germany.
Correspondence to Christoph Groden, MD, Department of Neuroradiology, University Hospital Eppendorf, Martinstr 52, D-20246 Hamburg, Germany. E-mail groden{at}uke.uni-hamburg.de
 |
Abstract
|
|---|
Background and PurposeThe most
common cause of poor treatment
outcome in patients suffering
aneurysmal subarachnoid hemorrhage
is cerebral
vasospasm, especially in cases of poor Hunt and
Hess grades (IV and V).
A further prognostic factor in surgically
treated patients is
aneurysm localization. The aim of the present
retrospective
study is to compare the endovascular treatment
outcome in such
poor-grade patients according to aneurysm localization
in
either the anterior (AC) or posterior (PC) circulation.
MethodsForty poor-grade patients admitted between 1993 and July
1998 were treated by endovascular approach within 23 days after
aneurysm rupture. Eighteen had aneurysms in the AC, 22
in the PC. Mean treatment delay was 4 days after rupture and median, 2
days. One patient showed multiple aneurysms. In 36 cases,
aneurysms were occluded by Guglielmi detachable coils; in 4
cases, by parent vessel balloon occlusion.
ResultsThe incidence of delayed ischemic neurological
dysfunction or cerebral infarct due to vasospasm did not differ
significantly between the AC and PC groups. Two procedure-related
complications with clinical effect were observed in each group. At 6
months follow-up, the result was good in 5 patients and poor in 13 in
the AC group and good in 11 patients and poor in 11 in the PC
group.
ConclusionsGiven comparable incidence of vasospasm in poor-grade
patients, a tendency toward better treatment outcome was found in
patients with aneurysms in the posterior circulation
(
2=2.04; P=0.15) than in the anterior
circulation. Endovascular therapy for poor-grade patients is
recommended, as are further studies to determine treatment differences.
Key Words: aneurysm subarachnoid hemorrhage endovascular therapy vasospasm outcome
 |
Introduction
|
|---|
Aneurysm surgery within 72 hours of
subarachnoid hemorrhage
(SAH) has proved to be a most
favorable treatment.
1 2 However,
the introduction of
acute-stage endovascular treatment and the
implementation of Guglielmi
detachable coils (GDC) or balloons
has become a genuine alternative.
Endovascular therapy results
are today comparable with those achieved
by surgery for aneurysms
localized in the posterior circulation
(PC).
3 4 5 The treatment
risks and outcome in patients with
aneurysms in the anterior
circulation (AC) have not been well
documented until now. Poor-grade
patients are often excluded from
longitudinal studies. But in
view of the promising treatment results
that we observed through
our clinical practice of the newer
neuroradiological methods
and to define future selection criteria for
patients assumed
to be treatable by endovascular therapy, we decided to
analyze
and compare outcomes and complication rates in
poor-grade patients
with aneurysms either in the AC or PC.
 |
Subjects and Methods
|
|---|
Between January 1993 and July 1998, 179 patients were
treated
endovascularly in our center. Forty-five of these were rated
as
Hunt and Hess (H&H)
6 grade IV or V on admission. (The
23
patients with H&H grade IV or V at admission that were
treated by
surgery [eg, mass effects] during the same period
are not evaluated
here.) Because some of the patients had first
been admitted to other
hospitals and were later transferred
to our treatment center for
specialized treatment, the beginning
of treatment was sometimes greatly
delayed. For the present
retrospective evaluation (see Table 1

), we also eliminated 4
patients in whom
the danger of vasospasm was judged as negligible
at >23 days after
admission (Table 1

). One other patient
who also was eventually
treated surgically could not be clearly
evaluated and was not studied.
Other than through these logical
criteria, no attempt was made to
select cases for evaluation.
No aneurysm sites were excluded.
Thus, case studies were performed
on 40 patients graded H&H IV or V on
admission among a total
of 179 endovascularly treated patients admitted
between January
1993 and July 1998. In 18 patients, aneurysms
were found in
the AC; in 22, in the PC (see Table 1

). Diagnosis
was reached
by clinical and neurological examination and computerized
tomographic
(CT) scan. Cerebral angiography was performed within the
first
24 hours after admission. Aneurysm size was classified
according
to Yasargil
7 (Table 1

).
A femoral treatment approach was used, and after fluoroscopic
establishment of an optimal projection for GDC treatment,
superselective catheterization of the aneurysm
was performed by use of microcatheters. For dissecting or fusiform
aneurysms, a parent vessel occlusion was chosen; 2 detachable
balloons were used to ensure success. Treatments were performed with
the patient under general anesthesia and 5 000 U of
heparin IV. In the acute phase, the Glasgow Coma Scale was recorded
every hour. CT scans were performed in each case of clinical
neurological deterioration and at least every 48 hours within the first
7 days after SAH onset. Transcranial Doppler ultrasound
(TCD) was performed at least every 24 to 48 hours to detect elevated
flow velocities. Mean flow velocities of >130 cm/s in major vessels of
the anterior cerebral circulation and intracranial extracranial
velocity ratio >3 were defined as vasospasm. All such patients
received intravenous nimodipine and hypervolemic,
hypertensive, hemodilution (3H) therapy that consisted of an aggressive
volume expansion by means of administration of high-volume crystalloid
to maintain central venous pressure between 8 and 10 mm Hg and
the fluid balance in a positive range between 500 and 1000 mL/d. This,
of course, was individualized in relation to
hemodynamic parameters. Hematocrit was
maintained at approximately 35% (between 30% and 40%) and
systolic blood pressure between 160 and 180 mm Hg,
sometimes by use of catecholamines. All patients were
monitored by use of serial chest x-ray films to screen for
pulmonary edema. 3H therapy was begun immediately after
complete endovascular aneurysm occlusion and continued until
normalization of mean blood flow velocities. Symptomatic
vasospasm was defined as cerebral infarction or delayed
ischemic neurological dysfunction (DIND). The outcome according
to the Glasgow Outcome Scale8 was evaluated after 6
months. Follow-up angiograms were performed in 7 of the GDC treated
cases after 1 year (see Table 1
).
 |
Results
|
|---|
AC Aneurysms
Eighteen patients with AC aneurysms were treated by
endovascular
therapy, 17 by GDC, and 1 by balloon technique. One
patient
(patient A-5) had 3 aneurysms, which were all treated
at once
because of a diffuse SAH (Figure 1

). Thirteen patients were
treated within
3 days after SAH onset; mean interval was 4 days
(range 0 to 19 days).
During GDC treatment, 1 aneurysm rupture
(patient A-9) and 2
distal branch clots were observed (patients
A-1 and A-7), which led to
a complication rate of 3 of 8=17%.
No further procedure-related
embolic infarctions were judged
to have occurred during the follow-up
period. In 1 patient (patient
A-4) (6%), the aneurysm was
intentionally occluded only 90%
to avoid collateral clotting damage. A
giant aneurysm in another
patient (patient A-13) was
intentionally closed only partially
during the initial treatment and
completely occluded in a second
treatment session after 3 months.
Elevated mean flow velocities
measured by TCD were observed in 5 (28%)
cases, and angiographic
narrowing of the vessels (angiographic
vasospasm) was seen in
5 (28%) patients. Seven (39%) patients
developed DIND, and cerebral
infarct due to vasospasm was diagnosed by
CT scan in 8 (44%)
patients (Table 2

;
see also Figure 2

). Cerebral
infarct or DIND
(symptomatic vasospasm) were seen in 9
(50%) patients. At 6
months, the outcome was good in 5 patients but
poor in 13 in
the AC group (Table 3

).

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Figure 1. Patient A-5. Posterior-anterior
projection of the right carotid artery before (A) and after (B)
occlusion of an aneurysm of the right middle cerebral artery
and communicating posterior artery by GDC. C, Same projection with
anatomic background. Posterior-anterior projection of the left
vertebral artery before (D) and after (E) occlusion of the additional
basilar tip aneurysm by GDC. F, Cerebral CT scan reveals the
initial diffuse SAH distribution, which disallowed localization of the
aneurysm.
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Figure 2. Patient A-6. Cerebral CT scan depicts signs of
early cerebral ischemia induced by vasospasm (arrow) before
therapy (A). After 5 days, the residual infarct is seen (B). Lateral
projection of the aneurysm of the right communicating
artery before (C) and after (D) occlusion by GDC.
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Table 3. Comparison of Glasgow Outcome Scale Results in
Poor-Grade Patients Treated for Aneurysms of the Anterior or
Posterior Circulation
|
|
PC Aneurysm
Fortunately for the present evaluation, many "difficult"
cases were transferred to our treatment center from other clinics, so
that the disproportionately large number of 22 patients with PCs in the
PC system could be treated. All 22 patients with PC aneurysms
were treated by endovascular approach: 19 by GDC and 3 by balloon
occlusion technique. Thirteen were treated within the first 3 days
after onset of SAH, with a mean interval of 5 days (range, 0 to 23
days). One GDC patient (patient P-22) had to be retreated as a result
of the coil compacting after 1 month. During the GDC treatment, 1
aneurysm rupture (patient P-1) was observed and 1 coil broke
(patient P-6), without clinical effect. In 1 patient (patient P-13)
with a clot, an infarct of the posterior cerebral artery occurred under
GDC treatment. One balloon occlusion of a vertebral artery was
complicated by a posterior inferior cerebellar
arterial infarct (patient P-3). Other than in these
4 of 22 (18%) patients, no further procedure-related complications or
deficits were observed within the follow-up period. In 2 patients
(patients P-8 and P-14; 9%) aneurysms were intentionally only
partially occluded to avoid collateral clotting damage. A giant
aneurysm in another patient (patient A-13) was intentionally
only partially closed in the initial treatment and completely occluded
in a second treatment session after 3 months. Elevated mean blood flow
velocities were diagnosed in 12 (55%) cases by TCD and in 7 (32%)
cases angiographically. Six (27%) patients developed a DIND and 8
(36%) a cerebral infarct due to vasospasm (Table 2
). Cerebral
infarct or DIND (symptomatic vasospasm) was seen in 8
(36%) patients. At 6 months, the outcome was good in 11 patients and
poor in 11 in the PC group (Table 3
).
Follow-Up
Sixteen patients (1 with balloon occlusion) died within 30 days
after treatment (see cause of death in Table 1
). Routine control
angiographic examinations after GDC at 1 year after treatment could not
always be obtained because of death (n=15), poor condition (n=6),
noncompliance (n=5), or recent treatment (n=2) of the patient, so that
only 8 of 36 patients were examined between 8 and 22 months (mean, 16
months) after treatment. In these patients, treatment results remained
stable. Clinical follow-up examinations after balloon technique were
performed after 6 months (see Table 1
).
 |
Discussion
|
|---|
Endovascular treatment result in poor-grade patients has not
been
examined until the present study. Factors generally influencing
prognosis
are status on admission, type and timing of therapy,
complications,
and aneurysm localization.
2 9 10
The reported incidence of
vasospasm in poor-grade patients varies
between 1.5% and 91%,
11 12 which reflects the
diagnostic difficulties and the different
and hardly
comparable measurement methods and definitions of
vasospasm.
Definitions include angiographic findings
13 of vasospasm,
TCD
velocity elevations,
14 neurological deficits, and
amount of
cisternal blood.
15 Some authors
11
found a lower incidence
in poor-grade patients than in patients at H&H
grade I or
II, in contrast with the findings of Hirai et
al
16 and Awad
et al,
17 which showed a direct
correlation between initial
grade and severity of vasospasm. Fisher et
al,
15 who found
that vasospasm strongly correlates with
the amount of cisternal
blood seen in CT scans, developed a system of
classification.
In another study, 97% of cerebral angiograms on day 5
of SAH
showed evidence of angiographic spasm.
12 But to
date, no common
and definitive staging method has been created for
vasospasm
because of various diagnostic difficulties.
- Neurological deteriorations such as DIND can be
overlooked or misdiagnosed in unconscious and sedated
patients.18
- Blood-flow velocity elevations were not seen in every
vasospasm; some cases had lower velocities than expected in poor-grade
patients,19 so TCD alone could not be used for
diagnosis.
- A high percentage of patients died before they developed
vasospasm.12 20
Thus, it is not surprising that many published clinical series
exclude poor-grade patients from
analysis.18 21 22 23 In their prospective series,
Disney et al12 failed to clearly demonstrate an
association between severe diffuse angiographic vasospasm and worse
outcome, because many patients died from other causes or did not
survive long enough to manifest the deterioration. Fisher et
al15 showed a direct correlation between the amount of
cisternal blood and severity of vasospasm. Others reported that the
early surgical evacuation of cisternal blood was not able to displace
vasospasm from its major role.24 25 26
Endovascular techniques offer an alternative to surgery as a treatment
tool for ruptured aneurysms at the acute SAH stage.
Endovascular techniques prevent rebleeding and allow aggressive
management of symptomatic vasospasm by 3H
therapy27 and angioplasty.28 Murayama et
al18 were able to show that the 23% incidence of
symptomatic vasospasm in their endovascular series of H&H
grade I through III patients hardly differs from 2 surgical series
under similar clinical conditions and a symptomatic
vasospasm incidence of 22%29 or 25%.27 Our
43% incidence of DIND or cerebral infarct (symptomatic
vasospasm) for endovascular treatment of poor-grade patients stresses
its major effect on treatment outcome.
On the basis of results of Kassell et al24 concerning
early or late therapy for poor-grade patients, 2
studies1 30 showed identical results of 21% favorable,
37% poor outcome, and 42% death for all poor-grade patients with
selective surgical aggressive management. After an aggressive surgical
patient management, Le Roux et al31 demonstrated better
results of 38.5% favorable, 18% poor, and 43.5% death. Disney et
al12 differentiated between AC and PC in their study of
achieved surgical results but included patients with H&H grade III,
which makes a comparison with the present report difficult. In
contrast with the present report, their results showed a tendency
toward poorer outcome in the hind circulation. Hillman et
al32 achieved a 35% favorable outcome for posterior fossa
aneurysms by means of delayed and early surgery. Peerless et
al33 achieved a 27% favorable outcome with early surgery.
Results of endovascular trials include only few
patients.34 35 Our retrospective series with a 40% total
favorable outcome is comparable with the achieved surgical
results31 and somewhat better than previous reports on the
PC (Table 3
).
The 18% incidence of procedure-related complications (7 patients) in
our series is comparable with the 21% incidence reported in 75
patients in all H&H stages on admission with vertebrobasilar
aneurysms.36 Fatal outcome was seen in 4 patients
(10%) (Table 1
) who suffered complications during endovascular
therapy compared with 9% from the series with vertebrobasilar
aneurysms,36 which indicates that poor-grade
patients are not at higher risk for developing severe procedure-related
complications.
In conclusion, the endovascular treatment of poor-grade patients after
aneurysmal SAH is effective and offers results similar to those
from surgical series. In these patients, statistically significant
differences between cases of aneurysms in the PC and AC systems
could not be established (
2=2.04;
P=0.15); thus, further studies under inclusion of larger
populations could prove useful. We feel encouraged to recommend
endovascular therapy for these patients.
 |
Acknowledgments
|
|---|
The authors thank Dr Jarold Knispel, Hamburg, for his language
advice.
Received January 7, 1999;
revision received July 6, 1999;
accepted September 7, 1999.
 |
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