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Clinical predictors of delayed cerebral ischemia after subarachnoid hemorrhage: First experience with coil embolization in the management of ruptured cerebral aneurysms.

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  1. Clinical predictors of delayed cerebral ischemia after subarachnoid hemorrhage:First experience with coil embolization in the management of ruptured cerebral aneurysms • Yasuhiro Kawabata M.D.1, 3, Fumihiko Horikawa M.D.1, Yasushi Ueno M.D., Ph.D.2, Masahiro Sawada M.D. 1, Fumiaki Isaka M.D., Ph.D.1 and Hidenori Miyake M.D., Ph.D.1 • 1Department of Neurosurgery, Hamamatsu Rosai Hospital, Shizuoka, Japan • 2Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan • 3 Department of Neurosurgery, Osaka Red Cross Hospital, Osaka, Japan

  2. purpose The purpose of this study was to clarify the clinical predictors of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH).

  3. Definition of delayed cerebral ischemia • DCI was defined as clinical deterioration and/or a new infarct on CT or MRI that was not visible upon the admission or immediate postoperative scan, when the cause was thought to be vasospasm.

  4. cases • 102 pts with ruptured cerebral aneurysms • 77 pts treated by clipping, 25 pts treated by coiling • sex: 40 male, 62 female • age: median 59 y.o. (31-88) • Patients with SAH due to dissecting aneurysms and patients who died within 48 hours after the ictus despite technical success of the treatment were excluded from this study.

  5. cases(2) LOCATION P=0.003 MCA ACA-ACOM ICA-PCOM VA-BA

  6. Hunt & Kosnik Grade clipping coiling p=0.230 2 3 4 5

  7. trends of treatment modality

  8. Perioperative complications Clipping(77) Coiling (25) Intraprocedural rupture 1 Vasospasm 1 Postoperative rebleeding 1 Coil protrusion 1 Retreatment 4→clipping 2, →coiling 2 Procedure-related morbidity 4 • Infarction 8 • Epidural hematoma 2 • Intracerebral hematoma 1 • Infection 7 • Retreatment 0 • Procedure-related morbidity 7

  9. Prognosis (overall) (mRS at 3 months)

  10. Summary of patients with surgical vs. endovascular treatment by initial Hunt and Kosnik grade and clinical outcomes

  11. Prognosis(clipping vs. coiling) 49% P=0.053 56% mRS0-2 mRS3-6

  12. Prognosis(clipping vs. coiling) H&K grade1-3 H&K grade 4,5 P=0.15 P=0.04 clipping coiling

  13. delayed cerebral ischemia(clipping vs. coiling) 32.4% P = 0.001 4% delayed cerebral ischemia (+) delayed cerebral ischemia (-)

  14. Explanations of the difference • perioperative management is different(Heparinization, dual antiplatelet etc.) • surgical manipulation in the subarachnoid space can delay clearance of subarachnoid clot, which can potentially exacerbate vasospasm after SAH.

  15. Associations between potential clinical risk factors and delayed cerebral ischemia after subarachnoid hemorrhage were assessed using the chi-square test.

  16. Associations between potential clinical risk factors and delayed cerebral ischemia after subarachnoid hemorrhage were assessed using the chi-square test.

  17. outcomes of ruptured intracranial aneurysms treated by microsurgical clipping and endovascular coiling in a high-volume centerNatarajan SK et al. AJNR 29: 753-759, 2008 • 195 consecutive pts • 105 pts (clipping), 87pts (coiling) • mRS 0-2; 69% • no difference in the outcomes between patients in the clipping and coiling groups. • vasospasm rate: 66% (clipping) vs. 52% (coiling), (p=0.022)

  18. conclusions • DCI was less frequently observed in the coiling group, and as a result, clinical outcomes were superior in coiling group, especially for patients with severe SAH. • Our results showed a significant correlation between DCI and hydrocephalus.

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