Microsurgery versus embolization: different risk factors for short- and long- term outcomes of patients with ruptured aneurysms

Purpose: To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results: Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions: Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Seizures and Epilepsy following Subarachnoid Hemorrhage: A Review on Incidence, Risk Factors, Outcome and Treatment

The mortality rates of subarachnoid hemorrhage (SAH) average 51%, and survivors frequently experience acute and long-term neurological conditions, including seizures and epilepsy. The incidence of post SAH-related seizures and epilepsy, its risk factors, outcomes and management are controversial. The present paper aims to discuss these aspects, to provide the pros and cons of different management options of this condition. A review on PubMed was performed encompassing the incidence of seizures and epilepsy following SAH, the risk factors for its occurrence, its related outcomes, and treatment. The incidence of seizures and epilepsy following SAH varies widely in the literature (from 6 to 26%). Some possible risk factors were identified, such as middle cerebral artery (MCA) aneurysm, Hunt and Hess grade III, aneurysm clipping, thick subarachnoid clot, intracerebral hemorrhage, rebleeding, ischemic brain infarction, Fisher grade III or IV, acute hydrocephalus, hypertension history and poorWorld Federation of Neurosurgical Societies (WFNS) grade. Nevertheless, these relations are frequently uncertain. Also, it appears that the outcome of patients who suffered SAH is worsened by seizures. Given these uncertainties, the need for antiepileptic drug (AED) prophylaxis, the choice of the best drug and dose, as well as the duration of the treatment are controversial topics. However, some recommendations based on low quality evidence are reasonable to be adopted. These include considering AED prophylaxis when a seizure occur after SAH, considering routine long-term AED prophylaxis in specific populations, considering electroencephalogram (EEG) monitoring, and avoiding phenytoin prescription. That is, an individualized approach appears to be the best option, since there is no high-quality evidence.

Hemorragia subaracnoidea / Subarachnoid hemmorrhage

La hemorragia subaracnoidea es una entidad neuroquirúrgica que requiere de diagnóstico y tratamiento rápidos y eficaces, los cuales deben ser efectuados por personal ampliamente capacitado para menejo pre, trans y postoperatorio de estos enfermos con amplio conocimiento de las complicaciones potenciales que pueden presentarse, así como del manejo para resolverlas o disminuir sus consecuencias. La base común del tratamiento actual es el empleo de bloqueadores de los canales de calcio, el más utilizado es nimodipina, asociado a terapia ®triple-H¼. El pivote de la evaluación es el estado clínico del paciente; se requiere para ello evaluación neurológica constante y teniendo disponible equino médico auxiliar básico como: tomógrafo: angiogramas, Doppler transcraneal, etc. De todo lo anterior derivará la calidad de vida del paciente que ha sufrido este evento vascular

Uso de antifibrinolíticos em hemorragia subaracnóidea por ruptura de aneurisma cerebral: nota preliminar / Use of antifibrinolytics in subarachnoid hemorrhage due to cerebral aneurysm rupture

A utilizaçäo de drogas antifibrinolíticas (AFL), com o intuito de evitar o ressangramento de aneurisma cerebral, permanece como uma questäo controversa. embora eles sejam reconhecidos como capazes de reduzir os riscos de uma nova hemorrágia, os AFL aumentam os índices de outras complicaçöes que acompanham as hemorragias subaracnóides (HSA) por ruptura aneurismática. Nesta nota preliminar, os autores dividem os aneurismas cerebrais, baseados no stress hemodinâmico a que estäo submetidos, em 2 grupos: os de <>. A partir destes conceitos, propöem um protocolo de utilizaçäo dos AFL nas HSA por anurismas da artéria cerebral média (considerados de <>), contraindicando-os nos aneurismas do complexo artéria cerebral - artéria comunicante anterior (aneurismas de <> fluxo>>)

Terapêutica antifibrinolítica nos aneurismas intracranianos: estudo comparativo / Antifibrinolytic therapy for patients wits intracranial aneurysms: a comparative study

Os autores analisam 120 pacientes portadores de aneurisma intracraniano que foram tratados no período de janeiro de 1980 a dezembro de 1987. Os pacientes foram divididos em 2 grupos. No primeiro ficaram 80 pacientes que utilizaram, no pré-operatório, o ácido epsilon-aminocapróico e no segundo grupo os 40 pacientes restantes que näo fizeram uso deste fármaco. ªo primeiro grupo registramos 17,5% de vasoespasmo, sendo que, destes, 50% evoluiu para o óbito. Já no segundo grupo, 15% apresentou vasoespasmo com uma taxa de mortalidade de 16,6%. A taxa de ressangramento foi de 10% e 17,5% respectivamente e näo houve diferença estatística na taxa de mortalidade. Com estes dados, concluimos ser preferível evitar o uso de antifibrinolítico

Tratamento pré-operatório na cirurgia tardia das aneurismas intracranianas / Preoperative treatment of late surgery of intracranial aneurysms

O autor revisa os mais importantes trabalhos sobre cirurgia de aneurisma intracraniano e tece consideraçöes de ordem terapêutica sobre 552 pacientes operados de aneurisma intracranianos rotos, no período de 1979 a 1986. Descreve as medidas pré e pós-operatórias utilizadas de rotina no Serviço de Neurocirurgia do Hospital Cristo Redentor para prevenir as complicaçöes iniciais e tardias da hemorragia subaracnoidea. Descreve os procedimentos terapêuticos que já foram ou ainda säo adotados para combater as complicaçöes da hemorragia subaracnoidea no período pré e pós-operatório. Finalmente analisa o melhor momento para a intervençäo cirúrgica, optando pela ocasiäo em que os pacientes estäo em boas condiçöes clínicas sejam iniciais ou obtidas nos dias subseqüentes