Aneurysm management in patients over 80 years old with good grade subarachnoid haemorrhage.

BACKGROUND: An increasing proportion of aneurysmal subarachnoid haemorrhage (aSAH) occurs in older patients, in whom there is widespread variability in treatment rates due to a different balance of risks. Our aim was to compare outcomes of patients over 80 years old with good grade aSAH who underwent treatment of their aneurysm with those who did not. METHODS: Adult patients with good grade aSAH admitted to tertiary regional neurosciences centres contributing to the UK and Ireland Subarachnoid Haemorrhage Database (UKISAH) and a cohort of consecutive patients admitted from three regional cohorts were included for analysis. Outcomes were functional outcome at discharge, three months and survival at discharge. RESULTS: In the UKISAH, patients whose aneurysm was treated were more likely to have a favourable outcome at discharge (OR 2.34, CI 1.12-4.91, p = .02), at three months (OR 2.29, CI 1.11-4.76, p = .04), and lower mortality (10% vs. 29%, OR 0.83, CI 0.72-0.94, p < .01). In the regional cohort, a similar pattern was seen, but after correction for frailty and comorbidity there was no difference in survival (HR 0.45, CI 0.12-1.68, p = .24) or favourable outcome at discharge (OR 0.83, CI 0.23-2.94, p = .77) and at three months (OR 1.03, CI 0.25-4.29, p = .99). CONCLUSIONS: Better early functional outcomes in those undergoing aneurysm treatment appear to be explained by differences in frailty and comorbidity. Therefore, treatment decisions in this patient group are finely balanced with no clear evidence overall of either benefit or harm in this cohort.

Comparison between outcomes of endovascular and surgical treatments of ruptured anterior communicating artery aneurysms.

INTRODUCTION: The natural history and optimal treatment of previously ruptured anterior communicating artery (ACOM) aneurysms that recur is unknown. This study looks at rates of complications and recurrences of ruptured ACOM aneurysms treated endovascularly and surgically. MATERIALS AND METHODS: A retrospective observational study of all patients presenting to a single tertiary neurosurgical centre with the first presentation of subarachnoid haemorrhage (SAH) secondary to a ruptured ACOM aneurysm. Data was collected from November 2012 to September 2018 and included baseline demographics, aneurysm characteristics, management, complications, follow-up imaging, and clinical outcomes. RESULTS: 137 patients were included in the study. 113 aneurysms were coiled and 19 were clipped. Management decisions were taken by the multidisciplinary team based on aneurysm morphology or the presence of a haematoma exerting mass effect. There were 187.5 patient-years of follow-up, with a median of 3 years (range 0-73 months). Rates of vasospasm, infarction, CSF diversion, rebleed, length of stay, and functional outcome were not significantly different in the two cohorts. There was a statistically significant increase in the risk of ACOM recurrence in the coiled group when compared to the clipped group at one year (p = .0433). 15 patients required further treatment at a median time of 16 months. In a subgroup group analysis of coiled aneurysms, there was no statistical differences in rates of rebleeding or the functional outcome in those that had aneurysm recurrence and those that did not. CONCLUSIONS: This study suggests patients with aneurysms treated by endovascular coiling have an increased risk of recurrence versus those treated with clipping. However, the risk of rebleed was not statistically significant. The prevention and impact of recurrence and residual aneurysms remains incompletely understood. Hence, treatment decisions should be taken by patients after they have been given carefully considered recommendations from the multi-disciplinary team.

Intracranial extramedullary haematopoiesis: A case report.

Extramedullary haematopoiesis (EMH) is an ectopic production of blood cells to compensate for ineffective haematopoiesis. We report a rare symptomatic presentation of intracranial EMH and discuss its investigation and management. EMH should be considered a differential diagnosis in patients with haemoglobinopathies, haemolytic anaemias and myeloproliferative disorders, who present with symptoms of raised intracranial pressure.

Delayed caroticocavernous fistula after stent-assisted coil embolization of intracavernous carotid aneurysm: should we manage conservatively?

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1 month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report.

Surgical options in ICH including decompressive craniectomy.

Intracerebral haemorrhage (ICH) accounts for 15 to 20% of strokes. The condition carries a higher morbidity and mortality than occlusive stroke. Despite considerable research effort, no therapeutic modality either medical or surgical has emerged with clear evidence of benefit other than in rare aneurysmal cases. Intracerebral haemorrhages can be divided into those that arise from pre-existing macroscopic vascular lesions - so called "ictohaemorrhagic lesions", and those that do not; the latter being the commoner. Most of the research that has been done on the benefits of surgery has been in this latter group. Trial data available to date precludes a major benefit from surgical evacuation in a large proportion of cases however there are hypotheses of benefit still under investigation, specifically superficial lobar ICH treated by open surgical evacuation, deeper ICH treated with minimally invasive surgical techniques, and decompressive craniectomy. When an ICH arises from an ictohaemorrhagic lesion, therapy has two goals: to treat the effects of the acute haemorrhage and to prevent a recurrence. Three modalities are available for treating lesions to prevent recurrence: stereotactic radiosurgery, endovascular embolisation, and open surgical resection. As with ICH without an underlying lesion there is no evidence to support surgical removal of the haemorrhage in most cases. An important exception is ICHs arising from intracranial aneurysms where there is good evidence to support evacuation of the haematoma as well as repair of the aneurysm.

Unruptured intracranial aneurysms: benign curiosity or ticking bomb?

15 years ago, the treatment of incidentally discovered intracranial aneurysms was straightforward with a good evidence base behind it. When intracranial aneurysms were identified, people were referred to neurosurgeons who would offer surgical repair if the patient was in reasonable health and had a good life expectancy. Since that time, several studies have given contradictory evidence for what should be done with these lesions, and a new technique for the repair of aneurysms, endovascular coil embolisation, has been developed. Here we review the research and make several recommendations. First, incidentally discovered aneurysms in the anterior circulation less than 7 mm in size in people with no personal or family history of subarachnoid haemorrhage should be left untreated. Second, people with remaining life expectancy of less than 20 years or so (ie, those over age 60 years) should be informed that from a statistical point of view the benefits of treatment do not outweigh the risks. Third, in all other cases treatment with surgical clipping or coil embolisation should be advised. And finally, if surgical treatment is not feasible then medical hypotensive treatment may be a viable alternative.

Subarachnoid haemorrhage.

Aneurysmal SAH is a devastating condition arising suddenly and usually without warning. The best outcomes may be facilitated by prompt recognition/suspicion and immediate referral to the neurosurgical unit. Many contentious issues surround this subject and the ISAT trial should resolve many of these. Modern developments alongside evidence-based practice should hopefully optimise results.