Vasospasm of the basilar artery following spontaneous SAH-clinical observations and implications for vascular research.

The basilar artery (BA), as a reference vessel for laboratory investigations of cerebral vasospasm (CVS) in many experimental models, warrants a sufficient blood supply despite hemodynamic changes during CVS. In a prospective evaluation study, we analyzed  patients who were admitted to our department with subarachnoid hemorrhage (SAH) for the occurrence and sequelae of CVS. Specifically, we sought to identify patients with CVS of the BA. As per institutional protocol, all patients with CVS detected in the posterior circulation had magnetic resonance imaging (MRI) examinations instead of CTA. Between January and December 2016, 74 patients were treated for spontaneous SAH. CVS occurred in 45 (61%) patients, and 31 (42%) patients developed associated cerebral infarctions (CI). CVS was significantly associated with CI (p < 0.0001; OR 44). In 18 (24.3%) patients, CVS significantly affected the basilar artery. Poor admission clinical state, younger age, and treatment modalities were significantly associated with BACVS. BACVS was more often detected in patients with severe CVS (p < 0.046; OR 4.4). Patients with BACVS developed cerebral infarction in a frequency comparable to other patients with CVS (61% vs. 70%, p = 0.7), but none of these infarctions occurred in the brain stem or pons even though vessel diameter was dramatically reduced according to CT- and/or MR-angiography. BACVS does not appear to be followed by cerebral infarction in the BA territory, presumably due to a vascular privilege of this vessel and its perforating branches. In contrast, brain ischemia can frequently be observed in the territories of other major arteries affected by CVS.

Comparison of carotid and basilar bifurcation aneurysms versus non-T-angled bifurcations: the geometry is associated with the outcome.

Patients with ruptured aneurysms of carotid bifurcation artery seem to suffer less often from cerebral vasospasm and early brain injury and have a better clinical outcome. Aim of our study was to identify differences in clinical course and outcome in aneurysms of terminus segments (carotid bifurcation artery and basilar tip) compared to aneurysms of other aneurysm locations except carotid bifurcation artery and basilar tip. Patients with SAH were entered into a prospectively collected database (1999 to June 2014). A total of 471 patients ('T-shaped' aneurysms n = 63, 'non-T-shaped' aneurysms n = 408) were selected. Outcome was assessed by modified Rankin Scale (mRS) 6 months after SAH. Mean age was 53.75 years. Statistically, analysis showed a significant better outcome in 'T-shaped' aneurysms (p = 0.0001) and a significant lower mortality rate (p = 0.02) despite higher rates of Fisher 3 bleeding pattern and CVS. In 'T-shaped' aneurysms, no prognostic factors for outcome could be detected. In 'non-T-shaped' aneurysms admission status (p < 0.0001), early hydrocephalus (p < 0.0001), shunt-dependence (p = 0.001), and the occurrence of severe CVS (p = 0.01) statistically were factors influencing patients' outcome. Multivariate analysis showed 'non-T-shaped' aneurysms itself as independent prognostic factor for patients' outcome. Despite same rate of poor admission status, early hydrocephalus and shunt dependence 'T-shaped' aneurysms have a highly significantly better. Pathophysiological mechanism actually is not understood. Further studies are necessary to identify, which factors lead to the decreased outcome in "non-T-shaped"- aneurysms.

Non-aneurysmal subarachnoid hemorrhage in 173 patients: a prospective study of long-term outcome.

BACKGROUND AND PURPOSE: In some patients with subarachnoid hemorrhage (SAH) a bleeding source cannot be identified. Perimesencephalic (PM) SAH is assumed to have an excellent outcome. Our objective was to analyze the long-term physical and psychological outcome of patients after non-aneurysmal SAH. METHODS: One hundred and seventy-three patients met the inclusion criteria. Short-term follow-up 6 months after SAH was assessed according to the modified Rankin Scale (0-2 favorable). A short-form health survey with 36 questions (SF-36) and eight scales was used as questionnaire for long-term follow-up. RESULTS: Thirty-seven answers were received from the two groups, PM and non-perimesencephalic (NPM) SAH, on average 76 months after ictus (range 1.5-14 years). PM- and NPM-SAH without Fisher grade 3 blood pattern have excellent short-term outcomes. The quality of life (QoL) is significantly reduced after non-aneurysmal SAH, especially in NPM-SAH. In particular, patients with a Fisher 3 blood pattern had significantly higher risks for cerebral vasospasm, delayed cerebral ischaemia, unfavorable outcome, reduced QoL and mortality in short- and long-term follow-up. CONCLUSIONS: Excluding rolph, only patients with a PM-SAH have a similar QoL at long-term follow-up compared to the standard population. Patients with NPM-SAH have a significantly decreased QoL in long-term follow-up. Furthermore, the Fisher 3 blood pattern group in particular had a significantly worse outcome - at short-term and long-term follow-up. Therefore the NPM-SAH group was stratified into patients with Fisher 3 blood pattern and patients without Fisher 3 in further investigations.

Optimization of the Surgical Approach in AVMs Using MRI and 4D DSA Fusion Technique : A technical note.

PURPOSE: Previously published data demonstrated the possibility of displaying the angioarchitecture of intracranial vascular malformations using time-resolved 3D imaging (4D digital subtraction angiography [DSA]). The purpose of our study was to prove the technical feasibility of creating fused images of time-resolved 3D reconstructions and MPRAGE MRI data sets and to check the reliability of the correct anatomical display of the angioma nidus and the venous drainage in the fused images of patients with intracranial arteriovenous malformations (AVM). PATIENTS AND METHODS: In this study 20 patients with intracranial AVM underwent pretherapeutic DSA and time-resolved 3D DSA in addition to MRI including MPRAGE sequences. The images were post-processed with the fusion software tool on a dedicated research workstation. The fusion of both imaging modalities was done semi-automatically with automatic co-registration software followed by a manual co-registration. RESULTS: Co-registered DSA/MRI data sets of 20 untreated AVMs were evaluated independently by two reviewers. Image fusion was successful in all 20 cases with an acceptable additional set-up time. The fused images were highly scored by the two raters in respect to their congruency of the dedicated regions. Precise anatomical localization of the nidus, the feeding arteries and the draining veins were possible with the merged images. CONCLUSION: Creating fused images of time-resolved 3D DSA and contrast-enhanced T1-weighted MPRAGE MR images might be beneficial for the preoperative and intrasurgical workflow in patients with AVMs. This new software tool fulfils the required quality and accuracy of the merged images. The clinical validation has to be proven in further studies.