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1.  Results of Surgical and Nonsurgical Treatment of Aneurysms in a Developing Country 
Stroke Research and Treatment  2011;2011:560831.
Background. The impact of invasive methods of treatment on results in developing countries may differ from that in developed countries. Methods. This is a prospective clinical study of consecutive patients with Subarachnoid Haemorrhage (SAH) admitted to the Ghaem Hospital, Mashhad during the period from 2005 to 2009. The initial diagnosis and investigations were carried out by neurologists. The patients were divided into two groups. One received surgical treatment whilst the other group was managed medically. The decision as to the choice of the method of treatment was made by the neurosurgeons. The initial medical treatment was standardised for all the patients. The rate of complications and mortality was compared in both medical and surgical groups. Results. 120 SAH patients (52% females) with a mean age of 50.6 ± 7 years were evaluated. The angiography revealed the presence of an aneurysm in 62 patients. 63.5% of the patients received medical treatment and 37.5% underwent aneurysmal surgery. Difference of rebleeding rate in the two therapeutic groups was not significant; X2 = .014, P = .91. The effect of rebleeding on mortality was not significant; X2 = 2.54, P = .14. Within 62 SAH patients with cerebral aneurysm, the mortality rate in both therapeutic groups was also not significantly different; X2 = .16, P = .77. Conclusion. There is no significant difference in the mortality rate between the “surgical” and non-“surgical” groups of Iranian patients with SAH. This could be due to delay in performance of surgery in Iranian neurovascular centers.
PMCID: PMC3137994  PMID: 21776362
2.  Subarachnoid haemorrhage (spontaneous aneurysmal) 
Clinical Evidence  2009;2009:1213.
Subarachnoid haemorrhage (SAH) may arise spontaneously or as a result of trauma. Spontaneous SAH accounts for about 5% of all strokes. Ruptured aneurysms are the cause of 85% of spontaneous SAH. The most characteristic clinical feature is sudden-onset severe headache. Other features include vomiting, photophobia, and focal neurological deficit or seizures, or both. As the headache may have insidious onset in some cases, or may even be absent, a high degree of suspicion is required to diagnose SAH with less typical presentations.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical treatments for people with confirmed aneurysmal subarachnoid haemorrhage? What are the effects of medical treatments to prevent delayed cerebral ischaemia in people with confirmed aneurysmal subarachnoid haemorrhage? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 6 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: endovascular coiling; surgical clipping; timing of surgery; and oral and intravenous nimodipine.
Key Points
Subarachnoid haemorrhage (SAH) may arise spontaneously or as a result of trauma. Spontaneous SAH accounts for about 5% of all strokes. Ruptured aneurysms are the cause of 85% of spontaneous SAH. This review deals with only spontaneous aneurysmal SAH. Without treatment, mortality rates of about 50% at 1 month after spontaneous aneurysmal SAH have been reported.
Treatment is aimed at prevention of re-bleeding from the same aneurysm. This can be performed by surgical clipping or by endovascular coiling. In people suitable for either procedure, endovascular coiling has lower rates of poor functional outcome compared with surgical clipping, but it is also associated with increased rate of recurrent haemorrhage from the treated aneurysm and a higher rate of re-treatment for the same aneurysm. Most evidence is in small (<11 mm) aneurysms of the anterior circulation. Therefore, the conclusions cannot be applied to all aneurysms (particularly large and giant aneurysms, and aneurysms with broad necks).Factors that should be considered when deciding on the method of treatment include the morphology of the aneurysm, the age and clinical condition of the person, and the presence or absence of a space-occupying intracranial haematoma.
We do not know the optimal timeframe for carrying out surgical clipping or endovascular coiling after aneurysmal SAH. However, early surgery will prevent re-bleeding from the aneurysm, and is preferred in most people.
Oral nimodipine reduces poor outcome (death or dependence), secondary ischaemia, and CT/MRI evidence of infarction after aneurysmal SAH.
We found no evidence on the effects of intravenous nimodipine alone.
PMCID: PMC2907802  PMID: 21726472
3.  Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies 
Objective: Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned.
Method: Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed.
Results: A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2–5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa).
Conclusions: Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.
PMCID: PMC3187677  PMID: 22010040
intracranial aneurysms; clipping; coiling; interdisciplinary treatment
4.  Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study 
Objectives: The debate on the timing of aneurysm surgery after subarachnoid haemorrhage (SAH) pivots on the balance of the temporal risk for fatal rebleeding versus the risk of surgical morbidity when operating early on an acutely injured brain. By following a strict management protocol for SAH, the hypothesis has been tested that in the modern arena of treatment for aneurysmal SAH the timing of surgery to secure supratentorial aneurysms does not affect surgical outcome.
Methods: Over a 6 year period, patients admitted with a diagnosis of SAH to a regional neurosurgical unit have been prospectively studied. All have been on a management protocol in which early transfer and resuscitation has been followed regardless of age and clinical condition. Angiographic investigation and surgery have been pursued in those who have been able to at least flex to pain. A total of 1168 patients (60.7% female, mean age 54.3) with proved SAH were received on median day 1 (86.4% arrived within 3 days) of the ictus. Of these, 784 (67.1%) showed aneurysms on angiography and were prepared for surgery. Those who received surgery for a supratentorial aneurysm within 21 days of the ictus were included in the final analysis (n=550). Patients with an initial negative angiogram, with posterior circulation aneurysms, or aneurysms treated by endovascular means, with aneurysms requiring emergency surgery for space occupying haematomas, with aneurysms which re-bled before surgery, and those who received very late surgery (after 21 days from ictus) were excluded. Surgical outcomes at hospital discharge and after 6 months were assessed using the Glasgow outcome score (GOS). Discharge destination and duration of stay in a neurosurgical ward were also documented. The influence of the timing of surgery (early group day 1–3 postictus, intermediate group day 4–10, or late group day 11–21) was analysed prospectively.
Results: 60.2% of cases fell into the early surgery group, 32.4% into the intermediate group, and 7.5% into the late operated group. Late surgery was due to delays in diagnosis, transfer, and logistic factors, but not clinical decision. The demographic characteristics, site of aneurysm, and clinical condition of the patients at the time of initial medical assessment were balanced in the three surgical timing groups. There was no significant difference in GOS between the surgical timing groups at 6 months (favourable GOS score 4 and 5: 83.2%, 80.5%, and 83.8% respectively; p=0.47, Kruskal-Wallis test). Outcome was favourable in 84% of patients under 65 years, and 70% in those over 65. The discharge destinations (home, referring hospital, nursing home, rehabilitation centre) showed no significant difference between surgical timing groups. There was no significant difference in mean time to discharge after admission to this hospital from the referring hospital (16.2, 16.2, and 14.6 days for early, intermediate, and late groups respectively; p=0.789, Analysis of variance (ANOVA)). As a result, there was reduction in the mean duration of total hospital inpatient stay in favour of the earliest operated patients (mean time 18.1, 22.0, and 28.3 days respectively; p=0.001. ANOVA showed that besides age, the only determinant of surgical outcome and duration of stay was presenting clinical grade (p<0.0005).
Conclusion: The current management of patients presenting with SAH from anterior circulation aneurysms allows early surgery to be followed safely regardless of age. The only independent variables affecting outcome are age and clinical grade at presentation. The timing of surgery did not significantly affect surgical outcome, promoting a policy for early surgery that avoids the known risks of rebleeding and reduces inpatient stay.
PMCID: PMC1737846  PMID: 11909907
5.  Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery 
OBJECTIVE—To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome.
METHODS—A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded.
RESULTS—The proportion of patients that was operated on early—that is, within three days after SAH—was 55%. Thirty seven of all 102admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome.
CONCLUSIONS—In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.

PMCID: PMC2169792  PMID: 9343129
6.  Safety assessment of anticoagulation therapy in patients with hemorrhagic cerebral venous thrombosis 
Iranian Journal of Neurology  2013;12(3):87-91.
Anticoagulation therapy is a routine treatment in patients with hemorrhagic cerebral venous thrombosis (CVT). However, fear of hemorrhagic complications and deterioration course following anticoagulation often disturbs the responsible physician.
This was a Prospective observational study on consecutive CVT patients with hemorrhagic venous infarction or subarachnoid hemorrhage (SAH) admitted in Ghaem Hospital, Mashhad, Iran, during 2006-2012. The diagnosis of CVT in suspected cases was confirmed by magnetic resonance imaging/magnetic resonance venography (MRI/MRV), and computerized tomography (CT) angiography following established diagnostic criteria. Demographic data, clinical manifestations from onset to end of the observation period, location of thrombus, location and size of infarction and hemorrhage, and clinical course during treatment were recorded. Choice of the treatment was left to the opinion of the treating physician. Clinical course during 1 week of treatment was assessed based on the baseline modified National Institute of Health Stroke Scale (NIHSS) score. Three or more points decrease or increase of modified NIHSS after 1 week of treatment was considered as improvement or deterioration courses, respectively. Other clinical courses were categorized as stabilization course.
102 hemorrhagic CVT patients (80 females, 22 males) with mean age of 38.6 ± 8 years were prospectively investigated. Of the 102 hemorrhagic CVT patients in the acute phase, 52 patients (50.9%) were anticoagulated with adjusted dose intravenous heparin infusion and 50 cases (49.1%) received subcutaneous enoxaparin 1mg/Kg twice daily. Decreased consciousness had a significant effect on the clinical course of the patients (X2 = 9.493, df = 2, P = 0.009). Presence of SAH had no significant effect on the clinical course of our anticoagulated hemorrhagic CVT cases (X2 = 0.304, df = 2, P = 0.914). Extension of Infarction in more than two thirds of a hemisphere had a significant influence on the distribution of clinical courses (X2 = 5.867, df = 2, P = 0.044). Difference in distribution of clinical course among the two groups of our hemorrhagic CVT patients was not significant (X2 = 8.14, df = 1, P = 0.87).
Patients with hemorrhagic CVT without other contraindication for anticoagulation should be treated either with dose-adjusted intravenous heparin or body-weight-adjusted subcutaneous low molecular-weight heparin.
PMCID: PMC3829295  PMID: 24250911
Cerebral Vein; Thrombus; Hemorrhagic
7.  Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary? 
Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA.
A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA.
Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups.
In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.
PMCID: PMC3491216  PMID: 23210049
Subarachnoid hemorrhage; Digital subtraction angiography; Aneurysm
8.  The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm 
The British Journal of Radiology  2011;84(999):279-281.
We present a new MRI finding within the lumbar spine in a series of six patients admitted with CT proven subarachnoid haemorrhage (SAH) where cerebral angiography demonstrated no aneurysm and who had not had a lumbar puncture.
A retrospective audit of 130 patients presenting to a regional neurosciences centre over a 13 month period with a suspected diagnosis of SAH was performed. Seven patients with proven SAH underwent MRI of the lumbar spine during the same admission. In six of these patients layering of haemorrhagic blood products was demonstrated within the lumbosacral spine. The process is analogous to the previously ubiquitous bedside erythrocyte sedimentation rate assay and has has been termed the “lumbar sedimentation” sign. This finding has not previously been reported in the literature in relation to SAH.
While this is a small unselected group it may provide a useful adjunct in the diagnosis of SAH.
PMCID: PMC3473883  PMID: 21325365
9.  Massive intraventricular haemorrhage from aneurysmal rupture: patient proportions and eligibility for intraventricular fibrinolysis 
Journal of Neurology  2009;257(3):354-358.
Massive intraventricular haemorrhage (IVH) complicating aneurysmal subarachnoid haemorrhage (SAH) is associated with a poor prognosis. Small observational studies suggest favourable results from fibrinolysis of the intraventricular blood. We performed an observational study on IVH in a large series of patients with SAH to assess the proportion of patients that may benefit from fibrinolytic treatment. From our prospective database we retrieved patients with aneurysmal SAH admitted between January 2000 and January 2005. We calculated the proportion of patients with massive IVH and the proportion of patients that are eligible for fibrinolysis on basis of clinical and CT-scan characteristics and assessed neurological outcome in a treatment strategy without fibrinolysis. Poor neurological condition was defined as World Federation of Neurological Surgeons scale 4 and 5, poor outcome as death or dependence 3 months after SAH. Of the 573 patients admitted with aneurysmal SAH, 59 (10%; 95% confidence interval CI 8–13%) had massive IVH, of which 55 were in poor clinical condition. For these 55 patients, the case-fatality rate was 78% (95% CI 66–88%) and the proportion with poor outcome 91% (95% CI 81–97%). Of the 55 patients, 31 (56%, and 5% of all patients SAH within the study period) fulfilled our eligibility criteria and were considered suitable for intraventricular fibrinolysis. At 3 months, 30 of these 31 eligible patients (97%; 95% CI 85–100%) had a poor outcome. Massive IVH occurs in 10% of patients with aneurysmal SAH. Half of these patients may benefit from intraventricular fibrinolysis. Without fibrinolysis outcome is almost invariably poor in these patients.
PMCID: PMC2837879  PMID: 19823896
Aneurysm; Subarachnoid; Intraventricular; Haemorrhage; Fibrinolysis
10.  Risk analysis of treatment of unruptured aneurysms 
OBJECTIVES—To calculate the expected number of life-years saved by surgical treatment of unruptured intracranial aneurysms at ages over 20years.
METHODS—An actuarial risk analysis of the treatment of unruptured intracranial aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms (ISUIA). The benefits of operative treatment are calculated in terms of average life-years saved.
RESULTS—Results are presented as graphs of life-years saved or lost against age at the time of operative treatment for three groups of aneurysms: those under 10 mm in diameter with no history of subarachnoid haemorrhage (SAH) from another aneurysm, those under 10 mm in diameter and a history of previous SAH from a different aneurysm, and those over 10 mm in diameter. Life-years are lost at all ages in the group under 10 mm with no history of SAH. For the group under 10 mm with a history of SAH about 4 years are saved at age 20 declining to 0 at around age 50. For aneurysms 10 mm or more in diameter about 8 life-years are saved at age 20 declining to 0 at around 50.
CONCLUSIONS—Clipping of unruptured aneurysms under 10 mm in diameter with no history of subarachnoid haemorrhage is not justified on actuarial grounds. Intervention in other unruptured aneurysms produces benefits in life expectancy up to the age of 50. There may be subgroups of aneurysms in which larger benefits exist.

PMCID: PMC1736916  PMID: 10766886
11.  Treatment of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms by neurosurgeons in Colombia: A survey 
Trends in management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms among neurosurgeons is very variable and had not been previously described in any Latin American country. This study was conducted to determine the preferences of Colombian neurosurgeons in pharmacologic, surgical, and endovascular management of patients with aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms.
A survey-based descriptive study was performed in a sample of members from the Colombian Association of Neurosurgery. Questions about pharmacologic, surgical, and endovascular management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysm were carried out. We calculated the mean and the standard deviation of the results obtained from the continuous variables. The results of the categorical variables are presented as percentages.
The preference of medication with poor clinical evidence, such as magnesium sulfate, aspirin, statins, and anti-fibrinolytics was lower than 10%. The use of intravenous nimodipine and systemic glucocorticoids was as high as 31%. The availability of endovascular therapy was 69%. The indication for treatment of patients with unruptured intracranial aneurysms that required intervention was less than 13.8%. In patients with ruptured or unruptured intracranial aneurysms, coiling was the preferred method for exclusion.
Reported compliance of evidence-based clinical guidelines was similar to that described in developed countries, and even better. However, there is little agreement in treating patients with unruptured intracranial aneurysms. For other issues, the conducts reported by Colombian neurosurgeons are in accordance with the current guidelines.
PMCID: PMC3205495  PMID: 22059120
Intracranial aneurysms; national survey; subarachnoid hemorrhage
12.  Depression and post-traumatic stress disorder after aneurysmal subarachnoid haemorrhage in relation to lifetime psychiatric morbidity 
British Journal of Neurosurgery  2011;25(6):693-700.
Little is known about the roles that lifetime psychiatric disorders play in psychiatric and vocational outcomes of aneurysmal subarachnoid haemorrhage (SAH).
Materials and methods
Eighty-three SAH patients without apparent cognitive dysfunction were assessed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I) after their SAH. Diagnoses were assessed for three time periods, ‘lifetime before SAH', ‘12 months before SAH’ and ‘7 months after SAH'.
Forty-five percentage of patients with SAH reported at least one lifetime psychiatric disorder. After SAH, symptoms of depression and/or post-traumatic stress disorder (PTSD) were seen in 41%, more often in those with a psychiatric history prior to SAH (p = 0.001). In logistic regressions, depression after SAH was associated with a lifetime history of major depression, or of anxiety or substance use disorder, as well as with lifetime psychiatric comorbidity. Subsyndromal or full PTSD was predicted by a lifetime history of major depression. After the SAH, 18 patients (22%) had received psychotropic medication and/or psychological treatment, 13 of whom had a disorder. Those with a lifetime history of major depression or treatment with antidepressants before SAH had lower return to work rates than others (p = 0.019 and p = 0.031, respectively). This was also true for those with symptoms of depression and/or PTSD, or with antidepressant treatment after SAH 0 = 0.001 and p = 0.031, respectively).
Depression and PTSD are present in a substantial proportion of patients 7 months after SAH. Those with a history of psychiatric morbidity, any time before the SAH, are more at risk and also constitute a risk group for difficulties in returning to work.
PMCID: PMC3233275  PMID: 21591856
Subarachnoid haemorrhage; mental disorders; depression; stress disorders; post-traumatic
13.  Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review 
Critical Care  2010;14(1):R23.
Triple-H therapy and its separate components (hypervolemia, hemodilution, and hypertension) aim to increase cerebral perfusion in subarachnoid haemorrhage (SAH) patients with delayed cerebral ischemia. We systematically reviewed the literature on the effect of triple-H components on cerebral perfusion in SAH patients.
We searched medical databases to identify all articles until October 2009 (except case reports) on treatment with triple-H components in SAH patients with evaluation of the treatment using cerebral blood flow (CBF in ml/100 g/min) measurement. We summarized study design, patient and intervention characteristics, and calculated differences in mean CBF before and after intervention.
Eleven studies (4 to 51 patients per study) were included (one randomized trial). Hemodilution did not change CBF. One of seven studies on hypervolemia showed statistically significant CBF increase compared to baseline; there was no comparable control group. Two of four studies applying hypertension and one of two applying triple-H showed significant CBF increase, none used a control group. The large heterogeneity in interventions and study populations prohibited meta-analyses.
There is no good evidence from controlled studies for a positive effect of triple-H or its separate components on CBF in SAH patients. In uncontrolled studies, hypertension seems to be more effective in increasing CBF than hemodilution or hypervolemia.
PMCID: PMC2875538  PMID: 20175912
14.  Long-term excess mortality of patients with treated and untreated unruptured intracranial aneurysms 
Background and aim
Subarachnoid haemorrhage (SAH) patients have an excess mortality proportion in long-term outcome studies because of the high rate of cerebrovascular and cardiovascular deaths. The aim of the present study was to assess the excess long-term mortality among patients with unruptured aneurysms with no previous SAH and to compare excess mortality after coiling, clipping and without treatment.
Between 1989 and 1999, a total of 1294 patients with intracranial aneurysms were admitted to our hospital. Of these, 1154 had previous SAH and were excluded leaving 140 patients with 178 intracranial unruptured aneurysms as the study population. The patients were followed up until death or by the end of April 2011. Causes of death were determined. Relative survival ratios (RSRs) were calculated and compared with the matched general population.
Mean follow-up time was 13 years (range 1–19). During the follow-up period, 36% of patients died. Death was caused by cerebrovascular event in half of the cases. There were 12% excess mortality at 15 years in men and 35% excess mortality in women compared with general population. Excess mortality among women over 50 years was significantly higher than that among men (p=0.018).
Patients with untreated unruptured aneurysms have 50% excess long-term mortality compared with general population. Men with treated unruptured aneurysms have a survival proportion comparable with matched general population. Women, instead, have 28% excess mortality after surgical treatment and 23% excess mortality after endovascular treatment of unruptured aneurysms.
PMCID: PMC3717756  PMID: 23424191
Cerebrovascular; Stroke
15.  Aneurysmal and clinical characteristics as risk factors for intracerebral haematoma from aneurysmal rupture 
Journal of Neurology  2010;258(5):862-865.
Intracerebral haematoma (ICH) occurs in one-third of patients with aneurysmal subarachnoid haemorrhage (SAH) and is associated with poor prognosis. Identification of risk factors for ICH from aneurysmal rupture may help in balancing risks of treatment of unruptured aneurysms. We assessed potential clinical and aneurysmal risk factors for ICH from aneurysmal rupture. In all 310 SAH patients admitted to our service between 2005 and 2007, we compared clinical risk factors (gender, age, smoking, hypertension, history of SAH and family history) of patients with and without an ICH. From the latest admitted, 50 patients with and 50 without ICH, we compared the location, shape and direction of blood flow of the aneurysms on CT-angiography. Relative risks (RRs) of ICH were 1.2 (95% confidence interval, CI):0.7–1.8) for males, 1.0 (95%CI:0.7–1.4) for age ≥55 year, 1.0 (95%CI:0.6–1.6) for smoking, 0.9 (95%CI:0.5–1.5) for hypertension, 0.6 (95%CI:0.1–3.8) for history of SAH and 0.5 (95%CI:0.2–1.3) for family history of SAH. RRs of ICH were 1.8 (95%CI:1.2–2.5) for MCA aneurysms, 0.5 (95%CI:0.3–1.0) for ICA aneurysms, 0.4 (95%CI:0.1–1.3) for posterior circulation aneurysms, and 0.7 (95%CI:0.3–1.3) for multilobed aneurysms. The RRs of other aneurysmal characteristics varied between 0.9 and 1.2. Patients with MCA aneurysms are at a higher risk of developing ICH. The other aneurysmal or clinical factors have no or only minor influence on the risk of ICH after rupture and are, therefore, not helpful in deciding on treatment of unruptured aneurysms.
PMCID: PMC3090569  PMID: 21153834
Cerebrovascular disease; Clinical neurology; Subarachnoid haemorrhage; Intracerebral haematoma; CT-angiography; Risk factors
16.  Coping strategies, health-related quality of life and psychiatric history in patients with aneurysmal subarachnoid haemorrhage 
Acta Neurochirurgica  2010;152(8):1375-1382.
Subarachnoid haemorrhage (SAH) reduces health-related quality of life (HRQoL) and increases the risk of psychiatric sequels such as depression and posttraumatic stress disorder. Especially those with a psychiatric history and those using maladaptive coping strategies are at risk for such sequels. The extent to which HRQoL after SAH was related to a history of psychiatric morbidity and to the use of various coping strategies was assessed.
Patients admitted to the Uppsala University Hospital with aneurysmal SAH (n = 59) were investigated prospectively. Seven months after SAH, data were collected using the Structured Clinical Interview for DSM-IV axis I disorders, the Short Form-36 (SF-36) Health Survey and the Jalowiec Coping Scale.
Patients with SAH had lower HRQoL than the general Swedish population in all eight domains of the SF-36. The lower HRQoL was almost entirely in the subgroup with a psychiatric history. HRQoL was also strongly correlated to the use of coping. Physical domains of SF-36 were less affected than mental domains. Those with a psychiatric history used more coping than the remainder with respect to all emotional coping scales. Coping and the presence of a psychiatric history were more strongly related to mental than to physical components of HRQoL.
A psychiatric history and the use of maladaptive emotional coping were related to worse HRQoL, more to mental than to physical aspects.
PMCID: PMC2901493  PMID: 20440628
Subarachnoid haemorrhage; Health-related quality of life (HRQoL); Coping; Psychiatric history
17.  “Real-world” comparison of non-invasive imaging to conventional catheter angiography in the diagnosis of cerebral aneurysms 
Based on numerous reports citing high sensitivity and specificity of non-invasive imaging [e.g. computed tomography angiography (CTA) or magnetic resonance angiography (MRA)] in the detection of intracranial aneurysms, it has become increasingly difficult to justify the role of conventional angiography [digital subtraction angiography (DSA)] for diagnostic purposes. The current literature, however, largely fails to demonstrate the practical application of these technologies within the context of a “real-world” neurosurgical practice. We sought to determine the proportion of patients for whom the additional information gleaned from 3D rotational DSA (3DRA) led to a change in treatment.
We analyzed the medical records of the last 361 consecutive patients referred to a neurosurgeon at our institution for evaluation of “possible intracranial aneurysm” or subarachnoid hemorrhage (SAH). Only those who underwent non-invasive vascular imaging within 3 months prior to DSA were included in the study. For asymptomatic patients without a history of SAH, aneurysms less than 5 mm were followed conservatively. Treatment was advocated for patients with unruptured, non-cavernous aneurysms measuring 5 mm or larger and for any non-cavernous aneurysm in the setting of acute SAH.
For those who underwent CTA or MRA, the treatment plan was changed in 17/90 (18.9%) and 22/73 (30.1%), respectively, based on subsequent information gleaned from DSA. Several reasons exist for the change in the treatment plan, including size and location discrepancies (e.g. cavernous versus supraclinoid), or detection of a benign vascular variant rather than a true aneurysm.
In a “real-world” analysis of intracranial aneurysms, DSA continues to play an important role in determining the optimal management strategy.
PMCID: PMC3205496  PMID: 22059129
Aneurysm; angiography; computed tomography angiography; magnetic resonance angiography
18.  Subarachnoid haemorrhage in patients ⩾75 years: clinical course, treatment and outcome 
The number of elderly patients being admitted with aneurysmal subarachnoid haemorrhage (SAH) has been increasing. Treatment of the aneurysm may be offset by the higher rate of surgical or endovascular complications.
To study the clinical condition at onset, complications during clinical course, treatment and outcome in a consecutive series of elderly patients.
Patients who were ⩾75 years at the onset of SAH were selected from the databases of two hospitals. Data on clinical condition at onset (poor condition defined as World Federation of Neurological Surgeons (WFNS) Scale IV and V), clinical course, treatment and outcome were extracted. Univariate and multivariate regression analyses were carried out to identify predictors for in‐hospital death and poor outcome, defined as death or dependency.
The data of 170 patients were retrieved, of whom 25 (15%) patients were independent at discharge; none of these patients had been admitted in a poor condition. Poor clinical condition on admission (odds ratio (OR) 7.9; 95% confidence interval (CI) 3.7 to 17) and recurrent haemorrhage (OR 7.5; 95% CI 2.5 to 23) were the strongest predictors for in‐hospital death. Recurrent haemorrhage was the strongest predictor for poor outcome in the subset of patients who were admitted in good clinical condition. In all, 10 of 47 (21%) patients were independent at discharge after neurosurgical clipping (n = 34) or endovascular coiling (n = 13).
Elderly patients with SAH have a poor prognosis. The effect of the initial haemorrhage is the most common reason for poor outcome. For patients who are admitted in good clinical condition, the most important complication leading to poor outcome is recurrent haemorrhage. Treatment of the aneurysm in patients ⩾75 years is feasible, may improve the outcome and should be strongly considered in patients who are admitted in a good condition.
PMCID: PMC2077608  PMID: 16638789
19.  Role of magnesium sulfate in aneurysmal subarachnoid hemorrhage management: A meta-analysis of controlled clinical trials 
Asian Journal of Neurosurgery  2011;6(1):26-31.
There has been longstanding controversy over the use of magnesium sulfate infusion in the medical management of aneurysmal subarachnoid hemorrhage (SAH). Several clinical trials evaluating the beneficial effects of magnesium on cerebral vasospasm and their poor outcome have been published. However, results from the majority of these studies have been inconclusive. This meta-analysis was performed to evaluate the effectiveness of magnesium on patient outcomes after aneurysmal SAH.
Materials and Methods:
PubMed and the Cochrane library were searched for controlled clinical trials assessing the efficacy of magnesium sulfate infusion after aneurysmal SAH. Eight studies consisting of 936 patients were included.
There was a decreased risk of poor outcome at 3–6 months after SAH in magnesium treatment groups when compared to placebo [0.78 (95% CI 0.66–0.93)]. Poor outcome was defined as severe disability, persistent vegetative state, or death, as measured by the Glasgow outcome scale (GOS), extended Glasgow outcome scale (GOSE) or modified Rankin scale (mRS). The risk of mortality after SAH was unaffected by magnesium treatment [RR 0.68 (95% CI 0.58–1.27)].
Magnesium sulfate infusion decreases risk of poor outcome after aneurysmal SAH. Current studies in the literature do not suggest a role for magnesium sulfate in mortality reduction after SAH.
PMCID: PMC3205548  PMID: 22059101
Cerebral vasospasm; delayed cerebral ischemia; magnesium sulfate; subarachnoid hemorrhage
20.  Cerebral microdialysis for detection of bacterial meningitis in aneurysmal subarachnoid hemorrhage patients: a cohort study 
Critical Care  2009;13(1):R2.
Bacterial meningitis (BM) is a severe complication in patients with aneurysmal subarachnoid haemorrhage (SAH). Clinical signs of meningitis are often masked by SAH-related symptoms, and routine cerebrospinal fluid (CSF) analysis fails to indicate BM. Microdialysis (MD) is a technique for monitoring cerebral metabolism in patients with SAH. A cohort study was performed to investigate the value of MD for the diagnosis of BM.
Retrospectively, 167 patients with SAH in an ongoing investigation on cerebral metabolism monitored by MD were analysed for the presence of BM and related MD changes. Diagnosis of BM was based on microbiological CSF culture or clinical symptoms responding to antibiotic treatment, combined with an increased CSF cell count and/or fever. Levels of MD parameters before and after diagnosis of BM were analysed and compared with the spontaneous course in controls.
BM developed in 20 patients, of which 12 underwent MD monitoring at the time of diagnosis. A control group was formed using 147 patients with SAH not developing meningitis. On the day BM was diagnosed, cerebral glucose was lower compared with the value three days before (p = 0.012), and the extent of decrease was significantly higher than in controls (p = 0.044). A decrease in cerebral glucose by 1 mmol/L combined with the presence of fever ≥ 38°C indicated BM with a sensitivity of 69% and a specificity of 80%. CSF chemistry failed to indicate BM, but the cell count increased during the days before diagnosis (p < 0.05).
A decrease in MD glucose combined with the presence of fever detected BM with acceptable sensitivity and specificity, while CSF chemistry failed to indicate BM. In patients with SAH where CSF cell count is not available or helpful, MD might serve as an adjunct criterion for early diagnosis of BM.
PMCID: PMC2688112  PMID: 19154580
21.  Management of aneurysmal subarachnoid hemorrhage 
Critical care medicine  2009;37(2):432-440.
Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many SAH patients are seriously ill and require a prolonged ICU stay. Cardiopulmonary complications are common. The management of SAH patients focuses on the anticipation, prevention and management of these secondary complications.
Data Sources
Source data were obtained from a PubMed search of the medical literature.
Data Synthesis and Conclusion
The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means.
Over the first 1-2 weeks after hemorrhage, patients are at risk for delayed ischemic deficits due to vasospasm, autoregulatory failure and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty and intra-arterial vasodilators. Subarachnoid hemorrhage is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
PMCID: PMC2820121  PMID: 19114880
aneurysm; subarachnoid hemorrhage; vasospasm; hypertension; treatment; endovascular
22.  The incidence of radiologically demonstrable aneurysm and arteriovenous malformation in spontaneous subarachnoid haemorrhage 
Postgraduate Medical Journal  1982;58(676):74-76.
The incidence of radiologically demonstrable aneurysm and arteriovenous malformation (AVM) in patients admitted to the Midland Centre for Neurosurgery and Neurology (MCNN) with the diagnosis of spontaneous subarachnoid haemorrhage (SAH) between 1959-80 inclusive was determined. Bilateral carotid angiography (BCA) showed 65·8% to have one or more aneurysms and 7·5% an AVM, each figure including 0·6% with both conditions. When BCA was negative, 65·8% proceeded to vertebral angiography (VA) and of these 12·5% were shown to have an aneurysm and 4·2% an AVM.
The probability of demonstrating an aneurysm by either of these radiological methods is an important factor in deciding whether or not to proceed to angiography, especially in patients presenting an above average anaesthetic or operative risk, bearing in mind the high mortality of untreated aneurysm in this condition and the improved prognosis when successful surgical management is possible.
PMCID: PMC2426298  PMID: 7100028
23.  Predisposing Factors Related to Shunt-Dependent Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage 
Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion.
Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (≥14 days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography.
Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence on the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not correlate with the development of shunt-dependent chronic hydrocephalus.
Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.
PMCID: PMC2588257  PMID: 19096639
Subarachnoid hemorrhage; Ventriculoperitoneal shunt; Chronic hydrocephalus; Related factor
24.  Early Treatment for Ruptured Cerebral Aneurysms 
Interventional Neuroradiology  2008;10(Suppl 2):35-40.
The purpose of this study was to evaluate the effect of endovascular treatment with Guglielmi detachable coils (GDC) on the outcomes of subarachnoid haemorrhage (SAH) patients of poor grades and high ages for each location of aneurysms.
Between 1990 and 2003, 529 SAH cases underwent angiograghy as candidates of early aggressive treatment in our hospital. For the 299 cases in 1990-96 (Group 1), treatment options were early and intensively delayed craniotomy surgery and conservative management, while for the 230 cases in 1997-2003 (Group 2), GDG embolization at acute stage was added to these three treatment options. We compared clinical courses and outcomes of the poor grade (Hunt & Kosnik Grade 4-5) patients and high age (> = 70 years old) patients between two groups for each location of aneurysms.
Introduction of GDC embolization expanded the indication for early treatment in the poor grade patients with anterior communicating artery aneurysm (A-Comm An), the high age patients with internal carotid artery aneurysm (IC An) and all patients with Basilar bifurcation aneurysm (BA-Top An), and has contributed to improvement of their outcomes. To the poor grade patients with middle cerebral artery aneurysm (MCA An), GDC embolization was hardly indicated, because haematoma evacuation concomitantly performed with aneurysm occlusion would be necessary for those patients.
In conclusion, results of treatment with GDC embolization at an acute stage are desirable for poor grade patients with A-Comm An, aged patients with IC An and all patients with BA-Top An. The indication of GDC embolization for the patients with MCA An is limited.
PMCID: PMC3522219  PMID: 20587247
GDC, SAH, outcome, location of aneurysms
25.  The Incidence of Aneurysmal Subarachnoid Hemorrhage in Youngdong District, Korea 
The purpose of this study is to investigate the incidence of aneurysmal subarachnoid hemorrhage (SAH) in Youngdong district for 10 years.
From Jan. 1997 to Dec. 2006, 732 patients (327 males, 405 females, mean age: 54.8±13.1 years) with spontaneous SAH were admitted to our hospital. We reviewed the medical records and radiological findings regarding to the ictus of SAH, location and size of the ruptured aneurysms, Hunt-Hess grade and Fisher grade on admission, personal details such as address, age, and sex, and previous history of medical diseases.
In these 732 patients, 672 cases were confirmed as aneurysmal SAH. Among them, 611 patients (262 males, 349 females, mean age: 54.9±13.2 years) came from Youngdong district. The average crude annual incidence of aneurysmal SAH for men, women, and both sexes combined in Youngdong district was 7.8±1.7, 10.5±2.7, and 9.1±2.1 per 100,000 population, respectively. Because of the problems related to the observation period and geographical confinement, it was suspected that the representative incidence of aneurysmal SAH in Youngdong district should be made during the later eight years in six coastal regions. Therefore, the average age-adjusted annual incidence for men, women, and both sexes combined was 8.8±1.4, 11.2±1.3 and 10.0±1.0, respectively in the coastal regions of Youngdong district from 1999 to 2006.
In overall, our results on the incidence of aneurysmal SAH was not very different from previous observations from other studies.
PMCID: PMC2588204  PMID: 19096553
Aneurysmal SAH; Epidemiology; Incidence

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