Elsevier

Surgical Neurology

Volume 51, Issue 1, January 1999, Pages 81-88
Surgical Neurology

Original Articles
Effect of clot removal and surgical manipulation on regional cerebral blood flow and delayed vasospasm in early aneurysm surgery for subarachnoid hemorrhage

https://doi.org/10.1016/S0090-3019(97)00508-9Get rights and content

Abstract

BACKGROUND

Effect of clot removal and surgical manipulation on cerebral blood flow (CBF) and delayed vasospasm was studied in early aneurysm surgery for subarachnoid hemorrhage (SAH).

METHODS

Thirty-two patients in this study fulfilled the following criteria: ruptured anterior communicating aneurysms, computed tomography (CT) within 2 days and unilateral pterional approach within 3 days after the ictus, bilaterally symmetrical clots without intracerebral hematoma, no postoperative complication, and CBF studies with single photon emission computed tomography (SPECT) with 123I-IMP.

RESULTS

Postoperative regional hypoperfusion due to brain retraction was frequently recognized on 123I-IMP-SPECT without infarction. The regional CBF (rCBF) showed a continuous fall during the first 4 weeks after the ictus, followed by improvement. The rCBF in the vicinity of the surgical route was significantly lower, especially in the acute stage (Day 3–7). A significant association between decrease of cisternal blood after surgery and the degree of local vasospasm and local CBF values during spasm stage was observed in the interhemispheric cisterns, A2 and medial frontal cortex, but not in the sylvian fissure or insular cisterns, M1 or M2, and frontal watershed and temporal cortex.

CONCLUSIONS

The present study provides evidence for the effectiveness of direct clot removal by early surgery for SAH on local vasospasm and CBF reduction. However, a potential improvement in local CBF with clot removal could be masked by brain retraction, which was demonstrated to affect rCBF adversely. Therefore, it is critical to perform brain retraction as gently as possible.

Section snippets

Patient selection

The present series was composed of 32 patients who were admitted between November 1988 and April 1995 and fulfilled the following criteria: a ruptured anterior communicating artery (Acom) aneurysm, for which hospital admission and CT were obtained within 2 days after the initial SAH; bilaterally symmetrical clots in the basal and sylvian-insular cisterns on CT; and direct neck clipping by unilateral pterional approach within 3 days after the initial SAH. Exclusion criteria were an

Results

The patients’ preoperative clinical condition was Grade I in 6 patients, Grade II in 13, Grade III in 7, and Grade IV in 6. There were 21 in Group II and 11 in Group III according to CT grade. Right pterional approach was performed in 12 patients and left pterional approach in 20 patients. Twenty-seven (85%) of 32 patients obtained good outcome (good recovery, n = 21 + moderate disability, n = 6), 3 patients (9%) suffered severe disability, and 2 patients (6%) died. A total of 61 SPECT scans

Discussion

Most previous studies of CBF after SAH have included patients with aneurysms located in various intracranial arteries 8, 11, 15, 17, 18, 28. On the other hand, it has been noticed that surgical intervention itself could interfere with CBF change 18, 25. In addition, the effect of cisternal clot on the development of delayed vasospasm has been suggested 3, 21, 23, 26. Therefore, only patients with a ruptured Acom aneurysm and with bilaterally symmetrical clots in the basal and sylvian-insular

Acknowledgements

We gratefully acknowledge the technical assistance of Tatsuhiko Ashihara and Ichiro Izawa. We also express our gratitude to Junko Koyama and Maki Tajiri for their assistance in the preparation of the manuscript.

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