Original ArticlesEffect of clot removal and surgical manipulation on regional cerebral blood flow and delayed vasospasm in early aneurysm surgery for subarachnoid hemorrhage
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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2020, World NeurosurgeryCitation Excerpt :Therefore, these mechanisms were likely not a factor in this specific case. Manipulation of cerebral arteries already irritated by subarachnoid blood may yield a vasospasm that is not detectable on angiography but still has a clinically significant impact: surgery-induced vasospasm may facilitate further decrease of cerebral blood flow (CBF) by the hemorrhage itself, with retraction on swollen brain further contributing to CBF impairment.13-17 CBF studies, supported by single photon emission computed tomography imaging, indicate that CBF is significantly lowered on the side that has been surgically treated.15,18,19
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2014, World NeurosurgeryCitation Excerpt :This significant superiority of interventional therapy is difficult to comprehend from a surgical point of view, particularly after comparison of both methods. Using surgical exposure, operative removal of blood clots with rinsing and cleaning of the subarachnoid spaces may decrease the risk of cerebral vasospasm and chronic hydrocephalus (14, 17, 20-22, 24, 29, 43, 46, 47, 53). With an additional opening of the lamina terminalis, the intracranial cerebrospinal fluid circulation also can be effectively improved (3, 27, 45).
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2010, World NeurosurgeryCitation Excerpt :The preferred treatment method in the setting of existing vasospasm is also controversial. Manual manipulation of cerebral blood vessels may decrease distal blood flow (3), and there is concern for increased risk of ischemia with surgical manipulation in the setting of vasospasm. On the other hand, endovascular therapy also has a potential for increased risk in this setting; passage of a microwire through a vasospastic vessel during endovascular coiling might be associated with higher risk of vessel perforation.
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