Korean Journal of Cerebrovascular Surgery 2010;12(3):141-146.
Published online September 1, 2010.
Optimal Treatment in Patients with Ruptured Middle Cerebral Artery Aneurysms and Intracranial Hematoma According to Hematoma Distribution.
Kim, Se Hun , Choi, Jong Hun , Lee, Ho Kook , Moon, Jae Gon , Kim, Chang Hyun
Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea. nscjh@hallym.or.kr
Abstract
OBJECTIVE
This study aimed to determine the clinical courses and optimal treatments for patients suffering from ruptured middle cerebral artery (MCA) aneurysms with either intracerebral (ICHs) or sylvian hematomas (SylH), based on hematoma distribution. METHODS: We grouped 49 patients with Fisher grade III or IV subarachnoid hemorrhages, who underwent aneurysmal neck clipping and hematoma evacuation within 24 hours of developing an intracranial hematoma, according to hematoma distribution. Group A comprised 21 patients who had ICHs<30 ml, while group B comprised 28 patients with dense SylHs<30 ml. Result: Immediate postoperative brain computerized tomography findings showed residual hematomas in 3 group A patients (14.3%) and 20 group B patients (71.7%). We noted post-operative brain edema in 5 group A (23.8%) and 15 group B patients (53.6%). Vasospasm developed in 4 group A (19.0%) and 20 group B patients (71.4%; p<0.05). In group A, 12 patients (57.1%) had focal neurologic deficits upon discharge, while 5 patients died. In group B, 9 patients (32.1%) had focal neurologic deficits upon discharge, while 8 died (p<0.05). Normal pressure hydrocephalus developed in 1 patient (4.8%) in group A and 5 in group B (17.9%). Favorable outcomes were achieved in 9 patients (42.9%) in group A and 4 (14.3%) in group B. CONCLUSION: Patients who experienced ruptured MCA aneurysms with SylHs had more severe clinical courses and poorer outcomes than patients with ICHs did. The SylH patients had a higher incidence of both vasospasm and brain edema. Therefore, physicians must consider differences in clinical features based on hematoma distribution when choosing an appropriate therapeutic approach for patients with ruptured MCA aneurysms and intracranial hematomas.
Key Words: Aneurysm, Intracerebral hematoma, Middle cerebral artery, Subarachnoid hemorrhage
 

Introduction


Middle cerebral artery (MCA) aneurysms account for approximately 20% of all intracranial aneurysms.1)15)18) Because MCA aneurysms are located more peripherally than are aneurysms at other sites, intracranial hematomas frequently occur in the temporoparietal lobe or sylvian fissure.12-14)

Although MCA aneurysm ruptures can cause these two types of hematomas, intracerebral hematomas (ICHs) and sylvian hematomas (SylHs) have different clinical courses and prognoses. The present study determined the clinical courses and prognoses for patients whose ruptured MCA aneurysms produced either ICHs or SylHs.


Patients and Methods


1.  Patient population

Participants were 49 patients receiving surgical treatment between January 2005 and December 2009 at Hallym University Medical Center after their Fisher grade III or IV subarachnoid hemorrhages (SAHs), due to ruptured aneurysms of the MCA bifurcation, led to ICHs or SylHs. There were 20 males (40.8%) and 29 females (59.2%), with a mean age of 52.7 years (range, 24 ± 80 years).

Exclusion criteria were as follows: 1) age > 80 years (because of such patients' generally poor overall health); 2) hematoma volume > 30 ml (because of the potential direct brain herniation effect); and 3) the presence of one or more lethal co-morbidities, such as cancer or pneumonia.


2.  Hematoma distribution

We diagnosed all patients as having a ruptured aneurysm of the MCA bifurcation and either ICH or SylH by pre-operative angiography and brain computerized tomography (CT). To measure hematoma volume, we used a picture archiving and communication system (PACS, PiViewSTAR 5051, INFINITT, Seoul, Korea). There were 23 patients (46.9%) with left side hematomas and 26 patients (53.1%) with right side hematomas. We classified ICH types into 2 groups, based on hematoma distributions according to our CT findings upon patient admission, as follows: group A comprised patients with SAHs (due to rupture of a middle cerebral artery aneurysm) resulting in ICHs< 30 ml (Fig. 1), and group B comprised patients with the same type SAHs, but which resulted in SylHs< 30 ml (Fig. 2).


3.  Operative protocols

All patients underwent aneurysmal neck clipping and hematoma evacuation within 24 hours after developing their intracranial hematomas. If a large ICH or a dense SylH was present, we performed a craniotomy or craniectomy significantly larger than in the standard pterional approach. During surgery, patients underwent osmotic diuresis (mannitol at 12 mg/kg) and cerebrospinal fluid (CSF) drainage, if necessary, to relieve brain swelling. We did not routinely manage patients using intra-operative hyperventilation and avoided intra-operative hypotension to maintain appropriate perfusion pressure.


4.  Management protocol

Patients received aggressive post-operative treatment in the neurologic intensive care unit (NICU), including intracranial pressure (ICP) monitoring, to avoid intracranial hypertension and vasospasm. In addition, we drained CSF to decrease the ICP caused by hydrocephalus. To prevent cerebral vasospasm, patients underwent prophylactic hypervolemic hyperdynamic therapy for at least 2 weeks after surgery, including the intravenous administration of calcium channel antagonists and plasma volume expansion through the infusion of albumin and/or low-molecular-weight dextran, to maintain the serum oncotic pressure.


5.  Assessment of prognostic indications

To assess patient outcome upon discharge, we used the Glasgow Outcome Scale (GOS), which comprises 5 levels: good recovery (GR), moderate disability (MD), severe disability (SD), vegetative state (VS), and death (D).7) The GOS describes GR and MD as favorable outcomes, whereas SD, VS, and D constitute unfavorable outcomes.16) To identify prognostic determinants, we recorded the following information for each patient: age; gender; mental status; neurologic deficit on admission; Hunt-Hess grade; side of aneurysm; development of vasospasm, hydrocephalus, or post-operative brain edema; residual hematoma after surgery, and duration of NICU admission. We recorded focal neurologic deficits noted on admission (hemiparesis, dysarthria, and visual field defects) by checking them as ?ositive?on the list.

To diagnose vasospasm, we examined patients with transcranial Doppler ultrasonography (TCD) or angiography if they developed a delayed ischemic neurologic deficit (DIND), such as a significant change in mental status or a new focal neurologic deficit. Brain edema was defined as > 5 mm midline shifting on an operative follow-up CT.


6.  Statistical analysis

We compared data from patients?charts using the chi-square test, unpaired t-test, and Fisher? exact test. In all cases, a difference was considered significant when p value < 0.05.


Results


1.  Characteristics of both groups of patients

Table 1 gives the characteristics of both groups of patients. There were no significant differences in gender, age, or side of aneurysm between the groups. All patients in both groups were admitted on the day of their SAH. With respect to mental status on admission, drowsiness was the most common, in group A (10 patients [47.6%]) and in group B (12 patients [42.8%]). Hematoma mean volume, calculated by CT upon admission, was greater in group A (22.0 ml) than in group B (17.6 ml; p<0.05). Focal neurologic deficits developed in 15 patients (71.4%) in group A and in 6 patients (21.4%) in group B (p<0.05). Hunt-Hess grade IV was the most common grade in both groups.


2.  Clinical course and outcome

Table 2 shows the clinical courses and outcomes of both patient groups. The immediate post-operative CT findings showed residual hematoma in 3 group A patients (14.3%) and 20 group B patients (71.4%; p<0.05). We observed post-operative brain edema in 5 group A (23.8%) and 15 group B patients (53.6%; p<0.05). The incidence of vasospasm was significantly higher in group B (20 patients [71.4%]) than in group A (4 patients [19.0%]; p<0.05). In group A, 12 patients (57.1%) had focal neurologic deficits upon discharge, while 5 patients (23.8%) died. In group B, 9 patients (32.1%) had focal neurologic deficits and 8 patients (28.6%) died; there were no statistically significant differences between the two groups. Normal pressure hydrocephalus (NPH) developed in 22.7% of all patients; there was no statistically significant difference between the two groups. Nine patients in group A (42.9%) and 4 patients in group B (14.3%) achieved favorable outcomes; there were no significant differences between the two groups.


3.  Correlations between outcomes and various factors

Table 3 shows the relationship between the various factors and groups?outcomes.

In both groups, there were no significant differences between having a favorable or poor outcome and mean age, clinical Hunt-Hess grade on admission, duration of NICU admission, hematoma volume, vasospasm, or residual hematoma. In group A, post-operative brain edema correlated with outcome, but there was no similar significant difference in group B.


Discussion


Pasqualin et al. reported that the ICH incidence in 899 patients with ruptured aneurysms was 34% and that the most frequent aneurysm site is the MCA (55%).13) Several authors have proposed that clinical outcomes of SAH patients with intracranial hematomas are usually worse than those of SAH patients without intracranial hematomas.2)4) Crompton reported that ICHs?possible anatomic locations include the external capsule, temporal lobe, and the sylvian fissure and stated important factors that predispose patients to intracerebral rupture of an aneurysm include rapid obstruction of the subarachnoid space by blood, fibrin, and fibrous arachnoid and adhesion of the aneurysm sac to the pia mater.3)

Shimoda et al. reported on outcomes of patients who underwent surgical interventions for intracerebral hemorrhages due to ruptured MCA aneurysms.16) They classified hematoma distribution locations as intracerebral or intrasylvian and stated favorable outcomes were higher in the intracerebral hematoma group (89%) than in the sylvian hematoma group (69%). However, these studies provided no determinations of which prognostic factor(s) benefited most from post-operative treatment. In the present study, we investigated the optimal treatment for patients with intracranial hematomas due to ruptured MCA aneurysms by comparing hematoma distribution and clinical courses.


1.  Hematoma distribution

Although mean hematoma volume was less in group B than in group A, the clinical outcomes were poorer for group B patients. Only 4 patients had favorable outcomes in group B, while 9 patients had favorable outcomes in group A. This might be due to differences in clinical course and prognostic factors. In group B, the patients had higher incidences of developing vasospasm or post-operative brain edema (Fig. 2) than patients in group A had (Fig. 1). Consequently, new neurologic deficits developed in group B patients, leading to poor outcomes.


2.  Intracerebral hematoma

The group A patients had localized hematomas in the brain parenchyma. Approximately 71.4% of patients in group A had disabilities upon admission, such as hemiparesis, dysarthria, and visual field defects. The main cause of such disabilities seemed to be initial brain damage due to the ICHs. In group A, aneurysms ruptured only at the site at which the sac adhered to the pia mater and bled directly into the brain parenchyma rather than the subarachnoid space; thus, vasospasm would not be a significant problem. Furthermore, post-operative brain edema did not develop, as it did in patients with SylHs. The 5 group A patients who died had massive brain edema around the ICH upon admission. Only 4 group A patients (19.0%) developed vasospasm during the admission period.

Due to these factors, a poor outcome in a group A patient could result from increased ICP, which would be due to hematoma volume, rather than other factors.

Research has associated increased ICP with several detrimental effects, such as cerebral ischemia following reduced perfusion pressure.5) Several investigators have reported that intractable intracranial hypertension is associated with a poor outcome among poor grade patients with aneurysmal SAHs.8-10)17) Heuer et al. showed that ICP increases in over 50% of all SAH patients, particularly among those with a poor grade who also have ICHs.6)

Patients with ICHs due to ruptured MCA aneurysms need decompressive hematoma evacuation and aneurysm obliteration as soon as possible to achieve better outcomes.


3.  Sylvian hematoma

In patients with hematoma SylH, additional pathologic events can occur, such as primary brain damage caused by the SAH and SylH, secondary brain damage following the SAH (vasospasm), secondary brainstem compression due to the SylH, or direct brainstem compression due to a cisternal clot.16)

The patients in group B had a different clinical course from group A patients. First, according to post-operative brain CTs, group B patients had a higher incidence of residual hematoma (Table 2), and we consider that these were the main cause of their poor outcomes. Second, vasospasm developed during the post-operative period in 71.4% of the SylH patients and correlated with poor outcomes (Table 2). Third, post-operative brain edema developed more frequently in group B. The factors leading to this edema may have included residual hematoma, modulation of blood-brain barrier permeability after trauma, and surgical manipulation, such as mechanical traumatization, electrocautery, desiccation, and retractor compression.11)

It is difficult to evacuate SylH because due to perforating vessels in the subarachnoid space and fibrous adhesions of the clots. Therefore, residual hematomas may contribute to development of post-operative brain edema and vasospasm (Fig. 2). In our cases, most patients who had post-operative residual SylHs had brain edema on post-operative days 2-7 and vasospasm on post-operative days 5-14. Some of these patients recovered from those events, but some had fatal outcomes. They suffered from the development of new neurologic deficits due to vasospasm and focal brain ischemic changes. Consequently, although the hematoma volume was much greater in group A, the patients in group B had poorer outcomes in this study. Therefore, aneurysm rupture with SylH requires aggressive evacuation and aneurysm obliteration followed by prophylactic use of anti-brain edema agents, such as mannitol and furosemide. Those patients at risk for vasospasm around post-operative day 7 require therapies such as induced hypertension, hypervolemia, and hemodilution.   


Conclusion


Patients who have ruptured MCA aneurysms with ICHs or SylHs undergo different clinical courses and outcomes. The patients with SylHs had a higher incidence of vasospasm and brain edema development. Patients with ICHs due to ruptured MCA aneurysms need decompressive hematoma evacuation and aneurysm obliteration as soon as possible to achieve better outcomes.

Therefore, physicians must consider the differences in clinical features based on hematoma distribution in ruptured MCA aneurysms with intracranial hematomas and choose an appropriate therapeutic approach for the accompanying hematoma type.


References

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