Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage

Abel Po Hao Huang, Sandeep Arora, Max Wintermark, Nerrissa Ko, Yong Kwang Tu, Michael T. Lawton

Research output: Contribution to journalReview article

31 Citations (Scopus)

Abstract

BACKGROUND: Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention. OBJECTIVE: To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery. METHODS: A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes. RESULTS: Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes. CONCLUSIONS: PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

Original languageEnglish
Pages (from-to)964-974
Number of pages11
JournalNeurosurgery
Volume67
Issue number4
DOIs
Publication statusPublished - Oct 1 2010
Externally publishedYes

Fingerprint

Subarachnoid Hemorrhage
Patient Selection
Perfusion
Ruptured Aneurysm
Coma
Aneurysm
Tomography
Intracranial Pressure
Critical Care
Resuscitation
Cerebrovascular Circulation
Glasgow Outcome Scale
Hematoma
Brain Injuries

Keywords

  • Aneurysm
  • Hemicraniectomy
  • Microsurgical clipping
  • Perfusion computed tomography
  • Subarachnoid hemorrhage

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage. / Huang, Abel Po Hao; Arora, Sandeep; Wintermark, Max; Ko, Nerrissa; Tu, Yong Kwang; Lawton, Michael T.

In: Neurosurgery, Vol. 67, No. 4, 01.10.2010, p. 964-974.

Research output: Contribution to journalReview article

Huang, Abel Po Hao ; Arora, Sandeep ; Wintermark, Max ; Ko, Nerrissa ; Tu, Yong Kwang ; Lawton, Michael T. / Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage. In: Neurosurgery. 2010 ; Vol. 67, No. 4. pp. 964-974.
@article{0f8193c1131349098d567c4f0b7d1888,
title = "Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage",
abstract = "BACKGROUND: Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention. OBJECTIVE: To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery. METHODS: A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes. RESULTS: Among 58 grade IV patients (74{\%}) and 20 grade V patients (26{\%}), 44 patients (56{\%}) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44{\%}) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71{\%}, whereas mortality among grade V patients was 60{\%}. Sixteen patients (89{\%}) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes. CONCLUSIONS: PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.",
keywords = "Aneurysm, Hemicraniectomy, Microsurgical clipping, Perfusion computed tomography, Subarachnoid hemorrhage",
author = "Huang, {Abel Po Hao} and Sandeep Arora and Max Wintermark and Nerrissa Ko and Tu, {Yong Kwang} and Lawton, {Michael T.}",
year = "2010",
month = "10",
day = "1",
doi = "10.1227/NEU.0b013e3181ee359c",
language = "English",
volume = "67",
pages = "964--974",
journal = "Neurosurgery",
issn = "0148-396X",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage

AU - Huang, Abel Po Hao

AU - Arora, Sandeep

AU - Wintermark, Max

AU - Ko, Nerrissa

AU - Tu, Yong Kwang

AU - Lawton, Michael T.

PY - 2010/10/1

Y1 - 2010/10/1

N2 - BACKGROUND: Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention. OBJECTIVE: To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery. METHODS: A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes. RESULTS: Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes. CONCLUSIONS: PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

AB - BACKGROUND: Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention. OBJECTIVE: To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery. METHODS: A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes. RESULTS: Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes. CONCLUSIONS: PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

KW - Aneurysm

KW - Hemicraniectomy

KW - Microsurgical clipping

KW - Perfusion computed tomography

KW - Subarachnoid hemorrhage

UR - http://www.scopus.com/inward/record.url?scp=77958008246&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77958008246&partnerID=8YFLogxK

U2 - 10.1227/NEU.0b013e3181ee359c

DO - 10.1227/NEU.0b013e3181ee359c

M3 - Review article

C2 - 20881562

AN - SCOPUS:77958008246

VL - 67

SP - 964

EP - 974

JO - Neurosurgery

JF - Neurosurgery

SN - 0148-396X

IS - 4

ER -