Comparison of Large Intrasylvian and Subpial Hematomas Caused by Rupture of Middle Cerebral Artery Aneurysm

Abstract

The clinical characteristics of intrasylvian and subpial hematomas caused by rupture of middle cerebral artery (MCA) aneurysm were examined in 86 patients admitted to our department with subarachnoid hemorrhage (SAH) caused by ruptured MCA aneurysms. A retrospective study of 26 patients with a large hematoma associated with SAH treated surgically within 48 hours evaluated clinical grade at admission, secondary development of cerebral swelling, ratio of hematoma removal, and incidence of symptomatic vasospasm. Clinical grade on admission, age, and sex showed no significant differences. Ratio of cerebral swelling against the initial hematoma volume (p ＝ 0.005), and incidence of symptomatic vasospasm (p ＝ 0.041) were significantly lower, and the ratio of hematoma was significantly higher (p ＝ 0.01) in the subpial hematoma group. Removal of hematoma was more difficult and symptomatic vasospasm was more frequent in the intrasylvian hematoma group. The clinical features of subpial and intrasylvian hematomas caused by rupture of MCA aneurysm should be considered for the better management of associated SAH.

Surgical treatment of poor grade middle cerebral artery aneurysms associated with large sylvian hematomas following prophylactic hinged craniectomy

“…Lack of collateral circulation in MCA and tight adhesion between perforator vessels and clots contribute to the difficulty of complete evacuation of hematoma, and remnant hematoma constitutes the high rate of brain edema and symptomatic vasospasm most. Therefore, the outcome is comparatively poorer in this type of aneurysm than in others [2,6,7] . Strong attention is paid to this special type of aneurysmal intracranial cerebral hematoma (ICH) since Shimoda et al [8] first confirmed its etiology.…”

“…Intracranial hypertension and brain herniation are apt to happen in MCAAs patients associated with large SylH after aneurysm clipped, because of frequent postoperative vasospasm and severe secondary cerebral edema [7,18] . Thus, early prophylactic decompressive craniectomy would be useful to avoid this clinical dilemma.…”

Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage

“…Removal of an ISH is technically more difficult than that of an ICH, due to involvement of fragile pial vessels. 18,24 In our cohort of patients with ISH, subpial hematoma expanded after uneventful surgery and required repeated craniotomy in 1 case, which may be a specific complication of the ISH group. Complications related to endovascular coiling exclusively occurred in the non-ISH group.…”

“…6 Indeed, Saito et al reported that delayed postoperative brain swelling (1 week after surgery) more likely developed in patients with SAH with ISH than in patients with SAH with intraparenchymal ICH. 18 Given less initial brain damage and associated secondary brain swelling, previous studies have aimed at intervening to treat one of these pathological processes by early hematoma evacuation or external decompression and have obtained reasonable outcomes from poor-grade SAH with ISH. 2,[19][20][21] Our results also supported validity of early decompression for treatment of SAH with ISH.…”

“…Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and has distinct features. 2,18,19 Poor-grade SAH with ISH has been considered to be less associated with severe initial injury and regarded as a potential responder to intensive treatment. 2,19,20 The purpose of this study is to clarify whether the presence of ISH predicts good functional recovery from poor-grade aneurysmal SAH.…”