Prevention of Vasospasm by Early Operation with Removal of Subarachnoid Blood

Abstract

Sixty-four patients who were operated on within 4 days after acute subarachnoid hemorrhage are included in this study. All patients underwent preoperative computed tomographic (CT) scanning, and the amount and distribution of subarachnoid blood clot were noted. Operation was carried out by the frontobasal lateral approach, and the subarachnoid clot was removed by microsurgical suction-irrigation after clipping of the aneurysm. Immediate postoperative CT scanning was performed to evaluate the completeness of the subarachnoid blood clot removal. The presence or absence of postoperative vasospasm was determined with angiography performed between the 7th and 10th postoperative days. All patients were, of course, also evaluated for evidence of neurological deterioration. Approximately two-thirds of the patients in this series showed high density subarachnoid blood clot on the preoperative CT scan. The postoperative CT scans showed that it was possible to remove the majority of the blood clot except that located in the frontal interhemispheric fissure, the posterior part of the insular cistern on the approached side, and all of the insular cistern on the contralateral side. There was no spasm or only mild spasm in any site where the blood clot had been successfully removed. Delayed neurological deficits occurred only in those cases in which subarachnoid blood clot remained in the cisterns. These results suggest that it is possible to prevent intracranial arterial spasm and associated neurological deterioration by early operation and removal of clotted blood from the subarachnoid space.

Occurrence and impact of delayed cerebral ischemia after coiling and after clipping in the International Subarachnoid Aneurysm Trial (ISAT)

“…Expert opinions differ largely. Some authors describe that during neurosurgical clipping, the blood clot (and thereby spasmogenic agents) can be removed from the subarachnoid space, which would diminish the risk of symptomatic vasospasm and DCI [6, 7]. Others believe that manipulation of the brain and abluminal vessel walls during surgery increases the risk of vasospasm and DCI [8], when compared to the risk of DCI after coiling.…”

Does Treatment Modality of Intracranial Ruptured Aneurysms Influence the Incidence of Cerebral Vasospasm and Clinical Outcome?

“…Although the effect of treatment used for the aneurysm on the incidence of cerebral vasospasm and consequent delayed ischemic neurologic deficit is largely unknown, previous reports have suggested that vasospasm might be prevented by clot removal within 48–72 h of SAH [9, 10, 11, 12, 13]. Furthermore, the irrigation of the cisterns by the same way has been reported to produce some success in preventing cerebral vasospasm [11, 12, 13, 14, 15, 16]. Whereas partial or complete removal of subarachnoid blood is possible during early aneurysm surgery, this procedure cannot be used in aneurysms treated with endovascular techniques [17, 18].…”

Prognostic factors for cerebral infraction and outcome in patients with intracranial aneurysm

“…Although there are studies where the results have failed to prove the efficacy of clot removal,some authors have demonstrated its role in vasospasm reduction, while others have suggested that its benefits could likely be overlapped by secondary cerebral lesions caused by brain retraction or a higher incidence of vasospasm triggered by vessel manipulation during surgery …”