The Outcomes of Surgical Treatment of Patients with Severe Aneurysmal Subarachnoid Hemorrhage

ABSTRACT. The choice of surgical treatment for patients with severe subarachnoid hemorrhage due to cerebral aneurysm (CA) rupture remains one of the key challenges in vascular neurosurgery. The widespread introduction of endovascular technology into clinical practice allowed to slightly change the paradigm of surgical treatment of ruptured cerebral aneurysms, making it possible to rapidly and practically atraumatically exclude aneurysms regardless of the initial severity in patients. However, the availability of endovascular (EV) interventions and the high cost of the procedure are limiting factors.

STUDY OBJECTIVE: to evaluate the treatment outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) of high severity (IV and V according to WFNS) depending on the method of aneurysm exclusion from the blood flow.

MATERIALS AND METHODS: From 2010 to 2020, a prospective study including two patient groups was performed: Group 1 comprised 100 patients with SAH of aneurysmal etiology who underwent endovascular occlusion of the ruptured aneurysm cavity, and Group 2 included 35 patients who underwent microsurgical clipping. All the patients were evaluated according to the accepted clinical and instrumental scales, and investigations were performed accordg to the standards of medical care.

OUTCOMES AND DISCUSSION: The patients enrolled in both study groups were comparable in terms of baseline severity. Immediate treatment outcomes were better in the endovascular group. Our study demonstrated the applicability of this statement in patients with severe aSAH. However, the effect of aneurysm exclusion procedure on patient survival during treatment has not been established. The risk of intraoperative complications in both endovascular and microsurgical groups is low, and the radicality degree of aneurysm exclusion is significantly higher in the microsurgical clipping group.

CONCLUSIONS: The EV and MC remain complementary treatment modalities for the ruptured cerebral aneurysms. When choosing the treatment method, if both procedures are available, intravascular interventions should be given priority in patients with severe aSAH, especially in the presence of sub- or decompensated somatic pathology (long history of diabetes mellitus and arterial hypertension).

1. Mitra D, Gregson B, Jayakrishnan V, Gholkar A, Vincent A, White P, Mitchell P. Treatment of poor-grade subarachnoid hemorrhage trial. AJ NR Am J Neuroradiol. 2015;36(1):116–120. https://doi.org/10.3174/ajnr.A4061

2. Bobinov V. V., Rozhchenko L. V., Goroshchenko S. A., Kolomin E. G., Petrov A. E. Immediate and long-term results of endovascular coiling of cerebral aneurysms. Polenov Neurosurgical Institute — branch of Almazov Medical Research Centre. 2022;14(2):29–36. (In Russ.) https://doi.org/10.17650/1683‑3295‑2023‑25‑2‑10‑19 EDN MMANZK.

3. Krylov V. V., Konovalov A. N., Dash’yan V.G., Kondakov E. N., Tanyashin S. V., Gorelyshev S.K. et al. Neurosurgery in Russian Federation. Burdenko’s Journal of Neurosurgery. 2017;81(1):5–12. (in Russ.) https://doi.org/10.17116/neiro20178075–12

4. Konovalov A. N., Krylov V. V., Filatov Yu.М., Eliava Sh. Sh., Belousova О. B., Tkachev V. V. et al. Recommendation protocol for management of patients with subarachnoid hemorrhage. Materials of the VI Congress of Neurosurgeons of Russia. Novosibirsk; 2012 (in Russ.)

5. Bobinov V. V., Petrov A. E., Goroshchenko S. A., Ivanova N. E., Rozhchenko L. V., Sinitsyn P. S., Ivanov A. A. Historical aspects of cerebral aneurysms surgery. Part 1. Polenov Neurosurgical Institute — branch of Almazov Medical Research Centre. 2020;12(1):5–11. (In Russ.) EDN KIJIIH.

6. Rawal S, Alcaide-Leon P, Macdonald RL, et al. Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day J Neurol Neurosurg Psychiatry 2017;88:241–248. https://doi.org/10.1136/jnnp‑2016–314596

7. Krylov V. V., Godkov I. M ., Dmitriev A. Y. Intraoperative risk factors in the surgery of cerebral aneurysms. Materials of the city scientific and practical conference. Moscow: N. V. Sklifosovsky Research Institute for Emergency Medicine; 2007;200:16–22. (In Russ.) https://doi.org/10.35401/2500‑0268‑2022‑25‑1‑19‑26

8. Catapano JS, Nguyen CL, Frisoli FA, Sagar S, Baranoski JF, Cole TS, Labib MA, Whiting AC, Ducruet AF, Albuquerque FC, Lawton MT. Small intracranial aneurysms in the Barrow Ruptured Aneurysm Trial (BRA T). Acta Neurochir (Wien). 2021;163(1):123–129. https://doi.org/10.1007/s00701‑020‑04602‑4

9. Hua X, Gray A, Wolstenholme J, Clarke P, Molyneux AJ, Kerr RSC, Clarke A, Sneade M, Rivero-Arias O. Survival, Dependency, and Health-Related Quality of Life in Patients With Ruptured Intracranial Aneurysm: 10-Year Follow-up of the United Kingdom Cohort of the International Subarachnoid Aneurysm Trial. Neurosurgery. 2021;88(2):252–260. https://doi.org/10.1093/neuros/nyaa454

10. Darsaut TE, Keough MB, Sagga A, Chan VKY, Diouf A, Boisseau W, Magro E, Kotowski M, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Bilocq A, Estrade L, Lejeune JP , Bricout N, Scholtes F, Martin D, Otto B, Findlay JM , Chow MM , O’Kelly CJ, Ashforth RA, Rempel JL , Lesiuk H, Sinclair J, Altschul DJ , Arikan F, Guilbert F, Chagnon M, Farzin B, Gevry G, Raymond J. Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison. World Neurosurg. 2021;149: e521-e534. https://doi.org/10.1016/j.wneu.2021.01.142

11. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809–817. https://doi.org/10.1016/S 0140–6736 (05) 67214‑5

12. Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RS. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet. 2015;385(9969):691–697. https://doi.org/10.1016/S 0140–6736 (14) 60975‑2

13. Mascitelli JR, Cole T, Yoon S, Nakaji P, Albuquerque FC, McDougall CG, et al. External validation of the Subarachnoid Hemorrhage International Trialists (SAHIT) predictive model using the Barrow Ruptured Aneurysm Trial (BRA T) cohort. Neurosurgery. 2020;86(1):101–106. https://doi.org/10.1093/neuros/nyy600

14. Spetzler, Robert & McDougall, Cameron & Albuquerque, Felipe & Zabramski, Joseph & Hills, Nancy & Partovi, Shahram & Nakaji, Peter & Wallace, Robert. (2013). The Barrow Ruptured Aneurysm Trial: 3-year results. Journal of neurosurgery. 119. https://doi.org/10.3171/2013.3

15. Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, Partovi S, Nakaji P, Wallace RC. The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg. 2015;123(3):609–617. https://doi.org/10.3171/2014.9.JNS 141749

16. Shetova IM, Shtadler VD, Aronov MS, Piradov MA, Krylov VV. Long-term results of surgical treatment of patients with cerebral arterial aneurysms. S. S. Korsakov Journal of Neurology and Psychiatry = Zhurnal nevrologii i psikhiatrii imeni S. S. Korsakova. 2023;123(3):41–49. (In R uss.). https://doi.org/10.17116/jnevro202312303241

17. Dual antiplatelet therapy after intracranial stents implantation for cerebral aneurysms. Vyazgina E. M., Ivanova N. E., Ivanov A. Yu., Petrov A. E., Rozhchenko L. V., Blagorazumova G. P., Goroschenko S. A., Bobinov V. V., Ivanov A. A., Sinitsyn P. S. (in Russ.)

18. Grasso G., Perra G. Surgical management of ruptured small cerebral aneurysm: outcome and surgical notes. Surg Neurol Int 2015;6:185. https://doi.org/10.4103/2152–7806.171257

19. Kumar G, Dumitrascu OM, Chiang CC, O’Carroll CB, Alexandrov AV. Prediction of delayed cerebral ischemia with cerebral angiography: a meta-analysis. Neurocrit Care.2018;30:62–71. https://doi.org/10.1007/s12028‑018‑0572‑2

20. Crowley RW, Medel R, Dumont AS, Ilodigwe D, Kassell NF, Mayer SA, et al. Angiographic vasospasm is strongly correlated with cerebral infarction after subarachnoid hemorrhage. Stroke. 2011;42(4):919–923. https://doi.org/10.1161/STROKEAHA.110.597005

21. Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res. 2021;12(3):428–446. https://doi.org/10.1007/s12975‑020‑00867‑0 Epub 2020 Oct 19.

22. Shetova I. M., Shtadler V. D., Matveev P. D. Surgical treatment of cerebral aneurysms in the acute period of subarachnoid hemorrhage: long-term result. Neotlozhnaya meditsinskaya pomoshch’. Zhurnal im. N. V. Sklifosovskogo. 2021;10(2):328–336. (In Russ.) https://doi.org/10.23934/2223‑9022‑2021‑10‑2‑328‑336

23. Bobinov V. V., Rozhchenko L. V., Petrov A. E., Goroshchenko S. A., Kolomin E. G., Samochernikh N. K., Tukanov N. Yu., Samochernikh K. A. Early and long-term results of endovascular treatment of cerebral aneurysms. Russian journal of neurosurgery. 2023;25(2):10–19. (In Russ.) https://doi.org/10.17650/1683‑3295‑2023‑25‑2‑10‑19 EDN JTKNWY.