J Cerebrovasc Endovasc Neurosurg.  2017 Jun;19(2):81-91. 10.7461/jcen.2017.19.2.81.

A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase

Affiliations
  • 1Department of Neuroradiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
  • 2Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea. tgkim@chamc.co.kr
  • 3Department of Neurosurgery, Seoul Medical Center, Seoul, Korea.

Abstract


OBJECTIVE
Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase.
MATERIALS AND METHODS
We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%).
RESULTS
In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality.
CONCLUSION
If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms.

Keyword

Endovascular coil embolization; Intracerebral hemorrhage; Intrasylvian hemorrhage; Ruptured cerebral aneurysm; Stereotactic aspiration of hematoma

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Brain
Cerebral Hemorrhage
Craniotomy
Embolization, Therapeutic*
Hematoma*
Hemorrhage
Humans
Intracranial Aneurysm*
Middle Cerebral Artery
Mortality
Neurosurgeons
Retrospective Studies
Urokinase-Type Plasminogen Activator*
Urokinase-Type Plasminogen Activator

Figure

  • Fig. 1 A 41-year-old female patient with ruptured right MCA aneurysm. (A) Brain CT scan revealed a diffuse subarachnoid hemorrhage and a large ICH and ISH in the right perisylvian area, with an estimated volume of 55 mL. (B) brain CTA and DSA revealed a 5 mm ruptured right-MCA aneurysm. (C–F) She underwent endovascular coil embolization using 6 coils (C: preoperative, D: postoperative), which was followed by SRH using urokinase (E: postoperative, F: postoperative 14 days). MCA = middle cerebral artery; CT = computed tomography; ICH = intracerebral hemorrhage; ISH = intrasylvian hemorrhage; CTA = CT angiography; DSA = digital subtraction angiography.

  • Fig. 2 A 39-year-old female patient with ruptured right IC-ophthalmic aneurysm. (A) Brain CT scan revealed a diffuse IVH, and a large ICH in the left prefrontal area with an estimated volume of 56 mL. (B) Brain CTA and DSA revealed a 12 mm ruptured right-IC-Ophthalmic aneurysm. (C–E) She underwent endovascular coil embolization using 7 coils (C: preoperative, D: postoperative), which was followed by SRH and EVD (E: postoperative). (F) Seven days later, a brain CT scan revealed a significant decrease in ICH and IVH. CT = computed tomography; IVH = intraventricular hemorrhage; ICH = intracerebral hemorrhage; CTA = CT angiography; DSA = digital subtraction angiography; SRH = stereotactic aspiration of hematomas; EVD = extra-ventricular drainage.


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