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Background: A reliable method to specifically identify low vasospasm risk in aneurysmal subarachnoid hemorrhage (aSAH) patients has not been previously proposed., Objective: To develop a clinical algorithm using admission aSAH clinical severity and subarachnoid blood distribution to identify patients at low risk of clinical vasospasm., Methods: Clinical severities, admission noncontrasted head computerized tomography (CT) scan, and incidences of vasospasm among 291 aSAH patients treated at our institution were evaluated. Admission head CTs were assessed for distributions of cisternal and ventricular blood. Patients with the following 4 criteria experienced considerably lower risk of vasospasm: (1) Hunt Hess grade 1 to 2, (2) Lack of thick subarachnoid blood filling 2 adjacent cisterns, (3) Lack of thick interhemispheric blood, and (4) Lack of biventricular intraventricular hemorrhage., Results: One hundred thirty-three patients (45.7%) developed cerebral vasospasm. Hunt Hess grade greater than 2 (odds ratio [OR] 4.52, 95% confidence interval [CI] 2.74-7.46), adjacent cistern blood (OR 4.1, 95% CI 2.51-6.7), interhemispheric thick blood (OR 5.72, 95% CI 3.41-9.59), and biventricular intraventricular hemorrhage (OR 1.92, 95% CI 1.19-3.02) were significant risk factors. Application of our algorithm yielded a sensitivity of 29%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 54.5%, which was superior compared to metrics from current institutional practice criteria. Inter-rater agreement was substantial at mean kappa = 0.75., Conclusion: Application of our novel clinical algorithm produced successful identification of aSAH patients who experience zero risk of clinical vasospasm. Our algorithm is simple to apply with high reliability and is superior to currently available clinical and radiographic metrics.

Background: No randomized controlled trial has successfully compared outcomes between endovascular coiling and microsurgical clipping for unruptured intracranial aneurysms (UIAs)., Objective: To perform a cost comparison between index hospitalizations of patients with UIAs treated with coil embolization or surgical clipping to identify the current primary drivers of costs of either management approach., Methods: We obtained index hospitalization costs for 125 cases of UIAs treated with coiling or clipping from 2010 to 2012 at our institution. Comparisons were stratified based on patient age, gender, aneurysm size, and aneurysm location. Using linear regressions, we identified clinical parameters that drive total hospital costs., Results: 69 cases were treated with clipping and 56 cases were treated with coiling. Morbidity and length of stay for patients treated with clipping was higher. Total hospital costs and variable direct costs for clipping were significantly lower than for coiling (p=0.003, p<0.001, respectively). Fixed direct costs and fixed indirect costs for clipping were higher than for coiling (p<0.001, p<0.001, respectively). Variable direct costs comprised 50.5% and 68.6% of total hospital costs for clipping and coiling, respectively (p<0.001). Length of stay, aneurysm size, and patient age drove total hospital costs for clipping. Length of stay was a weak driver of total hospital costs for coiling., Conclusions: Total index hospitalization costs for clipping are lower than for coiling. Costs of clipping and coiling are driven by different clinical variables. The cost of coils and devices is the predominant contributor to the higher total costs of coiling., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Typically occurring between 3 days and 3 weeks post-hemorrhage, cerebral vasospasm in the acute stage after aneurysmal subarachnoid hemorrhage is a major contributor to the morbidity and mortality associated with patient outcomes, despite advances in aneurysm treatment and vasospasm management. Though incompletely understood, cerebral vasospasm is well described in the immediate post-hemorrhage patient. Less detailed descriptions exist of delayed or progressive restenosis after aneurysmal subarachnoid hemorrhage and resultant vasospasm. We report a case of delayed progressive supraclinoid internal carotid artery restenosis treated with angioplasty 10 weeks after initial hemorrhage.

Background and Objectives: Traumatic intracranial aneurysms (TICAs) are highly unstable lesions that may rupture within minutes after formation or remain quiescent for several weeks and manifest with delayed hemorrhage and neurologic deterioration. Mortality following a rupture may be 30% to 40%. Among all cerebral aneurysms, the incidence of TICAs is less than 1%; 20% to 30% of TICAs occur in children., Methods and Materials: A child with a low-caliber craniocerebral gunshot wound deteriorated neurologically 12 days after the initial injury and emergency evacuation of an intracranial hematoma. A new massive left frontal hematoma was discovered, caused by the rupture of an unsuspected left pericallosal artery pseudoaneurysm. The new hematoma was evacuated, and the aneurysm was trapped using microsurgical techniques., Results And/or Conclusions: A high index of suspicion should be maintained for delayed pseudoaneurysm genesis and rupture. A cerebral arteriogram should be obtained when significant subarachnoid hemorrhage or intraparenchymal hematomas are present, when missiles traverse major arteries, or when the pterional or cranioorbitofacial regions are violated. Treatment should be prompt.