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Objective: Sylvian subpial hematoma (SSH) is occasionally observed in aneurysm subarachnoid hemorrhage (aSAH) when accompanied with the thick clot in the inferior limiting sulcus (ILS). We aimed to determine whether the thickness of the clot in the ILS (TCILS) was an indicator of SSH., Methods: Data from 150 consecutive patients with aSAH were retrospectively analyzed. The relationship between TCILS on axial computed tomography (CT) image and intraoperatively confirmed SSH was reviewed. In patients without SSH, the average of the clot thickness in the bilateral ILS was used. The primary outcome was SSH., Results: The median TCILS of the SSH group (n = 18, 12%) was larger than that of the non-SSH group (n = 132, 88%) (21 vs. 2.1 mm, respectively; P < 0.001). The intraclass correlation coefficients for clot thickness in the right and left ILS between 2 observers were 0.97 (P < 0.001) and 0.85 (P < 0.001). The TCILS threshold of ≥6.0 mm was associated with SSH, with a sensitivity of 89% and specificity of 99%. The unadjusted and adjusted odds ratios of the SSH of clot thickness in the affected ILS ≥6 mm relative to clot thickness in the affected ILS <6 mm were 263 (95% confidence interval [CI], 46-5063) and 137 (95% CI, 19-3029), respectively., Conclusions: The clot thickness in the ILS on CT image was easily measured and could be a marker of SSH. SSH assessment could be useful in helping us predict the clinical course in patients with aSAH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

OBJECTIVE Only a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs. METHODS Data from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models. RESULTS The patients' median age was 64 years (interquartile range [IQR] 56-71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%-0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%-0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0-255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1-215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months. CONCLUSIONS In this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.

Background: A subarachnoid clot is the strongest predictor of cerebral vasospasm. Our purpose was to analyze the relationship between the number of postoperative cisternal clots and cerebral vasospasm and to assess the efficacy of surgical clot removal., Methods: The subjects were 158 patients with aneurysmal subarachnoid hemorrhage. All patients underwent clipping with cisternal clot removal. The preoperative and postoperative number of clots was analyzed semiquantitatively using computed tomography, and cerebral vasospasm and its severity were analyzed using magnetic resonance angiography in a blind fashion. Factors related to cerebral vasospasm and poor outcome were analyzed retrospectively. Poor outcome was defined as modified Rankin Scale (mRS) score of 3 or greater., Results: Symptomatic cerebral vasospasm (SCV) was observed in 6 patients (3.8%). Angiographic vasospasm (AVS) was observed in 38 patients (24.1%). One year after the operation, 82.9% of patients had an mRS score of 0-2. The postoperative number of clots was significantly (P < 0.005) related to SCV (adjusted odds ratio [OR], 6.447; 95% confidence interval [CI], 2.063-20.146), AVS (OR, 2.634; 95% CI, 1.467-4.728), and poor outcome (OR, 2.103; 95% CI, 1.104-4.007). Poor outcome was also related to age over 65 (OR, 6.658; 95% CI, 2.389-18.559) and World Federation of Neurosurgical Societies scale grade (OR, 1.732; 95% CI, 1.248-2.403)., Conclusions: Surgically removing as many clots as possible in the acute stage can decrease SCV and reduce AVS severity. Irrigation should be performed on all approachable cisterns., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Symptomatic cerebral vasospasm (SCV) is the second most common of morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH) after rebleeding. Blood breakdown products are one of the leading causes of vasospasm. We hypothesized that meticulous subarachnoid clot removal in addition to continuous low-dose intravenous nicardipine (CLIN) could reduce the incidence of SCV., Methods: SCV was defined as new focal neurologic signs, consciousness deterioration, or both when the cause was believed to be ischemia attributable to vasospasm after other possible causes of worsening were excluded. Initial brain damage was defined as continued consciousness disturbance after clipping without acute hydrocephalus, ischemic lesions, or focal sign before clipping. Poor outcome was defined as a Glasgow Outcome Scale score of 3-5 at 30 days. We compared the variables for 460 aSAH patients with and without SCV, and with and without poor outcome by multivariate analysis., Results: All patients underwent clipping with meticulous irrigation for clot removal, and SCV was observed in 56 patients (12%). SCV was observed in 2 patients (2.9%) among 70 patients treated with CLIN. There was a higher proportion of patients who were older than 65 years (P = 0.032) and female (P = 0.038), and a lower proportion of patients with CLIN (P = 0.026) among patients with SCV. The outcomes for 109 patients (27%) were poor; age greater than 65 years (P < 0.0001) and initial brain damage (P = 0.008) were related to the poor outcomes., Conclusions: The present study showed that meticulous irrigation for clot removal and CLIN might reduce the incidence of SCV in patients with aSAH., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Patients with spontaneous intradural vertebral artery dissection (siVAD) developing subarachnoid hemorrhage (SAH) have been observed to have poor outcomes. Factors predisposing siVAD patients to SAH are not well known. We aimed to investigate the clinical and vertebrobasilar artery morphological characteristics associated with SAH in patients with siVAD., Methods: We reviewed 103 consecutive patients with siVAD managed at our facility between July 2003 and June 2012. We divided the patients into groups, with (n = 22) and without (n = 81) SAH, and compared clinical and vertebrobasilar artery morphological characteristics between them. The vertebral-union-basilar angle (VUBA) was defined as the most acute angle between the line of the basilar artery trunk and the line of the vertebral artery at the vertebral union on 3-dimensional magnetic resonance angiography, computed tomographic angiography, or digital subtraction angiography. 'Steep vertebral artery' was defined as VUBA >45°. Basilar artery bending was defined as the longest distance from the line which connected the basilar top and vertebral artery union to the greatest bending point of the basilar artery., Results: Stepwise logistic regression analysis was performed using variables that were marginally or significantly associated with SAH on univariate analysis (p < 0.10) and that were thought to be clinically important for SAH. It showed SAH patients to have significantly higher proportions of current smoking (OR: 7.7; 95% CI: 2.7-22; p = 0.0015), dissection of the dominant vertebral artery (OR: 4.9; 95% CI: 1.8-13; p = 0.043), steep vertebral artery of the dissecting side (OR: 7.2; 95% CI: 2.6-20; p = 0.0023), posterior inferior cerebellar artery involvement (OR: 4.0; 95% CI: 1.3-13; p = 0.011), basilar artery bending <3 mm (OR: 3.4; 95% CI: 1.3-9.5; p = 0.0040), and pearl-and-string sign (OR: 5.7; 95% CI: 2.0-16; p = 0.0033)., Conclusions: We suggest that the clinical and vertebrobasilar artery morphological characteristics demonstrated in the present study may be related to SAH induced by siVAD. Although all patients with siVAD should be closely monitored, those with siVAD who have these characteristics should perhaps be more closely followed than those who do not have such features., (Copyright © 2012 S. Karger AG, Basel.)

Object: It is well known that spontaneous intradural vertebral artery dissection (siVAD) is an important cause of nontraumatic subarachnoid hemorrhage (SAH). The factors that influence whether SAH develops, however, remain unclear. The aim of this study was to investigate whether clinical characteristics and imaging findings are different in patients with siVAD with SAH compared to those with siVAD without SAH., Methods: The authors conducted a retrospective, single-institution study involving patients in whom siVAD developed with or without SAH, between July 2003 and November 2010. Univariate and multivariate analyses were performed to evaluate clinical characteristics and MR angiography findings. The vertebral-union-basilar angle (VUBA) was defined as the most acute angle between line of the basilar artery trunk and line of the vertebral angle (VA) at the vertebral union on 3D MR angiograms., Results: Among 58 patients with siVAD, 21 developed SAH. The presence of siVAD and SAH was significantly associated with higher rates of current smoking (OR 13; 95% CI 3.6-38; p < 0.0001), dissection of the dominant VA (OR 9.2; 95% CI 2.5-19; p = 0.0004), and unruptured supratentorial nondissecting saccular aneurysms (OR 11; 95% CI 2.1-19; p = 0.0025), and the VUBA of the dominant VA was significantly larger (p < 0.0001, univariate analysis). Multivariate analysis showed that these differences were still significant (p < 0.05)., Conclusions: A larger VUBA of the dominant VA, the presence of unruptured supratentorial nondissecting saccular aneurysms, and current smoking may be factors that predict which patients with siVAD will develop SAH by dominant VAD.