Improved outcome in high-grade aneurysmal subarachnoid hemorrhage by enhancement of endogenous clearance of cisternal blood clots: A prospective study that demonstrates the role of lamina terminalis fenestration combined with modern microsurgical cisternal blood evacuation

Abstract

Introduction: Cisternal and ventricular blood predisposes to hydrocephalus and cerebral ischemia after high-grade aneurysmal subarachnoid hemorrhage (HGSAH). We studied the role of lamina terminalis fenestration combined with cisternal blood evacuation in HGSAH.

Patients/Materials and Methods: A clinical, prospective, non-randomized study of a series of HGSAH patients (Modified Fisher ≥3) treated in the acute phase was carried out. The microsurgical treatment included aneurysm clipping, cisternal blood evacuation, and fenestration of the lamina terminalis. A comparable, non-blood-cleansed, endovascular-treated group, was included as a control. Clinical results were evaluated by the Glasgow Outcome Scale (GOS).

Results: During a period of 30 months, 95 patients who met the selection criteria were treated by microsurgical procedures and 28 by endovascular procedures. The distribution of GOS scores was superior for the microsurgical group: good results (GOS 4-5) were obtained in 85.3%, with a mortality rate of 5.9%. By contrast, 60.3% of patients in the endovascular group achieved GOS 4-5 scores, and 15.8% died. Good results for the endovascular group correlated inversely with delay of treatment. A permanent ventriculo-peritoneal shunt was necessary in 3.2% and 7.1% of the microsurgical and endovascular groups, respectively. The incidence of cerebral infarct was 3.1% and 14.3% for the microsurgical and endovascular groups, respectively.

Discussion: Microsurgical management reduces the usually poor outcome of patients with HGSAH. Lamina terminalis fenestration diminishes the incidence of shunt-dependent hydrocephalus and, combined with extensive cisternal blood cleansing, can lower the incidence of stroke. A procedure for cleansing blood and clots from the cisterns in HGSAH, based on the pathophysiology of vasospasm, is proposed.