Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: The CARAT study

Department of Neurology, University of California San Francisco, San Francisco, CA 94143-0114, USA.
Stroke (Impact Factor: 5.72). 06/2008; 39(5):1501-6. DOI: 10.1161/STROKEAHA.107.504670
Source: PubMed


Intraprocedural rupture (IPR) is a well known complication of intracranial aneurysm treatment. Risks and predictors of IPR and its impact on outcome have not been clearly established.
Potential predictors of IPR were evaluated in patients treated in the Cerebral Aneurysm Rerupture After Treatment (CARAT) study using multivariate logistic regression with stepwise elimination stratified by treatment modality. Periprocedural death or disability was defined as death or a change of >or=2 points on the Modified Rankin Scale at discharge compared to before treatment.
IPR occurred in 14.6% of 1010 patients (299 coiled, 711 clipped): 19% with clipping and 5% with coiling (P<0.001). Among those clipped, 31% with IPR had periprocedural death or disability compared to 18% without IPR (P=0.001); among those coiled, 63% with IPR had periprocedural death or disability compared to 15% without IPR (P<0.001). Overall, coronary artery disease and initial lower Hunt and Hess Grade were independent predictors of IPR. For those undergoing coiling, independent predictors of IPR were Asian race, black race, COPD, and lower initial Hunt and Hess Grade. Among those undergoing clipping, hyperlipidemia and lower initial Hunt and Hess Grade were both independent predictors of IPR.
IPR was common in patients undergoing treatment of ruptured aneurysms, particularly with surgical clipping. The frequency of IPR with new disability was similar in the surgical and endovascular treatment groups. Coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess Grade were associated with greater risk of IPR, which may reflect differences in vessel fragility but requires further confirmation.

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Available from: Steven L Giannotta, Feb 05, 2015
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    • "A possible explanation is that vessel wall strength may be altered in the presence of this disease. In addition, the presence of associated risk factors such as smoking and hypertension can also alter vessel wall fragility [9]. Preoperative assessment should include thorough evaluation of CAD and associated risk factors, as these comorbidities carry high risk for both cardiac events and cerebrovascular catastrophe. "
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    ABSTRACT: Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
    Anesthesiology Research and Practice 03/2014; 2014:595837. DOI:10.1155/2014/595837
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    • "The intraprocedural rupture (IPAR) mainly depends upon vessel wall fragility which in turn may be modified by the several comorbidities including coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess grade (Table 1) [38]. "
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    ABSTRACT: Background: Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. Method: We have performed a PubMed search (1 January 1991-31 December 2012) using search terms including "cerebral aneurysm," "intracranial aneurysm," and "intraoperative/perioperative rupture." Results: Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. Conclusion: We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.
    The Scientific World Journal 11/2013; 2013:396404. DOI:10.1155/2013/396404 · 1.73 Impact Factor
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    ABSTRACT: It is a preliminary report on our ongoing prospective, randomized, controlled study to find the efficacy of intraoperative mild hypothermia in improving neurological outcome after intracranial aneurysm clipping. Materials and Methods: Seventy patients were randomly divided into mild hypothermia - 'H' (34.5 - 33.0 °C) or normothermia -'N' (36.0 - 37.5 °C) group. Preoperative SAH grades of all the patients were assessed. Balanced general anaesthetic technique was used. Continuous monitoring of ECG, IBP, CVP, SaO2, EtCO2, oesophageal temperature and urine output were carried out in all the patients. Intraoperative complications, frequency and duration of temporary clipping were recorded. In the hypothermic group, rewarming was started at 34.0 °C or soon after permanent aneurysm clipping. Postoperatively, patients were followed up till their discharge from hospital. During discharge, all the patients were assessed with Glasgow Outcome Scale (GOS). Results: Twenty-three (H=11; N=12) patients were excluded from the study, as we could not achieve the target temperature at the time of aneurysm clipping. Hence, the data of only 47 patients (H=24; N=23) were analysed. Demographic data were comparable in both the groups. Brain was tense more often in normothermic patients (6 Vs 3). Frequency (H=16/24; N=19/23) and duration of temporary clipping (8.68 ± 8.08 Vs 13.64 ± 11.66 min.) were more in normothermic patients. Temperature at permanent clipping was 33.81 ± 0.55 °C (H) and 36.47 ± 0.47 °C (N). Intraoperative aneurysm rupture (H=1; N= 2) and blood loss (H=350 ± 50; N=375 ± 50 mls.) were comparable in both the groups. More number of patients remained intubated on account of delayed recovery from anaesthesia in the hypothermie group (9 Vs 5). But, the requirement of postoperative ventilation for 24 hours or more was equal (3 patients in each group). The incidence of major postoperative complications was comparable among the groups. Neurological recovery was better in hypothermic patients (GOS grade V in 66% Vs 47%). Conclusion: Intraoperative mild hypothermia seems to improve neurological recovery in patients undergoing intracranial aneurysm clipping.
    Journal of Anaesthesiology Clinical Pharmacology 01/2006; 22(1):21-28.
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