Original ArticleBypass and Deconstructive Technique for Hunt and Hess Grade 3–5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping
Introduction
Mortality rates for patients with higher-grade aneurysmal subarachnoid hemorrhage (aSAH) remain significant despite recent advances in management.1,2 One large 2015 study reported in-hospital mortality rates of 9%, 24%, and 71% for patients with Hunt and Hess (H & H) grades 3, 4, and 5 aSAH, respectively,3 with similarly high rates reported in other works irrespective of treatment modality (surgical or endovascular).2,4, 5, 6, 7, 8, 9, 10 Despite the demonstrated importance of early aneurysm securement following higher-grade aSAH,2,7,9 treatment of patients with higher-grade hemorrhages from complex aneurysms remains challenging.
Endovascular approaches have increasingly become the first-line treatment for ruptured aneurysms following the International Subarachnoid Aneurysm Trial,11 although open surgical approaches remain relevant due to the higher recurrence risk, potential need for antiplatelet therapy, and inability to treat certain complex aneurysms with endovascular techniques (see Table 1 for a summary of complex aneurysm characteristics).12, 13, 14, 15 Recent data also suggest that the safety profile of endovascular approaches in daily clinical practice may be overestimated.16 Although most complex aneurysms requiring open surgery can be treated with primary clip reconstruction, in select cases where preservation of the parent and/or daughter vessel(s) is not possible, bypass combined with clipping or endovascular sacrifice can be employed. Although there is ample literature supporting bypass for the treatment of complex aneurysms, it is often deferred in patients with higher H & H grades due to the complexity and length of surgery, the worry of inducing vasospasm, and the poor prognosis in this patient subset.13,17,18 Accordingly, there is a paucity of data on outcomes after bypass in patients with higher H & H grade aSAH, and there are no prior studies directly comparing bypass versus clipping in this patient cohort.
The primary aim of this study is thus to investigate the safety and clinical outcomes of bypass (combined with clipping or endovascular sacrifice) for patients with higher-grade aSAH. Secondarily (acknowledging the obvious differences in aneurysm complexity between treatment groups), the outcomes of bypass versus clipping alone for higher-grade aSAH were compared.
Section snippets
Methods
This case series was conducted with ethical approval from the Institutional Review Board and in accordance with the Health Insurance Portability and Accountability Act. Informed consent was obtained for all patients. Data were collected by retrospective review of consecutive patients from a prospectively maintained single-institution, single-surgeon database over a 5-year period (2013–2018). All patients were reviewed by a comprehensive cerebrovascular team on presentation and recommended for
Results
A total of 83 patients met inclusion criteria (61 females, 22 males) with a mean age of 55.2 ± 12.8 years. Overall, 60 patients were treated with clipping alone, while 23 patients underwent bypass combined with clipping or endovascular sacrifice (Table 2). The bypass group had a higher proportion of males (P = 0.03). There were no significant differences in presenting H & H grade or Glasgow Coma Scale scores between groups (P = 0.21 and 0.40, respectively). Patient characteristics and group
Discussion
Bypass is an important and well-described treatment strategy for complex ruptured aneurysms unfavorable for endovascular or standard open approaches.17,18,20,21 Other strategies to be considered in these difficult cases include vessel wrapping or sacrifice, although they carry a risk of aneurysm regrowth, rehemorrhage, and/or stroke.22, 23, 24, 25, 26, 27 Widespread utilization of bypass in the setting of aSAH has nonetheless been limited by the technical complexity of this procedure and a lack
Conclusions
Treatment of patients with higher-grade aSAH unfavorable for endovascular intervention and traditional clipping remains challenging. Our data demonstrate that bypass (combined with clipping or endovascular sacrifice) is a viable alternative to deconstructive options, with comparable mortality and functional outcomes to clipping despite obvious differences in aneurysm complexity.
CRediT authorship contribution statement
Jordan Lam: Conceptualization, Methodology, Formal analysis, Investigation, Writing - original draft, Writing - review & editing, Visualization. Robert C. Rennert: Conceptualization, Methodology, Writing - review & editing. Kristine Ravina: Conceptualization, Methodology, Investigation, Writing - review & editing. Krista Lamorie-Foote: Conceptualization, Methodology, Investigation, Writing - review & editing. Shivani D. Rangwala: Conceptualization, Methodology, Investigation, Writing - review &
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Conflict of interest statement: Dr. Jonathan J. Russin has conducted previous work with funding from Carl Zeiss, Oberkochen, Germany. The authors have no other disclosures concerning the materials or methods used in this study or the findings specified in this paper.