Clearance of Subarachnoid Clots after GDC Embolization for Acutely Ruptured Cerebral Aneurysm. Comparison with Early Direct Surgery

Abstract

It is apparent that subarachnoid clots play an important role in the development of delayed vasospasm that is one of the major causes of mortality and morbidity in patients with acutely ruptured cerebral aneurysm. The purpose of this study is to compare the clearance of subarachnoid clots in the acute stage after the treatment with Guglielmi detachable coils (GDC) and after treatment with direct surgery. Forty-nine patients were treated by GDC embolization within four days of the ictus. After GDC embolization, adjunctive therapies, such as ventricular and/or spinal drainage (67%), intrathecal administration of urokinase (41%), continuous cisternal irrigation (16%), and external decompression (16%), were performed. Seventy-four surgically treated patients were subsequently treated by continuous cisternal irrigation with mock-CSF containing ascorbic acid for ten days. The clearance of subarachnoid clots was assessed by the Hounsfield number serial changes on the CT scans taken on days 0, 4, 7, 10 after subarachnoid hemorrhage. The incidence of symptomatic vasospasm was lower in the GDC group (6%) than in the surgery group (12%). The clearance of subarachnoid clots from both the basal cistern and the Sylvian fissure was more rapid in the GDC cases than in the surgery cases in the first four days. Intrathecal administration of urokinase accelerated the clearance significantly. GDC embolization followed by intrathecal administration of thrombolytic agents accelerates the reduction of subarachnoid clots and favorably acts to prevent delayed vasospasm.

Figure 1

Serial CT scans of a representative case treated with GDC embolization.

Figure 2

Serial changes in the Hounsfield number of the basal cistern (left) and the Sylvian fissure (right) in the GDC-treated group and the surgically-treated group.

Figure 3

Serial changes in the Hounsfield number of the basal cistern (left) and the Sylvian fissure (right) in the GDC-treated group with or without intrathecal administration of urokinase (UK) and in the surgically-treated group.