Aneurysmal subarachnoid hemorrhage: posterior communicating artery aneurysms and long-term excess mortality

Tutkimustuotos: OpinnäyteVäitöskirjaArtikkelikokoelma

Abstrakti

Introduction. Aneurysmal subarachnoid hemorrhage (aSAH) is a serious form of stroke, caused by a ruptured intracranial aneurysm, that often strikes at the working age. The origin of the posterior communicating artery (PComA) is one of the most common locations for ruptured aneurysms causing aSAH. There are specific features related to the risk of rupture, severity of bleeding and occlusive treatment of PComA aneurysms, identified in few previous studies. It has been believed that after successful rehabilitation aSAH patients should have a similar life-expectancy to that of the general population. However, lately there have been indications of excess mortality in the long run, at least among some aSAH patient groups. The aims of this work are 1) to identify the morphological features related to PComA aneurysms and their rupture, 2) to study the treatment and outcome after PComA aneurysm rupture and aSAH, 3) to discover if there is long-term excess mortality after aSAH compared to the general population. Patients and Methods. Each publication includes a subgroup of 7289 patients with intracranial aneurysms treated in Helsinki University Hospital between 1980 and 2014. The computed tomography angiography analysis on PComA aneurysm morphology was based on images of 391 PComA aneurysm patients; the treatment and outcome was evaluated in 620 patients with ruptured PComA aneurysm and long-term excess mortality was evaluated after long-term follow-up of 3078 aSAH one-year survivors. Results. The most marked morphological features of the PComA aneurysms were saccular nature (99%), inferoposterior dome orientation (42%), infrequency of large or giant aneurysms (4%), narrow neck compared to the aneurysm size, PComA originating directly from the aneurysm neck or the dome (28%), and fetal or dominant PComA on the side of the aneurysm (35%). A significant proportion (38%) of PComA aneurysms ruptured at small sizes (<7mm), and there were location-related parameters that were associated with rupture, highest odds of rupture related to irregular aneurysm dome. Most of the patients made a good recovery at 1 year after PComA aneurysm rupture and aSAH (62%). A small proportion of patients were left severely disabled (4%). Of all, 20% died during the first year. The risk factors for impaired outcome were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65, artery occlusion in postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm and hydrocephalus requiring a shunt. There was long-term excess mortality after aSAH compared to matched general population even among young patients and patients who recovered well initially. The highest excess mortality was among patients with multiple aneurysms, old age, poor preoperative clinical condition, conservative aneurysm treatment, and unfavorable clinical outcome at 1 year. Conclusions. PComA aneurysms rupture also at small sizes, and there are location-related morphological parameters associated with the rupture: irregularity of the aneurysm dome, wider aneurysm neck and aspect ratio >1.5. Even though most treated aSAH patients recover well after PComA aneurysm rupture, there are occlusive treatment-related complications like artery occlusions and treatment-related brain infarctions causing impaired outcome irrespective of the treatment method. PComA aneurysms may have been seen as fairly uncomplicated lesions, but occlusive treatment of a ruptured PComA aneurysm seems to be a high-risk procedure even in a high-volume neurosurgical center. Some of the complications can possibly be avoided as the variety of treatment modalities increases. There is excess mortality after aSAH among patients with all aneurysm locations in a long-term follow-up. Cardiovascular events at younger ages and cerebrovascular causes were overrepresented as causes of death. Treatment of vascular risk factors is important after aSAH. Certain patient groups require long-term follow-up.
Alkuperäiskielienglanti
Valvoja/neuvonantaja
  • Lehecka, Martin, Valvoja
  • Kivisaari, Riku, Valvoja
Myöntöpäivämäärä18 toukok. 2018
JulkaisupaikkaHelsinki
Kustantaja
Painoksen ISBN978-951-51-4229-0
Sähköinen ISBN978-951-51-4230-6
TilaJulkaistu - 2018
OKM-julkaisutyyppiG5 Tohtorinväitöskirja (artikkeli)

Lisätietoja

M1 - 129 s. + liitteet

Tieteenalat

  • 3126 Kirurgia, anestesiologia, tehohoito, radiologia

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