Introduction: Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with high Hunt & Hess (H&H) grades. The complexity and length of surgery, the risk of inducing vasospasm and the poor prognosis for high grade patients are commonly cited reasons for deferment. However, there is a paucity of literature comparing revascularization techniques to more traditional open surgical treatment. This study aims to compare outcomes in patients with high H&H grade aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular treatment who were managed with revascularization versus direct surgical clipping.
Methods: A prospective database of patients treated for aSAH with Hunt & Hess grade three and above between 2013-2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients that underwent bypass surgery versus direct clipping. All patients were reviewed by a comprehensive cerebrovascular team and recommended for open surgical treatment over endovascular therapy.
Results: There were 23 patients who underwent revascularization while 61 were treated with clipping alone. All-cause 30-day mortality rate was 16% (bypass: 15%, clipping: 16%, p=.92). There were no significant differences in outcomes as measured by the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) at discharge or last follow-up of median six months (p>.32). A significant difference in the surgical stroke rate was identified (bypass: 4/23, 17%; clipping: 2/61, 3%; p=.03). There were no differences in medical complication, seizures, rerupture or death (p>.12).
Conclusions: Bypass is a viable option for patients presenting with high H&H grade aSAH deemed unfavorable for endovascular therapy. Comparable outcomes to clipping can be achieved despite obvious differences in aneurysm complexity.
Patient Care: Consensus on management of high-grade aneurysmal subarachnoid hemorrhage remains uncertain and there has been caution in recommending aggressive management. In patients unamenable to endovascular intervention or traditional clipping, we show that intracranial bypass surgery is a viable option with favorable outcomes.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) identify the challenges of high-grade aneurysmal subarachnoid hemorrhage unnameable to endovascular treatment, 2) discuss the advantages and disadvantages of different management strategies; 3) critically evaluate the use of revascularization techniques as a viable management option.