Introduction: Craniotomy for hematoma evacuation and aneurysm clipping is the treatment modality of choice for ruptured middle cerebral artery (MCA) aneurysms with intracranial hematomas (Figure 1). Recent literature suggests that endovascular coil embolization followed by hematoma evacuation can be an acceptable alternative.
Methods: The records of 49 patients with ruptured MCA aneurysms with large intracranial hematomas treated with hematoma evacuation and aneurysm clipping between January 2000 and December 2013 were retrospectively reviewed.
Results: Within this cohort, 35 (71.4%) patients were Hunt and Hess grade IV or V on presentation. The mean hematoma volume was 100.4±77.2 cc. Craniectomy was performed in 40 (81.6%) patients. Angiographic vasospasm developed in 15 (30.6%) patients. The in-hospital mortality rate was 28.6% (14 patients). At 25.3±34.0 months mean follow-up, a good outcome (modified Rankin Scale [mRS] 0-3) was observed in 18 patients (36.7%). Significant factors associated with poor outcome or death (mRS 4-6) included increasing age (P < .01), increasing Hunt and Hess grade (P = .03), increasing modified Fisher grade (P = .01), presence of IVH (P < .01), decreasing percent hematoma evacuation (P < .05), need for craniectomy (P <. 01), need for external ventricular drainage (P = .04), and angiographic vasospasm (P = .02).
Conclusions: MCA aneurysm rupture with concomitant large intraparenchymal or Sylvian fissure hematoma formation carries a grave prognosis. Simultaneous hematoma evacuation and aneurysm clipping with or without craniectomy can be an effective treatment modality.
Patient Care: Ruptured MCA aneurysms with associated large intracranial hematomas carry a grave prognosis, with mortality rates exceeding 80% in patients who undergo non-operative management. Urgent hematoma evacuation and aneurysm clipping has been the mainstay of neurosurgical treatment, with long-term functional neurological outcomes directly relating to presenting Hunt and Hess grade, hematoma size, and hematoma location. Recently, however, several groups have reported encouraging results in patients with aneurysmal SAH and associated hematomas who undergo urgent endovascular coil embolization followed by hematoma evacuation. This hybrid operative approach achieves early aneurysm occlusion, in an attempt to lower intraoperative rerupture rates during attempted microsurgical clip obliteration and allow for a more aggressive hematoma evacuation and decompression. As vascular neurosurgery moves forward within this endovascular era, we sought to provide long-term data from a high-volume neurovascular center that employs an aggressive surgical approach toward ruptured MCA aneurysms with large hematomas in order to provide a benchmark that future endovascular studies should surpass.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Discuss the various treatment options for patients with ruptured MCA aneurysms and intracranial hematomas.
2) Identify factors associated with poor outcome in patients with ruptured MCA aneurysms with intracranial hematomas.
3) Discuss novel endovascular technologies that may improve outcomes when utilized in patients with ruptured MCA aneurysms with intracranial hematomas.