1. Clinical predictors of delayed cerebral ischemia after subarachnoid hemorrhage: First experience with coil embolization in the management of ruptured cerebral aneurysms Yasuhiro Kawabata M.D. 1, 3, Fumihiko Horikawa M.D. 1, Yasushi Ueno M.D., Ph.D. 2, Masahiro Sawada M.D. 1, Fumiaki Isaka M.D., Ph.D. 1 and Hidenori Miyake M.D., Ph.D. 1 1 Department of Neurosurgery, Hamamatsu Rosai Hospital, Shizuoka, Japan 2 Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan 3 Department of Neurosurgery, Osaka Red Cross Hospital, Osaka, Japan

2. purpose The purpose of this study was to clarify the clinical predictors of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH).

3. Definition of delayed cerebral ischemia DCI was defined as clinical deterioration and/or a new infarct on CT or MRI that was not visible upon the admission or immediate postoperative scan, when the cause was thought to be vasospasm.

4. cases 102 pts with ruptured cerebral aneurysms 77 pts treated by clipping, 25 pts treated by coiling sex: 40 male, 62 female age: median 59 y.o. (31-88) Patients with SAH due to dissecting aneurysms and patients who died within 48 hours after the ictus despite technical success of the treatment were excluded from this study.

5. cases(2) aneurysm siteCLIPPINGCOILING anterior circulation MCA312 ACA-ACOM3013 ICA-PCOM167 posterior circulation 03 LOCATION MCA ACA-ACOM ICA-PCOM VA-BA P=0.003

6. Hunt & Kosnik Grade clippingcoiling 234 5 p=0.230

7. trends of treatment modality

8. Perioperative complications Clipping(77)  Infarction 8  Epidural hematoma 2  Intracerebral hematoma 1  Infection 7  Retreatment 0  Procedure-related morbidity 7 Coiling (25)  Intraprocedural rupture 1  Vasospasm 1  Postoperative rebleeding 1  Coil protrusion 1  Retreatment 4 → clipping 2, → coiling 2  Procedure-related morbidity 4

9. Prognosis (overall) (mRS at 3 months)

10. Summary of patients with surgical vs. endovascular treatment by initial Hunt and Kosnik grade and clinical outcomes modality modified Rankin Scale 0123456total clipping Hunt and Kosnik grade 16 21 110 2136 5 1 25 35 3411 14 4 2415315 5 1240613 total246816671077 coiling Hunt and Kosnik grade 11 1 2541 12 13 3 1 12 4 1 11 14 5 1 315 total671125325

11. Prognosis (clipping vs. coiling) mRS0-2mRS3-6 56% 49% P=0.053

12. Prognosis (clipping vs. coiling) H&K grade1-3 H&K grade 4,5 clippingcoiling P=0.15 P=0.04

13. delayed cerebral ischemia (clipping vs. coiling) 32.4% 4% delayed cerebral ischemia (+) delayed cerebral ischemia (-) P = 0.001

14. Explanations of the difference perioperative management is different (Heparinization, dual antiplatelet etc.) surgical manipulation in the subarachnoid space can delay clearance of subarachnoid clot, which can potentially exacerbate vasospasm after SAH.

15. Associations between potential clinical risk factors and delayed cerebral ischemia after subarachnoid hemorrhage were assessed using the chi- square test. DCI(+)DCI(-) P value Multiple regression analysis age0.539 >651127 <651549 sex0.195 0.211 male1327 female1349 hypertension0.883 (+)1028 (-)1648 dyslipidemia0.543 (+)29 (-)2467 smoking0.341 current smoker1133 past smoker02 non-smoker1440 unknown01 Fisher group0.141 0.692 128 2221 31125 4919 n.a.23

16. Associations between potential clinical risk factors and delayed cerebral ischemia after subarachnoid hemorrhage were assessed using the chi- square test. DCI(+)DCI(-) P value Multiple regression analysis Hunt and Kosnik grade 0.113 0.817 129 2533 3610 4811 5513 intracerebral hemorrhage 0.096 0.118 (+)424 (-)2252 hydrocephalus<0.001 0.002 (+)1720 (-)956 modality0.001 0.042 clipping2452 coiling124 anti-spasm treatment0.045 0.632 conventional2353 intensive323 Treatment period0.016 0.382 1999, Nov-2005, Nov1832 2005, Dec-2010, Apr844

17. outcomes of ruptured intracranial aneurysms treated by microsurgical clipping and endovascular coiling in a high-volume center Natarajan SK et al. AJNR 29: 753-759, 2008 195 consecutive pts 105 pts (clipping), 87pts (coiling) mRS 0-2; 69% no difference in the outcomes between patients in the clipping and coiling groups. vasospasm rate: 66% (clipping) vs. 52% (coiling), (p=0.022)

18. conclusions DCI was less frequently observed in the coiling group, and as a result, clinical outcomes were superior in coiling group, especially for patients with severe SAH. Our results showed a significant correlation between DCI and hydrocephalus.