Coiling of Ruptured Aneurysms Followed by Evacuation of Hematoma

OBJECTIVE: To report a series of patients with aneurysmal subarachnoid hemorrhage (SAH) and associated intracranial hematoma (ICH) who underwent coiling of the aneurysm followed immediately by open surgical decompression with evacuation of the hematoma. METHODS: With the hypothesis that aneurysm coiling before hematoma evacuation may simplify surgery, prospectively collected data at two neurovascular institutions were retrospectively reviewed. Patients with aneurysmal SAH and associated ICH who underwent combined endovascular and open surgery were identified; only cases of coiling before open surgery were analyzed. Relevant information was collected from medical records and imaging studies for analysis. The Glasgow Outcome Scale (GOS) was used to evaluate clinical outcome. RESULTS: There were 30 patients who were treated with endovascular obliteration of aneurysms followed by surgical decompression (9 men and 21 women; mean age 50 years). Patients presented with Hunt and Hess (H&H) grade 3 or higher except for one patient who presented initially with grade 1 and deteriorated to grade 5 after rerupture and before treatment. At discharge, GOS scores were as follows: 1 in 5 patients, 2 in 1 patient, 3 in 22 patients, and 4 in 2 patients. At a mean follow-up of 18 months (range 3-60 months), 28 patients had an outcome that could be evaluated, and GOS scores were as follows: 1 in 6 patients, 3 in 5 patients, 4 in 8 patients, and 5 in 9 patients. One patient required retreatment for aneurysm recurrence; no patient had aneurysm rerupture. CONCLUSIONS: In selected patients with aneurysmal SAH and associated ICH, reasonable outcomes can be achieved using aggressive control of intracranial pressure (ICP) with combined endovascular and open surgical techniques. Endovascular aneurysm obliteration before surgical decompression represents a paradigm in the management of ruptured aneurysms associated with ICH and can transform surgery to a simple decompression. In expert hands, consecutive procedures can be performed rapidly with 60.7% of patients having a favorable outcome (GOS score of 4 or 5) and becoming independent.