Letter to the Editor, Regarding "The Method of Aneurysm Treatment Does Not Affect Clot Clearance After Aneurysmal Subarachnoid Hemorrhage"

To the Editor:

Ibrahim et al¹ present a study that showed that the treatment of aneurysmal subarachnoid hemorrhage (SAH) does not affect the clot clearance. We strongly believe that even though this article is statistically correct, the conclusion is not correct.

We reported in 2007² a prospective, nonrandomized study of high-grade aneurysmal SAH (modified Fisher Scale score ≥3) treated with clipping vs coiling. The microsurgical group (95 patients) was treated with aneurysm clipping, cisternal blood evacuation, opening of Liliequist membrane and fenestration of the lamina terminalis; the endovascular group (28 patients) was treated with coils for the ruptured aneurysm as a control. When we analyze the results, microsurgery had better clinical results with a Glasgow Outcome Score of 4 to 5 (85.3% vs 60.3%) and a lower mortality rate (5.9% vs 15.8%). The need for a permanent ventriculoperitoneal shunt was more frequent in the endovascular group than the microsurgical group (7.1% vs 3.2%), and finally the incidence of cerebral infarct was more than fourfold in the endovascular group (14.3% vs 3.1%).

We strongly believe that the results of Ibrahim et al of microsurgery vs endovascular treatment are not comparable because, as pointed out by Dr Rafael Tamargo in his comment on their article, we do not know the extent of blood cleansing in the microsurgery performed in this study, besides the usual cleaning in the cistern near the clipped aneurysm, and so we cannot compare both groups properly.

Moreover, we think that our results are explained because since 2001 our team uses a protocol for cleansing the cisterns in high-grade SAH, with at least 2 L of warm normal saline with papaverine, and the cleansing of the cisterns is in a predetermined order despite the ruptured aneurysm localization, completely performed after the clipping of the lesion: Wide opening and cleansing the ipsilateral sylvian fissure cistern; opening and cleansing the ipsilateral carotid artery cistern; opening the Liliequist membrane to communicate the infratentorial with the supratentorial cisterns and blood removal from the interpeduncular cistern; opening and cleansing the ipsilateral optic, chiasmatic, and lamina terminalis cisterns; fenestration of the lamina terminalis and eventual drainage of blood in the third ventricle; and finally opening and cleansing the contralateral optic cistern, carotid cistern, and proximal root of the contralateral sylvian fissure. This protocol is always possible to perform despite brain swelling or the presence of acute hydrocephalus; the difference is the transient intraoperative necessity of catheter ventriculostomy.

Other factors to consider are based on 3 articles by Komotar et al^3-5 that are interesting to analyze. In the first article, published in Neurosurgery in 2002, the authors suggest that the lamina terminalis fenestration reduces the shunt rate in aneurysmal SAH secondary hydrocephalus. In the second article, published in Neurosurgery in 2008, they analyzed a retrospective clinical series and concluded that the microsurgical fenestration of the lamina terminalis has no impact on the shunt-dependent hydrocephalus and, more importantly, has no impact on the vasospasm secondary to aneurysmal SAH. Finally, the third paper, published in theJournal of Neurosurgery in 2009, is the most concerning because they performed a systematic review of lamina terminalis fenestration and its impact on reducing shunt-dependent hydrocephalus after aneurysmal SAH; they searched MEDLINE between 1950 and 2007 using the key words used in the report of our study published in December 2007 in Minimally Invasive Neurosurgery, cited previously.²However, our study was not in their analysis. They concluded in their second article that lamina terminalis fenestration has no significant association with a reduction in shunt-dependent hydrocephalus secondary to aneurysmal SAH.

Their analysis of the literature in third article had an enormous negative impact on modern microsurgery management and prevention of aneurysmal SAH complications, namely, vasospasm and hydrocephalus, because the rationale for cisternal opening to clean the blood beyond the cistern of the clipped ruptured aneurysm and the effort to reach the lamina terminalis and open it lost the evidence-based medicine support. The article by Ibrahim et al is a reflection of the current microsurgical approach to the aneurysmal SAH in many centers focused exclusively on clipping the aneurysm.

Nevertheless, we strongly believe that a protocol of cistern cleansing combined with fenestration of the lamina terminalis and opening the Liliequist membrane must be made standard practice in the microsurgical approach to high-grade aneurysmal SAH, and therefore the results of clot clearance can be actually compared with the endovascular group and, more importantly, their impact on the occurrence of complications of aneurysmal SAH.

In other words, we promote that the treatment of the aneurysmal SAH must be focused not only in the rebleeding of the ruptured aneurysm as is currently done. We want to include the prevention and treatment of the other major complications of this disease, essentially symptomatic vasospasm and chronic hydrocephalus.

A prospective, multicenter, randomized study involving a large number of patients can definitively address the issue of the microsurgical vs endovascular treatment of aneurysmal SAH.

Mura, Jorge; Torche, Esteban

Santiago, Chile

References

1. Ibrahim GM, Vachhrajani S, Ilodigwe D, et al.. Method of aneurysm treatment does not affect clot clearance after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2012;70(1):102–109.
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2. Mura J, Rojas-Zalazar D, Ruíz A, Vintimilla LC, Marengo JJ. Improved outcome in high-grade aneurysmal subarachnoid hemorrhage by enhancement of endogenous clearance of cisternal blood clots: a prospective study that demonstrates the role of lamina terminalis fenestration combined with modern microsurgical cisternal blood evacuation. Minim Invasive Neurosurg. 2007;50(6):355–362.
PubMed | CrossRef

3. Komotar RJ, Olivi A, Rigamonti D, Tamargo RJ. Microsurgical fenestration of the lamina terminalis reduces the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2002;51(6):1403–1413.
View Full Text | PubMed | CrossRef

4. Komotar RJ, Hahn DK, Kim GH, et al.. The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2008;62(1):123–134.
View Full Text | PubMed | CrossRef

5. Komotar RJ, Hahn DK, Kim GH, et al.. Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. J Neurosurg. 2009;111(1):147–154.
PubMed | CrossRef

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