Abstract
Introduction: Cisternal and ventricular blood predisposes to hydrocephalus and cerebral ischemia
after high-grade aneurysmal subarachnoid hemorrhage (HGSAH). We studied the role of
lamina terminalis fenestration combined with cisternal blood evacuation in HGSAH.
Patients/Materials and Methods: A clinical, prospective, non-randomized study of a series of HGSAH patients (Modified
Fisher ≥3) treated in the acute phase was carried out. The microsurgical treatment
included aneurysm clipping, cisternal blood evacuation, and fenestration of the lamina
terminalis. A comparable, non-blood-cleansed, endovascular-treated group, was included
as a control. Clinical results were evaluated by the Glasgow Outcome Scale (GOS).
Results: During a period of 30 months, 95 patients who met the selection criteria were treated
by microsurgical procedures and 28 by endovascular procedures. The distribution of
GOS scores was superior for the microsurgical group: good results (GOS 4-5) were obtained
in 85.3%, with a mortality rate of 5.9%. By contrast, 60.3% of patients in the endovascular
group achieved GOS 4-5 scores, and 15.8% died. Good results for the endovascular group
correlated inversely with delay of treatment. A permanent ventriculo-peritoneal shunt
was necessary in 3.2% and 7.1% of the microsurgical and endovascular groups, respectively.
The incidence of cerebral infarct was 3.1% and 14.3% for the microsurgical and endovascular
groups, respectively.
Discussion: Microsurgical management reduces the usually poor outcome of patients with HGSAH.
Lamina terminalis fenestration diminishes the incidence of shunt-dependent hydrocephalus
and, combined with extensive cisternal blood cleansing, can lower the incidence of
stroke. A procedure for cleansing blood and clots from the cisterns in HGSAH, based
on the pathophysiology of vasospasm, is proposed.
Key words
poor-grade subarachnoid hemorrhage (SAH) - stroke - vasospasm - hydrocephalus - endovascular
treatment - clipping
References
Fenestration of lamina terminalis reduces vasospasm after subarachnoid hemorrhage
from anterior communicating artery aneurysms. In: Cerebral Vasospasm Advances in Research and Treatment. Macdonald RL (ed). Thieme
Medical Publishers, New York, NY 20045
Correspondence
jorgemura@terra.cl
