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Letters to the Editor / Clinical Neurology and Neurosurgery 115 (2013) 2549–2556
[3] Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365(9457):387–97. [4] Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013;382(9890):397–408. [5] Hemphill 3rd JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32(4):891–7. [6] Adeoye O, Ringer A, Hornung R, Khatri P, Zuccarello M, Kleindorfer D. Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial. Neurocrit Care 2010;13(1):82–6. [7] Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, et al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013;44(3):627–34.
Dale Ding ∗ University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville 22908, USA ∗ Tel.:
+1 434 924 2203; fax: +1 434 982 5753. E-mail address: [email protected] 20 September 2013 Available online 20 September 2013 http://dx.doi.org/10.1016/j.clineuro.2013.09.041
Ruptured intracranial aneurysms in young adults: Seeing the forest for the trees Dear Sir, We read with interest the article by Chalouhi et al. “Aneurysmal subarachnoid hemorrhage in patients under 35-years-old: A singlecenter experience,” [1] and subsequent commentary, addressing the impact of the International Subarachnoid Aneurysm Trial (ISAT) [2] and the Barrow Ruptured Aneurysm Trial (BRAT) [3] on the choice of treatment modality for ruptured aneurysms. Both demonstrated greater rates of independence after endovascular treatment of ruptured aneurysms at 1 year. Though these rates remained superior for endovascular treatment at longer follow-up, the difference no longer met statistical significance at 3 years in BRAT [3] and 5 years in ISAT [2]. However, in BRAT, patients assigned to coiling that actually underwent coiling continued to have a statistically significantly greater rate of independence at 3 year follow-up as compared to patients that underwent clipping [3]. Regardless, assuming equivalence of these modalities at long-term follow-up, is it not better to have a better chance of independence at 1 year while undergoing a less invasive procedure? Even assuming “equivalence” of these two treatment modalities at any time, would this not then favor the less invasive approach? Are families really only interested to hear if their young adult relative can simply live independently after treatment? Of particular significance in the young adult age group are outcome measures in the form of return to work, neuropsychological outcome and even cosmesis. What is the value of temporalis wasting and frontalis palsy in young adults? Although potentially not affecting independence at 1 year, how does one value the rate of craniotomy incision
infection and CSF leak? Some may weigh these as microsurgical correlates to endovascular “re-treatment” if managed operatively, though they are not quantified as such. Of paramount importance is neurocognition. An analysis of 474 nondisabled patients in ISAT demonstrated significantly less cognitive impairment after endovascular treatment (OR 0.58, p = 0.0055) [4]. Rates of neurocognitive deficits in each assessed domain were essentially always greater after clipping, meeting statistical significance for verbal memory (p = 0.03) and processing speed (p = 0.008) and nearing statistical significance for executive skills (p = 0.06) and spatial working memory (p = 0.09). Such neurocognitive parameters are of great importance in this young age group, and remain poorly studied for these patients. Nevertheless, the best evidence demonstrates that rates of independence are similar to superior after endovascular treatment of ruptured aneurysms amenable to coiling or clipping. This invites studies describing outcomes for endovascular approaches in less studied patient cohorts such as that by Chalouhi et al. [1]. Conflict of interest The authors both declare no conflicts of interest/disclosures. References [1] Chalouhi N, Teufack S, Chandela S, Dalyai R, Tjoumakaris S, Hasan DM, et al. Aneurysmal subarachnoid hemorrhage in patients under 35-years-old: a singlecenter experience. Clin Neurol Neurosurg 2013;115:665–8. [2] Molyneux AJ, Kerr RSC, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid hemorrhage, death or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009;8:427–33. [3] Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 2013;119:146–57. [4] Scott RB, Eccles F, Molyneux AJ, Kerr RSC, Rothwell PM, Carpenter K. Improved cognitive outcomes with endovascular coiling of ruptured intracranial aneurysms: neuropsychological outcomes from the international subarachnoid aneurysm trial (ISAT). Stroke 2010;41:1743–7.
a
a
Ajith J. Thomas a,b Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, 02115, USA b Department of Neurological Surgery, Harvard Medical School, Boston, 02115, USA
Bradley A. Gross a,b,∗ Department of Neurological Surgery, Brigham and Women’s Hospital, Boston, 02115, USA b Department of Neurological Surgery, Harvard Medical School, Boston, 02115, USA
∗ Corresponding author at: Department of Neurological Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA. Tel.: +1 617 732 5500. E-mail address: [email protected] (B.A. Gross)
29 September 2013 Available online 20 September 2013 http://dx.doi.org/10.1016/j.clineuro.2013.10.006
Letters to the Editor / Clinical Neurology and Neurosurgery 115 (2013) 2549–2556
[3] Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365(9457):387–97. [4] Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013;382(9890):397–408. [5] Hemphill 3rd JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32(4):891–7. [6] Adeoye O, Ringer A, Hornung R, Khatri P, Zuccarello M, Kleindorfer D. Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial. Neurocrit Care 2010;13(1):82–6. [7] Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, et al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013;44(3):627–34.
Dale Ding ∗ University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville 22908, USA ∗ Tel.:
+1 434 924 2203; fax: +1 434 982 5753. E-mail address: [email protected] 20 September 2013 Available online 20 September 2013 http://dx.doi.org/10.1016/j.clineuro.2013.09.041
Ruptured intracranial aneurysms in young adults: Seeing the forest for the trees Dear Sir, We read with interest the article by Chalouhi et al. “Aneurysmal subarachnoid hemorrhage in patients under 35-years-old: A singlecenter experience,” [1] and subsequent commentary, addressing the impact of the International Subarachnoid Aneurysm Trial (ISAT) [2] and the Barrow Ruptured Aneurysm Trial (BRAT) [3] on the choice of treatment modality for ruptured aneurysms. Both demonstrated greater rates of independence after endovascular treatment of ruptured aneurysms at 1 year. Though these rates remained superior for endovascular treatment at longer follow-up, the difference no longer met statistical significance at 3 years in BRAT [3] and 5 years in ISAT [2]. However, in BRAT, patients assigned to coiling that actually underwent coiling continued to have a statistically significantly greater rate of independence at 3 year follow-up as compared to patients that underwent clipping [3]. Regardless, assuming equivalence of these modalities at long-term follow-up, is it not better to have a better chance of independence at 1 year while undergoing a less invasive procedure? Even assuming “equivalence” of these two treatment modalities at any time, would this not then favor the less invasive approach? Are families really only interested to hear if their young adult relative can simply live independently after treatment? Of particular significance in the young adult age group are outcome measures in the form of return to work, neuropsychological outcome and even cosmesis. What is the value of temporalis wasting and frontalis palsy in young adults? Although potentially not affecting independence at 1 year, how does one value the rate of craniotomy incision
infection and CSF leak? Some may weigh these as microsurgical correlates to endovascular “re-treatment” if managed operatively, though they are not quantified as such. Of paramount importance is neurocognition. An analysis of 474 nondisabled patients in ISAT demonstrated significantly less cognitive impairment after endovascular treatment (OR 0.58, p = 0.0055) [4]. Rates of neurocognitive deficits in each assessed domain were essentially always greater after clipping, meeting statistical significance for verbal memory (p = 0.03) and processing speed (p = 0.008) and nearing statistical significance for executive skills (p = 0.06) and spatial working memory (p = 0.09). Such neurocognitive parameters are of great importance in this young age group, and remain poorly studied for these patients. Nevertheless, the best evidence demonstrates that rates of independence are similar to superior after endovascular treatment of ruptured aneurysms amenable to coiling or clipping. This invites studies describing outcomes for endovascular approaches in less studied patient cohorts such as that by Chalouhi et al. [1]. Conflict of interest The authors both declare no conflicts of interest/disclosures. References [1] Chalouhi N, Teufack S, Chandela S, Dalyai R, Tjoumakaris S, Hasan DM, et al. Aneurysmal subarachnoid hemorrhage in patients under 35-years-old: a singlecenter experience. Clin Neurol Neurosurg 2013;115:665–8. [2] Molyneux AJ, Kerr RSC, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid hemorrhage, death or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009;8:427–33. [3] Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 2013;119:146–57. [4] Scott RB, Eccles F, Molyneux AJ, Kerr RSC, Rothwell PM, Carpenter K. Improved cognitive outcomes with endovascular coiling of ruptured intracranial aneurysms: neuropsychological outcomes from the international subarachnoid aneurysm trial (ISAT). Stroke 2010;41:1743–7.
a
a
Ajith J. Thomas a,b Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, 02115, USA b Department of Neurological Surgery, Harvard Medical School, Boston, 02115, USA
Bradley A. Gross a,b,∗ Department of Neurological Surgery, Brigham and Women’s Hospital, Boston, 02115, USA b Department of Neurological Surgery, Harvard Medical School, Boston, 02115, USA
∗ Corresponding author at: Department of Neurological Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA. Tel.: +1 617 732 5500. E-mail address: [email protected] (B.A. Gross)
29 September 2013 Available online 20 September 2013 http://dx.doi.org/10.1016/j.clineuro.2013.10.006
