title: Initial Clinical Status and Spot Sign Are Associated with Intraoperative Aneurysm Rupture in Patients Undergoing Surgical Clipping for Aneurysmal Subarachnoid Hemorrhage.
abstract: OBJECTIVE
  To assess clinical and radiographic risk factors for intraoperative aneurysm rupture (ioAR) during surgical clipping after aneurysmal subarachnoid hemorrhage (aSAH) and to analyze its influence on patient outcome.
  
  
  METHODS
  Patient selection was based on a retrospective analysis of our prospective subarachnoid hemorrhage patient database including consecutive patients between January 2008 and August 2012 with aSAH undergoing microsurgical clipping. Demographic data, cardiovascular risk factors, preoperative radiologic aneurysm characteristics, as well as timing of surgery and preoperative severity grades (Hunt and Hess [HH], Fisher, World Federation of Neurological Societies [WFNS]), were collected from hospital charts and surgery videos and compared between patients with and without ioAR.
  
  
  RESULTS
  Of 100 patients (38 men, 62 women) with a median age of 57.4 years (range: 23-85 years), ioAR occurred in 34 cases (34%). Univariate analyses showed that severity grades were significantly higher in the ioAR group (Fisher p = 0.012; HH p = 0.002; WFNS p = 0.023). IoAR was significantly associated with intracerebral hemorrhage (ICH) (23% versus 47%; p = 0.013) and the spot sign as an indicator of active bleeding within the ICH (0% vs 44%; p = 0.007). Multivariate analysis showed that HH was the only significant predictor of ioAR (p = 0.03; odds ratio: 2.3; 95% confidence interval, 1.1-5.0). With a mean follow-up of 17.6 months ( ± 16.6), Glasgow Outcome Scale score, mortality rate (12% versus 15%; p = 0.82), delayed cerebral ischemia (36% versus 38%; p = 0.51), and shunt dependency (32% versus 44%; p = 0.23) were comparable between the non-ioAR and ioAR group.
  
  
  CONCLUSIONS
  Initial clinical status and spot sign were associated with ioAR during microsurgical clipping of ruptured aneurysms. However, there was no difference regarding clinical outcome and complications of the two groups.
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
authors.forename: Jan-Karl
authors.initials: JK
authors.lastname: Burkhardt
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
authors.forename: Marian Christoph
authors.initials: MC
authors.lastname: Neidert
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
authors.forename: Malte
authors.initials: M
authors.lastname: Mohme
authors.affiliation: Division of Biostatistics, University of Zurich, Institute for Social and Preventive Medicine, Zurich, Switzerland.
authors.forename: Burkhardt
authors.initials: B
authors.lastname: Seifert
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
authors.forename: Luca
authors.initials: L
authors.lastname: Regli
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
authors.forename: Oliver
authors.initials: O
authors.lastname: Bozinov
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000175:diagnosis* / Q000209:etiology; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D013525:Surgical Instruments / Q000009:adverse effects*; D016896:Treatment Outcome; D055815:Young Adult