Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establishreliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm ruptureresults in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determininginitial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and themixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinicaland radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmalsubarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past20 years are discussed and summarized in a proposed treatment flowchart.
1. Introduction
Rupture of a cerebral aneurysm normally results in subarach-noid hemorrhage (SAH) and is often complicated by intrac-erebral hematoma (ICH), but only on rare occasions doesit cause acute subdural hematoma (aSDH) [1]. Diagnosisof aneurysmal SAH can be difficult in comatose patients inwhom loss of conscious due to aneurysm rupture resultsin or mimics a traumatic brain injury [2]. Determining adifferential diagnosis and treatment modalities can furtherbe complicated by the rapid clinical course and the mixtureof symptoms due to the ruptured aneurysm and the masseffect of the hematoma.
Rapid decision making is required to treat this life-threatening condition. The majority of patients withaneurysmal SAH and coincidental acute subdural bleedingpresent in a severe clinical condition, and immediate surgicalmanagement is required [2–4]. Decisions to be made includewhether preoperative diagnostic studies should precedesurgery and whether obliteration of the aneurysm shouldbe performed during hematoma evacuation or in a separatedelayed intervention after resuscitation procedures.
The incidence of combined SAH and aSDH variesfrom 0.5% [5, 6] to 10% [7] in clinical series. The rarity
of aneurysmal aSDH makes it difficult to design reliableclinical treatment guidelines. Large systematic series do notexist, and thus treatment decisions are mainly based onpersonal experience. The aim of this review is to proposea management flow chart and protocol based on publishedexperience with such cases over the past two decades.
2. Materials and Methods
2.1. Search Strategy. The literature was screened for casestudies of acute subdural hematoma secondary to rupturedintracranial aneurysm. Articles for this review were identifiedby MEDLINE PubMed database searches of the literaturefrom January 1990 through December 2009 using the terms“acute subdural hematoma,” “subarachnoid hemorrhage,”and “cerebral aneurysm” (by using the Boolean operatorAND) (Table 1). The senior author independently assessedthe reproducibility of the search strategy on August 30, 2010,two days after the first author’s search. Cross-references werechecked in each eligible article.
2.2. Selection Criteria. Articles were excluded based on titleand abstract because they (i) were not written in theEnglish language, (ii) were technical notes or laboratory
2 International Journal of Vascular Medicine
Table 1: Search Strategy∗.
Search numberProcess description Results
(“key words”) (no. of articles)
no. 1 Search “cerebral aneurysm” 22944
no. 2 Search “subarachnoid hemorrhage” 17883
no. 3 Search “subdural hematoma” 7732
no. 4 Search #1 AND #2 AND #3 155
no. 5 Search “01/1990–12/2009” AND #4 85∗
All searches for this study were performed on August 28, 2010, by the first author and verified by the second author on August 30, 2010. The publicationdate limits were set to January 1990–December 2009.
investigations, or (iii) were not peer-reviewed/original stud-ies. The remaining articles were selected for inclusion ifthe patients were adults and the single cases or case seriesprovided detailed descriptions of clinical characteristics andpatient management.
2.3. Data Acquisition. From selected cases, we extracted thefollowing characteristics and recorded them in a data sheet:age; gender; initial clinical findings, including Glasgow ComaScale (GCS) [8] score, clinical SAH grade based on theHunt and Hess (H&H) [9, 10], and the World Federation ofNeurological Surgeons (WFNS) [11] classifications; presenceof major (aphasia, hemiparesis, or hemiplegia) and minor(cranial nerve palsies) focal neurological deficits, hemo-dynamic situation at the time of admission; radiologicalassessment, including computed tomography (CT) scan, CTangiography (CTA), magnetic resonance imaging (MRI),MR angiography (MRA), and digital subtraction angiog-raphy (DSA); additional presence of SAH, intracerebralhematoma (ICH); side and size of aSDH and associatedmidline shift; aneurysm size and location; case management;outcome according to the Glasgow Outcome Scale (GOS),modified Rankin Score (mRS), and Barthel index (BI).
3. Results
The initial search retrieved 85 publications which matchedthe terms “cerebral aneurysm” AND “subarachnoid hemor-rhage” AND “acute subdural hematoma.” 59 publicationswere excluded after screening of titles and abstracts. Thisleft 26 articles potentially eligible for detailed evaluation.Six articles were not included as they did not match theselection criteria. The remaining 20 articles including 82cases underwent detailed analysis [2–4, 12–14, 16–26, 28–30]. Characteristics of the 82 cases are summarized inTable 2. Graphs displaying the analyzed data appear inFigure 1.
3.1. Initial Clinical Findings. Most of the patients wereadmitted with the worst initial clinical SAH grades andwith signs of uncal herniation. The distribution accordingto the WFNS was grade 5 (n = 46, 57.3%), grade 4 (n =14, 17.1%), grade 3 (n = 6, 7.3%), grade 2 (n = 8,9.8%), and grade 1 (n = 8, 9.8%). At admission, signsof uncal herniation, major focal neurological deficits, andminor focal neurological deficits were present in 35 (42.7%),
eight (9.8%), and six (7.3%) patients, respectively. Fourteen(17.1%) patients presented in an unstable cardiopulmonarycondition (e.g., ventricular arrhythmia, acute heart failure,and sudden pulmonary edema) at the time of admission.Four (4.9%) patients died during resuscitation. One (1.2%)patient was reported to have had prolonged hypoxia.
3.2. Diagnostic Approaches and Radiological Findings. For allpatients, the first radiological assessment was a CT scan (n =82, 100%). 68 (82.9%) patients underwent additional DSA,and 11 (13.4%) underwent additional CTA (Figure 2). Four(4.9%) patients underwent MRA prior to surgery. SAH wasdetected on initial CT scan in 68 (82.9%) patients. Therewere 13 (15.9%) cases of pure aSDH without associatedSAH. 28 (34.1%) patients presented with additional ICH.In 24 (29.3%) patients, the size of the aSDH was reported(mean ± SD: 9.6 ± 3.5, range: 5–20 mm). A total of 30(36.6%) patients were reported as presenting with midlineshift associated with aSDH (mean ± SD: 9.1± 4.0, range: 4–23 mm). All but six cases (7.3%) of aSDH were documentedipsilateral to the side of the aneurysm. Two cases presentedwith bilateral aSDH. Aneurysm size was reported in 37(45.1%) patients (mean± SD: 11.4±8.1, range: 1.5–30 mm).
3.3. Aneurysm Localization. In most of the cases, theaneurysm was located in the posterior communicating artery(Pcom) (n = 39, 46.6%). The rest of the aneurysms werelocated in the middle cerebral artery (MCA) (n = 20,23.2%), the anterior communicating artery (Acom) (n = 11,13.4%), the pericallosal artery (Pcal) (n = 8, 9.8%), or theinternal carotid artery ICA (n = 4, 4.9%).
3.4. Treatment Strategies. The treatment strategies includedurgent hematoma evacuation (n = 59, 72%), surgicalaneurysm obliteration in the same procedure as urgenthematoma evacuation (n = 41, 50%), delayed clipping (n =10, 12.2%), and delayed coiling (n = 6, 7.3%). Eighteenpatients (22%) died during resuscitation or did not meet thecriteria for undergoing any of the invasive procedures dueto cardiopulmonary instability. A total of six (7.3%) patientsunderwent external ventricular drainage, and ten (12.2%)patients were treated with hyperosmolar therapy.
3.5. Outcome. Half of the patients were reported to havefavorable outcomes (GOS 5 and GOS 4, n = 39, 47.6%). Poor
International Journal of Vascular Medicine 3
Ta
ble
2:Pa
tien
tch
arac
teri
stic
s∗.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Wat
anab
eet
al.
[30]
/199
11
51/m
WFN
S5,
GC
S4,
dece
rebr
ate
post
ure
,bi
late
rally
dila
ted
fixe
dpu
pils
atax
icbr
eath
CT
scan
No
No
Lt—
—Lt
Pca
l(A
CA
)—
Em
erge
ncy
cran
iect
omy
and
hem
atom
aev
acu
atio
n(1
h)
Dec
ease
d,G
OS
1,m
RS
6
Wat
anab
eet
al.
[30]
/199
12
72/f
WFN
S4,
GC
S12
,rig
ht
hem
ipar
esis
CT
scan
,DSA
Yes
No
Lt—
—R
tP
cal
(AC
A)
—C
lippi
ng
(on
day
15)
Ret
urn
edto
nor
mal
daily
life,
GO
S5,
mR
S1
Wat
anab
eet
al.
[30]
/199
13
74/f
WFN
S5,
GC
S4,
dece
rebr
ate
post
ure
,ata
xic
brea
th,
dila
tion
ofth
ele
ftpu
pil
CT
scan
,DSA
faile
dYe
sN
oR
t—
—
LtP
cal
(AC
A)
(fou
nd
atau
tops
y)
—In
oper
able
Dec
ease
d(3
days
afte
ron
set)
,GO
S1,
mR
S6
Kam
iya
etal
.[5
]/19
914
67/f
H&
HIV
,pa
resi
sC
Tsc
an,D
SAYe
sN
o—
——
MC
A30
mm
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Veg
etat
ive
stat
e,G
OS
2,m
RS
5
Kam
iya
etal
.[5
]/19
915
50/f
H&
HII
IC
Tsc
an,D
SAYe
sYe
s—
——
ICA
28m
m
Inop
erab
lebe
cau
seof
reru
ptu
reon
adm
issi
on
Dec
ubi
tus
and
pneu
mon
ia,
dece
ased
,G
OS
1,m
Rs
6
Kam
iya
etal
.[5
]/19
916
67/f
H&
HV
,pa
resi
sC
Tsc
an,D
SAYe
sYe
s—
——
MC
A4
mm
Inop
erab
le
Dec
ease
d(o
nar
riva
l),
GO
S1,
mR
s6
Kam
iya
etal
.[5
]/19
917
52/f
H&
HV
CT
scan
,DSA
Yes
Yes
——
—N
otde
tect
ed—
Inop
erab
le
Dec
ease
d(o
nar
riva
l),
GO
S1,
mR
s6
Kam
iya
etal
.[5
]/19
918
69/f
H&
HII
CT
scan
,DSA
Yes
Yes
——
—A
com
27m
m
Inop
erab
lebe
cau
seof
seve
resp
asm
onad
mis
sion
Dec
ease
d,G
OS
1,m
Rs
6
4 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Kam
iya
etal
.[5
]/19
919
63/f
H&
HII
CT
scan
,DSA
Yes
No
——
—M
CA
4m
m
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Kam
iya
etal
.[5
]/19
9110
73/m
H&
HIV
,pa
resi
sC
Tsc
an,D
SAYe
sN
o—
——
Aco
m7
mm
Clin
ical
dete
rior
atio
n,
no
oper
atio
nim
poss
ible
Dec
ease
d,G
OS
1,m
Rs
6
Kam
iya
etal
.[5
]/19
9111
64/m
H&
HV
,pr
eop
erat
ive
reru
ptu
re,
card
iac
failu
re
CT
scan
,DSA
faile
dYe
sN
o—
——
Not
dete
cted
—In
oper
able
Dec
ease
d(n
onfi
llin
gst
ate
DSA
),G
OS
1,m
Rs
6
Kam
iya
etal
.[5
]/19
9112
72/f
H&
HIV
,pa
resi
sC
Tsc
an,D
SAYe
sYe
s—
——
Dis
talA
CA
4m
m
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Kam
iya
etal
.[5
]/19
9113
70/m
H&
HIV
,pa
resi
sC
Tsc
an,D
SAYe
sYe
s—
——
MC
A6
mm
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Kam
iya
etal
.[5
]/19
9114
72/f
H&
HV
CT
scan
,DSA
Yes
Yes
——
—IC
A4
mm
Inop
erab
le
Dec
ease
d(d
ay1)
,G
OS
1,m
Rs
6
Kam
iya
etal
.[5
]/19
9115
59/m
H&
HV
CT
scan
,DSA
Yes
Yes
——
—M
CA
22m
mIn
oper
able
Dec
ease
d(d
ay2)
,G
OS
1,m
Rs
6
Kam
iya
etal
.[5
]/19
9116
39/f
WFN
S5,
GC
S4,
dece
rebr
ate
post
uri
ng,
dila
tion
ofth
eri
ght
pupi
l
CT
scan
,DSA
Yes
Yes
——
Mod
erat
eto
mar
ked
Dis
talA
CA
3m
m
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Kam
iya
etal
.[5
]/19
9117
71/f
H&
HII
IC
Tsc
an,D
SAYe
sYe
s—
——
Aco
m11
mm
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
International Journal of Vascular Medicine 5
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Ru
syn
iak
etal
.[1
2]/1
992
1974
/f
WFN
S5,
GC
S4,
dece
rebr
ate
post
uri
ng,
bila
tera
llym
ioti
cpu
pils
CT
scan
,CTA
Yes
Yes
Rt
——
Rt
ICA
-Pco
m—
Hem
atom
aev
acu
atio
n,
imm
edia
tecl
ippi
ng
Com
plet
ere
cove
ry,
GO
S5,
mR
S1
Rag
lan
det
al.
[13]
/199
320
27/m
GC
S5
righ
tpu
pil
non
reac
tive
left
myd
rias
is
CT
scan
,DSA
No
no
Rt
—M
oder
ate
tom
arke
dA
com
20m
m
Hem
atom
aev
acu
atio
n,
Max
imal
med
ical
trea
tmen
t
Dec
ease
d,G
OS
1,m
RS
6
O’S
ulli
van
etal
.[3]
/199
421
32/m
WFN
S5,
GC
S4,
bila
tera
llyfi
xed
pupi
ls,
hyp
erte
nsi
vew
ith
brad
ycar
dia
CT
scan
Yes
—Lt
——
LtIC
A-P
com
12m
m
Man
nit
ol,
wit
hou
teff
ect
onpu
pilla
ryre
spon
se(3
h),
died
befo
rede
com
pres
sion
Dec
ease
d,G
OS
1,m
RS
6
O’S
ulli
van
etal
.[3]
/199
422
48/f
WFN
S5,
GC
S4,
dila
ted
un
reac
tive
pupi
ls,
un
stab
leca
r-di
opu
lmon
ary
situ
atio
n
CT
scan
,DSA
Yes
Yes
Rt
——
Rt
ICA
-Pco
m15
mm
Man
itol
,w
ith
out
effec
ton
pupi
llary
resp
onse
,h
emat
oma
evac
uat
ion
,an
dcl
ippi
ng
ofth
ean
eury
sm(7
h)
Dec
ease
d,G
OS
1,m
RS
6
O’S
ulli
van
etal
.[3]
/199
423
36/f
WFN
S5,
GC
S3,
bila
tera
llyfi
xed
pupi
lsC
Tsc
an,D
SAYe
sYe
sR
t—
—R
tM
CA
12m
m
Hem
atom
aev
acu
atio
n(4
h)
and
dela
yed
clip
pin
g(d
ay4)
Res
idu
alm
ildle
fth
emip
ares
is,
retu
rned
tow
ork
asa
teac
her
,G
OS
4,m
RS
3
O’S
ulli
van
etal
.[3]
/199
424
63/f
WFN
S5,
GC
S3,
dila
ted
un
reac
tive
pupi
ls
CT
scan
,DSA
Yes
—R
t—
—R
tIC
A-P
com
20m
m
Hem
atom
aev
acu
atio
n(4
h)
and
dela
yed
clip
pin
g(d
ay7)
Full
reco
very
,re
turn
edto
nor
mal
lifes
tyle
,G
OS
5,m
RS
1
6 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
O’S
ulli
van
etal
.[3]
/199
425
62/f
WFN
S3,
GC
S14
,mild
left
hem
ipar
esis
CT
scan
,DSA
Yes
No
Rt
20m
m—
Rt
ICA
-Pco
m4
mm
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Un
even
tfu
lre
cove
ry,
retu
rned
ton
orm
allif
esty
le,
GO
S5,
mR
S1
Now
aket
al.
[14]
/199
526
52/f
WFN
S5,
GC
S3,
dila
ted
un
reac
tive
pupi
ls,
hyp
erte
nsi
vecr
isis
(sys
tolic
BP
280
mm
Hg)
CT
scan
Yes
No
Rt
——
Rt
Pca
l(A
CA
)—
Man
itol
,em
erge
ncy
hem
atom
aev
acu
atio
n
Dec
ease
d,G
OS
1,m
RS
6
Now
aket
al.
[14]
/199
527
45/f
WFN
S1,
GC
S15
,di
stu
rban
ces
ofvi
sion
CT
scan
,DSA
Yes
Yes
Rt
10m
m—
Rt
MC
A—
Hem
atom
aev
acu
atio
nan
dcl
ippi
ng
(day
1)
Full
reco
very
,re
turn
edto
nor
mal
lifes
tyle
,G
OS
5,m
RS
1
Now
aket
al.
[14]
/199
528
49/f
WFN
S5,
GC
S3,
mild
left
-sid
edh
emip
ares
is
CT
scan
Yes
—R
t—
Mar
ked
Rt
MC
A>
25m
m
Em
erge
ncy
hem
atom
aev
acu
atio
nw
ith
glu
ing
ofth
ean
eury
sm
Dec
ease
d,G
OS
1,m
RS
6(r
eble
edin
g)
Now
aket
al.
[14]
/199
529
63/m
WFN
S5,
GC
S<
6,ri
ght
dila
ted
pupi
lC
Tsc
an,D
SAYe
s—
Rt
——
Rt
MC
A10
mm
Imm
edia
teh
emat
oma
evac
uat
ion
and
dela
yed
clip
pin
g(w
eek
5)
Full
reco
very
,no
seri
ous
neu
rolo
gica
lde
fici
ts,
GO
S5,
mR
S1
Ish
ibas
hie
tal
.[1
5]/1
997
3054
/f
WFN
S1,
GC
S15
,no
neu
rolo
gica
lde
fici
t
CT
scan
,DSA
No
No
Lt—
—Lt
ICA
-PC
om—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(<
24h
)
No
neu
rolo
gica
lde
fici
t,re
turn
ton
orm
allif
e,G
OS
5,m
RS
1
International Journal of Vascular Medicine 7
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Non
aka
etal
.[1
6]/2
000
3152
/f
GC
S4,
dece
rebr
ate
rigi
dity
,an
dle
ftoc
ulo
mot
orpa
resi
s
CT
scan
,DSA
No
No
Lt—
Mod
erat
eto
mar
ked
LtIC
A-P
Com
10m
m
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(>
24h
)
Full
reco
very
,no
neu
rolo
gica
lde
fici
ts,
GO
S5,
mR
S1
Inam
asu
etal
.[1
7]/2
002
3268
/mW
FNS
2,G
CS
14,H
&H
IIC
Tsc
an,D
SAYe
sN
o—
<25
cc<
5m
mA
com
—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(6
h)
Goo
dre
cove
ry,
GO
S5,
mR
s1
Inam
asu
etal
.[1
7]/2
002
3361
/fW
FNS
4,G
CS
10,H
&H
IVC
Tsc
an,D
SAYe
sYe
s—
<25
cc<
5m
mR
tM
CA
—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(6
h)
Goo
dre
cove
ry,
GO
S5,
mR
s1
Inam
asu
etal
.[1
7]/2
002
3475
/fW
FNS
4,G
CS
11,H
&H
IVC
Tsc
an,D
SAYe
sYe
s—
<25
cc<
5m
mLt
MC
A—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(6
h)
Seve
redi
sabi
lity,
GO
S3,
mR
S5
Inam
asu
etal
.[1
7]/2
002
3528
/fW
FNS
5,G
CS
5,H
&H
IVC
Tsc
an,
No
No
Rt
<25
cc>
10m
mLt
ICA
-Pco
m(a
uto
psy)
—C
ran
iect
omy
and
hem
atom
aev
acu
atio
n
Dec
ease
d(5
days
afte
rad
mis
sion
),G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
3653
/f
WFN
S5,
GC
S4,
H&
HV
,bi
late
rally
dila
ted
pupi
ls
CT
scan
,DSA
Yes
No
Rt
<25
cc>
10m
mR
tIC
A-P
com
—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dcl
ippi
ng
Dec
ease
d(3
days
afte
rad
mis
sion
due
tose
vere
post
-op
erat
ive
brai
nsw
ellin
g),
GO
S1,
mR
S6
Inam
asu
etal
.[1
7]/2
002
3772
/fW
FNS
5,G
CS
4,H
&H
VC
Tsc
an,
Yes
No
—<
25cc
>10
mm
LtIC
A-P
com
(au
tops
y)—
Infu
sion
sof
man
itol
,bu
rrh
ole
Dec
ease
d,G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
3853
/mW
FNS
5,G
CS
5,H
&H
VC
Tsc
anYe
sN
o—
<25
cc>
10m
mU
nkn
own
—In
fusi
ons
ofm
anit
ol,b
urr
hol
e
Dec
ease
d,G
OS
1,m
RS
6
8 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Inam
asu
etal
.[1
7]/2
002
3947
/fW
FNS
5,G
CS
4,H
&H
VC
Tsc
anYe
sN
o—
<25
cc>
10m
mU
nkn
own
—In
fusi
ons
ofm
anit
ol,b
urr
hol
e
Dec
ease
d,G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
4070
/fW
FNS
5,G
CS
4,H
&H
VC
Tsc
anYe
sYe
s—
<25
cc>
10m
mU
nkn
own
—
No
resp
onse
tom
anit
olin
fusi
on,
con
serv
ativ
etr
eatm
ent
Dec
ease
d,G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
4181
/fW
FNS
5,G
CS
4,H
&H
VC
Tsc
anYe
sN
o—
<25
cc>
10m
mU
nkn
own
—
No
resp
onse
tom
anit
olin
fusi
on,
con
serv
ativ
etr
eatm
ent
Dec
ease
d,G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
4255
/mW
FNS
5,G
CS
3,H
&H
VC
Tsc
anYe
sN
o—
<25
cc>
10m
mU
nkn
own
—
No
resp
onse
tom
anit
olin
fusi
on,
con
serv
ativ
etr
eatm
ent
Dec
ease
d,G
OS
1,m
RS
6
Inam
asu
etal
.[1
7]/2
002
4349
/mW
FNS
5,G
CS
3,H
&H
VC
Tsc
anYe
sN
o—
<25
cc>
10m
mU
nkn
own
—
No
resp
onse
tom
anit
olin
fusi
on,
con
serv
ativ
etr
eatm
ent
Dec
ease
d,G
OS
1,m
RS
6
Gel
aber
t-G
onza
lez
etal
.[1
8]/2
004
4468
/fW
FNS
5,G
CS
4,fi
xed
pupi
lsC
Tsc
an,D
SAYe
sN
oLt
——
LtIC
A-P
com
—
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(4
h)
Mild
righ
t-si
ded
hem
ipar
esis
,G
OS
4,m
RS
2
Gel
aber
t-G
onza
lez
etal
.[1
8]/2
004
4564
/fW
FNS
4,G
CS
9,di
lati
onof
the
righ
tpu
pil
CT
scan
,CTA
Yes
—R
t—
Mar
ked
LtIC
A-P
com
—
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(2
8h
)
Full
reco
very
,n
euro
logi
-ca
llyin
tact
,G
OS
5,m
RS
1
Gel
aber
t-G
onza
lez
etal
.[1
8]/2
004
4641
/f
WFN
S5,
GC
S4,
righ
toc
ulo
mot
orpa
resi
s
CT
scan
,DSA
Yes
Yes
Lt—
Mar
ked
LtIC
A-P
com
—
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(5
h)
Dec
ease
d,G
OS
1,m
RS
6
International Journal of Vascular Medicine 9
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Gel
aber
t-G
onza
lez
etal
.[1
8]/2
004
4759
/fW
FNS
5,G
CS
6,bi
late
rally
fixe
dpu
pils
CT
scan
,DSA
Yes
No
Rt
——
Rt
ICA
3m
m
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(9
h)
Dec
ease
d,G
OS
1,m
RS
6
Kri
shn
aney
etal
.[19
]/20
0448
42/f
WFN
S2,
GC
S14
CT
scan
,M
RI,
MR
A,
DSA
No
No
Bila
tera
l—
—A
com
10m
m
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
and
clip
pin
g,(6
days
)
Un
even
tfu
lre
cove
ry,n
on
euro
logi
cal
defi
cits
,G
OS
5,m
RS
1
Kim
etal
.[2
0]/2
005
4972
/fW
FNS
2,G
CS
14C
Tsc
an,D
SAYe
sYe
sR
t6
mm
8m
mLt
dist
alA
CA
—
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(4
8h
)
Dys
phas
ia,
righ
th
emip
ares
is,
GO
S3,
mR
S4
Kim
etal
.[2
0]/2
005
5042
/mW
FNS
5,G
CS
3,bi
late
rally
fixe
dpu
pils
CT
scan
,DSA
Yes
—L
t6.
5m
m10
mm
LtIC
A-P
com
—
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g(3
h)
Mild
left
-sid
edar
mpa
resi
s,G
OS
4m
RS
3
Mar
inel
liet
al.
[21]
/200
551
62/f
WFN
S1,
GC
S15
,com
plet
ele
ftth
ird
ner
vepa
lsy
CT
scan
,M
RI,
MR
A,
DSA
No
No
Lt—
—Lt
ICA
-Pco
m10
mm
En
dova
scu
lar
embo
lizat
ion
Full
reco
very
ofle
ftth
ird
ner
vepa
lsy,
GO
S5,
mR
S1
Hor
iet
al.
[22]
/200
552
57/m
WFN
S2,
GC
S13
-14,
inco
mpl
ete
righ
toc
ulo
mot
orpa
lsy
CT
scan
,DSA
No
No
Rt
—M
oder
ate
tom
arke
dR
tM
CA
1.5
mm
Hem
atom
aev
acu
atio
nan
dim
med
iate
clip
pin
g
Full
reco
very
,G
OS
5,m
RS
1
Koe
rbel
etal
.[2
3]/2
005
5362
/f
WFN
S4,
GC
S10
-11,
rapi
dn
euro
logi
cal
dete
rior
atio
n
CT
scan
,DSA
No
No
Lt—
Mod
erat
eto
mar
ked
LtIC
A-P
com
5m
m
Hem
atom
aev
acu
atio
nfo
llow
edby
coili
ng
Ret
urn
edto
nor
mal
lifes
tyle
,G
OS
5,m
RS
1
10 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Wes
term
aier
etal
.[4]
/07
5455
/fW
FNS
5,G
CS
6,an
isoc
oria
righ
tC
Tsc
an,D
SAYe
sYe
sR
t—
—R
tA
com
—
EV
Dco
ilin
gan
dh
emat
oma
evac
uat
ion
(24
h)
No
form
alde
fici
ts,
mob
ilefo
rsh
ort
dist
ance
,G
OS
4,B
arth
el70
Wes
term
aier
etal
.[4]
/07
5556
/f
WFN
S5,
GC
S3,
MI,
bila
tera
llyfi
xed
pupi
ls,c
ar-
diop
ulm
onar
yu
nst
able
CT
scan
,DSA
Yes
Yes
Rt
——
Rt
MC
ALa
rge
Rep
eate
din
fusi
ons
ofm
anit
ol,
hem
atom
aev
acu
atio
n,
and
imm
edia
tecl
ippi
ng
(24
h)
Sim
ple
com
mu
ni-
cati
on,l
eft
hem
ipar
esis
,p
erm
anen
tca
re,G
OS
3,B
arth
el20
Wes
term
aier
etal
.[4]
/07
5655
/fW
FNS
5,G
CS
3,di
lati
onof
the
righ
tpu
pil
CT
scan
,DSA
Yes
No
Rt
——
Rt
ICA
-Pco
m—
Imm
edia
teh
emat
oma
evac
uat
ion
,E
VD
and
dela
yed
coili
ng
(24
h)
Mild
left
hem
ipar
esis
,G
OS
4,B
arth
el70
Wes
term
aier
etal
.[4]
/07
5755
/fW
FNS
5,G
CS
<6,
anis
ocor
iari
ght
CT
scan
,DSA
Yes
No
Rt
——
Rt
Aco
m—
Imm
edia
teh
emat
oma
evac
uat
ion
,E
VD
,an
dde
laye
dco
ilin
g(2
4h
)
Full
reco
very
,re
turn
tow
ork,
GO
S5,
mR
S1
Wes
term
aier
etal
.[4]
/07
5843
/f
WFN
S5,
bila
tera
llyfi
xed
and
dila
ted
pupi
ls
CT
scan
Yes
No
Lt—
—Lt
ICA
-Pco
m—
Hem
atom
aev
acu
atio
nfo
llow
edby
coili
ng
Rt
hem
ipar
esis
usi
ng
aw
hee
lch
air
for
lon
ger
dist
ance
s,G
OS
3,B
arth
el70
Wes
term
aier
etal
.[4]
/07
5954
/f
WFN
S5,
GC
S3,
dila
tion
ofth
eri
ght
pupi
l,ca
rdia
cin
stab
ility
CT
scan
,DSA
Yes
—R
t—
—R
tA
com
—
EV
D,d
elay
edco
ilin
g(2
4h
),h
emat
oma
evac
uat
ion
thre
ew
eeks
late
r(b
urr
hol
e)
Not
able
tow
alk,
depe
nde
nt
onp
erm
anen
tca
re,G
OS
3,B
arth
el0
International Journal of Vascular Medicine 11
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Wes
term
aier
etal
.[4]
/07
6042
/fW
FNS
5,di
lati
onof
the
righ
tpu
pil
CT
scan
,DSA
Yes
—R
t—
—R
tIC
A-P
com
—
EV
D,
hem
atom
aev
acu
atio
n,
and
imm
edia
tecl
ippi
ng
Ret
urn
edto
nor
mal
lifes
tyle
,G
OS
5,B
arth
el10
0
Wes
term
aier
etal
.[4]
/07
6155
/f
WFN
S5,
bila
tera
llyfi
xed
pupi
ls,
cyan
otic
and
hypo
xic
CT
scan
Yes
Yes
Rt
5m
m4
mm
Rt
MC
A14
mm
No
ther
apy
asa
resu
ltof
prol
onge
dhy
pox
iabe
fore
adm
issi
on
Dec
ease
d,G
OS
1,m
RS
6
Gila
det
al.
[24]
/200
762
47/m
WFN
S1,
GC
S15
,par
tial
left
sixt
hcr
ania
ln
erve
pals
y
CT
scan
,M
RI,
MR
A,
DSA
No
No
Ten
tori
um
mid
line
——
Intr
asel
lar
Aco
m13
mm
Coi
lem
boliz
atio
nal
one
Un
even
tfu
l,n
on
euro
logi
cal
defi
cits
,G
OS
5,m
RS
1
Suh
ara
etal
.[2
5]/2
008
6327
/fW
FNS
4,G
CS
8C
Tsc
an,D
SAN
oN
oR
t—
—Lt
Pca
l(A
CA
)7
mm
Cra
nie
ctom
y,im
med
iate
hem
atom
aev
acu
atio
n,
and
dela
yed
clip
pin
g(5
days
)
Un
even
tfu
lre
cove
ry,n
on
euro
logi
cal
defi
cits
,G
OS
5,m
RS
1
Nis
hik
awa
etal
.[26
]/20
0964
45/m
WFN
S5,
GC
S5,
dila
ted
slow
lyre
acti
ng
pupi
ls
CT
scan
,M
RI,
MR
AN
oYe
sB
ilate
ral
—M
oder
ate
tom
arke
dL
tIC
A—
Em
erge
ncy
hem
atom
aev
acu
atio
n,
and
clip
pin
g
Dec
ease
d(c
ereb
ral
her
nia
tion
6da
ysaf
ter
adm
issi
on),
GO
S1,
mR
S6
Koc
aket
al.
[27]
/09
6568
/fW
FNS
5,G
CS
6C
Tsc
an,D
SAYe
sN
o—
—R
tIC
Abi
furc
atio
n—
Pati
ent
died
duri
ng
resu
scit
atio
n
Dec
ease
d,G
OS
1,m
RS
6
Koc
aket
al.
[27]
/09
6653
/mW
FNS
2,G
CS
14C
Tsc
an,D
SAYe
sN
o—
—Lt
Pco
m—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
12 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Koc
aket
al.
[27]
/09
6748
/fW
FNS
3,G
CS
10
CT
scan
,DSA
(aft
erh
emat
oma
evac
uat
ion
)
Yes
No
—M
oder
ate
tom
arke
dR
tP
com
—
Cra
nio
tom
yan
dim
med
iate
hem
atom
aev
acu
atio
n,
dela
yed
clip
pin
g(6
days
)
Seve
redi
sabi
lity,
GO
S3,
mR
S5
Koc
aket
al.
[27]
/09
6863
/fW
FNS
1,G
CS
15C
Tsc
an,D
SAYe
sN
o—
—Lt
MC
A—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Koc
aket
al.
[27]
/09
6951
/fW
FNS
2,G
CS
14C
Tsc
an,D
SAYe
sN
o—
—A
com
—
Cra
nio
tom
y,SD
Hev
acu
atio
n,
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Koc
aket
al.
[27]
/09
7072
/fW
FNS
4,G
CS
8C
Tsc
an,D
SAYe
sYe
s—
Mod
erat
eto
mar
ked
Rt
MC
A—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
(aSD
H+
ICH
)an
dim
med
iate
clip
pin
g
Dec
ease
d,G
OS
1,m
RS
6
Koc
aket
al.
[27]
/09
7156
/fW
FNS
4,G
CS
7C
Tsc
an,D
SAYe
sYe
s—
Mod
erat
eto
mar
ked
Rt
MC
A—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
(aSD
H+
ICH
),an
dim
med
iate
clip
pin
g(6
h)
Dec
ease
d,G
OS
1,m
RS
6
Koc
aket
al.
[27]
/09
7267
/mW
FNS
5,G
CS
5
CT
scan
,DSA
(aft
erh
emat
oma
evac
uat
ion
)
Yes
No
—M
oder
ate
tom
arke
dR
tP
com
—
Cra
nio
tom
yan
dim
med
iate
hem
atom
aev
acu
atio
n,
dela
yed
clip
pin
g(8
days
)
Seve
redi
sabi
lity,
GO
S3,
mR
S5
Koc
aket
al.
[27]
/09
7347
/fW
FNS
1,G
CS
15C
Tsc
an,
CTA
,DSA
No
No
——
Aco
m—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
International Journal of Vascular Medicine 13
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Koc
aket
al.
[27]
/09
7457
/fW
FNS
3,G
CS
13C
Tsc
an,
CTA
,DSA
Yes
No
——
LtP
com
—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Goo
dre
cove
ry,
GO
S5,
mR
s1
Koc
aket
al.
[27]
/09
7546
/fW
FNS
4,G
CS
12C
Tsc
an,
CTA
,DSA
Yes
No
——
Rt
Pco
m—
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g
Seve
redi
sabi
lity,
GO
S3,
mR
S5
Mar
bach
eret
al.[
2]/1
076
44/f
WFN
S5,
GC
S3,
bila
tera
llyfi
xed
pupi
lsC
Tsc
an,D
SAYe
sN
oR
t15
mm
10m
mR
tP
cal
(AC
A)
5m
m
Cra
nie
ctom
y,h
emat
oma
evac
uat
ion
(4h
),an
dde
laye
dcl
ippi
ng
Full
reco
very
,m
ildco
gnit
ive
defi
cits
,G
OS
5,m
RS
1
Mar
bach
eret
al.[
2]/1
077
50/f
WFN
S3,
GC
S13
,mild
left
-sid
edh
emip
ares
is
CT
scan
,CTA
Yes
Yes
Rt
9m
m23
mm
Rt
MC
A11
mm
Cra
nie
ctom
y,h
emat
oma
evac
uat
ion
(12
h),
and
dela
yed
coili
ng
Mild
left
-sid
edar
mpa
resi
s,G
OS
4,m
RS
2
Mar
bach
eret
al.[
2]/1
078
39/m
WFN
S5,
GC
S4,
bila
tera
llyfi
xed
pupi
lsC
Tsc
an,C
TAYe
sN
oR
t10
mm
14m
mR
tIC
A-P
com
5m
m
EV
D,
cran
iect
omy,
hem
atom
aev
acu
atio
n,
and
imm
edia
tecl
ippi
ng
(18
h)
Res
idu
alle
ft-s
ided
hem
ipar
esis
,G
OS
4,m
RS
2
Mar
bach
eret
al.[
2]/1
079
58/f
WFN
S5,
GC
S5,
dila
tion
ofth
eri
ght
pupi
lC
Tsc
an,C
TAYe
sYe
sR
t5
mm
4m
mR
tM
CA
14m
m
Cra
nie
ctom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(3
h)
Full
reco
very
,m
ildco
gnit
ive
defi
cits
,G
OS
5,m
RS
1
Mar
bach
eret
al.[
2]/1
080
45/f
WFN
S5,
GC
S4,
dila
tion
ofth
eri
ght
pupi
lC
Tsc
an,D
SAYe
sN
oR
t20
mm
18m
mR
tIC
A-P
com
7m
m
Cra
nie
ctom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(2
h)
Gai
tat
axia
,G
OS
4,m
RS
3
14 International Journal of Vascular Medicine
Ta
ble
2:C
onti
nu
ed.
Seri
es/y
ear
ofpu
blic
atio
nC
ase
no.
Age
/sex
Init
ialc
linic
alfi
ndi
ngs
Init
ial
diag
nos
tics
SAH
ICH
Side
ofaS
DH
Size
ofaS
DH
MLS
Loca
tion
ofan
eury
smSi
zeof
aneu
rysm
Man
agem
ent
(hou
rsfr
omic
tus)
Ou
tcom
e
Mar
bach
eret
al.[
2]/1
081
68/f
WFN
S1,
GC
S15
,rig
ht
ocu
lom
otor
pare
sis
CT
scan
,CTA
Yes
No
Rt
10m
m6
mm
Rt
Dis
tal
ICA
-Pco
m2
mm
Cra
nio
tom
y,h
emat
oma
evac
uat
ion
,an
dim
med
iate
clip
pin
g(6
h)
Full
reco
very
,no
sym
ptom
sat
all,
GO
S5,
mR
S0
Mar
bach
eret
al.[
2]/1
082
27/f
WFN
S5,
GC
S3,
bila
tera
llyfi
xed
myd
rias
is,
un
stab
leca
r-di
opu
lmon
ary
con
diti
on
CT
scan
,DSA
Yes
No
Rt
10m
m7
mm
Rt
Pca
l(A
CA
)12
mm
Cra
nie
ctom
y,h
emat
oma
evac
uat
ion
(1h
)
Dec
ease
d,G
OS
1,m
RS
6
∗Su
mm
ary
(ch
arac
teri
stic
s)of
82ca
ses
from
20cl
inic
alca
sese
ries
orca
sere
port
sof
aneu
rysm
alac
ute
subd
ura
lhem
atom
as.A
bbre
viat
ion
s:SA
H=
suba
rach
noi
dh
emor
rhag
e;IC
H=
intr
acer
ebra
lhem
orrh
age;
aSD
H=
acu
tesu
bdu
ralh
emat
oma;
MLS
=m
idlin
esh
ift;
mm
=m
illim
eter
;f=
fem
ale;
m=
mal
e;W
FNS=
Wor
ldFe
dera
tion
ofN
euro
logi
calS
urg
eon
s;G
CS=
Gla
sgow
Com
aSc
ale;
CT=
com
pute
dto
mog
raph
y;R
t=
righ
t;Lt
=le
ft;m
RS=
mod
ified
Ran
kin
Scor
e;G
OS=
Gla
sgow
Ou
tcom
eSc
ale;
FU=
follo
wu
p;N
OS=
not
oth
erw
ise
spec
ified
;Bar
thel=
Bar
thel
Inde
x;D
SA=
digi
tals
ubt
ract
ion
angi
ogra
phy;
MR
I=
mag
net
icre
son
ance
imag
ing;
MR
A=
mag
net
icre
son
ance
angi
ogra
phy;
MC
A=
mid
dle
cere
bral
arte
ry;C
TA=
CT
angi
ogra
phy;
ICA=
inte
rnal
caro
tid
arte
ry;P
com
=po
ster
ior
com
mu
nic
atin
gar
tery
;Aco
m=
ante
rior
com
mu
nic
atin
gar
tery
;AC
A=
ante
rior
cere
bral
arte
ry;P
cal=
per
ical
losa
lart
ery;
EV
D=
exte
rnal
ven
tric
ula
rdr
ain
age;
MI=
myo
card
iali
nfa
rcti
on.
International Journal of Vascular Medicine 15
WFNS 5 WFNS 4 WFNS 3 WFNS 2 WFNS 1
0
10
20
30
40
50Admission grade
Nu
mbe
r of
pat
ien
ts (n
)
(a)
0
20
40
60
80
100 Diagnostics
CT-scan
Nu
mbe
r of
pat
ien
ts (n
)
+DSA +CTA +MRA
(b)
0
5
10
15
20
1–7 mm 8–12 mm 13–24 mm >25 mm
Aneurysm size
Nu
mbe
r of
an
eury
sm (n
)
(c)
Pcom MCA Acom Pcal ICA
0
10
20
30 Aneurysm localization
Nu
mbe
r of
an
eury
sm (n
)
(d)
GOS 5 GOS 4 GOS 3 GOS 2 GOS 1
0
10
20
30
40 Overall outcome
Nu
mbe
r of
pat
ien
ts (n
)
(e)
GOS 5 GOS 4 GOS 3 GOS 2 GOS 1
0
10
20
30
40 Treatment outcome
Nu
mbe
r of
pat
ien
ts (n
)
(f)
GOS 5 GOS 4 GOS 3 GOS 2 GOS 1
0
10
20
30 Outcome aSDH with SAH
Nu
mbe
r of
pat
ien
ts (n
)
(g)
GOS 5 GOS 4 GOS 3 GOS 2 GOS 1
0
2
4
6
8
10Outcome aSDH w/o SAH
Nu
mbe
r of
pat
ien
ts (n
)
(h)
Figure 1: Data analysis of 82 cases of aneurysmal aSDH∗. ∗Abbreviations: WFNS = World Federation of Neurological Surgeons; CT =computed tomography; DSA = digital subtraction angiography; CTA = CT angiography; MRA = Magnetic resonance angiography; mm =millimeter; Pcom = posterior communicating artery; MCA = middle cerebral artery; Acom = anterior communicating artery; Pcal =pericallosal artery; ICA = internal carotid artery; GOS = Glasgow Outcome Scale.
16 International Journal of Vascular Medicine
(a) (b)
(c) (d)
Figure 2: Illustrative case: Panels (a–d) display axial CT scans with 3D reconstructions showing a right acute subdural hematoma withmidline shift after rupture of a giant aneurysm located in the right middle cerebral artery. Panels (a) and (b): noncontrast-enhanced andcontrast-enhanced axial CT scan, demonstrating a large aneurysm in the right silvian fissure with surrounding SAH, right-sided aSDH, anduncal herniation. Panel (c) shows a marked midline shift due to the mass effect of the aSDH. Panel (d) depicts the aneurysm with outgoingvessels.
outcome (GOS 3 and GOS 2) was reported in nine (11%)patients. 32 patients (26.6%) had fatal outcomes (GOS 1).Overall distribution according to the GOS was GOS 5 (n =31, 37.8%), GOS 4 (n = 8, 9.8%), GOS 3 (n = 8, 9.8%),GOS 2 (n = 1, 1.2%), and GOS 1 (n = 32, 39%). In19 (23.2%) out of 32 patients with fatal outcome (GOS 1),the critical status at admission did not allow any surgicalor endovascular intervention. Four (4.9%) patients diedduring resuscitation, two (2.4%) patients died immediatelyafter diagnosis, and one (1.2%) patient received no furthertherapy as a result of prolonged hypoxia before admission.Most of the 63 patients who met the criteria for invasivetreatment achieved good outcomes (GOS 5 and GOS 4, n =39, 69.9%). The distribution of these patients by treatmentoutcome according to the GOS was GOS 5 (n = 31, 49.2%),GOS 4 (n = 8, 12.7%), GOS 3 (n = 8, 12.7%), GOS2 (n = 1, 1.6%), and GOS 1 (n = 13, 20.6%). Patientswho suffered aneurysmal aSDH without SAH demonstratedbetter outcomes (GOS 5, n = 9, 69.2%; GOS 1, n = 5,38.5%) than patients who presented with aneurysmal aSDHand SAH (GOS 5, n = 22, 31.4%; GOS 4, n = 8, 11.4%;
GOS 3, n = 8, 11.4%; GOS 2, n = 1, 1.4%; GOS 1, n = 27,38.6%).
3.6. Outcome Stratified by Therapeutic Strategies (Table 3).All patients presenting in good clinical condition withoutrapid neurological deterioration (n = 15) demonstratedgood outcomes (GOS 5 and GOS 4). These outcomes werefavorable irrespective of whether hematoma evacuation andaneurysm obliteration were immediate (n = 10) or delayed(n = 5). However, patients with rapidly deteriorating levelsof consciousness (including signs of brain herniation) andurgent (<24 h) intervention had a higher likelihood of goodoutcomes (GOS 5 and GOS 4) than patients with rapiddeterioration who had undergone delayed (24 h) treatment(64% versus 25%).
4. Discussion
This meta-analysis of 82 reported cases presenting withaneurysmal aSDH and rapid neurological deterioration
International Journal of Vascular Medicine 17
Acute subdural hematoma due toruptured intracranial aneurysm
Patients with a stable neurologicalcondition (no signs of brain herniation)
Patients with rapid deteriorating level ofconsciousness (signs of brain herniation)
Figure 3: Illustrative schematic diagram of the protocol (management algorithm) for diagnosis and treatment of aneurysmal acute subduralhematoma. CT = computed tomography. CTA = CT angiography. DSA = digital subtraction angiography. ∗ = if available.
Table 3: Outcome stratified according to therapeutic strategies∗.
Patients presenting with rapidly deterioratingneurological condition
Patients presenting without rapidly deterioratingneurological condition
revealed that urgent surgical decompression and immediateocclusion of the aneurysm seem to be an acceptable treat-ment strategy in order to achieve better outcome (GOS 5and GOS 4 = 64%). Good outcomes are found in patientsmaintaining stable neurological condition irrespective ofwhether intervention was immediate or delayed (GOS 5 =100%). Patients with pure aSDH due to a ruptured aneurysmdemonstrated better outcomes than patients who sufferedaneurysmal aSDH associated with SAH. Patients in unstablecardiopulmonary condition, with unstable blood pressureand serious ventricular arrhythmias, have the highest riskof unfavorable outcomes. All patients who did not meet thecriteria for invasive treatment had fatal outcomes.
Poor clinical presentation per se is not associated withworse outcome. However, the combination of marginalcardiac output and reduced cerebral perfusion and cerebralblood flow due to the mass effect [31] during the acute phaseof SAH [32] is likely to result in poor final outcome. Patientspresenting in such condition do not meet the criteria forurgent hematoma evacuation, which additionally worsens
the likelihood of favorable outcome (GOS 5 and GOS 4 =25%). Patients in stable hemodynamic condition are suitablefor rapid surgical decompression and maximal medicaltreatment and have a higher chance of recovering in goodneurological condition (GOS 5 and GOS 4 = 64%) despitesevere SAH and poor initial GCS admission scores. Two-thirds of all patients with either poor grade SAH or traumaticaSDH usually do not survive, and functional outcome israre [33–35]. The good recovery of patients with aneurysmalaSDH might be explained by the space-occupying effect ofthe hematoma, which mimics a worse clinical situation anddoes not reflect vital brain destruction.
Pure aSDH due to ruptured intracranial aneurysm isextremely rare. Only 20 cases have been reported so far,including 14 cases during the last two decades [16]. Inmost cases of aneurysmal aSDH, the history will distinguisha traumatic from a spontaneous cause [1]. However, theabsence of hematomas and subarachnoid blood collectionsrelated to common aneurysm sites can impede the diagnosis.The finding that pure aneurysmal aSDH results in better
18 International Journal of Vascular Medicine
outcome than aSDH with SAH may be explained by thefact that these patients less frequently have complications(delayed cerebral vasospasm and hydrocephalus).
Due to the rarity of the disease, no guidelines havebeen established. In most reports, patients have bad clinicalfeatures on admission, often presenting in a comatosestate with pupillary abnormalities. Fast decision makingis mandatory. Determining a differential diagnosis, as wellas treatment modalities, can be complicated by the rapidclinical course and the mixture of symptoms due to theruptured aneurysm or mass effect of the hematoma.
To address the lack of guidelines, we developed aflowchart for treatment of patients with aSDH. However, theevidence for the proposed treatment flowchart comes fromcase series and case reports with relatively small sample sizes.Therefore, the estimation of effects is imprecise, and clinicalrecommendations included in the management protocol areweak [36, 37].
In patients who are in good neurological condition at thetime of admission, management may proceed in a standardmanner (Figure 3, left side of the flowchart). After initial CTand CTA examination, DSA is the diagnostic modality ofchoice to verify the angioarchitecture of the aneurysm. If theaneurysm is suitable for endovascular obliteration and theaSDH remains clinically insignificant, the aneurysm can beoccluded during the same procedure [4]. If a decision is madeto occlude the aneurysm surgically, DSA provides relevantanatomical information and guidance in determining aclipping strategy and surgical approach.
For the management of patients who are in a comaor whose level of consciousness is deteriorating rapidly,the choice of initial diagnostics is more demanding, andmanagement decisions become difficult (Figure 3, right sideof the flowchart). The aSDH may be the major determinantof neurological grade, and prompt hematoma evacuationmay be life saving. At the minimum, neuroradiologicalinvestigations should consist of an emergency CT and CTAto visualize potential bleeding sources. Emergency treatmentmodalities such as maximal sedation, osmotherapy, andexternal ventricular drainage to reverse signs of brainherniation should be performed as quickly as possible. Inthese cases, the emergency situation forces the neurosurgeonto postpone DSA.
Intraoperative DSA would allow safe and completeaneurysm occlusion to be carried out at the same time asurgent hematoma evacuation [38, 39]. Patients would bespared a second procedure. However, Westermaier et al.[4] recently presented four patients who underwent sepa-rate delayed endovascular coiling after decompression andhematoma evacuation. Despite good neurological recoveryin three of these four patients, subjecting patients to twoseparate procedures rather than clipping at the same timeas hematoma removal remains controversial. Patients whopresent in unstable cardiopulmonary conditions cannot beoperated on immediately. It seems that this subgroup ofpatients is exceptionally at risk of poor outcome. Withhold-ing aggressive therapy in poor-grade patients in order toprevent vegetative survival is highly controversial and cannotbe recommended.
5. Conclusion
Due to the rarity of aneurysmal aSDH, it remains difficultto define a comprehensive management protocol. In patientswith poor neurological grade at admission and rapidly dete-riorating levels of consciousness, urgent surgical decompres-sion and immediate aneurysm obliteration result in favorableoutcome (GOS 5 and GOS 4; 64%). Delay of immediatetreatment in patients with rapidly deteriorating neurologicalconditions decreases the likelihood of a favorable outcome(GOS 5 and GOS 4; 25%). Good outcomes are observed inpatients maintaining stable neurological condition irrespec-tive of whether the intervention was immediate or delayed(GOS 5; 100%). Overall outcome of patients who sufferedaneurysmal aSDH without SAH proved to be better (GOS5, 69.2%) than the outcome of patients who presented withaneurysmal aSDH and SAH (GOS 5; 31.4%).
Conflict of Interests
The authors are solely responsible for the design and conductof the presented study and report no conflict of interests. Nofunds were or will be received for this study.
References
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