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Original Report
Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: A retrospective analysis and review of the literature
Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía
E. Murias Quintanaa,
Corresponding author
emuriass@hotmail.com

Corresponding author.
, A. Gil Garcíaa, P. Vega Valdésa, E. Morales Dezaa, D. Escudero Augustob, L. Viña Soriab, J.C. Gutiérrez Moralesc
a Unidad de Neurorradiología Intervencionista, Servicio de Radiología, Hospital Universitario Central de Asturias, Oviedo, Spain
b Unidad de Cuidados Intensivos, Hospital Universitario Central de Asturias, Oviedo, Spain
c Servicio de Neurocirugía, Hospital Universitario Central de Asturias, Oviedo, Spain
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to 40&#37; and with a mortality of 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#8211;4</span></a> In addition&#44; if an intracranial haematoma is associated with subarachnoid haemorrhage in these patients with poor clinical status at admission&#44; the mortality rate climbs to 50&#37; with surgical treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the series of patients published after the ISAT study of endovascular treatment of patients with SAH and poor clinical status at admission&#44; an improvement in the prognosis was observed when the rate of dependent patients was reduced to 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite this improvement in the prognosis of patients with SAH and poor clinical status with endovascular treatment and the suboptimal result of surgical treatment with clipping of the aneurysm associated with decompression with evacuation of the haematoma&#44; in most hospitals&#44; and in the published papers&#44; surgical treatment continues to be recommended as the treatment of choice&#44; especially in patients with haemodynamic instability&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#8211;12</span></a> According to some series&#44; this double surgical technique offers these results not only due to the clinical state of the patient&#44; but also due to the manipulation of the oedematous brain and the complexity of the clipping technique in this scenario&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#8211;8&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the results of urgent combined treatment with embolisation of the aneurysm followed by surgical evacuation of the haematoma in patients with SAH&#44; intracranial haematoma and clinical signs of intracranial hypertension&#46; In addition&#44; we conducted a review of the literature of published series with a similar technique&#44; with the aim of assessing whether this technique is safe and effective and an alternative to isolated surgical treatment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted an observational retrospective study&#46; The inclusion criteria were patients with SAH associated with intracranial haematoma and clinical signs of intracranial hypertension from January 2008 to October 2017&#46; In all cases&#44; the corresponding informed consent for the treatment was obtained and the site&#39;s ethics committee approved the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Inclusion criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patients treated by the combination of embolisation of the aneurysm and surgery of the haematoma&#44; as long as the two treatments had been performed within four hours from the onset of symptoms&#46; Clinical criteria of intracranial hypertension were considered to be the presence of one or more of the following signs&#58; non-reactive mydriasis&#44; absence of reaction to painful stimuli and a decrease in the level of consciousness that forces invasive life support measures&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#8211;8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients treated only with surgery with clipping of the aneurysm&#44; patients in whom the treatments were postponed for more than four hours and others who were not considered candidates for treatment due to clinical and radiological criteria were all excluded &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Procedures</span><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnostic and treatment protocol includes performing an urgent cranial computed tomography &#40;CT&#41; scan in the event of clinical suspicion of subarachnoid haemorrhage&#44; after taking the necessary measures to achieve respiratory and haemodynamic stability of the patient&#44; associated with CT angiography of the intracranial arteries for the diagnosis of cerebral aneurysm&#46; Subsequently&#44; the patient undergoes a clinical examination to confirm the presence of signs of intracranial hypertension by expert staff of the intensive care and emergency unit&#46; All these findings are evaluated by medical personnel from the neurosurgery and interventional neuroradiology departments&#44; who decide the most appropriate approach&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patients considered candidates were transferred to the angiography room where the endovascular treatment was performed while the neurosurgery operating room was being prepared&#46; Endovascular treatment includes emergency embolisation of the aneurysm using GDC coils &#40;MicruSphere cerecyte coils&#44; Micrus&#44; San Jose California and Target Detachable Coils&#44; Boston Scientific&#44; Irvine&#44; California&#41; associated with balloon remodelling&#44; if technically possible &#40;HyperForm remodelling balloon&#44; Medtronic&#44; Irvine&#44; California and Eclipse remodelling balloon&#44; BALT Extrusion&#44; Montmorency&#44; France&#41;&#46; All procedures were performed by two interventional radiologists with more than 10 years&#8217; experience&#46; Intravenous heparinisation and intraoperative antiplatelet therapy were not used by protocol&#46; At the end of the embolisation&#44; the patient was transferred to undergo a craniectomy with surgical evacuation of the intracranial haematoma&#46; This procedure was performed by the on-call neurosurgery team&#44; always guided by a doctor with more than 10 years&#8217; experience&#44; with the primary objective of reducing&#44; as far as possible&#44; the mass effect of the haematomas&#44; without performing treatment on the aneurysm causing the bleeding&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Variables</span><p id="par0050" class="elsevierStylePara elsevierViewall">The following were collected and analysed&#58; epidemiological variables &#40;age&#44; sex&#44; history of hypertension and active smoking&#41;&#59; clinical variables&#59; value on the Hunt and Hess scale &#40;HHS&#41; and the Glasgow coma scale &#40;GCS&#41;&#44; on admission to the hospital and upon arrival at the angiography room&#59; radiological findings &#40;Fisher scale value&#44; aneurysm geometry and location&#41;&#46; In addition&#44; variables were collected related to the embolisation technique&#44; measurements were taken of the aneurysm of the neck and the greatest neck-dome distance&#44; complications of the endovascular procedure &#40;thromboembolic complications and rupture of the aneurysm&#41; and surgical complications &#40;arterial haemorrhages and re-bleeding&#41; and duration from the arrival in the emergency department until the end of both treatments&#46; The degree of closure of the aneurysm was assessed using the Raymond-Roy scale&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a> In the follow-up&#44; the presence of hydrocephalus was analysed with or without surgical treatment with drainage&#44; vasospasm and stroke&#46; Patients were clinically evaluated monthly using the modified Rankin scale &#40;mRS&#41;&#44; and those with a mRS less than or equal to 2 were considered independent patients&#46; For the values of the variables described&#44; the criteria included in the ISAT study were maintained&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a> by considering it the reference work in ruptured cerebral aneurysms and the same as those used in methodology studies similar to this one&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;14&#44;15</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Out of a total of 495 aneurysmal subarachnoid haemorrhages&#44; 13&#46;5&#37; had an associated haematoma&#46; Of these&#44; 23 patients were included in the review &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; 14 women and 9 men&#44; who met the treatment criteria before the first four hours and signs of haemodynamic instability&#46; The mean on the GCS was 8&#8211;9 at admission to the emergency department and several patients worsened clinically until they decreased to 6&#8211;7 at the time of their arrival in the angiography room&#44; all below 9 points&#46; The HHS value was 4 in all cases&#46; All patients required mechanical ventilation before their arrival in the room&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Thirty-eight patients with cerebral haematoma and ruptured aneurysm were rejected for analysis because they did not meet the inclusion criteria&#58; 26 of these patients were not candidates for treatment because of the poor clinical status&#44; advanced age or consensus decision with their legal representatives&#44; and 12 of the patients either did not require surgery for the haematoma or it was delayed for more than four hours&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">91&#46;3&#37; of patients had a localised aneurysm in the middle cerebral artery &#40;MCA&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and two patients had an aneurysm at the origin of the posterior cerebral artery &#40;PostCA&#41;&#44; both with associated acute subdural haematoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; All patients had a value on the Fisher scale of 4&#44; and intraventricular bleeding was identified in 12 of them &#40;52&#46;1&#37;&#41;&#46; The average size of the aneurysms was 8&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#44; and of the neck&#44; 3&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#46; The mean time from the identification of the aneurysm on the CT scan to the embolisation of the aneurysm was 115<span class="elsevierStyleHsp" style=""></span>min&#46; A remodelling balloon was used in 78&#37; of the cases achieving an adequate closure &#40;Raymond grade of 1 and 2&#41; in 82&#46;6&#37; of the cases&#46; Two complications were observed during the endovascular treatment&#44; a distal thromboembolism and a controlled intraoperative rupture with the remodelling balloon and coils&#46; Both complications were clinically asymptomatic&#44; since in the former cerebral ischaemia was not identified and in the second there was no increase in subarachnoid bleeding or contrast extravasation in the control CT scan&#59; both patients were independent at one month&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The evacuation of the haematoma was performed in all cases&#44; and there was arterial bleeding during one of the surgical procedures solved with the clipping of a Sylvian branch&#46; The clipping of the aneurysm was not required in any of the cases&#46; During surgery&#44; a ventricular drain was placed in 9 &#40;39&#46;1&#37;&#41; patients&#46; In the postoperative period&#44; ischaemic lesion was identified by imaging in 9 &#40;39&#46;1&#37;&#41; patients&#59; in 7 &#40;30&#46;4&#37;&#41; of these&#44; vasospasm was detected&#44; treated with haemodynamic measures&#44; and one of them required intra-arterial treatment&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the follow-up at one month from the cerebral haemorrhage&#44; 13 &#40;56&#46;5&#37;&#41; patients were independent&#44; with a mortality of 13&#37;&#46; One patient died due to oedema produced by cerebral vasospasm and infarcted tissue&#44; another due to the mass effect of the haematoma associated with cerebral oedema and a third due to pulmonary complications &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; There were no re-bleedings&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The functional prognosis of patients with SAH is related&#44; classically&#44; to the clinical status at hospital admission measured by both the GCS and the HHS&#46; The results of several series of published cases show that patients with poor clinical status at admission&#44; HHS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#44; have a probability of being independent at one month from bleeding of less than 50&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;12&#8211;16</span></a> There are even authors who ask if the treatment of these types of patients is effective&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">If in addition to presenting poor clinical status at admission&#44; patients have an intracranial haematoma associated with signs of intracranial hypertension &#40;a concept presented in some papers as compressive haematoma&#41; the prognosis is even worse&#44; with the number of independent patients at one month less than 30&#37;&#46; This rate of independent patients is reflected in several published series of surgical treatment with clipping of the aneurysm and drainage of the haematoma in the same procedure<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;17&#8211;22</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The surgical technique consisting of the clipping of the aneurysm and the evacuation of the haematoma is associated with significant technical difficulties that are related to intracranial hypertension and cerebral oedema&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> The surgical manoeuvres related to brain tissue manipulation and excessive retraction are sometimes necessary in these types of patients due to cerebral oedema&#46; These manoeuvres can damage the ischaemic brain tissue and cause secondary brain damage&#46; This secondary damage can damage local self-regulation and aggravate the cerebral oedema&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#44;10</span></a> The dissection of the arachnoid mater around the neck of the aneurysm is essential for good control of the parental artery during the clipping of the aneurysm&#46; In most cases&#44; the cerebral haematoma surrounds the aneurysm and&#44; in this condition&#44; the dissection may cause re-bleeding of the aneurysm during the evacuation of the haematoma&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> It is sometimes necessary to place a temporary clip prior to the clipping of the aneurysm&#59; this situation can worsen the ischaemic condition of the ischaemic tissue&#44; which conditions the presence of a cerebral infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a> The difficulty of the aforementioned surgical technique can prolong the surgical time and increase the rate of complications such as infection&#44; pneumonia&#44; pulmonary oedema or heart failure&#44; situations that can aggravate the prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The surgical results are also directly related to the volume of the cerebral haematoma and its location&#46; Large-volume haematomas&#44; especially those that have a greater intracerebral component&#44; compared to Sylvian blood&#44; have a worse surgical prognosis and are technically more complicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">This surgical complexity has led to the development of alternative techniques to the clipping and evacuation of the aneurysm in the same procedure&#46; These alternatives include minimally-invasive surgical techniques&#44; stereotactic-guided evacuation&#44; endoscopic evacuation of the haematoma and image-guided percutaneous evacuation techniques of the haematoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25&#8211;31</span></a> In any case&#44; these studies have a low number of patients and there are no prospective and randomised studies that support the routine use of these theoretical applications&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The endovascular treatment of the aneurysm prior to the surgical evacuation of the haematoma has been described in several published studies of a few patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;32&#44;33</span></a> with some promising results in terms of technical efficacy&#44; safety and clinical efficacy &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Despite being series that include few patients&#44; the percentage of independent patients at 30 days exceeds 50&#37;&#44; as in our series&#44; with a relatively low mortality compared to the surgical series and practically similar to the series of patients with poor clinical status without haematoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2&#44;10&#44;15&#44;16&#44;32&#44;33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">One of the biggest criticisms of this protocol is the delay in the surgical evacuation of the haematoma&#46; In our series&#44; the mean time from diagnosis to embolisation of the haematoma is 115<span class="elsevierStyleHsp" style=""></span>min&#44; and several cases have been obtained that are around 80<span class="elsevierStyleHsp" style=""></span>min&#46; These times seem quite adequate&#44; since during the embolisation the neurosurgical operating room can be prepared or even&#44; as several groups point out&#44; the embolisation and surgery can be performed in the same room&#44; or associate minimally invasive techniques for the removal of the haematoma in the angiography room&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#44;25&#8211;31</span></a> Currently&#44; in the era of endovascular treatment of ischaemic stroke&#44; this response time could be adjusted and improved&#44; since in most centres of excellence experienced in mechanical thrombectomy the room is usually available in less than 20<span class="elsevierStyleHsp" style=""></span>min from the notice to the endovascular team&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">34&#8211;36</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In spite of this urgency in the speed of the treatment&#44; an adequate closure of the aneurysm is achieved in more than 80&#37; of the cases with use of the remodelling balloon of more than 70&#37;&#46; This is reflected both in our series and in the references&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> In addition&#44; according to our experience&#44; the clipping of the embolised aneurysm is not necessary&#44; since there were no re-bleeds&#46; These re-bleeds are present in a very significant way in the surgical series&#44; mainly due to the high percentage of partial closures&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">8&#44;17&#44;20</span></a> This speed in treatment is also not reflected in the endovascular complications&#44; which in our series are equivalent to those published with the rest of ruptured aneurysms&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The main advantage of this protocol is the optimisation of the surgical evacuation of the haematoma&#44; which&#44; when performed in terms of safety&#44; allows for an appropriate technique and adequate results&#46; In our series&#44; evacuation of more than half of the haematoma was achieved in 82&#46;6&#37; of the cases&#44; and ventricular drainage could be associated in those patients who required it&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">This work has significant limitations&#58; it is a retrospective study that includes a small sample of patients&#46; In addition&#44; these patients are not consecutive&#44; since during the period of data collection there were several aneurysms with haematoma treated only with surgical techniques&#46; Prospective studies should be conducted to evaluate these combined protocols of endovascular and surgical techniques&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Like other published series&#44; this work confirms&#44; in our setting&#44; that endovascular treatment with subsequent neurosurgical evacuation of the intracranial haematoma in patients with SAH is a safe and effective combined treatment modality that could enable the improvement of the prognosis of patients with respect to classic surgical management&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authorship</span><p id="par0140" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Study design&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Data collection&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Analysis and interpretation&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Statistical processing&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Literature review&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Drafting of text&#58; EMQ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Critical review&#58; EMQ&#44; AGG&#44; PVV&#44; EMD&#44; DEA&#44; LVS&#44; AFC and JCGM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; EMQ&#44; AGG&#44; PVV&#44; EMD&#44; DEA&#44; LVS&#44; AFC and JCGM&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4<span class="elsevierStyleHsp" style=""></span>h of the onset of symptoms&#46; All patients had clinical signs of intracranial hypertension and&#47;or altered levels of consciousness&#44; including coma due to rostrocaudal deterioration&#46; We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients&#8217; prognosis one month after the procedures&#59; we evaluated safety by analyzing the complications of the treatments&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All but two of the patients &#40;21&#47;23&#59; 91&#46;3&#37;&#41; had an aneurysm of the middle cerebral artery&#46; All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V&#46; The mean time from the identification of the aneurysm on computed tomography to embolization was 115<span class="elsevierStyleHsp" style=""></span>min&#46; A balloon remodelling technique was used in 18 &#40;78&#37;&#41; patients&#59; embolization achieved adequate closure in 19 &#40;82&#46;6&#37;&#41; patients&#46; During surgery&#44; a ventricular drain was placed in 9 &#40;39&#46;1&#37;&#41; patients&#46; One month after treatment&#44; 13 &#40;56&#46;5&#37;&#41; patients were functionally independent and 3 &#40;13&#37;&#41; had died&#46; No episodes of rebleeding were observed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our experience&#44; combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Valorar si la t&#233;cnica de embolizaci&#243;n urgente del aneurisma cerebral y posterior cirug&#237;a del hematoma es segura y eficaz en pacientes con hematoma y signos de hipertensi&#243;n intracraneal por rotura de aneurisma cerebral&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 23 pacientes consecutivos con aneurisma cerebral roto y mal estado cl&#237;nico debido a un hematoma intracraneal&#44; ambos tratamientos completados en las primeras 4 horas del inicio de la cl&#237;nica&#46; Todos los pacientes presentaban signos cl&#237;nicos de hipertensi&#243;n intracraneal y&#47;o alteraci&#243;n del nivel conciencia&#44; incluido coma por deterioro rostrocaudal&#46; Se valor&#243; la eficacia de la t&#233;cnica mediante el grado de cierre de los aneurismas y el pron&#243;stico de los pacientes un mes despu&#233;s&#44; y la seguridad&#44; mediante el an&#225;lisis de las complicaciones de los tratamientos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 91&#44;3&#37; de los pacientes ten&#237;a un aneurisma localizado en la arteria cerebral media &#40;ACM&#41;&#46; Todos los pacientes presentaban un valour de 4 en la escala de Fisher y de IV-V en la escala de Hunt y Hess&#46; El tiempo medio desde la identificaci&#243;n del aneurisma en la tomograf&#237;a computarizada hasta la embolizaci&#243;n del aneurisma fue de 115 minutos&#46; Se us&#243; bal&#243;n de remodelling en el 78&#37; de los casos&#44; con el que se logr&#243; un cierre adecuado en el 82&#44;6&#37; de los pacientes&#46; Durante la cirug&#237;a se coloc&#243; un drenaje ventricular en 9 &#40;39&#44;1&#37;&#41; pacientes&#46; Al mes&#44; 13 &#40;56&#44;5&#37;&#41; pacientes eran independientes&#44; con una mortalidad del 13&#37;&#46; No existieron resangrados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra experiencia&#44; el tratamiento combinado mediante embolizaci&#243;n del aneurisma y descompresi&#243;n quir&#250;rgica con evacuaci&#243;n del hematoma es segura y efectiva&#44; y es una alternativa al tratamiento quir&#250;rgico aislado&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Coordinated work from the Interventional Neuroradiology Unit of the Radiology Service of the Central University Hospital of Asturias&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Murias Quintana E&#44; Gil Garc&#237;a A&#44; Vega Vald&#233;s P&#44; Morales Deza E&#44; Escudero Augusto D&#44; Vi&#241;a Soria L&#44; et al&#46; Tratamiento combinado&#44; mediante embolizaci&#243;n y cirug&#237;a&#44; de los aneurismas cerebrales rotos con hematoma cerebral e hipertensi&#243;n intracraneal&#58; An&#225;lisis retrospectivo y revisi&#243;n de la bibliograf&#237;a&#46; Radiolog&#237;a&#46; 2019&#59;61&#58;42&#8211;50&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Temporary scheme of the screening of patients&#46; SAH&#44; subarachnoid haemorrhage of aneurysmal aetiology&#46;</p>"
        ]
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        "figura" => array:1 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A 47-year-old patient who went to the emergency department for severe headache with loss of consciousness&#46; During the patient&#39;s stay&#44; their condition worsened clinically with right-sided hemiparesis&#44; mydriasis and decreased level of consciousness&#46; &#40;A&#41; Urgent cranial computed tomography &#40;CT&#41; without contrast showing the presence of an intraparenchymal and left Sylvian haematoma&#46; &#40;B&#41; Digital subtraction arteriography showing an aneurysm in the bifurcation of the left MCA with signs of rupture&#46; &#40;C&#41; It is embolised urgently and an adequate closure is achieved with a spiral of a coil in the subarachnoid space&#44; probably a rupture of the contained aneurysm&#46; &#40;D&#41; Cranial CT scan after the surgery of evacuation of the haematoma&#46; &#40;E&#41; Control CT scan at 90 days after cranioplasty&#59; the patient presented an adequate clinical evolution with mRS 1 at discharge&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A 27-year-old patient with severe headache associated with papilloedema and right mydriasis during transfer by the emergency services&#44; which forced urgent intubation&#46; &#40;A&#41; Cranial computed tomography &#40;CT&#41; scan on arrival at the hospital with acute subdural haematoma and cerebral herniation with deviation of the midline&#46; &#40;B&#41; Bilobed aneurysm at the origin of the posterior cerebral artery&#46; &#40;C&#41; Urgent embolisation of the aneurysm&#46; &#40;D&#41; Control after the surgery of evacuation of the haematoma with right wide craniectomy&#46; &#40;E&#41; Control after cranioplasty at 27 days after the haemorrhage&#46; The patient presented a good clinical evolution with mRS of 0 at discharge&#46;</p>"
        ]
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      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">MCA&#44; middle cerebral artery&#59; mRS&#44; modified Rankin scale&#59; PostCoA&#44; posterior communicating artery&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group of variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Values&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Epidemiological</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Age</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">53&#46;1 Mean &#40;32&#8211;71&#41;</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;13&#46;0&#37;&#41; over 65 years old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20 &#40;86&#46;9&#37;&#41; under 65 years old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;60&#46;8&#37;&#41; women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;21&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;56&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Clinical</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Hunt and Hess scale</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">4 Mean</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#46;0&#37;&#41;<br>HHS I&#44; II or III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">23 &#40;100&#46;0&#37;&#41;<br>HHS IV or V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Glasgow coma scale</td><td class="td" title="table-entry  " align="left" valign="top">Admission to urgent care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;13 Mean &#40;4&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angiography room&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;78 Mean &#40;4&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Radiological</td><td class="td" title="table-entry  " align="left" valign="top">Fisher scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">23 &#40;100&#46;0&#37;&#41;<br>Value of 4</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Location of haematoma</td><td class="td" title="table-entry  " align="left" valign="top">Intraparenchymal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;91&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subdural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;8&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Related to the aneurysm</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Location</td><td class="td" title="table-entry  " align="left" valign="top">MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;91&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PostCoA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;8&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemisphere&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;56&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;43&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Size of the aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">8&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;4&#8211;16&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Size of the neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">3&#46;4<span class="elsevierStyleHsp" style=""></span>mm &#40;2&#8211;6&#41;</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Related to the endovascular technique</td><td class="td" title="table-entry  " align="left" valign="top">Use of the remodelling balloon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">18 &#40;78&#46;3&#37;&#41;</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Degree of closure</td><td class="td" title="table-entry  " align="left" valign="top">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;52&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest of the neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;30&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest of the aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;17&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thromboembolic complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">1 &#40;4&#46;3&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemorrhagic complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">1 &#40;4&#46;3&#37;&#41;</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Related to the surgical technique</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Evacuation of the haematoma</td><td class="td" title="table-entry  " align="left" valign="top">More than 50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;82&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less than 50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;17&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Placement of ventricular drain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">9 &#40;39&#46;1&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intraoperative arterial bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">1 &#40;4&#46;3&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Related to time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Time to complete the endovascular treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">115<span class="elsevierStyleHsp" style=""></span>min &#40;84&#8211;180&#41;</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Post-operative</td><td class="td" title="table-entry  " align="left" valign="top">Hydrocephalus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">10 &#40;43&#46;5&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vasospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">7 &#40;30&#46;4&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endovascular treatment of vasospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">1 &#40;14&#46;3&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Re-bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">0 &#40;0&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">9 &#40;39&#46;1&#37;&#41;</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Prognosis</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">mRS at one month</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">2&#46;96 mean</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;56&#46;5&#37;&#41;<br>mRS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 &#40;43&#46;5&#37;&#41;<br>mRS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 &#40;13&#37;&#41; deaths<br>mRS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tokuda<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smith<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sasaki<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nakagawa<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Otani<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Otani<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bohnstedt<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Zhao<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Schuss<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">mRS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#47;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Re-bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Including a small number of embolised aneurysms&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">tmRS&#58; modified Rankin scale&#59; SAH&#58; subarachnoid haemorrhage of aneurysmal aetiology&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Prognosis of patients with SAH and intracranial haematoma treated with direct surgery&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Jeong<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Niemann<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">mRS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aneurysm location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&#37; MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&#37; MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;3&#37; MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adequate closure of the aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Series of patients with aneurysmal subarachnoid haemorrhage and intracranial haematoma in whom the treatment performed was embolisation of the aneurysm with subsequent surgical evacuation of the haematoma&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:36 [
            0 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Aneurysm surgery of patients in poor grade condition&#46; Indications and experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46; Ungersb&#246;ck"
                            1 => "H&#46; B&#246;cher-Schwarz"
                            2 => "P&#46; Ulrich"
                            3 => "A&#46; Wild"
                            4 => "A&#46; Perneczky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurol Res"
                        "fecha" => "1994"
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Article information
ISSN: 21735107
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos