Derivation of transcranial Doppler criteria for angiographically proven middle cerebral artery vasospasm after aneurysmal subarachnoid hemorrhage

BACKGROUND

Transcranial Doppler (TCD) has been subjected to criticism for detecting vasospasm (VSP). Our study's aim is to derive criteria for middle cerebral artery (MCA) vasospasm (MCA-VSP) based on cerebral angiography (CA).

METHODS

A prospective data of patients with aneurysmal subarachnoid hemorrhage (aSAH) from January 2004 to August 2009. TCD was performed daily from day 2 to 14 from symptom's onset. Follow-up CA was done at day 7-9. TCD mean flow velocities (MFV) of all vessels at baseline (b), middle (m) and before CA (preangio) were recorded. Several MCA MFV ratios were computed. Moderate to severe VSP on CA was defined as >1/3 luminal narrowing. Univariate and stepwise logistic regression analysis were performed.

RESULTS

One hundred sixty-nine patients (338 MCA) with aSAH were included, mean age: 54.8 ± 13, women: 103 (62%). Twenty-nine patients (8.6%) had angiographic MCA-VSP. TCD scoring system of 3 points for MCA-VSP was computed based on (a) bMCA MFV ≥ 120 cm/s (sensitivity: 59.3%, specificity: 85%, PPV: 36.4%, NPV: 93.5%, P < .001) (1 point), Preangio MCA MFV ≥ 150 cm/s (79.3%, 89.9%, 39%, 97.3%, <.001) (1 point), and affected preangio MCA/bMCA MFV ratio ≥ 1.5 (84%, 63%, 25.6%, 96.3%, .001) (1 point). The score of 3 has 96% sensitivity and 96% specificity (OR: 300) whereas the score of 1 has 12% sensitivity and 58% specificity (OR: 4.3) for identifying MCA-VSP.

CONCLUSION

TCD stringent criteria for moderate to severe MCA-VSP are feasible and applicable in aSAH population.

Aneurysmal subarachnoid hemorrhage in third and fourth decades of life

Objective

The aim of this study was to compare clinical characteristics of ruptured aneurysms in young adults, of the third and fourth decades of life, and to compare several clinical characteristics affecting the outcome of patients.

Methods

We retrospectively investigated 1459 patients who underwent surgery and endovascular treatment for ruptured cerebral aneurysms from June 1992 to December 2010 and compared clinical characteristics. We also reviewed pre-existing medical conditions and perioperative complications.

Results

Among 1459 patients, there were 21 patients (1.44%) in the third decade and 104 patients (7.13%) in the fourth decade of life. Within two age groups, 88 (70.4%) were male and 37 (29.6%) were female, a ratio of 2.37 : 1. In both groups, we observed the anterior cerebral artery (ACA) aneurysm with the most frequency (p=0.028). In general, favorable outcome was achieved in both age groups (90.5% and 81.7%, respectively). An initial univariate analysis showed Hunt-Hess grade, Fisher grade, location of aneurysm, and rebleeding significantly associated with outcome after aneurysm rupture. Further, multivariate analysis demonstrated that only Hunt-Hess grade (grade 4-5) was a risk factor for the outcome (odds ratio=9.730, 95% confidence interval 2.069-45.756, p=0.004).

Conclusion

The incidence of subarachnoid hemorrhage (SAH) was higher in the male population of the third and fourth decades of life. Aneurysms on the ACA were most frequently occurred in both age groups and the outcome of aneurysmal SAH among the third and fourth decades was favorable. Multivariate analysis revealed that high Hunt-Hess grade was a risk factor for patient's outcome.

Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report-

Neurogenic pulmonary edema (NPE) is a well-known complication of acute central neurologic injury, particularly aneurysmal subarachnoid hemorrhage. Both increased intracranial pressure and severe over-activation of the sympathetic nervous system seem to be pathogenetic for the onset of NPE. Although intracranial endovascular therapy is minimally invasive, it may affect brain stem regions and result in sympathetic activation. We now report the case of a 70-year-old woman who suddenly developed pulmonary edema during coil embolization of a ruptured aneurysm. During the intervention, oxygen saturation declined suddenly and a chest radiograph revealed pulmonary edema. The delayed appearance of NPE in this patient implies a risk for sympathetically mediated NPE during endovascular therapy.

Long-term health-related quality of life after spontaneous nontraumatic subarachnoid hemorrhage: self and proxy reports in a 10-year period

BACKGROUND

This study sought to examine health-related quality of life several years after spontaneous nontraumatic subarachnoid hemorrhage. Recent studies report impairments to be improved as far as normal levels. We question such an improvement in our own patient population over a period of 10 years.

METHODS

The Medical Outcomes Study 36-Item and Medical Outcomes Study 12-Item Short-Form Health Surveys on health-related quality of life were used to question 236 patients and 235 proxies. The patients were assigned to 5 groups according to the time that had elapsed since their hemorrhage: 1 year N = 22, 2 years N = 36, 5 years N = 86, 8 years N = 61, and 10 years N = 31. Analyses of variance (ANOVA, Kruskal-Wallis) and correlation (Spearman, Kendall tau) were used in an exploratory approach. Significance was established as P ≤ 0.05.

RESULTS

Over a period of 10 years, health-related quality of life is found to be impaired, and is reported as such by the patients themselves and their proxies. Comparison of the mean values between the groups, ie, 1, 2, 5, and 10 years, revealed no significant differences in health-related quality of life. The calculations with a view to correlations between the group means and time since hemorrhage also produced only very weak correlations of no significance.

CONCLUSIONS

Health-related quality of life is impaired over a period of 10 years. Spontaneous nontraumatic subarachnoid hemorrhage should be regarded as a chronic cerebrovascular condition.

Y-stenting endovascular treatment for ruptured intracranial aneurysms : a single-institution experience in Korea

Objective

Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. To achieve reconstruction of intracranial vessels with preservation of parent artery the use of stents has the greatest potential for assisted coiling. We report the results of our experiences in ruptured wide-necked intracranial aneurysms using Y-stent coiling.

Methods

From October 2003 to October 2011, 12 patients (3 men, 9 women; mean age, 62.6) harboring 12 complex ruptured aneurysms (3 middle cerebral artery, 9 basilar tip) were treated by Y-stent coiling by using self-expandable intracranial stents. Procedural complications, clinical outcome, and initial and midterm angiographic results were evaluated. The definition of broad-necked aneurysm is neck diameter over than 4 mm or an aneurysm with a neck diameter smaller than 4 mm in which the dome/neck ratio was less than 2.

Results

In all patients, the aneurysm was successfully occluded with no apparent procedure-related complication. There was no evidence of thromboembolic complication, arterial dissection and spasm during procedure. Follow-up studies showed stable and complete occlusion of the aneurysm in all patients with no neurologic deficits.

Conclusion

The present study did show that the Y-stent coiling seemed to facilitate endovascular treatment of ruptured wide-necked intracranial aneurysms. More clinical data with longer follow-up are needed to establish the role of Y-stent coiling in ruptured aneurysms.

Angiographic features and clinical outcomes of intra-arterial nimodipine injection in patients with subarachnoid hemorrhage-induced vasospasm

OBJECTIVE

The aim of this study was to determine the role of intra-arterial (IA) nimodipine injections for cerebral vasospasm secondary to ruptured subarachnoid hemorrhage (SAH) and to investigate the factors that influence vasodilation and clinical outcomes.

METHODS

We enrolled 29 patients who underwent aneurysm clipping for ruptured cerebral aneurysms between 2009 and 2011, and who received IA nimodipine after subsequently presenting with symptomatic vasospasm. The degree of vasodilation shown in angiography was measured, and the correlation between the degree of vasodilation and both the interval from SAH to cerebral vasospasm and the interval from clipping to cerebral vasospasm was determined. The change in blood flow rate after IA injection was assessed by transcranial Doppler ultrasound. Multiple clinical parameters were completed before and after IA nimodipine injection to evaluate any improvements in clinical symptoms.

RESULTS

For eight patients, Glasgow Coma Scale (GCS) scores increased by two or more points. The regression analysis demonstrated a positive correlation between the change in GCS scores after IA nimodipine injection and the change in blood vessel diameter (p=0.025). A positive correlation was also observed between the interval from SAH to vasospasm and the change in diameter (p=0.040); and the interval from clipping to vasospasm and the change in diameter (p=0.022).

CONCLUSION

IA nimodipine injection for SAH-induced vasospasm led to significant vasodilation in angiography and improvement in clinical symptoms without significant complications. Our findings suggest that IA nimodipine injection should be utilized when intractable vasospasm develops despite rigorous conservative management.

Cerebral hemodynamic changes induced by a lumbar puncture in good-grade subarachnoid hemorrhage

Background

Patients with good-grade subarachnoid hemorrhage (SAH) are those without initial neurological deficit. However, they can die or present severe deficit due to secondary insult leading to brain ischemia. After SAH, in a known context of energy crisis, vasospasm, hydrocephalus and intracranial hypertension contribute to unfavorable outcome. Lumbar puncture (LP) is sometimes performed in an attempt to reduce intracranial pressure (ICP) and release headaches. We hypothesize that in good-grade SAH patients, a 20-ml LP releases headaches, reduces ICP and improves cerebral blood flow (CBF) as measured with O¹⁵ PET scan.

Methods

Six good-grade (WFNS grade 1or 2) SAH patients (mean age 48 years, 2 women, 4 men) were prospectively included. All aneurysms (4 anterior communicating artery and 2 right middle cerebral artery) were coiled at day 1. Patients were managed according to our local protocol. LP was performed for severe headache (VAS >7) despite maximal painkiller treatment. Patients were included when the LP was clinically needed. The 20-ml LP was done in the PET scan (mean delay between SAH and LP: 3.5 days). LP allows hydrostatic measurement of ICP. Arterial blood pressure (ABP) was noninvasively gauged with photoplethysmography. Every signal was monitored and analyzed off-line. Regional CBF (rCBF) was measured semiquantitatively with O¹⁵ PET before and after LP. Then we calculated the difference between baseline and post-LP condition for each area: positive value means augmentation of rCBF after the LP, negative value means reduction of rCBF. Individual descriptive analysis of CBF was first performed for each patient; then a statistical group analysis was done with SPM for all voxels using t statistics converted to Z scores (p < 0.01, Z score >3.2).

Results

A 20-ml LP yielded a reduction in pain (–4), a drop in ICP (24.3 ± 12.5 to 6.9 ± 4.7 mm Hg), but no change in ABP. Descriptive and statistical image analysis showed a heterogeneous and biphasic change in cerebral hemodynamics: rCBF was not kept constant and either augmented or decreased after the drop in ICP. Hence, cerebrovascular reactivity was spatially heterogeneous within the brain. rCBF seems to augment in the brain region roughly close to the bleed and to be reduced in the rest of the brain, with a rough plane of symmetry.

Conclusions

In good-grade SAH, LP releases headaches and lowers ICP. LP and the drop in ICP have a heterogeneous and biphasic effect on rCBF, suggesting that cerebrovascular reactivity is not spatially homogeneous within the brain.

The relationship between subarachnoid hemorrhage volume and development of cerebral vasospasm

Objective

The objective of this study is to verify the relationship between subarachnoid hemorrhage (SAH) volume (not Fisher grade) and development of cerebral vasospasm prospectively.

Methods

Patients who visited our hospital with a diffuse or localized thick subarachnoid blood clot seen on computed tomography (CT), taken within 48 hours after SAH and the aneurysm was confirmed by CT Angiogram (CTA) from March 2010 to July 2011 were enrolled in this study. CTA was checked at least twice after admission. Angiographic vasospasm (AVS) on CTA was defined as irregularity or narrowing of intracranial vessels on follow up CTA compared with initial CTA. Total intracranial hemorrhage (ICH) volume (subdural, SAH, intracerebral and intraventricular) was calculated and SAH volume (all supratentorial and infratentorial cisterns) was also calculated using the MIPAV software package.

Results

A total of 55 patients were included in our study. Thirty six patients did not show AVS on CTA or clinical deterioration (non vasospasm group: NVS). AVS without ischemic neurologic symptoms was observed in four patients and development of symptomatic vasospasm (SVS), defined as AVS with ischemic symptoms, was observed in 15 patients. SAH volume in SVS patients was statistically larger than that in NVS patients (p < 0.05). Total ICH volume in SVS patients was larger than that in NVS patients. However, the difference was not statistically significant.

Conclusion

Results of this study indicate an association of development of vasospasm with the SAH volume, not intracranial hemorrhage.

Subarachnoid hemorrhage with negative baseline digital subtraction angiography: is repeat digital subtraction angiography necessary?

INTRODUCTION

Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA.

METHODS

A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA.

RESULTS

Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups.

CONCLUSION

In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.

Subarachnoid and intracerebral hemorrhage in patients with churg-strauss syndrome: two case reports

Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis of the small and medium vessels, associated with extravascular eosinophilic granulomas, peripheral eosinophilia, and asthma. The exact etiology of CSS is unknown. This syndrome commonly affects the lungs, peripheral nerves, skin, heart, and gastrointestinal tract, but rarely the central nervous system. Subarachnoid and intracerebral hemorrhage in CSS patients is extremely rare; however, clinicians should consider that CSS may be a cause of intracranial hemorrhage and its high rate of mortality and morbidity. The authors report on two cases of subarachnoid and intracerebral hemorrhage with CSS and discuss a brief review of CSS.

[Subhyaloid macular haemorrhage in Terson syndrome, treated by rupture of the posterior hyaloid using YAG laser]

CASE REPORT

We present the case of a 48 year-old man who had a sudden onset of vomiting, headache and loss of consciousness. The visual acuity was severely reduced in the left eye, with a large subhyaloid haemorrhage being observed in the fundus.

DISCUSSION

The combination of subarachnoid haemorrhage and a vitreous haemorrhage is called Terson syndrome. The details of the treatment of this case with YAG laser are also discussed.

Which clinical variable influences health-related quality of life the most after spontaneous subarachnoid hemorrhage? Hunt and Hess scale, Fisher score, World Federation of Neurosurgeons score, Brussels coma score, and Glasgow coma score compared

OBJECTIVE

To determine the strength of the correlation between the Hunt and Hess scale, Fisher score, Brussels coma score, World Federation of Neurosurgeons score, and Glasgow coma score and health-related quality of life.

METHODS

Evaluable questionnaires from 236 patients (5.6 years [± standard deviation, 2.854 years] on average after hemorrhage) were included in the analysis. Quality of life was documented using the MOS-36 item short form health survey. Because of the ordinal nature of the variables, Kendall tau was used for calculation. Significance was established as P ≤ 0.05.

RESULTS

Weak and very weak correlations were found in general (r ≤ 0.28). The strongest correlations were found between the Glasgow coma score and quality of life (r = 0.236, P = 0.0001). In particular, the "best verbal response" achieved the strongest correlations in the comparison, at r = 0.28/P = 0.0001. The Fisher score showed very weak correlations (r = -0.148/P = 0.012). The Brussels coma score (r = -0.216/P = 0.0001), Hunt and Hess scale (r = -0.197/P = 0.0001), and the World Federation of Neurosurgeons score (r = -0.185/P = 0.0001) revealed stronger correlations, especially in terms of the physical aspects of quality of life.

CONCLUSIONS

The Glasgow coma scale revealed the strongest, and the Fisher score showed the weakest correlations. Thus the Fisher score, as an indicator of the severity of a hemorrhage, has little significance in terms of health-related quality of life.

Cerebral vasospasm and health-related quality of life after subarachnoid hemorrhage

OBJECTIVE

To examine the influence of cerebral vasospasm on health-related quality of life after subarachnoid hemorrhage. An additional objective was to determine how the timing of nimodipine therapy can influence health-related quality of life.

METHODS

Patients treated between 1998 and 2008 for nontraumatic subarachnoid hemorrhages were sent a standardized questionnaire for the purposes of documenting their health-related quality of life. Initially the patients were divided into two groups: those with and those without cerebral vasospasm after hemorrhage (radiologically confirmed). They were then differentiated according to four types of treatment options for vasospasm: 1) nimodipine since admission (N = 179); 2) nimodipine since diagnosis of vasospasm (N = 14); 3) no nimodipine/no vasospasm (N = 34); and 4) no nimodipine despite vasospasm (N = 5). Significance was established as P ≤ 0.05.

RESULTS

Evaluable questionnaires were returned by 236 patients (68% women, mean age 56.35 ± 12.68 years; 32% men, mean age 54.57 ± 12.20 years). Health-related quality of life generally appeared to be impaired. Yet with the exception of the subscale (1 of 8) of physical role (P = 0.019), there were no differences between patients with and without vasospasm. Variations in the different treatment options revealed significant effects in terms of the component summaries and subscales: physical role and pain, general health, vitality, social functioning, emotional role, mental health, and mental component summary (P ≤ 0.04).

CONCLUSIONS

Cerebral vasospasm had little influence on health-related quality of life in our patient population. Health-related quality of life cannot be used as the only argument in favor of treating cerebral vasospasm with nimodipine.

Intravenous magnesium infusion for the prevention of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The study examined the difference in the incidence of symptomatic cerebral vasospasm with magnesium supplementation in aneurysmal subarachnoid hemorrhage (SAH) in a Korean population.

METHODS

This retrospective analysis was performed in 157 patients diagnosed with aneurysmal SAH from January 2007 to December 2011 at a single center. Seventy patients (44.6%) received a combination treatment of nimodipine with magnesium and 87 patients (55.4%) received only nimodipine. A matched case-control study using propensity scores was conducted and 41 subjects were selected from each group. A dosage of 64 mmol/day of magnesium was administrated.

RESULTS

The infusion of magnesium did not reduce the incidence of symptomatic cerebral vasospasm (n=7, 17.1%, p=0.29) compared with simple nimodipine injection (n=11, 26.8%). The ratios of good clinical outcome (modified Rankin scale 0-2) at 6 months were similar, being 78% in the combination treatment group and 80.5% in the nimodipine only group (p=0.79). The proportions of delayed cerebral infarction was not significantly lower in patients with combination treatment (n=2, 4.9% vs. n=3, 7.3%; p=0.64). There was no difference in the serum magnesium concentrations between the patients with symptomatic vasospasm and without vasospasm who had magnesium supplementation. No major complications associated with intravenous magnesium infusion were observed.

CONCLUSION

Magnesium supplementation (64 mmol/day) may not be beneficial for the reduction of the incidence of symptomatic cerebral vasospasm in patients with aneurysmal SAH.

Transient stress cardiomyopathies in the elderly: Clinical & Pathophysiologic considerations

Transient stress-induced cardiomyopathies have been increasingly recognized and while rare, they tend to affect elderly women more than other demographic groups. One type, often called tako-tsubo cardiomyopathy (TTC), is typically triggered by significant emotional or physical stress and is associated with chest pain, electrocardiogram (ECG) changes and abnormal cardiac enzymes. Significant left ventricular regional wall motion abnormalities usually include an akinetic “ballooning” apex with normal or hyperdynamic function of the base. A second type, often called neurogenic stunned myocardium, typically associated with subarachnoid hemorrhage, also usually presents with ECG changes and positive enzymes, but the typical wall motion abnormalities seen include normal basal and apical left ventricular contraction with akinesis of the mid-cavity in a circumferential fashion. The pathophysiology, clinical care and typical courses, are reviewed.

A Rare Case of Subarachnoid Hemorrhage due to Rupture of Isolated Anterior Spinal Artery Aneurysm in a Patient with Polycystic Kidney Disease

Only a very few cases of subarachnoid hemorrhage due to isolated anterior spinal artery aneurysms have been reported in the literature. We report a case of subarachnoid hemorrhage due to anterior spinal artery aneurysm rupture in a renal transplant patient at our institution. A 47-year-old male had abrupt onset of left lower extremity weakness with bowel and bladder disturbances which prompted emergent surgical evacuation of the clot and hence immediate diagnostic angiography was not performed. However, follow-up serial intracranial arterial ultrasound studies showed only vasospasm of the basilar artery. Repeat MRI of the thoracic spine showed persistence of subarachnoid blood products, but no larger foci compared to previous imaging. When spinal subarachnoid hemorrhage is present in the appropriate clinical setting, isolated anterior spinal artery aneurysm should be considered as a possible, treatable cause.

Effectiveness of nicardipine for blood pressure control in patients with subarachnoid hemorrhage

OBJECTIVE

The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH).

METHODS

We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure.

RESULTS

The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p < 0.001). In each subgroups of Fisher grade and different dose, SBP/DBP also decreased after the use of nicardipine. These were statistically significant (p < 0.05), but there was no significant difference in effectiveness between subgroups (p > 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications.

CONCLUSION

Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.

Salvage surgical treatment for failed endovascular procedure of a blood blister-like aneurysm

The blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) is a rare but clinically important cause of subarachnoid hemorrhage (SAH), which accounts for 0.5% of incidences of ruptured intracranial aneurysms. BBA is a thin-walled, broad-based aneurysm that lacks an identifiable neck and is one of the most difficult lesions to treat. In this paper, a case is presented of a 57-year-old woman with SAH. Her cerebral angiography demonstrated a small BBA on the dorsal wall of her right ICA. Endovascular treatment that consisted of a stent-within-a-stent was attempted, but the replacement of the second stent failed, and the aneurysm became bigger. Surgery was performed by clipping the BBA with a Sundt slim-line encircling graft clip. The patient completely recovered with no complications. This treatment may be a salvageable option for BBA, especially when endovascular treatment has failed.

Clinically significant cardiac arrhythmia in patients with aneurysmal subarachnoid hemorrhage

Objective

Many previous studies have shown that electrocardiographic (ECG) changes occur patients with subarachnoid hemorrhage (SAH). This study was designed to identify the frequency, influencing factors, and outcome of clinically significant cardiac arrhythmias after SAH.

Methods

We retrospectively analyzed clinical data of 122 patients including ECG finding, age, sex, the Hunt-Hess grade, the Fisher's grade, the history of hypertension, peak blood pressure and heart rate, location of aneurysm, Glasgow Outcome Scale (GOS) score, the days of admission to the intensive care unit, the presence of symptomatic vasospasm.

Results

Of 122 SAH patients, 50% (n = 61) had a verified clinically significant arrhythmia. There were no statistically significant independent factors associated with clinically significant arrhythmia in multivariate analysis. Although adjustments for the effects of age, Hunt-Hess grade, and the presence of symptomatic vasospasm on death were made, clinically significant arrhythmias were still independently predictive of death (no arrhythmia versus arrhythmia, 11.5% versus 27.9%, adjusted odds ratio [OR] 3.524, 95% confidence interval [CI] 1.229-10.100, p = 0.019) and poor outcome (GOS ≤ 2, 13.1% versus 29.5%, adjusted OR 3.202, 95% CI 1.174-8.732, p= 0.023).

Conclusion

Clinically significant arrhythmias after SAH are associated with a high mortality rate, and serious cardiac and neurological comorbidity. Patients with an abnormal ECG on admission should undergo close cardiac monitoring, and the presence of rhythm disturbances should prompt aggressive measures to treat myocardial infarction (MI), maintain a normal cardiac rhythm, and minimize the presence of autonomic stress.

Grading of intracerebral hemorrhage in ruptured middle cerebral artery aneurysms

OBJECTIVE

To propose grading of intracerebral hemorrhage (ICH) in ruptured middle cerebral artery (MCA) aneurysms, which helps to predict the prognosis more accurately.

METHODS

From August 2005 to December 2010, 27 cases of emergent hematoma evacuation and aneurysm clipping for MCA aneurysms were done in the author's clinic. Three variables were considered in grading the ICH, which were 1) hematoma volume, 2) diffuse subarachnoid hemorrhage (SAH) that extends to the contralateral sylvian cistern, and 3) the presence of midline shifting from computed tomography findings. For hematoma volume of greater than 25 mL, we assigned 2 points whereas 1 point for less than 25 cc. We also assigned 1 point for the presence of diffuse SAH whereas 0 point for the absence of it. Then, 1 point was assigned for midline shifting of greater than 5 mm whereas 0 point for less than 5 mm.

RESULTS

According to the grading system, the numbers of patients from grade 1 to 4 were 4, 6, 8 and 9 respectively and 5, 7, 8, 4 and 3 patients belonged to Glasgow Outcome Scale (GOS) 5 to 1 respectively. It was found that the patients with higher GOS had lower ICH grade which were confirmed to be statistically significant (p<0.01). Preoperative Hunt and Hess grade and absence of midline shifting were the factors to predict favorable outcome.

CONCLUSION

The ICH grading system composed of above three variables was helpful in predicting the patient's outcome more accurately.

Subarachnoid Hemorrhage Misdiagnosed as an Acute ST Elevation Myocardial Infarction

Without significant coronary artery stenosis, ischemic electrocardiographic change including ST segment elevation, segmental wall motion abnormality and elevated serum cardiac-specific markers (creatine kinase-MB, Troponin-T) may develop after central nervous system injuries such as subarachnoid, intracranial or subdural hemorrhage. Misdiagnosing these patients as acute myocardial infarction may result in catastrophic outcomes. By reporting a case of a 55-year old female with subarachnoid hemorrhage mimicking acute ST elevation myocardial infarction, we hope to underline that careful attention of neurologic abnormality is critical in making better prognosis.

Coil embolization of a ruptured basilar tip aneurysm associated with bilateral cervical internal carotid artery occlusion: a case report and literature review

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms

OBJECTIVE

Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures.

METHODS

A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10-82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome.

RESULTS

The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome.

CONCLUSIONS

Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

Subarachnoid hemorrhage mimicking leakage of contrast media after coronary angiography

We report a patient who developed subarachnoid hemorrhage (SAH) just after coronary angiography (CAG) with non-ionic contrast media (CM) and minimal dose of heparin. The 55-year-old man had a history of acute ST elevation myocardial infarction that had been treated with primary percutaneous coronary intervention and was admitted for a follow-up CAG. The CAG was performed by the transradial approach, using 1000 U of unfractionated heparin for the luminal coating and 70 mL of iodixanol. At the end of CAG, he complained of nausea and rapidly became stuporous. Brain CT showed a diffusely increased Hounsfield unit (HU) in the cisternal space, similar to leakage of CM. The maximal HU was 65 in the cisternal space. No vascular malformations were detected on cerebral angiography. The patient partially recovered his mental status and motor weakness after 2 days. Two weeks later, subacute SAH was evident on magnetic resonance imaging. The patient was discharged after 28 days.

Was Terson's Tersons?

Terson's syndrome has had multiple definitions. The original definition is unlikely to have included Terson's original case. An updated definition based on mechanism is proposed and related to the original case described by Terson.

Modified 'y-configured stents with waffle cone technique' for broad neck basilar top aneurysm

Stent assisted coiling on intracranial broad neck aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. However, stent navigation and application themselves often have the problems especially when the parent vessel angle (entrance between afferent and efferent vessel) is over 90 degrees. We report here a case of a ruptured broad neck basilar top aneurysm that was successfully coiled using two self-expandable stents (Enterprise and Neuroform) placed in a fashion of modified Y-configured stents with waffle cone technique.

De novo aneurysm after treatment of glioblastoma

A rare case of spontaneous subarachnoid hemorrhage from newly developed cerebral aneurysm in glioblastoma patient is presented. A 57-year-old man was presented with headache and memory impairment. On the magnetic resonance image and the magnetic resonance angiography, a large enhancing mass was found at right frontal subcortex and intracranial aneurysm was not found. The mass was removed subtotally and revealed as glioblastoma. He took concurrent PCV chemotherapy and radiation therapy, but the mass recurred one month later after radiotherapy. He was then treated with temozolomide for 7 cycles. Three months after the completion of temozolomide therapy, he suffered from a subarachnoid hemorrhage due to a rupture of a small de novo aneurysm at distal anterior cerebral artery. He underwent an aneurysm clipping and discharged without neurologic complication.

Predicting factors affecting clinical outcomes for saccular aneurysms of posterior inferior cerebellar artery with subarachnoid hemorrhage

OBJECTIVE

The aim of this study is to investigate the clinical outcomes of surgery and coiling and analyze the predicting factors affecting the clinical outcomes of ruptured posterior inferior cerebellar artery (PICA) aneurysms.

METHODS

During the last 15 years, 20 consecutive patients with ruptured PICA aneurysms were treated and these patients were included in this study. The Fisher's exact test was used for the statistical significance of Glasgow Outcome Scale (GOS) according to initial Hunt-Hess (H-H) grade, treatment modalities, and the presence of acute hydrocephalus.

RESULTS

Eleven (55%) and nine (45%) patients were treated with surgical clipping and endovascular treatment, respectively. Among 20 patients, thirteen (65.0%) patients had good outcomes (GOS 4 or 5). There was the statistical significance between initial poor H-H grade, the presence of acute hydrocephalus and poor GOS.

CONCLUSION

In our study, we suggest that initial H-H grade and the presence of acute hydrocephalus may affect the clinical outcome rather than treatment modalities in the ruptured PICA aneurysms.

Clinical features of acute subdural hematomas caused by ruptured intracranial aneurysms

OBJECTIVE

Spontaneous acute subdural hematomas (aSDH) secondary to ruptured intracranial aneurysms are rarely reported. This report reviews the clinical features, diagnostic modalities, treatments, and outcomes of this unusual and often fatal condition.

METHODS

We performed a database search for all cases of intracranial aneurysms treated at our hospital between 2005 and 2010. Patients with ruptured intracranial aneurysms who presented with aSDH on initial computed tomography (CT) were selected for inclusion. The clinical conditions, radiologic findings, treatments, and outcomes were assessed.

RESULTS

A total of 551 patients were treated for ruptured intracranial aneurysms during the review period. We selected 23 patients (4.2%) who presented with spontaneous aSDH on initial CT. Ruptured aneurysms were detected on initial 3D-CT angiography in all cases. All ruptured aneurysms were located in the anterior portion of the circle of Willis. The World Federation of Neurosurgical Societies grade on admission was V in 17 cases (73.9%). Immediate decompressive craniotomy was performed 22 cases (95.7%). Obliteration of the ruptured aneurysm was achieved in all cases. The Glasgow outcome scales for the cases were good recovery in 5 cases (21.7%), moderate disability to vegetative in 7 cases (30.4%), and death in 11 cases (47.8%).

CONCLUSION

Spontaneous aSDH caused by a ruptured intracranial aneurysm is rare pattern of aneurysmal subarachnoid hemorrhage. For early detection of aneurysm, 3D-CT angiography is useful. Early decompression with obliteration of the aneurysm is recommended. Outcomes were correlated with the clinical grade and CT findings on admission.

Angiographically occult vascular malformation of the cauda equina presenting massive spinal subdural and subarachnoid hematoma

We report a case of a non traumatic spinal subdural hematoma or subarachnoid hematoma manifesting as lumbago, leg pain and bladder dysfunction that showed angiographically occult vascular malformation (AOVM). Although the spinal angiogram did not reveal any vascular abnormality, the follow-up magnetic resonance image showed AOVM. Complete surgical removal was performed due to the aggravated bladder dysfunction. This case highlights the need to consider bleeding due to spinal AOVM, even when angiography is negative.

Safety and efficacy of transluminal balloon angioplasty using a compliant balloon for severe cerebral vasospasm after an aneurysmal subarachnoid hemorrhage

OBJECTIVE

Vasospasm of cerebral vessels remains a major source of morbidity and mortality after an aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to evaluate the safety and efficacy of transluminal balloon angioplasty (TBA) for SAH-induced vasospasm.

METHODS

Eleven patients with an angiographically confirmed significant vasospasm (>50% vessel narrowing and clinical deterioration) were studied. A total of 54 vessel segments with significant vasospasm were treated by TBA. Digital subtraction angiography was used to confirm the presence of vasospasm, and TBA was performed to dilate vasospastic arteries. Medical and angiographic reports were reviewed to determine technical efficacy and for procedural complications.

RESULTS

TBA using Hyper-Glide or Hyper-Form balloons (MicroTherapeutics, Irvine, CA) was successfully accomplished in 88.9% vasospastic segments (48 of 54), namely, in the distal internal carotid artery (100%, n=7), the middle cerebral artery (100%), including the M1 (n=10), M2 (n=10), and M3 segments (n=4), in the vertebral artery (100%, n=2), basilar artery (100%, n=1), and in the anterior cerebral artery (ACA), including the A1 (66%), A2 (66%), and A3 segments (100%). Vessel diameters significantly increased after TBA. There were no cases of vessel rupture or thromboembolic complications. GCS at one day after TBA showed an improvement in all patients except one.

CONCLUSION

This study suggests that TBA using Hyper-Glide or Hyper-Form balloons is a safe and effective treatment for subarachnoid hemorrhage-induced cerebral vasospasm.

The challenge of managing fusiform basilar artery aneurysms: from acute ischemic stroke to a massive subarachnoid hemorrhage

We present the case of a patient with acute brain stem ischemic stroke who was found to have a fusiform basilar aneurysm with a thrombus within the dilated vessel. Three days after the ischemic stroke, the patient had a massive subarachnoid hemorrhage and died. This case illustrates the difficulties in the acute management of ischemic events in patients with basilar fusiform aneurysms, because the natural history of this disease encompasses both bleeding and thrombosis.

Transient left ventricular apical ballooning in a patient with cardiac arrest after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) often accompanies cardiac abnormalities. Sudden cardiac arrest is also known to occur after SAH. A 32-year-old woman was admitted to our hospital because of cardiac arrest immediately after the onset of SAH. Return of spontaneous circulation was obtained by conventional advanced cardiovascular life support. After resuscitation, her echocardiogram showed left ventricular apical ballooning, which improved within 7 days. This is the first report presenting both sudden cardiac arrest and transient left ventricular apical ballooning after SAH.

Subarachnoid hemorrhage from a dissecting aneurysm of the posterior cerebral artery in a child : rebleeding after stent-assisted coiling followed by stent-within-stent technique

Pediatric patients with dissecting aneurysms usually present with ischemia rather than bleeding. We report a case of a 15-year-old boy with a dissecting aneurysm of the posterior cerebral artery (PCA) presenting with hemorrhage. He was first treated with stent-assisted coil embolization, in an attempt to avoid trapping of the PCA and preserve the perforators. After the procedure, he recovered well from general anesthesia, but rebleeding occurred from the same lesion 6 hours after the procedure, therefore endovascular segmental occlusion of the parent artery was performed secondarily. Apparently, a reconstructive method of stent-assisted coiling is worth trying to preserve the parent vessel and perforators, but it is not always efficient and durable for dissecting aneurysms.

Subarachnoid hemorrhage in neurofibromatosis type 1: case report of extracranial cerebral aneurysm rupture into a meningocele

Described here is a case of subarachnoid hemorrhage due to rupture of an extracranial vertebral artery (V3 segment) aneurysm in a patient with neurofibromatosis type 1 (NF-1). The pathophysiology of this never-before reported complication of NF-1 is examined in the light of a focused literature review and with illustrations characteristic of this unique case, involving complex malformations of the spine and meningeal spaces, as well as of the vertebral artery wall itself. All these abnormalities are directly related to the underlying NF-1 disease.

Treatment of vitamin K-dependent coagulation factor deficiency and subarachnoid hemorrhage

BACKGROUND

In adults, vitamin K-dependent coagulation factor deficiency (VKCFD) increases in the recent years. We treated a VKCFD patient with subarachnoid hemorrhage, with favorable outcomes.

METHODS

A 19-year-old male student with VKCFD was treated at our hospital. The initial treatment was injection of a large dose of vitamin K and fresh plasma, and then with oral high dose of vitamin K4.

RESULTS

At 4 weeks after admission, the focus of hemorrhage subsided, neurological examination was normal, and the patient was discharged.

CONCLUSIONS

VKCFD is rare and its diagnosis should be based on the history of the patient and the results of laboratory examinations. A large dose of vitamin K is the first choice of treatment.

Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

OBJECTIVE

The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH).

METHODS

We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated.

RESULTS

According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients.

CONCLUSION

Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.

Characteristics and management of residual or slowly recurred intracranial aneurysms

OBJECTIVE

Residual aneurysm from incomplete clipping or slowly recurrent aneurysm is associated with high risk of subarachnoid hemorrhage. We describe complete treatment of the lesions by surgical clipping or endovascular treatment.

METHODS

We analyzed 11 patients of residual or recurrent aneurysms who had undergone surgical clipping from 1998 to 2009. Among them, 5 cases were initially clipped at our hospital. The others were referred from other hospitals after clipping. The radiologic and medical records were retrospectively analyzed.

RESULTS

All patients presented with subarachnoid hemorrhage at first time, and the most frequent location of the ruptured residual or recurrent aneurysm was in the anterior communicating artery to posterior-superior direction. Distal anterior cerebral artery, posterior communicating artery, and middle cerebral artery was followed. Repositioning of clipping in eleven cases, and one endovascular treatment were performed. No residual aneurysm was found in postoperative angiography, and no complication was noted in related to the operations.

CONCLUSION

These results indicate the importance of postoperative or follow up angiography and that reoperation of residual or slowly recurrent aneurysm should be tried if such lesions being found. Precise evaluation and appropriate planning including endovascular treatment should be performed for complete obliteration of the residual or recurrent aneurysm.

A ruptured internal carotid artery aneurysm located at the origin of the duplicated middle cerebral artery associated with accessory middle cerebral artery and middle cerebral artery aplasia

Background:

Intracranial vascular anomalies involving the middle cerebral artery (MCA) are relatively rare, as such knowledge will be helpful for planning the optimal surgical procedures.

Case Description:

We herein present the first case of a ruptured internal carotid artery aneurysm arising at the origin of the hypoplastic duplicated MCA associated with accessory MCA and main MCA aplasia, which was revealed by angiograms and intraoperative findings.

Conclusion:

In practice, this case highlights the urgent need to preoperatively recognize such vascular anomalies as well as understand the collateral blood supply in cerebral ischemia associated with these MCA anomalies.

Revisiting normal perfusion pressure breakthrough in light of hemorrhage-induced vasospasm

Cerebral arteriovenous malformations (AVMs) have abnormally enlarged arteries and veins prone to spontaneous hemorrhage. Immediately following surgical excision of a cerebral AVM, even normal brain tissue surrounding the lesion is subject to hemorrhage, a phenomenon termed normal perfusion pressure breakthrough (NPPB) syndrome. According to this theory, arteries supplying cerebral AVMs become dilated and lose their capacity to dilate or constrict to autoregulate pressure. Acutely after removal of a cerebral AVM, excessive blood pressure in these arterial feeders can cause normal brain tissue to bleed. However, this theory remains controversial. We present a patient with a cerebral AVM that demonstrated cerebrovascular reactivity and argues against an assumption underlying the theory of NPPB syndrome.

Effects of mindfulness based stress reduction program on depression, anxiety and stress in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE

In this study, the Mindfulness Based Stress Reduction (MBSR) program was applied to patients presenting with depression and anxiety after surgery from spontaneous subarachnoid hemorrhage (SAH) and the effects were assessed.

METHODS

The subjects were patients admitted for cerebral aneurysm rupture and treated by means of surgery from March to December, 2007. More than 6 months had passed after surgery, without any special lesions showing up on computed tomography (CT), and the Glasgow outcome scale (GOS) was 5 points. Among patients with anxiety and depression symptoms, 11 patients completed the program. The MBSR program was conducted once a week, 2.5 hours each, for 8 weeks. The evaluation criteria were : 1) the Beck Depression Inventory (BDI): it measures the type and level of depression, 2) the State-Trait Anxiety Inventory : the anxiety state of normal adults without mental disorder, and 3) Heart Rate Variability (HRV) : the influence of the autonomous nervous system on the sinoarterial node varies continuously in response to the change of the internal/external environment.

RESULTS

The BDI value was decreased from 18.5 +/- 10.9 to 9.5 +/- 7.1 (p = 0.013) : it was statistically significant, and the depression level of patients was lowered. The state anxiety was decreased from 51.3 +/- 13.9 to 42.3 +/- 15.2; the trait anxiety was reduced from 50.9 +/- 12.3 to 41.3 +/- 12.8, and a borderline significant difference was shown (p = 0.091, p = 0.056). In other words, after the treatment, although it was not statistically significant, a decreased tendency in anxiety was shown. In the HRV measurement, standard deviation normal to normal (SDNN), square root of the square root of the mean sum of squared differences between adjacent normal to normal intervals (RMSSD), and total power (TP) showed significant increase, Physical Stress Index (PSI) showed a significant reduction, and thus an improvement in the homeostatic control mechanism of the autonomic nervous system was ween.

CONCLUSION

The MBSR program was applied to the patients showing anxiety and depression reaction after SAH treatment, and a reduction in depression symptoms and physiological reactions were observed. The application of the MBSR program may be considered as a new tool in improving the quality of life for patients after surgery.

Isolated, contralateral trochlear nerve palsy associated with a ruptured right posterior communicating artery aneurysm

Trochlear nerve palsy associated with spontaneous subarachnoid hemorrhage (SAH) is known to be a rare malady. We report here on a patient who suffered with left trochlear nerve palsy following rupture of a right posterior communicating artery aneurysm. A 56-year-woman visited our emergency department with stuporous mental change. Her Hunt-and-Hess grade was 3 and the Fisher grade was 4. Cerebral angiography revealed a ruptured aneurysm of the right posterior communicating artery. The aneurysm was clipped via a right pterional approach on the day of admission. The patient complained of diplopia when she gazed to the left side, and the ophthalmologist found limited left inferolateral side gazing due to left superior oblique muscle palsy on day 3. Elevated intracranial pressure, intraventricular hemorrhage or a dense clot in the basal cisterns might have caused this trochlear nerve palsy.

Subarachnoid Hemorrhage and Intracerebral Hematoma due to Sildenafil Ingestion in a Young Adult

Sildenafil citrate (Viagra(R); Pfeizer US Pharmaceutical Group, New York, NY, USA) is a potent vasodilating agent to treat male erectile dysfunction. Among its adverse effects, hemorrhagic stroke has not been widely reported yet. We present a case of a 33-year-old healthy man who ingested 50 mg sildenafil a half hour before onset of headache, nervousness and speech disturbance. Head computed tomogram of this stuporous man showed huge intracerebral hemorrhage and thick subarachnoid hemorrhage, but angiography failed to disclose any vascular anomalies. Subsequent surgical procedure was followed, and rehabilitation was provided thereafter. Sildenafil seems to act by redistributing arterial blood flow, and concurrent sympathetic hyperactivity, which lead to such hemorrhagic presentation. Extreme caution should be paid on even in a young adult male patient wven without known risk factors.

Cervical schwannoma presenting with acute intracranial subarachnoid hemorrhage

A subarachnoid hemorrhage (SAH) associated with negative finding on four-vessel angiography is seen in 5 to 30% of patients with intracranial SAH. A previously silent lesion in the spinal canal may be responsible for the angiographically negative finding for cause of intracranial SAH. We report a case of upper cervical (C1-2) intradural schwannoma presenting with acute intracranial SAH. Repeated cerebral angiographic studies were negative, but cervical magnetic resonance imaging study and tissue pathology revealed a intradural-extramedullary schwannoma in C1-2 level. This case illustrates the importance of a high index of clinical suspicion for spinal disease in angiographically negative intracranial SAH patients.

Incidence rate of Aneurysmal SAH in Gwangju City and Jeollanamdo Province in 2007

OBJECTIVE

The incidence of subarachnoid hemorrhage (SAH) worldwide varies considerably. In spite of many reports about the incidence of SAH, there has been no report about the incidence of SAH on the basis of the Korean population. The purpose of this hospital-based study was to assess the actual incidence rates of aneurysmal SAH in Gwangju city and Jeollanamdo province.

METHODS

All cases of SAH confirmed by computerized tomography (CT) between January 2007 and December 2007 were selected for analysis. For the data collection, three major training hospital and ten general hospitals working the CT in Gwangju city and four major general hospitals in Jeollanamdo province participate in this study.

RESULTS

According to the official census of Korea, the population was 1,413,444 in Gwangju city and 1,929,836 in Jeollanamdo province in 2007. There were 163 patients in Gwangju city and 266 patients in Jeollanamdo province confirmed SAH by CT in 2007. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages in Gwangju city were 11.5 and 12.4 for aneurysmal SAH and in Jeollanamdo province were 13.8 and 10.8. The incidence was higher in women and increased with age. The gender distribution varied with age. At young ages, the incidence was higher in men while after the age of 40 years, the incidence was higher in women.

CONCLUSION

In the present study, the age- and sex-adjusted annual incidence rates is 11.8 in Gwangju city and Jeollanamdo province. The incidence was higher in women and increased with age.

Aneurysmal rebleeding : factors associated with clinical outcome in the rebleeding patients

OBJECTIVE

Aneurysmal rebleeding is a major cause of death and disability. The aim of this study is to investigate the incidence of rebleeding, and the factors related with patient's outcome.

METHODS

During a period of 12 years, from September 1995 to August 2007, 492 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) underwent surgery at our institution. We reviewed the patient's clinical records, radiologic findings, and possible factors inducing rebleeding. Also, we statistically analyzed various factors between favorable outcome group (FG) and unfavorable outcome group (UG) in the rebleeding patients.

RESULTS

Rebleeding occurred in 38 (7.7%) of 492 patients. Male gender, location of aneurysm (anterior communicating artery) were statistically significant between rebleeding group and non-rebleeding group (p = 0.01 and p = 0.04, respectively). Rebleeding occurred in 26 patients (74.3%) within 2 hours from initial attack. There were no statistically significant factors between FG and UG. However, time interval between initial SAH to rebleeding was shorter in the UG compared to FG (FG = 28.71 hrs, UG = 2.9 hrs).

CONCLUSION

Rebleeding occurs more frequently in the earlier period after initial SAH. Thus, careful management in the earlier period after SAH and early obliteration of aneurysm will be necessary.

Recurrent subarachnoid hemorrhage after complete obliteration of intracranial aneurysm

The authors report a case of recurrent subarachnoid hemorrhage (SAH) after complete occlusion of an intracranial aneurysm. It is known that regrowth of an aneurysm after the complete clipping is a rare event. For detection of recurrence, however, it may be necessary to follow up with the patient regularly after the initial operation for intracranial aneurysms, because re-rupture of an aneurysm can cause a fatal result, and the cumulative risk of a recurrent SAH is thought to be not low over time.