Ruptured intracranial aneurysms. Case morbidity and mortality

The effects of epsilon aminocaproic acid on contractile properties and catecholamine content of rat carotid arteries

The prevalent use of epsilon aminocaproic acid (EACA) to prevent rebleeding in the preoperative management of ruptured intracranial aneurysms raises the question of a relationship between this drug and cerebral vasospasm. The effects of EACA on the contractile properties of the rat common carotid artery were measured in vitro, and the effects of EACA on the catecholamine content of these arteries were determined qualitatively. When carotid artery segments from rats that had been infused with lactated Ringer's solution alone were incubated in the presence of 1 mM EACA, they exhibited a decrease in contractile activity brought about by the presence of either serotonin or norepinephrine, and an increase in contractile activity when potassium chloride was used. These changes were not witnessed if the arterial segments came from rats that had been infused with lactated Ringer's solution containing EACA. No effect of epsilon aminocaproic acid was found on the median effective dose values for each vasoconstrictor used. Fluorescence histochemistry showed no qualitative changes in the catecholamine content of carotid arteries following EACA treatment.

Antifibrinolytic treatment in subarachnoid haemorrhage: present state

Two randomised controlled clinical trials in patients with recently ruptured intracranial aneurysms were undertaken using tranexamic acid (AMCA) to prevent early recurrent bleeding. In our accumulated series of 105 patients 53 were given AMCA and 52 were controls. 13% of the AMCA-treated patients and 31% of the controls rebled. In patients treated with AMCA the recurrent bleeding took place later than the rebleeding in the control patients. Vasospasm and delayed cerebral ischaemic deficits were seen more frequently in patients treated with AMCA. Total mortality from rebleeding and cerebral ischaemia was 25% in AMCA-treated patients and 19% in the controls during the six weeks' observation time. Coagulation factors remained unaffected by the drug. Local fibrinolysis in the cerebrospinal fluid decreased after one week in patients treated with AMCA. After two weeks the fibrinolytic activity was similar in AMCA-treated patients and in the controls. After experimental subarachnoid haemorrhage in 90 rabbits, AMCA was found to suppress plasminogen activator activity, mainly in the leptomeninges. This occurred however only during the first few postbleeding days. Antifibrinolytic agents only appear to reduce the risk of recurrent bleeding during the first ten day period after the primary aneurysm rupture. However they also seem to produce delayed cerebral ischaemia in patients with subarachnoid haemorrhage. Synthetic antifibrinolytics evidently shift the incidence of rebleeding curve to the right but these drugs are probably of diminished value in the subsequent weeks of risk.

Subarachnoid haemorrhage: epidemiology, natural history, and surgical treatment

We analysed 360 patients who presented with a proven subarachnoid haemorrhage during the period 1971-78. The most common cause was a cerebral aneurysm (75%), with the anterior communicating artery being the most common site for a ruptured aneurysm. Overall mortality rate before surgical intervention was 28%. During the period of study, 106 Grade 1 patients underwent direct clipping of their aneurysms; this procedure was associated with a 6.6% mortality rate. Delayed surgical intervention was associated with a lower surgical mortality rate.

Influence of timing of admission after aneurysmal subarachnoid hemorrhage on overall outcome. Report of the cooperative aneurysm study

The overall management results after aneurysmal rupture were studied in 158 patients admitted to the hospital on day 0--3 and 175 patients admitted on day 4--7 following subarachnoid hemorrhage. In this series surgery was planned no sooner than 12 days following the ictus. Despite effective medical and surgical therapy overall results were disappointing: 3 months following the initial hemorrhage only 43% of patients in the 0--3 day group and 53% of patients in the 4--7 day group were capable of independent functional living. Patients admitted on days 4--7 also had a lower mortality rate, re-bled less frequently, and had lower postoperative mortality and morbidity than those admitted on days 0--3. For reasons not well defined, time of admission following aneurysmal SAH has an important influence on outcome. Accordingly, in evaluating outcome for patients with ruptured aneurysms treated with different therapeutic modalities, time of admission must be carefully controlled.

Progress in cerebrovascular disease. Management of cerebral aneurysm

The primary effort of neurosurgery over the past two or three decades has been to deal effectively with cerebral aneurysms surgically. Concomitantly with aggressive medical treatment, considerable progress has occurred in the prevention of early rebleeding and the treatment of the ischemic syndrome, the most serious features of the natural history of a ruptured aneurysm. The major problem now becoming evident is that in spite of this progress, the majority of patients are not seen by physicians and there has been only a small impact on the overall morbidity. It is dismaying to realize that many patients go unrecognized, at least until a massive brain-destroying hemorrhage has occurred. Only a small fraction of the patients are seen after the initial bleed when the greatest therapeutic reward would occur. The challenge for the future, then, will be the early recognition of the initial bleeding, the warning bleeding. It will require public education about the problem in a continuing fashion, as well as continuing emphasis on it for students and physicians. The potential for prevention of death or dreadful disability is large for thousands in the prime of life each year. While delayed surgery is safe, a significant amount of rebleeding and ischemia with vasospasm still occur, resulting in an unsatisfactory overall morbidity. A collaborative study is desirable to determine with sufficient patients whether very early modern operation in many hands will reduce this morbidity.

Coagulation and fibrinolysis in blood and cerebrospinal fluid after aneurysmal subarachnoid haemorrhage: effect of tranexamic acid (AMCA)

Serial assays of blood coagulation factors as well as of fibrin/fibrinogen degradation products (FDP) and plasminogen activatory activity (PA) on fibrin plates in blood and cerebrospinal fluid (CSF) were performed in 41 consecutive patients with recently ruptured cerebral aneurysms, 21 of whom were randomly treated with tranexamic acid (AMCA). Coagulation factors were unaffected by the drug and plasminogen and FDP decreased in blood after two weeks' treatment. After one week, PA in CSF was increased in control patients and unchanged in AMCA-treated patients, whereas CSF-FDP had decreased among AMCA-treated patients. After two weeks PA as well as FDP in CSF showed the same values in both groups. An increase in CSF-FDP occurred after rebleeding and in patients with cerebral ischaemic symptoms. The results indicate that AMCA inhibits local fibrinolysis in CSF in patients with aneurysm rupture.

Vasoconstrictive effects of human post-hemorrhagic cerebrospinal fluid on cat pial arterioles in situ

Cat cortical arterioles were exposed in vivo to cerebrospinal fluid (CSF) from four patients with subarachnoid hemorrhage (SAH) due to a ruptured intracranial aneurysm. Pial arteriolar caliber was measured by the television image-splitting technique. There was a consistent vasoconstrictive response to CSF. This effect could be ascribed neither to the pH of the CSF nor to the potassium concentration. The vasoconstriction, which was more pronounced with decreasing arteriolar caliber, could be resolved by the perivascular application of nifedipine.

Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm

One hundred consecutive patients treated with epsilon aminocaproic acid 24 grams daily prior to surgery for ruptured intracranial aneurysms have been compared with the previous 100 patients managed similarly but without anti-fibrinolytic drugs. No other alterations in management were made and the two series are closely comparable in all other respects. Fewer episodes of recurrent haemorrhage and deaths from this cause occurred in the treated patients, but more cases of cerebral ischaemia occurred. Neither difference is statistically significant and overall more deaths occurred in the patients treated with antifibrinolytic drugs. The value of this method of treatment in the management of aneurysmal subarachnoid haemorrhage is questioned.

Early management of aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study

The overall results are presented of early medical management and delayed operation among 249 patients studied during the period 1974 to 1977, treated within 3 days of subarachnoid hemorrhage (SAH) and evaluated 90 days after aneurysm rupture. The results included 36.2% mortality, 17.9% survival with serious neurological sequelae, and 46% with a favorable outcome. Of the patients admitted in good neurological condition, 28.7% had died and only 55.7% had a favorable recovery at 90 days after SAH. These figures represent the results despite effective reduction in early rebleeding by antifibrinolytic therapy and successful surgery in those patients reaching operation. Further therapeutic advances are needed for patients hospitalized within a few days after SAH.

Long-term prognosis in surgically treated intracranial aneurysms. Part 1: Mortality

A series of 265 consecutive cases of intracranial aneurysm were reviewed to assess mortality and its causes. Preoperative and postoperative factors were considered in isolation and in combination. The mortality rate was 20%. Postoperative generalized vasospasm was found to be the major cause of mortality. Advanced age, hypertension, and a poor neurological state at operation were associated with poor results. The study emphasizes the importance of considering variables in combination rather than singly in the assessment of prognosis.

Thrombosis: the relationship of hemostatic mechanisms to drug therapy

The mechanism of action and present clinical role of drugs affecting hemostasis in the therapy of spontaneous, postoperative, and posttraumatic arterial thrombosis, arterial embolism, venous thrombosis, pulmonary embolism, and intracranial aneurysm have been reviewed. Both the management of neurosurgical problems and the development of antithrombotic regimens are improving. In regard to the use of drug therapy, discussed herein, each surgeon will reach his own decision based on his findings in the individual patient, and may wisely elect in specific situations not to employ drug therapy. The comments offered in ths analysis are to be construed as suggestions not mandates, as they will undoubtedly undergo modification with time. In closing, it is appropriate to recall a famous Chinese curse: "May you live," it reads, "in a time of transition."

Myoglobinuria following epsilon-aminocaproic acid (EACA) therapy. Case report

Myoglobinuria developed in a patient with subarachnoid hemorrhage treated with a course of 1.43 kg of epsilon-aminocaproic acid (EACA) given over 41 days. Review of eight other cases with a variety of medical disorders shows that this effect occurs after at least 4 weeks of taking doses of a minimum of 24 gm EACA per day. The effect seems to be reversible if discovered early. This side-effect should provide impetus for restricting the duration of EACA therapy to periods under 28 days, in doses no higher than 24 gm/day.

Surgical mortality in an aneurysm population: effects of age, blood pressure and preoperative neurological state

The mortality of 256 patients surgically treated for ruptured intracranial aneurysms was assessed with regard to age, systemic blood pressure on admission and preoperative neurological state. Increasing age, hypertension, and a poor neurological state (both singly and in combination) were found to influence surgical results dramatically. It is suggested that preoperative treatment of hypertension, and delay of operation in those patients aged over 50 years or hypertensive, as well as waiting for the neurological state to improve prior to operation, may lead to better results.

Intracranial aneurysms. Age, sex, blood pressure, and multiplicity in an unselected series of patients

All cases of intracranial aneurysm, arteriovenous malformation, and subarachnoid hemorrhage of undetermined etiology seen at one hospital over a 13-year period were reviewed to assess relationships between age, sex, systolic and diastolic blood pressure, and number of aneurysms. There were 350 patients, of whom 212 had aneurysms. The major findings were as follows: 1) Hypertension was not significantly more prevalent in the aneurysm population than in the age-matched general population, except for females aged 18 to 54 years (systolic pressure elevation of 10 to 15 mm Hg). 2) Under 55 years of age, both male and female hypertensive patients were twice as likely to have multiple aneurysms as normotensive patients. 3) Females were more likely than males to have multiple aneurysms. 4) For females but not males, increasing age, higher systolic pressure, and higher diastolic pressure all correlated with an increasing number of aneurysms. Hypertension appears to be more prevalent in certain subgroups of the total aneurysm population, although the individual relationships between hypertension, atherosclerosis, and aneurysms cannot be determined from either the present or previous studies. The possible role of familial factors, as well as implications for both diagnosis and further research, are briefly noted.

Prevention of early recurrence of spontaneous subarachnoid haemorrhage by epsilon-aminocaproic acid

A controlled clinical trial of epsilon-aminocaproic acid (E.A.C.A.), 36 g/day, was undertaken to assess its effectiveness in reducing immediate recurrence in patients with spontaneous subarachnoid haemorrhage (S.A.H.) proved by lumbar puncture. Of 83 patients treated with E.A.C.A., 3 (4%) had recurrent haemorrhage, and 1 (33%) of these died. Of 82 control patients who were not given any antifibrinolytic drug, 22 (26%) had recurrent haemorrhage, and 10 (45%) of these patients died. E.A.C.A. produced a striking reduction in the early recurrence of S.A.H. No serious side-effect resulted.

Scope of surgery for intracranial aneurysm in the elderly: a preliminary report

Thirty-two elderly patients were reviewed six months to six years after intracranial surgery for subarachnoid haemorrhage. Out of 24 patients whose surgical outcome had been satisfactory, one had died from an unrelated illness and the remainder were well and leading normal lives. Eight patients had a poor outcome, which in some cases was due to factors other than age. In only three could a poor outcome be attributed to early surgery and advanced age. The results confirm that in at least three-quarters of patients aged 60-65 the risk of further haemorrhage can be removed by surgery without causing a major neurological deficit.

Subarachnoid hemorrhage from intracranial aneurysms. Surgical management and natural history of disease

We analyzed the management of 310 patients with acute subarachnoid hemorrhage from a ruptured intracranial aneurysm, 280 of whom survived to operation, according to preoperative neurologic function, location and size of the aneurysm and timing of operation. Severe initial bleeding, rebleeding (usually within two weeks) and delayed ischemia were major preoperative problems; 10 per cent died, and 13 per cent deteriorated before operation. Operative mortality was 5 per cent, ranging from 1.6 per cent of patients with normal preoperative neurologic function to 35 per cent of severely disabled patients. Intraoperative complications (5 per cent of cases) related chiefly to the size and location of the aneurysm, but postoperative delayed ischemia (minor and reversible in 10 per cent and severe in 5 per cent) related to timing of operation and occurred primarily in patients afflicted within the previous 10 days. The results of surgical treatment, including preoperative deaths, were better than the natural history of the illness, the difference being apparent after one month's observation.

Comparative study of intracranial aneurysms in advanced age

A correlative angiographic and clinical analysis of 108 intracranial subdural aneurysms in patients from 60 to 84 years of age is presented. Angiographically defined spasm was present in about 54% of the cases. Spasm grades I and II had no apparent influence on clinical course, and grades III and IV were in some instances associated with arterial occlusion and infarction. There was no clear evidence that the spasm was related to hypertension, and no relationship could be established between preoperative and postoperative spasm. Atherosclerotic alterations in some cases were combined with a persistent narrowing of the arterial lumen.