1
|
Tasiou A, Brotis AG, Tzerefos C, Lambrianou X, Fountas KN. Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool. Neurosurg Focus 2022; 52:E11. [PMID: 35231886 DOI: 10.3171/2021.12.focus21649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/21/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations. METHODS A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis. CONCLUSIONS These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.
Collapse
|
2
|
Does Transport by a Doctor Helicopter Affect Blood Pressure in Stroke Patients? Air Med J 2020; 39:360-363. [PMID: 33012472 DOI: 10.1016/j.amj.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/01/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Herein we investigate whether transportation by doctor helicopter (DH) affects blood pressure (BP) in stroke patients. METHODS A total of 119 stroke patients treated by the DH between April 2015 and March 2019 were analyzed. The average BP before and after admission to the DH was compared for all stroke patients. The average BP before and after in the infarct group (cerebral infarction/transient ischemic attack) and the bleeding group (cerebral hemorrhage/subarachnoid hemorrhage) was compared. The average BP before and after in Glasgow Coma Scale (GCS) mild, moderate, and severe groups was also compared. Statistical analysis was performed using a paired t-test. RESULTS The average BP of stroke patients increased after admission to the DH (before = 156.8 mm Hg and after = 165.0 mm Hg, P < .01). Both the infarct group and the bleeding group had elevated BP after admission (infarct group: before = 151.2 mm Hg and after = 157.8 mm Hg, P = .02; bleeding group: before = 167.5 mm Hg and after = 178.5 mm Hg, P = .04). The BP after admission was elevated only in the mild GCS group. CONCLUSION When transporting conscious stroke patients by the DH, it is necessary to keep in mind that BP may elevate.
Collapse
|
3
|
Sin EG, Lee CY. Marked morphologic change of cerebral vessel with coexistence of severe flow compromise during endovascular treatment for ruptured aneurysm. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
4
|
|
5
|
Li Q, Yang Y, Pan Y, Duan L, Yang H. The quality assessment of clinical practice guidelines for intracranial aneurysms: a systematic appraisal. Neurosurg Rev 2017; 41:629-639. [PMID: 28905137 DOI: 10.1007/s10143-017-0905-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/17/2017] [Accepted: 09/04/2017] [Indexed: 11/27/2022]
Abstract
Intracranial aneurysms are common in adults. The relevant guidelines for patients with intracranial aneurysms aim to standardize the clinical practice and decision making for these patients. However, their management is controversial, and the quality of the guidelines has not been assessed. We aim to evaluate the quality of the guidelines for intracranial aneurysms as well as to compare and analyze the recommendations between different guidelines. Systematic searches were conducted to identify the guidelines for intracranial aneurysms from general electronic and guideline databases. Two independent reviewers identified the guidelines and extracted the data, and four reviewers independently evaluated the eligible guidelines through the AGREE II tool. Agreement among reviewers was measured using the intraclass correlation coefficient. A total of 12 guidelines, which were published from 1997 to 2016, were included. The agreement among reviewers was high (intraclass correlation coefficient, 0.85 (95% CI: 0.8-0.89)). The mean scores of six domains ranged from 16.5 to 57.5% (scope and purpose 57.5% (39-68%); stakeholder 30.8% (19-46%); rigor 31.9% (19-52%); clarity 57.2% (42-79%); applicability 24.9% (16-42%); and editorial independence: 16.5% (0-58%)). Furthermore, 202 recommendations related to intracranial aneurysms were collected from the included guidelines. Of these, 143 reported the quality of evidence and/or strength, and 119 reported both the quality of evidence and the strength. Of the 119 recommendations, there were six class A and 20 class B recommendations based on level III evidence. There were 12 recommendations in which the contents were similar between different guidelines and two recommendations with the opposite contents. The AGREE II scores of the guidelines for intracranial aneurysms were relatively low. The majority of recommendations were rated as classes A and B and based on levels II and III evidence. Approximately a fifth of strong recommendations was based on a low quality of evidence without interpretation or explanation.
Collapse
Affiliation(s)
- Qiao Li
- Department of Neurosurgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen Road, Chengguan District, Lanzhou, 730030, China
| | - Yingchun Yang
- Department of Neurosurgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen Road, Chengguan District, Lanzhou, 730030, China
| | - Yawen Pan
- Department of Neurosurgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen Road, Chengguan District, Lanzhou, 730030, China.
| | - Lei Duan
- Department of Neurosurgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen Road, Chengguan District, Lanzhou, 730030, China
| | - Hu Yang
- Department of Neurosurgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen Road, Chengguan District, Lanzhou, 730030, China
| |
Collapse
|
6
|
Konczalla J, Seifert V, Beck J, Güresir E, Vatter H, Raabe A, Marquardt G. Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980-1995) versus post-ISAT era (2005-2014). J Neurosurg 2017; 128:100-110. [PMID: 28298025 DOI: 10.3171/2016.8.jns161075] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre-International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction. METHODS The authors analyzed cases of Hunt and Hess Grade V SAH from 1980-1995 (referred to in this study as the earlier period) and 2005-2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0-2) or unfavorable (mRS score of 3-6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions. RESULTS Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period. Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0-3 (vs 3 and 7, respectively, for the DC MCA trials). CONCLUSIONS Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0-3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005-2014) had a favorable outcome. However, careful individual decision making is essential in these cases.
Collapse
|
7
|
Ahmed O, Kalakoti P, Hefner M, Cuellar H, Guthikonda B. Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature. J Cerebrovasc Endovasc Neurosurg 2015; 17:113-9. [PMID: 26157691 PMCID: PMC4495085 DOI: 10.7461/jcen.2015.17.2.113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 10/17/2014] [Accepted: 03/19/2015] [Indexed: 11/23/2022] Open
Abstract
Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.
Collapse
Affiliation(s)
- Osama Ahmed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Matthew Hefner
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| |
Collapse
|
8
|
English SW, Chassé M, Turgeon AF, Tinmouth A, Boutin A, Pagliarello G, Fergusson D, McIntyre L. Red blood cell transfusion and mortality effect in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis protocol. Syst Rev 2015; 4:41. [PMID: 25927348 PMCID: PMC4392797 DOI: 10.1186/s13643-015-0035-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to important morbidity and mortality in a young patient population. Anemia following aSAH is common and may be exacerbated by the treatments instituted by clinicians as part of standard care. The role and optimal thresholds for red blood cell (RBC) transfusion in this patient population remains unknown. METHODS/DESIGN We will conduct a systematic review of the literature using MEDLINE, EMBASE, and EBM Reviews (including Cochrane Central databases) using a comprehensive search strategy for observational and interventional studies of RBC transfusion in aSAH. Our primary objective is to evaluate the association of RBC transfusion with mortality in aSAH patients. Secondary objectives include a) determining associations between RBC transfusion and poor neurologic outcome, b) defining an optimal RBC transfusion threshold in aSAH patients, and c) describing complications associated with RBC transfusion in aSAH patients. We plan a descriptive reporting of all included citations including study characteristics, methodological quality, and reported outcomes. Clinical and statistical heterogeneity observed between studies will be described. If appropriate, meta-analyses of suitable studies and interpretation of their results will be performed. Effect measures will be converted to obtain relative risks and odds ratios (RR and ORs) with 95% confidence intervals and pooled according to study design (randomized trials and observational studies respectively) using a random effects model. DISCUSSION This review will summarize the existing observational and trial evidence regarding RBC transfusion in aSAH patients. The analytical plan has made considerations for different study designs, both observational and interventional in nature, and will summarize the best available evidence to inform the end user and policy and guideline producers and to highlight areas in need of further study. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014014806.
Collapse
Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada. .,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Michaël Chassé
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Alexis F Turgeon
- Department of Anesthesia (Critical Care), Hôpital L'Enfant-Jésus, 1401, 18e Rue, H-037, Québec, QB, G1J 1Z4, Canada.
| | - Alan Tinmouth
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Amélie Boutin
- Department of Anesthesia (Critical Care), Hôpital L'Enfant-Jésus, 1401, 18e Rue, H-037, Québec, QB, G1J 1Z4, Canada.
| | - Giuseppe Pagliarello
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada.
| | - Dean Fergusson
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada. .,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| |
Collapse
|
9
|
Chun-jing H, Shan O, Guo-dong L, Hao-xiong N, Yi-ran L, Ya-ping F. Effect of cervical sympathetic block on cerebral vasospasm after subarachnoid hemorrhage in rabbits. Acta Cir Bras 2013; 28:89-93. [PMID: 23370920 DOI: 10.1590/s0102-86502013000200001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 12/12/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Cerebral vasospasm (CVS) is a major complication after subarachnoid hemorrhage (SAH) induced by the rupture of intracranial aneurysms. The aim of the present study was to investigate the effect and mechanism of cervical sympathetic block on cerebral vasospasm of the rabbits after SAH. METHODS After successful modeling of cervical sympathetic block, 18 healthy male white rabbits were randomly divided into three groups (n=6), ie, sham operation group (Group A), SAH group (Group B) and SAH with cervical sympathetic block group (Group C). Models of delayed CVS were established by puncturing cisterna magna twice with an injection of autologous arterial blood in Groups B and C. A sham injection of blood through cisterna magna was made in Group A. 0.5 ml saline was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 3 d in Group B (bilateral alternating). 0.5 ml of 0.25% bupivacaine was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 7 d in Group B. 2 ml venous blood and cerebrospinal fluid were obtained before (T1), 30 min (T2) and 7 d (T3) after the first injection of blood, respectively, and conserved in a low temperature refrigerator. Basilar artery value at T1, T2 and T3 was measured via cerebral angiography. The degree of damage to nervous system at T1 and T3 was recorded. RESULTS There was no significant difference in diameter of basilar artery at T1 among three groups. The diameters of basilar artery at T2 and T3 of Groups B and C were all smaller than that in Group A, which was smaller than Group C, with a significant difference. There was no significant difference in NO and NOS in plasma and cerebrospinal fluid among three groups. The NO and NOS contents at T2 and T3 of Groups B and C were all lower than Group A; Group C was higher than Group B, with a significant difference. The nerve function at T3 of Groups B and C were all lower than Group A and that of Group C higher than Group B, with a significant difference. CONCLUSION Cervical sympathetic block can relieve cerebral vasospasm after subarachnoid hemorrhage and increase NO content and NOS activity in plasma and cerebrospinal fluid to promote neural functional recovery.
Collapse
Affiliation(s)
- He Chun-jing
- Department of Anesthesiology, People's Hospital of Guizhou Province, China
| | | | | | | | | | | |
Collapse
|
10
|
Shaygannejad V, Janghorbani M, Ashtari F, Zakeri H. Comparison of the effect of aspirin and amantadine for the treatment of fatigue in multiple sclerosis: a randomized, blinded, crossover study. Neurol Res 2013; 34:854-8. [DOI: 10.1179/1743132812y.0000000081] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Vahid Shaygannejad
- Department of NeurologyMedical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Janghorbani
- Department of Epidemiology and BiostatisticsSchool of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fereshteh Ashtari
- Department of NeurologyMedical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hasanali Zakeri
- Department of NeurologyMedical School, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
11
|
Liu J, Yao GE, Zhou HD, Jiang XJ, Xie P. Clinical investigation of fasudil for the prevention of cerebral vasospasm in extracranial carotid artery stenting. Cell Biochem Biophys 2013; 68:185-8. [PMID: 23801155 DOI: 10.1007/s12013-013-9687-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To evaluate fasudil hydrochloride for the prevention of cerebral vasospasm (CVS) in extra-cranial carotid angioplasty and stenting (CAS). We retrospectively analyzed 178 patients with unilateral CAS who were given intravenous fasudil hydrochloride during the perioperative period. CVS, hypotension, stroke, and mortality incidence rates were recorded. Of the cohort studied, 80.9 % patients exhibited no local CVS, asymptomatic vasospasm was observed in 17.4 % patients and symptomatic vasospasm in 1.7 % patients via DSA imaging. All CVS was relieved and symptoms disappeared after intra-arterial infusion of papaverine hydrochloride. Intracerebral hemorrhage occurred in two cases during the perioperative period, one of which resulted in death. CVS is a severe complication of CAS. Fasudil hydrochloride can rapidly relieve cerebral vasospasm, has no selective effect on cerebral vasculature, and little influence on blood pressure. It is suitable for the prevention of CVS during interventional treatment of ischemic cerebrovascular disease.
Collapse
Affiliation(s)
- Juan Liu
- Department of Neurology, Daping Hospital, Third Military Medical University, Chongqing, China
| | | | | | | | | |
Collapse
|
12
|
McNeill L, English SW, Borg N, Matta BF, Menon DK. Effects of Institutional Caseload of Subarachnoid Hemorrhage on Mortality. Stroke 2013; 44:647-52. [DOI: 10.1161/strokeaha.112.681254] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lisa McNeill
- From the Division of Anaesthesia, University of Cambridge, Cambridge, UK (L.M., D.K.M.); Department of Medicine (Critical Care), the Ottawa Hospital, Ottawa, Ontario, Canada (S.W.E.); and Department of Clinical Neurosciences (N.B.) and Neurosciences Critical Care Unit (B.F.M.), Addenbrooke’s Hospital, Cambridge, UK
| | - Shane W. English
- From the Division of Anaesthesia, University of Cambridge, Cambridge, UK (L.M., D.K.M.); Department of Medicine (Critical Care), the Ottawa Hospital, Ottawa, Ontario, Canada (S.W.E.); and Department of Clinical Neurosciences (N.B.) and Neurosciences Critical Care Unit (B.F.M.), Addenbrooke’s Hospital, Cambridge, UK
| | - Nicholas Borg
- From the Division of Anaesthesia, University of Cambridge, Cambridge, UK (L.M., D.K.M.); Department of Medicine (Critical Care), the Ottawa Hospital, Ottawa, Ontario, Canada (S.W.E.); and Department of Clinical Neurosciences (N.B.) and Neurosciences Critical Care Unit (B.F.M.), Addenbrooke’s Hospital, Cambridge, UK
| | - Basil F. Matta
- From the Division of Anaesthesia, University of Cambridge, Cambridge, UK (L.M., D.K.M.); Department of Medicine (Critical Care), the Ottawa Hospital, Ottawa, Ontario, Canada (S.W.E.); and Department of Clinical Neurosciences (N.B.) and Neurosciences Critical Care Unit (B.F.M.), Addenbrooke’s Hospital, Cambridge, UK
| | - David K. Menon
- From the Division of Anaesthesia, University of Cambridge, Cambridge, UK (L.M., D.K.M.); Department of Medicine (Critical Care), the Ottawa Hospital, Ottawa, Ontario, Canada (S.W.E.); and Department of Clinical Neurosciences (N.B.) and Neurosciences Critical Care Unit (B.F.M.), Addenbrooke’s Hospital, Cambridge, UK
| |
Collapse
|
13
|
Audibert G, Hoche J, Baumann A, Mertes PM. Désordres hydroélectrolytiques des agressions cérébrales : mécanismes et traitements. ACTA ACUST UNITED AC 2012; 31:e109-15. [DOI: 10.1016/j.annfar.2012.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
14
|
Evidence-Based Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage English Edition. Neurol Med Chir (Tokyo) 2012; 52:355-429. [DOI: 10.2176/nmc.52.355] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
15
|
Hemorragia subaracnoidea aneurismática: Guía de tratamiento del Grupo de Patología Vascular de la Sociedad Española de Neurocirugía. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70007-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
16
|
Consolidating a Resilience Network to Boost Civilian Resilience during Emergencies. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00022482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
17
|
Guerrero López F, de la Linde Valverde CM, Pino Sánchez FI. [General management in intensive care of patient with spontaneous subarachnoid hemorrhage]. Med Intensiva 2009; 32:342-53. [PMID: 18842226 DOI: 10.1016/s0210-5691(08)76212-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency and often a neurologic catastrophe. Nontraumatic subarachnoid hemorrhage is characterized by the extravasation of blood into the spaces covering the central nervous system. The leading cause of SAH is rupture of an intracranial aneurysm, which accounts for about 80-85% of cases. Mortality and morbidity can be reduced if SAH is treated urgently. Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH; computered tomography (CT) scanning is mandatory in all the patients with symp toms that are suggestive of SAH. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. Diagnosing SAH can be challenging and treatment is complex, sophisticated and multidisciplinary. Reble eding is the most imminent danger, which must be prevented by endovascular occlusion with detachable coils (coiling) or by surgical clipping of the aneurysm; the risk of delayed cerebral ischemia is reduced with nimodipine and avoiding hypovolemia; hydrocephalus can be treated by ventricular drainage. Intensive care plays a more important role in the management of SAH than in any other neurological disorder. Excellence in neurologic diagnosis, in operative neurosurgery or neuroradiologic procedures must be accompanied by excellence in Intensive Care. This review emphasizes treatment in the Intensive Care Unit, surgical and endovascular therapeutic options and the current state of treatment of major complications such as rebleeding, cerebral vasospasm and acute hydrocephalus.
Collapse
Affiliation(s)
- F Guerrero López
- Servicio de Cuidados Críticos y Urgencias. Medicina Intensiva. Hospital de Rehabilitación y Traumatología. Hospital Universitario Virgen de las Nieves. Granada. España.
| | | | | |
Collapse
|
18
|
Qureshi AI, Janardhan V, Hanel RA, Lanzino G. Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review. Lancet Neurol 2007; 6:816-25. [PMID: 17706565 DOI: 10.1016/s1474-4422(07)70217-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intracranial aneurysms can be treated with endovascular or surgical techniques. We provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials. We compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2-6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients' clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.
Collapse
Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN 55455, USA.
| | | | | | | |
Collapse
|
19
|
Tanno Y, Homma M, Oinuma M, Kodama N, Ymamoto T. Rebleeding from ruptured intracranial aneurysms in North Eastern Province of Japan. A cooperative study. J Neurol Sci 2007; 258:11-6. [PMID: 17512010 DOI: 10.1016/j.jns.2007.01.074] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Revised: 11/29/2006] [Accepted: 01/23/2007] [Indexed: 11/25/2022]
Abstract
OBJECT Rebleeding from ruptured intracranial aneurysms is a major cause of death and disability. With regard to the factors that precipitate the rebleeding and influence the time course after initial bleeding, previous reports differ in their results, and the number of patients investigated was not sufficient for valid conclusions. This study was thus designed to clarify the factors related to rebleeding from ruptured intracranial aneurysms in a large group of patients of the North Eastern Province of Japan. METHODS We found 181 patients with rebleeding after hospitalization among 5612 cases of ruptured intracranial aneurysms from January 1997 to December 2001 in 33 major hospitals in the North Eastern Province of Japan. We analyzed the data with respect to the time course after bleeding and rebleeding, the arterial blood pressure, the situation when rebleeding occurred, the methods of neuroimaging, the level of consciousness, the treatment and the outcome. RESULTS Of 181 patients who were hospitalized, rebleeding occurred in 65 (35.9%) within 3 h and 88 (48.6%) within 6 h after the initial subarachnoid hemorrhage (SAH). The consciousness level before the rebleeding varied widely in distribution, but belonged to the drowsiness or less [Japan coma scale (JCS) single-digit] in 83 patients (45.8%), but after rebleeding, JCS triple-digits (semicoma to coma) included 152 patients (84.0%). Systolic arterial blood pressure prior to rebleeding was most commonly between 120 and 140 mmHg. Rebleeding did occur more frequently during angiography (totally 29 patients, 20%) and much less frequently during 3D-CTA and MRA procedures (a single case). Treatment consisted of aneurysm neck clipping in 72 patients (40.0%), endovascular therapy with coils in 4 patients (2.2%) and conservative ones in 103 patients (56.9%). As to outcome, 109 patients with rebleeding (60.2%) died in 3 months following initial SAH. CONCLUSION Rebleeding occurs more frequently in the earlier period after the initial SAH than previously believed. Thus, more aggressive pharmacologically induced systemic arterial hypotension appears to be important for preventing rebleeding but ultimate outcome of more aggressive hypotension is yet to be determined. If feasible, in order to avoid catheter-angiography related rebleeding, evaluations solely with 3D-CTA and MRA should be in consideration and earlier surgical intervention seems essential as rebleeding does occur often within the first 3 h of onset.
Collapse
Affiliation(s)
- Yoshihiro Tanno
- Department of Neurology, Fukushima Medical University Fukushima, Fukushima, Japan.
| | | | | | | | | |
Collapse
|
20
|
Kurata A, Suzuki S, Niki J, Ozawa H, Yamada M, Fujii K, Kan S, Kitahara T, Miyasaka Y, Ohmomo T. Endovascular surgery for ruptured aneurysms with vasospasm. Interv Neuroradiol 2007; 13 Suppl 1:48-52. [PMID: 20566076 DOI: 10.1177/15910199070130s105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 01/15/2007] [Indexed: 11/17/2022] Open
Abstract
SUMMARY With the existence of vasospasm, it is recommended that direct clipping surgery for a ruptured aneurysm be delayed until its disappearance, but this may be associated with aneurysmal re-rupture resulting in a poor outcome for the patients. Indications for endovascular coil embolization in such cases are discussed. Since November in 2003, we have applied endovascular coil embolization in 11 consecutive patients with ruptured aneurysms and apparent vasospasm of the parent artery from two to 17 days (average: eight days) after initial subarachnoid hemorrhage. Three patients had aneurysmal re-rupture before treatment, but the other eight had only experienced the one episode of subarachnoid hemorrhage. With one exception, all endovascular procedures could be successfully performed, resulting in complete occlusion of aneurysms and remarkable dilatation of inserted spastic vessels without technical complications or aneurysmal re-rupture. For the one case of failure because of a tortuous artery, direct clipping surgery was performed after disappearance of vasospasm. Cerebral infarction occurred in four, but only one correlated with the distribution of catheterization, and neurological deficits had completely disappeared three months after the onset. This preliminary report concerning a small number of patients suggests that endovascular coil embolization is not contra-indicated for aneurysms with vasospasm requiring catheterization. A large study for confirmation is now warranted.
Collapse
Affiliation(s)
- A Kurata
- Departments of Neurosurgery, Radiology and Critical Care Medicine, Kitasato University School of Medicine, Kanagawa, Japan -
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Kitsuta Y, Suzuki N, Sugiyama M, Yamamoto I. Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage. Prehosp Disaster Med 2006; 21:190-5. [PMID: 16892884 DOI: 10.1017/s1049023x00003666] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION It is crucial to predict and prevent re-bleeding from ruptured intracranial aneurysms in patients with subarachnoid hemorrhage (SAH). During the prehospital period and on arrival to the hospital, blood glucose and serum potassium levels, as well as changes in levels of consciousness were assessed in patients in the acute stage of spontaneous subarachnoid hemorrhage. These assessments were analyzed as possible risk factors for re-bleeding and as potential contributors to the prevention of re-bleeding, both in prehospital care and after hospital admission. METHODS Upon the arrival of 202 patients with spontaneous subarachnoid hemorrhage, the following indications were examined retrospectively: (1) presence/absence of re-bleeding; (2) time interval between the onset of SAH and re-bleeding; (3) level of consciousness using the Glasgow Coma Scale (GCS) score before and on arrival; (4) amount and distribution of subarachnoid blood using Fisher's Computerized Tomography Classification; (5) blood pressure; (6) blood glucose concentration; and (7) serum potassium concentration. The patients were hospitalized in the Yokohama City University Critical Care and Emergency Center (Yokohama, Japan) between January 1991 and December 2000. The re-bleeding rate was analyzed using the chi-square (chi2 test, and the averages and standard deviations of hematological data were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. RESULTS The overall re-bleeding rate was 20.8%. Among 119 patients with a GCS score of 3-7 before arrival, 42 (35.3%) had re-bleeding, but none of the 83 patients with a GCS score of 8-15 before arrival had re-bleeding. Of 105 patients with a GCS score of 13-15 on arrival, 14 (51.8%) of 27 patients whose consciousness level was a GCS score of 3-7 before arrival experienced re-bleeding. The re-bleeding rate of this group was high. Moreover, this rebleeding group had a significantly higher blood glucose concentration than did the patients whose GCS score was 13-15 both before and on arrival. Between the patients with or without re-bleeding, there was no significant difference in the blood pressure on arrival or in distribution according to Fisher's Computerized Tomography Classification CONCLUSION Since the re-bleeding rate is high in patients who have hyperglycemia and a history of a level of consciousness as low as a GCS score of 3-7, a detailed assessment of level of consciousness and blood glucose tests performed on arrival provide important information that will contribute to predicting and preventing re-bleeding. This may be extended to the prehospital phase, because blood glucose tests are simple and safe when performed by paramedics.
Collapse
Affiliation(s)
- Yoichi Kitsuta
- Critical Care and Emergency Center and Department of Neurosurgery, School of Medicine, Yokohama City University, Yokohama, Japan.
| | | | | | | |
Collapse
|
22
|
Imhof HG, Yonekawa Y. Management of ruptured aneurysms combined with coexisting aneurysms. ACTA NEUROCHIRURGICA. SUPPLEMENT 2005; 94:93-6. [PMID: 16060246 DOI: 10.1007/3-211-27911-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
In patients suffering from subarachnoid haemorrhage (SAH) and presenting with multiple intracranial aneurysms (MIA) two questions have to be decided on: 1st when is the ideal moment to eliminate the ruptured aneurysm and 2nd when to treat the coexisting aneurysms. In our series we retrospectively analysed 124 SAH-patients presenting with a total of 323 aneurysms. In 57 patients the ruptured aneurysm and all coexisting aneurysms were clipped during the first operation, whereas in 9 patients only some of the coexisting aneurysms (group-A; age in median 55 years) were clipped besides the ruptured one. In 55 patients (group-B; age in median 55 years) the first operation was restricted to clipping the ruptured aneurysm, dealing with the coexisting aneurysm subsequently. Immediately after admission 3 patients passed away. One of the 64 patients waiting (average 60 days, median 14 days) for the subsequent clipping of the not yet secured aneurysms suffered a SAH. Six to 12 months after the initial SAH, 78% of the cases in both groups reached a Glasgow Outcome Score of 4 or 5. Even if in patients with coexisting unruptured intracranial aneurysms the elimination of each and every aneurysm is recommended, the advantages of an unstaged procedure versus the additional strain caused by the prolongation of the procedure, e.g. approach over the midline, 2 or more craniotomies, and the risk of additional ischemic damage to the brain, caused by increased manipulation of cerebral arteries and brain tissue, have to be carefully considered. This is of special importance in dealing with patients in higher Hunt and Hess grades.
Collapse
Affiliation(s)
- H G Imhof
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
| | | |
Collapse
|
23
|
Audibert G, Puybasset L, Bruder N, Hans P, Berré J, Beydon L, Ravussin P, Boulard G, Ter Minassian A, de Kersaint-Gilly A, Dufour H, Gabrillargues J, Bonafé A, Proust F, Lejeune JP. Hémorragie sous-arachnoïdienne grave : natrémie et rein. ACTA ACUST UNITED AC 2005; 24:742-5. [PMID: 15885975 DOI: 10.1016/j.annfar.2005.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- G Audibert
- Service d'anesthésie-réanimation chirurgicale, hôpital central, CO n 34, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy cedex, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Chieregato A, Tagliaferri F, Tanfani A, Cocciolo F, Benedettini W, Compagnone C, Ravaldini M, Pascarella R, Battaglia R, Frattarelli M, Targa L, Fainardi E. Cerebral blood flow in mean cerebral artery low density areas is not always ischemic in patients with aneurysmal subarachnoid hemorrhage--relationship with neurological outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2005; 95:153-8. [PMID: 16463841 DOI: 10.1007/3-211-32318-x_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) can be complicated by reduction of regional cerebral blood flow (rCBF) from large conductance vessels leading to focal edema appearing as an area of hypoattenuation on CT. In this study we included 29 patients with SAH due to aneurysmal rupture, having 36 CT low density areas within the middle cerebral artery territory in whom a total of 56 Xenon-CT (Xe-CT) studies were performed. Collectively, we evaluated 70 hypoattenuated areas. rCBF levels were measured in two different regions of interest drawn manually on the CT scan, one in the low density area and the other in a corresponding contralateral area of normal-appearing brain tissue. In the low density area (22.6 +/- 22.7 ml/100 gr/min) rCBF levels were significantly lower than in the contralateral area (32.8 +/- 17.1 7 ml/100 gr/min) (p = 0.0007). In the injured areas deep ischemia (CBF < 6 ml/ 100 g/min) was present in only 25.7% of Xe-CT studies, suggesting that hypodense areas are not always ischemic, whereas in 43.7% of the lesions/Xe-CT studies we found hyperemic values. Patients with a better outcome had hyperemic lesions, suggesting brain tissue recovery in injured areas.
Collapse
Affiliation(s)
- A Chieregato
- Neurorianimazione, Ospedale M. Bufalini, Cesena, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Selo-Ojeme DO, Marshman LAG, Ikomi A, Ojutiku D, Aspoas RA, Chawda SJ, Bawa GPS, Rai MS. Aneurysmal subarachnoid haemorrhage in pregnancy. Eur J Obstet Gynecol Reprod Biol 2004; 116:131-43. [PMID: 15358453 DOI: 10.1016/j.ejogrb.2004.04.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2003] [Revised: 02/23/2004] [Accepted: 04/05/2004] [Indexed: 11/24/2022]
Abstract
Although uncommon, aneurysmal subarachnoid haemorrhage (SAH) in pregnancy can be devastating for both mother and baby. It is the leading cause of other indirect maternal death in England and Wales accounting for 60 deaths in the decade 1988-1999. No single obstetric or neurosurgical unit has sufficiently large database or experience in managing this condition in pregnancy. With significant improvements in antenatal care and management of deliveries, non-obstetric causes of maternal death such as aneurysmal subarachnoid haemorrhage are likely to become increasingly significant. The clinical features of aneurysmal subarachnoid haemorrhage closely resemble those of other commoner conditions seen in pregnancy. It is therefore imperative that awareness by obstetricians and other frontline staff is increased so that a high index of suspicion is maintained when pregnant women present with unique headaches. Prompt neurosurgical referral is vital and early involvement of an experienced neuroradiologist essential. It is only when an early diagnosis is made and an aggressive treatment instituted that the bleak case-fatality figure associated with aneurysmal subarachnoid haemorrhage in pregnancy can be improved. This review, by a multidisciplinary and multicenter team, provides a comprehensive update on the epidemiology, aetiology, clinical presentation, diagnosis and the complexities of the multidisciplinary management of this serious and potentially fatal condition when it occurs in pregnancy.
Collapse
Affiliation(s)
- Daniel O Selo-Ojeme
- Directorate of Obstetrics, Gynaecology and Paediatrics, Basildon and Thurrock University Hospitals NHS Trust, Nethermayne, Basildon, Essex SS16 5NL, UK.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Zhou C, Yamaguchi M, Kusaka G, Schonholz C, Nanda A, Zhang JH. Caspase inhibitors prevent endothelial apoptosis and cerebral vasospasm in dog model of experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2004; 24:419-31. [PMID: 15087711 DOI: 10.1097/00004647-200404000-00007] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Apoptosis in the endothelium of major cerebral arteries may play a role in the initiation and maintenance of cerebral vasospasm after subarachnoid hemorrhage (SAH). We tested the therapeutic effect of caspase inhibitors on endothelial apoptosis and on cerebral vasospasm in an established dog double-hemorrhage model. Thirty-one mongrel dogs were divided into five groups: control; SAH; SAH treated with vehicle [DMSO]; SAH treated with Ac-DEVD-CHO [a specific caspase-3 inhibitor]; and SAH treated with Z-VAD-FMK [a broad caspase inhibitor]. The inhibitors (100 microM) were injected into the cisterna magna daily from Day 0 through Day 3. Angiography was performed on Day 0 and Day 7. Histology, TUNEL staining, and immunohistochemistry were conducted on basilar arteries collected on Day 7 after SAH. Positive staining of TUNEL, poly(ADP)-ribose polymerase (PARP), caspase-3, and caspase-8 was observed in the endothelial cells of the spastic arteries. Double fluorescence labeling demonstrated co-localization of TUNEL with caspase-3 and TNFalpha receptor-1 (TNFR1). Ac-DEVD-CHO and Z-VAD-FMK prevented endothelial apoptosis and reduced angiographic vasospasm. The mechanism of apoptosis in endothelial cells involves TNFR1 and the caspase-8 and caspase-3 pathways. Caspase inhibitors may have potential in the treatment of cerebral vasospasm.
Collapse
Affiliation(s)
- Changman Zhou
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, 71130-3932, USA
| | | | | | | | | | | |
Collapse
|
27
|
Adams HP, Davis PH. Aneurysmal Subarachnoid Hemorrhage. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
28
|
Treggiari MM, Romand JA, Martin JB, Reverdin A, Rüfenacht DA, de Tribolet N. Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage. Stroke 2003; 34:961-7. [PMID: 12649526 DOI: 10.1161/01.str.0000060893.72098.80] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage. METHODS Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure. RESULTS No complications occurred in this short series. The procedure appeared to be simple and safe. Horner's signs appeared within 12+/-0.1 minutes and lasted for an average of 6.3+/-4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment. CONCLUSIONS Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.
Collapse
Affiliation(s)
- Miriam M Treggiari
- Division of Surgical Intensive Care, Department of Anesthesia, Pharmacology, and Surgical Intensive Care, Geneva University Hospital, Geneva, Switzerland.
| | | | | | | | | | | |
Collapse
|
29
|
Abstract
While there have been many advances in the field of microneurosurgery, the clipping of aneurysms remains an intricate procedure. Technical complications include residual aneurysm, perforator injuries, parent artery occlusion and cranial nerve injuries. The neuroendoscope is a useful tool and adjunct to the microsurgical clipping of these aneurysms. We study the usefulness of the neuroendoscope in enhancing visualisation during surgery. Twenty-four cases of ruptured cerebral aneurysms were operated on over a duration of 6 months in which a 1mm diameter rigid endoscope was used. We discuss our preliminary results and examine the advantages of the neuroendoscope. These include the ability to look around corners and behind obstructions. While this provides an additional view to the surgeon, the high magnification gives good definition of the surrounding structures. With less brain retraction, smaller operative exposures and yet better visualisation offered, neuroendoscopy may reduce operative morbidity.
Collapse
Affiliation(s)
- Ernest Wang
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | | | | |
Collapse
|
30
|
Perkins E, Kimura H, Parent AD, Zhang JH. Evaluation of the microvasculature and cerebral ischemia after experimental subarachnoid hemorrhage in dogs. J Neurosurg 2002; 97:896-904. [PMID: 12405379 DOI: 10.3171/jns.2002.97.4.0896] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECT Whether cerebral vasospasm occurs only in surface vessels or also in parenchymal arterioles is debatable. The present study was undertaken to evaluate comprehensively the microvasculature of the brainstem after experimental subarachnoid hemorrhage (SAH). METHODS Nine mongrel dogs of either sex, each weighing between 18 and 24 kg, underwent double blood injections spaced 48 hours apart; the injections were infused into the cisterna magna immediately after angiography of the basilar arteries (BAs). Three additional dogs assigned to a control group received no blood injections. The dogs were killed on Day 7. Axial sections obtained from the midpontine region of both control dogs and animals subjected to SAH were evaluated with respect to the morphological characteristics of vessels and neurons, and for ultrastructural changes. Severe vasospasm occurred in the BAs of all dogs subjected to SAH. Nevertheless, in these animals, the luminal areas and vessel perimeter in parenchymal arterioles, but not in parenchymal venules, were observed to have increased when compared with those of control dogs (p < 0.01, t-test). No corrugation of the internal elastic lamina was observed and smooth-muscle and endothelial cells remained normal at the ultrastructural level in the dogs with SAH. CONCLUSIONS In this model, vasospasm of the BAs did not extend into the region of the pons to affect the intraparenchymal arterioles. Dilation of the parenchymal arterioles might serve as compensation for reduced blood flow. Thus, no neuronal ischemia or infarction resulted in the pontine region of the brain.
Collapse
Affiliation(s)
- Eddie Perkins
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, USA
| | | | | | | |
Collapse
|
31
|
Koivisto T, Vanninen E, Vanninen R, Kuikka J, Halonen P, Hernesniemi J, Vapalahti M. Cerebral Perfusion before and after Endovascular or Surgical Treatment of Acutely Ruptured Cerebral Aneurysms: A 1-Year Prospective Follow-up Study. Neurosurgery 2002. [DOI: 10.1227/00006123-200208000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
32
|
Koivisto T, Vanninen E, Vanninen R, Kuikka J, Halonen P, Hernesniemi J, Vapalahti M. Cerebral Perfusion before and after Endovascular or Surgical Treatment of Acutely Ruptured Cerebral Aneurysms: A 1-Year Prospective Follow-up Study. Neurosurgery 2002. [DOI: 10.1097/00006123-200208000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
33
|
Rollins S, Perkins E, Mandybur G, Zhang JH. Oxyhemoglobin produces necrosis, not apoptosis, in astrocytes. Brain Res 2002; 945:41-9. [PMID: 12113950 DOI: 10.1016/s0006-8993(02)02562-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Subarachnoid blood, resulting from traumatic brain injury or subarachnoid hemorrhage, has been linked with cell injury and stress gene induction. We investigated whether oxyhemoglobin (OxyHb), a major component in blood clots, exerts a cytotoxic effect on cultured astrocyte cells, and the pattern of cell death. METHODS A murine astrocyte cell line was used (passages 28-35). Cell growth studies were performed 24, 48, and 72 h after exposure to OxyHb (1, 10, and 30 microM). Western blot analysis of poly adenosine diphosphate [ADP]-ribose polymerase (PARP) cleavage and TUNEL stain analysis were performed to determine the presence of apoptosis. Cells treated with OxyHb were also evaluated with transmission electron microscopy to determine changes that may have occurred at the ultra-structural level. RESULTS OxyHb (10-30 microM), after 72-h incubation, inhibited cell growth. Western blot analysis of PARP and TUNEL staining for the presence of apoptosis were essentially negative in all groups. Ultrastructural analysis revealed an abundance of necrosis and random occurrences of apoptosis in a few cells. CONCLUSION Cultured astrocytes exposed to OxyHb causing cell growth inhibition could possibly be a result of cellular cytotoxicity and necrosis.
Collapse
Affiliation(s)
- Shadon Rollins
- Department of Neurosurgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MI 39216, USA
| | | | | | | |
Collapse
|
34
|
Newfield P, Hamid RK. Pediatric neuroanesthesia. Arteriovenous malformations. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2001; 19:229-35. [PMID: 11469062 DOI: 10.1016/s0889-8537(05)70226-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intracranial arteriovenous malformations can occur singly, multiply, and in conjunction with aneurysms and denovo, family, or in conjunction with connective-tissue disorders. Intracranial hemorrhage is the most common presentation, occurring in 20% to 50% of cases. In children, seizures are the second most common presentation occurring in 15% to 20% of cases. The modalities available treatment of arteriovenous malformations are microsurgery, embolization, and stereotactic radiosurgery with heavy particles, alpha knife, or linear accelerator. Induction, maintenance, and emergence from anesthesia are designed to prevent rupture of arteriovenous malformation and aneurysm and to improve intracranial compliance in the presence of an intracranial hematoma, during both diagnostic (CT, MR scanning) and therapeutic procedures.
Collapse
Affiliation(s)
- P Newfield
- Department of Anesthesiology, California Pacific Medical Center, San Francisco, California, USA
| | | |
Collapse
|
35
|
García-Delgado M, Colmenero-Ruiz M, Fernández-Sacristán MA, Rus-Mansilla C, Fernández-Mondéjar E. Effect of a catecholamine-induced increase in cardiac output on extravascular lung water. Crit Care Med 2001; 29:931-5. [PMID: 11378599 DOI: 10.1097/00003246-200105000-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the influence of dopamine- and dobutamine-induced increases in cardiac output on the extravascular lung water in an experimental model of pulmonary edema. DESIGN Animal experimental study. SETTING Animal experimental laboratory of a tertiary hospital. SUBJECTS Mixed-race pigs (n = 20) weighing 28-32 kg. INTERVENTIONS After the animals were anesthetized and tracheotomized, they were injected with 0.1 mL/kg of oleic acid, producing a pulmonary edema by increased permeability. The animals then were randomized into two groups: Group I (n = 10) received no medication to alter cardiac output and remained on mechanical ventilation during the 240 mins of the experiment; group II (n = 10) received a continuous infusion of dopamine and dobutamine to produce a cardiac output increase of >or=30% the basal value and underwent the same mechanical ventilation regimen as group I. MEASUREMENTS AND MAIN RESULTS Hemodynamic and respiratory variables were measured at 0 (baseline) and 30, 60, 120, 180, and 240 mins after the infusion of oleic acid. At 30 mins, the cardiac output of group II (5.40 +/- 0.94 L/min) was significantly (p < .005) higher than that of group I (3.65 +/- 1.02 L/min), and a similar significant increase was recorded at all measurement times until the end of the experiment. The mean pulmonary arterial pressure was similar in both groups except that at 240 mins it was significantly higher in group I (normal cardiac output) than in group II (high cardiac output; 34.9 +/- 7.9 mm Hg vs. 27.2 +/- 3.8 mm Hg, p = .01). The extravascular lung water was calculated by gravimetric method after the death of the animal. The extravascular lung water of group I (13.8 +/- 3.6 mL/kg) did not significantly differ from that of group II (11.5 +/- 4.0 mL/kg). CONCLUSIONS An increase in cardiac output experimentally produced by the infusion of dopamine and dobutamine does not modify the amount of extravascular lung water.
Collapse
Affiliation(s)
- M García-Delgado
- Department of Emergency and Critical Care, Virgen de las Nieves University Hospital, Granada, Spain.
| | | | | | | | | |
Collapse
|
36
|
Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC, Brott T, Hademenos G, Chyatte D, Rosenwasser R, Caroselli C. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2000; 31:2742-50. [PMID: 11062304 DOI: 10.1161/01.str.31.11.2742] [Citation(s) in RCA: 243] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
37
|
Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC, Brott T, Hademenos G, Chyatte D, Rosenwasser R, Caroselli C. Recommendations for the management of patients with unruptured intracranial aneurysms: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation 2000; 102:2300-8. [PMID: 11056108 DOI: 10.1161/01.cir.102.18.2300] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
38
|
Sturaitis MK, Rinne J, Chaloupka JC, Kaynar M, Lin Z, Awad IA. Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution. J Neurosurg 2000; 93:569-80. [PMID: 11014534 DOI: 10.3171/jns.2000.93.4.0569] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy. METHODS The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option. CONCLUSIONS The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.
Collapse
Affiliation(s)
- M K Sturaitis
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06520, USA
| | | | | | | | | | | |
Collapse
|
39
|
Rosenberg AL, Zimmerman JE, Alzola C, Draper EA, Knaus WA. Intensive care unit length of stay: recent changes and future challenges. Crit Care Med 2000; 28:3465-73. [PMID: 11057802 DOI: 10.1097/00003246-200010000-00016] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare case-mix adjusted intensive care unit (ICU) length of stay for critically ill patients with a variety of medical and surgical diagnoses during a 5-yr interval. DESIGN Nonrandomized cohort study. SETTING A total of 42 ICUs at 40 US hospitals during 1988-1990 and 285 ICUs at 161 US hospitals during 1993-1996. PATIENTS A total of 17,105 consecutive ICU admissions during 1988-1990 and 38,888 consecutive ICU admissions during 1993-1996. MEASUREMENTS AND MAIN RESULTS We used patient demographic and clinical characteristics to compare observed and predicted ICU length of stay and hospital mortality. Outcomes for patients studied during 1993-1996 were predicted using multivariable models that were developed and cross-validated using the 1988-1990 database. The mean observed hospital length of stay decreased by 3 days (from 14.8 days during 1988-1990 to 11.8 days during 1993-1996), but the mean observed ICU length of stay remained similar (4.70 vs. 4.53 days). After adjusting for patient and institutional differences, the mean predicted 1993-1996 ICU stay was 4.64 days. Thus, the mean-adjusted ICU stay decreased by 0.11 days during this 5-yr interval (T-statistic, 4.35; p < .001). The adjusted mean ICU length of stay was not changed for patients with 49 (75%) of the 65 ICU admission diagnoses. In contrast, the mean observed hospital length of stay was significantly shorter for 47 (72%) of the 65 admission diagnoses, and no ICU admission diagnosis was associated with a longer hospital stay. Aggregate risk-adjusted hospital mortality during 1993-1996 (12.35%) was not significantly different during 1988-1990 (12.27%, p = .54). CONCLUSIONS For patients admitted to ICUs, the pressures associated with a decrease in hospital length of stay do not seem to have influenced the duration of ICU stay. Because of the high cost of intensive care, reduction in ICU stay may become a target for future cost-cutting efforts.
Collapse
Affiliation(s)
- A L Rosenberg
- ICU Research, The Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC 20037, USA
| | | | | | | | | |
Collapse
|
40
|
Kaptain GJ, Lanzino G, Kassell NF. Subarachnoid haemorrhage: epidemiology, risk factors, and treatment options. Drugs Aging 2000; 17:183-99. [PMID: 11043818 DOI: 10.2165/00002512-200017030-00003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The present review focuses on subarachnoid haemorrhage (SAH) secondary to the rupture of an intracranial aneurysm, a condition with a high case fatality rate. Additionally, many of the surviving patients are left with significant disabilities. Risk factors for aneurysmal SAH include both genetic and acquired conditions. The most common presenting symptom is sudden onset of severe headache. Since headache is very common in the general population, it is not unusual that SAH is misdiagnosed at its onset with often catastrophic consequences. Unlike other acute neurological disorders such as brain injury, in which patient outcome is closely related to the extent of the injury occurring at the time of the trauma, patients with aneurysmal SAH are at risk of subsequent deterioration from 'avoidable' complications such as rebleed, vasospasm, hydrocephalus, and several other non-neurological general medical complications. Thus, the critical care management of the patient with SAH is of utmost importance in order to maximise the chances of satisfactory recovery. Although surgical clipping of the ruptured aneurysm remains the gold standard therapy, with the continuing refinement of endovascular techniques, a new, 'less invasive' option is now available, especially for patients considered poor surgical candidates.
Collapse
Affiliation(s)
- G J Kaptain
- Department of Neurosurgery, Derriford Hospital, Plymouth, England
| | | | | |
Collapse
|
41
|
Hino A, Fujimoto M, Iwamoto Y, Yamaki T, Katsumori T. False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage. Neurosurgery 2000; 46:825-30. [PMID: 10764255 DOI: 10.1097/00006123-200004000-00011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms. METHOD We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information. RESULTS The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding. CONCLUSION In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.
Collapse
Affiliation(s)
- A Hino
- Department of Neurosurgery, Saiseikai Shigaken Hospital, Ritto, Shiga, Japan
| | | | | | | | | |
Collapse
|
42
|
Hino A, Fujimoto M, Iwamoto Y, Yamaki T, Katsumori T. False Localization of Rupture Site in Patients with Multiple Cerebral Aneurysms and Subarachnoid Hemorrhage. Neurosurgery 2000. [DOI: 10.1227/00006123-200004000-00011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
43
|
Qureshi AI, Suarez JI, Bhardwaj A, Yahia AM, Tamargo RJ, Ulatowski JA. Early predictors of outcome in patients receiving hypervolemic and hypertensive therapy for symptomatic vasospasm after subarachnoid hemorrhage. Crit Care Med 2000; 28:824-9. [PMID: 10752836 DOI: 10.1097/00003246-200003000-00035] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Symptomatic vasospasm after subarachnoid hemorrhage (SAH) is associated with a high incidence of permanent disability and death. For early identification of patients who are at risk for poor outcome, we determined the predictors of outcome in patients with symptomatic vasospasm after SAH. DESIGN We retrospectively determined the prognostic value of clinical characteristics and computed tomographic scan both at admission and at the time of initiation of hypervolemic and hypertensive therapy. SETTINGS Neurosciences critical care unit at a University hospital. PATIENTS A total of 70 consecutive patients who developed symptomatic vasospasm after SAH. INTERVENTION Treatment with oral nimodipine, hypervolemic therapy, and hypertensive therapy. Angioplasty and intra-arterial papaverine were used in patients with vasospasm resistant to standard treatment. MEASUREMENTS AND MAIN RESULTS Poor outcome, defined as Glasgow Outcome Scale Score of 3-5 at 2 months or discharge, was observed in 32 (46%) patients. In the logistic regression analysis, a Glasgow Coma Scale (GCS) score of < or =11 (odds ratio, 11.0; 95% confidence interval, 3.6-39.3) and hydrocephalus (odds ratio, 4.3; 95% confidence interval, 1.2-18.2) at the time of initiation of hypervolemic and hypertensive therapy were significantly associated with poor outcome. Poor outcome was observed in 91% of the patients who had both a GCS score of < or =11 and hydrocephalus compared with 15% of patients with a GCS score of >11 and no hydrocephalus at the time of initiation of hypervolemic and hypertensive therapy. A GCS score of < or =11 was also independently associated with length of intensive care unit stay (F ratio = 18.0; p = .0011) and hospital stay (F ratio = 9.2; p = .0034) after initiation of hypervolemic and hypertensive therapy. CONCLUSIONS The results of this study suggest that outcome in patients with symptomatic vasospasm can be effectively predicted by routinely available information, including GCS score at the time of initiation of hypervolemic and hypertensive therapy. This information can be used for selection and stratification of patients in future treatment studies of patients with symptomatic vasospasm.
Collapse
Affiliation(s)
- A I Qureshi
- Division of Neurosciences Critical Care, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | | | | | | | | |
Collapse
|
44
|
Affiliation(s)
- J A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA.
| | | |
Collapse
|
45
|
Roda J, Conesa G, Diez Lobato R, Garcia Allut A, Gomez Lopez P, Gonzalez Darder J, Lagares A, Ley Garcia A, Lloret J, Martinez Rumbo R, Prada J, de la Riva A, Ruiz F, Soto M, Campollo J. Hemorragia subaracnoidea aneurismática. Introducción a algunos de los aspectos más importantes de esta enfermedad. Neurocirugia (Astur) 2000. [DOI: 10.1016/s1130-1473(00)70954-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
46
|
Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S, Hepner H, Picard L, Laxenaire MC. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke 1999; 30:1402-8. [PMID: 10390314 DOI: 10.1161/01.str.30.7.1402] [Citation(s) in RCA: 190] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH were studied as well. METHODS Symptomatic vasospasm was defined as the association of deterioration in a patient's neurological condition between 3 and 14 days after SAH with no other explanation and an increase in mean transcranial Doppler velocities of >120 cm/s. The prognostic factors were registered on admission and during the intensive care stay. RESULTS Symptomatic vasospasm occurred in 22.2% surgical patients compared with 17.2% endovascular treatment patients (P=0.37). Multivariate analysis revealed that the probability of occurrence of symptomatic vasospasm decreased with age >50 years (relative risk [RR], 0.47 [0.25 to 0.88]) and severe World Federation of Neurological Surgeons (WFNS) grade measured on admission (RR, 0.43 [0.20 to 0.90]) and increased with hyperglycemia occurring during the intensive care stay (RR, 1.94 [1.04 to 3.63]). No difference in risk of symptomatic vasospasm could be identified between surgical and endovascular treatment. Symptomatic vasospasm (OR, 4.73 [CI, 1. 77 to 12.6]) as well as WFNS grade of >2 (OR, 8.95 [3.46 to 23.2]), treatment complications (OR, 8.39 [3.16 to 22.3]), and secondary brain insults were associated with an increased risk of 6-month sequelae. CONCLUSIONS Age <50 years, good neurological grade, and hyperglycemia were all associated with an increased risk of cerebral vasospasm whereas treatment was not. This provides a basis for future clinical prospective randomized trials comparing both treatments.
Collapse
Affiliation(s)
- C Charpentier
- Department of Anesthesiology, Clinical Epidemiology UPRES EA 1124, Nancy University Hospital, Nancy, France
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Massicotte EM, Del Bigio MR. Human arachnoid villi response to subarachnoid hemorrhage: possible relationship to chronic hydrocephalus. J Neurosurg 1999; 91:80-4. [PMID: 10389884 DOI: 10.3171/jns.1999.91.1.0080] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECT The origin of chronic communicating hydrocephalus following subarachnoid hemorrhage (SAH) is not well understood. Fibrosis of the arachnoid villi has been suggested as the cause for obstruction of cerebrospinal fluid (CSF) flow, but this is not well supported in the literature. The goal of this study was to determine the relationship between blood, inflammation, and cellular proliferation in arachnoid villi after SAH. METHODS Arachnoid villi from 50 adult patients were sampled at autopsy. All specimens were subjected to a variety of histochemical and immunohistochemical stains. The 23 cases of SAH consisted of patients in whom an autopsy was performed 12 hours to 34 years post-SAH. Fifteen cases were identified as moderate-to-severe SAH, with varying degrees of hydrocephalus. In comparison with 27 age-matched non-SAH controls, the authors observed blood and inflammation within the arachnoid villi during the 1st week after SAH. Greater mitotic activity was also noted among arachnoid cap cells. The patient with chronic SAH presented with ventriculomegaly 2 months post-SAH and exhibited remarkable arachnoid cap cell accumulation. CONCLUSIONS The authors postulate that proliferation of arachnoidal cells, triggered by the inflammatory reaction or blood clotting products, could result in obstruction of CSF flow through arachnoid villi into the venous sinuses. This does not exclude the possibility that SAH causes generalized fibrosis in the subarachnoid space.
Collapse
Affiliation(s)
- E M Massicotte
- Department of Surgery, University of Manitoba and Health Sciences Centre, Winnipeg, Canada
| | | |
Collapse
|
48
|
Rosenwasser RH, Armonda RA, Thomas JE, Benitez RP, Gannon PM, Harrop J. Therapeutic modalities for the management of cerebral vasospasm: timing of endovascular options. Neurosurgery 1999; 44:975-9; discussion 979-80. [PMID: 10232530 DOI: 10.1097/00006123-199905000-00022] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To determine if a window of time could be defined during which angioplasty would be most effective in reversing neurological decline and ultimately improving outcome. METHODS Of a group of 466 patients, 93 underwent endovascular management of clinical vasospasm that was medically refractory. Eighty-four of the 93 patients were available for follow-up for at least 6 months. All patients underwent mechanical angioplasty using compliant microballoon systems and, if distal spasm was present, the administration of papaverine. RESULTS Fifty-one patients underwent endovascular management within a 2-hour window, and 33 patients underwent treatment more than 2 hours after the development of their symptoms. Compared with the group treated more than 2 hours after neurological decline (P < 0.01; chi2 = 8.02), the group that underwent endovascular management within a 2-hour window after the development of symptoms demonstrated sustained clinical improvement. CONCLUSION When a patient develops symptomatic vasospasm and is unresponsive to traditional measures of critical care management, angioplasty may be effective in improving the patient's neurological status if this procedure is performed as early as possible. The results indicate that a 2-hour window may exist for restoration of blood flow to ultimately improve the patient's outcome.
Collapse
Affiliation(s)
- R H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospital-Wills Neurosensory Institute, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | |
Collapse
|
49
|
Subarachnoid hemorrhage and intracerebral hemorrhage. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199904000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Findlay JM, Deagle GM. Causes of morbidity and mortality following intracranial aneurysm rupture. Can J Neurol Sci 1998; 25:209-15. [PMID: 9706722 DOI: 10.1017/s031716710003403x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the current recovery rates and causes for morbidity and mortality in patients suffering aneurysmal subarachnoid hemorrhage (SAH). METHODS We reviewed a recent consecutive series of 95 patients with ruptured intracranial aneurysms who presented to our hospital between 1994 and 1995. When administered, active treatment consisted of early surgery for aneurysm clipping and aggressive prevention and treatment of SAH-related complications. RESULTS Eighty-eight (93%) of the patients were admitted within 24 hours of rupture. One-quarter of the patients in this series did not undergo aneurysm clipping due to poor neurological condition on presentation. Of the 75 patients initially considered for active treatment, 83% underwent surgery within 48 hours of rupture, all received nimodipine, 16% received tissue plasminogen activator to lyse subarachnoid or intraventricular clots, 40% underwent hypertensive treatment, and 7% underwent transluminal balloon angioplasty for vasospasm. At one year followup, 29% of patients had died, 7% had severe disabilities, 13% had moderate disabilities, 51% had made a good recovery, and 64% of all surviving patients had returned to their previous work status. Primary and contributing causes of death and disability, affecting 47 patients at one year, were: direct effects of the initial hemorrhage (79% of affected patients), surgical complications (13%), vasopasm (11%), rebleeding (11%) and medical complications (13%). CONCLUSIONS Almost two-thirds of patients suffering aneurysm rupture make a satisfactory recovery with modern treatment. While vasospasm has become a less common cause of poor outcome following SAH, surgical complications remain an important problem.
Collapse
Affiliation(s)
- J M Findlay
- Division of Neurosurgery, University of Alberta, Edmonton, Canada
| | | |
Collapse
|