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Ariyada K, Ohida T, Shibahashi K, Hoda H, Hanakawa K, Murao M. Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment. Neurol Med Chir (Tokyo) 2020; 60:390-396. [PMID: 32669527 PMCID: PMC7431870 DOI: 10.2176/nmc.oa.2020-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.
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Affiliation(s)
- Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Tomoya Ohida
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
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Wang MQ, Zhao X, Wang XF, Han C, Xing DG, Wang CW. Surgical Management of Aneurysmal Hematomas in the Presence of Brain Herniation on Arrival: A Single-Center Case Series Analysis. World Neurosurg 2018; 114:e468-e476. [PMID: 29545220 DOI: 10.1016/j.wneu.2018.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the outcomes in aggressively treated patients with aneurysmal intracerebral hematoma (ICH) and signs of brain herniation, and to investigate possible predictive factors. METHODS This retrospective study included 43 patients with aneurysmal ICH who presented to the Emergency Department with brain herniation and received aggressive surgical treatment between 2008 and 2016. Emergency surgical clipping, hematoma removal, and external decompression were combined as an aggressive surgical treatment. Outcomes were assessed using in-hospital survival and the Glasgow Outcome Scale at a 6-month follow-up. RESULTS All the patients were World Federation of Neurological Societies grade V on presentation. The mean hematoma volume was 59.1 ± 16.5 mL. The in-hospital mortality rate was 48.8%. At the 6-month follow-up, favorable outcomes were achieved in 7 patients (16.3%). Significant factors related to death included bilateral mydriasis, lower initial Glasgow Coma Scale (GCS) score, larger hematoma volume, and no recovery of pupil reactivity after surgery. Bilateral restoration of pupil reactivity and higher initial GCS score were associated with 6-month favorable outcomes. Patients with an intrasylvian hematoma were more likely than those with an intraparenchymal hematoma to achieve a favorable outcome (62.5% vs. 5.7%; P = 0.001). CONCLUSIONS Our data indicate that the protocol of aggressive surgical treatment in patients with a herniated aneurysmal ICH might be warranted. Despite mydriasis, favorable outcomes might be achieved in some patients. However, careful individual patient-centered decision making is essential, particularly when bilateral pupil dilation persists.
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Affiliation(s)
- Min-Qing Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China
| | - Xu Zhao
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China
| | - Xiao-Fei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China
| | - Chao Han
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China
| | - De-Guang Xing
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China
| | - Cheng-Wei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China.
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Current Management of Aneurysmal Subarachnoid Hemorrhage Guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 2015. [DOI: 10.1017/s0317167100021521] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT:Published medical evidence pertaining to the management of aneurysmal subarachnoid hemorrhage (SAH) was critically reviewed in order to prepare practice guidelines for this condition. SAH should be considered as a possible cause of all sudden and/or unusual headaches, and every attempt should be made to recognize mild SAHs, as they are still frequently misdiagnosed. The first test for SAH is computed tomography (CT), followed by lumbar puncture when the CT is negative for intracranial bleeding (the case in only several per cent of patients within 24 hours of aneurysm bleeding). Urgent cerebral angiography is necessary to detect the underlying cerebral aneurysm. The advantage of rapid diagnosis of SAH followed by early aneurysm repair is minimizing the risk of catastrophic aneurysm rebleeding. Early surgery for aneurysm repair is often possible and is recommended, unless the aneurysm location or size renders it technically difficult to expose in clot-laden subarachnoid cisterns beneath an acutely swollen brain. Aneurysm ablation is optimally accomplished with open microsurgery and clipping of the aneurysm neck, although other options include proximal parent artery occlusion, “trapping” of the aneurysmal segment of the artery, and embolization of thrombogenic materials (e.g., platinum “microcoils”) directly into the aneurysm dome using endovascular techniques. Neurological outcome following SAH is also optimized through the prevention of secondary SAH complications, and further management specific for ruptured cerebral aneurysms can include anticonvulsants, neuroprotectants, and various agents and techniques to prevent or reverse delayed-onset cerebral vasospasm. All patients with aneurysmal SAH should be treated with the calcium antagonist nimodipine, and in certain circumstances patients should receive anticonvulsants. Induced arterial hypertension, hypervolemia and in some instances percutaneous balloon angioplasty are recommended to reverse vasospasm causing symptomatic cerebral ischemia prior to cerebral infarction.
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Life-Threatening Cerebral Hematoma Owing to Aneurysm Rupture. World Neurosurg 2015; 85:215-27. [PMID: 26361325 DOI: 10.1016/j.wneu.2015.08.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To refine the surgical indications of surgery for life-threatening cerebral hematomas caused by aneurysm rupture, through the analysis of possible outcome predictors. METHODS Forty-nine consecutive patients requiring prompt clot evacuation were retrospectively reviewed. In all cases, the hematoma was equal to or greater than 60 mL. The bleeding aneurysm was located on the middle cerebral artery in 26 cases, on the internal carotid artery in 10 cases, and on the anterior cerebral artery in 13 cases; four aneurysms were giant. Six patients underwent aneurysm coiling followed by clot removal, whereas 43 patients were managed by concomitant clot evacuation and aneurysm clipping. The main clinical and radiologic features, the management paths and the treatment modalities were correlated with the outcomes. A statistical analysis was conducted. RESULTS Overall mortality was 32.6%, severe morbidity was 22.4% and 22 patients (44.8%) achieved favorable results. The short-term results were more significantly influenced by the radiological parameters than by the initial clinical conditions. The prognostic weight of the radiologic findings was partially lost for six-month results, whereby management factors gained in importance. CONCLUSIONS The bleeding severity was strongly determinant for early mortality. However, if patients can survive the initial crucial phase, their chances of a favorable outcome are not negligible. Further improvement may be possible through better patient selection and the identification of nonsalvageable subjects.
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Lee JG, Moon CT, Chun YI, Roh HG, Choi JW. Comparative Results of the Patients with Intracerebral and Intra-sylvian Hematoma in Ruptured Middle Cerebral Artery Aneurysms. J Cerebrovasc Endovasc Neurosurg 2013; 15:200-5. [PMID: 24167800 PMCID: PMC3804658 DOI: 10.7461/jcen.2013.15.3.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 08/22/2013] [Accepted: 08/30/2013] [Indexed: 11/28/2022] Open
Abstract
Objective To clarify the prognosis of the patients with intra-sylvian hematoma (ISH) and intracerebral hematoma (ICH) in ruptured middle cerebral artery (MCA) aneurysms. Methods We categorized hematoma into ISH and ICH by the presence of intra-hematomal contrast enhancing vessel (IHCEV) on computed tomography angiography (CTA). Forty-four ruptured MCA aneurysm patients with ICH or ISH were grouped by the grading system proposed by the authors in our previous study. We investigated the relevance of the following factors: patient's age, gender, Hunt-Hess grade, Glasgow outcome scale (GOS) and changes in Glasgow coma scale (GCS) between pre-operation and 7 days after operation. Results There were no significant differences statistically in age, gender, Hunt-Hess grade, and GOS between the ISH and ICH groups. In their peri-operative GCS change, the ICH group showed greater improvement compared to the ISH group (p = 0.0391). The hematoma grade had a significant relevance with the patients' GOS. Conclusion Although there were no significant statistic differences in the GOS of the 2 hematoma groups, there were prominent improvements of post-operative GCS in the ICH group. Unlike in the ISH group, effective removal of hematoma was possible in most patients of the ICH group. Thus although there is no difference in the prognosis of the 2 groups, early surgical evacuation of hematoma seems to be effective in improving the short-term GCS score in peri-operative period.
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Affiliation(s)
- Jong Gon Lee
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
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Brown-Sequard syndrome revealing intradural thoracic disc herniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20:65-70. [PMID: 20589517 DOI: 10.1007/s00586-010-1498-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 05/11/2010] [Accepted: 06/11/2010] [Indexed: 10/19/2022]
Abstract
Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5-24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5-T6 and T9-T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients' condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.
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Magge SN, Chen HI, Ramakrishna R, Cen L, Chen Z, Elliott JP, Winn HR, Le Roux PD. Association of a younger age with an increased risk of angiographic and symptomatic vasospasms following subarachnoid hemorrhage. J Neurosurg 2010; 112:1208-15. [DOI: 10.3171/2009.9.jns081670] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vasospasm is a leading cause of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). It is important to predict which patients are at risk for vasospasm so that interventions can be made. There are several potential risk factors for vasospasm, one of which is age. However, the effect of age on vasospasm, particularly symptomatic vasospasm, remains controversial.
Methods
Three hundred ninety-one patients were retrospectively identified from a prospective observational database of patients with SAH who had been admitted to a single center. Demographic and clinical data were recorded, and cerebral angiograms obtained at admission and between 5 and 10 days later were compared. The relationship between age and angiographic and symptomatic vasospasms was examined using logistic regression techniques.
Results
Mild (86 patients), moderate (69 patients), severe (56 patients), and no angiographic vasospasms (180 patients) were documented by comparing admission and follow-up angiograms in each patient. Symptomatic vasospasm was identified in 69 patients (17.6%). Angiographic vasospasm was more frequent as age decreased. Except in patients < 30 years old, the frequency of symptomatic vasospasm also increased with decreasing age (p = 0.0001). After adjusting for variables known to be associated with vasospasm, an advanced age was associated with a reduced incidence of any angiographic vasospasm (OR 0.96, 95% CI 0.94–0.97), severe angiographic vasospasm (OR 0.96, 95% CI 0.95–0.98), and symptomatic vasospasm (OR 0.98, 95% CI 0.96–0.99).
Conclusions
Results in this study show that a younger age is associated with an increased incidence of angiographic and symptomatic vasospasm.
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Affiliation(s)
| | | | | | - Liyi Cen
- 2Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zhen Chen
- 2Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - H. Richard Winn
- 4Department of Neurosurgery, Mount Sinai Hospital, New York, New York
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Moon SJ, Lee JK, Jang JW, Hur H, Lee JH, Kim SH. The transdural approach for thoracic disc herniations: a technical note. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1206-11. [PMID: 20143105 DOI: 10.1007/s00586-010-1294-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 11/10/2009] [Accepted: 01/15/2010] [Indexed: 11/29/2022]
Abstract
Surgery for thoracic disc herniations is still challenging, and the disc excision via a posterior laminectomy is considered risky. A variety of dorsolateral and ventral approaches have been developed. However, the lateral extracavitary and transthoracic approach require extensive surgical exposure. Therefore, we adopted a posterior transdural approach for direct visualization without entry into the thoracic cavity. Three cases that illustrate this procedure are reported here with the preoperative findings, radiological findings and surgical techniques used. After the laminectomy, at the involved level, the dorsal dura was opened with a longitudinal paramedian incision. The cerebrospinal fluid was drained to gain more operating space. After sectioning of the dentate ligaments, gentle retraction was applied to the spinal cord. Between the rootlets above and below, the ventral dural bulging was clearly observed. A small paramedian dural incision was made over the disc space and the protruded disc fragment was removed. Neurological symptoms were improved, and no surgery-related complication was encountered. The posterior transdural approach may offer an alternative surgical option for selected patients with thoracic paracentral soft discs, while limiting the morbidity associated with the exposure.
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Affiliation(s)
- Sung-Jun Moon
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, 671 Jebongno, Dong-Ku, Kwangju, 501-757, South Korea
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Outcome after emergency surgery without angiography in patients with intracerebral haemorrhage after aneurysm rupture. Acta Neurochir (Wien) 2009; 151:911-5. [PMID: 19387536 DOI: 10.1007/s00701-009-0326-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 02/25/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients with large intracerebral haematomas (ICH) from aneurysm rupture often present in a poor clinical condition and have a poor prognosis. Time delay for preoperative angiography might in some cases be unappealing. We evaluated the outcome after immediate haematoma removal and aneurysm occlusion without preoperative angiography. METHODS We retrospectively identified 13 consecutive patients. We recorded clinical data and evaluated mortality and morbidity with the Glasgow Outcome Score (GOS) and Telephone Interview of Cognitive Status (TICS). FINDINGS At follow up seven of thirteen patients had favourable outcome assessed by GOS. Three patients had severe disability and three patients died. None of the survived patients interviewed had impaired cognition. CONCLUSIONS In patients presented in a critical state with aneurysmal ICH, emergency haematoma removal and aneurysm clipping without the delay for diagnostic angiography may be life saving and a satisfactory outcome can be accomplished.
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Niikawa S, Yasokawa Y, Ito T. Development of early cerebral swelling in surgically treated ruptured aneurysm of acute stage, its significance, and management. J Stroke Cerebrovasc Dis 2008; 14:58-66. [PMID: 17904002 DOI: 10.1016/j.jstrokecerebrovasdis.2004.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Revised: 11/15/2004] [Accepted: 11/22/2004] [Indexed: 10/25/2022] Open
Abstract
The present study includes 38 patients treated surgically for ruptured aneurysm manifesting subarachnoid hemorrhage without intracerebral hematoma, evaluating clinical grade at admission, secondary development and management of early cerebral swelling, subsequent complications such as cerebral infarction caused by vasospasm, and clinical outcome. Six of 32 patients treated by early surgery within 24 hours developed critical cerebral swelling in the early period after SAH. Five of these 6 patients received barbiturate therapy. Two patients died of advancing cerebral swelling. Three of 5 patients who received barbiturate therapy showed good recovery without any neurologic deficit, 1 suffered intellectual impairment, and the other 1 died. Serial computed tomography (CT), CT angiography, and dynamic CT evaluated elapsing of cerebral swelling, progression of cerebral vasospasm, and change of cerebral blood perfusion (flow) in 2 patients who suffered early cerebral swelling. In these 2 patients, progression or persistence of vasospasm was recorded for a longer period, whereas the cerebral swelling resolved within a short period. Cerebral infarction caused by vasospasm was seen in 8 of these 38 surgical cases, and hydrocephalus was seen in 15 of 38 cases. All 4 survivors after early cerebral swelling developed hydrocephalus and underwent shunting. Development of cerebral swelling in patients with ruptured aneurysm greatly affects outcome. Although barbiturate therapy is useful for the treatment of patients who suffer serious cerebral swelling, improvements in management may be required.
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Affiliation(s)
- Shuji Niikawa
- Department of Neurosurgery, Sumi Memorial Hospital, Gifu, Japan
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Yi S, Kim SH, Shin HC, Kim KN, Yoon DH. Outcome of surgery for a symptomatic herniated thoracic disc in relation to preoperative characteristics of the disc. Acta Neurochir (Wien) 2007; 149:1139-45; discussion 1145. [PMID: 17876496 DOI: 10.1007/s00701-007-1287-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 05/14/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND This report presents general information on herniated thoracic discs, their clinical manifestations as well as surgical treatment, and examines the differences in the surgical outcome based on disc characteristics. METHODS This study includes 33 thoracic discectomies in 29 patients with a ventrally situated herniated thoracic disc reaching to the thoracic cord. Using preoperative computed tomography scanning and magnetic resonance imaging, the direction of the disc was classified as either central or lateral, and disc consistency classified as either soft or hard. Clinical outcome was assessed according to the Japanese Orthopedic Association (JOA) Score for thoracic myelopathy. The score was obtained by analysing motor, sensory and bladder function. Recovery rate was assessed, comparing preoperative and postoperative status based on disc characteristics. The correlations between outcome, symptom duration and recovery rate were also investigated. FINDINGS Clinical outcome according to the JOA Score showed significant postoperative improvement, increasing from 7.0 +/- 3.1 points to 8.2 +/- 2.7 points postoperatively (p < 0.01). The mean recovery rate was 12.4 +/- 56.9%, and 16 patients (55.2%) showed improvement. In the soft disc group, there was improvement in all categories, but the hard disc group showed no improvement. The central disc group showed improvement in sensory function, but the lateral disc group showed little improvement. Regression analysis revealed a statistically significant correlation between the preoperative and postoperative score, symptom duration and recovery rate. CONCLUSIONS Clinical outcome after surgery of a herniated thoracic disc proved successful, especially when the disc was considered to have a soft consistency. In order to decide the optimal surgical strategy and prospective surgical outcome, disc characteristics, including consistency and direction of prolapse should be considered preoperatively.
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Affiliation(s)
- S Yi
- Department of Neurosurgery, College of Medicine, Yonsei University, Seoul, Korea
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Carvi y Nievas M, Haas E, Höllerhage HG. Severe intracranial bleedings during endovascular procedures: outcome of surgically treated patients. Neurol Res 2007; 29:81-90. [PMID: 17427281 DOI: 10.1179/174313206x152492] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication. METHOD Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed. RESULTS Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism. CONCLUSION Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.
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Affiliation(s)
- Mario Carvi y Nievas
- Department of Neurosurgery, Städtische Kliniken, Frankfurt am Main-Höchst, Germany.
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Leonardi M, Cenni P, Simonetti L, Raffi L, Battaglia S. Retrospective Study of Complications Arising during Cerebral and Spinal Diagnostic Angiography from 1998 to 2003. Interv Neuroradiol 2005; 11:213-21. [PMID: 20584477 DOI: 10.1177/159101990501100303] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 08/25/2005] [Indexed: 11/16/2022] Open
Abstract
SUMMARY This retrospective study aimed to assess the percentage of complications in the daily practice of cerebral and spinal cord diagnostic angiography at our institution and to compare this with literature reports published in the last twenty years and guidelines for angiography. From 1(st) December 1998 to 1(st) December 2003 2154 patients underwent digital angiography for a total of 5996 vessels selected. Three neurological complications arose during angiographic procedures in the five year period. * Focal neurological deficit resolving within 24h in two patients, * Permanent neurological deficit in one patient. There were no adverse systemic reactions to contrast medium. Retrospective analysis of our cohort disclosed a complication rate of 0.1% for transient neurological complications and 0.05% for permanent deficits.
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Affiliation(s)
- M Leonardi
- Servizio di Neuroradiologia, Ospedale Bellaria; Bologna, Italy -
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Boudriot U, Schmitt J, Pfeiffer M. Thoracic herniation after lumbar spine fusion. Arch Orthop Trauma Surg 2005; 125:493-8. [PMID: 16052339 DOI: 10.1007/s00402-005-0012-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Indexed: 10/25/2022]
Abstract
We report on a 65-year-old male patient with rapid onset of incomplete paraparesis, based on a massive thoracic herniation following adjacent instability of the thoracolumbar spine after lumbar fusions with transpedicular instrumentation.
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Affiliation(s)
- U Boudriot
- Klinik für Orthopädie und Rheumatologie der Philipps-Universität, Marburg, Germany.
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Proust F, Dufour H, Lejeune JP, Bonafé A, de Kersaint-Gilly A, Puybasset L, Berré J, Bruder N, Ravussin P, Hans P, Audibert G, Boulard G, Ter Minassian A, Beydon L, Gabrillargues J. [Severe subarachnoid haemorrhage: treatment of rebleeding and of an intracerebral haematoma]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:756-60. [PMID: 15885969 DOI: 10.1016/j.annfar.2005.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- F Proust
- Service de neurochirurgie, hôpital Charles-Nicolle, rue de Germont, 76031 Rouen cedex, France.
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Isaacs RE, Podichetty VK, Sandhu FA, Santiago P, Spears JD, Aaronson O, Kelly K, Hrubes M, Fessler RG. Thoracic microendoscopic discectomy: a human cadaver study. Spine (Phila Pa 1976) 2005; 30:1226-31. [PMID: 15897840 DOI: 10.1097/01.brs.0000162275.95579.ee] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. OBJECTIVE To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. SUMMARY OF BACKGROUND Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. METHODS Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. RESULTS Nine discectomies were performed in two cadaveric specimens, from T5-T6-T9-T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (+/-1.9 mm) of the ipsilateral facet, which amounted to 35.4% (+/-17.5%) of the facet complex. Canal decompression averaged 73.5% (+/-7.9%). CONCLUSIONS Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.
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Affiliation(s)
- Robert E Isaacs
- Spine Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Nakagawa T, Suga S, Mayanagi K, Akaji K, Inamasu J, Kawase T. Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study. ACTA ACUST UNITED AC 2005; 63:329-34; discussion 334-5. [PMID: 15808711 DOI: 10.1016/j.surneu.2004.04.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2004] [Accepted: 05/26/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients. METHODS Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score). RESULTS The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome. CONCLUSIONS In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.
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Affiliation(s)
- Toru Nakagawa
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, 326-0808, Japan.
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Castaño-Duque CH, Ruscalleda-Nadal J, de Juan-Delago M, Guardia-Mas E, San Roman-Manzanera L, Bartomeus-Jene F, Molet-Teixido J, Tresserras-Ribo P, Pares-Muñoz P, Clavel Laria P. Early Experience Studying Cerebral Aneurysms with Rotational and Threedimensional Angiography and Review of CT and MR Angiography Literature. Interv Neuroradiol 2004; 8:377-91. [PMID: 20594499 DOI: 10.1177/159101990200800407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2002] [Accepted: 10/12/2002] [Indexed: 11/16/2022] Open
Abstract
SUMMARY From september 2000 to september 2001, 32 consecutive patients with ruptured intracranial aneurysms were examined with rotational and 3D reconstruction angiography using an Integris V5000 Philips Medical System: 39 aneurysms were detected. After a selective cerebral artery was catheterized with a 5F or 4F-catheter, 35 ml of contrast medium was intra-arterially administered at a rate of 4 ml/s and a 180 degrees rotational angiography was performed in eight seconds. This information was transferred to a computer (Silicon Graphics Octane) with software (Integris 3DRA, Philips Integris Systems) and a three-dimensional reconstruction was made. The information provided by Angio-3D was useful for evaluating the parent artery, aneurysmal sac, aneurysmal neck and arterial branches. It was also very useful in selecting the therapeutic method. For open surgery, this technique provides preoperative images that are useful for planning microsurgical approaches, especially in cases of large aneurysm showing complex surrounding arteries. For endovascular embolization, various anatomic characteristics of the aneurysm such as neck and sac size, shape, lobularity, parent artery and arterial branches adjacent to the aneurysmal neck must be demonstrated. This is very important to determine the best projection for embolization and to avoid multiple series. This is also essential in the choice of the first coil to create a good basket producing total occlusion. Microaneurysms are demonstrated well with this technique whereas this is difficult to do with conventional arteriography. The Angio-RM and Angio-CT literature show a lower sensitivity and specificity in comparasion with our experience with 3D IA-ROT-DSA. For this reason, we believe that 3D IA-ROTDSA is now the gold standard for patients presenting intracranial aneurysms.
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Affiliation(s)
- C H Castaño-Duque
- Department of Radiology, Unit of Neuroradiology - Interventional Neuroradiology; Barcelona, Spain -
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Heuer GG, Smith MJ, Elliott JP, Winn HR, LeRoux PD. Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2004; 101:408-16. [PMID: 15352597 DOI: 10.3171/jns.2004.101.3.0408] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Increased intracranial pressure (ICP) is well known to affect adversely patients with head injury. In contrast, the variables associated with ICP following aneurysmal subarachnoid hemorrhage (SAH) and their impact on outcome have been less intensely studied. METHODS In this retrospective study the authors reviewed a prospective observational database cataloging the treatment details in 433 patients with SAH who had undergone surgical occlusion of an aneurysm as well as ICP monitoring. All 433 patients underwent postoperative ICP monitoring, whereas only 146 (33.7%) underwent both pre- and postoperative ICP monitoring. The mean maximal ICP was 24.9 +/- 17.3 mm Hg (mean +/- standard deviation). During their hospital stay, 234 patients (54%) had elevated ICP (> 20 mm Hg), including 136 of those (48.7%) with a good clinical grade (Hunt and Hess Grades I-III) and 98 (63.6%) of the 154 patients with a poor grade (Hunt and Hess Grades IV and V) on admission. An increased mean maximal ICP was associated with several admission variables: worse Hunt and Hess clinical grade (p < 0.0001), a lower Glasgow Coma Scale (GSC) motor score (p < 0.0001); worse SAH grade based on results of computerized tomography studies (p < 0.0001); intracerebral hemorrhage (p = 0.024); severity of intraventricular hemorrhage (p < 0.0001); and rebleeding (p = 0.0048). Both intraoperative cerebral swelling (p = 0.0017) and postoperative GCS score (p < 0.0001) were significantly associated with a raised ICP. Variables such as patient age, aneurysm size, symptomatic vasospasm, intraoperative aneurysm rupture, and secondary cerebral insults such as hypoxia were not associated with raised ICP. Increased ICP adversely affected outcome: 71.9% of patients with normal ICP demonstrated favorable 6-month outcomes postoperatively, whereas 63.5% of patients with ICP between 20 and 50 mm Hg and 33.3% with ICP greater than 50 mm Hg demonstrated favorable outcomes. Among 21 patients whose raised ICP did not respond to mannitol therapy, all experienced a poor outcome and 95.2% died. Among 145 patients whose elevated ICP responded to mannitol, 66.9% had a favorable outcome and only 20.7% were dead 6 months after surgery (p < 0.0001). According to results of multivariate analysis, however, ICP was not an independent outcome predictor (odds ratio 1.26, 95% confidence interval 0.28-5.68). CONCLUSIONS Increased ICP is common after SAH, even in patients with a good clinical grade. Elevated ICP post-SAH is associated with a worse patient outcome, particularly if ICP does not respond to treatment. This association, however, may depend more on the overall severity of the SAH than on ICP alone.
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Affiliation(s)
- Gregory G Heuer
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19107, USA
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20
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Vates GE, Zabramski JM, Spetzler RF, Lawton MT. Intracranial Aneurysms. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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21
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Yoshimoto Y. Early aneurysm surgery. J Neurosurg 2003; 98:443-4; author reply 444-6. [PMID: 12593642 DOI: 10.3171/jns.2003.98.2.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Carvi y Nievas MN, Haas E, Höllerhage HG, Drathen C. Complementary Use of Computed Tomographic Angiography in Treatment Planning for Posterior Fossa Subarachnoid Hemorrhage. Neurosurgery 2002. [DOI: 10.1227/00006123-200206000-00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Matsumoto M, Sato M, Nakano M, Endo Y, Watanabe Y, Sasaki T, Suzuki K, Kodama N. Three-dimensional computerized tomography angiography—guided surgery of acutely ruptured cerebral anuerysms. J Neurosurg 2001; 94:718-27. [PMID: 11354402 DOI: 10.3171/jns.2001.94.5.0718] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The aim of this study was to assess whether aneurysm surgery can be performed in patients with ruptured cerebral aneurysms by using three-dimensional computerized tomography (3D-CT) angiography alone, without conventional catheter angiography.
Methods. In a previous study, 60 patients with subarachnoid hemorrhage (SAH) from ruptured aneurysms were prospectively evaluated using both 3D-CT and conventional angiography, which resulted in a 100% accuracy for 3D-CT angiography in the diagnosis of ruptured aneurysms, and a 96% accuracy in the identification of associated unruptured aneurysms. The results led the authors to consider replacing conventional angiography with 3D-CT angiography for use in diagnosing ruptured aneurysms, and to perform surgery aided by 3D-CT angiography alone without conventional angiography. Based on the results, 100 consecutive patients with SAH who had undergone surgery in the acute stage based on 3D-CT angiography findings have been studied since December 1996. One hundred ruptured aneurysms, including 41 associated unruptured lesions, were detected using 3D-CT angiography. In seven of 100 ruptured aneurysms, which included four dissecting vertebral artery aneurysms, two basilar artery (BA) tip aneurysms, and one BA—superior cerebellar artery aneurysm, 3D-CT angiography was followed by conventional angiography to acquire diagnostic confirmation or information about the vein of Labbé, which was needed to guide the surgical approach for BA tip aneurysms. All of the ruptured aneurysms were confirmed at surgery and treated successfully. Ninety-three patients who underwent operation with the aid of 3D-CT angiography only had no complications related to the lack of information gathered by conventional angiography. The 3D-CT angiography studies provided the authors with the aneurysm location as well as surgically important information on the configuration of its sac and neck, the presence of calcification in the aneurysm wall, and its relationship to the adjacent vessels and bone structures.
Conclusions The authors believe that 3D-CT angiography can replace conventional angiography in the diagnosis of ruptured aneurysms and that surgery can be performed in almost all acutely ruptured aneurysms by using only 3D-CT angiography without conventional angiography.
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Affiliation(s)
- M Matsumoto
- Department of Neurosurgery, Fukushima Medical School, Japan.
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Başkaya MK, Menendez JA, Yüceer N, Polin RS, Nanda A. Results of surgical treatment of intrasylvian hematomas due to ruptured intracranial aneurysms. Clin Neurol Neurosurg 2001; 103:23-8. [PMID: 11311472 DOI: 10.1016/s0303-8467(01)00104-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this retrospective study, the surgical outcome of patients with intrasylvian hematomas due to rupture of intracranial aneurysms was analyzed. The authors studied ten patients who underwent aneurysm surgery and evacuation of the hematoma within 12 h of the onset of bleeding. All patients had an intrasylvian hematoma classified with computerized tomography and all patients underwent pre-operative angiography. In all patients, the origin of bleeding was a middle cerebral artery aneurysm, with the exception of one patient whose bleeding originated from a posterior communicating artery aneurysm. Three patients achieved good recovery without any significant neurological deficit and four achieved good recovery with moderate disabilities. One patient died due to pneumonia and two were in a vegetative state. Notably, three patients who were comatose (Hunt and Hess Grade V) at the time of presentation achieved good recovery following surgery. In this study, neurological status at presentation did not predict the outcome. The only significant prognostic factor in those patients who had intrasylvian hematoma was early surgery within 12 h of the bleeding. We suggest that early surgical treatment be performed in patients with intrasylvian hematoma, regardless of the neurological findings and grade on admission. Pre-operative angiography seems to be essential in identifying the source of bleeding.
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Affiliation(s)
- M K Başkaya
- Department of Neurosurgery, Louisiana State University Health Science Center, 1501 Kings Highway, P.O. Box 33932, Shreveport, LA 71130-3932, USA.
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Jansen FE, Vandertop WP, Velthuis BK. Aneurysm detection with computed tomographic angiography in a 1-month-old infant. Pediatr Neurol 2000; 23:361-3. [PMID: 11068173 DOI: 10.1016/s0887-8994(00)00201-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report an infant whose clinical condition deteriorated acutely at 1 month of age because of a subarachnoid hemorrhage with an intracerebellar hematoma. Computed tomographic angiography revealed an aneurysm of the left posterior inferior cerebellar artery. Because of the critical condition of the child and her very young age, the decision to perform surgery was based solely on the computed tomographic angiography findings.
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Affiliation(s)
- F E Jansen
- Department of Neurology; University Medical Center;, Utrecht, The Netherlands
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Velthuis BK, Van Leeuwen MS, Witkamp TD, Ramos LM, Berkelbach van Der Sprenkel JW, Rinkel GJ. Computerized tomography angiography in patients with subarachnoid hemorrhage: from aneurysm detection to treatment without conventional angiography. J Neurosurg 1999; 91:761-7. [PMID: 10541232 DOI: 10.3171/jns.1999.91.5.0761] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to determine prospectively whether and to what extent computerized tomography (CT) angiography can serve as the sole imaging method for a preoperative workup in patients with ruptured intracranial aneurysms. METHODS During a 1-year period, all patients who presented to the authors' hospital with subarachnoid hemorrhage demonstrated by unenhanced CT scanning or lumbar puncture underwent CT angiography. Two radiologists evaluated the CT angiography source images and maximum intensity projection slabs and arrived at a consensus. They categorized the quality of the CT angiography as adequate or inadequate and classified aneurysms that were detected as definitely or possibly present. The parent artery of anterior communicating artery aneurysms was identified by asymmetrical anterior cerebral artery size and asymmetrical aneurysm location. The parent artery was indicated by the larger A1 segment in cases of asymmetrical A1 size. Only CT angiograms of adequate quality that revealed aneurysms classified as definitely present and with an unequivocal parent artery were presented to the neurosurgeons, who decided whether preoperative digital subtraction (DS) angiography should still be performed. Forty-nine of the 100 studied patients did not undergo surgery because of poor clinical condition, nonaneurysmal cause of the hemorrhage, or endovascular treatment of the ruptured aneurysm. Of the 51 patients who underwent surgery, radiologists required DS angiography in 17 patients; the imaging technique provided greater certainty in 13 instances. The neurosurgeons required DS angiography 11 times; this provided additional information in two instances. Twenty-three (45%) of the 51 patients were surgically treated successfully on the basis of CT angiography findings alone. CONCLUSIONS Computerized tomography angiography can replace DS angiography as the preoperative neuroimaging technique in a substantial proportion of patients with ruptured intracranial aneurysms.
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Affiliation(s)
- B K Velthuis
- Department of Radiology, Utrecht University Hospital, The Netherlands.
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Hall CA, Kaufmann AM, Firlik A. Aneurysmal intracerebral hemorrhage: Clinical outcome after emergent surgical treatment. J Stroke Cerebrovasc Dis 1999; 8:240-7. [PMID: 17895171 DOI: 10.1016/s1052-3057(99)80073-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/1998] [Accepted: 12/01/1998] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Management guidelines and recovery potentials for individuals presenting with poor clinical condition owing to an aneurysmal intracerebral hemorrhage are not well established. METHODS We assessed the outcome of a consecutive series of 6 patients with aneurysmal intracerebral hemorrhages presenting with Hunt and Hess clinical grade IV or V selected to undergo emergent hematoma evacuation and aneurysm clip obliteration. Their presenting clinical condition and neuroradiology were assessed, as well as early surgical results and follow-up outcome. RESULTS The 2 women and 4 men were 30 to 59 years old. All 6 patients had profound neurological deficits on admission, with Glasgow Coma Scale scores of 4 to 9. Aneurysmal intracerebral hemorrhage diameters measured from 6 to 8 cm and were associated with 5 to 15 mm of midline shift. Surgical intervention was initiated within 3 hours of ictus in 5 patients and within 7 hours in one patient. All 6 patients survived, demonstrated clinical improvement postoperatively, and were transferred to rehabilitation centers 19 to 30 days after presentation. The Glasgow Outcome Scores were 2 to 3 with a minimum follow-up interval of 12 months. Four patients returned home and resumed independent activities of daily living; one required partial supervision. One patient remained in a chronic care facility. CONCLUSION An acute management protocol, including aggressive neurosurgical intervention, with craniotomy for hematoma evacuation and aneurysm clip obliteration, can result in good neurological outcome in carefully selected, poor-grade patients with aneurysmal intracerebral hemorrhage.
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Affiliation(s)
- C A Hall
- Department of Family Medicine, University of Calgary, Alberta, Canada
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Le Roux PD, Winn HR. Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient. ACTA NEUROCHIRURGICA. SUPPLEMENT 1999; 72:7-26. [PMID: 10337410 DOI: 10.1007/978-3-7091-6377-1_2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.
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Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, New York University, New York, USA
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Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke 1999; 30:317-20. [PMID: 9933266 DOI: 10.1161/01.str.30.2.317] [Citation(s) in RCA: 285] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A well-defined complication rate of cerebral angiography in patients with subarachnoid hemorrhage (SAH), cerebral aneurysm, and arteriovenous malformation (AVM) would be useful to physicians making decisions regarding the imaging of these patients. We sought to define a statistically significant complication rate through meta-analysis of prospective studies in the literature. METHODS Meta-analysis of 3 published prospective studies of complications in cerebral angiography was performed to specifically define the risk of cerebral angiography in patients presenting with SAH, cerebral aneurysm, and AVM. The complication rates for cerebral angiography in patients with SAH and AVM/aneurysm without SAH were compared with the complication rates in patients who underwent cerebral angiography for transient ischemic attack (TIA)/ischemic stroke with use of the Fisher exact test. RESULTS The combined risk of permanent and transient neurological complication was significantly lower in patients with SAH compared with patients with TIA/stroke (1.8% versus 3.7%; P=0.03). The combined risk of permanent and transient neurological complication was significantly lower in patients with aneurysm/AVM without SAH compared with patients with TIA/stroke (0.3% versus 3.7%; P=0.001). When the patients with SAH and cerebral aneurysm/AVM were combined, the overall risk of permanent and transient neurological complication was significantly lower than for the TIA/stroke patients (0.8% versus 3.0%; P=0.001), as was the risk of permanent neurological complication (0.07% versus 0.7%; P=0.004). CONCLUSIONS The risk of permanent neurological complication associated with cerebral angiography in patients with SAH, cerebral aneurysm, and AVM is quite low (0.07%). This risk is lower than previously recognized.
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Affiliation(s)
- H J Cloft
- Departments of Radiology and Neurosurgery, Emory University, Atlanta, GA, USA.
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McKhann GM, Le Roux PD. Perioperative and Intensive Care Unit Care of Patients with Aneurysmal Subarachnoid Hemorrhage. Neurosurg Clin N Am 1998. [DOI: 10.1016/s1042-3680(18)30255-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Le Roux PD, Elliott JP, Eskridge JM, Cohen W, Winn HR. Risks and benefits of diagnostic angiography after aneurysm surgery: a retrospective analysis of 597 studies. Neurosurgery 1998; 42:1248-54; discussion 1254-5. [PMID: 9632182 DOI: 10.1097/00006123-199806000-00026] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Cerebral angiography performed after aneurysm surgery can identify causes of morbidity and mortality that may be corrected. The risks and benefits of angiography that is performed after aneurysm surgery, however, have not been clearly defined. We therefore reviewed our experience with postoperative angiography to determine its dangers and benefits. METHODS During 10 years, 543 consecutive patients received treatment for cerebral aneurysms. A retrospective analysis of 597 diagnostic angiograms obtained after aneurysm surgery for 494 of these patients was performed. RESULTS Catheter-induced vessel spasm and dissection, occurring most frequently in the internal carotid artery, were observed in seven (1.2%) and six (1%) studies, respectively. No angiography-associated strokes were identified. No association between age, smoking, hypertension, blood pressure, atherosclerosis, or severe vasospasm and angiographic complications was observed. Aneurysm remnants were identified in 36 (5.7%) of the 637 aneurysms that were surgically treated. Atherosclerosis (P < 0.01) or multiple clip applications (P < 0.01) were significantly associated with aneurysm remnants. Angiographic vessel occlusion was observed in 28 (5.7%) patients and resulted in stroke in 14 of these patients. Vessel occlusion was significantly associated with increasing aneurysm size (P < 0.001), atherosclerosis (P < 0.001), temporary clips (P < 0.001), multiple clips (P=0.03), multiple clip applications (P=0.001), and a new postoperative neurological deficit (P=0.002). Severe vasospasm and newly identified aneurysms were observed in 51 and 16 patients, respectively. CONCLUSION Angiography after aneurysm surgery is safe and can be routinely performed. Angiography after aneurysm surgery should be particularly considered for patients with large aneurysms or cerebrovascular atherosclerosis and for those who develop new postoperative neurological deficits.
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Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, University of Washington, Seattle 98195, USA
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Nakajima Y, Yoshimine T, Yoshida H, Sakashita K, Okamoto M, Kishikawa M, Yagi K, Yokota J, Hayakawa T. Computerized tomography angiography of ruptured cerebral aneurysms: factors affecting time to maximum contrast concentration. J Neurosurg 1998; 88:663-9. [PMID: 9525712 DOI: 10.3171/jns.1998.88.4.0663] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT This study was conducted to assess the diagnostic value of three-dimensional computerized tomography (3-D CT) angiography in demonstrating cerebral aneurysms in 42 consecutive patients presenting with acute subarachnoid hemorrhage (SAH). METHODS To obtain the volume data for selective visualization of the cerebral arteries without enhancement of the venous system, the time delay was established between the injection of contrast medium and the start of scanning by using two different methods. The circulation time was calculated with Schad's formula in the first 13 cases, but the results were not satisfactory. In the 29 subsequent cases the time delay was established using a single-level dynamic CT prescan. The dynamic prescan demonstrated the statistical differences in peak time with regard to patient age, SAH grade, and the postresuscitation state after cardiopulmonary arrest. The 3-D CT angiograms were generated from the volume data by using a voxel transmission method. Computerized tomography angiography obtained after optimally adjusted time delay demonstrated the contour of the cerebral arteries in 97% of cases, and aneurysms were detected in 93%. Enhancement of the cavernous sinus and major cortical veins was avoided. Even in patients who suffered cardiopulmonary arrest, images of the major arteries were clearly demonstrated after resuscitation. CONCLUSIONS In an emergency situation, CT angiography with a dynamic prescan may be an alternative to magnetic resonance angiography or digital subtraction angiography in the diagnosis of ruptured aneurysms. This modality would also be useful for the precise assessment of small aneurysms, blebs, and aneurysms adjacent to the cavernous sinus.
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Affiliation(s)
- Y Nakajima
- Osaka Prefectural Senshu Critical Care Medical Center, Japan
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Elliott JP, Newell DW, Lam DJ, Eskridge JM, Douville CM, Le Roux PD, Lewis DH, Mayberg MR, Grady MS, Winn HR. Comparison of balloon angioplasty and papaverine infusion for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg 1998; 88:277-84. [PMID: 9452236 DOI: 10.3171/jns.1998.88.2.0277] [Citation(s) in RCA: 175] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT The purpose of this study was to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients. METHODS Blood flow velocities of the involved vessels were assessed by using transcranial Doppler (TCD) monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papaverine infusion cohorts were compared based on mean pre- and posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment after balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), a decrease that was sustained. CONCLUSIONS Balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.
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Affiliation(s)
- J P Elliott
- Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle 98104, USA
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Shimoda M, Oda S, Mamata Y, Tsugane R, Sato O. Surgical indications in patients with an intracerebral hemorrhage due to ruptured middle cerebral artery aneurysm. J Neurosurg 1997; 87:170-5. [PMID: 9254078 DOI: 10.3171/jns.1997.87.2.0170] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In this retrospective study, the authors analyzed surgical outcomes in patients who suffered an intracerebral hemorrhage (ICH) as a result of a ruptured middle cerebral artery aneurysm. They studied 47 patients who underwent early aneurysm surgery and hematoma evacuation within 24 hours after onset of ICH. The types of ICH were classified into three groups according to their appearance on computerized tomography scanning: 1) temporal ICH; 2) intrasylvian hematoma; and 3) ICH with diffuse subarachnoid hemorrhage (SAH). Overall, 25 patients (53%) achieved a favorable outcome and 18 (38%) died. Factors that could be used to predict a favorable outcome included age less than 60 years, temporal ICH, World Federation of Neurological Surgeons Grade II or III, absence of a surgical complication, and a hematoma volume less than 25 ml. In the patients with temporal ICH, eight of nine patients achieved a good recovery and no patient developed a surgical complication or delayed ischemic deficit. The significant prognostic factor in patients with an intrasylvian hematoma was surgery within 6 hours after onset of symptoms. In patients with temporal ICH or intrasylvian hematoma, the results of the initial neurological examination did not accurately predict outcome. On the other hand, in patients with ICH and diffuse SAH, those patients who developed an ICH with a volume greater than 25 ml had a poor prognosis. These results indicate that aggressive surgical treatment should be performed in patients with a temporal ICH or an intrasylvian hematoma, regardless of the neurological findings on admission; in patients with ICH and diffuse SAH, a careful review of surgical indications is required.
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Affiliation(s)
- M Shimoda
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Elliott JP, Le Roux PD, Ransom G, Newell DW, Grady MS, Winn HR. Predicting length of hospital stay and cost by aneurysm grade on admission. J Neurosurg 1996; 85:388-91. [PMID: 8751621 DOI: 10.3171/jns.1996.85.3.0388] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To determine the relationship between clinical grade on admission and treatment cost after aneurysm rupture, the authors retrospectively examined the length of hospital stay (LOS) and total hospitalization costs (excluding professional fees) for 543 patients admitted for aneurysm surgery between 1983 and 1993. The overall median LOS was 18 days, with a range of 1 to 165 days. Increased median LOS correlated with Hunt and Hess Grades 0 to IV on admission (p < 0.001). Median LOS for Grade V patients was reduced, in part, because of early mortality. Increased treatment cost also correlated with worse admission clinical grade (p < 0.001). A significant proportion of total expenditures occurred early in the hospitalization for patients in all clinical grades. Identification of additional factors affecting the cost of aneurysm treatment is indicated to complement treatment outcome studies.
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Affiliation(s)
- J P Elliott
- Department of Neurological Surgery, University of Washington, Seattle, USA
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Le Roux PD, Elliott JP, Newell DW, Grady MS, Winn HR. Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases. J Neurosurg 1996; 85:39-49. [PMID: 8683281 DOI: 10.3171/jns.1996.85.1.0039] [Citation(s) in RCA: 236] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To determine what factors predict outcome, the authors retrospectively reviewed the management of all 159 poor-grade patients admitted to Harborview Medical Center at the University of Washington who suffered aneurysmal subarachnoid hemorrhage between 1983 and 1993. Favorable outcome (assessed by the Glasgow Outcome Scale) occurred in 53.9% of Hunt and Hess Grade IV, and 24.1% of Grade V patients. Outcome was largely determined by the initial hemorrhage and subsequent development of intractable intracranial hypertension or cerebral infraction. Using multivariate analysis, the authors developed three models to predict outcome. It was found that predicting outcome based only on clinical and diagnostic criteria present at admission may have resulted in withholding treatment from 30% of the patients who subsequently experienced favorable outcomes. It is concluded that aggressive management including surgical aneurysm obliteration can benefit patients with poor neurological grades and should not be denied solely on the basis of the neurological condition on admission.
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Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, University of Washington, Seattle, USA
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Le Roux PD, Elliot JP, Newell DW, Grady MS, Winn HR. The incidence of surgical complications is similar in good and poor grade patients undergoing repair of ruptured anterior circulation aneurysms: a retrospective review of 355 patients. Neurosurgery 1996; 38:887-93; discussion 893-5. [PMID: 8727813 DOI: 10.1097/00006123-199605000-00006] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
To determine how clinical grade after subarachnoid hemorrhage impacts operative characteristics and the incidence of intra- and postoperative surgical complications, we retrospectively compared the surgical management of all good grade (n = 224) and poor grade (n = 131) patients who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The majority of good grade (74.2%) and poor grade (89.8%) patients underwent surgery < 3 days after subarachnoid hemorrhage. The results in this series demonstrate that severe cerebral swelling, often secondary to intracerebral hemorrhage, was significantly more frequent in poor grade patients. The incidence of complications, such as failure to occlude the aneurysm, major vessel occlusion, intraoperative aneurysm rupture, or surgical contusion, however, was similar in poor grade and good grade patients. We conclude, therefore, that except for severe cerebral swelling associated with intracerebral hemorrhage, the risk of surgical complications is similar in good and poor grade patients undergoing surgical repair of ruptured anterior circulation aneurysms.
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Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, University of Washington, Seattle, USA
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Hsiang JN, Liang EY, Lam JM, Zhu XL, Poon WS. The role of computed tomographic angiography in the diagnosis of intracranial aneurysms and emergent aneurysm clipping. Neurosurgery 1996; 38:481-7 discussion 487. [PMID: 8837799 DOI: 10.1097/00006123-199603000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Conventional cerebral angiography has always been regarded as the gold standard for intracranial aneurysm detection. However, conventional angiography has the disadvantages of being invasive and time consuming. We present here 30 patients who underwent computed tomographic angiography (CTA) with three-dimensional reconstruction for the detection of intracranial aneurysms. All of these patients had subarachnoid hemorrhage or suspected intracranial aneurysms. CTA was performed in all patients with the use of a General Electric Hispeed Advantage helical scanner. Iohexol, 135 ml, was used as the contrast agent. Twenty-five patients also underwent conventional angiography for comparison. The five patients who underwent CTA only did not have conventional angiography because of poor clinical condition, and four of them subsequently died. Five patients had subarachnoid hemorrhage, but the results of both CTA and conventional angiography were negative for aneurysms. One patient had an incidental finding of a 3-mm left posterior communicating artery aneurysm on CTA, which was confirmed by conventional angiography. In the remaining 19 patients, 19 saccular aneurysms and 1 fusiform aneurysm were detected by CTA. Locations and sizes were confirmed by conventional angiography in all except two. The first exception was a patient who had a 2.5-mm anterior communicating artery aneurysm detected by CTA but not by conventional angiography. Surgical exploration confirmed the CTA diagnosis. The other exception was a patient in whom a 2-mm right posterior communicating artery aneurysm was detected by CTA but in whom conventional angiography showed a 2-mm left posterior communicating artery aneurysm. Unfortunately, there was no surgical confirmation in this case because the family of the patient refused surgery. Our results have demonstrated that CTA is a quick, reliable, and relatively simple diagnostic tool for intracranial aneurysms. In an emergent situation, such as a deteriorating patient with a hematoma, it is superior to either empiric exploration or infusion computed tomographic scans because it delineates the orientation and configuration of the aneurysm and its associated vascular anatomy.
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Affiliation(s)
- J N Hsiang
- Department of Surgery, Chinese University of Hong Kong, Shatin
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Hsiang JN, Liang EY, Lam JM, Zhu XL, Poon WS. The Role of Computed Tomographic Angiography in the Diagnosis of Intracranial Aneurysms and Emergent Aneurysm Clipping. Neurosurgery 1996. [DOI: 10.1227/00006123-199603000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP, Feinberg W. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994; 90:2592-605. [PMID: 7955232 DOI: 10.1161/01.cir.90.5.2592] [Citation(s) in RCA: 157] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M R Mayberg
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596
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Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP, Feinberg W. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25:2315-28. [PMID: 7974568 DOI: 10.1161/01.str.25.11.2315] [Citation(s) in RCA: 273] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M R Mayberg
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596
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Abstract
Subarachnoid hemorrhage (SAH) remains a devastating neurological disorder, which most commonly develops after rupture of an intracranial aneurysm. Advances have occurred in the areas of epidemiology, diagnostic imaging, medical management and surgical intervention, related to aneurysmal SAH. Interested physicians must become aware of these and other advances to diagnose and manage this potentially lethal disorder more effectively. This review provides information about the pathogenesis and complications of aneurysmal SAH and an update of new and evolving treatment modalities to provide an in-depth overview for the clinician and researcher involved in this rapidly evolving field.
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Affiliation(s)
- J P Weaver
- Division of Neurosurgery, University of Massachusetts Medical School, Worcester 01655
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