Problems in Endovascular Procedures in Acute Ruptured Intracranial Aneurysms

Fifteen patients with acute ruptured intracranial aneurysms were treated with interlocking detachable coil (IDC) embolization. All graded poorly, i.e., Hunt & Kosnik grades IV and V. Aneurysm occurred in the anterior circulation in 14 patients and at the basilar tip in one, of these, 13 were small and 2 large. The endovascular procedure was conducted in a transfemoral approach under local anesthesia. Aneurysmal obliteration was examined transitionally after embolization.

Final outcome was evaluated using the Glasgow outcome scale (GOS). Total aneurysmal occlusion was observed immediately after IDC embolization in 11 patients. Two cases of coil migration to the parent artery occurred during endovascular procedure in patients with severe atherosclerosis. Aneurysmal rupture occurred during the endovascular procedure in a small internal carotid artery aneurysm when coil detachment failed.

Follow-up angiography showed coil compaction in 2 patients, one patient experienced deterioration when the aneurysm ruptured. Eleven patients (73.3%) retained total aneurysmal occlusion and had no rebleeding. The overall GOS indicated good recovery in 5 patients, severe disability in 2, persistent vegetative state in 2, and death in 6.

IDC embolization in severe acute ruptured intracranial aneurysm successfully prevented rebleeding, but our series was limited by the very small aneurysm size and the presence of severe atherosclerosis.

Neuronal damage in pericontusional edema zone

In this study, we investigated the molecular biological and histopathological aspects of the etiological mechanisms for pericontusional edema zone (PEZ). The subjects were 5 patients with traumatic brain injury who underwent surgery to evacuate the resulting hematoma. The average age of the subjects was 52 +/- 27.5 years. The GCS at the time of admission was 5-9. At operation apart from evacuating the hematoma, the PEZ was also excised and then examined histopathologically. Cerebrospinal fluid (CSF) levels of IL-6, IL-8, and IL-10 were measured at the time of admission and at 24 and 72 hours. Histological examination revealed large numbers of neutrophils accumulating within blood vessels in the PEZ, with some focal migration. IL-6: CSF levels at the time of admission and at 24, 72, and 72 hours were 550, 4350, and 878000 pg/ml, respectively (median values). IL-8: CSF levels were 715, 804, and 24900 pg/ml, respectively. IL-10: CSF levels were 15, 4, and 5 pg/ml, respectively. High levels of IL-6 and IL-8 were seen from an early stage, and became markedly higher with enlargement of the PEZ. The PEZ is thought to be due to microvascular disturbance by neutrophils stimulated by inflammatory cytokines, and neuronal damage from migrated neutrophils.

Characteristics of parietal-parasagittal hemorrhage after mild or moderate traumatic brain injury

The aim of this study is to clarify the clinical characteristics of parietal-parasagittal traumatic intracranial hemorrhage (TICH) after mild or moderate traumatic brain injury (TBI). METHODS; Subjects were 105 patients with mild or moderate TBI. The patients with parietal-parasagittal TICH were clinically analyzed based on the initial brain CT findings, hematoma sites and the clinical course as compared to those with TICH at other sites.

RESULTS

Hematoma was located in the frontal or temporal lobes in 89.5% of the subjects and the parietal-parasagittal in 10.5%. Ten of the 11 patients suffering parietal-parasagittal TICH had skull fractures (7 depressed and 3 linear) but no depressed fracture observed in patients with frontal or temporal lobe hemorrhage. Neurological deterioration leading to a comatose state more frequently occurred in 63.6% of patients with parietal-parasagittal TICH than in those with frontal or temporal lobe hemorrhage (19.1%, p < 0.01). The incidence of hematoma growth was significantly higher in patients with parietal-parasagittal TICH (63.6%) than in those with frontal or temporal lobe hemorrhage (31.9%, p < 0.05).

DISCUSSION

The incidence of parietal-parasagittal TICH is low, but the risk of neurological deterioration due to hematoma enlargement is significantly high. Parietal-parasagittal TICH may differ clinically from frontal-temporal TICH.

The risk factors for the occurrence of acute brain swelling in acute subdural hematoma

There are many cases of acute subdural hematoma (ASDH) in which acute brain swelling (ABS) occurs intra- or post-operative period and the control of intracranial pressure becomes impossible, resulting in death. Consequently, we investigated the risk factors for ABS in ASDH. Thirteen cases were used for this study. The average age was 53.8 years, and all the subjects were males whose Glasgow Coma Scale (GCS) was an average of 4.8 when hospitalized. We examined the relationship of blood gas values (pH, PaO2, PaCO2, HCO3-, and base excess) when hospitalized, mean arterial blood pressure (MAP) before surgery, and the presence of hypotension during the surgery with ABS. There were no cases, which showed evidence of hypoxia or hypotension when hospitalized or before the surgery. No statistical differences in blood gas values when hospitalized were observed between the 7 cases with ABS and the 6 cases without ABS. However, all of 7 cases with ABS showed MAP > or = 140 mmHg, and 6 cases demonstrated intraoperative hypotension (systolic pressure < 90 mmHg). Conspicuous hypertension before the surgery was shown to be a possible risk factor for ABS. Therefore; MAP > or = 140 mmHg may be a warning sign for the occurrence of ABS.

IL-8 is a key mediator of neuroinflammation in severe traumatic brain injuries

The subjects were 22 patients with severe head injury. The average age was 45 +/- 18.3 years. There were 13 survivors and 9 fatalities. Samples of peripheral blood and cerebrospinal fluid (CSF) were taken four times, at the time of admission and at 24, 72, and 168 hours later. IL-6: For the survivor group, peripheral blood levels were 181, 105, 37, and 26 pg/ml, respectively (median values). CSF levels were 5376, 3565, 328, and 764 pg/ml, respectively. For the fatality group, peripheral blood levels were 102, 176, 873, and 3059 pg/ml, respectively, whereas CSF levels were 15241, 97384, 548225, and 366500 pg/ml, respectively. IL-8: For the survivor group, peripheral blood levels were 36, 15, 15, and 15 pg/ml, respectively, whereas CSF levels were 23736, 4074, 355, and 1509 pg/ml, respectively. For the fatality group, peripheral blood levels were 21, 28, 43, and 77 pg/mL, respectively, whereas CSF levels were 29003, 8906, 5852, and 8220 pg/ml, respectively. IL-6 and IL-8 levels were significantly higher after 72 hours in the fatality group. The fact that CSF IL-8 was 1000 times that in the peripheral blood at the time of admission, and decreased thereafter, indicates that IL-8 is a key mediator of neuroinflammation.

Importance of metabolic monitoring systems as an early prognostic indicator in severe head injured patients

We have analyzed and evaluated what is the best metabolic monitoring system to determine the prognosis for maintenance of neurological function in severe head injured patients. Acute subdural hematoma (ASDH) was recognized in fifteen of 22 patients and cerebral contusion in seven in this series. Intracranial pressure (ICP), jugular venous pH and jugular bulb venous oxygen saturation (SjO2) were continuously monitored as soon as possible following stabilization. The measurement of cerebral blood flow (CBF) was carried out using a stable Xenon-computerized tomography (Xe-CT). After measuring CBF, 3% carbon dioxide (CO2) loading was conducted to determine CO2 responses (delta CBF/delta CO2). In patients who died (D), jugular venous pH showed evidence of acidosis (6.3-7.2) with delta CBF/delta CO2 < 1 and cerebral metabolic rate of oxygen (CMRO2) < 1.21 within several hours of the trauma. On the other hand, arterial pH was shown to be within the normal range. In vegetative state (VS) and severe disability (SD) patients, jugular venous pH was shown to be within normal range, with delta CBF/delta CO2 < 1 and 1.44 < CMRO2 < 1.79. In all of moderate disability (MD) and good recovery (GR) patients, jugular venous pH was shown to be within the normal range, with delta CBF/delta CO2 > 1 and 1.65 < CMRO2 < 1.85. These results suggest that jugular venous pH, CO2 response and CMRO2, were useful as early prognostic indicators in the maintenance of neurological function.

Gadolinium DTPA-enhanced magnetic resonance imaging of cerebral contusions

The morphological characteristics of cerebral contusions in head trauma patients suggest that an increase in cerebrovascular permeability is responsible for the contusion edema which develops within 1-3 days posttrauma. In the present study, 10 patients with cerebral contusions (mean age, 38 years old; 8 males and 2 females) were examined by gadolinium (Gd)-DTPA enhanced magnetic resonance imaging (MRI) at 1-2 days after trauma. Gd-DTPA (0.3 mmol/kg) was infused intravenously over a period of 30 min. MRIs were taken before, and at 2 and 4 hours after initiation of the Gd-DTPA administration. It was found that contusion edema areas were frequently enhanced by Gd-DTPA at 2 hours. The enhancement diminished at 4 hours. These findings appear to be inconsistent with the results of previously reported similar studies in which enhancement was detected at 6-9 days posttrauma but not during the period earlier than 6 days. This discrepancy may be attributable to the presence of a high blood concentration of Gd-DTPA for a longer period of time and a delay in the time at which MRIs were taken in the present study. The present data indicate that an increased cerebrovascular permeability occurs at as early as 1-2 days posttrauma, and suggest that contusion edema which progresses during the initial 1-3 days may be at least partially vasogenic in nature.

Pituitary adenoma combined with Rathke's cleft cyst--case report

A rare pituitary adenoma associated with Rathke's cleft cyst was discovered incidentally in a 44-year-old male admitted after head trauma. Neurological and physiological examination found no abnormalities, except for panhypopituitarism. Computed tomography and magnetic resonance imaging demonstrated a solid mass in the sellar cavity with suprasellar extension, associated with a cystic mass extending into the third ventricle. The tumor was removed subtotally by the transcranial approach. Light microscopy demonstrated that the cyst wall was composed of ciliated columnar cells, cuboidal cells, and goblet cells, and the solid part indicated chromophobe pituitary adenoma. Immunohistochemistry demonstrated that a few adenoma cells were positive for prolactin and the cyst wall cells were positive for cytokeratin and negative for S-100 protein.

[A case of penetrating head injury caused by nail-gun]

A rare case of penetrating head injury caused by a nail-gun was described. A 24-year-old male was admitted to our hospital due to head injury. He had handled a nail-gun at a construction site. On admission the patient was fully conscious with no neurological defects. A small wound was observed at the left front-temporal region. Skull films showed a large nail embedded in the skull cavity. A computed tomographic (CT) scan, changing level of window, demonstrated intracerebral hematoma, fragment of skull bone and nail. Cerebral angiography (CAG) showed extravasation at the left frontal region. Emergency operation was performed and his recovery was uneventful. Twenty-two craniocerebral injuries caused by nail-guns have been reported in world medical literature but this was the first report in Japan. The characteristics of craniocerebral nail-gun injuries were less damage and better prognosis compared with gunshot injuries. However intracranial infection and vascular injury were possible lethal complications. In this case, preoperative examination, such as CT scan and CAG was valuable and the early operation for the sake of safety was very effective.

[Development of cerebral blood flow measurement using skull impedance plethysmography]

Using skull impedance plethysmography, a developmental approach was made to the measurement of mean cerebral blood flow (mCBF) from brain volume exchanging ratio (delta V) involved in bilateral jugular venous occlusion. An experimental study thereof revealed the following results: Comparative examinations were made between total cerebral blood flow obtained by the superior sagittal sinus hydrogen clearance method and delta V X t obtained by the present approach led to the establishment of a linear correlation there between and also of the following calculating formula: mCBF = k X delta V X t (omega X sec) k: proportional coefficient t: blood flow increasing time (10 sec.) The experimental results revealed that the present approach was valid enough as an index of cerebral blood flow. Some future improvements therein seem to make also its clinical application possible. The theory and method of the present approach are described with an examination of several points raised thereby.

[Multiple giant aneurysm--a case report]

We report a case of five aneurysms, including three giant aneurysms, a pair of symmetric aneurysms, and two fusiform aneurysms. The initial clinical symptom was a cerebral ischemic attack. On admission, the patient complained of sudden onset of speech disturbance. Physical examination showed left hemiparesis. Radiological studies, including computed tomography and cerebral arteriography, revealed multiple low density areas bilaterally in the basal ganglia and three fusiform giant aneurysms bilaterally in the middle cerebral arteries and basilar artery. Considering the difficulty of surgical treatment, the patient was discharged. Six months later, complaining of right hemiparesis and total dysphasia, the patient was readmitted to our department. CT scan on admission revealed no changes except for ischemic changes. During the second admission, another attack of subarachnoidal hemorrhage due to rupture of the left middle cerebral artery aneurysm occurred, and the patient died. Autopsy was performed, and two more aneurysms, not visualized in the former studies, were found in the right anterior communicating artery and the cortical branch of the right middle cerebral artery. The occurrence of aneurysms in such a fashion as seen in the present case is to be very rare in the aspect of the size, the multiplicity and the bilaterally development.