Acute Operation and Preventive Nimodipine Improve Outcome in Patients with Ruptured Cerebral Aneurysms

Neurosurgery ◽  
1984 ◽  
Vol 15 (1) ◽  
pp. 57-66 ◽  
Author(s):  
Ludwig M. Auer
Keyword(s):  
Surgical Complication ◽  
Cerebral Aneurysms ◽  
Intracerebral Hematoma ◽  
Improve Outcome ◽  
Symptomatic Vasospasm ◽  
Postoperative Control ◽  
Intraventricular Bleeding ◽  
Subarachnoid Blood ◽  
Clinical Grading ◽  
Control Angiography

Abstract Sixty-five patients with ruptured aneurysms were operated upon within 48 to 72 hours after subarachnoid hemorrhage (SAH) and were treated with a regimen of intra- and postoperative nimodipine for the prevention of symptomatic vasospasm. The clinical grading (Hunt and Hess) was I to III in 49 patients and IV or V in 16. The SAH was mild in 15 patients, moderate in 27, and severe in 23; 12 patients harbored an intracerebral hematoma, and 6 had intraventricular bleeding. Acute hydrocephalus was observed on preoperative computed tomography (CT) in 19 patients. On CT 3 days postoperatively (i.e., Day 3-4 after SAH), 30 of 65 patients still had subarachnoid blood; however, severe symptomatic vasospasm as the deciding threatening event during the delayed postoperative period was not encountered in this series. Transient symptoms of ischemia were noted in 2 patients (3%) and were accompanied by angiographic spasm in 1. Irreversible neurological deficit occurred in 2 patients (3%); in 1 of these, it was a complication of postoperative control angiography. Of the patients preoperatively graded I or II, 96% had an excellent to fair outcome 6 months postoperatively, and 1 patient (4%) had died because of a surgical complication. Among patients preoperatively graded III or IV, 86% had an excellent to fair outcome, and the remaining 14% had a poor outcome. Shunt-dependent hydrocephalus developed in 7% of the patients. Acute surgical repair of ruptured cerebral aneurysms and preventive topical and intravenous administration of nimodipine reduce management complications and improve outcome; above all, ischemic lesions from symptomatic vasospasm are reduced to a minimum.

scholarly journals Clinical Outcomes of Coil Embolization for Acutely Ruptured Aneurysm

2004 ◽  
Vol 10 (2_suppl) ◽  
pp. 49-53 ◽  
Author(s):  
M. Hirohata ◽  
T. Abe ◽  
N. Fujimura ◽  
Y. Takeuchi ◽  
H. Morimitsu ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Surgical Complication ◽  
Cerebral Aneurysms ◽  
Clinical Results ◽  
Primary Treatment ◽  
Additional Treatment ◽  
Intracerebral Hematoma ◽  
Complication Rates ◽  
Symptomatic Vasospasm ◽  
Primary Treatment Modality

The purpose of this prospective study was to evaluate clinical results in patients with acutely ruptured cerebral aneurysm treated by neck clipping (NC) or coil embolization (CE) when CE was considered the first option. Between 1998 and 2003, 280 patients with acutely ruptured cerebral aneurysms excluding intracerebral hematoma were evaluated. Patients were managed prospectively according to the following protocol: primary treatment modality was CE (n =179). NC (n=101) was selected for the patients with aneurysms that were small (less than 2 mm) or an unsuitable shape for CE. Surgical complication rates were 4.5% for CE and 16.8% for NC. Symptomatic vasospasm occurred in 8.4% of CE patients and 29% of NC patients. Good recovery on the Glasgow Outcome Scale was achieved by 71% of CE patients and 50% of NC patients at discharge. Surgical complications and symptomatic vasospasm were significantly reduced in CE compared to NC. Clinical outcome at discharge was also better with CE. Although 18.3% of CE patients showed various degrees of aneurysmal recanalization and 7% of CE patients required additional treatment (re-CE or NC), aneurysmal rebleeding occurred in only one patient during follow-up (mean, 3.95 years).

Multiple middle cerebral artery aneurysms in an infant

1990 ◽  
Vol 72 (5) ◽  
pp. 806-809 ◽  
Author(s):  
Cornelia Cedzich ◽  
J. Schramm ◽  
G. Röckelein
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Systemic Disease ◽  
Intracerebral Hematoma ◽  
Left Middle Cerebral Artery ◽  
Content Type ◽  
Middle Cerebral Artery Aneurysms ◽  
Subarachnoid Blood ◽  
Left Middle ◽  
Control Angiography

✓ An 11-month-old boy was admitted for evaluation of drowsiness, vomiting, and convulsions. Computerized tomography showed subarachnoid blood in the left sylvian fissure and a small intracerebral hematoma in the temporal lobe. Angiography revealed several aneurysms of the left middle cerebral artery (MCA). During surgery, 13 aneurysms were found arising from one main branch of the left MCA, and this segment of the MCA was trapped. Somatosensory evoked potentials did not show any change during surgery. The diseased arterial segment was examined histologically and the pathogenetic aspects of the case are discussed. Control angiography 6 months later excluded systemic disease or other aneurysms. The rarity of such lesions in childhood and their successful surgical treatment are discussed briefly.

Cisternal Drainage after Early Operation of Ruptured Intracranial Aneurysm

Neurosurgery ◽  
1987 ◽  
Vol 20 (1) ◽  
pp. 8-14 ◽  
Author(s):  
Yasuto Kawakami ◽  
Yutaka Shimamura
Keyword(s):  
Intracranial Aneurysm ◽  
Anterior Part ◽  
Signs And Symptoms ◽  
Early Operation ◽  
Neurological Condition ◽  
Social Lives ◽  
Symptomatic Vasospasm ◽  
Ruptured Intracranial Aneurysm ◽  
Cisternal Drainage ◽  
Subarachnoid Blood

Abstract The authors reviewed 22 cases of intracranial aneurysm of the anterior part of the circle of Willis. All patients presented with the signs and symptoms of subarachnoid hemorrhage (SAH) and were in good neurological condition on admission. In all cases, early operation was performed to obliterate aneurysm. Subarachnoid blood clots were extensively removed and cisternal drainage was done. With topical application of povidone-iodine and intravenous administration of antibiotics, cisternal drainage continued for 14 days or more after the onset of SAH in 21 cases. Five patients developed symptomatic vasospasm, which was treated with hypervolemia and hypertension, and three received shunts later for chronic hydrocephalus. The overall result demonstrated that 21 patients were independent and had returned to their previous social lives. Therefore, it was strongly recommended that patients is good neurological condition after SAH secondary to ruptured intracranial aneurysm be treated with early operation, removal of subarachnoid clots, and long term application of cisternal drainage.

Moyamoya Disease Presenting as Intracerebral Hemorrhage during Pregnancy: Case Report and Review of the Literature

Neurosurgery ◽  
1987 ◽  
Vol 20 (1) ◽  
pp. 33-35 ◽  
Author(s):  
Hitomi Enomoto ◽  
Hiroshi Goto
Keyword(s):  
Intracranial Hemorrhage ◽  
Moyamoya Disease ◽  
Cerebral Aneurysms ◽  
Intracerebral Hematoma ◽  
Review Of The Literature ◽  
Left Temporal Lobe ◽  
Third Trimester ◽  
Intracranial Hemorrhages ◽  
Operative Indications ◽  
Pregnancy Result

Abstract Intracranial hemorrhage during pregnancy is rare. The authors present a case of moyamoya disease associated with pregnancy. A 32-year-old woman who was at 32 weeks of gestation experienced sudden severe headache followed by loss of consciousness. Computed tomography revealed an intracerebral hematoma in the left temporal lobe, and left carotid angiograms revealed moyamoya disease. The patient underwent emergency craniotomy, the hematoma was removed, and encephaloduroarteriosynangiosis was performed. The patient showed good recovery and, 2 months later, delivered a child vaginally without any trouble. Most intracranial hemorrhages during pregnancy result from cerebral aneurysms or arteriovenous malformations (AVMs), and few cases due to moyamoya disease have been reported. It is generally believed that subarachnoid hemorrhage due to cerebral aneurysms is likely to occur during the middle trimester of gestation, with the risk increasing progressively toward the third trimester. This may be explained by the fact that the cardiac output increases rather acutely from the first to the middle trimester. There seems to be no significant correlation between the stage of pregnancy and the occurrence of hemorrhage due to AVM. Most authors think that the operative indications for intracranial hemorrhage during pregnancy should be the same as for the nonpregnant state.

Intraoperative rerupture during surgical treatment of aneurysmal subarachnoid hemorrhage is not associated with an increased risk of vasospasm

2014 ◽  
Vol 120 (2) ◽  
pp. 409-414 ◽  
Author(s):  
Sunil A. Sheth ◽  
Daniel Hausrath ◽  
Adam L. Numis ◽  
Michael T. Lawton ◽  
S. Andrew Josephson
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Surgical Clipping ◽  
Acute Hemorrhage ◽  
Exact Test ◽  
Symptomatic Vasospasm ◽  
Angiographic Vasospasm ◽  
Fisher Grade ◽  
Increased Risk ◽  
Male Sex

Object Intraoperative rerupture during open surgical clipping of cerebral aneurysms in subarachnoid hemorrhage (SAH) is a relatively frequent and potentially catastrophic occurrence. Patients who suffer rerupture have been shown to have worse outcomes at discharge compared with those who do not have rerupture. Perioperative injury likely plays a large part in the clinical worsening of these patients. However, due to the increased vessel manipulation and repeat exposure to acute hemorrhage, it is possible that secondary injury from increased incidence of vasospasm also contributes. Identifying an increased rate of vasospasm in these patients would justify early aggressive treatment with measures to prevent delayed cerebral ischemia. The authors investigated whether patients who suffer intraoperative rerupture during surgical treatment of ruptured cerebral aneurysms are at increased risk of developing vasospasm. Methods Five hundred consecutive patients treated with open surgical clipping for SAH were reviewed, and clinical and imaging data were collected. Angiographic vasospasm was defined as vessel narrowing believed to be consistent with vasospasm on angiography. Symptomatic vasospasm was defined as angiographic vasospasm in the setting of a clinical change attributable to vasospasm. Rates of angiographic and symptomatic vasospasm among patients with and without intraoperative rerupture were compared. Results There were no significant differences between the groups with and without rupture with respect to age, sex, modified Fisher grade, history of hypertension, or smoking. The group with intraoperative rupture had more patients with Hunt and Hess Grade I. Angiographic vasospasm was noted in 279 (66%) of the 425 patients without rerupture compared with 49 (65%) of the 75 patients with rerupture (p = 1.0, Fisher's exact test). Symptomatic vasospasm was noted in 154 (36%) of the 425 patients without rerupture, compared with 31 (41%) of the 75 patients with rerupture (p = 0.44, Fisher's exact test). In multivariate analysis, higher modified Fisher grade was significantly predictive of vasospasm, whereas older age and male sex were protective. Conclusions This study found no significant influence of intraoperative rerupture during open surgical clipping on the rate of angiographic or symptomatic vasospasm. Brief exposure to acute hemorrhage and vessel manipulation associated with rerupture events did not affect the rate of vasospasm. Risk of vasospasm was related to increased modified Fisher grade, and inversely related to age and male sex. These results do not justify early, targeted vasospasm therapy in patients with intraoperative rerupture.

Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage

2012 ◽  
Vol 117 (1) ◽  
pp. 15-19 ◽  
Author(s):  
Elias A. Giraldo ◽  
Jay N. Mandrekar ◽  
Mark N. Rubin ◽  
Stefan A. Dupont ◽  
Yi Zhang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Infarction ◽  
Functional Outcome ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Intracerebral Hematoma ◽  
Poor Functional Outcome ◽  
Poor Outcome ◽  
Grade Assessment ◽  
Clinical Grading

Object Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (SAH). The primary objective of this study was to identify at which time point clinical assessment using the World Federation of Neurosurgical Societies (WFNS) grading scale and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome. Methods This study is a retrospective cohort study on the association between poor outcome and clinical grading determined at presentation, nadir, and postresuscitation. Poor functional outcome was defined as a Glasgow Outcome Scale score of 1–3 at 6 months after SAH. Results The authors identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. The patients' mean age (± SD) was 56.9 ± 13.7 years, and 63% were women. Twenty-four percent had poor functional outcome (the mortality rate was 17%). On univariable logistic regression analyses, GCS score determined at presentation (OR 0.80, p < 0.0001), nadir (OR 0.73, p < 0.0001), and postresuscitation (OR 0.53, p < 0.0001); modified Fisher scale (OR 2.21, p = 0.0013); WFNS grade assessed at presentation (OR 1.92, p < 0.0001), nadir (OR 3.51, < 0.0001), and postresuscitation (OR 3.91, p < 0.0001); intracerebral hematoma on initial CT (OR 4.55, p < 0.0002); acute hydrocephalus (OR 2.29, p = 0.0375); and cerebral infarction (OR 4.84, p < 0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR 5.80, p = 0.0013) and WFNS grade postresuscitation (OR 3.43, p < 0.0001) were associated with poor outcome. Receiver operating characteristic/area under the curve (AUC) analysis demonstrated that WFNS grade determined postresuscitation had a stronger association with poor outcome (AUC 0.90) than WFNS grade assessed upon admission or at nadir. Conclusions Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

Neoplastic cerebral aneurysm from metastatic gestational choriocarcinoma

1985 ◽  
Vol 63 (4) ◽  
pp. 644-647 ◽  
Author(s):  
Michael Pullar ◽  
Peter C. Blumbergs ◽  
Gael E. Phillips ◽  
Paul G. Carney
Keyword(s):  
Intracerebral Hemorrhage ◽  
Histopathological Examination ◽  
Cardiac Myxoma ◽  
Cerebral Aneurysms ◽  
Artery Aneurysm ◽  
Undifferentiated Carcinoma ◽  
Intracerebral Hematoma ◽  
Content Type ◽  
Gestational Choriocarcinoma ◽  
Child Bearing

✓ This case of metastatic gestational choriocarcinoma presented as intracerebral hemorrhage from an atypical distal middle cerebral artery aneurysm. Operative evacuation of the intracerebral hematoma was undertaken and histopathological examination revealed choriocarcinoma invading the vessel wall. Neoplastic cerebral aneurysms are unusual, being reported in metastatic choriocarcinoma, cardiac myxoma, bronchogenic carcinoma, and undifferentiated carcinoma. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral hemorrhage in women of child-bearing age. Recent advances in treatment have resulted in a 75% cure rate for metastatic choriocarcinoma.

Disturbed Cerebrospinal Fluid Circulation after Subarachnoid Hemorrhage and Acute Aneurysm Surgery

Neurosurgery ◽  
1990 ◽  
Vol 26 (5) ◽  
pp. 804-809 ◽  
Author(s):  
Ludwig M. Auer ◽  
Michael Mokry
Keyword(s):  
Cerebrospinal Fluid ◽  
Subarachnoid Hemorrhage ◽  
Blood Clot ◽  
Cerebral Aneurysms ◽  
External Ventricular Drainage ◽  
Easy Access ◽  
Cerebrospinal Fluid Circulation ◽  
Aneurysm Dissection ◽  
Subarachnoid Blood ◽  
The Brain

Abstract In 138 patients with ruptured cerebral aneurysms operated on within 48 to 72 hours after subarachnoid hemorrhage, an external ventricular drainage catheter was inserted before craniotomy and was used intermittently during the first week after surgery. In 51 patients, intracranial pressure (ICP) was measured intraoperatively. The majority of patients showed increased ICP intraoperatively irrespective of the preoperative Hunt and Hess grade and the amount of subarachnoid blood accumulation or intraventricular blood clot. Intraoperative drainage of cerebrospinal fluid allowed easy access for aneurysm dissection by making the brain slack in more than 90% of patients. Postoperative ICP measurements revealed that significant brain swelling did not occur in the majority of patients, In 7 patients, persistently elevated ICP (&gt;20 mm Hg) was recorded. Nine patients (8%) developed shunt-dependent hydrocephalus; all of these patients had suffered an intraventricular hemorrhage. Measurements of the volumes of cerebrospinal fluid drained did not allow prediction of shunt-dependent hydrocephalus.

scholarly journals Early surgery of hemorrhaging aneurysms of brain blood vessels

2008 ◽  
Vol 55 (2) ◽  
pp. 17-25
Author(s):  
N.P. Lakicevic
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Surgical Treatment ◽  
High Risk ◽  
Blood Vessels ◽  
Early Surgery ◽  
Intracerebral Hematoma ◽  
Perioperative Treatment ◽  
Delayed Surgery ◽  
The Brain ◽  
Clinical Grading

Comprehension of the natural course of the aneurisms on the blood vessels of the brain has imposed the need for timely surgical treatment. The comfort of delayed surgery, due to the high risk of the rupture had to be overlooked. Early surgery, within the first three days from the rupture of the aneurysm, has a double role - it prevents rupture, but considerably decreases the risk of complications caused by subarachnoid hemorrhage, vasospasm and hydrocephalus. We present the results of the surgical treatment of 710 patients operated during the period from year 1994 until 1996. We point out that the treatment of patients was conducted in conditions that were not standard, due to sanctions. During operations at our disposal most of the time was only one clip and a limited quantity of drugs for the perioperative treatment. Our results show that compulsory candidates for early surgery are small patients in good clinical grading, without associated illnesses. Patients without clinical and angiographic signs of vasospasm may also be operated in the intermediary term. Patients with massive intracerebral hematoma caused by the rupture of the aneurysm who are in a coma should be urgently operated.

scholarly journals Intraaneurysmal GDC Embolization for Ruptured Aneurysm in the Acute Stage

2000 ◽  
Vol 6 (1_suppl) ◽  
pp. 75-78
Author(s):  
M. Ezura ◽  
A. Takahashi ◽  
T. Yoshimoto
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Systemic Disease ◽  
Cerebral Aneurysms ◽  
Acute Stage ◽  
Ruptured Aneurysm ◽  
Poor Grade ◽  
Symptomatic Vasospasm ◽  
Tissue Plasminogen ◽  
High Age

This report focused on our treatment protcol and results on the intraaneurysmal GDC embolization for ruptured aneurysm in the acute stage. Clinical materials of this study consist of 39 patients who were treated with intraaneurysmal GDC embolization within 72 hours after the onset of subarachnoid hemorrhage from March 1997 to May 1999. Patients with cerebral aneurysms are always examined as a possible candidate for neurosurgical clipping. If the patient had any difficulties and/or problems on neurosurgical clipping (high age 24, poor grade 12, surgically difficult location 11, systemic disease 2), the patient was treated by intraaneurysmal GDC embolization. GDCs were inserted as tight as possible. Then, spinal drainage was set in patients with thick subarachnoid hemorrhage. Tissue plasminogen activator was administered via the drainage in patients with thicker subarachnoid hemorrhage. Two patients experienced rerupture during peritherapeutic period. Symptomatic vasospasm was observed in 2 patients (5.1%). Good outcome was obtained in 31 out of 34 surviving patients. Symptomatic complication caused by distal embolism occurred in 1 patient, parent artey occlusion in 3 patients. In conclusion, intraaneurysmal GDC embolization is thought to be sufficient regarding prevention of rerup tu re, incidence of vasospasm, and clinical outcome.

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