Transluminal Angioplasty of Intracerebral Vessels for Cerebral Arterial Spasm: Reversal of Neurological Deficits after Delayed Treatment

Neurosurgery ◽  
1989 ◽  
Vol 25 (3) ◽  
pp. 424-429 ◽  
Author(s):  
Stanley L. Barnwell ◽  
Randall T. Higashida ◽  
Van V. Halbach ◽  
Christopher F. Dowd ◽  
Charles B. Wilson ◽  
...  
Keyword(s):  
Parietal Lobe ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
Transluminal Angioplasty ◽  
Neurological Deficits ◽  
Delayed Treatment ◽  
Vascular Flow ◽  
Symptomatic Vasospasm ◽  
The Right ◽  
Risk Of Hemorrhage

Abstract We used intracerebral transluminal angioplasty to treat two episodes of symptomatic vasospasm in a patient recovering from an aneurysmal subarachnoid hemorrhage. The procedures were performed after medical therapies, intravascular volume expansion, and induced arterial hypertension failed to alleviate the patient's neurological condition. The first angioplasty, confined to the right middle cerebral and distal internal carotid arteries, took place more than 30 hours after the onset of left hemiplegia. Despite the subsequent discovery of a small parietal lobe infarct, it brought about a marked improvement in left motor function and may have also limited the spread of necrotic damage. The second angioplasty was necessitated when stenotic segments of the basilar and posterior cerebral arteries caused a 24-hour decline in the patient's mental status. Although delayed in relation to the onset of symptoms, it successfully reversed the patient's comatose state. The use of transluminal angioplasty for vasospasm is generally limited to cases where it can be performed shortly after the onset of neurological symptoms; delaying the procedure increases the risk of hemorrhage from reperfused areas of infarction. Our experience with this patient demonstrates that delayed angioplasty can improve vascular flow to ischemic territory, even after infarction, without complications and with resultant improvement in neurological function.

scholarly journals Ischemic stroke with agraphestesia signal focus

2021 ◽  
Author(s):  
Ana Luísa Lopes Espínola da Costa Reis ◽  
Leonardo Henrique Gandolfi de Souza ◽  
Vitor Roberto Pugliesi Marques
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Parietal Lobe ◽  
Cerebral Arteries ◽  
Sudden Onset ◽  
Neurological Deficits ◽  
Motor Deficits ◽  
Ischemic Event ◽  
The Right ◽  
Sensory Ability

Introduction: The ischemic stroke is one of the main causes of death and disability in Brazil. Among the main risk factors are age, atrial fibrillation (AF), diabetes, dyslipidemia and physical inactivity. The main etiology of stroke is cardioembolic, resulting in obstruction of the cerebral arteries by a thrombus of cardiac origin. The artery most affected in ischemic strokes is the middle cerebral artery. The stroke has main characteristics, with emphasis on the sudden onset of symptoms, involvement of a focal area, ischemia caused by obstruction of a vessel and neurological deficits depending on the affected area. Graphesthesia is defined as a cutaneous sensory ability to recognize letters or numbers traced on the skin. The loss of this sensory ability is known as agraphesthesia. Case Report: M.A.F.O. female, 78a, arrived at the UPA complaining of mental confusion. Patient denies previous stroke. Personal history of systemic arterial hypertension. Upon physical examination, the patient was conscious, self and disoriented and inattentive. He was able to repeat and evoke words, without measurable motor déficits. Left upper limb with agraphestesia. Computed tomography was requested, which showed an extensive hypodense area in the right parietoccipital region, which leads to the erasure of the furrows between the adjacent gyres, which may correspond to a recent ischemic event. Magnetic resonance imaging, diffusion-restricted area with correspondence on the ADC map, located in the right temporoparietal region inferring an acute ischemic event. An electrocardiogram was also requested, which showed an irregular rhythm, characteristic of atrial fibrillation, resulting in a diagnostic hypothesis of cardioembolic ischemic stroke. Discussion: The involvement of post-central ischemic gyrus lesions may correspond to paresthesia, anesthesia, hypoesthesia; the involvement of secondary and terciary areas of sensitivity in the upper parietal lobe, especially in the active movements of the hand and in the modalities of integrated sensitivity, their lesions may be clinically affected by: apraxias, dysgraphias, hemineglect, agraphestesia, stereoagnosia and spacial disorientation.

Effect of transluminal angioplasty on cerebral blood flow in the management of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage

1997 ◽  
Vol 86 (5) ◽  
pp. 830-839 ◽  
Author(s):  
Andrew D. Firlik ◽  
Anthony M. Kaufmann ◽  
Charles A. Jungreis ◽  
Howard Yonas
Keyword(s):  
At Risk ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Transluminal Angioplasty ◽  
T Test ◽  
Neurological Deficits ◽  
Symptomatic Vasospasm ◽  
The Mean

✓ In this study the authors have examined the effects of transluminal angioplasty on cerebral blood flow (CBF) in the management of intractable vasospasm following aneurysmal subarachnoid hemorrhage (SAH). Fourteen consecutively enrolled patients underwent attempted angioplasty with or without intraarterial infusion of papaverine. Twelve patients underwent pre- and postangioplasty xenon-enhanced computerized tomography (Xe-CT) scanning to measure regional CBF in 55 to 65 regions of interest (ROIs) per patient. Angioplasty was possible in 13 (93%) of 14 patients, with angiographically demonstrated improvement in all 13. Twelve (92%) of the 13 patients were neurologically improved following angioplasty; seven (58%) of the 12 patients who improved had a complete reversal of all delayed ischemic deficits. Angioplasty significantly decreased the mean number of ROIs at risk (11.4 ROIs pre- and 0.9 ROIs postangioplasty) (p < 0.00005, t-test). All patients had a reduction in the number of ROIs at risk after angioplasty; six (50%) of 12 no longer had any ROIs remaining at risk after angioplasty. Angioplasty significantly increased the mean CBF within at-risk ROIs (13 ml/100 g/minute pre- and 44 ml/100 g/minute postangioplasty) (p < 0.00005, t-test). All patients experienced an improvement in mean CBF in at-risk ROIs after angioplasty, with the mean CBF improving to above 20 ml/100 g/minute in all cases. No differences in the degree of improvement were found in patients who received intraarterial papaverine compared with those who did not. In the majority of patients with refractory vasospasm following SAH, angioplasty effectively dilated spastic arteries, reversed delayed neurological deficits, and significantly improved CBF in areas of brain at risk of infarction.

Predicting Delayed Ischemic Deficits after Aneurysmal Subarachnoid Hemorrhage Using a Transient Hyperemic Response Test of Cerebral Autoregulation

Neurosurgery ◽  
2000 ◽  
Vol 47 (4) ◽  
pp. 819-826 ◽  
Author(s):  
Joseph M. K. Lam ◽  
Peter Smielewski ◽  
Marek Czosnyka ◽  
John D. Pickard ◽  
Peter J. Kirkpatrick
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Transcranial Doppler ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
Neurological Deficits ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Response Test ◽  
Baseline Values ◽  
Hyperemic Response

Abstract OBJECTIVE To assess whether the development of delayed ischemic deficits (DIDs) after aneurysmal subarachnoid hemorrhage can be predicted using transcranial Doppler ultrasonography and the transient hyperemic response test (THRT). METHODS An increase in the middle cerebral artery peak flow velocity (FV) of more than 9% of baseline values after 5 to 9 seconds of carotid artery compression was defined as a normal THRT result, indicating good autoregulatory reserve. The transcranial Doppler criteria for vasospasm were a FV of more than 120 cm/s and a Lindegaard ratio of more than 3. Twenty patients with no immediate postoperative neurological deficits were studied. The FVs at all of the major cerebral arteries were measured daily after surgery, and the THRT results were assessed bilaterally. RESULTS Five of six patients with abnormal THRT results in the first examination after surgery (primary THRT impairment) developed DIDs; none of the remaining patients developed DIDs (Fisher exact test, P = 0.0004). All five patients with DIDs initially exhibited low FVs but all subsequently developed increases in FVs to values of more than 150 cm/s and four exhibited FVs of more than 200 cm/s. The time of onset of DIDs corresponded to the time of onset of moderate vasospasm (FV &gt; 150 cm/s). None of the patients with initially normal THRT results developed DIDs, although four patients did exhibit late (secondary) THRT impairment, which was associated with FVs of more than 120 cm/s. CONCLUSION When the effects of primarily impaired (after surgery) autoregulation are magnified by vasospasm, the risk of DIDs seems to be very high. Vasospasm alone does not seem to cause DIDs. The development of DIDs could therefore be predicted using the THRT for patients after aneurysm clipping.

Short-Term Antifibrinolytic Therapy Before Early Aneurysm Treatment in Subarachnoid Hemorrhage: Effects on Rehemorrhage, Cerebral Ischemia, and Hydrocephalus

Neurosurgery ◽  
2010 ◽  
Vol 67 (4) ◽  
pp. 935-940 ◽  
Author(s):  
Mark R Harrigan ◽  
Kiran F Rajneesh ◽  
Agnieszka A Ardelt ◽  
Winfield S Fisher
Keyword(s):  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Aminocaproic Acid ◽  
Neurological Deficits ◽  
Short Term ◽  
Symptomatic Vasospasm ◽  
Term Administration ◽  
Ischemic Complications

Abstract BACKGROUND: Long-term administration of the antifibrinolytic agent epsilon aminocaproic acid (EACA) reduces the rate of rehemorrhage in patients with aneurysmal subarachnoid hemorrhage (SAH), but is associated with cerebral ischemia. OBJECTIVE: To evaluate short-term administration of EACA before early surgery in patients with SAH. METHODS: Retrospective review of 356 patients admitted between June 2002 and December 2007 with a diagnosis of aneurysmal SAH. Medical records were reviewed to determine SAH risk factors, clinical grade at the time of admission, and incidence of rehemorrhage, permanent new-onset focal neurological deficits, computed tomography evidence of cerebral infarction, symptomatic vasospasm, and hydrocephalus. RESULTS: Patients underwent treatment of the ruptured aneurysm an average of 47.4 hours after admission and received an average total dose of 40.6 g of EACA. The mean length of time of administration of EACA was 35.6 hours. There was a total of 5 rehemorrhages, for an overall rebleeding rate of 1.4% and a rate of rehemorrhage per 24-hour period of 0.71%. Overall, the rates of symptomatic vasospasm and permanent neurological deficits attributable to ischemic stroke were 11.5% and 7.2%, respectively, and the incidence of shunt-dependent hydrocephalus was 42.3%. Patients who were treated with coiling had higher rates of symptomatic vasospasm and ischemic complications than patients who had surgery. CONCLUSION: Short-term administration of EACA is associated with rates of rehemorrhage, ischemic stroke, and symptomatic vasospasm that compare favorably with historical controls. The rate of hydrocephalus is relatively high and may be attributable to EACA treatment.

scholarly journals Distal Access to Wide-Necked Aneurysms—‘Around the World’ Technique: 2-Dimensional Operative Video

2020 ◽  
Vol 20 (1) ◽  
pp. E39-E40
Author(s):  
Andrew J Ringer ◽  
Adam Arthur ◽  
Mark Bain ◽  
Bernard Bendock ◽  
Mandy Jo Binning ◽  
...  
Keyword(s):  
Cerebral Arteries ◽  
Balloon Catheter ◽  
Neurological Deficits ◽  
Parent Vessel ◽  
Gradual Onset ◽  
The World ◽  
The Wire ◽  
The Right ◽  
Wide Neck

Abstract Wide-necked aneurysms often pose challenges for distal access to the distal vasculature. This 64-yr-old woman without neurological deficits presented with atypical headaches of gradual onset. MRI revealed a large, symptomatic, unruptured carotid terminus aneurysm incorporating the origin of both the middle (MCA) and anterior cerebral arteries (ACA). Its wide neck created significant risks to coil prolapse and parent vessel compromise, risking stroke. With other options of higher risks, we recommended an around-the-world technique. Standard transfemoral access was used to the right internal carotid artery (ICA) with a 6F-Shuttle sheath and intracranial carotid with a 6F-Sofia distal access catheter. With dual-microcatheter access, 1 catheter was placed in the aneurysm dome, a second in the MCA for stent placement. Advancing the wire around the aneurysm first formed a loop from the lateral to medial wall for access to the MCA. The microcatheter was then advanced around the wire into the MCA, keeping the loop within the dome. With the loop's distal tip anchored, the distal end of the stent was deployed and anchored into the MCA. Both pitfalls (ie, lack of sufficient distal access, collapse of stent device during deployment) were resolved using a balloon catheter. With the balloon positioned and inflated as the anchor, the wire and catheter were pulled together. The loop in the aneurysm's dome straightened out across the neck, the stent was advanced into the MCA, and coiling proceeded. A large neck remnant had partially closed on 6-mo follow-up angiogram. Patient consented to undergo the procedure. Illustrations in video published/printed with permission from Mayfield Clinic.

scholarly journals Sphingosine 1-phosphate levels in cerebrospinal fluid after subarachnoid hemorrhage

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Anika Männer ◽  
Dominique Thomas ◽  
Marlies Wagner ◽  
Jürgen Konczalla ◽  
Helmuth Steinmetz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Subarachnoid Hemorrhage ◽  
Neurological Outcome ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
High Sensitivity ◽  
Control Subjects ◽  
Symptomatic Vasospasm ◽  
Significant Difference ◽  
Hemorrhage Volume

Abstract Background and purpose Sphingosin-1-phosphate (S1P) plays a crucial role as a signaling molecule in the immune system and the vasculature. Previous studies suggested a role as a vasoconstrictor of cerebral arteries via the S1P3-Receptor. Cerebral vasospasm (VS) following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of disability and poor neurological outcome. Early detection of vasospasm could facilitate the prevention of cerebral ischemia in SAH patients. The aim of this prospective case-control study was to characterize the dynamics of S1P in the cerebrospinal fluid (CSF) of patients with SAH in relation to hemorrhage volume, the occurrence of VS, and neurological outcome. Methods S1P levels in CSF of 18 control subjects and 18 SAH patients with placement of an external ventricular drainage (EVD) were determined by high sensitivity mass spectrometry from day 1 through 14 after SAH onset. Hemorrhage volume, development of asymptomatic vasospasm (aVS) and symptomatic vasospasm (sVS), and neurological outcome were correlated to day 1 S1P levels. Results The intrathecal S1P levels of SAH patients were higher than those of the control subjects, and correlated with hemorrhage volume. There was no significant difference in S1P levels between patients with aVS and those with sVS. S1P levels significantly correlated with neurological outcome on a sliding modified Rankin scale. Conclusion S1P levels were highest directly after placement of the EVD and correlated strongly with hemorrhage volume, which may be caused by the intrathecal clot and subsequent lysis of red blood cells, an important source of S1P. We did not detect a second peak of S1P release over the course of the intensive care period.

Lower Incidence of Transcranial Doppler and Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Aneurysm Clipping in the Elderly Patient?

Neurosurgery ◽  
2011 ◽  
Vol 69 (2) ◽  
pp. 261-267 ◽  
Author(s):  
Dorothee Wachter ◽  
Franz Hans ◽  
Ilonka Kreitschmann-Andermahr ◽  
Veit Rohde
Keyword(s):  
Elderly Patient ◽  
Subarachnoid Hemorrhage ◽  
Transcranial Doppler ◽  
Lower Incidence ◽  
Older Patients ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
The Elderly ◽  
Neurological Deficits ◽  
Medical Complications ◽  
Symptomatic Vasospasm

Abstract BACKGROUND: Vasospasm is the major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. It is well known that the vasoreactivity decreases with advancing age, but it is not well investigated in a large patient cohort whether, as a consequence, the incidence of vasospasm is lower in elderly patients. OBJECTIVE: To investigate whether transcranial Doppler vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are less frequent in older patients. METHODS: Seven hundred fifty-eight patients who suffered from subarachnoid hemorrhage were included in this study. Clinical presentation, Hunt and Hess score, Fisher grade, incidence of vasospasm, neurological deficits and ischemic lesions on radiographic imaging, transcranial Doppler blood flow velocities, medical complications, and outcome were registered. RESULTS: Four hundred seventy-eight patients &lt; 60 years of age and 280 patients ≥ 60 years of age were identified; 55.2% of the younger and 25.7% of the older age group developed post-hemorrhagic vasospasm (P &lt; .001). Older patients developed less vasospasm (P = .00), fewer neurological deficits (P &lt; .001), and fewer ischemic lesions on computed tomography imaging (P = .06). On the other hand, older patients had significantly worse outcomes than younger patients (P = .01) and more frequently died of medical complications (P = .01). CONCLUSION: Vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are more likely to occur in patients &lt; 60 years of age than in older patients. The lower incidence of vasospasm and vasospasm-related ischemia in the elderly patient does not translate into better outcome because of the higher rate of fatal medical complications in patients ≥ 60 years of age.

scholarly journals Association of venous varix and developmental venous anomaly: report of a case and review of literature

2019 ◽  
Vol 12 (3) ◽  
pp. e228067
Author(s):  
Suprava Naik ◽  
Sanjeev K Bhoi
Keyword(s):  
White Matter ◽  
Parietal Lobe ◽  
Symptomatic Treatment ◽  
Developmental Venous Anomaly ◽  
Mri Findings ◽  
Cortical Vein ◽  
Vascular Flow ◽  
Flow Void ◽  
The Right ◽  
Venous Varix

Cerebral developmental venous anomalies (DVAs) are the most frequently encountered cerebral vascular malformation. Most are asymptomatic and incidentally detected. Here we present a case of DVA associated with venous varix presented with chronic headache. A 50-year-old woman presented with right hemicranial headache since 6 months. There was no neurological deficit. MRI showed a well-defined oval T2 hyperintense, T1 isointense extra-axial lesion in the right parietal region showing intense homogeneous enhancement. Prominent vascular flow void was extending from the lesion up to the deep parietal white matter. Subtle thin linear areas of blooming noted in the parietal white matter converging towards the vascular flow void. The venous sac is in communication with the cortical vein draining to the superior sagittal sinus. These MRI findings favoured a diagnosis of DVA in the right parietal lobe with prominent draining vein forming a cortical venous varix. The patient was managed conservatively with symptomatic treatment for headache.

scholarly journals Early and aggressive treatment of medically intractable cerebral vasospasm with pentobarbital coma, cerebral angioplasty and ICP reduction

1998 ◽  
Vol 5 (4) ◽  
pp. E9 ◽  
Author(s):  
Rocco A. Armonda ◽  
Jeffrey E. Thomas ◽  
Robert H. Rosenwasser
Keyword(s):  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Vegetative State ◽  
Combined Treatment ◽  
Persistent Vegetative State ◽  
Senior Author ◽  
Neurological Deficits ◽  
Aggressive Treatment ◽  
Symptomatic Vasospasm ◽  
Select Group

The authors present the unique experience of one neurovascular service under the direct supervision of the senior author, for which surgical, endovascular, and intensive care treatments were conducted in a select group of 32 patients with aneurysmal subarachnoid hemorrhage who had medically intractable symptomatic vasospasm. A protocol of early and aggressive treatment was instituted using pentobarbital coma, cerebral angioplasty, and intracranial pressure (ICP) reduction. The patient population consisted of 25 women and seven men, whose ages ranged from 34 to 60 years (average 47 years). The patients' Hunt and Hess grades on presentation were as follows: Grade 0 (one); Grade I (three); Grade II (two); Grade III (nine); Grade IV (10); Grade V (seven). Microsurgical clipping alone was performed in 15 of 32 patients, endosaccular occlusion was performed in 17 of 20 patients, and two patients underwent combined treatment. Subsequent angioplasty was performed in 26 of 32 patients. Additionally, all 32 patients underwent treatment of increased ICP with ventriculostomy placement, removal of the bone flap (11), evacuation of associated intracranial hematoma (five), and decompressive obectomy (four). Twenty-one patients survived and 11 died. Of the 21 survivors, seven have returned to work, live independently, and have no neurological deficits; eight require minimal assistance at home; four are in rehabilitation with moderate deficits at 3 months; and two remain in a persistent vegetative state. In this group of aggressively treated patients who received pentobarbital cerebral protection, successful treatment of medically intractable cerebral vasospasm was related to time of treatment (< 2 hours), expeditious reduction of elevated ICP, and angioplasty.

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