Cerebral vasospasm following aneurysm rupture

1980 ◽  
Vol 52 (2) ◽  
pp. 149-152 ◽  
Author(s):  
Alan S. Fleischer ◽  
George T. Tindall
Keyword(s):  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Volume Replacement ◽  
Aneurysm Surgery ◽  
Preoperative Period ◽  
Circulating Blood Volume ◽  
Content Type ◽  
Ruptured Intracranial Aneurysms ◽  
Grade Iii ◽  
Fine Print

✓ A retrospective study was made of 195 patients who had ruptured intracranial aneurysms without significant intracerebral hematomas and who recovered to at least Grade III by Hunt and Hess' classification. The first 121 patients underwent aneurysm surgery 10 days to 2 weeks after subarachnoid hemorrhage (SAH) without repeat preoperative angiography and without special attention to volume replacement or avoidance of hypotension. Vasospasm resulted in cerebral ischemia in 15% of this group, more than half of these postoperatively, and was treated successfully in half the patients with a combination of aminophylline and isoproterenol. The later 74 patients were managed with aggressive maintenance of normal circulating blood volume and preoperative angiography at 2 weeks following SAH. If significant vasospasm persisted on angiography, surgery was delayed an additional week and, if spasm was still present then, aminophylline and isoproterenol were added prophylactically to aggressive volume replacement before surgery. In this second group of patients, the incidence of clinical vasospasm was essentially unchanged; however, it was almost completely limited to the preoperative period, and was more effectively treated with aminophylline and isoproterenol. Postoperative vasospasm was almost completely eliminated from the second group of patients.

Anosmia following operation for cerebral aneurysms in the anterior circulation

1990 ◽  
Vol 72 (6) ◽  
pp. 864-865 ◽  
Author(s):  
Kjeld Dons Eriksen ◽  
Torben Bøge-Rasmussen ◽  
Christian Kruse-Larsen
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Olfactory Nerve ◽  
Aneurysm Surgery ◽  
Anterior Circulation ◽  
Widespread Occurrence ◽  
Content Type ◽  
High Incidence ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ Damage to the olfactory nerve during frontotemporal approach to the basal cisternal region has not previously been investigated in a quantified manner. In this retrospective study of 25 patients operated on for ruptured intracranial aneurysms via the frontotemporal route, 22 patients suffered postoperatively from anosmia ipsilateral to the side of surgery. This complication most often goes unrecognized by the patient as well as the physician, and attention should be drawn to it because of its widespread occurrence. This investigation demonstrates a high incidence of anosmia (24 (88.9%) of 27 surgical sides) occurring ipsilateral to the frontotemporal approach in aneurysm surgery. Recovery after traumatic anosmia has been recorded up to 5 years after injury.1 Nevertheless, the authors believe that the damage is permanent when lasting 35 months or longer.

Significance of vasospasm in the treatment of ruptured intracranial aneurysms

1977 ◽  
Vol 47 (3) ◽  
pp. 412-429 ◽  
Author(s):  
Isamu Saito ◽  
Yasuichi Ueda ◽  
Keiji Sano
Keyword(s):  
Intracranial Aneurysms ◽  
Surgical Intervention ◽  
Blood Clot ◽  
Timing Of Surgery ◽  
Neurological Deficits ◽  
Aneurysm Surgery ◽  
Content Type ◽  
Ruptured Intracranial Aneurysm ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ The authors have analyzed a total of 96 consecutive cases in which vasospasm followed subarachnoid hemorrhage (SAH). The SAH was caused by ruptured intracranial aneurysm or developed after aneurysm surgery. Usually at least 4 days elapsed between SAH and the onset of vasospasm. Vasospasm subsided an average of 2 weeks after onset. Of 68 patients with preoperative vasospasm, eight died due to cerebral edema resulting from ischemia, and 49% of the survivors had neurological deficits. Preoperative vasospasm was not aggravated by surgical intervention when operations were carried out more than 7 days after the onset of vasospasm. Postoperative vasospasm was found in 25 of 52 patients who underwent operation within 1 week after SAH (excluding cases in Grade V). Five of these patients died, all of whom underwent surgery between the fourth and seventh day after SAH (the day of SAH was counted as the first day). There were no deaths among 20 patients operated on within the first 3 days after SAH. Postoperative vasospasm was always mild in these cases, when it occurred, probably because blood clot or blood-stained cerebrospinal fluid was removed by operative procedures. In all cases, 4 to 11 days elapsed between the last SAH and the onset of postoperative vasospasm regardless of the timing of surgery.

Ruptured intracranial aneurysms in the first two decades of life

1971 ◽  
Vol 35 (5) ◽  
pp. 571-576 ◽  
Author(s):  
Aneel N. Patel ◽  
Alan E. Richardson
Keyword(s):  
Carotid Artery ◽  
Intracranial Aneurysms ◽  
Postmortem Examination ◽  
Surgical Mortality ◽  
Terminal Portion ◽  
Good Tolerance ◽  
Content Type ◽  
Intracranial Operation ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ An analysis of 3000 ruptured intracranial aneurysms revealed 58 cases in patients under the age of 19 years. There was a striking incidence of aneurysms of the carotid termination and anterior cerebral complex, accounting for 43 of 58 cases, and of these 20 involved the terminal portion of the carotid artery. Vasospasm occurred slightly less often than in adults and infarction was only seen in one postmortem examination. The surgical mortality in alert patients was 7% whereas in a comparable bedrest group it was 38%. This good tolerance to surgery was evident whether intracranial operation or carotid ligation was used, but the surgical method was not randomly allocated.

The risk of rebleeding from ruptured intracranial aneurysms

1987 ◽  
Vol 67 (3) ◽  
pp. 329-332 ◽  
Author(s):  
Jarl Rosenørn ◽  
Vagn Eskesen ◽  
Kaare Schmidt ◽  
Frits Rønde
Keyword(s):  
Mortality Rate ◽  
Life Table ◽  
Intracranial Aneurysms ◽  
Study Group ◽  
Neurosurgical Department ◽  
Content Type ◽  
Life Table Method ◽  
Daily Rate ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ In the 5-year period from 1978 to 1983, 1076 patients with ruptured intracranial aneurysms were admitted to the six neurosurgical departments in Denmark and were entered in a prospective consecutive study conducted by the Danish Aneurysm Study Group. The patients were followed with 3-month and 2-year examinations or to death. A total of 133 patients suffered at least one rebleed after their initial hemorrhage during their first stay in the neurosurgical department; these patients had a mortality rate of 80% compared to 41 % for patients without a rebleed (p < 0.0001). During the first 2 weeks after the initial insult, 102 rebleeds were registered. The daily rate of rebleeds during these 2 weeks, calculated using a life-table method, varied from 0.2% to 2.1%. The rebleed rate during the first 24 hours (Day 0) was 0.8%, and the maximum risk of rebleeding was observed between Day 4 and Day 9. Significantly fewer rebleeds were reported in patients with good clinical grades (Grades 1 to 3, Hunt Grades I and II) compared to those with poor clinical grades (Grades 4 to 9, Hunt Grades III to V: p < 0.001).

A method for monitoring antifibrinolytic therapy in patients with ruptured intracranial aneurysms

1981 ◽  
Vol 54 (1) ◽  
pp. 12-15 ◽  
Author(s):  
Kim J. Burchiel ◽  
Gottfried Schmer
Keyword(s):  
Fibrinolytic Activity ◽  
Intracranial Aneurysms ◽  
Aminocaproic Acid ◽  
Content Type ◽  
Antifibrinolytic Therapy ◽  
Epsilon Aminocaproic Acid ◽  
Ruptured Intracranial Aneurysms ◽  
Control Plasma ◽  
Fine Print

✓ A rapid fluorometric assay technique has been utilized to assess the degree of fibrinolytic inhibition in 20 patients with ruptured intracranial aneurysms treated with epsilon-aminocaproic acid (EACA). This method quantitates the available plasminogen activity (APA) of plasma, and has proven to be a reliable means of monitoring antifibrinolytic therapy. Determination of the plasma APA also permits correlation of the level of fibrinolytic activity with putative complications of EACA therapy. Normal control plasma APA was 3.1 ± 0.7 CTA units/ml, but in patients with subarachnoid hemorrhage (SAH), pretreatment fibrinolytic activity was supranormal at 3.78 ± 0.88 CTA units/ml. During continuous intravenous administration of EACA (1.5 gm/hr) in patients with SAH, the plasma fibrinolytic activity was decreased to 0.9 ± 0.31 CTA units/ml. A case is described which exemplifies the use of this assay. In addition, an approach to monitoring antifibrinolytic therapy using the plasma APA is proposed.

Epsilon-aminocaproic acid and recurrent subarachnoid hemorrhage

1980 ◽  
Vol 53 (1) ◽  
pp. 28-31 ◽  
Author(s):  
William A. Shucart ◽  
S. K. Hussain ◽  
Paul R. Cooper
Keyword(s):  
Clinical Trial ◽  
Intracranial Aneurysms ◽  
Aminocaproic Acid ◽  
Antifibrinolytic Agents ◽  
Recurrent Hemorrhage ◽  
Content Type ◽  
Epsilon Aminocaproic Acid ◽  
Arterial Aneurysms ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ A clinical trial of epsilon-aminocaproic acid (EACA) in preventing recurrent hemorrhage from intracranial arterial aneurysms is reported. Previous reports were reviewed, and their results concerning antifibrinolytic agents were inconclusive in establishing their efficacy. One hundred patients with documented ruptured intracranial aneurysms were admitted to this study within 48 hours of the initial hemorrhage: 45 patients received 36 gm of EACA/day, with 11 documented rebleeds and one suspected rebleed; 55 patients did not receive EACA, and there were four documented rebleeds and one suspected rebleed. No benefit was seen from the use of EACA.

Role of apoptosis in intracranial aneurysm rupture

2004 ◽  
Vol 101 (6) ◽  
pp. 1018-1025 ◽  
Author(s):  
Luigi Pentimalli ◽  
Andrea Modesti ◽  
Andrea Vignati ◽  
Enrico Marchese ◽  
Alessio Albanese ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Superficial Temporal Artery ◽  
Aneurysm Rupture ◽  
Terminal Deoxynucleotidyl Transferase ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Aneurysm Wall ◽  
Unruptured Intracranial Aneurysms ◽  
Fine Print

Object. Mechanisms involved in the rupture of intracranial aneurysms remain unclear, and the literature on apoptosis in these lesions is extremely limited. The hypothesis that apoptosis may reduce aneurysm wall resistance, thus contributing to its rupture, warrants investigation. The authors in this study focused on the comparative evaluation of apoptosis in ruptured and unruptured intracranial aneurysms. Peripheral arteries in patients harboring the aneurysms and in a group of controls were also analyzed. Methods. Between September 1999 and February 2002, specimens from 27 intracranial aneurysms were studied. In 13 of these patients apoptosis was also evaluated in specimens of the middle meningeal artery (MMA) and the superficial temporal artery (STA). The terminal deoxynucleotidyl transferase—mediated deoxyuridine triphosphate nick-end labeling technique was used to study apoptosis via optical microscopy; electron microscopy evaluation was performed as well. Apoptotic cell levels were related to patient age and sex, aneurysm volume and shape, and surgical timing. Significant differences in apoptosis were observed when comparing ruptured and unruptured aneurysms. High levels of apoptosis were found in 88% of ruptured aneurysms and in only 10% of unruptured lesions (p < 0.001). Elevated apoptosis levels were also detected in all MMA and STA specimens obtained in patients harboring ruptured aneurysms, whereas absent or very low apoptosis levels were observed in MMA and STA specimens from patients with unruptured aneurysms. A significant correlation between aneurysm shape and apoptosis was found. Conclusions. In this series, aneurysm rupture appeared to be more related to elevated apoptosis levels than to the volume of the aneurysm sac. Data in this study could open the field to investigations clarifying the causes of aneurysm enlargement and rupture.

Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization

2001 ◽  
Vol 95 (1) ◽  
pp. 24-35 ◽  
Author(s):  
Brian L. Hoh ◽  
Christopher M. Putman ◽  
Ronald F. Budzik ◽  
Bob S. Carter ◽  
Christopher S. Ogilvy
Keyword(s):  
Intracranial Aneurysms ◽  
Massachusetts General Hospital ◽  
Treatment Strategies ◽  
Aneurysm Rupture ◽  
Morbidity Rate ◽  
Content Type ◽  
Flow Alteration ◽  
Fisher Grade ◽  
Number Of Patients ◽  
Fine Print

Object. Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels, are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the “inflow zone,” the site most vulnerable to aneurysm growth and rupture, is used. Methods. From 1991 to 1999 the combined neurosurgical—neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0–5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies—surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively. Conclusions. Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.

Hypermetabolism in the acute stage of hemorrhagic cerebrovascular disease

1990 ◽  
Vol 72 (5) ◽  
pp. 710-714 ◽  
Author(s):  
Hajime Touho ◽  
Jun Karasawa ◽  
Hisashi Shishido ◽  
Toshitaka Morisako ◽  
Keisuke Yamada ◽  
...  
Keyword(s):  
Postoperative Period ◽  
Respiratory Quotient ◽  
Intracranial Aneurysms ◽  
Acute Stage ◽  
Nitrogen Excretion ◽  
Content Type ◽  
Ruptured Intracranial Aneurysms ◽  
Urinary Nitrogen Excretion ◽  
Fine Print ◽  
Urinary Nitrogen

✓ Oxygen consumption carbon dioxide production , urinary nitrogen excretion, respiratory quotient, resting energy expenditure (REE), %REE, and the consumption rates of carbohydrate, fat, and protein (%CHO, %Fat, %Prot, respectively) were determined pre- and postoperatively by indirect calorimetry in 13 patients with ruptured intracranial aneurysms and 11 patients with hypertensive intracerebral hemorrhage in the acute stage. The preoperative urinary nitrogen excretion, respiratory quotient, REE, and %REE were, respectively (mean ± standard deviation): 171 ± 46 ml/min, 203 ± 56 ml/min, 10.3 ± 1.7 gm/day, 0.84 ± 0.01, 1397 ± 389 Cal/day, and 129% ± 8%. The values for REE, and %REE were all increased above normal levels. The %Prot was increased to 26.1% ± 9.1%. In the postoperative period, the urinary nitrogen excretion, REE, and %REE significantly increased to: 186 ± 44 ml/min, 229 ± 56 ml/min, 14.8 ± 2.9 gm/day, 1557 ± 384 Cal/day, and 141% ± 21%, respectively. The %Fat and %Prot also increased significantly, but the %CHO significantly decreased. Preoperatively, in the patients with ruptured intracranial aneurysms, there was a greater increase in %Prot in eight patients classified (according to Fischer) as having a Group 3 or 4 subarachnoid hemorrhage (SAH) on computerized tomography than in five patients classified as having a Group 1 or 2 SAH. In summary, increased metabolic expenditure, especially increased catabolism of protein and fat, is characteristic of accompanying hemorrhagic cerebrovascular disease, and there is an increase in consumption of fat and protein in the postoperative period. Lack of precise knowledge about the cause and consequences of these metabolic responses makes it impossible at present to judge the optimal extent of nutritional replacement. The hypermetabolic state should be taken into consideration when caring for these patients as it may cause weight loss, poor wound healing, and susceptibility to infection.

Cerebral perfusion, vascular spasm, and outcome in patients with ruptured intracranial aneurysms

1977 ◽  
Vol 47 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Patrick J. Kelly ◽  
Ralph J. Gorten ◽  
Robert G. Grossman ◽  
Howard M. Eisenberg
Keyword(s):  
Patient Outcome ◽  
Cerebral Perfusion ◽  
Intracranial Aneurysms ◽  
Perfusion Scintigraphy ◽  
Content Type ◽  
Intracranial Surgery ◽  
Dynamic Scan ◽  
Vascular Spasm ◽  
Ruptured Intracranial Aneurysms ◽  
Fine Print

✓ In a retrospective study of 44 patients with verified ruptured intracranial aneurysms, the results of radionuclide cerebral perfusion scintigraphy (dynamic brain scanning) and the presence or absence of arteriographic spasm were correlated with the clinical outcome. The data indicated that patients with normal dynamic scans had a better outcome as a group and following intracranial surgery than those in whom perfusion was reduced. Patients with normal perfusion had a higher incidence of preoperative rebleeding from their aneurysms, while patients with reduced perfusion had a higher incidence of infarction, especially after intracranial surgery. There was no correlation between the presence or absence of arteriographic spasm and the results of the dynamic scans, and no correlation between the presence or absence of spasm and the outcome of the group as a whole. However, in some individual cases with severe spasm, reduced perfusion on the dynamic scan and a poor outcome were noted. It was concluded that the results of the dynamic scan correlated better with eventual patient outcome than the presence or absence of arteriographic spasm. It is therefore suggested that patients in Grades I and II with normal dynamic scans be operated on promptly to prevent rebleeding, and that surgery in patients in Grades I and II with abnormal dynamic scans be delayed until the dynamic scan returns to normal.

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