The International Cooperative Studyon the Timing of Aneurysm Surgery

1990 ◽  
Vol 73 (1) ◽  
pp. 18-36 ◽  
Author(s):  
Neal F. Kassell ◽  
James C. Torner ◽  
E. Clarke Haley ◽  
John A. Jane ◽  
Harold P. Adams ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Complete Recovery ◽  
Elevated Blood ◽  
Aneurysm Surgery ◽  
Cooperative Study ◽  
Content Type ◽  
Level Of Consciousness ◽  
The Status ◽  
Fine Print

✓ The International Cooperative Study on the Timing of Aneurysm Surgery evaluated the results of surgical and medical management in 3521 patients between December, 1980, and July, 1983. At admission, 75% of patients were in good neurological condition and surgery was performed in 83%. At the 6-month evaluation, 26% of the patients had died and 58% exhibited a complete recovery. Vasospasm and rebleeding were the leading causes of morbidity and mortality in addition to the initial bleed. Predictors for mortality included the patient's decreased level of consciousness and increased age, thickness of the subarachnoid hemorrhage clot on computerized tomography, elevated blood pressure, preexisting medical illnesses, and basilar aneurysms. The results presented here document the status of management in the 1980's.

Antifibrinolytic therapy in the acute period following aneurysmal subarachnoid hemorrhage

1984 ◽  
Vol 61 (2) ◽  
pp. 225-230 ◽  
Author(s):  
Neal F. Kassell ◽  
James C. Torner ◽  
Harold P. Adams
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Aneurysm Surgery ◽  
Cooperative Study ◽  
Content Type ◽  
Antifibrinolytic Therapy ◽  
Rebleeding Rate ◽  
Relationship Of ◽  
The Relationship ◽  
Fine Print

✓ Antifibrinolytic therapy remains a controversial issue in the management of subarachnoid hemorrhage (SAH). The relationship of antifibrinolytic therapy with mortality, rebleeding, ischemia, hydrocephalus, and clotting abnormalities was studied in 672 patients in the International Cooperative Study on the Timing of Aneurysm Surgery. The patients with antifibrinolytic therapy had a significantly lower rebleeding rate, but higher rates of ischemic deficits and hydrocephalus. The net result was no difference in mortality in the 1st month following the initial SAH. Further clinical trials are needed to determine the overall effects of antifibrinolytic therapy.

Surgical experiences with giant intracranial aneurysms

1984 ◽  
Vol 61 (6) ◽  
pp. 1009-1028 ◽  
Author(s):  
Lindsay Symon ◽  
Janos Vajda
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Mortality Rate ◽  
Intracranial Aneurysms ◽  
Visual Loss ◽  
Considerable Improvement ◽  
Brain Circulation ◽  
Content Type ◽  
Space Occupying Lesion ◽  
Fine Print

✓ A series of 35 patients with 36 giant aneurysms is presented. Thirteen patients presented following subarachnoid hemorrhage (SAH) and 22 with evidence of a space-occupying lesion without recent SAH. The preferred technique of temporary trapping of the aneurysm, evacuation of the contained thrombus, and occlusion of the neck by a suitable clip is described. The danger of attempted ligation in atheromatous vessels is stressed. Intraoperatively, blood pressure was adjusted to keep the general brain circulation within autoregulatory limits. Direct occlusion of the aneurysm was possible in over 80% of the cases. The mortality rate was 8% in 36 operations. Six percent of patients had a poor result. Considerable improvement in visual loss was evident in six of seven patients in whom this was a presenting feature, and in four of seven with disturbed eye movements.

Acute cerebral blood flow response to dopamine-induced hypertension after subarachnoid hemorrhage

1994 ◽  
Vol 80 (5) ◽  
pp. 857-864 ◽  
Author(s):  
Joseph M. Darby ◽  
Howard Yonas ◽  
Elizabeth C. Marks ◽  
Susan Durham ◽  
Robert W. Snyder ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Systemic Blood Pressure ◽  
Content Type ◽  
Arterial Blood ◽  
Induced Hypertension ◽  
Fine Print

✓ The effects of dopamine-induced hypertension on local cerebral blood flow (CBF) were investigated in 13 patients suspected of suffering clinical vasospasm after aneurysmal subarachnoid hemorrhage (SAH). The CBF was measured in multiple vascular territories using xenon-enhanced computerized tomography (CT) with and without dopamine-induced hypertension. A territorial local CBF of 25 ml/100 gm/min or less was used to define ischemia and was identified in nine of the 13 patients. Raising mean arterial blood pressure from 90 ± 11 mm Hg to 111 ± 13 mm Hg (p < 0.05) via dopamine administration increased territorial local CBF above the ischemic range in more than 90% of the uninfarcted territories identified on CT while decreasing local CBF in one-third of the nonischemic territories. Overall, the change in local CBF after dopamine-induced hypertension was correlated with resting local CBF at normotension and was unrelated to the change in blood pressure. Of the 13 patients initially suspected of suffering clinical vasospasm, only 54% had identifiable reversible ischemia. The authors conclude that dopamine-induced hypertension is associated with an increase in flow in patients with ischemia after SAH. However, flow changes associated with dopamine-induced hypertension may not be entirely dependent on changes in systemic blood pressure. The direct cerebrovascular effects of dopamine may have important, yet unpredictable, effects on CBF under clinical pathological conditions. Because there is a potential risk of dopamine-induced ischemia, treatment may be best guided by local CBF measurements.

Ultra-early rebleeding in spontaneous subarachnoid hemorrhage

1996 ◽  
Vol 84 (1) ◽  
pp. 35-42 ◽  
Author(s):  
Yukihiko Fujii ◽  
Shigekazu Takeuchi ◽  
Osamu Sasaki ◽  
Takashi Minakawa ◽  
Tetsuo Koike ◽  
...  
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Multivariate Analysis ◽  
Subarachnoid Hemorrhage ◽  
Early Operation ◽  
Time Interval ◽  
High Systolic Blood Pressure ◽  
Content Type ◽  
Spontaneous Subarachnoid Hemorrhage ◽  
Fine Print

✓ To determine the incidence of, and risk factors for, the occurrence of rebleeding between admission and early operation (ultra-early rebleeding) in patients with spontaneous subarachnoid hemorrhage (SAH), the authors reviewed the cases of 179 patients admitted within 24 hours after their last attack of SAH. Thirty-one (17.3%) of these patients had ultra-early rebleeding despite scheduling of early operation (within 24 hours after admission). The incidence of rebleeding significantly decreased as the time interval between the last attack and admission increased. Patients with rebleeding before admission, high systolic blood pressure, intracerebral or intraventricular hematoma, those in poor neurological condition on admission, and those who underwent angiography within 6 hours of the last SAH were significantly more likely to have ultra-early rebleeding than those without these factors. The incidence of rebleeding also significantly increased as levels of enhancement of platelet sensitivity and thrombin—antithrombin complex increased. Multivariate analysis revealed that the following three factors were independently associated with ultra-early rebleeding: the level of enhancement of platelet sensitivity; the time interval between the last attack and admission; and the level of thrombin—antithrombin complex. On the basis of these findings, the authors suggest that many of the risk factors for ultra-early rebleeding are interrelated. A particularly high risk of ultra-early rebleeding was observed in those patients 1) who had platelet hypoaggregability; 2) who were admitted shortly after their last SAH; and 3) whose thrombin—antithrombin complex levels were extremely high and were thus in severe clinical condition.

The effect of nimodipine on cerebral oxygenation in patients with poor-grade subarachnoid hemorrhage

2004 ◽  
Vol 101 (4) ◽  
pp. 594-599 ◽  
Author(s):  
Michael F. Stiefel ◽  
Gregory G. Heuer ◽  
John M. Abrahams ◽  
Stephanie Bloom ◽  
Michelle J. Smith ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Brain Tissue ◽  
Cerebral Oxygenation ◽  
Content Type ◽  
Poor Grade ◽  
Physiological Variables ◽  
Arterial Blood ◽  
End Tidal ◽  
Fine Print

Object. Nimodipine has been shown to improve neurological outcome after subarachnoid hemorrhage (SAH); the mechanism of this improvement, however, is uncertain. In addition, adverse systemic effects such as hypotension have been described. The authors investigated the effect of nimodipine on brain tissue PO2. Methods. Patients in whom Hunt and Hess Grade IV or V SAH had occurred who underwent aneurysm occlusion and had stable blood pressure were prospectively evaluated using continuous brain tissue PO2 monitoring. Nimodipine (60 mg) was delivered through a nasogastric or Dobhoff tube every 4 hours. Data were obtained from 11 patients and measurements of brain tissue PO2, intracranial pressure (ICP), mean arterial blood pressure (MABP), and cerebral perfusion pressure (CPP) were recorded every 15 minutes. Nimodipine resulted in a significant reduction in brain tissue PO2 in seven (64%) of 11 patients. The baseline PO2 before nimodipine administration was 38.4 ± 10.9 mm Hg. The baseline MABP and CPP were 90 ± 20 and 84 ± 19 mm Hg, respectively. The greatest reduction in brain tissue PO2 occurred 15 minutes after administration, when the mean pressure was 26.9 ± 7.7 mm Hg (p < 0.05). The PO2 remained suppressed at 30 minutes (27.5 ± 7.7 mm Hg [p < 0.05]) and at 60 minutes (29.7 ± 11.1 mm Hg [p < 0.05]) after nimodipine administration but returned to baseline levels 2 hours later. In the seven patients in whom brain tissue PO2 decreased, other physiological variables such as arterial saturation, end-tidal CO2, heart rate, MABP, ICP, and CPP did not demonstrate any association with the nimodipine-induced reduction in PO2. In four patients PO2 remained stable and none of these patients had a significant increase in brain tissue PO2. Conclusions. Although nimodipine use is associated with improved outcome following SAH, in some patients it can temporarily reduce brain tissue PO2.

Management of ischemic complications after subarachnoid hemorrhage

1975 ◽  
Vol 43 (4) ◽  
pp. 418-425 ◽  
Author(s):  
Thoralf M. Sundt
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Picture ◽  
Relative Frequency ◽  
Drug Regimen ◽  
Content Type ◽  
Dramatic Effect ◽  
The Status ◽  
Ischemic Complications ◽  
Angiographic Evidence ◽  
Fine Print

✓ The author reviews a form of management for patients deteriorating preoperatively or postoperatively from apparent ischemia attributed to progressive vasospasm after a subarachnoid hemorrhage. The clinical picture and relative frequency of this complication are considered in relationship to the status (grade) of the patient, location of the aneurysm, and ultimate neurological recovery. Experience suggests that the drug regimen reported is useful when instituted early after the onset of symptoms and is safe with proper monitoring techniques. The data do not justify early operative intervention after a subarachnoid hemorrhage, operation when there is angiographic evidence of severe spasm, or expectation of a dramatic effect in patients with a profound deficit or a fixed deficit several hours old.

The effect of subarachnoid hemorrhage on blood and CSF atrial natriuretic factor

1989 ◽  
Vol 71 (1) ◽  
pp. 32-37 ◽  
Author(s):  
Jeffrey V. Rosenfeld ◽  
Gene H. Barnett ◽  
Cathy A. Sila ◽  
John R. Little ◽  
Emmanuel L. Bravo ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Serum Sodium ◽  
Atrial Natriuretic Factor ◽  
Venous Pressure ◽  
Sodium Concentration ◽  
Control Group ◽  
Central Venous ◽  
Content Type ◽  
Fine Print

✓ Atrial natriuretic factor (ANF) is a diuretic natriuretic peptide hormone produced by both the heart and brain which has been postulated to play a role in the hemodynamic and sodium instability that frequently follows subarachnoid hemorrhage (SAH). Levels of ANF were measured in 12 patients with nontraumatic SAH and nine control patients with unruptured cerebral aneurysms. At surgery, the mean plasma ANF level (± standard deviation) of the SAH group was significantly higher than that of the control group (158.1 ± 83.8 vs. 57.8 ± 45.3 pg/ml, respectively; p = 0.01). There was no significant difference in serum sodium concentration, blood pressure, or central venous pressure between these groups. Nine patients with SAH due to aneurysm rupture had plasma ANF levels similar to those in three patients with SAH due to other causes. Four patients with moderate to severe SAH had significantly higher mean cerebrospinal fluid (CSF) ANF values (17.7 ± 12.8 pg/ml) than five patients with minimal SAH (0.6 ± 0.9 pg/ml) or the control group of nine patients (3.7 ± 1.3 pg/ml) (p < 0.05). Five patients with moderate to severe SAH had significantly higher plasma ANF values (202.6 ± 72.2 pg/ml) than five with minimal SAH (86.8 ± 29.2 pg/ml) or the control group (57.8 ± 45.3 pg/ml) (p < 0.05). Plasma ANF values were substantially higher than CSF ANF content in the SAH group (p < 0.01) and in the control group (p = 0.05). From these data it is concluded that: 1) plasma ANF is elevated significantly after SAH; 2) this rise appears unrelated to the cause of hemorrhage, serum sodium concentration, blood pressure, or central venous pressure, but is related to the extent of the hemorrhage; 3) ANF concentrations in the CSF are significantly lower than in plasma, and are elevated after moderate to severe SAH; and 4) the source of CSF ANF is probably the plasma, and the source of plasma ANF is likely the heart.

Surgical anatomy of the cerebral arteries in patients with subarachnoid hemorrhage: comparison of computerized tomography angiography and digital subtraction angiography

2001 ◽  
Vol 95 (2) ◽  
pp. 206-212 ◽  
Author(s):  
Birgitta K. Velthuis ◽  
Maarten S. van Leeuwen ◽  
Theodoor D. Witkamp ◽  
Lino M. P. Ramos ◽  
Jan Willem Berkelbach van der Sprenkel ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Ct Angiography ◽  
Computerized Tomography ◽  
Cerebral Arteries ◽  
Digital Subtraction ◽  
Aneurysm Surgery ◽  
Content Type ◽  
Computerized Tomography Angiography ◽  
Vertebrobasilar Artery ◽  
Fine Print

Object. The purpose of this study was to compare computerized tomography (CT) angiography and digital subtraction (DS) angiography studies in patients with subarachnoid hemorrhage (SAH) to assess their vascular anatomy relevant to cerebral aneurysm surgery. Methods. From a prospective series of 100 patients with SAH, the authors selected 73 patients whose CT angiography studies were of adequate quality and in whom DS angiography of both carotid arteries had been performed. Eleven patients with no DS angiographic studies of the vertebrobasilar artery were only evaluated for the anterior half of the circle of Willis. Anterior communicating arteries (ACoAs), both precommunicating anterior cerebral arteries (A1 segments), both posterior communicating arteries (PCoAs), and both precommunicating posterior cerebral arteries (P1 segments) were assessed on CT angiography and DS angiography by two independent observers. Conclusions. Computerized tomography angiography compares well with DS angiography for visualizing normal-sized arteries, and is superior for visualizing ACoAs and hypoplastic A1 and P1 segments. Important preoperative aspects such as dominant A1 segments and PCoAs are equally well seen using either modality. Neither method enabled the authors to visualize more than 50% of PCoAs. Use of CT angiography can provide the required preoperative anatomical information for aneurysm surgery in most patients with SAH.

Cerebral arterial responses to induced hypertension following subarachnoid hemorrhage in the monkey

1978 ◽  
Vol 49 (1) ◽  
pp. 75-83 ◽  
Author(s):  
Donald P. Boisvert ◽  
Thomas R. Overton ◽  
Bryce Weir ◽  
Michael G. Grace
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
Control Group ◽  
Content Type ◽  
Csf Pressure ◽  
Arterial Blood ◽  
Subarachnoid Injection ◽  
Arterial Responses ◽  
Fine Print

✓ Regional cerebral blood flow (rCBF), angiographic cerebral arterial caliber, and cerebrospinal fluid (CSF) pressure were measured in rhesus monkeys to determine the effect of experimentally induced subarachnoid hemorrhage (SAH) on cerebral arterial responses to graded increases in blood pressure. These measurements were also performed in a control group of monkeys subjected to a mock SAH by injection of artificial CSF into the cerebral space. Before subarachnoid injection of blood or artificial CSF, graded increases in mean arterial blood pressure (MABP) to a level 40% to 50% above baseline values had no effect on rCBF. The major cerebral arteries constricted and CSF pressure remained unchanged. Similar responses were observed after injection of artificial CSF. When MABP was increased in animals that had been subjected to subarachnoid injection of blood, rCBF increased and was associated with dilatation of the major cerebral arteries and moderate increases in CSF pressure. These results demonstrate that cerebral arterial responses to increases in blood pressure may be abnormal in the presence of subarachnoid blood. The manner in which abnormal cerebral arterial reactivity, changes in blood pressure, and vasospasm combine to determine the level of cerebral perfusion following SAH is postulated.

Prognosis in subarachnoid hemorrhage of unknown etiology

1986 ◽  
Vol 64 (3) ◽  
pp. 359-362 ◽  
Author(s):  
Roar Juul ◽  
Torbjørn A. Fredriksen ◽  
Rolf Ringkjøb
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Mortality Rate ◽  
Tranexamic Acid ◽  
Complete Recovery ◽  
Unknown Etiology ◽  
Communicating Hydrocephalus ◽  
Content Type ◽  
Repeat Angiography ◽  
Shunting Procedure ◽  
Fine Print

✓ Thirty-two patients with subarachnoid hemorrhage of unknown etiology were followed for periods from 1 to 6½ years. Two more patients had normal initial angiograms, but were excluded when repeat angiography revealed an aneurysm. The mortality rate in this series was 6%. There was one possible early and no late episode of rebleeding. One patient developed epilepsy. Five patients developed communicating hydrocephalus and underwent a shunting procedure. A complete recovery was observed in 12 patients. An additional eight had minimal disability, seven were more severely disabled, and three patients were totally disabled. Antifibrinolytic treatment (tranexamic acid) was given in a nonstandardized regimen to 14 patients who showed a poorer result than did the 18 untreated patients.

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