颈内动脉分叉部动脉瘤的手术及血管内治疗 （英文）

BACKGROUND Aneurysms of the internal carotid artery(ICA)bifurcation are rare,and no studies have compared patient outcomes after endovascular vs surgical treatment.OBJECTIVE To report the safety,efficacy,and follow-up outcome of these 2treatment options for patients with ICA bifurcation aneurysms.METHODS Patient and aneurysm characteristics,treatment results,and follow-up outcomes(at 30 months)were analyzed from patient records and review of imaging findings.RESULTS A total of 58 patients with ICA bifurcation aneurysms were treated.By interdisciplinary consensus,30 aneurysms were assigned for coiling and 28 for clipping.Patients who underwent surgical clipping were younger and had larger aneurysms.More patients were assigned to coiling if their aneurysms originated only from the ICA bifurcation or projected superiorly.For the combined angiographic endpoint,complete and nearly complete occlusion(Raymond-Roy I+II),similar rates of 96%(coiling)or 100%(clipping)could be achieved.Raymond-Roy I occlusion occurred more often after clipping(79%vs 41%coiling).Follow-up of the endovascular group showed minor recanalization of the aneurysm neck(Raymond-Roy II)in 42%.One patient(4%)showed a major recanalization(Raymond-Roy III)and needed retreatment.For incidental findings,no bleeding complications or new persistent neurological deficits occurred during follow-up.CONCLUSION Treatment of ICA bifurcation aneurysms after interdisciplinary assignment to clipping or coiling is effective and safe.Despite significantly more minor recanalizations after coiling,the re-treatment rate was very low,and no bleeding was observed during follow-up.Multivariate analysis revealed that origin only from the ICA bifurcation was an independent predictor of aneurysm recanalization after endovascular treatment.     

Dynamic changes in growth factor levels over a 7-day period predict the functional outcomes of traumatic brain injury

Traumatic brain injury(TBI) can result in poor functional outcomes and death, and overall outcomes are varied. Growth factors, such as angiopoietin-1(Ang-1), vascular endothelial growth factor(VEGF), and granulocyte-colony stimulating factor(G-CSF), play important roles in the neurological functions. This study investigated the relationship between serum growth factor levels and long-term outcomes after TBI. Blood samples from 55 patients were collected at 1, 3 and 7 days after TBI. Blood samples from 39 healthy controls were collected as a control group. Serum Ang-1, G-CSF, and VEGF levels were measured using ELISA. Patients were monitored for 3 months using the Glasgow Outcome Scale-Extended(GOSE). Patients having a GOSE score of 5 at 3 months were categorized as a good outcome, and patients with a GOSE score of 1–5 were categorized as a bad outcome. Our data demonstrated that TBI patients showed significantly increased growth factor levels within 7 days compared with healthy controls. Serum levels of Ang-1 at 1 and 7 days and G-CSF levels at 7 days were significantly higher in patients with good outcomes than in patients with poor outcomes. VEGF levels at 7 days were remarkably higher in patients with poor outcomes than in patients with good outcomes. Receiver operating characteristic analysis showed that the best cut-off points of serum growth factor levels at 7 days to predict functional outcome were 1,333 pg/mL for VEGF, 447.2 pg/mL for G-CSF, and 90.6 ng/mL for Ang-1. These data suggest that patients with elevated levels of serum Ang-1, G-CSF, and decreased VEGF levels had a better prognosis in the acute phase of TBI(within 7 days). This study was registered with the Chinese Clinical Trial Registry(registration number: ChiCTR1800018251) on September 7, 2018.     

Recurrent intracerebral hemorrhage

Objective: In order to study the clinical manifestation and risk factor of recurrent intracerebral hemorrhage(ICH).Methods:The 256 patients were analysed who admitted to our hospital for intracerebral hemorrhage between 1995 and 1997.The 15(5 .86%)patients had a recurrent ICH.There were 9 men and 6 women and the mean age of the patients was 63.5 ± 6.4years at the first bleeding episode and 67.8± 8. 5 years at the second. The mean interval between the two bleeding episodes was 44.6 ± 12.5 months. The 73.3%patients were hypertensive .′The site of the first hemorrhage was ganglionic in 8 patients , ]ohar in six paients and brainstem in one .The recurrent hemorrhage occurred at a different location from the previous ICH.The most common pattern of recurrence was “ganglionic -ganglionic” (7 patients), lobar - ganglionic (3 patients), lobar-lobar(three patients), which was always observed in hypertensive patients. The outcome after the recurrent hemorrhage was usually poor. By comparison with 24 patients followed up to average 47.5± 18.7 months with isolated ICH without recurrence .Only lobar hematoma and a younger age were risk factors for recurrences whereas sex and previous hypertension were not. The mechanism of recurrence of ICH were multiple(hypertension, cerebral amyloid angiopathy).Contral of blood pressure and good living habit after the first hemorrhage may prevent ICH recurrences.     

Evaluating the prognosis and degree of brain injury by combined S-100 protein and neuron specific enolase determination

BACKGROUND: S-100 and neuron specific enolase (NSE) possess the characteristics of specific distribution in brain and relative stable content. Some studies suggest that combined detection of the both is of very importance for evaluating the degree of brain injury. OBJECTIVE: To observe the changes of S-100 protein and NSE levels at different time points after acute brain injury, and evaluate the values of combined detection of the both for different injury degrees, pathological changes and prognosis. DESIGN: Case-control observation. SETTING: Department of Neurosurgery, Second Affiliated Hospital, Lanzhou University. PARTICIPANTS: Thirty-four inpatients with brain injury, 19 males and 15 females, aged 15 to 73 years, who received treatment between September 2005 and May 2006 in the Department of Neurosurgery, Second Affiliated Hospital, Lanzhou University, were recruited. The patients were admitted to hospital at 24 hours after brain injury. After admission, skull CT confirmed that they suffered from brain injury. Following Glasgow coma score (GCS) on admission, the patients were assigned into 3 groups: severe group (GCS 3 to 8 points, n =15), moderate group (GCS 9 to 12 points, n =8) and mild group (GCS 13 to 15 points, n =11). Following Glasgow outcome scale (GOS) at 3 months after brain injury, the patients were assigned into good outcome group (GOS 4 to 5 points, good recovery and moderate disability included, n =19) and poor outcome group (GOS 1 to 3 points, severe disability, vegetative state and death, n =15). Ten subjects who received health examination concurrently were chosen as normal control group , including 6 males and 4 females , aged （45.4±14.3）years. In our laboratory, the normal level of NSE was ≤15.2 ng/L, and that of S100 was ≤ 0.105 μg/L. METHODS: ①Blood samples of control group were collected when the subjects received health examination. Blood samples of patients with brain injury were collected at 24 hours, 3, 7 and 14 days after injury. According to the instructions of NSE and S-100 kits purchased from Roche Company, serum NSE and S-100 levels were determined by electrochemiluminescence immunoassay (ECLIA). ②Analysis of variance was used for intergroup comparison, Spearman correlative analysis for comparison of different GCS and GOS, and linear regression analysis for comparison of correlation of two factors. MAIN OUTCOME MEASURES: ①The dynamic changes of NSE and S-100 of patients with different brain injuries and their correlations with GCS. ② The dynamic changes of NSE and S-100 of patients with different outcomes and their correlations with GOS. RESULTS: Thirty-four patients with brain injury and ten healthy persons were involved in the result analysis. ①Overall change rule of NSE and S100 after brain injury: NSE of patients with brain injury reached its peak at 24 hours after injury, then was gradually decreased with time and was below normal level in the 2nd week. The overall tendency of S-100 was the same as that of NSE in patients with brain injury. ② The dynamic changes of NSE and S100 of patients with different brain injuries and their correlations with GCS: NSE and S-100 levels at 24 hours after injury were significantly negatively correlated with those on admission （r = －0.537,－0.731, P < 0.05）. At 24 hours after injury, serum NSE and S-100 levels of patients with mild, moderate and severe brain injuries were significantly higher than those of control group (P < 0.05); At 14 days after brain injury, serum NSE and S-100 levels of patients with mild and severe brain injury were close to those of control group (P > 0.05); While at 24 hours, 3, 7 and 14 days after brain injury, the serum NSE and S-100 levels of patients with severe brain injury were significantly higher than those of control group (all P < 0.05). NSE level of patients with mild brain injury was decreased to normal level at 7 days after injury and that of patients with moderate brain injury at 14 days after injury. S-100 level of patients with mild and moderate brain injury was decreased to normal level at 14 days after injury. Serum NSE and S-100 levels of patients with severe brain injury always kept over normal level and those of patients with mild brain injury reached peak value at 3 days after injury. ③ The dynamic changes of NSE and S-100 levels of patients with different outcomes and their correlations with GOS: serum NSE and S-100 levels at 24 hours after injury were significantly negatively correlated with GOS （r =－0.573,－0.756, P < 0.05）. It suggested that the severer the injury was, the lower the GOS was. At 24 hours, 3, 7 and 14 days after injury, serum NSE and S-100 levels of patients in good outcome group were significantly lower than those of poor outcome group (P < 0.05). CONCLUSION: The injury degree and prognosis of patients with brain injury are correlated with serum NSE and S-100 levels. The detection of serum S-100 and NSE levels after injury can be used for evaluating injury and prognosis of brain injury     

Identification of risk factors for poor language outcome in surgical resection of glioma involving the arcuate fasciculus: an observational study

The arcuate fasciculus is a critical component of the neural substrate of human language function. Surgical resection of glioma adjacent to the arcuate fasciculus likely damages this region. In this study, we evaluated the outcome of surgical resection of glioma adjacent to the arcuate fasciculus under the guidance of magnetic resonance imaging and diffusion tensor imaging, and we aimed to identify the risk factors for postoperative linguistic deficit. In total, 54 patients with primary glioma adjacent to the arcuate fasciculus were included in this observational study. These patients comprised 38 men and 16 women(aged 43 ± 11 years). All patients underwent surgical resenction of glioma under the guidance of magnetic resonance imaging and diffusion tensor imaging. Intraoperative images were updated when necessary for further resection. The gross total resection rate of the 54 patients increased from 38.9% to 70.4% by intraoperative magnetic resonance imaging. Preoperative language function and glioma-to-arcuate fasciculus distance were associated with poor language outcome. Multivariable logistic regression analyses showed that glioma-to-arcuate fasciculus distance was the major independent risk factor for poor outcome. The cutoff point of glioma-to-arcuate fasciculus distance for poor outcome was 3.2 mm. These findings suggest that intraoperative magnetic resonance imaging combined with diffusion tensor imaging of the arcuate fasciculus can help optimize tumor resection and result in the least damage to the arcuate fasciculus. Notably, glioma-to-arcuate fasciculus distance is a key independent risk factor for poor postoperative language outcome. This study was approved by the Ethics Committee of the Chinese PLA General Hospital, China(approval No. S2014-096-01) on October 11, 2014.     

Outcomes of early physiotherapy in patients with cerebral aneurysms treated by surgical clipping or endovascular embolization

Early physiotherapy was given to 124 patients with ruptured or unruptured cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients were divided into four groups according to their Hunt and Hess grade at admission and aneurysm treatment modality: Group 1,Hunt and Hess grade≤II and surgical clipping;Group 2,Hunt and Hess grade≤II and endovascular embolization;Group 3,Hunt and Hess grade≥III and surgical clipping;Group 4,Hunt and Hess grade≥III and endovascular embolization.Level of consciousness was evaluated using the Glasgow Coma Scale,functional status using the Glasgow Outcome Scale,level of the mobility using the Mobility Scale for acute stroke patients,and independence in activities of daily living using the Barthel Index.After early physiotherapy,the level of consciousness and functional status improved significantly in Groups 1,3,and 4;mobility improved significantly in all groups;and independence in activities of daily living improved significantly in Groups 1 and 3.At discharge, Groups 1 and 2 had better functional status than Groups 3 and 4.Level of consciousness,functional status,mobility and independence in activities of daily living improved after early physiotherapy. These findings suggest that early physiotherapy improved the prognosis of patients with cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients with a worse clinical status at presentation had a poorer functional status at discharge.The outcome of physiotherapy was not affected by whether surgical clipping or endovascular embolization was chosen for treatment of the aneurysm.     

夹闭术与血管内治疗破裂性宽颈动脉瘤的比较

Objective To analyze the clinical efficacy of clipping and endovascular treatment for ruptured wide-necked aneurysm Methods 143 patients with ruptured wide- necked aneurysm were treated by clipping ( n =83) or endovascular treatment ( n =60). Their complication rates、recurrence rates and modified Rankin scale scores at six months after leaving hospital were evaluated. Results The complication rate in endovasular treatment group was less than that in clipping group( P ＜ 0.05) significantly. The recurrence rate in clipping group was less than that in endovasular treatment group( P ＜ 0. 05) significantly. The modified Rankin scale in endovasular embolization group was less than that in clipping group( P ＜ 0. 05) significantly. Higher recurrence rate and lower complication rate were observed in endovasular treatment group. Patients with endovascular treatment had better prognosis. Conclusion Endovascular treatment for ruptured wide - necked aneurysm is efficient and safe. Better quality of life could be achieved.     

夹闭术与血管内治疗破裂性宽颈动脉瘤的比较

Objective To analyze the clinical efficacy of clipping and endovascular treatment for ruptured wide-necked aneurysm Methods 143 patients with ruptured wide- necked aneurysm were treated by clipping ( n =83) or endovascular treatment ( n =60). Their complication rates、recurrence rates and modified Rankin scale scores at six months after leaving hospital were evaluated. Results The complication rate in endovasular treatment group was less than that in clipping group( P ＜ 0.05) significantly. The recurrence rate in clipping group was less than that in endovasular treatment group( P ＜ 0. 05) significantly. The modified Rankin scale in endovasular embolization group was less than that in clipping group( P ＜ 0. 05) significantly. Higher recurrence rate and lower complication rate were observed in endovasular treatment group. Patients with endovascular treatment had better prognosis. Conclusion Endovascular treatment for ruptured wide - necked aneurysm is efficient and safe. Better quality of life could be achieved.     

局限性非外伤性脑软化灶相关癫痫的手术治疗

Objective To analyze the strategy and outcome of complete lesion resection (CLR) and multiple subpial transaction (MST) for epilepsy caused by non - posttraumatic encephalomalacia.Methods 28 cases were treated with CLR and MST according to preoperative magnetic resonance image (MRI), positive (PET) and 128 - led long - term video EEG. They were followed up for more than 1 year,and their outcome was graded by Engel scales for analysis. Results Grade Ⅰ was observed in 6 cases and Grade Ⅱ in 11 cases, Grade Ⅲ in 9 cases and Grade Ⅳ in 2 cases. Satisfactory seizure control was found in patients with localized encephalomalacia, or far away from eloquent area, or without brain atrophy, more than 80%. Conclusion CLR combined with MST is effective and safe for epilepsy caused by nonposttraumatic encephalomalacia. And the cases with localized encephalomalacia, or far away from eloquent area, or without brain atrophy are likely to have a better outcome.     

Occurrence and impact of delayed cerebral ischemia after coiling and after clipping in the International Subarachnoid Aneurysm Trial (ISAT)

Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). We studied differences in incidence and impact of DCI as defined clinically after coiling and after clipping in the International Subarachnoid Aneurysm Trial. We calculated odds ratios (OR) for DCI for clipping versus coiling with logistic regression analysis. With coiled patients without DCI as the reference group, we calculated ORs for poor outcome at 2 months and 1 year for coiled patients with DCI and for clipped patients without, and with DCI. With these ORs, we calculated relative excess risk due to Interaction (RERI). Clipping increased the risk of DCI compared to coiling in the 2,143 patients OR 1.24, 95% confidence interval (95% CI 1.01–1.51). Coiled patients with DCI, clipped patients without DCI, and clipped patients with DCI all had higher risks of poor outcome than coiled patients without DCI. Clipping and DCI showed no interaction for poor outcome at 2 months: RERI 0.12 (95% CI −1.16 to 1.40) or 1 year: RERI −0.48 (95% CI −1.69 to 0.74). Only for patients treated within 4 days, coiling and DCI was associated with a poorer outcome at 1 year than clipping and DCI (RERI −2.02, 95% CI −3.97 to −0.08). DCI was more common after clipping than after coiling in SAH patients in ISAT. Impact of DCI on poor outcome did not differ between clipped and coiled patients, except for patients treated within 4 days, in whom DCI resulted more often in poor outcome after coiling than after clipping.     

Endovascular coiling versus neurosurgical clipping in patients with a ruptured basilar tip aneurysm

OBJECTIVES: To compare endovascular coiling with neurosurgical clipping of ruptured basilar bifurcation aneurysms. METHODS: Patient and aneurysm characteristics, procedural complications, and clinical and anatomical results were compared retrospectively in 44 coiled patients and 44 patients treated by clipping. The odds ratios for poor outcome (Glasgow outcome scale 1, 2, 3) adjusted for age, clinical condition, and aneurysm size were assessed by logistic regression analysis. RESULTS: In the endovascular group, five patients (11%) had a poor outcome v 13 (30%) in the surgical group; the adjusted odds ratio for poor outcome after coiling v clipping was 0.28 (95% confidence interval, 0.08 to 0.99). Procedural complications were more common in the surgical group. Optimal or suboptimal occlusion of the aneurysm immediately after coiling was achieved in 41 patients (93%). Clipping was successful in 40 patients (91%). CONCLUSIONS: The results suggest that embolisation with coils is the preferred treatment for patients with ruptured basilar bifurcation aneurysms.     

Direct costs of surgical clipping and endovascular coiling of unruptured intracranial aneurysms

BACKGROUND: Unruptured intracranial aneurysms can be preventively treated by surgical clipping or endovascular coiling. We determined in detail the costs of these treatments. METHODS: We included patients who were treated for an unruptured aneurysm between 1997 and 2003. Patients coiled in this period were matched with clipped patients according to the year of treatment, age and gender. Considering clipping and coiling, we compared all pre-admission costs of diagnostic procedures, all costs of treatment, and costs during follow-up including standard angiographic control examinations at 6 and 18 months after coiling. Costs were calculated as the product of the used resources and the costs of these resources. RESULTS: The mean price for clipping was EUR 8,865.42 and that for coiling EUR 10,370.29. The difference was mainly determined by the higher material costs of coiling (EUR 5,300) compared with clipping (EUR 690). Costs of clipping were mainly determined by the need for intensive care facilities (1.2 days after clipping and 0 days after coiling) and the length of hospital stay (10.5 days after clipping and 3.4 days after coiling). After bootstrapping the data, costs of coiling were on average EUR 1,553 (95% confidence interval: EUR 1,539-1,569) higher than those of clipping. CONCLUSIONS: For unruptured intracranial aneurysms, direct in-hospital costs of coiling are on average higher than those of clipping, mostly because of the more expensive coils.     

Magnesium and aspirin treatment in patients with subarachnoid haemorrhage

Objective   Aneurysm treatment with endovascular coiling is associated with a better outcome than neurosurgical clipping in patients with subarachnoid haemorrhage (SAH). The better outcome after coiling may decrease the risk reduction from other treatments in these patients, and thus may increase sample sizes for current or future neuroprotective trials. The influence of the method of aneurysm treatment was studied in our randomised MASH trial, which assessed in a factorial design the efficacy of magnesium and aspirin in preventing delayed cerebral ischaemia (DCI) and poor outcome. Methods   Between November 2000 and January 2004 315 patients were enrolled in the trial; 55 of them had no aneurysm treatment and were excluded for the current analysis, 176 underwent neurosurgical and 84 endovascular treatment. The effect of treatment on the risk of DCI was assessed by means of Cox proportional hazards modelling and that of poor outcome by means of logistic regression analysis. Results   The hazard ratio of DCI with aspirin was 1.4 (95 % CI 0.3 – 1.7) after coiling and 1.9 (0.8 – 4.4) after clipping, and with magnesium 0.4 (0.1 – 1.2) after coiling and 0.8 (0.4 – 1.7) after clipping. The odds ratio of poor outcome with aspirin was 0.7 (0.2 – 2.9) after coiling and 0.8 (0.3 – 2.3) after clipping, and with magnesium 0.3 (0.1 – 1.0) after coiling and 0.8 (0.4 – 1.6) after clipping. Conclusion   This post hoc analysis does not suggest that medical treatments are less effective after endovascular than after neurosurgical treatment in patients with SAH, and thus do not support a need for adjusting sample size calculations in future trials. Magnesium and Acetylsalicylic acid in Subarachnoid Haemorrhage (MASH) Study Group: W. M. van den Bergh,A. Algra, S. M. Dorhout Mees,J. van Gijn,G. J. E. Rinkel,Dept. of Neurology,University Medical Centre Utrecht,Utrecht, The Netherlands Ale Algra,Julius Centre for Health Sciences and Primary Care,University Medical Centre Utrecht,Utrecht, The Netherlands Fop van Kooten,Dept. of Neurology,Erasmus Medical Centre,Rotterdam, The Netherlands Clemens M.F. Dirven,Dept. of Neurology,VU University Medical Centre,Amsterdam, The Netherlands Marinus Vermeulen,Dept. of Neurology,Academic Medical CentreUniversity of Amsterdam,Amsterdam, The Netherlands W. M. van den Bergh, MD, PhD ✉, Dept. of Intensive Care, Room Q04.460,University Medical Centre Utrecht,P.O. Box 85500,3508 GA, Utrecht, The Netherlands,Tel.: +31-30/2508350,Fax: +31-30/2522782,E-Mail: w.m.vandenbergh@umcutrecht.nl     

脑动脉瘤夹闭术与栓塞术:竞争还是互补?

目的探讨颅内动脉瘤开颅夹闭术和介入栓塞术两种治疗方式的相互关系。方法回顾总结动脉瘤夹闭术和栓塞术互补性治疗的6例病例，其中3例先行手术治疗，3例先行介入治疗。3例手术治疗的患者其中1例出现后交通动脉瘤复发，1例前交通动脉瘤术后前交通动脉上发现新的动脉瘤，均行动脉瘤栓塞术补充治疗，1例双侧后交通动脉瘤左侧手术夹闭1年后行右侧后交通动脉瘤颅内支架血管内介入治疗。3例先介入治疗的患者中1例发生栓塞物堵塞载瘤动脉瘤导致大面积脑梗塞，1例发生栓塞物移位，1例发生再出血，均采取开颅手术予以补充治疗，夹闭动脉瘤并取出了栓塞物。结果所有补充治疗均未造成新的病残，其中5例恢复满意，1例恢复良好。结论颅内动脉瘤夹闭术和栓塞术之间既是竞争的关系同时也是互补的关系，两种手术方式都有需要发展的余地同时也有相互结合的必要。     

Which treatment modality is more injurious to the brain in patients with subarachnoid hemorrhage? Degree of brain damage assessed by serum s100 protein after aneurysm clipping or coiling

Background: Serum S100 protein has been known to reflect the severity of brain damage. The purpose of this study was to compare the degree of brain damage based on the serum S100 protein level between aneurysm clipping and coiling groups and to evaluate the prognostic value of S100 protein in patients with subarachnoid hemorrhage (SAH). Methods: Serum S100 protein was measured by Elecsys S100 immunoassay at admission, and at 6 and 24 h, and days 3 and 5 postoperatively for 100 consecutive SAH patients (clipping group: 56, coiling group: 44) and for 74 healthy controls. Hunt-Hess grade (HHG), Fisher grade (FG), the presence of intraventricular (IVH) or intracerebral hemorrhage (ICH), and outcome at discharge were evaluated. The time course of serum S100 was compared between the groups. The prognostic value of S100 protein was evaluated by logistic regression analysis. Results: The median S100 level in SAH patients on admission was significantly higher than in healthy controls (0.081 vs. 0.05 μg/l, p < 0.0001) and it was also higher as HHG and FG increased (p < 0.0001). Logistic regression analysis revealed that only the S100 value at admission was an independent prognostic factor for poor outcomes after adjusting for age, sex, HHG, presence of IVH or ICH, and treatment modality (OR: 100.5, 95% CI: 1.65-6,053.61). The baseline S100 value of 0.168 predicted poor outcomes with a sensitivity of 75% and a specificity of 83%. The time course of the median S100 level peaked at 6 h and then decreased serially in both clipping and coiling groups. However, the degree of S100 elevation was marked in the clipping group, especially at 6 h postoperatively (0.177 vs. 0.116 μg/l, p = 0.022), suggesting more severe brain damage in the clipping group. In the coiling group, the S100 value was significantly higher in patients who showed high signal intensity lesions in diffusion-weighted images, suggesting ischemic brain damage. Furthermore, even in patients who were categorized as good clinical grade at admission and as good outcome at discharge, the median S100 values at 6 and 24 h postoperatively were significantly higher in the clipping group than in the coiling group (p < 0.05). Conclusion: The initial S100 protein value is an independent prognostic factor for poor outcomes in SAH patients. Based on the S100 protein level, aneurysm clipping seems to provoke more brain damage than aneurysm coiling. Endovascular coiling should be considered the first therapeutic option for aneurysmal SAH patients.     

CT灌注成像预测及诊断蛛网膜下腔出血后迟发性脑缺血的Meta分析

目的 系统评价CT灌注成像（CTP）对蛛网膜下腔出血（SAH）后迟发性脑缺血（DCI）的诊断及预测价值。方法 计算机检索PubMed、Cochrane Database、Embase、CNKI及中国生物医学文献库中有关CTP与DCI关系的研究。使用Rev Man 5.3软件进行Meta分析。结果 共纳入10篇文献,包括519例SAH。Meta分析结果显示,SAH早期CTP的CBF、CBV、MTT、TTP与DCI无明显相关性（P>0.05）。高发时间窗内CTP的CBF降低、MTT增高与DCI有关（P<0.05）,而CBV、TTP与DCI无显著相关性（P>0.05）。对DCI的诊断界值,CBF在25~36.3 ml/100g/min范围内变化,而MTT则在5.0~6.5 s范围内变化。结论 CTP可用于诊断而不能用于早期预测SAH后DCI,但仍需标准化CTP测量方法及确定DCI的最佳诊断界值。     

Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus

Background  Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. Methods  Hospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated. Results  One hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients (p=0.5), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p=0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24±14 versus 15±8, 20.5±9 versus 11±7, and 30±13 versus 16±11 days, respectively; p≤0.01). In a logistic regression model, VS was independently associated with rebleeding, external ventricular drain placement, coiling, and UHC-expected LOS (odds ratios, 95% confidence interval 12.1, 2.3–62.6, 6.9, 1.6–30, 6.25, 1.3–29, and 1.1, 1.02–1.14, respectively). Conclusions  One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.     

Clipping versus coiling: neuropsychological follow up after aneurysmal subarachnoid haemorrhage (SAH)

Patients treated with microsurgical clipping of ruptured intracranial aneurysms often suffer from neuropsychological deficits in spite of a good neurological outcome. The purpose of this study was to explore if the deficits are related to the type of therapy. Two groups of 16 patients each suffering from aneurysmal SAH, matched for sex, age, aneurysm-site and Hunt and Hess score, and 16 control subjects were examined with a battery of neuropsychological tests including memory, attention, and executive function. Depression, mood, and quality of life were also assessed. One patient group had been treated with surgical clipping, the other with endovascular coiling. Both patient groups showed deficits in verbal and visual memory. Clipped patients were slightly more impaired than coiled patients, especially on measures of affect and on a self-assessment measure of executive function. The pattern of results suggests that the neuropsychological outcome after aneurysmal SAH is affected by both the severity of the bleeding and the type of therapy.     

Calcium Homeostasis During Magnesium Treatment in Aneurysmal Subarachnoid Hemorrhage

Objective  Magnesium treatment in patients with subarachnoid hemorrhage (SAH) can result in hypocalcemia; this hypocalcemia increases the risk of delayed cerebral ischemia (DCI) and poor outcome. We assessed whether low serum levels of total calcium in patients with SAH treated with magnesium is mediated by parathyroid hormone (PTH) or calcitriol, and whether increased PTH or low serum levels of ionized calcium are associated with an increased risk of DCI and poor outcome. Patients and Methods  We studied 167 patients included in a randomized, placebo controlled trial on magnesium in SAH. Mean serum magnesium during treatment was related to mean serum levels of ionized calcium, PTH and calcitriol with linear regression. Hypocalcemia (Ca²⁺) and high serum PTH were related to the occurrence of DCI by means of the Cox proportional hazards model and to poor outcome by logistic regression. Results  Serum magnesium was inversely related to ionized calcium (B = −0.1; 95% CI −0.12 to −0.06), but not to PTH or calcitriol. Neither hypocalcemia nor high serum PTH was related to DCI. Hypocalcemia did not increased the risk for poor outcome (OR 1.2; 95% CI 0.6–2.3). In the subgroup of patients with known PTH (n = 67), high serum PTH increased the risk for poor outcome (OR 5.4; 1.6–18.9). Conclusions  Magnesium treatment in patients with SAH leads to hypocalcemia without effect on outcome. PTH is related to poor outcome, but this is independent of magnesium therapy.