Early surgery for ruptured cerebral aneurysm

Preliminary experience with 150 consecutive cases of ruptured cerebral aneurysms operated on within 48 hours is reported. The rationale of this emergency procedure is to prevent early rerupture and also to prevent neurological ischaemic consequences of the subarachnoid haemorrhage likely to develop in the first week after a rupture. The acceptable outcome of the surgically treated cases (87% excellent and good outcome) has been favourably matched to those of a group of equal number of consecutive cases seen in suitable condition for surgery within 48 hours by medical personnel but that remained unoperated for various reasons. The incidence of delayed neurological ischaemia as the definite cause of death is lower in the group operated on in the acute stage than those with delayed surgery, although the overall incidence of clinical vasospasm does not seem significantly lower than in the delayed surgery group.     

脑动脉瘤破裂出血手术的麻醉处理

目的：探讨脑动脉瘤破裂出血围手术期的麻醉处理。方法：采用静脉快速诱导气管内插管、普鲁卡因静脉复合全麻、控制性降压等方法处理。结果：２６例患者术后无１例并发再出血，２例死于脑血管痉挛，２例偏瘫，２例巨大复杂后交通动脉瘤的患者在深低温体外循环下手术获得成功，余２２例痊愈出院。结论：围手术期麻醉处理关键是：采取有效措施防止再出血和脑血管痉挛，深低温体外循环、控制性降压、降低颅内压、脑室穿刺引流术等均有利于提高治愈率。     

Posterolateral approach to ruptured median and paramedian cervical disk

The trend toward anterior diskectomy for median and paramedian cervical disk rupture has tended to obscure progressive development of the posterolateral approach to these lesions. Modifications of surgical technique from the classic posterior approach have allowed direct access to these lesions, provided for satisfactory decompression of the spinal cord, especially when there is associated spondylosis, and avoided all of the disadvantages of anterior disk surgery. Of 28 patients operated on since 1950, 26 have had significant preoperative myelopathy or myeloradiculopathy. Two patients with obvious spinal cord compression and massive myelographic defects had no neurologic deficit. Improvement has been observed in every patient; 16 patients have had full recovery, and 8 others have had minor residual symptoms and asymptomatic signs. Although four patients have been lost to follow-up, they were all seen at least once after operation. No instance of increased deficit has been seen postoperatively, in contrast to the author's experience with spondylotic myelopathy. Postoperative contrast studies, which have now been performed on eight patients, confirm satisfactory excision of these lesions and decompression.     

Result of surgery for ruptured intracranial aneurysms in Nepal

Although aneurysmal subarachnoid haemorrhage appears to be fairly common in the developing countries, the data on the results of management appear to be relatively sparse. This is a retrospective study of 40 patients with 44 intracranial aneurysms operated upon at the National Neurosurgical Referral Centre in Kathmandu, Nepal from 1991 to 1999. The female male ratio was 1.5:1. Age ranged from 16 to 69 years with a mean of 43.2. In location, 18 (41%) were anterior communicating, 10 (23%) posterior communicating, nine (20%) middle cerebral, five (11%) internal carotid other than posterior communicating, two (5%) distal anterior cerebral and one (2%) posterior circulation. Multiple aneurysms were present in four (10%) and giant in three (8%). The timing of surgery ranged from 3 days to 3 months from the day of bleeding. Microsurgical clipping was possible in 37 (93%) and wrapping had to be done in three (7%). Overall mortality was four (10%), two (5%) had a surgery-related death and a further two (5%) died later due to pulmonary embolism. The remaining (90%) made a good recovery. The results compare favourably with that of the International Cooperative Study. Further reduction in mortality will have to await the introduction of endovascular techniques.     

Control-lateral sciatrica after surgery for herniated disk]

A study of 1,427 case records permitted the authors to discover 10 cases of reoperation for sciatica which appeared on the opposite side after removal of a dischernia. A new hernia was noted in 6 cases, whereas radiculitis of unknown origin, appeared to be responsible in 4 cases. The 10 patients who became cured, either after removal of the hernia, or after decompression through the foramin. These few cases, in fact rare, may be considered as relapses and thus poor surgical results. The provide a contribution to the understanding of intervertebral disc disease and raise an interesting medico-legal problem.     

Early complications and results of surgery for ruptured intracranial aneurysms

Summary A personal prospective study has been carried out on 91 consecutive patients undergoing direct surgery for aneurysms of the anterior Circle of Willis. The protocol particularly involved maintaining normotension for each patient during surgery, and operating on all patients in Grades I, II, and III and on those patients in Grades IV and V suffering from coincidental hydrocephalus or intra-cranial haematoma. The results are discussed with particular regard to earlier complications following surgery.     

Spondylodiscitis after lumbar disk surgery

The value of perioperative prophylactic use of antibiotics in lumbar disc surgery is investigated, based on a retrospective study of the operative results of 5041 patients. The rate of occurrence of postoperative spondylodiscitis was significantly higher during the period in which no perioperative prophylaxis was carried out, than it was during the period, in which perioperative prophylaxis was routine. Thus the perioperative prophylactic use of antibiotics seems highly recommendable.     

Vascular complications of lumbar disk surgery

Vascular complications of lumbar disc surgery are rare (about 0,04% of discectomies) but very severe. Great variations of the anatomical lesions and of their clinical aspects may be observed. These lesions are often unrecognised during the operation and they are sometimes identified several years after the injury. The treatment is mainly surgical but percutaneous endovascular treatment has been recently performed successfully in several patients.     

Endovascular surgery for untreated ruptured aneurysm with symptomatic vasospasm]

It is difficult to treat ruptured aneurysms with symptomatic vasospasm. Although direct surgery for such cases is associated with poor outcomes, conservative therapy has the risk of both rerupture and infarction. In two cases of ruptured aneurysms with symptomatic vasospasm, we performed aneurysmal coil embolization with Guglielmi electrodetatchable coils (GDC). At the same time we performed percutaneous transluminal angioplasty (PTA) with papaverine infusion. In both cases, rerupture did not occur and PTA was effective angiographically. A good outcome was achieved in case 1. However, broad cerebral infarction occurred in case 2, in which the patient had shown severe symptomatic vasospasm on admission. In advanced cases, such as in case 2, the outcome is poor. The aneurysm may not be able to be approached before PTA because of severe vasospasm. In such cases, PTA must be performed carefully to avoid aneurysmal rerupture. Intraarterial papaverine infusion is safer than PTA for severe spasm in distal vessels. However the efficacy of papaverine is known to be transient in many cases. It is often difficult to determine the exact relationship between branches and the aneurysm in the presence of vasospasm. In such cases, we recommend that the rupture point be packed and that the aneurysmal neck remain unpacked. After vasospasm is cured and good general condition has been recovered, direct surgery can be performed. In summary, endovascular surgery is an effective option for treatment of ruptured aneurysm with symptomatic vasospasm.     

A cost analysis of surgery for ruptured abdominal aortic aneurysm.

OBJECTIVE: This study compares our costs of salvaging patients with ruptured abdominal aortic aneurysms (AAA) with the costs for unruptured AAAs. METHODS: Details of all AAAs presenting over 18 months were obtained. Costs of repair were carefully calculated for each case and were based upon ITU and ward stay and the use of theatre, radiology and pathology services. We compared the costs in unruptured AAAs with both uncomplicated ruptures and ruptures with one or more system failure. RESULTS: The mortality rate for ruptures undergoing repair was 18% and for elective repairs was 1.6%. The median cost for uncomplicated ruptures was 6427 Pounds (range 2012-13,756 Pounds). For 12 complicated ruptures, it was 20,075 Pounds (range 13,864-166,446 Pounds), and for 63 unruptured AAAs, was 4762 Pounds (range 2925-47,499 Pounds). CONCLUSION: Relatively low operative mortality rates for ruptured AAA repair can be achieved but this comes at substantial cost. On average, a ruptured AAA requiring system support costs four times as much as an elective repair.