The use of computed tomography in the prediction of delayed cerebral infarction following acute aneurysm surgery for subarachnoid haemorrhage

Summary In order to predict the occurrence of cerebral infarction after aneurysmal surgery in patients with subarachnoid haemorrhage, we measured the amount of subarachnoid blood on initial and on post-operative computed tomograms. We used a reliable grading method to estimate the amount of blood on computed tomograms in 24 patients with infarction due to vasospasm and 45 patients without cerebral infarction, all of whom underwent aneurysmal surgery within 48 hours after the ictus.The total amount of subarachnoid blood on admission and on the day after operation was more in the cerebral infarction group than in the non-infarction group. The clearance rate of subarachnoid blood by surgery was lower in patients with cerebral infarction than in patients without infarction and the predominant site of subarachnoid blood corresponded with the site of the infarct. Of 24 patients with cerebral infarction, 22 (92%) belonged to the group whose initial total blood score was more than 10 on admission and whose clearance rate by surgery was less than 50%.Therefore, we propose this range to be an indication for the occurrence of cerebral infarction in postoperative patients due to cerebral vasospasm.The presence of intracerebral haematoma and the amount of ventricular blood and their clearance by surgery were also estimated for the prediction of delayed cerebral infarction after aneurysmal surgery. However, they had no relation to the occurrence of cerebral infarction due to vasospasm.     

Preventive therapy against delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: Trials of thromboxane A2 synthetase inhibitor and hyperdynamic therapy

Summary The effects of thromboxane A₂ synthetase inhibitor and hyperdynamic therapy on delayed cerebral ischaemia following aneurysmal subarachnoid haemorrhage were evaluated in a series of twenty eight patients, who underwent aneurysmal clipping with 72 hours after subarachnoid haemorrhage. Postoperatively, 13 patients were treated with thromboxane A₂ synthetase inhibitor, Xanbon^® {sodium (E)-3-[p-(1H-imidazol-1-ylmethyl)phenyl]-2-propenoate}. Hyperdynamic therapy with dobutamine was given to the remaining 15 patients. Of the 13 patients treated with Xanbon^®, nine patients (69%) developed delayed cerebral ischaemia and cerebral infarcts occurred in eight patients (62%). On the other hand, of the 15 patients treated with hyperdynamic therapy, only three patients (20%) manifested delayed cerebral ischaemia and two patients (13%) developed cerebral infarcts.In the present study, the patients treated with hyperdynamic therapy met an expected incidence of ischaemic events after subarachnoid haemorrhage by today's standards, while those treated with thromboxane A₂ synthetase inhibitor did not.     

Treatment-orientated classification of subarachnoid haemorrhage

The prognosis of patients with cerebral aneurysms has improved greatly with modern management, notably hypotensive and steroid therapy and microneurosurgical techniques. A new classification of subarachnoid haemorrhage is discussed to clarify the early management of patients and their referral to specialized units for intensive medical care and curative surgery.     

Ruptured intracranial dissecting aneurysms: management considerations with a focus on surgical and endovascular techniques to preserve arterial continuity

Background. The present retrospective analysis was undertaken to review an institutional experience with 13 intracranial dissecting aneurysms as source of subarachnoid haemorrhage (SAH) among a total of 585 ruptured intracranial aneurysms. Methods and results. In 6 patients the vertebral artery (VA) was affected, in 2 patients the basilar artery (BA), in 3 the internal carotid (ICA), in 1 the middle cerebral (MCA) and in 1 the postcommunicating (A2) segment of the anterior cerebral artery (ACA). Maintaining arterial patency was aimed at in all patients. Tangential clipping or circumferential wrapping were used as surgical methods. Endovascular stenting and/or coiling was applied in 2 instances. Four of the 6 VA dissecting aneurysms underwent surgical exploration between 1 and 22 days after haemorrhage. Two patients were in WFNS grade V and died subsequently with the aneurysms untreated, one after rehaemorrhage. In the patients with secured VA aneurysms the postoperative course was uncomplicated with the exception of additional caudal cranial nerve injury in 1 instance. Both BA aneurysms were initially treated by endovascular methods. In the first patient incomplete packing with Gugliemi detachable (GDC) coils was achieved. Follow-up angiography 6 months later showed growth and coil compaction and subsequent wrapping with Teflon fibres resulting in angiographic stabilization. The other BA aneurysm was treated by a combination of a coronary stent and GDC coils. The 3 dissecting ICA aneurysms were all explored surgically. In only 1 instance ICA continuity could be preserved by wrapping, in the other 2 cases a major portion of the vessel wall disintegrated upon removal of the surrounding clot. The only ACA dissecting aneurysm, on A2, was successfully treated with a Dacron cuff. In the single patient with a MCA aneurysm, a decision for conservative management was taken, because neither a surgical nor an endovascular solution was seen as a possibility that did not risk occlusion of lenticulostriate branches. The patient suffered a fatal rehaemorrhage 4 weeks later at her home. Conclusions. The reported experience suggests that in Western countries also dissecting aneurysms are an occasional source of SAH. The outcome in our conservatively managed patients confirms the poor prognosis of conservative management. Wrapping and endovascular stent based methods can achieve stabilization of the dissected artery without sacrificing the artery. Results of treatment appear to depend largely on the location of the dissecting aneurysm.     

Two patients treated with intra-aortic balloon pump counterpulsation after subarachnoid hemorrhage

Intra-aortic balloon pump counterpulsation (IABP) was used to treat two patients with symptomatic vasospasm after subarachnoid hemorrhage. One could not tolerate triple H therapy (hypertensive hypervolemic hemodilution) because of poor cardiac function and another suffered acute myocardial infarction after aneurysm surgery followed by cardiac failure. IABP increased cerebral blood flow and prevented cerebral infarction in the former case but this could not reverse cerebral ischemia in the latter. IABP may be one choice for patients with vasospasm after subarachnoid hemorrhage.     

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: a case report and review of the literature

BACKGROUND

Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction.

CASE DESCRIPTION

A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2.

CONCLUSION

This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.     

Unruptured intracranial aneurysms in polycystic kidney disease

Summary To detect unruptured intracranial aneurysms, we performed cerebral angiography in five patients with polycystic kidney disease (PKD) who had no neurological deficits and no history of subarachnoid haemorrhage. Three of the five patients had unruptured intracranial aneurysms and two underwent surgery with no mortality or morbidity. Our review of the literature revealed that the surgical risk of unruptured intracranial aneurysms is smaller than the risk of bleeding in conservatively treated patients. We discuss the importance of an early diagnosis, and early operation for unruptured aneurysms in patients with polycystic kidney disease and stress the need for intensive care for their renal dysfunction and hypertension during and after the operation.     

Simultaneous superficial temporal artery to middle cerebral or anterior cerebral artery bypass with pan-synangiosis for Moyamoya disease covering both anterior and middle cerebral artery territories

Some patients with moyamoya disease treated by conventional surgical procedures may develop postoperative refractory ischemia and perioperative cerebral infarction in the anterior cerebral artery (ACA) territory. We present a novel operative procedure for moyamoya disease to avoid the risk of ischemia in the ACA territory, which consists of simultaneous superficial temporal artery (STA) to middle cerebral artery (MCA) or ACA bypass with pan-synangiosis, encephalo-duro-arterio-myo-synangiosis for the lateral frontal and temporal areas, and encephalo-galeo-arterio-synangiosis for the medial frontal area. This procedure can establish direct bypass to the ACA territory at the first intervention. Simultaneous STA-MCA and STA-ACA bypasses with pan-synangiosis is suitable for patients with moyamoya disease associated with severely impaired perfusion of the ACA territory requiring direct bypass surgery.     

Anti-phospholipid antibodies and cerebral vasospasm following subarachnoid haemorrhage

Summary Delayed ischaemic deficits due to cerebral vasospasm contribute to the high morbidity and mortality rates associated with subarachnoid haemorrhage. We evaluated the usefulness of measuring anti-phospholipid antibodies (aPLs) for prediction of the occurrence of symptomatic vasospasm and the outcome after subarachnoid haemorrhage. 32 consecutive patients with subarachnoid haemorrhage due to ruptured cerebral aneurysms were studied. They were admitted and operated on within 72 hours after the onset of subarachnoid haemorrhage. aPLs such as lupus anticoagulants, anti-cardiolipin IgG and anti-cardiolipin IgM were measured repeatedly after admission. Furthermore, platelet count, platelet aggregability and plasma platelet factor 4 were also measured. Eleven among the 32 patients (34.4%) showed positive in the examination for aPLs. Although aPLs could not predict symptomatic vasospasm, once symptomatic vasospasm occurred, patients with aPLs frequently demonstrated cerebral infarction and there-fore their outcome was worse. aPLs were associated with a severe initial clinical grade and SAH grade on CT scan. Therefore it may explain the association of aPLs with worse outcome. aPLs were detected between 1 and 7 days. Four of 6 patients (67%) with aPLs became negative between 7 and 13 days after subarachnoid haemorrhage. The mechanism of transient aPLs is unclear but it is more likely to occur in the severer grade patients. The reduction in platelet count, the increased platelet aggregability, and the increased plasma platelet factor 4 concentration were also observed in aPLs-positive patients with symptomatic vasospasm.     

Saccular aneurysms of the distal anterior cerebral artery

We report a series of 42 consecutive patients with aneurysms of the distal anterior cerebral artery (ACA). Of these, 36 patients had one aneurysm, 5 had two aneurysms, and one had three aneurysms. Thirty patients had a ruptured distal ACA aneurysm; among these patients, the size of the aneurysm was less than 5 mm in diameter in 20, 6 to 10 mm in 7, and larger than 11 mm in 3. Eighteen patients (42.9%) had multiple aneurysms, and distal ACA aneurysms were responsible for a subarachnoid hemorrhage in 10. Thirty-four patients underwent direct surgery, and 30 of these had excellent outcomes 3 months after surgery. The treatment of patients with distal ACA aneurysms is often technically difficult, because of their broad neck configuration and the coexistence of other aneurysms. Nevertheless, the present study emphasizes that distal ACA aneurysms tend to bleed, irrespective of their size, and that excellent outcomes are obtainable by direct surgery.     

Spontaneous dissection of the anterior cerebral artery presenting subarachnoid hemorrhage and cerebral infarction: a case report

A case is reported of anterior cerebral artery dissecting aneurysm presenting with subarachnoid hemorrhage and cerebral infarction. A 50-year-old man presented with sudden onset of weakness of the left lower limb was admitted to our hospital. CT scan on admission showed a subarachnoid hemorrhage in the interhemispheric fissure and CT on the 6th day demonstrated a cerebral infarction on the right medial frontal lobe. A carotid angiogram 12 hours after the onset showed no aneurysmal lesion, but, the angiogram repeated 11 days after the onset revealed an aneurysmal dilatation with distal narrowing at the right A2-A3 segment. To prevent rebleeding, we performed a wrapping procedure through the interhemispheric route on the 18th day after onset. The postoperative course was uneventful. We reviewed 27 previously reported cases with symptomatic dissecting aneurysm confined to the anterior cerebral artery.     

Frameless stereotaxy-assisted clipping of distal anterior cerebral artery aneurysm: technical note and case series.

OBJECTIVE: Microsurgery for the clipping of cerebral aneurysms requires a working knowledge of the anatomy of the cerebral vasculature and its relationship to landmarks on the surface of the brain and along the skull base. However, for more distally located aneurysms of the anterior cerebral artery (ACA), locating the lesion can prove frustrating and may require much more extensive interhemispheric dissection than is otherwise needed for proximal control, exposure of the aneurysm, and clip application. We report a case series of five patients in which frameless stereotaxy and CT angiographic data sets were used to minimize the extent of surgery required to clip distal ACA aneurysms. CLINICAL PRESENTATIONS: Five patients were found to have distal ACA aneurysms during the work-up of subarachnoid hemorrhage or other neurologic symptoms. The patients comprised two with subarachnoid hemorrhage, one with dizziness, one with stroke, and one with migraines and polycystic kidney disease. Each patient was found to have an aneurysm at the pericallosal/callosal marginal junction. INTERVENTION: All five patients underwent a right parasagittal craniotomy and clipping of a distal ACA aneurysm. The location of the craniotomy and subsequent interhemispheric dissection were guided by CT angiographic data sets and computer-assisted frameless stereotaxy. CONCLUSION: Frameless stereotaxy using a CT angiographic data set is a useful adjunct to routine microsurgery in the clipping of distal ACA aneurysms. Its use obviates the need for extensive interhemispheric dissection, allows the surgeon to gain proximal control and expose the aneurysm more efficiently, and should minimize complications related to unwitting aneurysm exposure.     

Statistical Analysis of Factors Affecting the Outcome of Patients with Ruptured Distal Anterior Cerebral Artery Aneurysms

Summary  The clinical factors affecting the outcome of patients with ruptured distal anterior cerebral artery (ACA) aneurysms were analyzed using multiple logistic regression analysis.  The medical records were reviewed of 52 patients (57 aneurysms) with ruptured distal ACA aneurysms operated on by the same neurosurgeon over 25 years. The standard policy was early surgery for patients in Hunt and Kosnik grades I to IV. Age, sex, Hunt and Kosnik grade, timing of operation, size of aneurysms, number of aneurysms, association of intracerebral haemorrhage (ICH), intraventricular haemorrhage, and azygos ACA, use of temporary clipping , occurrence of premature rupture, and presence of psychiatric change were investigated. Univariant analysis disclosed that clinical grade (P=0.0006), size of aneurysm (P=0.005), and size of ICH (P=0.012) affected the outcome of patients. Multiple logistic regression analysis found that Hunt and Kosnik grade (P=0.010) and timing of operation (P=0.033) affected the outcome. There was no significant relationship between long-term outcome and clinical factors, although a close relationship was found with Hunt and Kosnik grade (P=0.071).  Clinical grade and timing of the operation affected the outcome of patients with ruptured distal ACA aneurysms. Patients harboring ICH of over 3 cm diameter in poor grades should also be carefully treated.     

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms

Summary One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances.More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage then a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p<0.04); the reverse was true for the placebo patient (p<0.05).     

One-session operation via bilateral craniotomies for multiple aneurysms after subarachnoid haemorrhage

One-session bilateral craniotomies for radical clipping of multiple aneurysms have been performed in 14 patients after subarachnoid haemorrhage. Bilateral small or medium sized aneurysms in pre-operatively good-grade Hunt and Hess (HH)I-III) patients (nine cases) were clipped without mortality or morbidity. Four poor-grade patients (HH IV at admission, improving to HH III pre-operatively) were treated, with unfavourable outcome in one patient. Another poor-grade patient (HH IV at surgery) with bilateral large middle cerebral artery aneurysms, a large intracerebral haematoma and a pontine angle meningioma survived with dysphasia and short-memory dysfunction. A slack brain at surgery and a short operation time justify one-session bilateral craniotomies also in the early post-bleeding period.     

Antifibrinolytic treatment in subarachnoid haemorrhage: Present state

Summary Two randomised controlled clinical trials in patients with recently ruptured intracranial aneurysms were undertaken using tranexamic acid (AMCA) to prevent early recurrent bleeding.In our accumulated series of 105 patients 53 were given AMCA and 52 were controls. 13% of the AMCA-treated patients and 31% of the controls rebled. In patients treated with AMCA the recurrent bleedings took place later than the rebleeding in the control patients.Vasospasm and delayed cerebral ischaemic deficits were seen more frequently in patients treated with AMCA. Total mortality from rebleeding and cerebral ischaemia was 25% in AMCA-treated patients and 19% in the controls during the six weeks' observation time.Coagulation factors remained unaffected by the drug. Local fibrinolysis in the cerebrospinal fluid decreased after one week in patients treated with AMCA. After two weeks the fibrinolytic activity was similar in AMCA-treated patients and in the controls.After experimental subarachnoid haemorrhage in 90 rabbits. AMCA was found to suppress plasminogen activator activity, mainly in the leptomeninges. This occurred however only during the first few postbleeding days.Antifibrinolytic agents only appear to reduce the risk of recurrent bleeding during the first ten day period after the primary aneurysm rupture. However they also seem to produce delayed cerebral ischaemia in patients with subarachnoid haemorrhage.Synthetic antifibrinolytics evidently shift the incidence of rebleeding curve to the right but these drugs are probably of diminished value in the subsequent weeks of risk.     

Dissecting intracranial aneurysms presenting as subarachnoid haemorrhage: report of two cases and review of literature

Subarachnoid haemorrhage due to intracranial non-traumatic dissecting aneurysms is rare. Most of the published reports refer to dissecting aneurysms in the vertebrobasilar territory. Anterior circulation dissecting aneurysms are rare and their pathogenesis, clinical features, angiographic findings and management are a matter of debate. Management of patients with intracranial arterial dissection is unclear. Unlike the well-established proximal occlusion and trapping approaches to vertebral artery dissections, choices of interventions for anterior circulation and basilar dissecting aneurysms are limited, and most reports have been limited to wrapping techniques for arterial wall reinforcement. The role of anticoagulation therapy in the presence of subarachnoid haemorrhage is also a matter of debate. As no clear-cut guidelines are available, treatment should be tailored to the individual patient. We describe two cases of intracranial dissecting aneurysms, which presented as subarachnoid haemorrhage (SAH) and discuss the management issues.     

Early effects of experimental arterial subarachnoid haemorrhage on the cerebral circulation part II: Regional cerebral blood flow and cerebral microcirculation after experimental subarachnoid haemorrhage

Summary Employing the experimental set-up and the methods described — in part I of the paper, the measurements of the regional cerebral blood flow (rCBF) and evaluation of brain microcirculation were performed. The control series provided normal values and constituted the reference for the results of the posthaemorrhagic measurements.Arterial subarachnoid haemorrhage increases transitorily the intracranial pressure to values close to the diastolic blood pressure. The rise of the blood pressure (Cushing response) is not adequate to prevent the reduction in the cerebral perfusion pressure.Cerebral blood flow diminishes after arterial subarachnoid haemorrhage during the elevation of intracranial pressure. It results in numerous, disseminated areas of reduced regional cerebral blood flow.During 4 hours following arterial subarachnoid haemorrhage global cerebral blood flow returns to normal values, while focal reductions in blood flow persist in the grey matter structures of both hemispheres. These foci are accompanied by confined areas of markedly increased regional cerebral blood flow.Disseminated foci with a reduced number of patent capillaries are found in the grey matter structures of both hemispheres 1 and 4 hours following arterial subarachnoid haemorrhage. Their number decreases during the 4 hours observation.     

Some observations on the microneurosurgical treatment of intracranial aneurysms

Summary This paper reports a retrospective study of the microneurosurgical management of intracranial aneurysm in 133 patients. Good or fair results were obtained in 76%, 12% of patients had a poor result and the mortality was 12%. Major factors which were found to influence the outcome of surgery were: pre-operatively, the Botterell grade of the patient, preexisting systemic hypertension and the time interval between the last subarachnoid haemorrhage and surgery. Post-operatively, the development of cerebral vasospasm was associated with a poor outcome from surgery. Better results might be obtained from the surgery of intracranial aneurysm by delaying operation to the second week after subarachnoid haemorrhage and by better management of hypertensive patients pre-operatively and patients who develop cerebral vasospasm post-operatively.     

Current pattern of in-hospital aneurysmal rebleeds

Summary The management of aneurysmal subarachnoid haemorrhage has recently changed considerably. Emergency admission to specialized centres and early surgery have become common practice. In addition, the use of nimodipine has gained widespread acceptance. Little data are available concerning the frequency and temporal profile of reruptures under the current policies.The case histories of 387 patients treated for aneurysmal subarachnoid haemorrhage between January 1984 and March 1992 were reviewed with regard to the incidence of in-hospital reruptures. All patients were managed according to the same protocol including a policy of individually timed early surgery and intravenous nimodipine. A total of 44 first in-hospital rebleeds were observed during the waiting period. Two percent of the patients admitted on the day of haemorrhage had a rebleed on the same day after admission to the hospital. No rebleeds were observed on the day after subarachnoid haemorrhage. Rebleed rates on day 2 and 3 were also low with 0.6 and 0.8% of the population with an undipped aneurysm. For the following 10 days, the daily rate of rerupture increased. A further peak was observed during the 4th week. Using life-table methods, the cumulative rate of rebleeds was calculated as 23% within 2 weeks and 42% within 4 weeks. Although patients suffering rebleeds differed in several respects from patients without rebleeds, most of the differences could be identified to be a consequence of a selection bias resulting in a longer period of exposure to the risk of rerupture for certain subgroups. Only patients suffering a loss of consciousness after the initial subarachnoid haemorrhage were definitively exposed to a higher daily risk of rerupture.Comparison with other series suggests that nimodipine treatment may add to the protective effect of bedrest, control of blood pressure and stress deprivation during the first days after subarachnoid haemorrhage. However, it cannot be excluded that withdrawal of nimodipine together with the general precautions in patients with unclipped aneurysms is responsible for the late peak of rebleeds. With regard to the timing of surgery, the low rebleed rates between days 1 and 3 justify semi-elective timing within this interval. On the other hand, in patients in whom aneurysm elimination has been deferred because of bad neurological condition or concomittant medical problems, surgery should be performed prior to the 4th week, unless the prognosis is considered hopeless at this time.