Treatment for serious cases of ruptured intracranial aneurysms with severe subarachnoid clot

Forty-one serious cases of ruptured intracranial aneurysms with severe subarachnoid clot were clinically analyzed, with special emphasis on the prognosis, pathophysiology, and surgical indications. All cases had thick subarachnoid clot without concurrent intracerebral hematoma and/or intraventricular hematoma causing mass signs on the CT scan. In this series, 23 cases underwent radical surgery while in the acute stage, 18 cases were treated conservatively (including 5 cases treated only by continuous ventricular drainage). The criterion for determining the degree of severity was defined as either a "semicoma" or "coma" state just prior to radical surgery for the radically-operated group, with the same designations for the conservative group at their time of admission. All patients except two in the conservatively-treated group died due to primary brain damage caused by massive subarachnoid hemorrhage. The two remaining cases died from other complications. On the other hand, the outcome for the 23 surgically-treated patients was as follows: Three (13%) fully recovered; three (13%) were capable of self-management; eight (34.8%) were partially or fully dependent. Nine (39.1%), died. In the radically-treated group, pre-operative factors that might predict clinical outcome were investigated. Those factors were the neurological grade, the brain-stem response, the response after the rapid administration of 20% Mannitol (300-900 ml), and the length of time from the last bleeding episode to the time that radical surgery was performed. It was recognized that there was no relationship between the neurological grade just prior to radical surgery and the outcomes in the serious cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cerebrovascular reactivity in patients with ruptured intracranial aneurysms

The cerebral vasomotor reactivity to arterial hypotension and hypocapnia was studied in 34 patients between the 3rd and 13th day after rupture of an intracranial saccular aneurysm. Using the intra-arterial xenon-133 injection method, regional cerebral blood flow (rCBF) and cerebral metabolic rate of oxygen (CMRO2) were measured. The intraventricular pressure and cerebrospinal fluid (CSF) lactate and pH levels were determined. The degree of vasospasm was measured on angiograms taken immediately following the rCBF study. The patients were graded clinically according to the system of Hunt and Hess. Cerebral autoregulation was intact in patients in good clinical condition, but was impaired in patients in poor clinical condition. There was a close correlation between the degree of vasospasm and the degree of autoregulatory impairment, which varied from focal disturbances to global impairment. Intracranial hypertension and CSF lactic acidosis were commonly found in association with vasoparalysis. Cerebrovascular response to hyperventilation was generally preserved, although often reduced. During hyperventilation, the cerebral perfusion pressure became elevated, and increases in CMRO2 were often found, even in patients with severe diffuse spasm and cerebral ischemia. The clinical significance of the results in relation to the treatment of delayed cerebral ischemia and to the use of intraoperative induced hypotension is discussed.     

Cerebral vasospasm in elderly patients with ruptured intracranial aneurysms

Cerebral vasospasm in elderly patients who were operated on the acute stage after subarachnoid hemorrhage was studied under strict criteria. The 138 patients were classified into three age groups: 59 years or younger (group A: 73 cases), 60 to 69 years (group B: 37 cases), and 70 years or older (group C: 28 cases). Severity of both the subarachnoid hemorrhages on computed tomography scan and the angiographic vasospasms was graded. The angiographic vasospasms were analyzed at the internal carotid artery, M1 segments of the middle cerebral artery, and A2 segments of the anterior cerebral. In all the relationships among the subarachnoid hemorrhage grades, the Hounsfield numbers, and the operative approaches to the angiographic vasospasm grade, there was a tendency for the angiographic vasospasm grades to be lower with increasing age in both the internal carotid artery and the M1 segment of the middle cerebral artery. This tendency was more apparent in the larger vessels, that is, the internal carotid arteries. Close correlations of the angiographic vasospasm grades to the incidences of symptomatic vasospasm and to low-density area on computed tomography scan were found in both the M1 and A2 territories in the three groups. However, there were no significant differences among the three groups in the incidences of symptomatic vasospasm and low-density area on computed tomography scan. Regarding the surgical outcome, the older the patients, the higher were the mortality rates: 8% in group A, 11% in group B, and 25% in group C.(ABSTRACT TRUNCATED AT 250 WORDS)     

Regional cerebral blood flow in patients with ruptured intracranial aneurysms.

Eighty-five studies of regional cerebral blood flow (rCBF) were performed on 49 patients with ruptured intracranial aneurysms. The changes in rCBF were analyzed under various pathophysiological conditions, The degree of flow abnormalities correlated well with the clinical severity of neurological deficits. All of the patients with diffuse vasospasm of severe grade, to less than half of their control value, showed focal areas of decreased flow below 30 ml/100 gm/min, in addition to a reduction in mean CBF. The relief or disappearance of vasospasm in angiograms was followed by the increase of rCBF in the ischemic focus and mean CBF. Marked reduction in rCBF was found in patients with intracerebral hematoma and ventricular dilatation. Impaired CO2 response and autoregulation were found in patients with severe neurological deficits, a severe degree of vasospasm and marked depression of CBF. In this series direct operation was delayed in patients with impaired vascular reactivity as well as marked decrease of mean CBF below 30 ml/100 gm/min; good clinical results were obtained in thses patients.     

Clinical features and outcome in 1076 patients with ruptured intracranial saccular aneurysms: a prospective consecutive study

In a well-defined area, The Kingdom of Denmark, 1076 patients with ruptured intracranial aneurysms were admitted to the six Danish neurosurgical departments in a prospective consecutive study in the 5-year period 1978-1983. Follow-up examinations were accomplished 3 months and 2 years after the admission. A total of 674 women and 402 men with a median age of 49 years were included in the study. The localisation of the ruptured aneurysms were: internal carotid artery 285, anterior communicating artery and horizontal part of anterior cerebral artery 383, middle cerebral artery 291, basilar and vertebral arteries 83 and peripheral or other localisation 34. A significantly better outcome was seen in cases with internal carotid aneurysms compared to other localisations. 670 patients underwent operation. A highly significantly better outcome was found in operated versus non-operated patients in comparable clinical conditions. The advantage of microneurosurgery was well documented. Patients with vasospasm had a significantly worse outcome. Within the first 2 weeks a daily rebleeding rate from 0.2% to 2.1% was observed, and patients who rebled had a significantly worse outcome compared to patients, who did not rebleed. The overall outcome at 2-year follow-up was: normal 27.5%, mild dementia 15.8%, severe dementia 9.9%, vegetative 1.3% and mortality 45.5%.     

Prognosis with 500 ruptured and operated intracranial arterial aneurysms

Based on a series of 500 operated intracranial aneurysms in 486 patients, we have analyzed the results of current neurosurgical treatment. The overall results (75% cures, 13% poor results, 12% deaths) depend on several factors, which have all to be analyzed: the age and general condition of the patient; the topography and mode of rupture of the aneurysm; and the timing of the surgical intervention.     

Liliequist membranotomy for patients with ruptured intracranial aneurysms (author's transl)

In order to reconstruct the blocked CSF pathway, we attempted to excise the Liliequist membrane in 22 patients with subarachnoid hemorrhage resulted from ruptured intracranial aneurysms. After clipping the aneurysmal neck, the Liliequist membrane was reached through the space between the optic nerve and the internal carotid artery within the same operative field. As a result, the incidence of postoperative ventricular dilatation was remarkably reduced in comparison with control cases without Liliequist membranotomy. The necessity for the shunt operation for post-SAH hydrocephalus was also reduced. On the other hand, the incidence of postoperative subdural effusion increased in the group with Liliequist membranotomy. This suggests that the blockage of the arachnoid villi is probably the cause of disturbances in CSF absorption in some cases following subarachnoid hemorrhage. In such cases, the Liliequist membranotomy may be ineffective in restoring CSF circulation following subarachnoid hemorrhage.     

Surgical indications to maintain quality of life in elderly patients with ruptured intracranial aneurysms

OBJECTIVE: We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life. METHODS: Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade. RESULTS: Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index >or=60), and 9 (11.8%) had a poor outcome (Barthel Index <60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (<12 mm) and located at the internal carotid artery-posterior communicating artery junction. CONCLUSION: Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.     

Regional CBF, intraventricular pressure, and cerebral metabolism in patients with ruptured intracranial aneurysms

Regional cerebral blood flow (rCBF), cerebral metabolic rate of oxygen (CMRO2), intraventricular pressure, and lactate/pH levels in the cerebrospinal fluid (CSF) were measured in 38 patients with ruptured intracranial aneurysms between the 3rd and 13th day after subarachnoid hemorrhage (SAH). Angiography was performed following the rCBF study and the degree of vasospasm was measured on the angiograms. The patients were graded clinically according to the system of Hunt and Hess. Cerebral vasospasm significantly influenced rCBF: global reductions and focal changes (ischemia, hyperemia, and tissue peaks) were commonly associated with vasospasm. Patients with severe diffuse spasm always had global ischemia (21 +/- 5 ml/100 gm/min), and cerebral infarctions were demonstrated subsequently, The CMRO2 was more reduced than rCBF, indicating an uncoupling between flow and metabolism. This relative luxury perfusion was associated with CSF lactic acidosis and intracranial hypertension. The arteriovenous difference of oxygen was equally reduced in all categories of patients, probably due to the primary insult of SAH. The CMRO2 decreased concomitantly with arterial caliber, indicating a secondary impairment of cerebral metabolism due to vasospasm.     

External pneumatic calf compression reduces deep venous thrombosis in patients with ruptured intracranial aneurysms

We evaluated the ability of intermittent external pneumatic calf compression to prevent deep venous thrombosis after subarachnoid hemorrhage from ruptured intracranial aneurysms. Fifty-six subarachnoid hemorrhage patients not given external pneumatic calf compression were compared with 90 patients who had calf compression after their subarachnoid hemorrhages. Both groups of patients were on strict bedrest for 7 to 21 days after aneurysm rupture, and both received epsilon-aminocaproic acid, 30 to 36 g/day intravenously, until operation. The risk factors in the two groups were similar, and the nursing and medical care did not seem to differ. Of patients without external pneumatic compression, 18% had venographically proven deep venous thrombi, which contrasts with 6% of patients receiving calf compression. This was a significant difference (P less than 0.05; chi 2). These retrospective data suggest that external pneumatic calf compression helps to prevent deep venous thrombosis in patients with subarachnoid hemorrhage when delayed operation, bedrest, and antifibrinolytic agents are used.