Results of early surgical evacuation of packed intraventricular hemorrhage from aneurysm rupture in patients with poor-grade subarachnoid hemorrhage.

OBJECT: The goal of this study was to evaluate the results of early surgical evacuation of "packed" intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH). METHODS: The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view. CONCLUSIONS: Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.     

Intraventricular hemorrhage from ruptured aneurysm: clinical characteristics, complications, and outcomes in a large, prospective, multicenter study population

OBJECT: In this study the authors analyzed the relationship of intraventricular hemorrhage (IVH) to in-hospital complications and clinical outcome in a large population of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Data from 3539 patients with aneurysmal SAH were evaluated, and these data were obtained from four prospective, randomized, double-blind, placebo-controlled trials of tirilazad that had been conducted between 1991 and 1997. Clinical characteristics, in-hospital complications, and outcome at 3 months post-SAH (Glasgow Outcome Scale score) were analyzed with regard to the presence or absence of IVH. RESULTS: Patients with SAH and IVH differ in demographic and admission characteristics from those with SAH but without IVH and are more likely to suffer in-hospital complications and a worse outcome at 3 months post-SAH. CONCLUSIONS: The presence of IVH in patients with SAH has an important predictive value with regard to these aspects.     

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

OBJECT: This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms. METHODS: In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization. CONCLUSIONS: Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.     

Clinical features of the haemorrhage type moyamoya disease based on 31 cases

Summary We evaluated and analysed our own 31 cases of the haemorrhagic type of moyamoya disease to clarify the clinical features of this disease. The cases were divided into three groups. Group A consisted of 12 cases with aneurysms. Aneurysms on the circle of Willis were treated as ordinary saccular aneurysms. Group B consisted of 14 cases with intracerebral haemorrhage (ICH) without aneurysms. These were managed almost as spontaneous ICH. Group C consisted of 5 cases with intraventricular haemorrhage (IVH) without aneurysms or ICH. Twenty-two surgical procedures for aneurysms, ICH and IVH were done in 19 cases (62%). Nineteen procedures for preventing future strokes were undertaken in 11 cases (35%). The overall initial outcome was excellent in 12 cases (39%), good in 7 cases (23%), poor in 7 cases (23%), and death in 5 cases (15%). During the follow-up period (mean: 6.5 years), rebleeding occurred in two cases (8%), and ischaemic attacks in two cases (8%). The rate of rebleeding or ischaemic attacks was 1.19% per patient-year during the follow-up period. There was no ischaemic or rebleeding episode in cases treated by STA-MCA bypass with encephalomyosynagiosis (EMS) during the follow-up period. Management of the primary haemorrhage should be according to the clinical condition, type of haemorrhage, and source of haemorrhage. When the patient needs to undergo revascularization surgery to prevent future strokes, we recommend STA-MCA bypass with EMS instead of encephaloduro-arteriosynangiosis (EDAS).     

Early CT features of ruptured cerebral aneurysms of the posterior cranial fossa

This report describes our retrospective evaluation of CT features of the acute phase in 34 cases of ruptured cerebral aneurysms of the posterior cranial fossa. The results are as follows. 1. Examination of cisternal haematoma distribution revealed that SAH had extended to the supra- and infratentorial cisterns in 28 cases (82%). There were only 6 cases (18%) in which SAH was confined to the posterior cranial fossa only but even when there was subarachnoid haematoma in both the supra- and infratentorial cisterns, thick haematomas were seen at the periphery of the brain stem. In cases of vertebral artery-posterior inferior cerebellar artery aneurysms (VA-PICA AN), haematomas in the ambient cistern were thicker on the aneurysm side. In addition, in cases of basilar artery-bifurcation (BA-Bifurcation AN) and basilar artery-superior cerebelli artery aneurysms (BA-SCA AN), there were many thick, high-density haematomas in the interpeduncular cistern. 2. The rate of intracerebral haemorrhage was extremely low (1 patient). 3. The rate of intraventricular haemorrhage was high, and these haemorrhages demonstrated a reflux pattern. 4. The rate of hydrocephalus was high (76.5%) in comparison with that noted in association with SAH due to the rupture of anterior circulation aneurysms.     

Fibrinolytic treatment of intraventricular haemorrhage preceding surgical repair of ruptured aneurysms and arteriovenous malformations

Previous studies have indicated that intraventricular administration of tissue-type plasminogen activator (TPA) might improve the prognosis of patients with intraventricular haemorrhage (IVH). In aneurysmal IVH, fibrinolytic treatment was always preceded by surgical repair of the aneurysm, since the risk of recurrent haemorrhage from a non-occluded aneurysm was estimated to be high. We reviewed a series of patients with IVH secondary to ruptured aneurysms (n = 4) or arteriovenous malformation (AVM; n = 1) who underwent emergency intraventricular administration of TPA before repair of the bleeding source. Fibrinolysis resulted in rapid decrease of haematoma volume and of ventricular dilatation, and prevented ventricular catheters from becoming obstructed. No intracranial haemorrhages or other complications occurred. The results suggest that the presence of recently ruptured aneurysms or AVM is not necessarily a contraindication for intraventricular administration of TPA. The potentially life saving benefits might outweigh the inherent risks of recurrent haemorrhage in carefully selected patients with massive IVH, in whom ventricular distension, periventricular brain compression, obstruction of CSF flow, and elevated ICP appear to be major determinants for the outcome.     

Natural course of the arteriovenous malformations of the brain

Arteriovenous cerebral malformations represent congenital malformations. Considering the anatomical characteristics of the cerebral angiomas and their localization, in a great number of cases they demand a combined therapeutic approach--surgery, embolization and radiotherapy. Besides the constant progress of technology, 5% of all cerebral angiomas can not be completely excluded from the circulation. Therefore, the need to understand their natural course became a necessity. Our results point to the fact that they are vascular malformations of a considerably more benign clinical course than the aneurysms. Our clinical model points to an annual risk of hemorrhage which is 3.3% with total mortality of 5.3%, especially if the size of the angioma is 2.5-5 cm, localized in the motor zone of the brain, with combined type of vein drainage and arterial supply from the vertebrobasilary confluence. Epilepsy caused by the cerebral angioma is in 26.7% refractory to medicamentous therapy and in 25% (every 4th patient) will have hemorrhage with an annual risk of 0.14%.     

Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm.

This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months, and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic scans performed within 72 h of hemorrhage were analyzed to determine the severity of intraventricular and subarachnoid hemorrhage and the volume of intracerebral hematomas. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Intraventricular hemorrhage extension occurred in 109 of the 219 patients studied. Fourteen-day mortality increased from 7.3% in patients without IVH to 14.1% in those with moderate IVH (IVH score 1-6) and to 41.7% in those with more severe IVH (IVH score > 6). The corresponding figures for unfavorable outcome at 6 months are 19.8%, 30.5%, and 66.7%, respectively. According to logistic regression analyses, the severity of IVH was an independent predictor of mortality and functional outcome. The clinical outcome after aneurysm rupture is at least in part determined by the severity of IVH. Knowledge of the effect of IVH may help guide physicians in the care of patients with aneurysmal bleeding.     

A case of cavernous angioma at the septum pellucidum

A 35-year-old female presented with a cavernous angioma of the septum pellucidum manifesting as headache and nausea. Computed tomography and magnetic resonance imaging revealed a mass at the septum pellucidum with intraventricular hemorrhage and mild hydrocephalus. Digital subtraction angiography showed no abnormal finding and thallium-201 single photon emission computed tomography showed no uptake in the lesion. The preoperative diagnosis was intraventricular tumor, such as subependymoma. The lesion was completely resected through the transcallosal approach. The histological diagnosis was cavernous angioma. Cavernous angiomas are usually located in the cerebral parenchyma and rarely occur in the cerebral ventricles. In particular, cavernous angioma at the septum pellucidum is very rare. If magnetic resonance imaging does not clearly show the typical peripheral hypointense rim, neuroimaging diagnosis will be difficult. Surgical resection should be considered to confirm the histopathology, in particular if bleeding and hydrocephalus are present.     

Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms

OBJECT: Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH. METHODS: Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases. CONCLUSIONS: This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.     

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND: Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients. METHODS: Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score). RESULTS: The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome. CONCLUSIONS: In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.     

Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm

This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months, and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic scans performed within 72 h of hemorrhage were analyzed to determine the severity of intraventricular and subarachnoid hemorrhage and the volume of intracerebral hematomas. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Intraventricular hemorrhage extension occurred in 109 of the 219 patients studied. Fourteen-day mortality increased from 7.3% in patients without IVH to 14.1% in those with moderate IVH (IVH score 1–6) and to 41.7% in those with more severe IVH (IVH score >6). The corresponding figures for unfavorable outcome at 6 months are 19.8%, 30.5%, and 66.7%, respectively. According to logistic regression analyses, the severity of IVH was an independent predictor of mortality and functional outcome. The clinical outcome after aneurysm rupture is at least in part determined by the severity of IVH. Knowledge of the effect of IVH may help guide physicians in the care of patients with aneurysmal bleeding. Electronic Publication     

Intraventricular hemorrhage in a term neonate secondary to a third ventricular AVM. Case report

An initially healthy infant born of an uncomplicated full-term gestation was brought for evaluation of the acute onset of vomiting, irritability, lethargy, and opisthotonus at 14 days of age. Computerized tomography demonstrated an intraventricular hemorrhage. Arteriography defined an angioma on the roof of the third ventricle which was successfully removed via the transcallosal interfornicial approach on the 34th day of life. Other than an easily controlled seizure disorder, the postoperative course was uneventful. At 8 months of age the child is developing normally. Arteriovenous malformations should be considered in the differential diagnosis of intraventricular hemorrhage in full-term neonates without predisposing trauma or bleeding diathesis. High-speed digital subtraction arteriography may be used to screen for this diagnosis. The transcallosal interfornicial exposure offers a satisfactory approach for excising third ventricular angiomas in young infants.     

动脉瘤性蛛网膜下腔出血的早期诊断及治疗

目的探讨动脉瘤性蛛网膜下腔出血（SAH）的早期诊断方法及治疗原则,并客观评价其治疗效果。方法对SAH患者采用影像学检查,结合病史、临床表现进行早期病因诊断;并对96例动脉瘤早期采用电解可脱性弹簧圈进行囊内栓塞;术后早期对症治疗。结果96个动脉瘤均被早期诊断并成功栓塞,其中100％闭塞者83个,95％闭塞者8个,90％闭塞者5个。术中并发动脉瘤破裂3例;并发脑血管痉挛5例;术后1例弹簧圈末端逸出;3例复发者均经二次补充电解可脱性弹圈（GDC）栓塞治愈。全组出现与栓塞技术相关的并发症9例;与SAH有关的永久性后遗症13例（13．5％）。Glasgow预后评分：Ⅰ级77例、Ⅱ级7例、Ⅲ级6例、Ⅳ级3例、Ⅴ级3例,死亡率3．1％。结论对破裂的动脉瘤性SAH进行早期病因学诊断,并采用电解可脱性弹簧圈进行动脉瘤囊内栓塞,术后积极对症治疗是提高动脉瘤性SAH治愈率和降低死亡率、致残率的重要方法。     

Management strategies for unruptured cerebral aneurysms]

We discussed management strategies for unruptured aneurysms by an analysis of 62 treated and 48 untreated cases. The treated cases were divided into the following two groups; Group A consisted of 38 patients with 46 aneurysms treated during our initial 13 years (7 males, 31 females, 54 +/- 9 years old), and Group B of 24 patients with 32 aneurysms (8 males, females 16, 57 +/- 9 years old) during the last 3 years. In Group A, 36 patients were treated with neck clipping, except for two patients, who had giant aneurysms treated with internal carotid ligation and bypass surgery. All the patients in Group B were treated with either clipping or endovascular coil embolization. Our indications for coil embolization include patients with aneurysms located in paraclinoid internal carotid or basilar arteries, or with multiple aneurysms requiring more than one operation, or with a systemic risky disease for general anesthesia. In group A, 2.6% of cases resulted in death during operation and 10.3% of cases resulted in morbidity, while in group B, there was neither mortality nor morbidity caused by clipping, except for a patient with mild hemiparesis who had been treated with clipping for SAH caused by a procedure of coil embolization. The 50 aneurysms of 48 untreated patients have been observed without any neurosurgical treatment during periods of 6 months to 10 years with a mean of 2 years 7 months. Eventually, four aneurysms resulted in SAH, which cases were treated with emergency clipping or coil embolization. The high rupture rate (3.1% per year) in the natural history may suggest that some aneurysms are more likely to rupture than generally considered. We also reviewed operative findings of all entry clipping cases; more than 80 percent of aneurysms, including those measuring less than 5 mm in diameter, had red colored, thin wall domes with or without bleb. Our conclusion is that surgical indications are for a complementary use of clipping and coil embolization.     

Influence of aneurysm location on the development of chronic hydrocephalus following SAH

Summary The incidence of chronic hydrocephalus was analysed in a series of 204 patients with aneurysmal subarachnoid haemorrhage (SAH). Its development was significantly related to the quantity of subarachnoid blood, but even more to the location of the haemorrhage and to the aneurysm site. Hydrocephalus was more frequent in patients under poor initial condition. Whereas intracerebral haemorrhage did not increase the risk of chronic cerebrospinal fluid (CSF) resorption disturbances, patients with intraventricular haemorrhage or voluminous haemorrhage in the basal cisterns have a significantly higher risk of such a complication. In this series 30 (15%) patients developed chronic hydrocephalus and required shunting. Surprisingly, in our series a shunt wasnever needed in patients with aneurysms of the middle cerebral artery (MCA). SAH from an aneurysm of the internal carotid artery (ICA) also never caused a shunt-dependent hydrocephalus except in cases with accompanying intraventricular haemorrhage. The percentage of chronic hydrocephalus was relatively high (19%) in patients with anterior communicating artery (ACoA) aneurysms but definitely highest in patients with an aneurysm of the vertebrobasilar (VB) system (53%).     

Subarachnoid hemorrhage caused by a dissecting aneurysm of the internal carotid artery

OBJECT: Subarachnoid hemorrhage (SAH) caused by the rupture of a dissecting aneurysm of the internal carotid artery (ICA) has been considered rare. Based on data from cooperatively collected cases, the clinical features of patients with dissecting aneurysms of the ICA who presented with SAH were examined. METHODS: Data from 18 patients with dissecting aneurysms of the ICA who presented with SAH diagnosed on the basis of clinical signs, neuroradiological findings, and intraoperative findings from 41 institutions were collected during a 5-year period between 1995 and 1999. The authors found that 0.3% of all cases of SAH and 3.1% of cases of SAH of unverified cause were attributable to a dissecting aneurysm of the ICA. Eleven patients (61%) were middle-aged women, and eight patients (44%) had hypertension. Rebleeding before admission was demonstrated in 13 patients (72%), and intraoperative bleeding was exhibited in half of the patients who underwent surgery during the acute stage. Postoperative growth of an aneurysm bulge or recurrent SAH was seen in five of 10 patients who had undergone wrapping or clipping of the aneurysm bulge in the acute phase. Trapping with or without bypass, which resulted in no postoperative recurrence, was performed in three patients in the acute stage and in two patients in the chronic stage. Twelve patients (67%) had a poor prognosis, primarily attributed to intraoperative bleeding and postoperative recurrence. CONCLUSIONS: Generally, dissecting aneurysms of the ICA are not thought of as frequent causes of SAH. Nonetheless. the presence of these aneurysms should be considered when dealing with SAH because they have a susceptibility to bleeding that can lead to a poor prognosis. Careful surgical planning is necessary to decrease intraoperative bleeding and to avoid postoperative recurrence.     

Computed tomography in the diagnosis of hemorrhage secondary to intracranial aneurysm. (author's transl)

In 168 patients with ruptured intracranial aneurysms, the pathology of intracranial hemorrhage visualized on CT was analyzed. Blood in the subarachnoid space could be visualized in 95% of cases within three days after SAH and 75% of 106 cases within two weeks after SAH. In one case blood clot in the subarachnoid space visible up to 13 days after SAH. Concerning the cases within two weeks after the bleeding, intracerebral hematomas were observed in 36% of anterior cerebral aneurysms and middle cerebral aneurysms, 16% of internal carotid aneurysms and none of vetebro-basilar aneurysms. The incidence of the intraventricular hemorrhage was as follows; vertebro-basilar, 44%; anterior cerebral, 38%; internal carotid, 28%; middle cerebral, 12%. On the basis of the pattern of distribution of extravasated blood the location of the ruptured aneurysm was properly predicted in 58% of anterior cerebral, 81% of middle cerebral, 58% of internal carotid and 30% of vertebro-basilar. Especially CT could contribute to predict which aneurysm has ruptured in patients with multiple aneurysms. It was possible to localize the site of bleeding in 11 out of 12 CT positive cases. The development of intracranial hemorrhage demonstrated by CT well correlated with the clinical grading of the patients and the clinical outcome. Patients merely showing subarachnoid hemorrhage were more likely to have good neurological grades, but ones showing complicated intracerebral hematomas and intraventricular hemorrhage had poor neurological grades at the time of the scan. The findings of extensive subarachnoid clot, which were followed by severe vasospasm, and marked intraventricular hemorrhage, usually correlated with poor prognosis. These pathology recognizable on CT was very helpful in determination of the timing of surgery and management of such patients. In conclusion CT is of great value in the examination of SAH when performed in the acute stage and should be the initial examination followed by angiography.     

Pitfalls in the preoperative evaluation of subarachnoid hemorrhage without digital subtraction angiography: report on 2 cases

BACKGROUND: Digital subtraction angiography has been used in the diagnosis of aneurysmal SAH and as a preoperative imaging method. However, new methods such as MRA and CTA are now deemed by many institutions to provide sufficient information to allow surgery to go ahead without a preliminary DSA scan. We report on 2 cases of SAH in which there were additional lesions that were difficult to evaluate because of the lack of DSA information. CASE DESCRIPTIONS: The fist patient demonstrated SAH with IVH. Computed tomographic angiography revealed an ACoA aneurysm with a bleb. We first thought that the SAH and IVH were both caused by a ruptured ACoA aneurysm but noted that hemorrhage pattern was inconsistent with the location and orientation of the aneurysm. A DSA scan revealed a dural arteriovenous fistula in the region of the craniocervical junction, supplied by the right occipital artery. We surmised that the SAH and IVH were caused by a large varix of DAVF and that the ACoA aneurysm would be unruptured. The second patient presented with a 1-week history of headaches and nausea and was diagnosed to have an SAH caused by a ruptured MCA aneurysm. We suspected vasospasm in the second portion of the MCA on CTA, but could not precisely evaluate the affected lesions. A diffusion-weighted MRI scan 4 days after surgery revealed a high-intensity area in the region of the right MCA. The MCA had already seemed to be affected at admission because vasospasm rarely develops within 4 days of the onset of SAH. CONCLUSIONS: As long as the CTA scan is of adequate quality and shows the aneurysm clearly, we consider that an additional DSA provides little useful information for surgery. However, in such cases, the information from a DSA scan is needed for the evaluation of secondary factors that are not directly associated with the aneurysm.     

Intracranial Haemorrhage Within the First two Years of Life

Summary. Summary. Background: Spontaneous intracranial haemorrhage is not common in infants, with differences from adults in both aetiology and severity. The infantile CNS is more vulnerable because of incomplete hydrovenous maturation. We analyzed infantile intracranial haemorrhage mainly caused by structural brain lesions and discuss specific aetiologies with regard to haemodynamic characteristics. Subjects and Methods: We reviewed 20 infants less than 2 years of age from a total of 328 neonates and infants with intracranial vascular lesions seen in our institution since 1985. Associated or causative lesions were arteriovenous malformation (AVM) in 6, dural sinus malformation (DSM) in 4, arteriovenous fistula (AVF) in 3, aneurysm in 2, developmental venous anomaly (DVA) in 1, vein of Galen malformation (VGAM) in 1, and others in 3. The locations of haematomas were intracerebral (ICH) in 8, combined ICH and intraventricular haemorrhage (IVH) in 5, IVH alone in 5, subarachnoid haemorrhage (SAH) in 1, and combined SDH and ICH in 1. Findings: Three patterns of haemorrhage were noted in high-flow vascular lesions such as AVM or AVF (n=9); haemorrhage at the site of nidus or fistula corresponding to nidal pseudoaneurysm in 4, regional venous hypertension with pial venous reflux in 3, global venous infarction causing multifocal haemorrhage in distant brain areas in 2. Aneurysmal bleeds were caused by dissecting aneurysms at the level of dural penetration of cranial vessels. One infant had haemorrhage near a DVA without evidence of cavernous malformation suggesting the possibility of venous ischaemia. IVH was associated with shunt operations in 4 infants with DSM, and SDH followed by ICH in a infant with VGAM. Interpretation: Spontaneous intracranial haemorrhage in infants and neonates is rare; it is associated with specific lesions which show some differences from their adult counterparts. The vein-related causes of hemorrhage are largely the pathophysiologic characteristics in this age group. Absence of hemorrhage in VGAM is remarkable in addition to occurrence of most hemorrhages after shunting.