Clinical differences between acute CVST and non-thrombotic CVSS

Background

Cerebral venous sinus thrombosis (CVST) is a rare stroke subtype, which has many overlapping symptoms with non-thrombotic cerebral venous sinus stenosis (CVSS) in the acute phase. Despite these similarities, their therapeutic regimens and outcomes are entirely different, and treatment delay is life-threatening. This study aims to address their clinical differences to help promote proper patient care.

Methods

34 cases of CVST and 34 cases of non-thrombotic CVSS diagnosed with digital subtraction angiography (DSA) in the acute phase (symptoms onset within 7 days) were consecutively enrolled in this prospective non-randomized and controlled study. Differences between CVST and CVSS in their clinical manifestation, plasma biomarkers, and MR or DSA imaging were compared.

Results

CVST and CVSS overlap in many ways, but differ in their respective medical histories and neurological deficits. However, 20.6% of CVST and 64.7% of CVSS occur without a definitive medical history, and 70.6% of CVST and 64.7% of CVSS occur without focal neurologic deficits. In the acute phase of CVST, d-dimer and fibrinogen are found to be abnormally elevated in 94.1% and 73.5% of cases, respectively. In the CVSS group, d-dimer and fibrinogen are only elevated in 17.6% and 5.9% of cases, respectively (binary logistic regressions test, all P < 0.001). In the CVST group, the predominant features in MRI/MRV and DSA imaging include local brain lesions, flow void signal loss, non-visualization, and a local filling defect sign at the involved sinus. Conversely, in the CVSS group, imaging revealed symmetrically small bilateral ventricles and the spread of cerebral edema in MRI/MRV. DSA imaging in the CVSS group revealed external compression and a narrow sinus with disproportionate venous engorgement. Despite these findings, positive imaging only appears in a minority of patients in the two groups during the acute phase ( Table 4).

Conclusions

DSA may be beneficial to diagnose CVST in ambiguous patients suspected to have either CVST or CVSS. Clinically useful biomarkers (d-dimer and fibrinogen) may predict CVST in the emergency room in the ambiguous patients with or without equivocal MRI/MRV imaging.     

Reversible cerebral vasoconstriction syndrome identification of prognostic factors

Object

: Reversible cerebral vasoconstriction syndrome (RCVS) is described as a clinical and radiological entity characterized by thunderclap headaches, a reversible segmental or multifocal vasoconstriction of cerebral arteries with or without focal neurological deficits or seizures. The purpose of this study is to determine risk factors of poor outcome in patients presented a RCVS.

Methods

A retrospective multi-center review of invasive and non-invasive neurovascular imaging between January 2006 and January 2011 has identified 10 patients with criterion of reversible segmental vasoconstriction syndrome. Demographics data, vascular risks and evolution of each of these patients were analyzed.

Results

Seven of the ten patients were females with a mean age of 46 years. In four patients, we did not found any causative factors. Two cases presented RCVS in post-partum period between their first and their third week after delivery. The other three cases were drug-induced RCVS, mainly vaso-active drugs. Cannabis was found as the causative factor in two patient, Sumatriptan identified in one patient while cyclosporine was the causative agent in also one patient. The mean duration of clinical follow-up was 10.2 months (range: 0–28 months). Two patients had neurological sequelae: one patient kept a dysphasia and the other had a homonymous lateral hemianopia. We could not find any significant difference of the evolution between secondary RCVS and idiopathic RCVS. The only two factors, which could be correlated to the clinical outcome were the neurological status at admission and the presence of intraparenchymal abnormalities (ischemic stroke, hematoma) in brain imaging.

Conclusions

Fulminant vasoconstriction resulting in progressive symptoms or death has been reported in exceptional frequency. Physicians had to remember that such evolution could happen and predict them by identifying all factors of poor prognosis (neurological status at admission, the presence of intraparenchymal abnormalities).     

Hemorrhage rates of external ventricular drain (EVD), intracranial pressure gauge (ICP) or combined EVD and ICP gauge placement within 48 h of endovascular coil embolization of cerebral aneurysms

Object

In single patients with a cerebral aneurysm an external ventricular drain (EVD), an intracranial pressure (ICP) gauge or a combined EVD and ICP gauge placement is necessary after coil embolization and initiation of postprocedural anticoagulation. The aim of this study was to examine the hemorrhage rates of drain placement within 48 h after aneurysm coiling and under anticoagulation or antiplatelet therapy.

Methods

We retrospectively analyzed hemorrhage rates of EVD, ICP gauge or combined EVD and ICP gauge placement in 27 patients within 48 h after coil embolization under different anticoagulation or antiplatelet schemes (heparin, acetylsalicylic acid, clopidogrel). In patients with continuous heparin via perfusor the application was stopped periprocedurally. The results were compared to literature.

Results

Four hemorrhages (14.8%) were observed. Three hemorrhages were petechial and one was by definition a larger hemorrhage with 8 mm × 10 mm in diameter.

Conclusions

EVD, ICP gauge or combined EVD and ICP gauge placements within 48 h after cerebral aneurysm coiling and under different anticoagulation or antiplatelet regimens seem to have no increased risk of hemorrhages compared to literature.     

Acute subarachnoid hemorrhage: An unusual clinical presentation of cerebral venous sinus thrombosis

Ruptured cerebral aneurysm is the most common cause of spontaneous subarachnoid hemorrhage (SAH). Rarely cerebral venous sinus thrombosis (CVST) may present initially as acute SAH, and clinically mimics aneurysmal bleed. We report 2 cases of CVST who presented with severe headache associated with neck pain and focal seizures. Non-contrast brain CT showed SAH, involving the sulci of the convexity of hemisphere (cSAH) without involving the basal cisterns. Both patients received treatment with anticoagulants and improved. Awareness of this unusual presentation of CVST is important for early diagnosis and treatment. The purpose of this paper is to emphasize the inclusion of vascular neuroimaging like MRI with venography or CT venography in the diagnostic workup of SAH, especially in a patient with strong clinical suspicion of CVST or in a patient where neuroimaging showed cSAH.Spontaneous subarachnoid hemorrhage (SAH) suggests the presence of a vascular lesion, most commonly ruptured cerebral aneurysm. It is rare for SAH to be associated with cerebral venous sinus thrombosis (CVST), and its location is usually different from the arterial aneurysms.1,2 The exact pathogenesis of SAH associated with CVST remains unknown; however, it is believed that it is probably induced by the rupture of dilated thin-walled cortical veins.1 Diagnosis of CVST associated with SAH usually depends on a high index of clinical suspicion combined with radiologic confirmation, so that appropriate treatment can be timely initiated. To date, 74 cases of CVST with radiological evidence of SAH, usually seen at the cerebral convexities, have been reported in the literature.3,4We are reporting 2 cases of superior sagittal sinus (SSS) thrombosis that presented initially with SAH. Our objective in presenting these cases is to highlight the fact that CVST may present early as SAH, and vascular neuroimaging should be considered in selected cases, especially those cases, in which cerebral aneurysm is not detected and there is still a clinical suspicious of CVST. We also have addressed the non-aneurysmal convexity SAH (cSAH) which is being increasingly recognized with characteristic radiological pattern of venous SAH, as opposed to aneurysmal SAH. The use of systemic anticoagulation as an initial therapy of CVST, even in the presence of SAH is also briefly discussed.     

Stereotactic brain biopsy: Single center retrospective analysis of complications

Objective

Stereotactic biopsy is a widely used surgical technique for the histological diagnosis of intracranial lesions. Potential risks of this procedure, such as hemorrhage, seizure, and infection have been established, and different risk factors have been characterized. However, these risks have been addressed by only few studies conducted in Asian countries.

Materials and methods

The study group is comprised of 299 consecutive stereotactic biopsy procedures by 11 neurosurgeons between 2004 and 2007. The pre-operative medical conditions, methods of biopsy and postoperative complications were analyzed.

Result

The overall diagnostic yield was 90.64%. Complications were observed in 7.36% of the cases, with symptomatic hemorrhages occurring in 4.35% of the cases, and the overall mortality rate in this study population was 1.34%. Patients with liver cirrhosis were at a higher risk of hemorrhage. Other clinical, radiological, or histological variables were not associated with an increased risk of complications.

Conclusion

Stereotactic brain biopsy is a safe and reliable way to obtain a histological diagnosis. Based on our recent clinical experiences, the data suggests that more attention should be paid to liver cirrhotic patients, since the chance on hemorrhage is significantly larger.     

Evaluation of cerebral arterial and venous system in tuberculous meningitis

Background

Central nervous system infection especially pyogenic results in cerebral venous sinus thrombosis. Tuberculous meningitis (TBM) although associated with infarctions but there is no comprehensive study evaluating the role of CVST contributing in infarction.

Epidemiological and clinical features of Moyamoya disease in Nanjing,China

Objective

The epidemiology of Moyamoya disease in mainland China has not been documented. Therefore, the present study was designed to examine the epidemiological and clinical features of Moyamoya disease in Nanjing, a provincial capital in China.

Methods

Patient records from multiple hospitals in Nanjing from January 2000 to December 2007 were collected. The clinical features of Moyamoya disease were retrospectively analyzed.

Results

A total of 202 patients were identified. There were 94 males and 108 females, with ages ranging from 2 to 78 years. There was a dual age peak, one in the group of patients 5–9 years of age and another in the group of patients 35–39 years of age. The initial symptoms included cerebral ischemia (81 patients, 40%), cerebral hemorrhage (113 patients, 55.9%) and asymptomatic disease (8 patients, 3.9%). An increasing incidence rate of Moyamoya disease was observed during the period of 2000–2007, with an average detection rate of 0.43 cases/100,000 persons/year (prevalence 3.92/100,000 persons). The incidence of ischemia associated with the disease was 0.16 cases/100,000 people-years and the incidence of hemorrhage was 0.22 cases/100,000 people-years.

Conclusion

This first study on the epidemiological and clinical features of Moyamoya disease in mainland China indicated an increasing incidence of Moyamoya disease with bimodal incidence distribution appearing more frequently in adults.     

Rate and clinical impact of intra-procedural complications during coil embolisation of ruptured small (3 mm or less) cerebral aneurysms

Objective

Coiling of small (≤3 mm) cerebral aneurysms can be technically challenging and is associated with increased procedural-related morbidity and mortality. The authors report the clinical and radiological results following coiling of ruptured small cerebral aneurysms in a single-institution, and define the rates of intra-procedural rupture and thromboembolism.

Methods

A retrospective analysis was conducted on consecutive patients from 01/01/2008 to 31/12/2010 with subarachnoid haemorrhage (SAH) from ruptured cerebral aneurysms (≤3 mm) managed in a tertiary neurosurgical institution in the United Kingdom.

Results

Of the 108 patients identified, 72 patients (66.7%) underwent coil embolisation. A favourable outcome, defined as a Glasgow outcome score of 4–5, was achieved in 63 (87.5%) of these patients. Intra-procedural complications were observed in 11.1% (±7.3% 95% CI) of cases, wherein the rate of intra-procedural rupture was determined to be 8.3% (±6.4% 95% CI) and intra-procedural thromboembolism to be 2.8% (±3.8% 95% CI).

Conclusion

Although coil embolisation of small ruptured cerebral aneurysms is technically feasible and an efficacious means of treatment, it is associated with an increased rate of intra-procedural complications. This should be taken into account when embarking upon treatment of patients with ruptured small cerebral aneurysms.     

New cerebral microbleeds in ischemic stroke patients on warfarin treatment: Two-year follow-up

Objective

Cerebral microbleeds (CMBs) are known to be indicative of bleeding-prone microangiopathy. Little is known about the significance of CMBs in anticoagulated patients. We determined the frequency of new CMBs in ischemic stroke patients who had been receiving warfarin treatment for 2 years.

Methods

A total of 204 ischemic stroke patients on warfarin therapy for 2 years underwent a repeat MRI. We compared demographic features, vascular risk factors, and radiological findings of patients with and without new CMBs.

Results

New CMBs on gradient-echo MRI were found in 29 of 204 patients (10%). Of 35 patients who had CMBs in the original study, 9 developed new CMBs after 2 years (26%), compared with 20 of the 169 patients (12%) who did not have CMBs at baseline (p = 0.03). Patients with new CMBs were older than patients without CMBs (p = 0.04), and the frequency of leukoaraiosis was significantly higher (p = 0.02). The mean duration of warfarin treatment was not significantly different between the patients with and without new CMBs (p = 0.28).

Conclusion

This longitudinal study suggested that the presence of CMBs at baseline increased the frequency of new CMBs in patients on warfarin therapy.     

Time-varying inter-hemispheric coherence during corpus callosotomy

Objective

Corpus callosotomy limits the bilateral synchrony of epileptic discharges. However, the instantaneous changes in bilateral synchrony during corpus callosotomy are unclear. The present study investigated how and when bilateral synchrony is suppressed in the anterior and then posterior steps of corpus callosotomy.

Methods

Intra-operative scalp electroencephalography (EEG) was recorded simultaneously with surgical video for six patients who underwent total corpus callosotomy for medically intractable drop attacks. The time-varying EEG inter-hemispheric coherence was quantified by wavelet transform coherence and trend analysis.

Results

The 4–13 Hz coherence decreased after corpus callosotomy in five patients. Significant decrease in coherence was observed only during the posterior step of callosal sectioning in three patients, but throughout both steps in two patients.

Conclusions

Decrease in inter-hemispheric coherence is not always correlated with the stages of callosal sectioning. Inter-hemispheric coherence is decreased during the final stage of corpus callosotomy and the effect is maximized after sectioning is completed.

Significance

Various patterns of coherence decrease suggest individual variations in the participation of the corpus callosum in the genesis of bilateral synchrony. Time-varying inter-hemispheric EEG coherence is useful to monitor the physiological completeness of corpus callosotomy.     

Cerebral venous thrombosis and myeloproliferative neoplasms: Results from two large databases

Introduction

Myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). Patients with MPNs are prone to develop arterial and venous thrombosis either at diagnosis or during follow-up; in particular splancnic vein is strongly associated with MPN. Conversely, presence of MPN is uncommon in patients with deep vein thrombosis of the lower extremities and with pulmonary embolism. Only few studies with conflicting results have evaluated the prevalence of an underlying MPN in patients with cerebral venous thrombosis (CVT), and limited evidence exists on the incidence of CVT in patients with established MPN.

Methods

We assessed the frequency of MPNs in a series of 706 patients with cerebral vein thrombosis (CVT) and the frequency of CVT in a cohort of 2,143 MPNs patients.

Results

Twenty-seven CVT patients (3.8%) were diagnosed with MPN: 9 before CVT (1.3%), 4 concomitantly (0.6%), and 14 after CVT (2.0%). Nine CVT cases (0.4%) were diagnosed in the MPN cohort, with a slightly higher frequency in PV (five of 735, 0.7%) than in ET (three of 964, 0.3%) and in PMF (one of 444, 0.2%).

Conclusion

Considering the analyses of these databases jointly, the results obtained suggest a weak association between CVT and MPNs and ultimately suggest that a thorough investigation looking for an underlying MPN may not be warranted in all the patients with CVT without overt myeloproliferative features.     

Cerebral microbleeds predict first-ever symptomatic cerebrovascular events

Objective

Cerebral microbleeds (CMB) on gradient-echo T2*-weighted magnetic resonance image (MRI) are frequently seen in patients with cerebral diseases. In this observational study we assessed whether CMB are a predictive factor for first-ever cerebrovascular events.

Patients and methods

This study consisted of 698 subjects without a history of symptomatic cerebrovascular events, who received gradient-echo T2*-weighted MRI for 3 months between November 2003 and January 2004 in Kishiwada City Hospital, Osaka, Japan. These subjects were then observed as outpatients for over 3.5 years.

Results

The prevalence of CMB at baseline was 17.0% (119/698) in this population, and the follow-up rate was 51%. A total of 36 first-ever symptomatic cerebrovascular events were observed during the 3 and a half-year follow-up period. First-ever symptomatic cerebrovascular events occurred significantly more frequently in subjects with CMB (15 cases) than those without CMB (21 cases) (p = 0.001). Even after adjusting for age, sex and hypertension, it was revealed that the presence of CMB was an independent predictor for the first-ever symptomatic cerebrovascular event by using the Cox proportional hazards model (hazard ratio, 2.87; 95% CI, 1.27–6.48; p = 0.01).

Conclusion

The presence of CMB is an independent predictor of first-ever symptomatic cerebrovascular diseases.     

Clinical characteristics of cerebral venous sinus thrombosis

Objectives:

To investigate the risk factors, clinical presentation, neuroimaging features, treatment, and prognosis of patients with cerebral venous sinus thrombosis (CVST).

Methods:

We retrospectively analyzed the data of 19 patients with a diagnosis of CVST admitted to Beijing Chao-Yang Hospital affiliated to Capital Medical University, Beijing, China between January 2010 and December 2013.

Results:

There were 9 men and 10 women (age range: 27-75 years). Headache (84.2%) and focal signs (57.9%) were the 2 most common symptoms. Direct evidence of thrombosis was found on CT in 42.1%, and on MRI in 52.6%. Two or more sinuses were involved in 78.9% of cases, in which the transverse sinus plus sigmoid sinus were the most commonly involved combination. All patients received anticoagulant therapy. Most patients (84.2%) had no neurological sequelae at discharge, and only 3 patients (15.8%) recovered with sequelae.

Conclusion:

Our study provides detailed information on the clinical manifestations, neuroimages, management, outcome, and risk factors of the patients with CVST.As an uncommon and frequently unrecognized type of stroke, cerebral venous sinus thrombosis (CVST) affects around 5 people per million annually, and accounts for less than 1% of all strokes.1,2 Cerebral venous sinus thrombosis usually presents with a wide spectrum of clinical manifestations and various models of onset, which is predisposed to overlook or delay its diagnosis. Previous studies have also indicated that the outcome of patients with CVST may vary from complete recovery to permanent neurological deficits in the natural course of the disease.3 Although CVST is a known entity, there remain difficulties in the diagnosis and management because the underlying risk factors are diverse and the standard treatment strategy is relatively lacking. The aim of the present study was to retrospectively analyze 19 cases with CVST and to provide clinical clues for its diagnosis and management.     

Risk factors and short-term outcome in patients with angiographically negative subarachnoid hemorrhage

Objectives

The objective of this study was to identify prognostic factors for clinical outcome in patients with non-traumatic, angiographically negative subarachnoid hemorrhage. Furthermore, the aim was to investigate if patients on anticoagulant therapy may have a more unfavorable outcome than patients not receiving anticoagulant therapy.

Materials and methods

This study contains a retrospective analysis of 95 patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage who were admitted to our institution in the period 2000–2011. The patients were classified according to risk factors, clinical presentation at admission, anticoagulant therapy at the time of hemorrhage and complications. The outcome was assessed with modified Rankin Score at discharge.

Results

Patients who were exposed to risk factors combined with a higher WFNS score at admission had an unfavorable outcome according to the modified Rankin Score at discharge. Unfavorable outcome was evaluated in relation to sex, anticoagulant therapy, hypertension, smoking and alcohol abuse. A strong correlation with anticoagulant therapy, smoking and alcohol abuse was found. None of the patients who developed vasospasms in this study were receiving anticoagulant therapy.

Conclusion

There is a correlation between antithrombotic state at admission and unfavorable outcome for patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage. The results from this study indicate that patients on anticoagulant therapy have a higher risk of developing complications after non-aneurysmal angiographically negative subarachnoid hemorrhage compared to patients who were not receiving anticoagulant therapy.     

Cerebral paragonimiasis: A retrospective analysis of 89 cases

Purpose

We reviewed the clinical and follow-up data of 89 cases with cerebral paragonimiasis and summarized the disease characteristics, diagnostic strategies and treatment experience, with an expectation of establishing standard diagnosis and treatment for cerebral paragonimiasis.

Methods

A total of 89 cases (age: 2–64 years) of cerebral paragonimiasis admitted and treated in our hospital in the past 10 years were included in this study. The clinical symptoms were manifested by headache, epilepsy, paralysis, etc. In order to confirm the diagnosis, we performed imaging examinations (e.g., CT and MRI) and laboratory tests (ELISA and eosinophil counting). Seventy-two patients received oral administration of praziquantel only, 16 cases received surgical resection of the lesions and 33 cases received appropriate anti-epileptic therapies. The diagnostic, treatment and follow-up data were statistically analyzed.

Results

Follow-up was performed for 73 cases for a period of 6–48 months and the original symptoms were markedly improved without recurrence. 15 patients were lost to follow-up after discharge. One patient died of epilepticus insult, high fever and convulsions. Although 4 patients still had seizures within 6 months of treatment, seizure frequency was significantly reduced. Histopathological evaluation demonstrated inflammatory changes with esoinophilic infiltration in all 16 patients who underwent surgical resection.

Conclusions

Young patients (age: <18 years) are more likely to have cerebral hemorrhage. SWI imaging contributes to the diagnosis of hemorrhagic lesions. Cerebral paragonimiasis can cause epilepsy, especially grand mal seizures.     

Interobserver variability in the detection of cerebral venous thrombosis using CT venography with matched mask bone elimination

Objectives

Computed tomography venography (CTV) has proven to be a reliable imaging method in the evaluation of cerebral venous thrombosis with good correlation to magnetic resonance (MR) imaging and digital subtraction angiography (DSA). It is fast and widely accessible, especially in the emergency setting. For better visualization of vascular structures bone is often removed from the images. The purpose of this study was to evaluate the quality of a fully automatic bone removal method, matched mask bone elimination (MMBE), and to assess the interobserver variability of the CTV technique.

Patients and methods

Fifty patients with clinical suspicion of cerebral venous thrombosis underwent multislice CTV with MMBE post-processing. Axial source images and maximum intensity projections were retrospectively evaluated by two neuroradiologists for quality of bone removal and for the presence or absence of thrombosis in nine dural sinuses and five deep cerebral veins. A per sinus/vein and a per patient analysis (thrombosis in at least one sinus or vein) was performed and interobserver agreement was assessed.

Results

Both observers considered bone removal good in all patients (100%). Interobserver agreement per patient was excellent (κ = 0.83), with a full agreement in 47 of 50 patients (94%). The interobserver agreement per sinus or vein was good (κ = 0.76), with a full agreement in 679 of 700 sinuses or veins (97%).

Conclusion

CTV aided with MMBE is a robust technique for visualization of the intracranial venous circulation, removing bone effectively. CTV has high interobserver agreement for presence or absence of cerebral venous thrombosis.     

Lack of association between cerebral microbleeds and low serum cholesterol in patients with acute intracerebral hemorrhage

Background

The association of cerebral microbleeds (CMBs) with intracerebral hemorrhage (ICH) is well known and its relationship with low serum cholesterol in ICH patients might be of interest.

Methods

A total of 105 patients with ICH were evaluated. In all subjects cholesterol levels were measured after 12 h of fasting and gradient-echo magnetic resonance imaging (GE-MRI) was performed for detecting CMBs.

Results

CMBs were more common among patients with hypertension and leukoaraiosis (p = 0.008 and p = 0.001). Patients with and without CMBs did not differ according to total cholesterol, LDL cholesterol, triglycerides and HDL cholesterol levels.

Conclusion

In this study, 61% of Turkish ICH patients had CMBs, which was not associated with lipid profiles. Leukoaraiosis was independently associated with CMBs.     

Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm

Objective

To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques.

Methods

Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients.

Results

CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p < 0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V significantly decreased when compared to patients with nCVS, asCVS, Fisher I–II and Hunt–Hess I–II (p < 0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V (p < 0.05).

Conclusion

The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.     

Diagnosis and surgical treatment of sporadic meningioangiomatosis

Objective

To discuss the clinical characteristics, radiological features, surgical treatment and prognosis of sporadic meningioangiomatosis (MA).

Methods

We retrospectively analyzed the medical records of ten histopathologically confirmed MA patients who were treated in the Department of Neurosurgery of Huashan hospital from 2002 to 2011. All of the patients presented with symptomatic seizure attacks before craniotomy surgeries. Magnetic resonance imaging (MRI) and/or computed tomography (CT) were the main radiological examination for preoperative diagnosis of all cases.

Results

All patients underwent craniotomy surgeries with gross total resections (GTRs) of the MA lesions. Postoperative follow-ups range from 8 to 108 months, in average 42.7 months, median 40.5 months. No radiological recurrence can be found in any case. Eight patients (80.0%) have achieved total symptomatic remission after surgeries (one of them underwent delayed remission), while two (20.0%) are still suffering from seizure attacks infrequently under several antiepileptic drugs (AEDs).

Conclusion

Although MA cases are quite rare and usually misdiagnosed presurgically, a correct preoperative diagnosis, at least a differential diagnosis, can be rationally achieved via a triad of patients’ ages, symptomatic seizure attacks and radiological features (both CT and MR). MA is curable and the prognosis is excellent since most patients became free of seizure and recurrence after surgical treatments.     

Fibrinolytic therapy versus craniotomy for anticoagulant-associated intracerebral hemorrhage

Object

Anticoagulant-associated intracerebral hemorrhages (AAICH) have a high morbidity and mortality, necessitating urgent treatment. We examined outcomes after conventional craniotomy and stereotactic fibrinolytic therapy in a series of patients with anticoagulant-associated hemorrhages.

Methods

Among 129 consecutive surgically treated patients with supratentorial intracerebral hemorrhage, 27 patients with AAICH were identified (mean age 62; range 36–79). Thirteen patients underwent craniotomy for surgical hematoma evacuation, and 14 patients hematoma puncture and catheter placement for clot lysis. The groups had comparable major prognostic factors such as hematoma volume, age, and Glasgow coma scale (GCS) score at admission.

Results

Nine patients died despite treatment (mortality = 33%). Mortality in the craniotomy group was comparable to that of the lysis group (46% versus 21%; p = 0.13). Good outcomes (Glasgow outcome score of 4 or 5) were seen in 3 craniotomy patients (23%) and 2 fibrinolysis patients (14%). Half the patients survived with major neurological deficits (GOS 2 or 3) (n = 13; 48%). One rebleed was observed two days after uneventful craniotomy and hematoma removal, while no patient who underwent fibrinolysis had rebleeding.

Conclusions

Approximately one-fifth of patients with AAICH managed surgically may have good outcomes. Mortality and favourable outcome rates are comparable between craniotomy and fibrinolytic therapy. Fibrinolytic therapy appears to be a reasonable less invasive alternative treatment modality for intracerebral hemorrhage in the anticoagulated patient.