Surgical considerations in cerebral amyloid angiopathy

In cerebral amyloid angiopathy, the contractile elements of the leptomeningeal and cortical arteries are replaced by noncontractile amyloid beta protein. The incidence of amyloid angiopathy increases with advancing age. It is associated with Alzheimer's disease and spontaneous cerebral hemorrhage. The latter can have the characteristic acute computed tomographic appearance of a hematoma at the cortex-white matter junction with extension of blood into the subarachnoid, subdural, and intraventricular spaces. Multiple hemorrhages are frequent. Additional bleeding can occur after evacuation of the hematoma, and postoperative hemorrhage can occur after cortical biopsy. To elucidate the role of surgery in this condition, we have reviewed 20 consecutive operated cases of cerebral amyloid angiopathy. A first group of 8 patients with senila dementia underwent cortical biopsy without resultant hemorrhage. A second group of 6 patients in good clinical condition had delayed evacuation of a spontaneous cerebral hematoma from cerebral amyloid angiopathy because of the radiological misdiagnosis of a hemorrhage within a tumor. One patient died of a pulmonary embolism, and another had subsequent multiple hemorrhages that were ultimately fatal. A third group of 6 patients in poor neurological condition had the acute evacuation of a spontaneous cerebral hematoma to relieve intracranial hypertension. All died or were severely disabled. One had repeated hemorrhages which added a progressively more severe organic dementia onto an initial hemiplegia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thrombolysis during cardiopulmonary resuscitation

Between 40 and 90 cardiopulmonary resuscitations are performed per 100,000 inhabitants each year in western industrialised nations. In 50-70% of these patients, either fulminant pulmonary embolism or acute myocardial infarction is the underlying cause of cardiac arrest. Based on this fact, thrombolysis may represent a new and effective causal therapeutic strategy in patients suffering from cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. In the past, thrombolysis was contraindicated during cardiopulmonary resuscitation due to great fears of severe bleeding complications (resuscitation-mediated or lysis-induced intracerebral bleeding). For a long time, only clinical case reports or small clinical case series were reported in the literature, however, recently, the first clinical studies focusing on the safety and efficacy of thrombolytic therapy during out-of-hospital cardiopulmonary resuscitation have been published. Besides a specific therapeutic causal effect on pulmonary artery emboli and coronary artery thrombosis, experimental data strongly indicate that thrombolysis might also have an impact on cerebral microcirculatory reperfusion during and after cardiopulmonary resuscitation. This effect might be responsible for the exceptionally good neurological outcome observed in patients treated with thrombolytic agents during cardiopulmonary resuscitation and might be a result of the proven imbalance of the endogenous coagulation system in patients suffering from cardiac arrest. This coagulation imbalance is thought to be responsible for postresuscitation cerebral microcirculatory reperfusion disorders in patients after cardiac arrest and cardiopulmonary resuscitation. In summary, recent clinical and experimental data focusing on thrombolysis during cardiopulmonary resuscitation strongly indicate, that thrombolysis may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms.     

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.     

Lobar intracerebral hemorrhage. A clinical, radiographic, and pathological study of 29 consecutive operated cases with negative angiography.

The authors operated consecutively on 50 patients with lobar intracerebral hemorrhage during a prospectively designed study period from January, 1986, to March, 1990. They investigated the correlations between the underlying causes and the clinicoradiographic features in 29 patients who showed no angiographic vascular abnormalities, in order to elucidate the operative indication for such cases. Patients with ruptured saccular aneurysm or trauma were not included in this study. There were 15 males and 14 females, ranging in age from 7 to 76 years (mean 52.4 years). Histological diagnoses of the surgical specimens were as follows: vascular malformation in nine cases (arteriovenous malformation (AVM) in six and cavernous malformation in three), microaneurysm in 11, cerebral amyloid angiopathy in six, and brain tumor in two; in the remaining case the cause was not verified histologically. The underlying cause was determined in 96.5% of cases. The mean patient age was lowest in the cavernous malformation group (27.0 years), followed by the AVM (45.8 years), microaneurysm (59.8 years), and cerebral amyloid angiopathy (70.0 years) groups. Four patients with vascular malformation (three AVM's and one cavernous malformation) had previous episodes of bleeding at the same site, whereas none of those with microaneurysms or cerebral amyloid angiopathy had such episodes. On computerized tomography (CT) scans, the round to oval hematoma was related to the presence of an AVM or cavernous malformation in contrast to microaneurysms and cerebral amyloid angiopathy. Upon infusion of contrast material, variable enhancement was seen in five (two AVM's and three cavernous malformations) of the nine vascular malformations while no enhancement was noted in any patient with microaneurysm or cerebral amyloid angiopathy at the acute stage. Subarachnoid extension of the hematoma was associated with cerebral amyloid angiopathy significantly more frequently than with AVM's (p less than 0.05) and microaneurysms (p less than 0.01). The results suggest that clinicoradiographic pictures in cases with negative angiography are quite different among the three major pathological categories; namely, vascular malformation (AVM and cavernous malformation), microaneurysm, and cerebral amyloid angiopathy. It is suggested that the underlying etiology of a given lobar intracerebral hemorrhage with negative angiography may be predicted by a combination of patient age, history of previous bleeding at the same site, hematoma shape, and subarachnoid extension of the hematoma on CT scans. Based upon these findings, the authors discuss operative indications for such cases.     

腹部手术对老年心脑血管病患者的影响

目的探讨老年患者腹部手术后心脑血管意外的发病特点及防治体会。 方法回顾性分析2011年1月至2013年12月本科室诊治的64例腹腔手术后发生心脑血管意外的老年患者临床资料,其中32例伴有心脑血管疾病为A组,同期无心脑血管疾病的32例行腹腔手术的患者为B组,探讨其发病的原因及防治方法。 结果A组术后11例发生了脑梗死,其中6例为脑栓塞,4例发生脑出血,心肌梗死6例,心电图有心肌缺血5例,ST段改变9例,急性心力衰竭2例,心律失常5例; B组术后3例发生了脑梗死,其中1例为脑栓塞,1例发生脑出血,心肌梗死1例,心电图有心肌缺血2例,ST段改变2例,心律失常1例。A组术后心脑血管疾病的发生率明显高于B组,组间差异有统计学意义(P < 0.05)。 结论患有腔隙性脑梗死、陈旧性脑梗死、心肌梗死、心肌缺血、ST段改变等心脑血管疾病的患者手术风险高,易出现猝死及心脑血管意外,必须引起临床医师的注意和重视。     

Thrombolytic therapy during cardiopulmonary resuscitation

Recently, efforts have been undertaken to investigate the effects of thrombolysis during cardiopulmonary resuscitation (CRP) in patients suffering from massive pulmonary embolism or acute myocardial infarction. In up to 70% of patients with cardiac arrest, one of these two diseases is the underlying cause of deterioration. Nevertheless, thrombolysis has not been conducted during CPR because of the fear of severe bleeding complications. However, an increasing number of clinical studies suggest that thrombolytic therapy during CPR can contribute to haemodynamic stabilisation and survival in patients with massive pulmonary embolism and acute myocardial infarction, when conventional CPR procedures have been performed unsuccessfully. Apart from the specific causal action of thrombolytic agents at the site of pulmonary emboli and coronary thrombosis, experimental data indicate that thrombolysis during CPR can improve microcirculatory reperfusion, which may be most important in the brain. In accordance with these data, marked activation of blood coagulation without adequate activation of endogenous fibrinolysis has been demonstrated early after cardiac arrest. In summary, thrombolysis during CPR is presently a treatment strategy that can be performed on an individual basis in patients with pulmonary embolism or acute myocardial infarction. It may become a routine measure if positive results of randomised, controlled clinical trials will be available in the future.     

Lyse zur Reanimation?

Thrombolysis represents a causal and effective therapy in patients suffering from pulmonary embolism or acute myocardial infarction. In 50–70% of patients with cardiac arrest, one of these two diseases is the underlying cause of deterioration. Nevertheless, thrombolysis during cardiopulmonary resuscitation (CPR) has been contraindicated in the past because of the fear of bleeding complications. Increasing data now suggest that thrombolysis during CPR can contribute to stabilization and survival in patients. Besides the specific causal action of thrombolytic agents at the site of pulmonary emboli and coronary thrombosis, experimental data indicate that thrombolysis during CPR can improve microcirculatory reperfusion, most important in the brain. Furthermore, marked activation of blood coagulation without adaequate activation of endogenous fibrinolysis has been demonstrated early after cardiac arrest. In conclusion, thrombolysis during CPR is presently a treatment strategy that can be performed on an individual basis in patients with pulmonary embolism or acute myocardial infarction. It may become a routine measure if positive results of randomized, controlled clinical trials will be available in the future.     

A restricted subarachnoid hemorrhage in the cortical sulcus in cerebral amyloid angiopathy: could it be a warning sign?

BACKGROUND: Cerebral amyloid angiopathy is a well-known disease that is predominantly recognized in elderly people and repeatedly causes large subcortical hemorrhages. These hemorrhages may be derived from vessel wall weakness because of Abeta depositions in the wall of the cortical and leptomeningeal arteries. Although vessel ruptures in CAA have been thought to occur in cortical arteries, it was recently demonstrated that the primary hemorrhage occurs in the subarachnoid space, particularly the cerebral sulci, as a result of multiple ruptures of meningeal arteries in some cases of subcortical hematoma caused by CAA. CASE DESCRIPTION: Case patient 1 was a 74-year-old woman who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Thirty-three days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontal lobe on CT. The hematoma was removed, and the patient was pathologically diagnosed with amyloid angiopathy. Case patient 2 was a 73-year-old man who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Twenty days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontoparietal area on CT. Hematoma removal was performed on both patients, and they were diagnosed pathologically with amyloid angiopathy. CONCLUSIONS: We report on the cases of 2 patients with CAA who presented with epileptic seizure and were found to have a restricted subarachnoid hematoma in the cerebral sulcus on MRI before their subcortical hemorrhages occurred. Both cases were diagnosed pathologically. This demonstrated that vessel ruptures in CAA can occur in the subarachnoid space, particularly the cerebral sulci, as a result of ruptures of meningeal arteries. A restricted SAH on CT/MRI could be a warning sign of a huge subcortical hemorrhage in CAA.     

Recurrence and extension of lobar hemorrhage related to cerebral amyloid angiopathy: multivariate analysis of clinical risk factors

BACKGROUND: Many recent studies have analyzed clinical risk factors for the recurrence and extension of intracerebral hemorrhage. However, they have not been investigated in patients with lobar hemorrhage related to cerebral amyloid angiopathy (CAA). METHODS: We studied 40 surgically treated patients with lobar hemorrhage diagnosed histologically as being related to CAA. To determine clinical factors influencing the recurrence and hematoma size their clinical data (demographics, medical history, and radiographic and laboratory data) were examined retrospectively and subjected to multivariate analysis. RESULTS: Twelve patients (30%) had recurrent lobar hemorrhage. Twenty-one patients had a small hematoma and 19 had a large hematoma. Hypertension was the only significant clinical factor influencing the recurrence of CAA-related lobar hemorrhage. There was no significant clinical factor influencing the hematoma size of CAA-related lobar hemorrhage. CONCLUSIONS: The history of hypertension is associated with an increase in the recurrence of CAA-related lobar hemorrhage.     

Anesthetic care of a patient with an intracranial hemorrhage after thrombolytic therapy

Thrombolytic therapy is being used with increasing frequency to treat acute myocardial infarction (MI). It is important for both the general and cardiac anesthesiologist to understand the effects of thrombolysis on hemostasis and myocardial function, since these patients can present for emergent surgery in the cardiac or general operating theater. The authors report a case of a patient who developed an intracranial hemorrhage following thrombolytic therapy that required emergency surgical intervention.     

Multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head trauma

Cerebral amyloid angiopathy (CAA) is an important cause of intracerebral hemorrhage and ischemic cerebrovascular disease in some normotensive elderly patients. The diagnosis is made by proof of amyloid deposition in the vessel wall. A case of recurrent and multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head injury is reported. A 74-year-old female was referred to our hospital because of head injury. CT scan showed traumatic subarachnoid hemorrhage and intraventricular hematoma. Her consciousness was clear but slight disorientation was recognized. Conservative therapy was performed. During the course subcortical hemorrhages occurred five times and during the second one, right frontal and right parietal hemorrhages occurred simultaneously. Her consciousness deteriorated. The second subcortical hemorrhage was especially complicated by a ventriculoperitoneal shunt operation. A biopsy of the cortex was performed and pathological examination revealed amyloid deposition in the walls of small pial and cortical vessels. Occasional duplicated wall, obliterative intimal proliferation and disappearance of elastic lamina were recognized. The patient sank into a vegetative state due to recurrent and multiple hemorrhages. CAA results in two possibilities, hemorrhage and ischemic cerebrovascular disease. When lobar or subcortical hemorrhage is encountered in a normotensive elderly patient, the possibility of a CAA-related hemorrhage should be considered. The author carefully emphasizes that there is indication for neurosurgical treatment in CAA patients and proposes that therapy for ischemic cerebrovascular disease should be given special attention.     

Intracerebral hemorrhage due to cerebral amyloid angiopathy. Case report

The case is presented of a 59-year-old man with cerebral amyloid angiopathy and three consecutive hemorrhages in the occipital lobes. The clinicopathological features and the relationship to Alzheimer's dementia are discussed. The correct treatment of intracerebral hemorrhage related to cerebral amyloid angiopathy is a matter of controversy.     

围术期心肌梗塞的诊疗进展

迄今越来越多的存在心脏高危疾病的患者进行各种手术治疗．由此产生的围术期心肌梗塞（PMI）日益受到关注。依据导致PMI的病理生理机制可以将PMI分为两种类型;1型为围术期出现急性冠脉综合征．2型则是由于在稳定的冠脉病变的基础上（在围手术期间）出现过长时间供氧与耗氧的不平衡而发生的。在围术期对心肌缺血细致严密的监护、在保证血压的基础上严格的控制心率,降低心输出置及预防心脏失代偿的发生,对PMI的预防具有积极的意义。而冠脉血管的外科干预治疗并不是推荐的预防PMI的治疗手段,常规的抗血栓治疗可能加重围术期出血。     

Acute subdural hematoma after intra-arterial thrombolysis for acute ischemic stroke--case report

A 79-year-old man with a cardiac pacemaker for bradycardia fell down and presented with sudden onset of right hemiplegia and aphasia. Initial computed tomography (CT) showed no cerebral infarction but angiography revealed occlusion of the left middle cerebral artery (MCA). Local intra-arterial thrombolysis with tissue plasminogen activator (tPA; tisokinase, 1,600,000 units) was performed 3 hours after the onset, and the MCA was partially recanalized. Further administration of tPA was suspended because of nosebleed. However, the patient's neurological findings did not improve. His consciousness gradually deteriorated to coma and quadriplegia with dilation of the left pupil 2.5 hours after thrombolysis. CT disclosed marked mass effect with a left acute subdural hematoma and a small intracerebral hematoma in the left frontal lobe. He underwent urgent craniotomy and removal of the subdural hematoma. The subdural hematoma originated in a frontal cerebral contusion. He died of severe brain edema 2 days after surgery. Acute subdural hematoma is a very rare complication of intra-arterial thrombolysis. Presumably he had suffered head trauma at the first onset. Evidence of head trauma should be considered a contraindication for the use of thrombolytic agents in a patient with acute stroke.     

Cerebral amyloid angiopathy associated with hemorrhage: immunohistochemical study of 41 biopsy cases.

The relationship between cerebral amyloid angiopathy and hemorrhage was investigated by an immunohistochemical study of biopsy cases to characterize the involvement of amyloid beta-protein, apolipoprotein E, and cystatin C in cerebral amyloid angiopathy associated with hemorrhage. The amyloid-laden vessels were examined in biopsy specimens from 41 surgical cases of sporadic cerebral amyloid angiopathy (36 cases with hemorrhage and 5 cases without hemorrhage), using immunohistochemical staining with antibodies against amyloid beta-protein, apolipoprotein E, cystatin C, and alpha-smooth muscle actin. The relationship between the occurrence, recurrence, and enlargement of the hemorrhage, and the semiquantitative estimation of the cerebrovascular amyloid-related protein deposition was analyzed using Fisher's exact test. Severe amyloid beta-protein (p < 0.013) and apolipoprotein E (p < 0.013) immunoreactivity were risk factors for the occurrence of the hemorrhage. Severe cystatin C immunoreactivity was a risk factor for the occurrence (p < 0.002) and enlargement (p < 0.014) of the hemorrhage, and tended to induce recurrent hemorrhage (p < 0.103). In addition, loss of the vascular smooth muscle was observed in the intensely amyloid-laden vascular walls that showed cystatin C-immunoreactivity. The present study indicates that intense amyloid beta-protein deposition with cystatin C deposition weakens the cerebrovascular walls, and that cystatin C deposition is a strong predictor of hemorrhage in cerebral amyloid angiopathy.     

电凝吸引器钝性分离法在重症急性胆囊炎早期腹腔镜胆囊切除术中的应用

目的探讨电凝吸引器钝性分离法在重症急性胆囊炎早期腹腔镜胆囊切除术中的应用价值。方法对2008年3月～2009年7月56例诊断为重症急性胆囊炎患者在四孔法腹腔镜下应用电凝吸引器钝性分离法处理胆囊三角及从胆囊床上分离胆囊,记录出血量、手术时间、中转开腹率,术后腹腔积液、脓肿,肺部并发症及合并心脑疾患、糖尿病并发症,出院后随访有无胆囊床积液及胆道狭窄等并发症。结果手术时间35～110(62.7±16.7)min,出血量40～200(80.2±40.5)ml。无中转开腹手术及胆道损伤、胆漏,无明显腹腔积液、脓肿,无严重肺部并发症,围手术期未发生脑梗死或脑出血,5例冠状动脉支架置入者无心绞痛、心肌梗死及心律失常。术后随访2～3个月,无发热、腹痛及黄疸,影像学检查无胆囊窝血肿、积液以及胆道狭窄等并发症。结论电凝吸引器钝性分离法治疗重症急性胆囊炎安全有效,值得临床推广。     

Modern treatment options for intracerebral hemorrhage

Opinion statement Spontaneous intracerebral hemorrhage (ICH) is a devastating neurological event with a 30-day mortality of approximately 40%. Recent research provides new insights into the pathophysiology of ICH-associated edema, with potential molecular and cellular targets for future therapy. Neuroimaging techniques such as gradient echo MRI are yielding insights into cerebral microbleeds and the microangiopathies associated with hypertension and cerebral amyloid angiopathy. Recent literature provides new medical treatment strategies for fever, acute hypertension, and perihematomal edema, and methods of reducing intracranial pressure. Two randomized controlled trials have provided crucial evidence regarding surgical and medical intervention for acute ICH intervention. Recombinant factor VIIa appears to lessen growth of ICH when administered within 4 hours of ictus. Further study of potential efficacy and safety is underway in an international phase III trial. In addition, the Surgical Trial in Intracerebral Hemorrhage reported results from an international randomized trial of 1033 patients who did not show benefit for surgical evacuation of ICH, compared with medical therapy alone. Less invasive surgical methods for hematoma evacuation, studied previously over the past decade, continue to be investigated.     

Long-term effects of invasive treatment in patients with a post-thrombolytic Q-wave myocardial infarction

Abstract

Objectives. The aim of the present study was to assess the effect of a deferred invasive treatment strategy on long-term outcome in patients with a post-thrombolytic Q-wave myocardial infarction and inducible myocardial ischemia. Design. Patients (N=751) with post-thrombolytic Q-wave myocardial infarction and inducible ischemia (angina pectoris or silent myocardial ischemia) were randomized to a deferred invasive treatment (balloon angioplasty or coronary bypass surgery) or medical treatment. Vital status and non-fatal cardiac events defined as hospitalization caused by acute cardiac events were recorded for a median of 11.4 years. Results. Survival was significantly improved in patients receiving invasive treatment compared to patients treated medically (hazard ratio 0.85 (95% confidence limits 0.73–0.99), p=0.034). Subgroup analysis showed a reduction of non-fatal cardiac events and improved survival among the patients with post-infarction angina pectoris and not among the patients with silent myocardial ischemia. Conclusions. A deferred invasive treatment strategy improves survival compared to medical treatment in patients with inducible myocardial ischemia after a post-thrombolytic Q-wave myocardial infarction.     

Thrombolytics in CPR. Current advantages in cardiopulmonary resuscitation

Cardiac arrest carries a very poor prognosis. More than 70% of cardiac arrests are caused by acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Thrombolysis during CPR has two major effects: first, it causally treats the condition that caused cardiac arrest and second, it has been shown to have beneficial effects on the microcirculatory cerebral reperfusion after cardiac arrest. However, this treatment has been widely withheld mainly because of the fear of severe bleeding complications. We reviewed the currently available in- and out-of-hospital studies on thrombolysis during CPR. Most studies found that thrombolytic therapy during CPR improves the chance for a restoration of spontaneous circulation in patients suffering from cardiac arrest and may even result in a better outcome. In addition, the neurological condition of surviving patients may be markedly improved by thrombolysis. Although thrombolytic therapy is associated with a risk of bleeding complications, currently available data do not suggest an increase of bleeding complications if thrombolysis is administered during CPR. Recently, a large randomized multicentre study has started to assess the efficacy and safety of thrombolysis during prehospital CPR.     

低分子肝素联合尿激酶静脉溶栓治疗急性心肌梗死的临床疗效和安全性评价

目的：对低分子肝素联合尿激酶静脉溶栓治疗急性心肌梗死的临床疗效及安全性进行评价。方法将46例急性心肌梗死患者随机分为溶栓组23例（溶栓再通组和溶栓未通组）、未溶栓组23例,通过低分子肝素联合尿激酶对溶栓组患者进行治疗;使用常规方法治疗未溶栓组患者,无溶栓治疗,对三组患者的射血分数、治疗效果以及死亡率进行观察。结果17例溶栓再通者（73.9%）显著高于6例溶栓未通者（26.1%）（P＜0.05）;溶栓再通组总有效率为88.2%,显著高于66.7%的溶栓未通组、65.2%的未溶栓组（P均＜0.05）。结论急性心肌梗死采用低分子肝素联合尿激酶的静脉溶栓治疗可有效降低死亡率、提升冠状动脉的再通率以及改善预后。