Effect of continuous cisternal drainage on cerebral vasospasm

Summary The effect of continuous cisternal drainage on cerebral vasospasm was studied under strict criteria in 140 patients with ruptured intracranial aneurysms. The degree of subarachnoid haemorrhage (SAH) on the computed tomography scan was graded from I to IV. The patients were classified according to the total amount of cisternal drainage into three groups, regardless of the duration of the drainage and whether or not it was accompanied by irrigation; i.e., those with less than 500 mL (group 157 cases), those with 500–3000 mL (group 2 44 cases), and those with 3000–9500 mL (group 3 39 cases).While correlations could be found between both clinical and SAH grades with the severity of vasospasm, closer correlation could be found in the SAH grades. In analyzing the cases with subarachnoid haemorrhage grades III–IV (severe clots), the angiographic vasospasm was less severe in groups 2 and 3 than in group 1, and the incidences of permanent symptomatic vasospasm and low-density area on computed tomography were lower in groups 2 and 3 than in group 1. Regarding the surgical outcome in cases with SAH grades III–IV, the mortality rate was lower in groups 2 and 3 (22% and 19%) than in group 1 (33%). Further, the rate of good recovery was higher in groups 2 and 3 (61% and 57%) than in group 1 (28%). However, there were no differences between groups 2 and 3 in cerebral vasospasm or in surgical outcome. As a shortcoming of continuous cisternal drainage, the need for shunt operation was higher in groups 2 and 3 than in group 1.     

The role of ventricular and cisternal drainage in the early operation for ruptured intracranial aneurysms

Summary In a series of 177 patients with ruptured supratentorial aneurysms we studied retrospectively the results of early and delayed operation without aggressive removal of subarachnoid blood clots but ventricular and cisternal drainage. The early and delayed groups were comparable demographically and neurologically. The overall results for the early group were a good outcome in 65%, poor outcome in 10% and death in 24%, compared to 53, 20 and 27% respectively in the delayed group. Thus, patients with an early operation and CSF drainage had better results. Permanent ischaemic neurological deficits due to cerebral vasospasm accounted for the poor outcome in 10 and 21% of the patients in the early and delayed groups, respectively and rebleeding accounted for the poor outcome in 5 and 10% in the early and delayed groups respectively.The mean amount of haemoglobin in the cerebrospinal fluid from cisternal drainage was 6.4 g, corresponding to about 40 ml of whole blood, during the 12-day period after SAH. The level was higher in patients with larger subarachnoid clots or with symptomatic vasospasm than in those with smaller clots or without such vasospasm.Early operation combined with ventricular and cisternal drainage is considered to be a useful surgical method for patient with a ruptured aneurysm.     

术中输注高渗氯化钠羟乙基淀粉溶液对脑动脉瘤术后早发性脑血管痉挛的影响

目的 探讨术中输注高渗氯化钠羟乙基淀粉溶液(hypertonic sodium chloride hydroxyethyl starch solution,HSH)对脑动脉瘤夹闭术后患者早发性脑血管痉挛(cerebral vasospasm,CVS)的影响.方法 选择美国麻醉医师协会(ASA)分级Ⅱ～Ⅲ级,Hunt and HessⅡ～Ⅲ级、Glasgow评分13～14分,年龄20岁～60岁拟行脑血管瘤夹闭术的动脉瘤性蛛网膜下腔出血(aneurysmal subarachnoid hemorrhage,aSAH)患者20例,按随机数字表法均等分为两组:A组:输注4.2％HSH(实验组) ;B组:常规输液(对照组).A组患者于麻醉诱导前和动脉瘤夹闭后分别静脉输注4.2％HSH40注射液各3 ml/kg,术中液体维持以平衡盐溶液和胶体液按2:1比例输注 ;B组患者麻醉和手术过程中按2:1比例匀速输注平衡盐溶液和胶体液.记录两组患者输液总量,术中及术后各时点两组患者颅内压(intracerebral pressure,ICP)、平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)、红细胞比容(HCT)及血浆渗透压(plasma osmotic pressure,POP),采用经颅多普勒超声(TCD)监测手术结束时(T5)、术后6(T6)、12(T7)、24 h(T8)两组患者的右侧大脑中动脉血流速度.结果 A组CVP在T6和T8时点分别显著高于B组(9.4±1.3 vs 7.6±1.0和9.4±1.5 vs 7.2±1.6,P＜0.05),而其余血流动力学参数两组间比较差异无统计学意义 ;A组ICP在T5、T6和T7时点分别低于B组,两组数据比较差异有统计学意义(16.5±4.7 vs 21.5±3.6,20.4±3.2 vs 28.2±3.9和22.6±3.7 vs 27.4±2.7,P＜0.05) ;A组大脑中动脉血流速度在T6和T7时点分别显著低于B组(121±15 vs 139±17和125±13 vs 137±15,P＜0.05).结论 脑动脉瘤夹闭术中输注4.2％ HSH 6 ml/kg可有效减轻术后患者早发性CVS发生程度.     

Morbidity and mortality after early aneurysm surgery — a prospective study with nimodipine prevention

Summary Based on the outcome in 116 consecutive patients who were subjected to early aneurysm operation combined with additional nimodipine treatment, and who were controlled by transcranial Doppler (TCD) sonography, a morbidity and mortality analysis was performed. Of the 84 patients who preoperatively were in Hunt & Hess grades III, 79 patients (94%) were considered to show a favourable (good-fair) late recovery, while one patient (1%) had a poor outcome, and four patients (5%) died. Of the 32 poor condition patients (H & H IV–V), 17 (53%) showed a favourable recovery, while seven (22%) had a poor outcome, and eight patients (25%) died. Altogether, 20 patients (17%) had an unfavourable (poor-dead) outcome. Only two of these patients showed delayed ischaemic deterioration, one as a consequence of a secondary occlusion of perforating branches from the basilar artery and one with decompensated vasospasm after the evacuation of an epidural haematoma and a longlasting severe systemic hypotension; both these patients died. In another six of the patients with an unfavourable outcome, this was mainly related to a complicated surgery. The unfavourable outcome was related to primary brain damage produced by the subarachnoid haemorrhage (SAH) in ten patients and in two patients to internal medical complications. In addition to the two patients who died following delayed deterioration, secondary neurological dysfunction occurred in 11 patients. In 10 of these patients transient neurological dysfunction was attributed to vasospasm or to a combination of vasospasm with intraoperative or postoperative complications. One further case of delayed deterioration was attributed to secondary occlusion of the internal carotid artery after a complicated operation. From these data we conclude that following early aneurysm operation combined with intravenous nimodipine treatment, vasospasm alone is no more a major clinical problem. Morbidity and mortality are mainly related to primary effects of the SAH and/or complicated surgery.     

Effect of cisternal drainage after early operation for ruptured intracranial aneurysms

The effect of postoperative cisternal drainage was assessed in 132 patients who underwent early surgery for ruptured aneurysms. Although the incidence of both cerebral vasospasm and mortality was low in the patients who had cisternal drainage, the incidence of hydrocephalus was significantly higher in these patients. Drainage has been recommended as a useful procedure because it has been shown to improve the prognosis through prophylaxis and relief of vasospasm and removal of bloodcontaminated cerebrospinal fluid. However, the results of this study indicate that extensive cerebrospinal fluid drainage may lead to hydrocephalus, which can be controlled by regulation of the drainage outflow and pressure.     

The surgery of middle cerebral artery aneurysms

Summary Aneurysms of the middle cerebral bifurcation represent an interesting entity among intracranial saccular aneurysms. Their shape, size, situation, and in particular their relation to the middle cerebral trunk and its branches show wide variations. Topographical analysis of the angiograms offers a great deal of interest in planning surgery.Our experience with 289 patients with middle cerebral artery aneurysms operated on since 1977 are presented. Factors such as number of previous haemorrhages, timing of surgery, preoperative condition, major intraoperative bleeding or brain oedema and delayed postoperative deterioration play a major role in the outcome. Others such as severity of the subarachnoid bleed, age, size of the sac seem to have much less influence.     

The effect of very early cisternal irrigation on basilar artery spasm after SAH in the rat model

Summary The authors have investigated the effect of very early irrigation of the cerebrospinal fluid (CSF) space in the haemorrhage rat model of vasospasm. Fifteen rats had basilar cistern irrigation with physiological saline for 3 hours after subarachnoid haemorrhage (SAH), and fifteen control rats had subarachnoid haemorrhage without irrigation of clot.The changes in basilar arteries diameters were determined by angiograms obtained from the rats. The post haemorrhage angiograms showed significant basilar artery spasm in both groups (P0.0005, t-test). However in the last angiogram the basilar artery diameter was found to have the same value measured before subarachnoid haemorrhage in the irrigation group whereas no obvious change was observed in the control group. In the irrigation group the mean diameter of the basilar artery in the last angiogram was 0.412 mm. (0.30 mm to 0.50 mm). None of the animals, treated by cisternal irrigation, showed angiographic vasospasm while the latter group did (P0.0005). Animals treated with physiological saline irrigation had a median clot grade of 0.40 (range grade 0 to 2); control rats had a median grade 2.86 (range grade 1 to 4, P<0.001, Mann-Withney U test), on the brain stem, indicating significant reduction of clot by lavage.In conclusion, performance of experimental physiological saline irrigation at a very early time after subarachnoid haemorrhage prevents the arteriographic and morphological changes of both acute and late vasospasms.     

HLA-type of cerebral vasospasm patients after aneurysmal subarachnoid hemorrhage

We studied human lymphocyte antigen (HLA) types in a group of 45 patients who had aneurysmal subarachnoid hemorrhage (SAH). A significantly increased frequency of HLA antigen A31 and a significantly decreased frequency of HLA antigen B40 were found. In patients with delayed ischemic neurological deficit (DIND) following aneurysmal SAH and HLA typing, HLA-Bw60 antigen showed significant increases; in patients who did not develop HLA-Aw33 and-Cw4 antigens showed significant. Among the patients with Fisher's Group 3 on CT, in particular, these antigens significantly increased when compared with controls from the same geographic area. These results suggest that HLA-Bw60 antigen plays a role as a predisposing factor of DIND resulting from vasospasm following aneurysmal SAH, and that HLA-Aw33 and-Cw4 exert protective influence against DIND.     

Nitric oxide metabolites in cisternal CSF correlate with cerebral vasospasm in patients with a subarachnoid haemorrhage

Summary.  Background: The pathogenesis of cerebral vasospasm is likely to be multifactorial. Exposure of the adventitia of large cerebral arteries to blood breakdown products initiates a cascade of changes in both morphology and vasomotor regulation of the exposed vessels. The role of nitric oxide (NO) in development of cerebral vasospasm process is controversial. Basal cerebral vascular tone requires the continuous release of NO, nevertheless NO is involved in free radical mediated injury of endothelial cell membrane. Concentrations of nitrate/nitrite (stabile endproducts of NO metabolism) were studied in cisternal cerebrospinal fluid (cCSF) in patients suffering from aneurysmal subarachnoid haemorrhage (SAH).  Method: 21 patients suffering from aneurysmal SAH were investigated. Treatment included aneurysm clipping, cisternal drainage of CSF and intravenous nimodipine in all patients as well as tripple H therapy when indicated. TCDS was performed on a daily basis. A mean flow velocity of more than 150 cm/sec and the development a delayed neurological deficit was defined as vasospasm. CSF samples were collected on the day of surgery and for the 7 days following. NO-M (nitrite and nitrate) were measured using a commercially available test kit.  Findings: 5 of 21 patients developed clinically symptomatic vasospasm. There was a significant difference in NO levels between the groups. Patients with cerebral vasospasm showed significantly higher levels of NO-M in CSF than patients with a uncomplicated follow-up between day 2 and 8.  Interpretation: Our preliminary results indicate that SAH leads to an increase in NO-M in CSF. This increase of NO-M significantly correlates with the flow velocities in TCDS measurement suggesting that NO plays an important role in the pathogenesis of cerebral vasospasm. Published online April 28, 2003  Correspondence: A. Woszczyk, Department of Neurosurgery, Justus-Liebig University, Klinikstro?e 29, 35292 Giessen, Germany.     

A long-term follow-up study in direct cerebral aneurysm surgery

Summary A long-term follow-up study covering between one and twenty-two years after surgery was carried out on 177 patients with direct operations for cerebral aneurysms.Rebleeding was detected in five out of 18 patients with incomplete operations; one patient within 6 months and four patients within 5 to 8 yeras after surgery. The rebleeding rate of incompletely operated patients in the first decade was similar to that of untreated patients with ruptured aneurysms. This suggests that wrapping, coating and incomplete clipping procedures provide some protection against rebleeding in the first 6 months but little in the period extending beyond 5 years after surgery.Showing two types of newly-formed aneurysms after complete surgery and enlarged residual aneurysms after incomplete surgery, the possibility of rebleeding from these aneurysms is discussed in the present report.     

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

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

急性高容量血液稀释联合瑞芬太尼控制性降压对颅内动脉瘤术患者血流动力学和脑氧代谢的影响

目的 观察颅内动脉瘤夹闭术患者在急性高容量血液稀释(AHH)联合瑞芬太尼控制性降压(CH)后血流动力学和脑氧代谢的变化,评价其可行性.方法 选择颅内动脉瘤夹闭术患者40例,随机均分为硝酸甘油组(A组)和瑞芬太尼组(B组).手术开始时以15～20 ml·kg-1·h-1的速率输入4％琥珀酰明胶,使Hct稀释为25％～32％.在剪开硬脑膜后行CH,A组泵入硝酸甘油1～5 μg·kg-1 ·min-1;B组泵入瑞芬太尼12～30 μg·kg-1·h-1,使MAP维持在60～65 mm Hg,动脉瘤夹闭后10 min停止CH.记录两组患者AHH前(T0)、AHH后(T1)、降压前(T2)、降压后30 min(T3)、动脉瘤夹闭后5 min(T4)的MAP、HR、Hb和Hct,分别于T2～T4时采集颈内静脉球部血和桡动脉血作血气分析,检测动、静脉血氧饱和度(SaO2、SjvO2)、动、静脉血氧分压(PaO2、PjvO2)、Hb和Hct,计算动脉氧含量(CaO2)、颈内静脉氧含量(CjvO2)、动脉颈内静脉球部血氧差(Da-jvO2)、颈内静脉球部动脉乳酸差(VADL)和脑氧摄取率(CERO2).结果 与T0时比较,T1～T4时两组Hb和Hct均显著降低(P＜0.01).与T2时比较,T3、T4时两组MAP明显降低,A组HR明显增快,B组的HR明显减慢(P＜0.01);T3、T4时B组SjvO2和CjvO2明显高于T2时和A组,Da-jvO2和CERQ明显低于T2时和A组(P＜0.01).结论 AHH联合瑞芬太尼CH用于颅内动脉瘤夹闭术中,不但维持血流动力学的相对稳定,而且明显降低脑氧代谢率,较AHH联合硝酸甘油CH更具优越性.     

Value of Electroencephalogram in prediction and diagnosis of vasospasm after intracranial aneurysm rupture

Summary The Electroencephalogram (EEG) of 151 patients whose ruptured aneurysm was confirmed by CT scan and angiography was recorded on the first day (D1) and the fifth day (D5).On D1, EEG had a prognostic value: among 46 patients with normal EEG, 72% presented neither further electrical ischaemic features nor delayed angiographic vasospasm; on the other hand, when bilateral bursts of slow waves, axial bursts or slow delta waves were recorded (78 cases), 97% exhibited EEG signs of ischaemia and angiographic vasospasm a few days later. These data were clearly related to the importance of the haemorrhage, specially when thick clots in the subarachnoid cisterns were found on the CT scan.On D5, EEG had a diagnostic value: focal or asymetrical bilateral delta waves occuring at that date seemed to correspond to ischaemia; among 107 patients with these electrical features, an angiographic vasospasm appeared in 96% of cases, and the importance of electrical abnormalities could be related to the degree of arterial narrowing.We conclude that EEG data are very useful in prediction as well in recognition of post-subarachnoid haemorrhage ischaemia due to vasospasm and are sufficiently precise to postpone control angiography and operation, when delayed surgery is programmed.     

Thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus

Summary Aneurysms presenting as third ventricular masses are uncommon; most are giant aneurysms arising from the basilar apex. We present a case of a thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus in a 55-year-old man. The case is unique in the literature as the aneurysm was completely thrombosed and angiographically occult. The lesion was explored to verify the diagnosis and a third ventriculostomy resolved the patients symptoms. Completely thrombosed aneurysms should be considered in the differential diagnosis of symptomatic third ventricular masses, even when angiographic studies are negative. The literature on aneurysms presenting as third ventricular masses is reviewed.     

Cerebral vasospasm in patients with unruptured intracranial aneurysms

Summary Intracranial arterial vasospasm is a typical sequela of subarachnoid haemorrhage. The association between symptomatic vasospasm and unruptured aneurysms has been sporadically presented in the literature. The pathogenesis of this unusual entity is unclear. The published cases were collected in this review and analysed with regard to timing, clinical presentation and possible relationship with surgical factors. We also added an illustrative case which was recently observed in our department.