Fibrinolytic activity of cerebrospinal fluid in subarachnoid hemorrhage (author's transl)

This study was aimed to investigate the correlation between recurrent hemorrhage of ruptured intracranial aneurysm and local fibrinolytic activity of aneurysmal fibrin plug. The fibrinolytic activity of cerebrospinal fluid (CSF) was investigated in 63 patients with various neurological diseases by means of modified fibrin plate method. No plasmin was elicited in normal CSF, however, it was confirmed that CSF contained an incomplete activator which became a complete activator inthe presence of streptokinase, and plasminogen was identified in the presence of urokinase. In 26 cases of subarachnoid hemorrhage, the fibrinolytic activity of CSF occurred in the patients within two weeks following hemorrhagic ictus. In almost cases, the fibrinolytic activity of CSF was not increased in the first three weeks after the onset of hemorrhage. This result agreed with the fact that rebleeding of intracranial aneurysm tended to occur within two weeks after the hemorrhage. Therefore, intensive antifibrinolytic therapy for two weeks after onset of hemorrhage is necessary in order to prevent recurrent hemorrhage of intracranial aneurysm, and its doses should be sufficient to inhibit local fibinolysis. It has been suggested that the local fibrinolysis after subarachnoid hemorrhage would be caused by activators released from damaged surrounding brain tissues. Furthermore, it is strongly suggested from the result of our in vitro experiments that coexistence of CSF and blood play an important role to increase local fibrinolysis.     

Subarachnoid hemorrhage and circulatory disturbance of cerebrospinal fluid--scanning electron microscopid study in clinical and autopsy cases (author's transl)]

The scanning electron microscopy (SEM) gives intersting information about the changes of the subarachnoid space. In this study, specimens from 16 patients (one during surgery and others at autopsy) were examined by SEM: 11 cases of subarachnoid hemorrhage, 2 of posterior fossa brain tumor operated and 3 of control cases without CNS diseases. In cases of subarachnoid hemorrhage, there seemed to be three stages of the obstruction in the subarachnoid space: a) obstruction by blood clots mainly consisted of red blood cells, b) obstruction by subarachnoid fibrosis with thickening of arachnoid, c) obstruction by arachnoid adhesion obliterating subarachnoid space. Specimens from parietal parasagittal area, lateral cerebral fissure and temporal base on both sides were systematically examined by SEM, and the degree of the obstructive changes of the subarachnoid space were classified into five grades: 0) no changes 1) minimal changes--slight thickening of arachnoid and perivascular fibrosis in subarachnoid space 2) moderate changes--thickening of arachnoid and fibrosis in subarachnoid space with patent meshwork 3) severe obstruction of subarachnoid meshwork 4) complete obstruction of subarachnoid space--no space for CSF circulation. We found high incidence of communicating hydrocephalus after SAH in those cases in which epicortical CSF circulation was obstructed more than grade 3 in the parasagittal area bilaterally.     

Source of fibrin/fibrinogen degradation products in the CSF after subarachnoid hemorrhage

In 48 patients with a subarachnoid hemorrhage, levels of fibrin/fibrinogen degradation products (FDP's), total protein, and plasminogen were measured in the cerebrospinal fluid (CSF) between Days 9 and 15 after the bleed. Of these 48 patients, 22 received tranexamic acid. Despite a significant reduction in the incidence of rebleeding in patients taking tranexamic acid, no difference in FDP levels was found between patients receiving tranexamic acid and a control group of patients who were not; nor was any relationship evident between FDP levels and rebleeding. In patients with detectable levels of FDP's, CSF protein and plasminogen values were also increased, and FDP's were found more frequently in the CSF of patients with an impaired level of consciousness or with a neurological deficit. These findings suggest that in the 2nd week after subarachnoid hemorrhage, the presence of FDP's in the CSF reflects a damaged blood-CSF barrier rather than ongoing local fibrinolysis in the subarachnoid space. A finding of FDP's in the CSF is, therefore, an unreliable monitor of antifibrinolytic treatment in subarachnoid hemorrhage and cannot be used for selecting patients at high risk of rebleeding.     

Remote cerebellar hemorrhage after foramen magnum decompression surgery for Chiari I malformation--case report

A 47-year-old woman underwent decompressive suboccipital craniectomy and C1 laminectomy with duroplasty in the prone position for Chiari malformation type I and syringomyelia. The arachnoid membrane was not injured. Intraoperative echography showed good enlargement of the subarachnoid space. No closed subcutaneous drain was used. The patient complained of repeated nausea and vomiting 3 hours after the operation, and computed tomography revealed remote cerebellar hemorrhage on postoperative day 1. The cerebellar hemorrhage was treated conservatively, and the symptoms continued only for 3 days after surgery. Dural opening with rapid loss of cerebrospinal fluid (CSF) has occurred in every reported case of remote cerebellar hemorrhage complicating intracranial and spinal procedures. Loss of CSF is the main pathogenesis of this condition. In our case, the most probable pathomechanism seems to involve stretching of the infratentorial cerebellar bridging veins due to cerebellar sagging because of dural opening in the prone position and drop in CSF pressure. Such a complication is rare but should be considered after foramen magnum decompression surgery if the patient shows unusual symptoms of repeated vomiting.     

Cisternal and lumbar CSF concentration of arachidonate metabolites in vasospasm following subarachnoid hemorrhage from ruptured aneurysm: biochemical and clinical considerations

Two representative cases of subarachnoid hemorrhage in which prostaglandin D2 (PGD2) and 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), stable metabolite of prostacyclin (PGI2), were monitored with serial lumbar punctures and detected in cisternal CSF during operations for aneurysm, are reported. In the case with demonstrated arterial vasospasm, prostaglandin D2 has a concentration trend with characteristic peak related to vasospasm; the synthesis of prostacyclin appears inhibited after the hemorrhage. In the patient without radiologic evidence of vasospasm, arachidonate metabolite concentration trend appears in a steady-state. Cisternal prostaglandin D2 concentration in the patient with demonstrated vasospasm is two times the highest lumbar CSF concentration, while 6-keto-prostaglandin F1 alpha concentration is very low. This suggests the role of the clotting phenomenon and likely confirms the importance of arachidonate metabolites in the genesis of cerebral arterial spasm following subarachnoid hemorrhage.     

Disturbances of cerebrospinal fluid circulation during the acute stage of subarachnoid hemorrhage

Radioisotope cisternography was performed and the erythrocyte and hemoglobin contents of the cerebrospinal fluid (CSF) were determined within the first 4 days after subarachnoid hemorrhage in 42 patients. The clinical condition of the patients was related to the severity of the CSF circulation disturbances. Thirty-five patients had some degree of disturbance of CSF flow, and only 2 of the 42 patients had normal flow. In 5 cases the cisternograms were inconclusive. The severity of CSF circulation disturbances correlated well with clinical condition. No relationship was found between the number of erythrocytes in the CSF and the development of CSF circulation disturbances. The CSF erythrocyte content did not correlate with the clinical condition. It is suggested that flow disturbances of the CSF during the acute stage of subarachnoid hemorrhage might play an important role in the pathomechanism of the disease.     

Cerebrospinal fluid transfer of cefotiam (CTM). Its relationship to CT

Drip intravenous infusion of cefotiam (CTM) was made on patients who underwent cerebrospinal fluid (CSF) drainage and study was made on CSF transfer of CTM and at the same time on the relationship between CSF transfer of iodine contrast medium and CT scan findings. This study was made on 11 cases of cisternal drainage and 8 cases of ventricular drainage. Cisternal drainage cases were all postoperative cases of ruptured cerebral aneurysm. Cases of ventricular drainage included 4 postoperative cases of ruptured cerebral aneurysm, 1 case of CSF rhinorrhea, 2 cases of brain tumor, and 1 case of ventricular hemorrhage. Drip intravenous infusion of 1.0 g of CTM was made in one hour and at given periods thereafter CSF was collected and measured. CTM transferred to the CSF in cistern at a comparatively high concentration (16.3-0.7 microgram/ml). Hardly any transfer of CTM to the CSF in ventricle was seen in one case of cerebral aneurysm, CSF rhinorrhea, and brain tumor, but transfer was observed in one case of cerebral aneurysm, one case of brain tumor, and case of ventricular hemorrhage. Transfer of iodine contrast medium showed the positive correlation to the transfer of CTM. In cases of brain tumor and ventricular hemorrhage with transfer of CTM with ventricular drainage, enhancement effect of the ventricular wall by the contrast medium could be observed by CT scan. From the foregoing, the following results were obtained. There was good transfer of CTM to the CSF in cistern in postoperative cases of ruptured aneurysm. CTM did not transfer to CSF in the normal ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery

Summary Objective. Cerebrospinal fluid (CSF) rhinorrhea is a potentially life-threatening complication following transsphenoidal surgery (TSS). Methods. To elucidate the risk factors that may affect the incidence of postoperative CSF rhinorrhea, we retrospectively reviewed 200 consecutive cases of TSS performed by a single surgeon for 168 adenomas and 32 other sellar and parasellar lesions. Results. Intra-operative CSF leakage was encountered in 38 cases (19.0%). Its incidence did not correlate to tumor size. Among 4 microadenoma cases with CSF leak, 3 were ACTH adenomas. In contrast, postoperative CSF rhinorrhea was observed in 5 cases (2.5%), all following TSS for adenomas. It was frequently noted in cases with prior TSS (3/40, 7.5%, p = 0.0235) and prior radiotherapy (2/7, 28.6%, p<0.0001). Two cases who required surgical intervention had received TSS and radiotherapy previously. Conclusion. The risk of postoperative CSF rhinorrhea is significantly increased in cases with prior TSS or radiotherapy or both. In addition, these cases tended to show delayed CSF leaks and require sellar reconstruction for its treatment. When a CSF leak was encountered during TSS in these high-risk cases, thorough sellar reconstruction and long-term follow-up is necessary.     

MRimaging Findings after Ventricular Puncture in Patients with SAH

Summary  Object. Using magnetic resonance (MR) imaging, we studied brain injury from ventricular puncture performed during craniotomy in the acute stage of subarachnoid hemorrhage (SAH).  Methods. 80 patients underwent craniotomy for aneurysm obliteration within 48 hr after SAH, ventricular puncture for drainage of cerebrospinal fluid (CSF) was perfomed to reduce intracranial pressure. MR imaging was performed within 3 days following surgery to measure the size of the lesion, and was repeated on postoperative days 14 and 30.  Conclusions. Of the 80 patients with ventricular puncture preceding craniotomy, 65 (81%) showed MR evidence of brain injury from the puncture. Overall, 149 lesions were detected. According to coronal images, cortical injuries (54 cases), penetrating injury to tracts along the ventricular tube (55 cases), caudate injury (25 cases), and corpus callosum injury (15 cases). Brain injuries from ventricular puncture did not correlate significantly to patient outcome. While ventricular puncture and drainage of CSF can readily be performed to decrease brain volume at the time of craniotomy in acute-stage SAH, neurosurgeons should be aware of a surprisingly high incidence of brain injury complicating puncture.     

Third ventriculostomy by microtechnique.

The microtechnical approach to third ventriculostomy is presented. Opening of the lamina terminalis and basal membrane of the floor of the third ventricle is combined with opening of the membrane of Liliequist. The technique was used in five cases of aqueductal stenosis. We stress the importance of the microscope, and opening of the membrane of Liliequist to gain additional access.     

Perioperative lumbar subarachnoid drainage could not prevent postoperative CSF leakage after spinal cord tumor resection using an artificial dura mater

BackgroundCerebrospinal fluid (CSF) leakage occurs in patients who undergo dural repair using artificial dura mater. This study aimed to determine if perioperative lumbar subarachnoid drainage could reduce the incidence of postoperative CSF leakage in cases of dural repair using artificial dura mater.MethodsWe retrospectively analyzed 84 patients (41 men, 43 women; mean age, 52.2 ± 20.1 years) who underwent intradural spinal cord tumor resection and dural repair using artificial dura mater. These patients were divided according to whether they underwent perioperative lumbar subarachnoid drainage (39 patients: D group) or had no drainage (45 patients: ND group). The incidence of radiographic and symptomatic CSF leakage as well as baseline characteristics and operative data were compared between the two groups.ResultsRadiographic CSF leakage was observed in 21 patients (25.0%), including 10 (25.6%) in the D group and 11 (24.4%) in the ND group. Symptomatic CSF leakage was observed in 12 patients (14.2%), including six (15,4%) in the D group and 11 (13.3%) in the ND group. There were no significant differences in the incidence of subcutaneous CSF accumulation and symptomatic CSF leakage between the two groups. In cases with symptomatic CSF leakage, the onset time of CSF leakage tended to be earlier (5.7 days vs 15.7 days), and the treatment period tended to be longer (5.8 weeks vs 2.8 weeks) in the ND group than in the D group.ConclusionsPerioperative lumbar subarachnoid drainage did not reduce the incidence of either radiographic or symptomatic CSF leakage. However, it might shorten the treatment period and reduce refractory CSF leakage, which requires multiple treatments over a long period.     

Endoscopic third ventriculostomy: can we predict success during surgery?

Endoscopic third ventriculostomy (ETV) is widely used as an alternative technique for hydrocephalus treatment. ETV success or failure may be influenced by numerous factors. In this study, we have analyzed preoperative and intraoperative risk factors and suggest an intraoperative scale to predict etV failure. Fifty-one patients (27 adults and 24 children) underwent an etV at Carlos Haya University Hospital, Malaga. Intraoperative video records were assessed and the following intraoperative findings were recorded: (1) abnormal ventricular anatomy, (2) intraoperative incident, (3) Liliequist membrane opening in a second endoscopic maneuver, (4) thickened or scarred membranes in the subarachnoid space, (5) absence or “weakness” of pulsation of third ventricle floor at etV completion, and (6) floppy premammillary membrane that needs edge coagulation. An intraoperative scale ranging from 0 to 6 points was performed. A significant relation was found between a higher result on the prognosis scale and etV failure (p?<?0.0001). An absence or weakness of pulsation of the third ventricle floor at etV completion was significantly related to etV failure (p?<?0.0001). The presence of thickened or scarred membranes in the subarachnoid space was significantly related to etV failure (p?<?0.04) as well as the Liliequist membrane opening in a second endoscopic maneuver (p?<?0.008). Intraoperative factors should be taken into account for prediction of etV success. More studies with larger case series are needed to determine the influence of all intraoperative factors over etV success.     

Clinical study on penetration of antibiotics into cerebrospinal fluid (second report),-Study on intravenous administration of sodium cephalothin with mannitol solution (author's transl)

Penetration of Sodium Cephalothin (CET) into CSF follwing intravenous administration was studied in 23 patients with intracranial diseases excluding inflammation and severe subarachnoid hemorrhage. 1) After intravenous injection of 2 g of CET, ventricular CSF was obtained in 4 cases. All these 4 cases showed CET concentration in CSF to be below 0.1 mcg/ml. 2) After intravenous injection of 2 g of CET, lumbar CSF was obtained in 6 cases. In two cases out of these 6 cases, CET concentration in CSF was higher than 0.7 mcg/ml. 3) In 13 cases 2 g of CET with 200ml of 20% Mannitol was injected intravenously and lumbar CSF was examined. CET concentrations in CSF between 0.7 mcg/ml and 6.0 mcg/ml were observed in 9 cases of this group. 4) According to the results it is strongly suggested that the administration of Monnitol and CET is very effective for penetration of CET into CSF.     

Endothelin-1 concentration increases in the cerebrospinal fluid in cerebral vasospasm caused by subarachnoid hemorrhage

BACKGROUND: Endothelin-1 (ET-1) was originally identified as a potent vasoconstrictor peptide. Numerous reports have suggested its roles in various disorders. Although there is a great deal of evidence establishing the relationship between ET-1 and cerebral vasospasm in animals, this relationship still remains to be clarified in humans. METHODS: The concentration of ET-1 in cerebrospinal fluid (CSF) was measured by radioimmunoassay in 23 subarachnoid hemorrhage patients. CSF samples were collected every 10 days after surgery from the cisternal drainage tube. RESULTS: Initial concentrations of ET-1 in the CSF collected the first day after operation were all increased compared with the control CSF. In seven of the eight vasospasm patients, the concentrations of ET-1 had increased before the observation of vasospasm and then decreased before the disappearance of the vasospasm. In 13 out of the 15 patients without vasospasm, the concentrations of ET-1 in CSF decreased with time. CONCLUSION: We confirmed that the concentration of ET-1 in CSF increased before the onset of cerebral vasospasm caused by subarachnoid hemorrhage. The ET-1 concentration in the CSF could be a useful marker to detect cerebral vasospasm after subarachnoid hemorrhage.     

Remote cerebellar hemorrhage following supratentorial craniotomy--case report

A 63-year-old man presented with sudden severe headache. Computed tomography (CT) demonstrated subarachnoid hemorrhage. Cerebral angiography demonstrated an aneurysm of the anterior communicating artery. Left frontotemporal craniotomy and neck clipping of the aneurysm via the pterional approach were performed. CT obtained 18 hours after surgery revealed cerebellar hemorrhage, and magnetic resonance (MR) imaging 17 days postoperatively demonstrated that the hemorrhage was located within the folia. Neurological examination after surgery revealed slight dysarthria after drainage of cerebrospinal fluid (CSF) but no other neurological deficits. Follow-up CT and MR imaging showed characteristic findings of postoperative cerebellar hemorrhage clearly different from those of hypertension. The cerebellar hemorrhage was probably secondary to overdrainage of CSF. He was discharged without deficits.     

Intraoperative radical clot removal therapy using a bipolar irrigation system for prevention of cerebral vasospasm following subarachnoid hemorrhage

To investigate cerebral vasospasm following subarachnoid hemorrhage (SAH), 65 cases were analyzed by the incidence of delayed ischemic neurological deficit (DIND). Eighty-four consecutive cases, who underwent surgery within 72 hours of SAH, were retrospectively analyzed. Sixty-five of these patients had diffuse subarachnoid hemorrhage in CT scan and had aneurysms of the anterior circulation. They were divided into two groups according to the operative procedure: Group A (35 cases) had radical clot removal therapy with urokinase in 5% glucose solutions using a bipolar irrigation system; Group B (30 cases) had conventional clot removal using manual irrigation. There were no significant differences between these two groups for age or pre-operative WFNS grade. The incidence of DIND was 17.1% in group A and 40.0% in groupB; this was a significant difference. Radical clot removal therapy was effective in preventing DIND due to vasospasm.     

A case of systemic lupus erythematosus associated with multiple intracranial aneurysms

The author reports a case of systemic lupus erythematosus (SLE) with multiple intracranial aneurysms and subarachnoid hemorrhage. A 31-year-old woman was admitted to the department of internal medicine of Shizuoka General Hospital for the treatment of nephrotic syndrome due to systemic lupus erythematosus on 1984. She spend an uneventful life until April, 1985 when she suddenly complained of severe headache and nausea. The computed tomographic scan revealed subarachnoid hemorrhage and the cerebral angiography showed multiple intracranial aneurysms and stenotic lesion. A review of the literature was made to clarify the incidence, the pathological change, and the prognosis of systemic lupus erythematosus with subarachnoid hemorrhage. The incidence of subarachnoid hemorrhage in SLE was about two percent in the reported clinical cases. The mechanisms of the subarachnoid hemorrhage and the aneurysmal formation in SLE seemed to be due to angitic changes, which involved the vessels of the whole body systematically. The exact prognosis of SLE with subarachnoid hemorrhage is difficult to say, but it seems to be unfortunately poor due to multiplicity of the lesion and the difficulty of its treatment.     

Risk factors for the occurrence of chronic subdural haematomas after neurosurgical procedures

Summary ¶Chronic subdural haematoma (CSDH) is a rare clinical complication of neurosurgical procedures. CSDH occurs sporadically after aneurysm clipping surgery and revascularisation surgery but the risk factors are not known. The present study reviewed 6613 consecutive neurosurgical procedures performed from January 1987 to July 2001, and identified 621 cases of CSDH. Fifty of these 621 cases had a past history of neurological disorders treated by neurosurgery. This study evaluated these 50 cases in order to elucidate the clinical and radiological characteristics of CSDH after neurosurgery and to investigate the etiology for identifying in the risk factors of CSDH as a postoperative complication. The incidence of CSDH after neurosurgery was 0.8% (50/6613). Twenty-seven of the 50 patients with a past history of neurosurgery had undergone aneurysm clipping surgery. The incidence after clipping surgery was 2.4%. Twelve of these 27 cases also underwent ventriculoperitoneal shunting. Three patients had postoperative CSDH after arachnoid cyst opening and/or shunting. The incidence was highest at 7.5%. Three patients had postoperative CSDH after brain tumour surgery. The incidence was low at 0.4%. However, the ventricular cerebrospinal fluid (CSF) space was opened during tumour removal in 2 of these 3 patients.Communication of the subarachnoid space to the subdural space is considered to be one of the causative factors and excessive CSF shunting facilitates formation of CSDH after neurological surgery. Repair of arachnoid tearing during neurosurgery and avoidance of excessive CSF shunting may reduce the risk of CSDH after neurosurgery.Published online May 19, 2003     

Aspergillotic aneurysm formation of cerebral artery following neurosurgical operation.

A rare case of intracranial aspergillotic aneurysm following neurosurgical operation for facial spasm is presented. Severe meningitis had persisted several days prior to the subarachnoid hemorrhage which occurred on 70th postoperative day. Angiography demonstrated a fusiform aneurysm at the peduncular segment of the superior cerebellar artery on the other side of operation. As the repeated cultures of CSF were negative, the pathogenetic factor causing aneurysm formation could not be identified before second operation of aneurysmal resection. Pathological study of the specimen revealed the arterial wall being deeply invaded by aspergillotic hyphae.     

Bilirubin as a cerebrospinal fluid marker of sentinel subarachnoid hemorrhage: a preliminary report in pigs

OBJECT: A model of subarachnoid hemorrhage (SAH) in pigs was developed to investigate bilirubin concentration in cerebrospinal fluid (CSF) as a potential marker of sentinel SAH. METHODS: Seven male Yorkshire pigs received a 250-microl injection of either whole autologous arterial blood (four animals) or isotonic saline (three animals) into the cisternae magna in an effort to produce volumetrically a model of sentinel SAH and a control injection model, respectively. Cerebrospinal fluid volumes of 100 microl were then collected from both the lumbar cistern and cisternae magna at 1 to 2-hour intervals for a total of 24 hours postinjection. The CSF was then tested for bilirubin. Mean concentrations of bilirubin (+/- standard deviation [SD]) obtained from the lumbar cistern 24 hours following the injection of blood or saline were 4.38 +/- 1.04 microM in the SAH animals and 1.02 +/- 0.05 microM in the controls. At 24 hours postinjection, mean concentrations (+/- SD) of cisternae magna bilirubin were 7.29 +/- 1.33 microM and 1.33 +/- 0.14 microM in the SAH animals and controls, respectively. In the SAH group, both the lumbar cistern and cisternae magna bilirubin concentrations differed significantly from baseline values 12 hours following SAH. CONCLUSIONS: Elevated concentrations of CSF bilirubin can be detected following a low-volume SAH, and the production of bilirubin occurred over a predictable time course. Twelve hours after hemorrhage, an elevated CSF bilirubin concentration was an indicator of hemolysis occurring in the subarachnoid spaces. The presence of bilirubin in CSF is a potential marker for differentiating SAHs from traumatic lumbar punctures in humans.