Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT: The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan. METHODS: During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival. CONCLUSIONS: The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.     

Case-control study of clinical outcome after aneurysmal subarachnoid hemorrhage

The clinical and neuropathological features of 84 nonsurvivors of aneurysmal subarachnoid hemorrhage (consecutive autopsy series) were compared with those of 51 survivors (consecutive clinical series). The groups differed significantly in the type of bleeding: 58% of the nonsurvivors had massive subarachnoid hemorrhage (MSAH) compared to 10% of the survivors (P less than 0.00001); 54% of the nonsurvivors had intraventricular hemorrhage (IVH) compared to 29% of the survivors (P less than 0.008); 45% of the nonsurvivors had intracerebral hematoma (ICH) compared to 8% of the survivors (P less than 0.00001). Only 1 of the 19 patients with both MSAH and ICH survived. The incidence of cerebral infarction was similar in nonsurvivors (31%) and survivors (29%). In the absence of associated MSAH, IVH, or ICH, cerebral infarction was uncommon (11%). Documented in-hospital rebleeding was uncommon in nonsurvivors (13%) and survivors (2%). Admission neurological status did not predict outcome independent of the extent of the initial bleeding. Comparison of the two groups suggests that the type and extent of initial bleeding are the most important determinants of mortality in aneurysmal subarachnoid hemorrhage.     

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation: influence of hematoma localization on outcome

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH. One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS). ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6 %); 63.8 % presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are “age,” “size of the hematoma,” and “admission status.” The location of the ICH seems not to be associated with outcome.     

Management of poor-grade patients with aneurysmal subarachnoid hemorrhage in the acute stage: Importance of close monitoring for neurological grade changes

BACKGROUND: The optimal management of poor-grade patients with aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We evaluated therapeutic outcomes to identify appropriate treatments for SAH patients admitted with a poor grade. METHODS: We retrospectively studied 136 patients admitted within 6 hours after SAH onset with a poor Hunt & Kosnik Grade (IV and V). RESULTS: Of 136 poor-grade patients, 20 with massive intracerebral or subdural hematoma underwent urgent hematoma evacuation and aneurysmal neck clipping. Seven of these achieved a favorable outcome (good recovery or moderate disability). Another 7 patients with prominent hydrocephalus or massive intraventricular hematoma underwent urgent continuous ventricular drainage. Of these, 4 manifested spontaneous grade improvement and underwent neck clipping; the other 3 died resulting from rebleeding. The remaining 109 patients whose poor grade was primarily because of SAH were observed without immediate surgery. In 43 patients of 109, the grade improved within 24 hours after hospitalization and within 38 hours in the other 4 patients. Aneurysmal neck clipping was performed in these 47 patients and a favorable outcome was achieved in 25 patients. The remaining 62 patients did not improve and the outcome was unfavorable. CONCLUSIONS: Poor-grade SAH patients should be treated according to the pathogenesis underlying their poor grade. Close monitoring for a grade change over the first 24 hours after hospitalization is mandatory in patients whose poor grade is primarily because of the SAH and helps to determine the appropriateness of surgery.     

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

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

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

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

Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study

OBJECT: Only limited data exist addressing the long-term outcome of patients with ganglionic hemorrhage complicated by intraventricular hemorrhage (IVH) and hydrocephalus that requires an external ventricular drain (EVD). The aim of this study was to compare the long-term outcome of patients with pure ganglionic hemorrhage and those requiring an EVD due to additional IVH and hydrocephalus. METHODS: For this study, 116 patients with supratentorial ganglionic hemorrhage and occlusive hydrocephalus were screened. To avoid any bias the authors excluded all patients with nonprimary intracerebral hemorrhage as well as those who received no treatment. Forty patients with IVH and subsequent hydrocephalus were examined, and 40 more patients with pure ganglionic hematomas were matched with regard to age, sex, Glasgow Coma Scale score, need for mechanical ventilation, and, in particular, hematoma volume. Outcome analysis was performed using the Barthel Index and the modified Rankin Scale (mRS). The mean hematoma volume was 25.3 +/- 15.2 ml. The overall long-term outcome was unfavorable (mRS Score 4-6) in 59% of all patients. Good outcome (mRS score < 4) was observed in 25 (62.5%) of 40 patients with hematoma volumes less than 25 ml, compared with eight (20%) of 40 who had hematoma volumes greater than 25 ml (p < 0.05, chi-square test). The need for an EVD was not associated with a worse long-term outcome in patients with comparable hematoma volumes. In contrast, the duration of treatment in the intensive care unit was longer for patients with EVDs than for those who had pure ganglionic hematomas (16 [range 5-29] days compared with 8 [range 2-19] days; p < 0.05, Mann-Whitney U-test), regardless of hematoma volume. CONCLUSIONS: The long-term outcome of treated patients with supratentorial ganglionic hemorrhage with ventricular involvement and occlusive hydrocephalus is comparable to that of patients with similar hematoma volumes but no IVH.     

Defining survivorship after high-grade aneurysmal subarachnoid hemorrhage

BACKGROUND: Outcome after high-grade aneurysmal SAH is poor. Various treatment paradigms have been advanced to improve treatment outcome and preserve resources, but none have addressed the potential salvageable life lost. METHODS: We retrospectively reviewed all patients with high-grade (H&H score, 4-5) aneurysmal SAH admitted to our institution from January 1998 to June 2002, all aggressively managed, to determine what clinical/radiographic criteria predicted favorable survival. RESULTS: There were 50 patients analyzed. All underwent emergency ventriculostomies or clot evacuations. Twenty-three patients (46%) improved and 7 (14%) worsened; 41 survived to receive definitive therapy. Twenty-one patients (42%) overall achieved a favorable outcome (GOS, 4-5). In the multivariate analysis (stepwise logistic regression), the postresuscitation GCSm alone predicted outcome (P= .004) with 70% cases correctly identified, whereas age, location of aneurysm (anterior circulation or not), presence of intraventricular hemorrhage, time to definitive intervention, clot on computerized tomography, type of therapy used (coil vs clip), pupillary abnormalities, and preresuscitation GCSm did not. Because the sole predictive parameter is obtained postresuscitation, no clinical or radiographic factor on presentation appears valid to determine eligibility for definitive care. CONCLUSION: Overall treatment outcome of our series is comparable with those of other articles. Our experience, as well as review of literature, does not support the existence of a validated "triage" schema to selectively treat patients with high-grade subarachnoid hemorrhage, implying that all such patients should be managed aggressively.     

Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage

OBJECT: Increased intracranial pressure (ICP) is well known to affect adversely patients with head injury. In contrast, the variables associated with ICP following aneurysmal subarachnoid hemorrhage (SAH) and their impact on outcome have been less intensely studied. METHODS: In this retrospective study the authors reviewed a prospective observational database cataloging the treatment details in 433 patients with SAH who had undergone surgical occlusion of an aneurysm as well as ICP monitoring. All 433 patients underwent postoperative ICP monitoring, whereas only 146 (33.7%) underwent both pre- and postoperative ICP monitoring. The mean maximal ICP was 24.9 +/- 17.3 mm Hg (mean +/- standard deviation). During their hospital stay, 234 patients (54%) had elevated ICP (> 20 mm Hg), including 136 of those (48.7%) with a good clinical grade (Hunt and Hess Grades I-III) and 98 (63.6%) of the 154 patients with a poor grade (Hunt and Hess Grades IV and V) on admission. An increased mean maximal ICP was associated with several admission variables: worse Hunt and Hess clinical grade (p < 0.0001), a lower Glasgow Coma Scale (GSC) motor score (p < 0.0001); worse SAH grade based on results of computerized tomography studies (p < 0.0001); intracerebral hemorrhage (p = 0.024); severity of intraventricular hemorrhage (p < 0.0001); and rebleeding (p = 0.0048). Both intraoperative cerebral swelling (p = 0.0017) and postoperative GCS score (p < 0.0001) were significantly associated with a raised ICP. Variables such as patient age, aneurysm size, symptomatic vasospasm, intraoperative aneurysm rupture, and secondary cerebral insults such as hypoxia were not associated with raised ICP. Increased ICP adversely affected outcome: 71.9% of patients with normal ICP demonstrated favorable 6-month outcomes postoperatively, whereas 63.5% of patients with ICP between 20 and 50 mm Hg and 33.3% with ICP greater than 50 mm Hg demonstrated favorable outcomes. Among 21 patients whose raised ICP did not respond to mannitol therapy, all experienced a poor outcome and 95.2% died. Among 145 patients whose elevated ICP responded to mannitol, 66.9% had a favorable outcome and only 20.7% were dead 6 months after surgery (p < 0.0001). According to results of multivariate analysis, however, ICP was not an independent outcome predictor (odds ratio 1.26, 95% confidence interval 0.28-5.68). CONCLUSIONS: Increased ICP is common after SAH, even in patients with a good clinical grade. Elevated ICP post-SAH is associated with a worse patient outcome, particularly if ICP does not respond to treatment. This association, however, may depend more on the overall severity of the SAH than on ICP alone.     

Prediction of death in patients with primary intracerebral hemorrhage: a prospective study of a defined population

OBJECT: Predictors of early (30-day) and long-term (1-year) mortality rates after primary intracerebral hemorrhage (ICH) were studied in a large population in southern Sweden. METHODS: All cases of primary ICH, verified using computerized tomography (CT) scanning or autopsy study, were prospectively registered at the 12 hospitals covering a defined population of 1.14 million during the calendar year 1996. Mortality was analyzed in relation to CT findings (hematoma location and volume and ventricular extension) and clinical parameters (patient age and sex, level of consciousness on admission, and history of preictal risk factors) by using univariate and multivariate statistical methods. Three hundred forty-one cases of primary ICH were detected. The overall mortality rate was 36% at the 30-day and 47% at the 1-year follow up. Multivariate analysis revealed that initial level of consciousness, hematoma volume, and a history of heart disease were independent predictors of death at 30 days postictus. One year after bleeding, independent predictors of mortality were the initial level of consciousness, patient age, and hematoma location. CONCLUSIONS: Primary ICH remains a stroke subtype associated with a high mortality rate and for which the level of consciousness on admission is the strongest predictor of fatal outcome both at 30 days and during the 1st year after bleeding. A preictal history of heart disease increased the 30-day mortality rate.     

Clinical features and management of intracranial hemorrhage in patients undergoing maintenance dialysis therapy

The management and outcome were retrospectively investigated in patients with chronic renal failure receiving maintenance blood purification who suffered intracranial hemorrhage. Patients with intracerebral hemorrhage (ICH, n = 36) or subarachnoid hemorrhage (SAH, n = 5) were evaluated. Both groups were initially managed using continuous hemofiltration (HF) after admission, except for two patients with SAH receiving maintenance peritoneal dialysis. Patients with ICH were managed with HF three times a week after computed tomography showed decreased peripheral edema. Nafamostat mesilate was used as the anticoagulant for both continuous HF and HF. Hemodialysis (HD) three times a week was initiated after confirming the absence of neurological deterioration using HF. Craniotomy was not performed in any patient with ICH, but if necessary, the hematoma was aspirated using burr-hole surgery. Angiography was performed on the day of admission in patients with SAH. Delayed neck-clipping surgery was performed after continuous HF for 2 weeks with lumbar cerebrospinal fluid drainage. In patients with ICH, continuous HF was continued for 2-9 days after admission (mean 5.2 +/- 2.2 days), followed by 2-9 courses of HF (mean 4.7 +/- 2.1 courses). HD was initiated 9-26 days after admission (mean 15.5 +/- 4.6 days). Favorable outcomes were achieved by 13 of the 36 patients with ICH and two of the five patients with SAH, whereas 22 patients with ICH and three patients with SAH died. Death occurred in 12 of 16 patients with ICH and diabetic nephropathy. In contrast, 10 of 20 non-diabetic patients with ICH had favorable outcomes. Ten of the 16 patients with initial GCS < or = 8 and six of the 20 with GCS > or = 9 were diabetic. Therefore, there were significant differences between diabetic and non-diabetic patients (p = 0.05). Poor outcomes in diabetic patients with ICH are caused by primary brain damage, reflected in the initial disturbance of consciousness.     

Brain temperature in patients with chronic hydrocephalus after subarachnoid hemorrhage

The relationships between temperature indices and clinical condition on admission or improvement after ventriculoperitoneal (VP) shunting were evaluated in patients with subarachnoid hemorrhage (SAH). Brain temperatures were measured at intervals of 1 cm from the brain surface to the lateral ventricle at shunt operation. Rectal temperature was also measured. The difference between intraventricular and rectal temperatures was correlated with age (p = 0.0486), Glasgow Coma Scale (p = 0.0129), Hunt and Hess grade (p = 0.0101), and improvement score after VP shunting (p = 0.0104). Measurement of brain temperature may predict the outcome of VP shunting in patients with SAH.     

Intracerebral hemorrhage in patients with chronic liver disease

The characteristics of intracerebral hemorrhage (ICH) accompanying chronic liver disease (CLD) were investigated in ICH patients hospitalized between 1998 and 2008 divided into the CLD group (55 ICHs in 49 patients) and the idiopathic group without CLD (668 ICHs in 648 patients). The CLD group included a subgroup with liver cirrhosis (LC). Age, sex, history of hypertension, Glasgow Coma Scale (GCS) score on admission, and hematoma locations were reviewed. Outcomes on discharge and causes of in-hospital death were also studied. Factors associated with life prognosis in CLD patients were investigated using uni- and multivariate analyses. History of hypertension and deep cerebral hemorrhage were less frequent in the LC subgroup compared to the idiopathic group. Distributions of GCS scores on admission were not significantly different, but incidence of in-hospital death was significantly higher in the CLD group than in the idiopathic group. LC was an independent prognostic factor for CLD patients, but hematoma enlargement was not. Death primarily due to ICH was less frequent in the CLD group than in the idiopathic group. In conclusion, hemostatic disorders seemed to be related to site of hemorrhage, but not to life prognosis in the CLD group. Prognosis was mainly worsened by non-neurological complications.     

Pituitary apoplexy manifesting as massive intracerebral hemorrhage

A 68-year-old man presented with severe conscious disturbance caused by pituitary apoplexy resulting in massive intracerebral hemorrhage (ICH). He had been periodically followed up for asymptomatic pituitary adenoma at another hospital for 8 years. Neuroimaging examination revealed pituitary apoplexy and massive ICH located in the left frontal lobe, and the ICH was directly connected to the intratumoral hemorrhage. The diagnosis was massive ICH from pituitary apoplexy. The patient underwent emergent evacuation of hematoma and removal of the pituitary adenoma via bi-frontal craniotomy. Postoperatively, he continued to exhibit deep consciousness disturbance and died 1 month after the operation. Pituitary apoplexy is usually characterized by intra-tumoral hemorrhage. The treatment strategy for asymptomatic pituitary adenoma is still controversial. This case shows that we should always consider the risk of pituitary apoplexy manifesting as ICH which may cause a fatal outcome.     

Rebleeding of ruptured intracranial aneurysms in the acute stage

We analyzed early aneurysmal rebleeding in 150 consecutive patients who suffered an aneurysmal subarachnoid hemorrhage (SAH) and who were admitted within 6 hours of the initial SAH. Of these patients, 33 patients rebled. The first rebleed occurred within 24 hours in 29 patients, among whom 23 cases rebled within 6 hours. The rebleeding rate within 6 hours after the initial SAH was not related to age or sex of the patient; blood pressure on admission; size, shape, or site of aneurysm; or presence or absence of intracerebral hematoma or intraventricular hemorrhage on computed tomography (CT) scan. The patients' clinical condition and SAH on CT scan were graded I-V. Evaluation of rebleeding of those patients with grade V was difficult. In examining the rebleeding rate in grades I-IV, the higher the grade, the greater the rebleeding. Rebleeding developed during angiography conducted within 6 hours from the initial SAH in four cases. This is approximately twofold higher than the rebleeding rate within 6 hours for the total series. It is concluded that rebleeding in the acute stage is predominant within 6 hours from the initial SAH and that this rebleeding rate is higher the more severe the initial SAH is.     

Hypomagnesemia after aneurysmal subarachnoid hemorrhage

OBJECTIVE: Hypomagnesemia frequently occurs in hospitalized patients, and it is associated with poor outcome. We assessed the frequency and time distribution of hypomagnesemia after aneurysmal subarachnoid hemorrhage (SAH) and its relationship to the severity of SAH, delayed cerebral ischemia (DCI), and outcome after 3 months. METHODS: Serum magnesium was measured in 107 consecutive patients admitted within 48 hours after SAH. Hypomagnesemia (serum magnesium <0.70 mmol/L) at admission was related to clinical and initial computed tomographic characteristics by means of the Mann-Whitney U test. Hypomagnesemia at admission and during the DCI onset period (Days 2-12) was related to the occurrence of DCI and hypomagnesemia at admission, and hypomagnesemia that occurred any time during the first 3 weeks after SAH was related to outcome. RESULTS: Hypomagnesemia at admission was found in 41 patients (38%) and was associated with more cisternal (P = 0.006) and ventricular (P = 0.005) blood, a longer duration of unconsciousness (P = 0.007), and a worse World Federation of Neurosurgical Societies scale score at admission (P = 0.001). The crude hazard ratio for DCI with hypomagnesemia at admission was 2.4 (95% confidence interval, 1.0-5.6), and after multivariate adjustment it was 1.9 (95% confidence interval, 0.7-4.7). The hazard ratio of hypomagnesemia from Days 2 to 12 for patients with DCI was 3.2 (range, 1.1-8.9) after multivariate adjustment. The crude odds ratio for poor outcome (Glasgow Outcome Scale score, 1-3) with hypomagnesemia at admission was 2.5 (range, 1.1-5.5). Hypomagnesemia at admission did not contribute to the prediction of outcome in the multivariate model. CONCLUSION: Hypomagnesemia is frequently present after SAH and is associated with severity of SAH. Hypomagnesemia occurring between Days 2 and 12 after SAH predicts DCI.     

Safety and efficacy of extra-ventricular drainage combined with urokinase administration in the management of intraventricular hemorrhage

BackgroundIntraventricular hemorrhage (IVH) is a severe form of stroke. Studies of existing treatment options are controversial. Therefore, we aimed to evaluate the safety and efficacy of extra ventricular drainage (EVD) combined with uPA administration for the treatment of IVH.MethodsThe clinical data of 157 IVH patients admitted to our department during 2019-2022 were retrospectively analyzed. Based on the Glasgow Outcome Score (GOS) after 30 days, patients were categorized into favorable outcome (GOS4-5) and poor outcome (GOS1-3), and factors with prognostic impact were screened by univariate and multifactorial analysis, followed by propensity score matching and screening of paired patients for comparative analysis between the uPA and non-uPA groups.ResultsPatient age, uPA use, initial GCS score, and intracranial hematoma volume can all influence the patient's GOS. After propensity score-matched screening, 72 patients were finally included, 36 each in the uPA and non-uPA groups. Analysis revealed that at the follow-up after 30 days, 50.0% of patients with a GOS score of 4-5 were in the uPA group compared with 30.6% in the non-uPA group; however, they were not statistically significantly different. In contrast, the mean clearance of hematoma after four days was significantly higher in the uPA group than in the non-uPA group (P < 0.05) and did not increase the incidence of postoperative complications (P > 0.05).ConclusionuPA treatment may eliminate hematomas faster and reduce the rate of obstruction. However, its effectiveness in improving patient prognosis does not appear to be significant. Therefore, studies with larger samples may be needed to further validate its effectiveness.     

无蛛网膜下腔出血的大脑中动脉动脉瘤破裂

目的总结无蛛网膜下腔出血（SAH）的大脑中动脉（MCA）动脉瘤破裂的临床特点。方法对6例在首次CT扫描上表现为脑内出血（ICH），或壁内出血（IMH）而无SAH的MCA动脉瘤破裂患者的临床表现、影像学检查、治疗方法和预后进行回顾性总结。结果本组首次CT扫描时间为起病后0—2d，表现为单纯ICH者4例，IMH者2例。DSA和手术证实为MCA动脉瘤破裂。开颅动脉瘤切除1例，夹闭5例，其中4例同时行血肿清除术。术后无死亡。结论MCA动脉瘤破裂首次CT扫描可仅表现为ICH或IMH而无SAH，与动脉瘤的部位、出血量以及CT扫描时间相关。     

Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage

OBJECT: Previous studies have indicated an increased incidence of death in patients with subarachnoid hemorrhage (SAH) who are currently receiving anticoagulation therapy. The significance of previous aspirin use in patients with SAH is unknown. The authors analyzed the effects of prior aspirin use on clinical course and outcomes following aneurysmal SAH. METHODS: The medical records of 305 patients with angiogram-confirmed aneurysmal SAH who consecutively presented to our institution between 1990 and 1997 within 7 days of ictus were analyzed. Twenty-nine (9.5%) of these patients had a history of regular aspirin use before onset of the SAH. The Glasgow Outcome Scale (GOS) was used to measure patient outcome at the longest available follow up. Aspirin users were older on average than nonusers (59 years of age compared with 53 years; p = 0.018). The mean admission Hunt and Hess grades of patients with and without aspirin use were similar (2 compared with 2.3; p = 0.51). Two trends, which did not reach statistical significance, were observed. 1) The rebleeding rate in aspirin users was 14.3%, compared with a 4.7% rebleeding rate in nonusers (p = 0.06). 2) Permanent disability from vasospasm was less common among aspirin users (23% compared with 50%; p = 0.069). Outcomes did not differ between aspirin users and nonusers (mean GOS Score 3.83 compared with GOS Score 3.86, respectively; p = 0.82). CONCLUSIONS: Despite trends indicating increased rebleeding rates and a lower incidence of permanent disability due to delayed ischemic neurological deficits, there was no significant effect of previous aspirin use on overall outcome following aneurysmal SAH. Based on these preliminary data, the presence of an intracranial aneurysm is not a strict contraindication to aspirin use.     

Spontaneous intracerebral hemorrhage: epidemiology and clinical presentation

The advent of widespread CT availability has dramatically changed our understanding of the incidence and risk factors regarding intracerebral hemorrhage (ICH). In the pre-CT era, many patients with a small ICH were misclassified having had ischemic strokes and patients with massive ICH or subarachnoid hemorrhage (SAH) were often difficult to classify correctly. The fact that the precise mechanism of spontaneous ICH is often difficult to ascertain without pathologic evidence continues to hamper epidemiologic studies. This article reviews the incidence rates, natural history, epidemiology, and clinical presentations of nontraumatic ICH.