The role of antifibrinolytic therapy in the preoperative management of recently ruptured intracranial aneurysms

In a retrospective study of the use of antifibrinolytic therapy in a series of patients with recently ruptured intracranial aneurysms, 131 patients were selected based on the following criteria: commencement of therapy within 3 days of the last subarachnoid hemorrhage (SAH); continuation of therapy for at least 6 days; and apparently uncomplicated surgery. Two main modalities of antifibrinolytic therapy were used: Group A, tranexamic acid (AMCA) 3 gm daily plus aprotinin k.i.u. (kallikrein inactivating units) daily (82 cases); Group B, AMCA 6 gm daily (41 cases). The remaining 8 patients were treated with epsilon-aminocaproic acid alone or in combination with aprotinin and were not considered to constitute a large enough group for statistical comparison. The rest of the preoperative treatment consisted of bed rest; mild sedation; antihypertensives, if the blood pressure exceeded 160 mm Hg; and osmotic diuretics as needed. The mean interval between last SAH and operation was about 13 days in both groups. The rates of rebleeding and thromboembolism were similar in the two groups but the rates of ischemic complications and post-SAH hydrocephalus were higher in Group B. The difference in the rate of severe cerebral ischemic complications was statistically significant (11 of 82 in Group A versus 12 of 41 in Group B, p less than 0.02), and in the main they were present preoperatively. The rates of rebleeding (approximately 10%) and of death from rebleeding (approximately 5%) are lower than in other published series on the natural history of this condition. In cases in which antifibrinolytics are indicated, present evidence indicates that low-dose AMCA plus aprotinin seems to be a rational combination for lowering the rebleeding, ischemic complication, and post-SAH hydrocephalus rates.     

Relation of cerebral vasospasm to operative findings of subarachnoid blood around ruptured aneurysms

Summary An investigation was carried out in 28 patients in order to evaluate the relationship between angiographically documented vasospasm, amount of subarachnoid blood found at surgery around ruptured intracranial aneurysms, and delayed ischaemic deficits. Angiography was performed at time intervals ranging between 5 and 17 days, and surgery not later than 21 days following subarachnoid haemorrhage. The absence of subarachnoid clots was associated in ten patients, with no or minor vasospasm and no or mild neurological deficits. Thin clots were found in eight patients; one of them had no vasospasm, six had minor vasospasm, and one showed severe vessel narrowing. Major clinical signs were absent in these cases. All ten patients with thick clots developed severe vasospasm, and eight of them severe neurological signs.The important aetiological role of local subarachnoid clots in determining vasospasm is emphasized in view of surgical timing.     

Spontaneous subarachnoid haemorrhage and ruptured aneurysms in the Middle East. A myth revisited

Summary The difficulties and controversies regarding the incidence of spontaneous subarachnoid haemorrhages (SSH) and ruptured intracranial aneurysms in the Middle East prompted the revision of the experience in the State of Qatar, considering the unique and favourable conditions provided by its size and Health Care System. Methodological sources of error such as diagnostic criteria and referral pattern were carefully scrutinized and evaluated.The incidence of both entities were in fact lower than any western reported values: 2.69 spontaneous subarachnoid haemorrhages and 1.04 ruptured aneurysms per 100000 inhabitants/year. This value remained low even when estimated values for possible underdiagnosing errors were added.Age, sex, population at risk and the low incidence of some risk factors are probably related to the values found.     

Rupture of intracranial aneurysms and ventricular opacification during carotid angiography

Summary Two cases of rupture of intracranial aneurysms and opacification of the lateral ventricles occurring during carotid angiography are reported and X-rays of the haemorrhage from the aneurysms are presented.Though the possibility of this complications remains a real one, the early use of this valuable procedure should not be precluded.     

Screening for intracranial aneurysms in autosomal dominant polycystic kidney disease

SUMMARY:   Screening patients with autosomal dominant polycystic kidney disease (ADPKD) for asymptomatic intracranial aneurysms has been proposed as a method of reducing the morbidity and mortality associated with aneurysm rupture. However, recent studies have shown lower spontaneous rupture rates of small aneurysms and higher risks of significant complications with interventions than previously reported. Risk-benefit analysis has not demonstrated any benefit of screening ADPKD patients without a history of subarachnoid haemorrhage (SAH) for intracranial aneurysms, and has suggested that screening might cause harm.     

Does a safe size-limit exist for unruptured intracranial aneurysms?

Summary Of 1076 patients with intracranial ruptured aneurysms (RA) included in the Danish Aneurysm Study, 948 had the RA verified by angiography. Of these cases 908 RA had a maximum diameter less than 25 mm. 162 RA were <5 mm, 474 and 272 were between 5–10 mm and 11–24 mm, respectively. The average diameter of the RA according to the day of angiography after the aneurysm rupture did not differ significantly within the first 10 days. In these circumstances, using this indirect method for estimation of aneurysm rupture according to the size, we also recommend that unruptured aneurysms with a size 10 mm or less should be seriously considerated for operation.     

Multiple intracranial aneurysms in identical twins

Summary Familial intracranial aneurysms are well documented, with the highest association occurring among siblings. Five pairs of identical twins with subarachnoid hemorrhage have been previously reported. We present the sixth set of identical twins with multiple aneurysms. These cases represent the first report in the literature of multiple mirror aneurysms in identical twins. One twin presented with subarachnoid hemorrhage. Her sister, who was asymptomatic, had elective angiography which demonstrated multiple aneurysms in locations identical to her sister's aneurysms.In families in which a twin presents with subarachnoid hemorrhage, it is appropriate to recommend angiography to the asymptomatic twin.     

Characteristics and management of ruptured distal middle cerebral artery aneurysms

Summary Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.     

Anaesthetic management of intracranial aneurysms, arteriovenous malformationsand carotid endarterectomy

Spontaneous subarachnoid haemorrhage is usually caused by rupture of intracranial aneurysms or arteriovenous malformations and requires treatment using surgical or endovascular techniques. Careful preparation of the patients is required before surgery. Intensive observation and management are required perioperatively to prevent rebleeding or cerebral ischaemia and to provide optimal operating conditions for the neurosurgeon. Rapid awakening after the operation allows early neurological assessment and treatment of operative complications. After surgery these patients should be managed on a high-dependency unit or an intensive care unit to allow rapid detection and treatment of post-operative complications. Hypertensive, hypervolaemic haemodilution may be indicated if cerebral vasospasm develops. Carotid endarterectomy can be performed under local or general anaesthesia and each technique has advantages and disadvantages. Careful monitoring is required to ensure adequate cerebral perfusion during cross-clamping of the artery and to detect and manage post-operative complications without delay.     

以蛛网膜下腔出血起病的颅内多发动脉瘤的诊治

【摘要】〓随着脑血管成像技术的广泛应用及不断提高,动脉瘤性蛛网膜下腔出血患者中多发动脉瘤检出率越来越高。研究表明既往有蛛网膜下腔出血病史患者的未破裂动脉瘤破裂风险要高于无蛛网膜下腔出血病史者,对于发生动脉瘤破裂的多发动脉瘤患者除明确责任动脉瘤并首先处理外,其未破裂动脉瘤也应尽量检出并积极治疗,因此多发动脉瘤的诊断和治疗均要比单发动脉瘤复杂。     

Familial occurrence of multiple intracranial aneurysms case reports and review of the literature

Summary The authors report a family in which two members had multiple intracranial aneurysms. This is the third reported family with more than one member affected by multiple cerebral aneurysms. The congenital nature and the patterns of inheritance of the disease are discussed. The indications for elective investigation of the asymptomatic relatives and surgical prophylaxis on asymptomatic aneurysms are also briefly discussed.     

Prognosis with 500 ruptured and operated intracranial arterial aneurysms

Based on a series of 500 operated intracranial aneurysms in 486 patients, we have analyzed the results of current neurosurgical treatment. The overall results (75% cures, 13% poor results, 12% deaths) depend on several factors, which have all to be analyzed: the age and general condition of the patient; the topography and mode of rupture of the aneurysm; and the timing of the surgical intervention.     

Spontaneous thrombosis of ruptured intracranial aneurysms during treatment with tranexamic acid (AMCA)

Summary Radiographically verified spontaneous disappearance of medium-sized arterial cerebral aneurysms is seldom reported, and only three times in connection with antifibrinolytic therapy (EACA). In our clinic repeat angiograms have shown non-filling of the aneurysms in three patients during treatment with tranexamic acid (AMCA) two, three, and four weeks respectively after primary bleeds. Initially, all three patients had severe radiological vasospasm associated with neurological deterioration. Follow-up angiograms have demonstrated partial reappearance of the aneurysm after one month in one patient and complete disappearance of the aneurysms in the other two patients after 9 and 22 months respectively. In two cases occlusion of cerebral arteries occurred. With regard to the higher risk of severe vasospasm and occlusion of cerebral arteries in our opinion it should not be a therapeutic goal to try to achieve a thrombosis of a ruptured aneurysm with antifibrinolytic drugs.The reason for spontaneous aneurysm thrombosis during treatment with AMCA may be a local inhibition of plasminogen activators in and around the aneurysm wall. It may also be related to the sympathomimetic property of the drug, with vasospasm and a subsequent flow-reduction inside the aneurysm or a possible interaction with other drugs and substances.     

Co-existence of abdominal aortic aneurysms and intracranial aneurysms

Summary The occurrence of abdominal aortic aneurysms (AAAs) and intracranial aneurysms (IAs) in the same patient and in the same family was studied among 89 patients with AAAs and 485 patients with IAs. Among the AAA-patients two had IAs themselves and five had IAs in the family, whereas three IA-patients had AAAs themselves and eight had AAAs in the family. Moreover, one of the patients with both AAA and IA had a blood relative with AAA, and in six of the families with both types of aneurysms there were more than two subjects with aneurysms. The results indicate, that AAAs and IAs may have a common aetiologic factor.     

Multiple intracranial aneurysms in elderly patients

Summary The clinical characteristics of elderly patients with multiple intracranial aneurysms were studied. A total of 481 patients, in whom the exact location of their ruptured aneurysms could be confirmed, were classified into two age groups, that is, those aged 59 years or younger (group 1: 247 cases, 51%) and those aged 60 years or older (group 2: 234 cases, 49%). The incidences of multiple aneurysms were 30% for group 1 and 27% for group 2. This difference is statistically not significant. The rate of multiple aneurysms was less frequent in males than in females in group 2, whereas no difference could be found in group 1. The age distribution of patients with multiple aneurysms was basically similar to that of patients with single aneurysms. While the highest rupture rate was observed in the anterior communicating artery aneurysms of both groups, this tendency was more prominent in group 2(79%) than in group 1 (59%). The rupture rates for other sites in group 2 were 50% for distal anterior cerebral artery aneurysms, 40% for internal carotid artery aneurysms and 28% for middle cerebral artery aneurysms. The pattern of surgical outcome showed no major differences between multiple and single aneurysms in either group 1 or 2. However, group 1 had better surgical results than group 2.Even though the surgical outcome for multiple aneurysms in elderly patients was satisfactory, awareness of the probability of rupture at each site is helpful, especially when it is necessary to decide whether unruptured aneurysms should be operated on or not.     

MRI in multiple vascular lesions: Identification of the ruptured malformation

Summary 4 patients were recently admitted for subarachnoid haemorrhage with multiple vascular lesions. 3 of them presented with multiple aneurysms, and one with an aneurysm associated with an arterio-venous malformation. In these 4 cases identification of the ruptured lesion was difficult in spite of clinical examination, CT scan, and complete panangiography; on magnetic resonance imaging (MRI) was found a signal hyperintensity, mainly on T2 weighted views, corresponding to blood clots around the ruptured aneurysm. This signal hyperintensity was completely absent in the vicinity of the associated vascular lesion, which appeared only as a signal void corresponding to the blood flow inside the unruptured lesion. Therefore MRI can be used in such cases to identify the ruptured lesion, so permitting the choice of the best approach and strategy of treatment.     

Spontaneous cure of ruptured intracranial arterial aneurysms

The case of a patient who had spontaneous cure of an intracranial saccular aneurysm, documented by angiography, is reported. This occurred in a 41-year-old patient, admitted four months after recurrent subarachnoid hemorrhage due to an angiographically verified supraclinoid internal carotid artery aneurysm. The relevant literature is reviewed, and the possible mechanism of spontaneous aneurysmal thrombosis is briefly discussed. It is concluded that repeating angiography is not without merit in patients with already documented cerebral aneurysms who are referred for surgical treatment some time after a subarachnoid hemorrhage.     

From intracranial pressure to intracranial pressure wave-guided intensive care management of a patient with an aneurysmal subarachnoid haemorrhage

We report on a 65-year-old female with an aneurysmal subarachnoid hemorrhage (SAH) that was followed clinically, radiologically and electrophysiologically before and after converting from intracranial pressure (ICP)-guided to ICP wave-guided intensive care management. Intracranial pressure-guided management is aimed at keeping mean ICP < 15-20 mmHg, while ICP wave-guided management is aimed at keeping mean ICP wave amplitude < 5 mmHg. The aims of management were obtained by adjusting cerebrospinal fluid (CSF) draining volume from her external ventricular drain. No improvement was seen clinically or in cerebral magnetic resonance imaging (MRI) scans during the ICP-guided management. Clinical, MRI and neurophysiologic (electroencephalography and auditory evoked responses) improvements were obvious within 2 days after converting from ICP- to ICP wave-guided management. This case report describes how we used various ICP parameters to guide intensive care management of an aneurysmal SAH patient.     

Effect of antifibrinolytic therapy on subarachnoid fibrosis in dogs after experimental subarachnoid haemorrhage

Summary The effect of antifibrinolytic therapy on posthaemorrhagic subarachnoid fibrosis was observed experimentally in dogs with the scanning electron microscope (SEM). The subchronic subjects, given intravenous injections of tranexamic acid (1 mg/day) for 12 days and sacrificed 3 weeks after cisternal blood injection, showed residual clot with thick fibrosis, especially around the haemorrhage. The chronic subjects, to which the same procedure was applied and which were sacrificed three months after cisternal blood injection, showed significant increases in the subarachnoid fibrosis, most remarkably in the parasagittal region.Tranexamic acid is widely used for preventing the recurrence of subarachnoid haemorrhage. However, it was revealed in this study that antifibrinolytic therapy might increase chronic posthaemorrhagic subarachnoid fibrosis, which is considered to be responsible for communicating hydrocephalus by disturbing epicortical CSF flow⁴.