Relation among aneurysm size, amount of subarachnoid blood, and clinical outcome

OBJECT: The authors of recent reports have suggested that smaller aneurysms are associated with more extensive subarachnoid hemorrhage (SAH), which could potentially presage poor outcome in patients harboring these lesions. The authors reviewed their clinical experience to determine if this theory has a basis in truth. METHODS: The authors undertook a retrospective review of a consecutive series of patients with aneurysmal SAH. Computed tomography scans and angiograms were studied to establish SAH scores and aneurysm size. RESULTS: One hundred thirty-three patients were treated during a 2-year period (January 2003-December 2004). There were 101 female and 32 male patients whose mean age was 56.7 years. The location distribution of aneurysms that bled was as follows: anterior communicating artery (56 cases), posterior communicating artery (34 cases), middle cerebral artery (21 cases), posterior circulation (16 cases), and paraclinoid region (six cases). The mean aneurysm size was 6.2 mm (range 2-26 mm). The mean SAH score was 18.3 (not normally distributed, p < 0.01, D'Agostino-Pearson test). One hundred three patients underwent surgical exploration and placement of an aneurysm clip, 21 underwent deployment of a coil, and two underwent both therapies; seven patients died prior to intervention. No correlation was found between aneurysm size and SAH score (r(s) = -0.023, p = 0.8) or between small aneurysm size and poor Glasgow Outcome Scale score (p = 0.13). In fact, the trend was the opposite. The SAH score did, however, correspond strongly with the admission Hunt and Hess grade (p < 0.0001), indicating the strong correlation between grade and volume of intracranial blood. Outcome was best explained in the multivariate analysis by the following factors: admission Hunt and Hess grade, age, and clinical vasospasm (p < 0.0001) with the proportion of cases correctly classified as 79.7%. CONCLUSIONS: Evaluation of the results in the present clinical series suggests that there is no relation between aneurysm size and volume of subarachnoid blood. The volume of cisternal blood correlates with Hunt and Hess grade but is not an independent determinant of outcome. Outcome is related to the following triad of well-established clinical factors: Hunt and Hess grade, age, and clinical vasospasm.     

Neurogenic pulmonary edema in patients with subarachnoid hemorrhage

Neurogenic pulmonary edema (NPE), leading to cardiopulmonary dysfunction, is a potentially life-threatening complication in patients with aneurysmal subarachnoid hemorrhage (SAH). We sought to assess the clinical presentation and risk factors for the development of NPE after SAH. The database contained prospectively collected information on 477 patients with SAH. Baseline characteristics, clinical and radiologic severity of the bleeding, localization of the ruptured aneurysm, and clinical outcome of patients with NPE were compared with those of patients without NPE. Further, in patients with NPE, intracranial pressure, serum cardiac biomarkers, and hemodynamic parameters during the acute phase were evaluated retrospectively. The incidence of NPE was 8% (39 of 477 patients). Most patients with NPE were severely impaired and all of them presented with radiologically severe hemorrhage. The incidence of NPE was significantly higher in patients with ruptured aneurysm in the posterior circulation. Elevated intracranial pressure was found in 67%, pathologically high cardiac biomarkers in up to 83% of patients with NPE. However, no patient suffered from persistent cardiac dysfunction. Compared with patients without NPE, patients with NPE showed poor neurologic outcome (Glasgow outcome scale 1 to 3 in 25% vs.77% of patients). In conclusion, patients with NPE have a high mortality rate more likely due to their severity grade of the bleeding. Morbidity and mortality due to cardiopulmonary failure might be reduced by appropriate recognition and treatment. The awareness of and knowledge about occurrence, clinical presentation, and treatment of NPE, are essential for all those potentially confronted with patients with SAH in the acute phase.     

Acute subdural haematoma due to ruptured intracranial aneurysms

Acute spontaneous subdural haematoma (SDH) is rarely associated with rupture of intracranial saccular aneurysm. We report our experience with four cases of non-traumatic SDHs secondary to rupture of an intracranial aneurysm and discuss the diagnosis and management of this condition. We retrospectively reviewed of four cases of acute SDH due to cerebral aneurysm rupture confirmed by cerebral angiography and surgery. Patients were evaluated using the Glasgow Coma Scale (GCS) and subarachnoid grade of the World Federation of Neurosurgical Societies (WFNS) and outcome with the Glasgow Outcome Scale (GOS). Of the 232 patients with non-traumatic subarachnoid haemorrhage (SAH) treated between 1993 and 2002, only four patients (1.72%) presented SDH due to aneurysmal rupture. The SAH grade on admission was grade IV in one patient and V in the other three. In all cases the aneurysm was located in the posterior communicating artery. Spontaneous acute SDH secondary to aneurysm rupture has been rarely reported. We suggested that timely SDH removal and aneurysmal clipping surgery should be performed in such patients, including those in poor neurological condition.     

Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial

OBJECTIVE: To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery. METHODS: In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected. RESULTS: Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different. CONCLUSIONS: Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.     

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.     

Nimodipine in aneurysmal subarachnoid hemorrhage: a randomized study of intravenous or peroral administration

OBJECT: The calcium antagonist nimodipine has been shown to reduce the incidence of ischemic complications following aneurysmal subarachnoid hemorrhage (SAH). Although most randomized studies have been focused on the effect of the peroral administration of nimodipine, intravenous infusion is an alternative and the preferred mode of treatment in many centers. It is unknown whether the route of administration is of any importance for the clinical efficacy of the drug. METHODS: One hundred six patients with acute aneurysmal SAH were randomized to receive either peroral or intravenous nimodipine treatment. The patients were monitored for at least 10 days after bleeding in terms of delayed ischemic neurological deficits (DINDs) and with daily measurements of blood flow velocities in the middle cerebral arteries by using transcranial Doppler ultrasonography. Three months after SAH, clinical outcome and new cerebral infarctions according to MR imaging studies were recorded. RESULTS: Baseline characteristics (age, sex distribution, clinical status on admission, radiological findings, and aneurysm treatment) did not differ between the treatment groups. There was no significant difference in the incidence of DINDs (28 vs 30% in the peroral and intravenous groups, respectively) or middle cerebral artery blood flow velocities (> 120 cm/second, 50 vs 45%, respectively). Clinical outcome according to the Glasgow Outcome Scale was the same in both groups, and there was no difference in the number of patients with new infarctions on MR imaging. CONCLUSIONS: The results suggest that there is no clinically relevant difference in efficacy between peroral and intravenous administration of nimodipine in preventing DINDs or cerebral vasospasm following SAH.     

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.     

Neuropsychological assessments in patients with aneurysmal subarachnoid hemorrhage, perimesencephalic SAH, and incidental aneurysms

Subarachnoid hemorrhage (SAH) is known to be associated with long-term cognitive deficits. Neurosurgical manipulation on the brain itself has been reported to have influence on neuropsychological sequelae. The following is a comparative study on perimesencephalic and aneurysmal subarachnoid hemorrhage patients as well as elective aneurysm patients that was carried out to determine the isolated and combined impact of surgical manipulation and hemorrhage, respectively, on long-term neuropsychological outcome. Inclusion criteria were good neurological recovery at discharge (modified Rankin Scale 0 or 1) without focal neurological deficit. Standardized psychological testing covered attention, memory, executive functions, and mood. Thirteen aneurysmal SAH patients, 15 patients undergoing elective clipping, and 14 patients with perimesencephalic SAH were analyzed. Standardized neuropsychological testing and social/professional history questionnaires were performed 2 years (mean) after discharge. Memory impairment and slower cognitive processing were found in the aneurysmal and perimesencephalic SAH groups, while elective aneurysm patients showed signs of impaired attention. However, compared with norm data for age-matched healthy controls, all groups showed no significant test results. In contrast, signs of clinical depression were seen in 9/42 patients, 45 % of all patients complained of stress disorders and 55 % of patients were unable to work in their previous professions. Nearly normal neuropsychological test results on long-term follow-up in SAH patients were unexpected. However, a 50 % rate of unemployment accompanied with stress disorders and depression manifests insufficient social and workplace reintegration. Therefore, even more specific rehabilitation programs are required following inpatient treatment to attain full recovery.     

Deteriorating factors on the outcome in patients with fair grade of subarachnoid hemorrhage (WFNS grade I and II)

BACKGROUND AND PURPOSE: Although, the overall treatment results in aneurysmal subarachnoid hemorrhage (SAH) has been improving in recent years, more than 10% of the patients with WFNS grade I and II we have sought to determine the clinical variables for predicting poor functional outcome and symptomatic vasospasm (VS) in patients with individual WFNS grades. MEASUREMENTS: The eligible patient fulfilled the following conditions; (1) ruptured aneurysm located in the anterior part of the circle of Willis, (2) surgically clipped followed by craniotomy under microscope, (3) early surgery within 72 hours, (4) classified to WFNS grade I or II. The medical records were retrospectively reviewed in 119 patients (63 of grade I and 56 of grade II). Sex, age, Fisher's CT group, intraventricular hemorrhage (IVH), site of aneurysm, VS, hydrocephalus, premature bleeding and complications of various kinds were selected as the dependent variables. The contributions of these factors to outcome (Glasgow Outcome Scale, GOS) as well as VS were analyzed using the logistic regression method. MAIN RESULTS: Outcome was better in WFNS grade I (p=0.039), and VS occurred less often and responded well to various interventional techniques and drug delivery. No significant variables contributed to the poor outcome or VS in WFNS grade I. In WFNS grade II, logistic regression analysis showed that VS (OR 34.6, 95% CI, 30.8-38.9, p =0.012) and the complications (OR 52.4, 95% CI, 46.5-59.1, p=0.004) were significant predictors for a poor outcome. Fisher's group 3 was also the only significant factors in VS (OR 3.78, 95% CI, 3.35-4.28, p =0.039). The cause for the difference in outcome and VS were discussed in detail. CONCLUSION: The vasospasm and various kinds of complications were the predictive factors of poor clinical outcome, in patient of WFNS garde II. Therefore, careful management and meticulous/pertinent surgical maneuvers are mandatory to obtain better results in aneurysmal SAH, even in better WFNS grades.     

Preoperative ventriculostomy and rebleeding after aneurysmal subarachnoid hemorrhage

OBJECT: Despite the widespread use of ventriculostomy in the treatment of acute hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), there is no consensus regarding the risk of rebleeding associated with ventriculostomy before aneurysm repair. This present study was conducted to assess the risk of rebleeding after preoperative ventriculostomy in patients with aneurysmal SAH. METHODS: The authors reviewed the records of all patients with acute SAH who were treated at a single institution between 1990 and 1997. Thus, the records of 304 consecutive patients in whom an aneurysmal SAH source was documented on angiographic studies and who had presented to the authors' institution within 7 days of ictus were analyzed. Re-bleeding was confirmed by evidence of recurrent hemorrhage on computerized tomography scans in all cases. Forty-five patients underwent ventriculostomy for acute hydrocephalus after aneurysmal SAH at least 24 hours before aneurysm repair. Ventriculostomy was performed within 24 hours of SAH in 38 patients, within 24 to 48 hours in three patients, and more than 48 hours after SAH in four patients. The mean time interval between SAH and surgery in patients who did not undergo ventriculostomy was no different from the mean interval between ventriculostomy and surgery in patients who underwent preoperative ventriculostomy (3.6 compared with 3.8 days, p = 0.81). Fourteen (5.4%) of the 259 patients who did not undergo ventriculostomy suffered preoperative aneurysm rebleeding, whereas two (4.4%) of the 45 patients who underwent preoperative ventriculostomy had aneurysm rebleeding. CONCLUSIONS: No evidence was found that preoperative ventriculostomy performed after aneurysmal SAH is associated with an increased risk of aneurysm rebleeding when early aneurysm surgery is performed.     

Subarachnoid hemorrhage in the presence of both intracranial dissecting and saccular aneurysms--two case reports

Two patients presented with subarachnoid hemorrhage (SAH) associated with both intracranial dissecting and saccular aneurysms. Case 1, a 48-year-old woman, had a saccular aneurysm of the right internal carotid artery and dissecting aneurysms of the bilateral vertebral arteries. Case 2, a 52-year-old man, had three saccular aneurysms in the anterior circulation and a dissecting aneurysm of the unilateral vertebral artery. A saccular aneurysm was responsible for the SAH in both patients. Ruptured saccular aneurysms were treated with surgical clipping and unruptured dissecting aneurysms remained untreated. SAH recurred due to bleeding from an untreated dissecting aneurysm 4 days after the initial SAH in Case 1. Triple-H therapy, which causes increased hemodynamic stress, was not administered for symptomatic cerebral vasospasm after SAH in Case 2, because of the risk of bleeding from the untreated dissecting aneurysm, and the patient suffered cerebral infarction. The risk factors for this rare association are unclear, but both patients were smokers and had hypocholesterolemia including low apolipoprotein E levels. The clinical management of patients with SAH and both dissection and saccular aneurysms is complicated. Asymptomatic dissecting aneurysm has a benign clinical course in general, but hemodynamic stress related to stroke may induce abrupt development of dissecting aneurysms. Prophylactic obliteration during the acute stage of SAH may provide better outcomes if the unruptured dissecting lesion appears as obvious aneurysmal dilatation or pearl-and-string sign and is safely treatable with endovascular trapping.     

Early surgery-related complications after aneurysm clip placement: an analysis of causes and patient outcomes

OBJECT: Most reports of series on ruptured intracranial aneurysms contain information on select intraoperative complications. An understanding of all surgical complications, however, may guide us toward improved surgical procedures and enrich discussions concerning alternative management strategies, such as endovascular treatment, which are not exempt from complications and aneurysm recurrence. METHODS: The study consists of a retrospective review of the charts, images, and notes from follow-up visits of 143 consecutive patients with subarachnoid hemorrhage (SAH) who were surgically treated during a 3-year period by one neurosurgeon. A surgical complication was determined based on findings of a clinical and/or radiological study in the absence of confounding factors such as the initial SAH ictus, vasospasm, hydrocephalus, and septic status. Functional outcome was assessed between 2 and 3 months post-SAH by using the Glasgow Outcome Scale (GOS). A procedure-related surgical complication was diagnosed in 29 (20.3%) of 143 patients studied. A brain tissue injury, including cerebral edema and hemorrhagic contusions, was diagnosed in 6.3% of patients, an unpredicted residual aneurysm neck in 5.3% of patients, and a cranial nerve deficit in 2.8% of patients. Functional outcome was good in 22 (75.9%) of the 29 patients with surgical complications. Death due to a surgical complication occurred in one (0.7%) of 143 patients. CONCLUSIONS: Surgical complications are more prevalent than previously thought. They may have been overlooked previously because of the high percentage of good functional outcomes and low mortality rates in this group. The identification of surgical complications may encourage the search for solutions to improve surgical treatment of aneurysmal SAH.     

Risk factors for ischemic lesions following aneurysmal subarachnoid hemorrhage

OBJECT: The aim of this study was to test whether enoxaparin treatment (40 mg subcutaneously once daily) reduces the risk of cerebral infarction after subarachnoid hemorrhage (SAH) and to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography (CT) scans obtained 3 months after SAH. METHODS: After undergoing surgery for a ruptured aneurysm, 170 patients were randomized in a prospective, double-blind, placebo-controlled trial to test the effect of enoxaparin on the occurrence of ischemic lesions, which were demonstrated on follow-up CT scans available for 156 patients. The presence of lesions correlated highly with an impaired outcome, as assessed using both the Glasgow Outcome and modified Rankin Scales (p < 0.01). Lesions occurred in 101 (65%) of the 156 patients. In half of the patients (51 patients) no lesion was visible on the CT scan obtained on the 1st postoperative day in 51 patients. On univariate analysis, the presence of lesions at 3 months post-SAH was not associated with enoxaparin treatment but did correlate with several clinical, radiological, and prehemorrhage variables. Significant independent risk factors for lesions consisted of an impaired initial clinical condition (odds ratio [OR] 2.63, 95% confidence interval [CI] 1.03-6.73), amount of subarachnoid blood (OR 6.51, 95% CI 2.27-18.65), nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m.; OR 4.32, 95% CI 1.28-14.52), fixed symptoms of delayed ischemia (OR 5.21, 95% CI 1.02-26.49), duration of temporary artery occlusion during surgery (OR 1.66 per minute, 95% CI 1.20-2.31), and body mass index (OR 1.13/kg/m2, 95% CI 1.01-1.28). CONCLUSIONS: The presence of ischemic lesions can be predicted by the severity of bleeding, delayed cerebral ischemia, excess weight, duration of temporary artery occlusion, and occurrence of nocturnal aneurysm rupture.     

颅内动脉瘤致蛛网膜下腔出血患者调节性T细胞的表达及其与分级的关系

【摘要】〓目的〓探讨颅内动脉瘤致蛛网膜下腔出血(SAH)患者CD4+CD25+调节性T细胞(Treg)的表达及其与分级的关系。方法〓收集动脉瘤致SAH患者、颅内感染患者及健康人各50例,采用流式细胞术检测外周血Treg百分含量及其细胞因子转化生长因子(TGF-β1)及白介素10(IL-10)的平均荧光强度。比较三组上述三者的差异,并分析三者与动脉瘤致SAH的Hunt分级的相关性。结果〓动脉瘤组患者Treg、TGF-β1及IL-10均显著低于健康组,且明显低于颅内感染组,差异均有统计学意义,但颅内感染组与对照组无统计学差异。动脉瘤组患者Treg、TGF-β1及IL-10三者当中任意一者与Ⅰ~Ⅴ级当中任意一级均呈负相关性(所得r绝对值均大于0.7,P均小于0.05),三者均与Ⅴ级的相关度最大(P均小于0.001)。结论〓Treg、TGF-β1及IL-10可能是颅内动脉瘤患者的一个保护因素,其含量越低则破裂后SAH程度越重,因此三者具有重要临床意义。     

Low-molecular-weight heparin versus saphenofemoral disconnection for the treatment of above-knee greater saphenous thrombophlebitis: a prospective study

The objective of this study was to assess the efficacy, safety, and cost of low-molecular-weight heparin compared to saphenofemoral disconnection for the treatment of internal saphenous proximal thrombophlebitis (SPT). Eighty-four consecutive patients diagnosed as presenting SPT alone (symptoms/echo-Doppler) were divided into 2 comparable groups treated with (1) saphenofemoral disconnection under local anesthesia with a short hospital stay (n = 45) or (2) prospective enoxaparin on an outpatient basis for 4 weeks (n = 39). Informed consent was obtained and inclusion, exclusion, and withdrawal criteria were established. Patients were followed up at 1, 3, and 6 months. Thirty patients per group completed the study requirements. In the disconnection group, 2 patients (6.7%) presented complications of the surgical wound, 1 (3.3%) had SPT recurrence (however, there was no deep venous thrombosis), and 2 (6.7%) had nonfatal pulmonary embolism confirmed by radionuclide scan. In the enoxaparin group, there were 2 cases (6.7%) of minor bleeding (epistaxis and rectal bleeding) and 3 (10%) recurrences of SPT. In the enoxaparin group there was no case of progression of the thrombosis to the deep venous system or pulmonary embolism. The study found no statistically significant differences between saphenofemoral disconnection and enoxaparin in the treatment of SPT, but the low-molecular-weight heparin group had socioeconomic advantages.     

Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm.

This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months, and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic scans performed within 72 h of hemorrhage were analyzed to determine the severity of intraventricular and subarachnoid hemorrhage and the volume of intracerebral hematomas. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Intraventricular hemorrhage extension occurred in 109 of the 219 patients studied. Fourteen-day mortality increased from 7.3% in patients without IVH to 14.1% in those with moderate IVH (IVH score 1-6) and to 41.7% in those with more severe IVH (IVH score > 6). The corresponding figures for unfavorable outcome at 6 months are 19.8%, 30.5%, and 66.7%, respectively. According to logistic regression analyses, the severity of IVH was an independent predictor of mortality and functional outcome. The clinical outcome after aneurysm rupture is at least in part determined by the severity of IVH. Knowledge of the effect of IVH may help guide physicians in the care of patients with aneurysmal bleeding.     

Aneurysmal subarachnoid hemorrhage in the Yaeyama Islands, Japan, from 1989 to 2002

The aim of this study was to analyze epidemiological and clinical data of patients with aneurysmal subarachnoid hemorrhage (SAH) in the Yaeyama islands, an isolated subtropical region of Japan. A total of 94 patients (31 men and 63 women, mean age 57.3 years) were diagnosed as having non-traumatic SAH during a 13-year period from 1989 to 2002. The age-and sex-adjusted annual incidence rate of SAH was 17.4 per 100,000 population. The incidence of SAH was the highest in August. Seventy-nine patients were hospitalized within 24 hours after onset of SAH. Seventeen patients were transferred by helicopter. The Hunt and Kosnik grade was I in 29 patients (30.9%). The CT Fisher group was 3 in 42 patients (44.7%). Ruptured aneurysm was detected in 78 patients (saccular type in 70 patients, small size in 49 patients, and internal carotid artery in 28 patients). Rebleeding occurred in 20 patients (21.3%). Symptomatic vasospasm occurred in 26 patients (27.7%). Acute and chronic hydrocephalus occurred in 25 (26.6%) and 22 (23.4%) patients respectively. A total of 120 neurosurgical operations were performed in 70 patients (operation for ruptured aneurysm in 62, early operation in 39). A total of 42 operative complications occurred in 29 patients. Fifty-one patients (54.3%) had a good outcome. The number of full-time neurosurgeons did not influence the performance of neurosurgical operation and outcome. In conclusion, epidemiologically, the high incidence of SAH in August is unusual. Patients with aneurysmal SAH in the Yaeyama islands have common clinical characteristics and undergo standard neurosurgical treatment.     

Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronary artery bypass surgery

BACKGROUND: The purpose of this study was to determine whether the use of low-molecular-weight heparin before coronary artery bypass surgery would be associated with an increase in bleeding and use of blood products after the operation. METHODS: Sixty-four patients (48 men and 16 women) aged 64 +/- 10 years who were undergoing primary coronary artery bypass surgery were prospectively studied. Forty-one patients were treated with either subcutaneous enoxaparin 1 mg/kg twice daily (n = 21; enoxaparin group) or intravenous heparin (n = 20; heparin group). Patients received the last dose of enoxaparin 8.7 +/- 0.75 hours (range, 8-10 hours) before skin incision. Heparin was stopped before transfer to the operating room. An additional 23 consecutive patients who received neither enoxaparin nor heparin served as controls (n = 23). Anti-factor Xa activity, a measure of enoxaparin and heparin activity, was measured at the start of the operation in all patients. RESULTS: There was no perioperative mortality. The length of stay and frequency of postoperative complications were similar between groups. Preoperative anti-factor Xa activity was present only in the enoxaparin group (0.43 +/- 0.25 IU/mL). Chest tube drainage at 24 hours was 553 +/- 160 mL, 532 +/- 140 mL, and 587 +/- 230 mL for the enoxaparin, heparin, and control groups, respectively (P =.48). There was no difference among groups in the amount of blood products transfused. CONCLUSIONS: Enoxaparin administration more than 8 hours before coronary artery bypass surgery is not associated with increased postoperative bleeding or blood product transfusion.     

Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm

This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months, and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic scans performed within 72 h of hemorrhage were analyzed to determine the severity of intraventricular and subarachnoid hemorrhage and the volume of intracerebral hematomas. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Intraventricular hemorrhage extension occurred in 109 of the 219 patients studied. Fourteen-day mortality increased from 7.3% in patients without IVH to 14.1% in those with moderate IVH (IVH score 1–6) and to 41.7% in those with more severe IVH (IVH score >6). The corresponding figures for unfavorable outcome at 6 months are 19.8%, 30.5%, and 66.7%, respectively. According to logistic regression analyses, the severity of IVH was an independent predictor of mortality and functional outcome. The clinical outcome after aneurysm rupture is at least in part determined by the severity of IVH. Knowledge of the effect of IVH may help guide physicians in the care of patients with aneurysmal bleeding. Electronic Publication     

Racial differences in demographics, acute complications, and outcomes in patients with subarachnoid hemorrhage: a large patient series

OBJECT: Few studies have focused on the impact of racial differences in demographics, clinical characteristics, acute complications, and outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to examine this issue. METHODS: The authors evaluated prospectively collected data on 1711 adult patients with aneurysmal SAH who were entered into two randomized, double-blind, placebo-controlled trials conducted at neurosurgical centers in North America between 1991 and 1997. Admission characteristics, treatment modalities, in-hospital complications, and 3-month outcomes assessed by application of the Glasgow Outcome Scale were compared using the chi-square test, a t-test, the Wilcoxon rank-sum test, and multiple logistic regressions based on a significance level of 0.05 in 241 African-American, 1342 Caucasian, and 128 other racial minority patients. Caucasian patients were significantly older than patients of other races (p < 0.0001). African-American patients more frequently had a history of hypertension (p < 0.0001) and an elevated blood pressure at the time of admission (p < 0.0001). African-Americans and other racial minorities were more likely to have internal carotid artery aneurysms and Caucasians were more likely to have posterior circulation aneurysms (p = 0.0002). Rates of in-hospital complications were not significantly different except that pulmonary edema occurred more commonly in Caucasians (p = 0.036). After an adjustment was made for significant admission characteristics, the 3-month outcome was not significantly different among the races. CONCLUSIONS: Race was not found to be a prognostic factor for outcome after aneurysmal SAH. The higher SAH mortality rate previously observed in African-American patients is likely a result of a higher incidence of SAH in this group. These findings highlight the importance of primary prevention programs aimed at modifying risk factors for SAH.