Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus

Background  Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. Methods  Hospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated. Results  One hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients (p=0.5), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p=0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24±14 versus 15±8, 20.5±9 versus 11±7, and 30±13 versus 16±11 days, respectively; p≤0.01). In a logistic regression model, VS was independently associated with rebleeding, external ventricular drain placement, coiling, and UHC-expected LOS (odds ratios, 95% confidence interval 12.1, 2.3–62.6, 6.9, 1.6–30, 6.25, 1.3–29, and 1.1, 1.02–1.14, respectively). Conclusions  One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.     

动脉瘤术后分流依赖性脑积水的危险因素分析

目的 筛选动脉瘤术后发生分流依赖性脑积水(shunt-dependent hydrocephalus,SDH)的危险因素,为动脉瘤术后SDH临床治疗提供指导意见.方法 回顾性分析2019-01—2019-12在中南医院神经外科接受治疗的246例动脉瘤手术患者的相关临床资料,按是否并发SDH分为SDH组(27例)和非SD...     

Pressure compensation in shunt-dependent hydrocephalus with CSF shunt malfunction

This study is a retrospective analysis of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) data from 56 children with active hydrocephalus and cerebrospinal fluid (CSF) shunt malfunction. The pressures were measured from a separately sited CSF access device placed in the frontal horn of the lateral ventricle. Of the patients, 79% had an elevated ICP (mean 20±12 mmHg). A subgroup of patients demonstrated ten different forms of CSF-filled swelling. This group had significantly lower ICP recordings (P=0.000075) with a mean ICP of 8.5 mmHg compared with the remainder (22.9 mmHg). This pressure ’compensation’ was because of additional nonphysiological accommodation of CSF volume. Overall the CPP was normal in 35% of cases despite normal ICP occurring in only 11% of cases. The CPPs were not significantly different in those with and without compensation. Measurement of ICP may not always be a reliable indicator of shunt malfunction in shunt- dependent children who present with compensatory CSF-filled spaces. Received: 10 March 2000     

颅内破裂动脉瘤夹闭术和栓塞术后分流依赖性脑积水的系统评价

目的系统评价颅内破裂动脉瘤夹闭术和栓塞术后分流依赖性脑积水发生率。方法以脑积水、夹闭、介入、栓塞、颅内动脉瘤、脑动脉瘤、蛛网膜下腔出血/蛛网膜下隙出血,以及hydrocephalus、shunt、clipping、coiling、surgical、endovascular、embolization、treatment、intracranial aneurysm、cerebral aneurysm、subarachnoid hemorrhage等中英文词组,计算机检索1990年1月-2015年9月美国国立医学图书馆生物医学信息检索系统、荷兰医学文摘、Cochrane临床对照试验中心注册库、中国知网中国知识基础设施工程、万方数据库,辅助手工检索《中华神经外科杂志》、《中国现代神经疾病杂志》和《中国脑血管病杂志》等相关杂志,查阅关于颅内破裂动脉瘤夹闭术和栓塞术后分流依赖性脑积水发生率的临床研究。采用Jadad量表和Newcastle-Ottawa量表评价文献质量,Rev Man 5.3和Stata 13.1统计软件进行Meta分析。结果共获得731篇文献,经剔除重复和不符合纳入标准者,最终纳入18项临床试验共计15 920例颅内破裂动脉瘤患者,行夹闭术者10 038例、行栓塞术5882例。Meta分析显示:两种治疗方式术后分流依赖性脑积水发生率差异无统计学意义(OR=0.860,95%CI:0.720~1.030;P=0.110);分析结果的稳定性较差,但不存在发表偏倚(Egger法:P=0.795)。结论颅内破裂动脉瘤夹闭术和栓塞术后分流依赖性脑积水发生率无显著差异,但尚待进一步的高质量临床研究加以证实。     

Small cerebral aneurysms presenting with symptoms other than rupture

BACKGROUND: Recent natural history studies have suggested that unruptured intracranial aneurysms smaller than 1 cm have a low risk of rupture. Symptomatic aneurysms may be underrepresented in natural history studies because they are preferentially treated. The authors compared the number of patients with symptoms caused by unruptured intracranial aneurysms smaller than 1 cm treated surgically at their institution with similar patients enrolled in the International Study of Unruptured Intracranial Aneurysms (ISUIA) from their institution over the same time period. METHODS: The records of all unruptured aneurysms treated surgically at the Mayo Clinic from 1980 through 1991 were reviewed. There were 97 patients with 117 unruptured aneurysms smaller than 1 cm by angiography. Aneurysms with a history of rupture or larger than 1 cm on cross-sectional imaging were excluded from analysis. The presence and characteristics of symptoms directly attributable to the aneurysm were recorded. Comparison was made with patients from the Mayo Clinic enrolled in the ISUIA retrospective natural history cohort over the same time period. RESULTS: Of the 97 patients studied, 15 presented with symptoms other than rupture (15.5%). The symptoms were third nerve deficit (seven patients), cerebral ischemia owing to emboli originating from within the aneurysm (five patients), and visual acuity loss (three patients). Eleven other aneurysms had possibly but not definitively caused symptoms; these were considered asymptomatic. No patient from the Mayo Clinic enrolled in the retrospective cohort of the ISUIA had a symptomatic aneurysm smaller than 1 cm on both angiography and cross-sectional imaging. CONCLUSIONS: Unruptured intracranial aneurysms smaller than 1 cm occasionally present with neurologic symptoms. These symptoms are typically owing to mass effect on the second and third cranial nerves or cerebral ischemia as a result of emboli originating from within the aneurysm. Patients with symptomatic unruptured aneurysms less than 1 cm at the Mayo Clinic were preferentially treated. Although existing natural history data may be applied to most unruptured aneurysms, small symptomatic aneurysms may be underrepresented in natural history studies.     

实验室参数预测动脉瘤性蛛网膜下腔出血患者分流依赖性脑积水发生的价值

目的探讨实验室参数对动脉瘤性蛛网膜下腔出血(a SAH)后分流依赖性脑积水(SDHC)发生的预测价值。方法应用单因素、多因素非条件Logistic回归分析探讨影响a SAH患者SDHC发生的危险因素。结果 (1)SDHC组在年龄、脑室内出血比例、术前Hunt-Hess分级≥III级比例、术前空腹血糖、术后3 d血钠、术后3 d血钾、术后3 d空腹血糖方面与无SDHC组比较差异有统计学意义(χ~2=2.49,11.15,22.39,5.96,2.45,-2.69,5.47;P0.05);(2)年龄≥60岁、脑室内出血、术前Hunt-Hess分级≥III级、术前血钾3.48 mmol/L、术前空腹血糖≥160.25 mg/d L、术后3 d血钠≥145.54 mg/L、术后3 d血钾3.02 mmol/L、术后3d空腹血糖≥167.55 mg/d L是影响a SAH后SDHC发生的危险性因素(P0.05)。结论夹闭术术前及术后第3d血钠、空腹血糖、血钾与a SAH患者SDHC发生密切相关。     

Learning disability and impairment of synaptogenesis in HTX-rats with arrested shunt-dependent hydrocephalus

Using HTX-rats with congenital hereditary hydrocephalus, we used neuropathological methods, including quantitative Golgi study and neurobehavioral evaluation, to investigate the following problems. (1) What kind of damage does congenital hydrocephalus cause to developing brain tissue? (2) How much can the damage be repaired by ventriculoperitoneal shunting if performed at 4 weeks of age, enabling 4-week-old hydrocephalic rats to survive beyond sexual maturation? (3) What is the status of learning ability of long-term surviving rats with arrested shunt-dependent hydrocephalus? The findings of our study suggest that congenital hydrocephalus impairs the development and formation of the dendrites and spines of the cerebrocortical neurons. Following ventriculoperitoneal shunting, we confirmed that rats with arrested shunt-dependent hydrocephalus demonstrated learning disability in a light-darkness discrimination test using a Y-maze. The development of the dendrites and spines of the cerebrocortical neurons seemed to take place to some degree after shunting, but normal spine density could not be restored. Also suggested was a possible relationship between learning disability and a decrease in spine density, i.e., impairment of synaptogenesis.     

动脉瘤性蛛网膜下腔出血后分流依赖性脑积水的危险因素分析

目的 探讨动脉瘤性蛛网膜下腔出血（aSAH）后分流依赖性脑积水（SDHC）的危险因素。方法 回顾性分析2011年7月至2014年6月收治的768例经开颅夹闭或血管内栓塞治疗的aSAH患者的临床资料,其中发生SDHC 151例。结果 Logistic回归分析发现,年龄≥40岁（OR=2.40;95%可信区间为1.25~4.61;P<0.01）、术前hunt-hess分级较高（ⅲ~ⅴ级;or>P<0.01）、术前fisher分级较高（ⅲ~ⅳ级;or>P<0.01）、合并脑室内出血（or>P<0.01）、急性脑积水（or>P<0.01）、脑室外引流术（or>P<0.01）是asah后发生sdhc的独立危险因素。>结论 SDHC的高发生率与患者的高龄、较差的起始神经系统状态、急性脑积水、脑室内出血、脑室外引流术有关。     

Mechanism of in-hospital cerebral ischemia

Of 171 patients evaluated prospectively and consecutively for cerebral ischemia, 26 (15%) developed symptoms while hospitalized. Cerebral ischemia complicated operative procedures in 12 patients, unsuccessful cardioversion in one and coronary angiography in another. Twelve patients had apparent cerebral embolism and 14 patients had cerebral thrombosis as a mechanism of their symptoms. Hospitalized patients who suffered cerebral ischemia had one or more of the following: risk factors for stroke including cardiac source of embolus, previous stroke, diagnostic or therapeutic procedures for vascular disease, or chronic hypertension complicated by acute hypotension.     

The Strata programmable valve for shunt-dependent hydrocephalus: the pediatric experience at a single institution

Background and objective The Medtronic PS Medical Strata valve has pressure flow characteristics that are noninvasively adjusted with a magnetic tool. The objective of this study was to examine its efficacy during our initial experience with it in shunt-dependent children. Materials and methods A retrospective review of 53 children with a median age of 2.0 years who had 61 Strata valves implanted. Conclusion The Strata valve is efficacious in the treatment of shunt-dependant hydrocephalus in children. The 1-year shunt survival rate of 67.2% is comparable to that previously reported from a multicenter trial. Of the 30 therapeutically aimed adjustments during the study period, 16 (53.3%) resulted in improvement in abnormal signs or symptoms. Our data indicate that adjustments can be used to treat signs or symptoms of cerebrospinal fluid overdrainage or underdrainage, which may obviate the need for additional surgery.     

Risk factors in intracranial saccular aneurysms Aspects on the formation and rupture of aneurysms, and development of cerebral vasospasm

Intracranial saccular aneurysms have been a well-known clinical and pathological entity for over two centuries. The pathophysiological events that lead to aneurysm formation and rupture are, however, poorly understood. Besides an HLA-associated genetic factor, the most widely accepted risk factors are arterial hypertension, female gender, and increasing age. Some aneurysm patients have a deficient formation of Type III collagen. This seems to interfere with the mechanical integrity of the cerebral arterial wall encouraging aneurysm formation. While some of the risk factors may be involved in the process of aneurysm formation, others may be of importance in the actual aneurysm rupture. Medical and surgical developments have only had a slight impact on mortality rates from aneurysm rupture. The principal cause of death and disability is cerebral arterial spasm. Considerable effort has been expended in investigating the etiology of this phenomenon. Previous studies have failed to yield conclusive evidence of the causative agent(s) or the nature of cerebral artery narrowing. The time course of vasospasm after the onset of subarachnoid hemorrhage is consistent with an immune-mediated response, and more recent observations suggest that immunological processes including activation of the complement system may be involved. Missed minor bleeding episodes may thus be a risk factor for aneurysm patients in respect to the development of cerebral vasospasm.     

疑似高血压脑出血的大脑中动脉瘤破裂的诊治

目的部分大脑中动脉瘤破裂入基底节区易与高血压脑出血相混淆,探讨对此类动脉瘤破裂的诊治。方法对2004年1月～2009年1月期间本院神经外科收治的113例大脑中动脉瘤破裂进行回顾性分析,其中表现为额、颞、基底节区、脑室内类似高血压脑内血肿42例。所有病例最终均行CTA或DSA后行显微手术治疗,其中单纯动脉瘤夹闭34例,动脉瘤切除加夹闭8例。结果CTA或DSA能清楚的显示动脉瘤,动脉瘤位于分叉部近端(M1)4例、分叉部36例、分叉部远端2例,11例患者合并其他部位动脉瘤。术后恢复良好34例,严重血管痉挛脑梗死5例,放弃治疗3例。结论对于疑似高血压脑出血的大脑中动脉瘤破裂必须行CTA或DSA检查,早期显微手术治疗可获得较满意疗效。     

颅内动脉瘤破裂后形成假性动脉瘤的显微手术治疗

目的探讨颅内动脉瘤破裂出血后假性动脉瘤形成的早期诊断、手术治疗。方法回顾性分析我院2002年1月至2012年1月收治的13例颅内动脉瘤破裂出血伴有假性动脉瘤形成的患者临床资料,8例术前确诊,5例术中确诊,均经病理学检查确诊为假性动脉瘤。结果13例患者均行动脉瘤夹闭＋血肿清除手术治疗。术后3个月,根据GOS标准评定,9例恢复良好,2例中残,1例重残,1例死亡。结论颅内动脉瘤破裂后短期内可以在动脉瘤周围血肿内形成假性动脉瘤,此类患者尽早手术是必要的,术中要谨慎处理动脉瘤周围血肿,避免动脉瘤术中破裂影响治疗效果。     

Local hemodynamics at the rupture point of cerebral aneurysms determined by computational fluid dynamics analysis

Background: Cerebral aneurysms carry a high risk of rupture and so present a major threat to the patient's life. Accurate criteria for predicting aneurysm rupture are important for therapeutic decision-making, and some clinical and morphological factors may help to predict the risk for rupture of unruptured aneurysms, such as sex, size and location. Hemodynamic forces are considered to be key in the natural history of cerebral aneurysms, but the effect on aneurysm rupture is uncertain, and whether low or high wall shear stress (WSS) is the most critical in promoting rupture remains extremely controversial. This study investigated the local hemodynamic features at the aneurysm rupture point. Methods: Computational models of 6 ruptured middle cerebral artery aneurysms with intraoperative confirmation of rupture point were constructed from 3-dimensional rotational angiography images. Computational fluid dynamics (CFD) simulations were performed under pulsatile flows using patient-specific inlet flow conditions. Time-averaged WSS (TAWSS) and oscillatory shear index (OSI) were calculated, and compared at the rupture point and at the aneurysm wall without the rupture point. We performed an additional CFD simulation of a bleb-removed model for a peculiar case in which bleb formation could be confirmed by magnetic resonance angiography. Results: All rupture points were located at the body or dome of the aneurysm. The TAWSS at the rupture point was significantly lower than that at the aneurysm wall without the rupture point (1.10 vs. 4.96 Pa, p = 0.031). The OSI at the rupture point tended to be higher than at the aneurysm wall without the rupture point, although the difference was not significant (0.0148 vs. 0.0059, p = 0.156). In a bleb-removed simulation, the TAWSS at the bleb-removed area was 6.31 Pa, which was relatively higher than at the aneurysm wall (1.94 Pa). Conclusion: The hemodynamics of 6 ruptured cerebral aneurysms of the middle cerebral artery were examined using retrospective CFD analysis. We could confirm the rupture points in all cases. With those findings, local hemodynamics of ruptured aneurysms were quanti-tatively investigated. The rupture point is located in a low WSS region of the aneurysm wall. Bleb-removed simulation showed increased WSS of the bleb-removed area, associated with the flow impaction area. Although the number of subjects in this study was relatively small, our findings suggest that the location of the rupture point is related to a low WSS at the aneurysm wall. Further investigations will elucidate the detailed hemodynamic effects on aneurysm rupture.     

Predictors of outcome in patients with normal-pressure hydrocephalus

Despite emerging knowledge of over 40 years, the postoperative results after shunt implantations in patients diagnosed for normal-pressure hydrocephalus (NPH) have not improved significantly in the last decade. For this reason, predictors have to be identified in order to preoperatively predict the course of disease. From 1982 to 2000, we examined in a prospective study 200 patients diagnosed for NPH. Of the patients who were surgically treated by a shunt implantation we could re-examine 155 (78%) in a mean time interval of 7 months after operation. The NPH was graduated according to the results of the intrathecal infusion test in an early state NPH (without brain atrophy) and late state NPH (with brain atrophy). In the study we focused our attention on the possible predictors: patient's age, length of disease, clinical signs--like gait ataxia, dementia and bladder incontinence, etiology idiopathic/secondary as well as implanted valve type and the value of resistance to cerebrospinal fluid outflow. To measure the outcome we used the NPH recovery rate, as statistical test the chi(2) according to Pearson. In 80 patients with an early stage NPH (without cerebral atrophy) and a short course of disease (<1 year), slightly distinct dementia and an implanted Miethke Dual-Switch valve were significant predictors for a positive postoperative outcome. The outflow resistance measured in the intrathecal infusion test showed only a minimal relevance for the outcome. Those 75 patients with a late state NPH (with cerebral atrophy) had a better outcome when dementia was not present, the outflow resistance was >20 mm Hg.min/ml, the CSF tap test was positive and a Miethke Dual-Switch valve was implanted.     

Predictors and outcome of acute symptomatic cerebral infarctions following aneurysmal subarachnoid hemorrhage

The leading cause of unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH) is cerebral infarction. In this 3-year retrospective study, we have retrospectively evaluated 172 hospitalized patients with aneurysmal SAH, and compared those who developed a complicated cerebral infarction with those who did not. In this study, acute symptomatic cerebral infarctions accounted for 22.6% (39/172) of all episodes. Significant statistical analysis between the two patient groups included age at onset, hypertension as the underlying disease, presence of symptomatic vasospasm, mean hospitalization days and Glasgow Outcome Score at the time of discharge. After a minimum 1.5-year follow-up period, the median (interquantile range) Barthel index score was 75 (6–85) for those patients who had cerebral infarctions, and 80 (0–90) for those who had no cerebral infarctions. Multiple logistic regression analysis demonstrated that the presence of symptomatic vasospasm was independently associated with the presence of acute symptomatic cerebral infarctions. The presence of symptomatic vasospasm implies the danger of acute symptomatic cerebral events after aneurysmal SAH. Although our study demonstrates a worse short-term outcome and longer duration of hospitalization in this special group of patients, the functional outcome for patients with cerebral infarction was not inferior to those patients without cerebral infarction after a follow-up of at least 1.5-years.     

Neuropsychological correlates of cerebral blood flow anomalies and MRI lesions after rupture of anterior communicating artery aneurysms

The aim of this study was to investigate relations between neuropsychological disorders resulting from rupture of aneurysms of the anterior communicating artery, regional cerebral blood flow anomalies and brain lesions revealed on MRI. Blood flow was analyzed in 22 consecutive patients at least 3 weeks after surgery using single photon emission computed tomography. Flow values were calculated in 10 regions of interest on each side of the brain. Attention, motor control, executive functions, short-term and long-term learning (verbal, visuo-spatial), categorical evocation, general intellectual performances were investigated. Flow drop was observed over frontal areas, which predominated on the right side. The correlation analyses showed that