Brain temperature and cerebral blood flow imaging in patients with severe subarachnoid hemorrhage: report of two cases

BACKGROUND: Temperature reversal, which is defined as observation of higher brain temperature than systemic temperature followed by lower brain temperature than systemic temperature, implies a poor prognosis in patients with severe subarachnoid hemorrhage (SAH). Serial regional cerebral blood flow (CBF) imaging using single-photon emission tomography (SPECT) was performed in 2 patients with severe SAH who showed temperature reversal. CASE DESCRIPTION: 54-year-old woman and a 55-year-old man with severe SAH underwent ventricular drainage using a catheter that allowed monitoring of the brain temperature. SPECT imaging in these two patients showed that CBF was preserved before the occurrence of the temperature reversal and was exhausted afterwards. These patients died within 2 to 3 days. CONCLUSIONS: Temperature reversal may indicate the exact time when absence of brain perfusion occurs, causing irreversible brain damage.     

Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery

In 138 patients with ruptured cerebral aneurysms operated on within 48 to 72 hours after subarachnoid hemorrhage, an external ventricular drainage catheter was inserted before craniotomy and was used intermittently during the first week after surgery. In 51 patients, intracranial pressure (ICP) was measured intraoperatively. The majority of patients showed increased ICP intraoperatively irrespective of the preoperative Hunt and Hess grade and the amount of subarachnoid blood accumulation or intraventricular blood clot. Intraoperative drainage of cerebrospinal fluid allowed easy access for aneurysm dissection by making the brain slack in more than 90% of patients. Postoperative ICP measurements revealed that significant brain swelling did not occur in the majority of patients. In 7 patients, persistently elevated ICP (greater than 20 mm Hg) was recorded. Nine patients (8%) developed shunt-dependent hydrocephalus; all of these patients had suffered an intraventricular hemorrhage. Measurements of the volumes of cerebrospinal fluid drained did not allow prediction of shunt-dependent hydrocephalus.     

Subcutaneous pneumocele associated with ventriculoperitoneal shunt migration into the mechanically occluded colon - case report

A 62-year-old man presented with shunt failure manifesting as consciousness disturbance 4 years after placement of a ventriculoperitoneal shunt for subarachnoid hemorrhage. Physical examination found subcutaneous pneumocele around the peritoneal catheter extending from the abdomen to the neck. He had undergone pelvic radiation therapy for bladder cancer 2 years before. The peritoneal catheter was removed from the cervical region, and external ventricular drainage and a descending colon stoma for ileus release were positioned. The cerebrospinal fluid was clear and yielded no cultures. No inflammatory changes were seen. He developed carcinomatous peritonitis and died 4 months later. Retrograde colon gas reflux due to catheter perforation into the colon occluded by metastatic sigmoid cancer was probably the cause. Fragility of the wall of colon associated with the prior abdominal radiation therapy might have been a contributing factor. Subcutaneous pneumocele around the peritoneal catheter, i.e. pneumocele within the fibrous sheath surrounding the catheter, is a differential diagnosis to cerebrospinal fluid collection in patients with subcutaneous swelling around the catheter.     

Interpeduncular high-density spot in severe shearing injury

Thirty cases of severe shearing injury were analyzed utilizing serial computed tomography scans and clinical observations. Fatalities occurred in the majority of patients whose Glasgow Coma Scale scores at admission were 6 or less. The presence of perimesencephalic subarachnoid hemorrhage, hemorrhage in the corpus callosum, acute brain swelling, and intraventricular hemorrhage on computed tomography scans resulted in high mortality rates. In 13 patients, interpeduncular high-density spots were observed on computed tomography scans, which were performed in the acute stage of injury. Eight of these patients died, and those surviving had poorer neurological outcomes than corresponding patients with identical Glasgow Coma Scale scores on admission. In the management of severe shearing injury patients, more attention should be given to the presence of interpeduncular high-density spots as well as other important diagnostic computed tomography findings regarding diffuse brain injury.     

Significance of acute cerebral swelling in patients with sylvian hematoma due to ruptured middle cerebral artery aneurysm, and its management

A retrospective study of 75 patients treated surgically for ruptured middle cerebral artery (MCA) aneurysm within 48 hours evaluated clinical grade at admission, secondary development and management of cerebral swelling associated with space-occupying hematoma, cerebral infarction caused by vasospasm, development of hydrocephalus, and clinical outcome. Clinical grade at admission was significantly better in patients without than in those with hematoma (p < 0.01). Twenty-seven patients with sylvian hematoma caused by ruptured MCA aneurysm often developed ipsilateral cerebral swelling in the early period after subarachnoid hemorrhage. Seventeen of these patients developed serious cerebral swelling and received barbiturate therapy. Nine of these 17 patients had good outcome, but six patients died of cerebral swelling. The incidence of hydrocephalus was significantly higher in patients with than in those without hematoma (p < 0.01). The incidence of infarction was more pronounced in patients with sylvian hematoma. Clinical outcome was significantly better in patients without than in those with sylvian hematoma (p < 0.01). Development of cerebral swelling in patients with sylvian hematoma due to ruptured MCA aneurysm has a significant effect on outcome, and improvements in management are required.     

Continuous jugular venous oximetry in the neurointensive care unit — a brief review

PURPOSE: To describe the technique of continuous jugular venous oxygen saturation (SjVO(2)) monitoring and review its applications in the neurointensive care unit (NICU), with special reference to the management of raised intracranial pressure (ICP) following severe acute brain injury. SOURCE: This narrative review is based on a selection of current literature on SjVO(2) monitoring in conjunction with local experience using this technique. Principal findings: Despite limitations, the use of SjVO(2) monitoring has the potential to impact on patient care in the NICU. The placement of the catheter is relatively simple. Studies have confirmed that abnormalities in cerebral venous oxygen saturation are associated with adverse outcome following traumatic brain injury. There is evidence that SjVO(2) may be a useful adjunct to ICP monitoring of patients with intracranial hypertension. Furthermore, managing cerebral extraction of oxygen in conjunction with cerebral perfusion pressure may result in an improved outcome. Further research in this area is needed. Other indications for SjVO(2) monitoring include subarachnoid hemorrhage, cardiopulmonary bypass and following ischemic stroke. CONCLUSION: In the past, the management of severe acute brain injury was targeted at ICP and perfusion pressure with little consideration for the metabolic requirements of the injured brain. SjVO(2) monitoring is another tool the intensivist can use to obtain information about the global oxygen requirements of the injured brain on a continuous basis. Whether this will impact on care in the long term remains to be seen.     

Study of the effects of mild hypothermia on cerebral PO2, PCO2 and pH and body temperature in patients with acute severe head injury

I nrecent20yearsmostanimalexperimentsandclinicalstudieshavedemonstratedthatmildhypothermia(32℃ 35℃)hasaffirmatoryeffectonbrainprotection.Butthereareafewresearchreportsthatdenythebrainprotectioneffectofmildhypothermia.Wetreated38patientswithacuteseverehe…     

Sex-related differences in patients with severe head injury: greater susceptibility to brain swelling in female patients 50 years of age and younger

OBJECT: The goal of this study was to study the influence of sex and age on factors affecting patient outcome in severe head injury. METHODS: Data from the prospectively conducted international trial of tirilazad mesylate in patients with head injury were analyzed retrospectively. Included were 957 patients, 23% of whom were female and all of whom were between the ages of 15 and 79 years. All patients presented with Glasgow Coma Scale (GCS) scores between 3 and 8 and evidence of structural brain damage and/or subarachnoid hemorrhage (SAH) on the initial CT scan. Frequencies of recognized risk factors, including brain swelling, intracranial hypertension, systemic hypotension, advanced age, SAH, and injury severity (based on GCS scores), as well as dichotomized Glasgow Outcome Scale (GOS) scores (good recovery or moderate disability compared with severe disability, persistent vegetative state, or death) obtained 6 months postinjury were compared between male and female patients. CONCLUSIONS: Overall significantly greater frequencies of brain swelling and intracranial hypertension were found in female compared with male patients (35% compared with 24% [p < 0.0008] and 39 compared with 31% [p < 0.03], respectively). The highest rates were found in female patients younger than 51 years old (38% compared with 24% [p < 0.002] and 40% compared with 30% [p < 0.02], respectively, in male patients younger than 51 years of age). This effect was independent of injury severity (GCS) scores, which were not different in male and female patients. Female patients younger than 50 years tended to have worse outcomes, but the difference was not statistically significant. Thus, female patients who sustain severe head injury, especially (presumably) premenopausal ones aged 50 years and younger, are significantly more likely to experience brain swelling and intracranial hypertension than male patients with a comparable injury severity, suggesting that younger women may benefit from more aggressive monitoring and treatment of intracranial hypertension.     

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.     

Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus--evaluation of risk factors.

Experience with a continuous-pressure controlled, external ventricular drainage system (EVD) in 100 patients (n = 49 female, n = 51 male; mean age, 56.3 yr) with acute hydrocephalus is reported. Cerebrospinal fluid circulation disturbances resulted from hemorrhages caused by subarachnoid hemorrhage (n = 45), parenchymal hemorrhages from angioma (n = 4), anticoagulants (n = 7), or hypertension or other reasons (n = 30); in addition, hydrocephalus developed from infections (n = 3), tumors (n = 2), infratentorial infarction (n = 5), or unknown reasons (n = 4); 52 patients had ventricular hemorrhages. No patient died of system-associated morbidity. Mean time of EVD treatment was 9.5 days, with 40 patients being treated for 10 to 29 days; routine refobacin (5 mg) flushing of the system was performed three times a day. Patients without cerebrospinal fluid leakage had a 2% rate of secondary infection compared with 13% in patients with cerebrospinal fluid leakage due to ventricular catheter placement (P < 0.05; overall infection rate, 5%). A clinical mortality rate of 29% during EVD treatment was observed in subarachnoid hemorrhage patients (Hunt and Hess Grades II, III, IV, and V; n = 9, 9, 18, and 9, respectively); recurrent hemorrhages during EVD treatment occurred in 19 patients (26 hemorrhages), and of these, 10 patients died. System occlusion was seen in 19 cases (12 of 45 patients with subarachnoid hemorrhage), requiring catheter and system renewal in 1 case; system extraction was seen in 3 cases, misplacement was seen in 11 cases, and disconnection was seen in 5 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anesthetic management of a patient with severe subarachnoid hemorrhage and diffuse lung edema

One of the most common problems in emergency anesthesia for cerebral aneurysm surgery is clinically significant ECG abnormalities. We had a 58 year old patient with severe subarachnoid hemorrhage and diffuse lung edema leading to fatal outcome probably due to catecholamine myocardial injury. During the operative intervention with enflurane and oxygen anesthesia, ST elevation on ECG suddenly appeared and heart failure developed in this patient. Intraoperative ECG suggested the development of acute myocardial infarction of the anterior and inferior wall, but echocardiography revealed a discrepant result; the wall motion abnormality was confirmed in the apex only. The serum CPK in this patient increased a little over the normal limit perioperatively. Overall results suggested that a cause of this patient's death was myocardial injury due to the excessive release of catecholamine. Therefore, we urge the need of through cardiac examinations as well as the administration of preventive drugs for catecholamine myocardial injury in the perioperative management of patients with severe subarachnoid hemorrhage.     

Myocardial dysfunction associated with brain death: clinical, echocardiographic, and pathologic features.

BACKGROUND: The sequelae of severe brain injury include myocardial dysfunction. We sought to describe the prevalence and characteristics of myocardial dysfunction seen in the context of brain-injury-related brain death and to compare these abnormalities with myocardial pathologic changes. METHODS: We examined the clinical course, electrocardiograms, head computed tomography scans, and echocardiographic data of 66 consecutive patients with brain death who were evaluated as heart donors. In a sub-group of patients, we compared echocardiographic findings with pathologic findings. RESULTS: Echocardiographic systolic myocardial dysfunction was present in 28 (42%) of 66 patients and was not predicted by clinical, electrocardiographic, or head computed tomographic scan characteristics. Ventricular arrhythmias were more common in the patients with, compared to those without, myocardial dysfunction (32% vs 0%; p < 0.001). Myocardial dysfunction was segmental in all 8 patients with spontaneous subarachnoid or intracerebral hemorrhage. In these patients, the left ventricular apex was often spared. Myocardial dysfunction was either segmental or global in 17 patients who suffered head trauma and in 3 patients who died of other central nervous system illnesses. In 11 autopsied hearts, we found poor correlation between echocardiographic dysfunction and pathologic findings. CONCLUSIONS: Systolic myocardial dysfunction is common after brain-injury-related brain death. After spontaneous subarachnoid or intracerebral hemorrhage, the pattern of dysfunction is segmental, whereas after head trauma, it may be either segmental or global. We found poor correlation between the echocardiographic distribution of dysfunction and light microscopic pathologic findings.     

Acute left ventricular dysfunction and subarachnoid hemorrhage.

OBJECTIVE: Severe left ventricular (LV) dysfunction associated with acute subarachnoid hemorrhage (SAH) due to cerebral aneurysm rupture. SETTING: An adult 12-bed surgical intensive care unit of a university hospital. PATIENT: A female patient presenting with SAH (Hunt & Hess grade III) and severe left ventricular dysfunction. INTERVENTIONS: Central venous pressure, arterial blood pressure, extravascular lung water catheter, transesophageal echocardiography, blood gas analysis, electrocardiograms, and chest x-ray for clinical management. MEASUREMENTS AND MAIN RESULTS: On admission to the district hospital, an electrocardiogram (ECG) revealed a sinus rhythm with transient ST elevations. A transesophageal echocardiography showed a left ventricular ejection fraction (LV-EF) of approximately 10%. Severe LV dysfunction required inotropic and vasopressor support to maintain mean arterial pressure above 60 mmHg, while the first measurement of an extravascular lung water catheter revealed a cardiac index of 2.0 L/min/m2 and moderate hypovolemia. Despite stepwise volume loading that increased intrathoracic blood volume--an indicator of cardiac preload--from 719 mL/m2 to 927 mL/m2, cardiac index remained poor. Enoximone lead to a marked increase of cardiac index up to 3.9 L/min/m2 and LV-EF to about 30%, but had to be stopped due to thrombopenia. Surgical clipping of an intracranial aneurysm was postponed because of the impaired cardiac function and was performed on day 18 after admission. Interestingly, neurologic outcome was not as poor as might be expected from the literature. CONCLUSION: Severe left ventricular dysfunction may occur in acute SAH and may necessitate delay of aneurysm surgery.     

Some practical problems and several methodological trials in continuous intracranial pressure monitoring

The continuous intracranial pressure monitoring has been widely applied in intensive or critical care, but there are various kinds of methods for its monitoring at present. One hundred and forty-one cases mostly with severe head injury were subject to the intracranial pressure recordings in the critical care ward in Department of Emergency Medicine, University of Tokyo Hospital, from October, 1980 through May, 1983, and in Neurosurgical Unit, Showa General Hospital, in April and May, 1984. The authors made several methodological trials for the monitorings in them and compared with one another from the aspect of clinical practice. The subarachnoid catheter was inserted into the subarachnoid or sometimes into the subdural spaces by way of the burr hole in 112 cases and proved not to demonstrate in some cases the intracranial pressure waves clearly due to so called damping phenomenon but to indicate the reliable values, or trustworthy mean pressures in all the cases except for impending brain dead patients with swollen hemispheres and least cerebrospinal fluid remained in intracranial subarachnoid spaces. The ventricular fluid pressure was monitored in nine cases and was most dependable as well as the subarachnoid pressure. The ventricular cannulation and its maintenance were, however, difficult when the ventricles were compressed or deviated, which were often experienced in acute severe head injury and also in impending brain death just because of the same above mentioned reasons. These demerits were attempted to be conqured with epidural pressure monitorings such as the fiberoptic sensor (Ladd) in 17 cases, the intracranial catheter tip pressure transducer (Gaeltec) in nine cases and the sensor of bioimplantable polymer (Plastimed) in three cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effectiveness of brain hypothermia treatment in patients with severe subarachnoid hemorrhage: comparisons at a single facility

The effectiveness of hypothermia treatment for severe subarachnoid hemorrhage (SAH) was evaluated at the same facility under the same director. A total of 187 patients with SAH, 67 admitted before the introduction of hypothermia treatment in May 1999 (early cases) and 120 treated thereafter (late cases), were transported to the National Cardiovascular Center and treated in the acute phase between November 1997 and September 2001. Brain hypothermia treatment was performed in 19 patients of the 120 late cases, 10 males and 9 females aged 33-72 years (mean 57. 6 years), treated by direct surgery in 15 and endovascular surgery in 4. The indications for hypothermia treatment were age of 75 years or younger, SAH due to rupture of a cerebral aneurysm, Japan Coma Scale score of 100 or higher, and initiation of treatment within 24 hours after the onset. The body core temperature was sustained at 34°C for 48 hours, rewarming was performed over 48 hours, and normothermia was maintained thereafter. The outcome, evaluated according to the modified Rankin scale (m-RS) on transfer to another hospital or after 3 months, was m-RS 3 in 1 patient, m-RS 4 in 4, m-RS 5 in 3, and death in 11. Before the introduction of hypothermia treatment (early period), 16 patients showed the indications for the treatment, and their outcomes were m-RS 3 in 2, m-RS 4 in 3, m-RS 5 in 2, and death in 9. Cerebral vasospasm was important as a prognostic factor, markedly deteriorating the outcome. Hyperthermia after therapeutic hypothermia induced brain swelling and markedly affecting the outcome. Brain hypothermia treatment did not improve the outcome of severe SAH compared with the period before its introduction. The emphasis in treating severe SAH should be placed on the maintenance of normothermia to prevent brain swelling and elimination of factors that may induce cerebral vasospasm, rather than interventional hypothermia for aggressive brain protection.     

Intracranial extradural pressure monitoring after direct operation on ruptured cerebral aneurysms

Intracranial extradural pressure (ICP) was monitored by using a miniaturized transducer for an average period of 8 days after direct operation in 55 patients with ruptured cerebral aneurysms. Acute stage operation and drainage of cerebrospinal fluid were simultaneously performed in most of the patients. In many grade I patients with satisfactory cisternal drainage, ICP was monotonously stable, with faint pressure waves. When the drained fluid volume decreased or drainage was removed, however, ICP was elevated moderately, with associated pressure waves present. There were no A-waves observed in any of the patients. Decreases of mean ICP and disappearance of pressure waves were found 2 to 3 hours after infusion of 200 or 300 ml of 10% glycerol or 20% mannitol in patients without drainage or with an inadequate drain, but were not found in patients with a good drain. In a patient showing diffuse severe vasospasm, a rapid elevation of ICP caused by marked brain edema was observed. In patients with residual aneurysms or incompletely clipped aneurysms, ICP increased immediately after rupture of these aneurysms. The daily mean ICP was higher in patients with a clinically poor condition and/or severe subarachnoid hemorrhage on admission than in those with a good condition and/or mild subarachnoid hemorrhage, in spite of a functional drain. There was a poor outcome in about half of the patients showing maximum daily mean ICP greater than 30 mm Hg or frequent B-waves. No complications caused by ICP monitoring were found.(ABSTRACT TRUNCATED AT 250 WORDS)     

Training protocol for intracranial pressure monitor placement by nonneurosurgeons: 5-year experience

BACKGROUND: This report evaluates a protocol for training nonneurosurgeon medical staff to perform ventricular catheter placement for ICP monitoring in traumatic brain injury and other appropriate patients under the guidance of neurosurgeons. METHODS: Eleven neurosurgery house officers were enrolled in the program to be certified for ventricular catheter placement. The training program using the Ghajar Guide is described as well as the preprocedural checklist. The results of these certified house officers were tracked over a 5-year period. RESULTS: Ten house officers successfully completed the certification process for ventricular catheter placement in a total of 106 patients. The majority of ventricular catheters were placed at the bedside. The reported results and the complication rates of catheter-related infections and intracranial hemorrhage are similar to that of neurosurgeons or neurosurgeons in training. CONCLUSION: House officers under the guidance of neurosurgeons can be trained to successfully and safely place ventricular catheters for ICP monitoring in patients needing ICP monitoring.     

Serious complications of microvascular decompression operations for trigeminal neuralgia and hemifacial spasm

Serious complications of microvascular decompression operations for trigeminal neuralgia or hemifacial spasm are reported. Among 278 patients who underwent microvascular decompression, 9 serious complications were observed: 1 intracerebellar hematoma with acute hydrocephalus, 1 cerebellar swelling with acute hydrocephalus, 1 supratentorial acute subdural hematoma, 2 status epilepticus, 1 infarction of the brain stem, 1 subarachnoid hemorrhage due to traumatic aneurysm, and 1 infarction in the territory of the posterior cerebral artery. Of the 9 patients with such complications, 2 died. The possible causes of such serious complications are discussed.     

Multimodality treatment of deep periventricular cerebral arteriovenous malformations.

The surgical treatment of arteriovenous malformations (AVMs) located in deep periventricular regions such as the basal ganglia is associated with marked morbidity and mortality. Approaches through critical brain regions afford limited exposure of the lesions, while surgical dissection is sometimes complicated by acute severe brain swelling and/or hemorrhage in the surrounding tissues. In our approach to deep AVMs, our regimen has evolved from direct staged microsurgical excision under routine fentanyl-N2O-relaxant anesthesia (first four patients) to the use of elective high-dose barbiturate anesthesia (subsequent 12 patients). In the first group of four patients, 11 operations were performed. Two patients improved, one of whom returned to normal neurologically. There were three episodes of acute brain swelling and/or hemorrhage. One patient died as a result, and another deteriorated. In the second group of 12 patients, all but two lesions were completely excised. Among the 10 patients in whom the AVM was completely excised, seven improved, six of whom achieved a good to excellent outcome, with two regaining full neurologic function. Three patients worsened (one as the result of acute brain swelling and/or hemorrhage). There was no death in this group. Only one incidence of acute brain swelling and/or hemorrhage occurred in 26 operations. Even though the number of patients is too small in the first group for meaningful statistical comparison, our intraoperative observations and postoperative results suggest that our evolved multimodality regimen, such as staged excision and the use of elective high-dose barbiturates, was likely to have contributed to the improved treatment results of these formidable lesions.     

Levels of catecholamine in plasma and cerebrospinal fluid in aneurysmal subarachnoid hemorrhage.

Despite intensive investigation into the cause of cerebral vasospasm (focal ischemic deficit) after subarachnoid hemorrhage, the morbidity and mortality associated with this condition remain high. Various studies have shown levels of catecholamine in plasma and cerebrospinal fluid (CSF) to be increased in subarachnoid hemorrhage, and it is possible that these vasoactive substances play an important role in the subsequent vasospasm. In an attempt to elucidate this possibility, the study presented here was undertaken to investigate the relationship between catecholamine levels in plasma and CSF and focal ischemic deficit (FID); the rupture of aneurysms on blood vessels supplying the hypothalamus as compared with the rupture of aneurysms on blood vessels supplying other areas of the brain; and the clinical outcome of the patients. Concentrations of adrenaline and noradrenaline in plasma and CSF samples obtained from 21 patients who had suffered aneurysmal subarachnoid hemorrhage were determined by a radioenzymatic technique. Significantly higher levels of adrenaline were found at the time of surgery in the CSF of patients with FID. A similar trend, though not statistically significant, was also observed for plasma. Patients with a rupture of aneurysms on blood vessels supplying the hypothalamus showed a tendency towards higher catecholamine levels in plasma and CSF. Subjects with a bad clinical outcome (i.e., those who were severely disabled or had died) had significantly higher levels of catecholamine in plasma than did those with a good clinical outcome (i.e., those with moderate or no disability). Further detailed analysis of the interrelationships showed that, within the group of patients with FID, those with rupture of aneurysms on blood vessels supplying the hypothalamus had significantly higher catecholamine levels in plasma than did those with rupture of aneurysms on other cerebral vessels. Furthermore, in the group of patients with rupture of aneurysms on blood vessels supplying the hypothalamus, those with a bad clinical outcome had significantly higher catecholamine levels in plasma than did those with a good clinical outcome. These findings lend support to the possibility that damage to the hypothalamus and subsequent elevations in catecholamine levels may be associated with FID and poor clinical outcome.