Improvement after treatment of hydrocephalus in aneurysmal subarachnoid haemorrhage: implications for grading and prognosis

Summary Two patients with aneurysmal subarachnoid haemorrhage and hydrocephalus are presented. On admission they scored E1M4V1 and E1M3Vtube on the Glasgow Coma Scale. The first patient recovered to E3M5Vtube after treatment of hydrocpehalus by extraventricular drainage. The second recovered to E2M5Vtube and later E4M6V4 after treatment of hydrocephalus with lumbar drainage. Based on the literature it is argued that these cases are no exception as to the improvement after treatment of hydrocephalus. The prognosis of patients with hydrocephalus after a subarachnoid haemorrhage, improves in parallel with the Glasgow Coma Scale after treatment of hydrocephalus. Therefore decision making on whether or not to treat a patient with a subarachnoid haemorrhage should be postponed until after treatment of hydrocephalus, if present.     

Risk Analysis of Thrombo-Embolic and Recurrent Bleeding Events in the Management Of Intracranial Haemorrhage Due to Oral Anticoagulation

Purposes : Intracranial haemorrhage (ICH) is a rare but potentially devastating complication of oral anticoagulants (OAC). This raises the difficult clinical choice between either permanent cessation of OAC, or continuing OAC and if so, when to restart. To make this choice, one needs to balance the thrombo-embolic risk after cessation of OAC against the risk of recurrent intracranial haemorrhage when OAC are restarted. There are few published data to base this difficult clinical decision on.

Methods : We present an observational study of a consecutive series of 108 patients, collected prospectively and admitted to our department, with an OAC-related intracranial haemorrhage, in whom we assessed the thrombotic event rate and the recurrent intracranial bleeding rate during follow-up.

Results : In the 25 patients in whom OAC were reinstituted no new thrombo-embolic events occurred (0/506 unprotected patient-days). In the group of patients in whom OAC were not restarted (n = 81), the thrombo-embolic event rate was 8/11590 unprotected patient-days, of which only 2 were cerebrovascular thrombo-embolisms. The overall risk of a thrombo-embolic complication can be estimated to be 0.66 events/1000 patient-days at risk (95% exact confidence limits of 0.3 to 1.3 events/1000 patient-days at risk). In three patients the thrombo-embolic event was fatal. We saw recurrent intracranial bleeding in eight patients, 2 of which were fatal. Seven of these occurred before the restarting of the OAC.

Conclusions : In OAC-related intracranial haemorrhages, OAC can be stopped safely for a considerable period, with a very low overall thrombotic event rate. The recurrent bleeding risk after restarting OAC is low. Recurrent bleeding mostly occurred before restarting OAC and is probably caused by insufficient or unsustained correction of the initial coagulation deficit. Immediate reversal of anticoagulation provides the patient with the best possible treatment options including surgery. OAC-related intracranial haemorrhages can therefore be actively treated.     

Subarachnoid haemorrhage and anaesthesia for neurovascular surgery

Subarachnoid haemorrhage (SAH) is a life-threatening condition with multiple sequelae. The treatment of SAH requires urgent resuscitation and stabilization of the patient to prevent re-bleeding and to optimize cerebral oxygenation and perfusion. The perioperative care of these patients involves meticulous attention to maintain an appropriate fluid balance, cerebral blood flow and intracranial pressure. The majority of cases of SAH result from rupture of an intracerebral aneurysm and treatment involves obliteration of the aneurysmal sac either by surgical clipping or endoscopic coiling. Arteriovenous malformations may also cause SAH and often require a combination of radiological and neurosurgical treatments. Haematomas resulting from SAH may require surgical intervention, depending on the location of the haematoma and the clinical condition of the patient.     

Simultaneous Dissection of Intra- and Extracranial Vertebral Artery. Report of two Cases and Review of Literature

Summary.  Two patients who developed subarachnoid haemorrhage are presented. The first patient was a 41-year-old woman whose angiograms showed right extracranial vertebral artery (VA) dissection starting at the C2 level extending to the intracranial VA near the VA union. Proximal occlusion of the right VA by the endovascular approach was performed. The second patient was a 57-year-old man whose angiograms showed the left intracranial VA dissection distal to the posterior inferior cerebellar artery and an extracranial aneurysmal dilatation of the left VA at the C1 level and extracranial VA dissection in the V3 portion of the right VA. Left intracranial VA dissection was surgically trapped, and the remaining lesions were conservatively treated.  Simultaneous dissection of the intracranial and extracranial portions of the VA is rare. Such lesions usually cause brain ischaemia, but may cause intracranial subarachnoid haemorrhage. Published online July 18, 2002     

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms

Summary One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances.More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage then a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p<0.04); the reverse was true for the placebo patient (p<0.05).     

The management of spontaneous primary intracerebral haemorrhage

Intracerebral haemorrhage (ICH) accounts for around 10–20% of all strokes and results from a variety of disorders. ICH is more likely to result in death or major disability than ischaemic stroke or subarachnoid haemorrhage. Rapid imaging allows early diagnosis and characterization of the localization and severity of the haemorrhage. Patients with significant acute ICH should be managed in a critical care unit. Treatment entails general supportive care, control of blood pressure and intracranial pressure, prevention of haematoma expansion and, where indicated, neurosurgical intervention. In those patients whose bleed extends into the ventricular system or who have infratentorial bleeds are at increased risk of associated hydrocephalus, rapidly increasing intracranial pressure requiring urgent CSF drainage. The 30-day mortality from intracerebral haemorrhage ranges from 35–52%. Among survivors, the prognosis for functional recovery depends upon the location of haemorrhage, size of the haematoma, level of consciousness, the patient's age, and overall medical condition.     

Haemangiopericytoma presenting with acute intracerebral haemorrhage

Summary Clinical presentation of brain tumour by acute haemorrhage is well known and occurs in around 5% of the cases. Haemangiopericytoma (HPC) is a richly vascularized tumour, but its clinical manifestation is most frequently related to tumour mass effect or seizures. We present the eighth case reported of a patient with acute intracerebral bleeding caused by HPC. Though HPC represents only about 2% of intracranial meningeal neoplasms it must be included in the differential diagnosis of intracranial haemorrhage.     

Control of major haemorrhage

Major haemorrhage defined as ‘life-threatening bleeding’ is associated with significant morbidity and mortality. Prompt and expeditious control of haemorrhage is essential to improve patient outcome and this requires a sound understanding of the fundamental principles of haemorrhage control. Knowledge of the mechanism of injury in trauma and a systematic approach to clinical examination and assessment of blood loss are essential to identify the patient with a life-threatening bleed. Permissive hypotension, correction of coagulopathy and avoidance of hypothermia are important during the resuscitation phase. Special investigations for major haemorrhage are reserved for the haemodynamically stable patient. There are some surgical principles which apply to the various scenarios of major haemorrhage and in particular the concept of damage control surgery is relevant here. Endovascular interventions have added a further dimension to our management strategy. This article aims to discuss some of the principles that govern the management of the patient with major haemorrhage.     

Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour

Summary We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air.The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.     

Even the smallest remnant of an avm constitutes a risk of further bleeding

Summary A case with an ill-defined arteriovenous malformation in the parieto-occipital region is presented. Open surgery was unsuccessful in removing the AVM totally, and treatment with gamma knife radiosurgery was then attempted. At 14 months after this treatment the AVM was believed to be obliterated. The patient had a new intracranial haemorrhage 59 months after radiosurgery. Renewed angiography showed an obvious AVM outside the previously irradiated area. Retrospective analysis of the angiogram at 14 months after radiosurgery revealed early filling of a draining vein as a sign of residual AVM at this time. Renewed radiosurgical treatment was performed. It is believed that an ill-defined margin, laminar flow, and effects of previous surgery might add to difficulties in a proper visualisation and delineation of an AVM. Further, a small remaining shunt may be overlooked if the angiogram is not carefully analysed or if the angiogram is of inferior quality. It should be stressed that partial or almost total obliteration of an AVM is no protection against rebleeding.     

Proximal clipping of dissecting intracranial vertebral aneurysm — effect of balloon Matas test with neurophysiological monitoring

Summary A case of repeated subarachnoid haemorrhage (SAH) caused by rupture of a dissecting intracranial vertebral aneurysm is reported. The clinical manifestations, angiographic findings, pre-operative assessment with neurophysiological monitoring, and surgery are presented. A review of the literature suggests that this type of intracranial aneurysm is being recognized with increasing frequency in SAH and fatality, and therefore exploration and treatment of vertebrobasilar (V-B) dissecting aneurysms is necessary. We emphasize that a balloon Matas test with monitoring of somatosensory evoked potentials (SEP), auditory brain stem responses (ABR), and its wedge pressure in occluding the vertebral artery before operation are objective assessments of treatment for dissecting intracranial vertebral aneurysm.     

Anaerobic change of bloody CSF in subarachnoid haemorrhage. Its relation to cerebral vasospasm

Summary In our in vitro study of subarachnoid haemorrhage, the anaerobic incubation of CSF-blood mixture led to marked fall in the pH value thereof, which suggested to us that intracranial focal acidosis may play some role in the pathogenesis of cerebral vasospasm or disturbance of consciousness after the haemorrhage. To test this hypothesis, we treated 16 clinical cases of such disorders with carotid injection of 7% sodium bicarbonate solution. The treatment resulted in considerable improvement of the disturbance of consciousness by dilating the cerebral peripheral arteries; this we could observe angiographically 15 minutes after carotid injection. We found no morphological changes, however, in the spastic vessel itself up to 30 minutes after the injection.Given the result both of this study and of our previous experiments, we offer the hypothesis that the synthesizing process of thromboxane A 2 and intracranial focal acidosis might play an important role in the pathogenesis of cerebral vasospasm.     

动态CT扫描联合TCD检查预测外伤性蛛网膜下腔出血患者预后

目的动态CT扫描联合TCD预测外伤性蛛网膜下腔出血（tSAH）患者预后。方法对155例外伤性蛛网膜下腔出血患者给予动态CT扫描及TCD监测脑血流,6个月后行GOS评分（预后评分）。结果CT扫描tSAH出血量多、Hidjra分型13分以上、出血部位位于颅底大血管周围（外侧裂池、基底池、鞍上池、环池、四叠体池）,合并明显颅内损伤,颅内压较高及TCD监测的大脑中动脉血流明显增快者GOS评分低,预后较差。结论tSAH患者动态CT表现严重、TCD血流增速明显者,预后差。     

Viscoelastic haemostatic point-of-care assays in the management of postpartum haemorrhage: a narrative review

Viscoelastic haemostatic assays provide rapid testing at the bed-side that identify all phases of haemostasis, from initial fibrin formation to clot lysis. In obstetric patients, altered haemostasis is common as pregnancy is associated with coagulation changes that may contribute to bleeding events such as postpartum haemorrhage, as well as thrombosis events. In this narrative review, we examine the potential clinical utility of viscoelastic haemostatic assays in postpartum haemorrhage and consider the current recommendations for their use in obstetric patients. We discuss the clinical benefits associated with the use of viscoelastic haemostatic assays due to the provision of (near) real-time readouts with a short turnaround, coupled with the identification of coagulation defects such as hypofibrinogenaemia. The use of viscoelastic haemostatic assay-guided algorithms may be beneficial to diagnose coagulopathy, predict postpartum haemorrhage, reduce transfusion requirements and monitor fibrinolysis in women with obstetric haemorrhage. Further studies are required to assess whether viscoelastic haemostatic assay-guided treatment improves clinical outcomes, and to confirm the utility of prepartum viscoelastic haemostatic assay measurements for identifying patients at risk of postpartum haemorrhage.     

Control of major haemorrhage and damage control surgery

Major haemorrhage is defined as ‘life-threatening bleeding’. It is associated with significant morbidity and mortality and prompt, expeditious control of haemorrhage is essential to improve patient outcome. Understanding the mechanism of injury in trauma and a systematic approach to clinical examination and assessment of blood loss are essential to identify the patient with a life-threatening bleed. Permissive hypotension, correction of coagulopathy and avoidance of hypothermia are important during the resuscitation phase. Special investigations for major haemorrhage are reserved for the haemodynamically stable patient. There are some generic surgical principles, which apply to all scenarios of major haemorrhage, and endovascular interventions have added a further dimension to this management strategy. Recent advances in survivability following polytrauma are credited to the modern concept of an integrated approach to damage control resuscitation and damage control surgery. This article aims to discuss some of these key principles that govern the management of the patient with major haemorrhage.     

Cavernomas of the central nervous system in children

Summary A series of 22 patients under the age of 15 years with cavernomas were treated at the Section of Paediatric Neurosurgery of the Catholic University of Rome between 1981 and 1995. The most common symptoms at presentation were epilepsy, in 12 children, and intracranial hypertension, in 9 children; seizures were present on admission in 14 patients; no patient had a family history of cerebro-vascular malformations, two had multiple lesions. Radiological signs of significant acute and subacute haemorrhage were found in 17 cases. The supratentorial compartment was the most frequent location of the lesions, with only three subtentorial cavernomas. The post-surgical results were good: only four children had a persistence of pre-surgical neurological signs, even though they were ameliorated by the treatment. No patient showed a progression of pre-operative neurological signs, nor the onset of new deficits. Only one child died, but his clinical condition was critical before surgery, because of deep coma, with bilaterally dilated and fixed pupils, and no response to any stimulation.Our results suggest that the younger children present significant haemorrhage more frequently than the older ones; this is demonstrated by the analysis of the mean age of the patients with macro-haemorrhage (=7 years) and the average age of those without macro-haemorrhage (=11 years). The removal of cavernomas was always able to control the seizure disorders of our patients, proving that in these cases lesionectomy alone may be sufficient to resolve epilepsy.     

Delayed intracranial haemorrhage in patients with multiple trauma and shock-related hypotension

Summary During an 11 year period, 10 cases of delayed traumatic intracranial haematomas, following the correction of shock, were discovered. The intracranial haematomas were not present on initial computerized tomography (CT) scans after stabilization of the vital signs. Skull fractures were found in six patients; five of them had epidural haematomas at the site of their skull fracture. Four patients developed intracranial haematomas during general anaesthesia for extracranial surgery. All the delayed intracranial haemorrhages (seven epidural haematomas and three delayed intracranial haematomas) occurred within 12 hours after initial resuscitation. Seven out of eight patients made a good recovery after surgical removal of their intracranial haematoma.The initial hypotension may have acted as a protective mechanism, obscuring the intracranial haemorrhage. Awareness of this possibility, and a high degree of suspicion in those patients who deteriorate following correction of their shock, is important. We suggest that, even with a negative initial CT scan the duration of extracranial surgery in the acute period should be as short as possible in patients with suspected head injury. If these patients fail to wake up as expected following anaesthesia or new neurologic deficits develop, an urgent follow up CT scan should be performed.     

The management of spontaneous primary intracerebral haemorrhage

Intracerebral haemorrhage (ICH) accounts for around 10–20% of all strokes and results from a variety of disorders. ICH is more likely to result in death or major disability than ischaemic stroke or subarachnoid haemorrhage. Rapid imaging allows early diagnosis and characterization of the localization and severity of the haemorrhage. Patients with significant acute ICH should be managed in a critical care unit. Treatment entails general supportive care, control of blood pressure (BP) and intracranial pressure (ICP), prevention of haematoma expansion and, where indicated, neurosurgical intervention. Those patients whose bleed extends into the ventricular system or who have infratentorial bleeds are at increased risk of associated hydrocephalus, rapidly increasing ICP requiring urgent cerebrospinal fluid drainage. The 30-day mortality from ICH ranges from 35% to 52%. Among survivors, the prognosis for functional recovery depends upon the location of haemorrhage, size of the haematoma, level of consciousness, and the patient's age and overall medical condition.     

Management of massive gastrointestinal haemorrhage

Gastrointestinal haemorrhage (GI bleeding) is a common medical emergency, with one patient presenting every 6 minutes in the UK, or 85,000 cases per annum. It is associated with a significant mortality rate that has remained relatively static at 10% for more than two decades. Haemorrhage is commonly categorized as upper or lower gastrointestinal in origin, but for organization of care, both groups should be regarded as one clinical entity. Rapid assessment, resuscitation and correction of coagulopathy should be undertaken, and investigation or definitive management urgently arranged. For upper GI haemorrhage, endoscopy remains the cornerstone of investigation and treatment. In lower GI haemorrhage, a more nuanced algorithm utilizing CT angiography and endoscopic evaluation is recommended. Clinicians may utilize a range of treatment modalities including endoscopic and interventional techniques to diagnose and control the source of haemorrhage, which should be tailored to the site of bleeding and pathology. Where control is not achieved the clinician should consider either repeat intervention, use of alternative haemostatic techniques or a different modality to achieve haemostasis. Surgery is rarely used as a treatment and should only be undertaken where all other measures to control haemorrhage have failed.     

The impact of donor spontaneous intracranial haemorrhage vs. other donors on long-term renal graft and patient survival

BACKGROUND: Donor cause of death has a significant impact on transplant survival in heart transplants recipients. The objective of this study was to determine if long-term renal allograft and patient survival differed between grafts donated by donors who died of spontaneous intracranial haemorrhage (SIH) compared with those with other causes of death (OCOD). METHODS: Between 1990 and 2001, 1526 renal transplants were performed (711 SIH donors and 815 OCOD donors) at our unit. Serum creatinine levels at 1 yr, graft half-life and annual graft failure rate were measured for both groups. Renal graft and patient survivals between the groups were compared. Relative risk for SIH donors and other confounding variables was measured using Cox proportional hazards models. RESULTS: Graft half-life results were obtained for SIH (8 yr) and OCOD (10.13 yr) recipients. Graft and patient survival at 5 and 10 yr was 68.5% and 39.3% respectively for the SIH group vs. 76.8% and 51.9% respectively for the OCOD group (p < 0.001). However, SIH graft recipients were significantly older with more females. After adjustment for differences in baseline variables between the groups, donor cause of death did not have an independent effect on long-term graft or patient survival. CONCLUSION: Spontaneous intracranial haemorrhage as a cause of donor death, failed to have a significant independent effect on long-term allograft and patient survival.