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).     

Ruptured aneurysm with intracerebral hemorrhage in an 8 year old boy

Report on a case of aneurysm in a child and its treatment with discussion of its rarity and origin.     

The forgotten lumbar puncture

Lumbar puncture is crucial in two distinct clinical situations in the diagnosis of the headache patient. The first is the patient who is suspected of having a symptomatic headache; the second is the patient with a chronic intractable or atypical headache disorder. This review discusses the usefulness of the lumbar puncture in the diagnosis of headache secondary to subarachnoid hemorrhage, meningitis, and intracranial hypotension and hypertension. The value of lumbar puncture in the presence of a normal CT/MRI scan is discussed.     

Clinical and long-term follow-up study in patients with spontaneous subarachnoid haemorrhage of unknown aetiology

Summary Clinical characteristics and the outcomes of 50 patients with confirmed subarachnoid haemorrhage (SAH) of unknown aetiology were evaluated. Twenty-nine of these patients were interviewed with a mean follow-up of 7.7 years. Seven patients experienced early rebleeding during hospitalization, and one patient experienced late rebleeding during the follow-up period.On admission to the hospital the consciousness level was clear in 43 of the patients, drowsy in 6, and semicomatose in only 1. Of 10 patients who underwent computerized tomography (CT) within 3 days after SAH, 6 showed no abnormal CT findings and 3 had mild subarachnoid blood. Another patient showed severe SAH. Neurological deficit due to symptomatic vasospasm persisted in only 1 case.Two patients died after re-bleeding during hospitalization, and two others died during the follow-up, thereby representing an overall mortality rate of 8%. Of the latter cases, one died of an unrelated disease, and the other died suddenly from an unknown cause. The remaining forty-six patients (92%) had a good outcome. These results confirm previously reported clinical characteristics, namely that the symptoms of the majority of such cases are mild, the incidence of symptomatic vasospasm is rare, the risk of late re-bleeding is very low (less than 1% per year), and the prognosis is good. The CT findings suggest that some of these features resulted from only mild SAH. Thus, SAH of unknown aetiology seems to be a disease entity with a good prognosis.     

原发性脑室出血的CT征象与治疗（附28例报告）

目的探讨原发性脑室出血的临床表现、脑CT征象及其与治疗的关系;方法回顾性分析28例经CT证实原发性脑室出血病人的临床表现及CT征象;结果多有头痛、呕吐等脑膜刺激征表现,无脑局灶受损体征,脑CT均示原发脑室出血;结论原发性脑室出血的诊断依靠脑CT,Ⅰ型脑室出血宜行侧脑室外引流术,预后较差,Ⅱ、Ⅵ型可行腰穿脑脊液置换术．预后较好。     

Laparoscopic transgastric suturing for bleeding peptic ulcers

Background: Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing. Methods: After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a lift and cut technique. Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots. Results: Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm³/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement. Conclusions: It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Ubiquitinated neurites are associated with preamyloid and cerebral amyloid β deposits in patients with hereditary cerebral hemorrhage with amyloidosis Dutch type

Summary Here ditary cerebral hemorrhage with amyloidosis Dutch type (HCHWA-D) is characterized clinically by recurrent strokes and pathologically by deposition of amyloid (A) in cerebral vessel walls and, to a lesser extent, in the neuropil. Distinct from Alzheimer's disease, amyloid formation in HCHWA-D is not associated with neurofibrillary changes. Since a central issue in the pathophysiology of Alzheimer's disease and related conditions is the role of A in the neurodegencrative process, we investigated HCHWA-D brains for the presence of neuritic abnormalities using antibodies to ubiquitin and to phosphorylated neurofilaments. The study showed that amyloid deposits in the vessel walls and in the neuropil were surrounded by abnormal ubiquitinated neurites, suggesting that A deposition induces neuritic changes.Supported by the Italian Ministry of Health. Department of Social Services, and by N.I.H. Grants AG05891 and AG08721 (to B.F.)     

Volume control during periodic changes of blood volume in the alert rat

Summary Blood (3.4–13.5% of blood volume) was pumped in and out of the circulation of rats at different rates and period lengths during continuous measurements of blood conductivity (reciprocally related to hematocrit) and arterial pressure. Hct followed the same zig-zag course as the induced changes of blood volume in every case, indicating that fluid shifts (v) between interstitium and intravascular space closely follow blood volume changes. As the het increase during reinfusion was not as great as the preceding decrease, hct dropped continuously during the 20–90 minutes of experimentation, so that a final volume increase (v) by about 4% was calculated, which was confirmed by a corresponding decrease of plasma protein concentration. Both final v and v during periodic volume change (% B.V.) were greater when arterial pressure dropped. v was directly related to % B.V. but not to its rate of change. Heart rate dropped slightly at the end of the reinfusion periods, whereas it rose to control at the end of the withdrawal periods. The results were regarded as evidence of blood volume regulation proportional to the absolute volume of blood lost in non-hypotensive hemorrhage.Supported by DFG-grant AZ 3/3