[show abstract][hide abstract] ABSTRACT: Intra-arterial papaverine (IAP) is used to treat symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). IAP, however, can increase intracranial pressure (ICP). In this study we examined whether IAP alters brain oxygen (BtO2).
Poor clinical grade (Hunt & Hess IV or V) SAH patients who underwent continuous ICP and BtO2 monitoring during IAP infusion for symptomatic cerebral vasospasm were evaluated as part of a prospective observational study.
Data are available for five patients (median age 58) who received IAP for cerebral vasospasm 4 to 7 days after SAH. In each patient, angiographic vasospasm was improved on postinfusion angiogram. Mean ICP before IAP was 23.04 +/- 1.18 mmHg; it increased immediately after IAP infusion and remained elevated (29.89 +/- 1.18 mmHg; p < 0.05) during IAP and for approximately 10 minutes after IAP ended. Baseline mean arterial pressure (MAP) was 110.55 +/- 1.36 mmHg. During IAP treatment MAP remained stable (110.90 +/- 2.00 mmHg; p = 0.31). Mean BtO2 before IAP was 32.99 +/- 1.45 mmHg. There was a significant BtO2 decrease in all patients during IAP to a mean of 22.96 +/- 2.9 mmHg (p < 0.05). BtO2 returned to baseline within 10 minutes after IAP ended. There was a modest relationship between the ICP increase and BtO2 decrease (R2 = 0.526).
IAP infusion to treat cerebral vasospasm following SAH can increase ICP and reduce BtO2. The IAP-induced reduction in BtO2 may help explain why IAP, although it reverses arterial narrowing, does not improve patient outcome.
Neurocritical Care 02/2006; 4(2):113-8. · 3.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: The study presents normal reference intervals and ranges of "normal" side-to-side and day-to-day variability of ocular blood flow Doppler parameters. Peak-systolic (PSV), end-diastolic velocity (EDV) and impedance indices in the ophthalmic artery (OA), the central retinal artery (CRA) and the short posterior ciliary artery (SPCA) of both orbits were determined with color-coded duplex sonography in 140 healthy volunteers (range 18 to 83 y; 68 men and 72 women). Decreases in flow velocities and concomitant increases in impedance indices were found in all arteries with advancing age. The PSV and the EDV values for the OA, the CRA and the SPCA in the age group less than 40 yr-old were 40.6 +/- 8.9 and 11.2 +/- 3.7, 9.9 +/- 1.8 and 3.7 +/- 0.9, 13.8 +/- 2.6 and 5.7 +/- 1.5 cm/s (mean +/- SD), respectively. In the 40 to 60 yr-old age group, the values were 35 +/- 7.9 and 10.7 +/- 4.3, 9.7 +/- 2 and 3.5 +/- 0.8, 13.5 +/- 2.9 and 5.3 +/- 1.5 cm/s. In the age group over 60 yr-old, the values were 34 +/- 8 and 8.4 +/- 3.3, 9.3 +/- 2 and 3 +/- 0.9, 12.8 +/- 2.4 and 4.3 +/- 1.2 cm/s. In the youngest age group, the EDV in the CRA and the SPCA was higher in women, while in the OA the PSV and the EDV were higher in men. Ranges of side-to-side variability in the OA, the CRA and the SPCA, determined with repeatability coefficient for the PSV and the EDV, were 24, 5.4, 7.5 cm/s and 11, 2.5, 4.2 cm/s, respectively, whereas the values for day-to-day variability were 16.8, 4.3, 6.7 cm/s and 5.6, 1.7 and 3.9 cm/s. Ocular blood flow Doppler parameters range widely and are significantly age and sex dependent. Ranges of "normal" side-to-side and day-to-day variability of the parameters can help to determine abnormal flow pattern.
Ultrasound in Medicine & Biology 08/2005; 31(7):895-903. · 2.46 Impact Factor
[show abstract][hide abstract] ABSTRACT: Dural arteriovenous fistulas (DAVFs) are frequently accompanied with raised intracranial pressure and clinical findings suggestive of pseudotumor cerebri. However, unlike pseudotumor cerebri, the clinical response to lumbar cerebrospinal fluid (CSF) removal can vary from beneficial to acute clinical deterioration leading to death. The criteria for the safe use of lumbar puncture (LP) in patients with a DAVF are not well established.
A 61-year-old man presented with visual difficulty. Magnetic resonance imaging (MRI) and angiography revealed a left transverse sinus DAVF. He underwent multiple embolizations of arterial feeders over 3 years. He was then noted to have cognitive deficits in short term memory, listening, and concentrating. Over several days after an LP he became increasingly lethargic but arousable. Within hours after a repeat LP there was a rapid deterioration in the patient's level of consciousness and he became unarousable.
A brain MRI revealed extensive dilated cortical veins and left temporal lobe venous ischemia without tonsillar herniation. A cerebral angiogram showed an extensive left transverse sinus DAVF with an occluded lateral transverse sinus and increased retrograde venous drainage. Embolization of the arterial feeders in combination with trans-venous coil embolization of the left transverse sinus reversed the patient's neurologic decline. He was discharged neurologically intact except for his chronic visual acuity problems.
We speculate that when a DAVF manifests retrograde venous flow sufficient to cause cognitive deficits, lumbar CSF drainage must be undertaken with extreme caution.
[show abstract][hide abstract] ABSTRACT: The petrous and cavernous segments of the extradural internal carotid artery take a complex course through the skull base before entering the subarachnoid space distal to the cavernous sinus. Despite the protection from trauma afforded by the anatomy, the petrous and carotid internal carotid artery (ICA) segments of the vessel remains subject to disease, the most important of which are aneurysms. Aneurysms affecting the petrous portion of the vessel are extremely uncommon, and presentation with otologic symptoms is unusual. These symptoms include hearing loss, tinnitus, and life threatening hemorrhage. This article emphasizes the need for a high level of suspicion for aneurysm as a potential cause for otologic symptoms. We report and discuss three cases of petrous carotid aneurysms with otologic manifestations to increase the awareness and aid in the diagnosis and treatment of this uncommon disorder.
The medical records and imaging studies of three patients presenting to our institution with aneurysms involving the petrous internal carotid artery were reviewed. One presented with progressive bilateral sensorineural hearing loss. The next patient presented with pulsatile tinnitus. The last patient presented to the emergency room unresponsive with severe epistaxis.
All three patients had imaging studies revealing petrous carotid aneurysms. Each patient had symptoms related to the aneurysms ranging from hearing loss, tinnitus, and life-threatening hemorrhage.
Petrous carotid aneurysms are rare, and presentation with otologic symptoms is unusual. Awareness of these lesions as a cause of otologic symptoms, however, is highly important. These cases also illustrate the usefulness of endovascular treatments for aneurysms of the petrous portion of the internal carotid artery, which are extremely difficult to treat by using an open surgical approach.
American Journal of Neuroradiology 26(6):1324-7. · 3.17 Impact Factor