- [Show abstract] [Hide abstract] ABSTRACT: Although, the overall treatment results in aneurysmal subarachnoid hemorrhage (SAH) has been improving in recent years, more than 10% of the patients with WFNS grade I and II we have sought to determine the clinical variables for predicting poor functional outcome and symptomatic vasospasm (VS) in patients with individual WFNS grades. The eligible patient fulfilled the following conditions; (1) ruptured aneurysm located in the anterior part of the circle of Willis, (2) surgically clipped followed by craniotomy under microscope, (3) early surgery within 72 hours, (4) classified to WFNS grade I or II. The medical records were retrospectively reviewed in 119 patients (63 of grade I and 56 of grade II). Sex, age, Fisher's CT group, intraventricular hemorrhage (IVH), site of aneurysm, VS, hydrocephalus, premature bleeding and complications of various kinds were selected as the dependent variables. The contributions of these factors to outcome (Glasgow Outcome Scale, GOS) as well as VS were analyzed using the logistic regression method. Outcome was better in WFNS grade I (p=0.039), and VS occurred less often and responded well to various interventional techniques and drug delivery. No significant variables contributed to the poor outcome or VS in WFNS grade I. In WFNS grade II, logistic regression analysis showed that VS (OR 34.6, 95% CI, 30.8-38.9, p =0.012) and the complications (OR 52.4, 95% CI, 46.5-59.1, p=0.004) were significant predictors for a poor outcome. Fisher's group 3 was also the only significant factors in VS (OR 3.78, 95% CI, 3.35-4.28, p =0.039). The cause for the difference in outcome and VS were discussed in detail. The vasospasm and various kinds of complications were the predictive factors of poor clinical outcome, in patient of WFNS garde II. Therefore, careful management and meticulous/pertinent surgical maneuvers are mandatory to obtain better results in aneurysmal SAH, even in better WFNS grades.
- [Show abstract] [Hide abstract] ABSTRACT: The preventative effect of cisternal irrigation with milrinone against vasospasm was evaluated in 12 patients with subarachnoid hemorrhage (SAH) of World Federation of Neurosurgical Societies grade IV or V treated between September 1999 and September 2000. All aneurysms were clipped or embolized within 72 hours of the onset of SAH. Inlet and outlet tubes were placed in either the supratentorial cisternal space, lateral ventricle, or spinal subarachnoid space. Lactated Ringer solution containing urokinase (120 IU/ml), ascorbic acid (3.5 mg/ml), and milrinone (3.6 microg/ml) was continuously infused at 30 ml/hr for as long as 2 weeks. Angiographical vasospasm was detected in only two of the 11 patients who received milrinone irrigation and underwent postoperative angiography. Vasospasm may have resulted from irrigation obstruction associated with pneumocephalus in one patient and clot in the sylvian fissure in the other patient. The outcome of the milrinone irrigation therapy was significantly better than that of the conventional therapy. This study suggests that cisternal irrigation with milrinone is safe and effective, and reduces the occurrence of vasospasm in patients with poor grade aneurysmal SAH.
- [Show abstract] [Hide abstract] ABSTRACT: Cerebral vasospasm remains a leading cause of morbidity and increasing mortality rates following aneurysmal subarachnoid hemorrhage (SAH). The rate of vasospasm and the outcome (Glasgow Outcome Scale; GOS) especially in poor WFNS grade were retrospectively analyzed over a 6-year period. Patients were divided into three different groups. The first group (pre-group) consisted of 43 patients (grade IV: 31, grade V: 12), who were admitted between 1996 and 1998. When vasospasm occurred, they were mainly treated by papaverine (PPV) and percutaneous transluminal angioplasty (PTA). In the second group (mil-cis group), for the prevention of vasospasm, cisternal irrigation therapy with milrinone was applied in 24 patients (grade IV: 13, grade V: 11), who were admitted in the period between 1999 and 2001. The third group, (w/o mil-cis group), consisted of 30 patients (grade IV: 15, grade V: 15), in whom cisternal irrigation therapy was not able to be carried out. In grade IV, vasospasm was observed in 66% of the patients the first group, 50% in the w/o mil-cis group and significantly less in the mil-cis group (15%, p<0.024). In grade V, the rate of vasospasm was also lower in the mil-cis group but no statistical significance was revealed. Although the rate of favorable outcome in GOS was highest and the rate of death was least in the mil-cis group in both grade IV and V, only the trend was observed. Many factors should be considered, Cisternal irrigation therapy with milrinone reduced the occurrence of vasospasm. However, outcome was not improved because of the initial poor clinical condition.
- [Show abstract] [Hide abstract] ABSTRACT: A case of intracranial bilateral vertebral artery (VA) dissection presenting with ischemic symptoms which following unilateral dissection is presented. A 42-year-old male with an occipital headache was pointed out right vertebral artery stenosis with magnetic resonance (MR) angiography 8 day before admission. He admitted to our hospital complaining of severe vertigo and tinnitus. MR images and cerebral angiograms revealed bilateral VA dissection with infarcts in light lower surface of cerebellum perfused by posterior inferior cerebellar artery and right hypothalamus. Conservative therapy was adopted and serial MR angiography was performed. His symptoms were improved gradually and MR angiograms obtained 2 months later revealed improvement of bilateral VA stenosis. It is generally accepted that VA dissection presenting ischemic symptoms has good outcome by conservative therapy only. However, its pathological process of progression is still unknown. Based on the serial MR findings, we discuss the mechanisms of bilateral VA dissection. In this case, we consider that unilateral VA dissection extended to contralateral vertebral artery through the vertebrobasilar junction. Frequent MR angiography in acute phase could be of great use for monitoring the progression of dissection.
- [Show abstract] [Hide abstract] ABSTRACT: A 67-year-old man died of subarachnoid hemorrhage (SAH) resulting from dissection of the distal part of the anterior cerebral artery (ACA). A saccular aneurysm in the anterior communicating artery had ruptured and was successfully clipped on Day 0. The patient recovered consciousness after surgery but his condition deteriorated due to another SAH on Day 1. A second surgical procedure disclosed bleeding from a laceration in the opposite wall of the ACA distal to the clipped aneurysm. Histological examination of the autopsy specimens revealed damage to the internal elastic lamina and inflammatory infiltration of leukocytes. The fatal dissection may have resulted from atherosclerosis, hemodynamic stress caused by hypertension, or trauma due to surgical manipulation.
- [Show abstract] [Hide abstract] ABSTRACT: Fenestration of the internal carotid artery (ICA) is extremely rare on clinical settings. Six cases of fenestration in intracranial and 8 in extracracranial ICA have ever been reported in literature. Authors describe two cases of fenestration at the extracranial ICA that were initially suspected of the dissection of ICA on MRA/I. Both angiography and CT angiography (CTA) disclosed the fenestration, which located at C2 vertebral levels. To confirm the fenestration at extracranial ICA is important in such an occasion that mimic the dissection of ICA, especially in patients who complain of cervical pain, mass and other related symptoms. Differences in the fenestration, the dissection and atherosclerosis on imaging, were reviewed and discussed.
- [Show abstract] [Hide abstract] ABSTRACT: The intra-arterial infusion of papaverine has been used for dilation of spastic cerebral vessels after aneurysmal subarachnoid hemorrhage, although its efficacy is controversial. Milrinone is an inotropic drug that dilates vessels by phosphodiesterase inhibition in a mechanism similar to that of papaverine. We examined the effects of intra-arterial and subsequent intravenous administration of milrinone on patients with symptomatic cerebral vasospasm. Seven patients with cerebral vasospasm were enrolled in this study. Milrinone was delivered intra-arterially via catheter at a rate of 0.25 mg/min. The total delivered dose was between 2.5 and 15 mg. Radiological measurement of the middle cerebral artery diameter and cerebral blood flow was carried out before and after arterial infusion. Intravenous treatment followed at 0.50 or 0.75 microg/kg/min for up to 2 weeks from the onset of subarachnoid hemorrhage. Dilation of the vasospastic vessels occurred in all patients. The rate of cerebral blood flow was calculated in six patients and was increased in all. Subsequent intravenous infusion was effective in preventing a recurrence of symptomatic vasospasm in four of the seven patients. It is suggested that milrinone was effective and safe for the treatment of cerebral vasospasm after subarachnoid hemorrhage in the patients in this series. Intra-arterial infusion with adjunctive intravenous infusion holds promise as a clinically advantageous treatment regimen.
- [Show abstract] [Hide abstract] ABSTRACT: A 24-year-old female presented with Terson syndrome secondary to bilateral ventricular hemorrhage as a complication of moyamoya disease. Ophthalmoscopy and magnetic resonance imaging clearly demonstrated vitreous hemorrhage in the left eye globe. Various visual symptoms are associated with moyamoya disease, almost all of which result from ischemic lesions in the visual cortex and optic pathways. In this case, the visual disturbance was caused by Terson syndrome secondary to ventricular hemorrhage. Close ophthalmological and radiological evaluation is mandatory even in patients with moyamoya disease and hemorrhagic manifestation located in the intracerebral, subarachnoid, or intraventricular space.