In this study we evaluated the effect of the intraoperative irrigation of subarachnoid blood clots in early-stage surgeries for subarachnoid hemorrhages (SAH) in the prevention of hydrocephalus and symptomatic vasospasms. All 25 patients had dense clots exhibiting Fisher groups 3 or 3+4 on a CT scan. The subarachnoid clots were extensively irrigated and washed out in 16 cases (the irrigation group) and minimally removed in 9 cases (the no-irrigation group). Spinal drainage was put into place before the craniotomy, and a trans-lamina terminalis third ventriculostomy was performed for safe retraction of the brain. A urokinase solution was dripped into the subarachnoid space during the subarachnoid dissection for the clotlysis. After the aneurysm was clipped, the clots of the subarachnoid cisterns were irrigated by a high-pressure physiological saline solution buffered by sodium bicarbonate. A 20ml syringe with a locked needle was used to manually inject the irrigation fluids. The occurrence of hydrocephalus and a subsequent need for a ventriculo-peritoneal shunt was 43.8% for patients in the irrigation group and 66.7% for those in the no-irrigation group. The occurrence of symptomatic vasospasms was 12.5% and 77.8%, respectively. In general, outcomes for patients in the irrigation group were better than for those in the no-irrigation group. This is a safe method for the removal of subarachnoid blood clots and results in a better prognosis for SAH patients with thick subarachnoid blood clots.
The natural history of the unruptured aneurysm is not clear. We retrospectively analyzed 7 cases with 10 unruptured aneurysms and in the literature 18 similar cases with 23 aneurysms that expanded or newly formed due to natural causes. In our series, the diameters of the aneurysms of the first angiograms were AN1 (mm) 0 to 28.63 (mean 8.40, median 6.45). Those of the last angiograms were AN2 (mm) 1.82 to 30.11 (mean 11.38, median 8.53). They were performed after 5.8 years of mean follow-up period: (=Int). The growth of the aneurysm diameter was G (mm)=AN2-AN1, 1.47 to 7.15 (2.98±2.02). The growth rate was Gratio (mm/yrs)=G/Int, 0.22 to 2.52 (0.71±0.70). In our series, 4 of 10 aneurysms were ruptured, and the remaining were intact. The mean diameter of the ruptured aneurysms expanded from AN1: 7.69 to AN2: 12.39. The unruptured ones expanded from AN1: 8.87 to AN2: 10.70. G of the ruptured aneurysm group was 4.70. The unruptured group was 1.83. Between these two Gs were significant differences. Gratio of the ruptured aneurysm group was 1.26. The unruptured group was 0.34. These two Gratios also had significant differences. In our series AN2 of the ruptured aneurysm group was 12.39. This was larger than the unruptured group (10.70). This does not contradict findings in the literature that unruptured aneurysms whose sizes are over 7mm~10mm have more risks of rupture. Together with our series and the literature's, there were 18 de novo aneurysms. Five were so called “mirror image” aneurysms, so suspected one of the causes of the de novo aneurysm was congenital defect of the media, for example. In our series the aneurysms whose Gs were equal to or grater than 2.5mm, or whose Gratios were equal to or greater than 20.49mm/years ruptured. We therefore consider 2.5mm≤G or 20.49mm/years≤Gratio as risk factors. We emphasize the need to estimate and follow up the sizes of the unruptured aneurysms with noninvasive examinations like MRA or CTA. If the sizes of the unruptured aneurysms are expanding by 2.5mm≤G or 20.49mm/years≤Gratio, the aneurysms have more risks of rupture, so some kind of surgical intevention is recommended.
Various intraoperative monitorings have been performed during neurosurgery. Intraoperative cerebral angiography during an operation on cerebrovascular disorders can contribute to the safety of the operation. We performed intraoperative cerebral angiography on 13 patients who had intracranial cerebral aneurysms. A portable digital subtraction angiography unit was used on all those patients. In 5 patients, angiography was performed by direct puncture of the common carotid artery, l had retrograde brachial arterial angiography, and the other 7 had Seldinger's angiography via the right brachial artery. Aneurysmal neck clipping was performed on all patients, and the complete disappearance of the aneurysm was confirmed by intraoperative cerebral angiography. With the portable digital subtraction angiography unit, the disappearance of the aneurysm and the preservation of arteries around the aneurysm were confirmed in the same way as conventional postoperative angiography. Intraoperative cerebral angiography was performed safely without thrombosis or embolism. In conclusion, intraoperative angiography is a safe and useful method for aneurysm operation. Especially, Seldinger's method via brachial artery is safe and convenient.
Objective: To identify the main causes of death in a contemporary series of surgically treated patients with subarachnoid hemorrhage (SAH) and angiographically proven aneurysm. Methods: Since August 1989, 390 patients with aneurysmal SAH underwent surgery. Early surgery within 72 hours was possible in 309 patients, who had been admitted in time. In all patients, the out-come was assessed at discharge and after six month. Cases with a fatal outcome were studied in detail with respect to the clinical state pre- and postoperatively, the incidence of cerebral vasospasm as measured by transcranial Doppler sonography (TCD), and the postoperative neuroradiological investigations to identify the cause of death. Results: Thirty-three of the 390 surgically treated patients died during the follow-up period of six months, accounting for a post-operative mortality rate of 8.4%. The main cause of death was the effect of the initial hemorrhage in 18 patients (4.6%), followed by surgical complications in 6 patients (1.5%), vasospasm in 4 patients (1%), and medical complication in 4 patients (1%). In one patient, the available records did not allow to identify the cause of death. Conclusion: In the past two decades, re-rupture and vasospasm had been the leading causes of death in patients with aneurysmal SAH. Today, the effect of the hemorrhage is the main reason for a fatal outcome, which could be explained by the current policy to perform early surgery in good- as well as in poor-grade patients.
Numerous operative procedures have been proposed for correction of the subclavian steal syndrome. To select reasonable operative procedures in the respective patients, we have studied the cerbral blood flow, especially in the posterior circulation, by 123I-IMP-SPECT imaging, and the blood flow in the upper extremities by 99mTc-HSA accumulation curve in 11 patients with subclavian steal syndrome. The causative lesions were left subclavian artery occlusion in 10 cases and inominate artery occlusion in 1 case. Although all patients presented distinct symptoms and signs of vertebrobasilar insufficiency, 123I-IMP-SPECT early image demonstrated no evident finding of decreased blood flow in the posterior circulation. However, in the delayed image 5 out of 11 patients revealed laterality of IMP uptake in cerebellar hemisphere. Four patients presented symptoms of the upper extremities including arm claudication, and all of them revealed 99mTc-HSA accumulation curve indicated decreased blood flow in the affected side of arm and forearm. We performed transposition of vertebral artery to common carotid artery in 7 patients without evidence of decreased blood flow in the upper extremities by 99mmTc-HSA accumulation curve, common carotid-subclavian dacron graft bypass in 3 cases with evidence of decreased blood flow in the upper extremities, and arch aortacommon carotid dacron graft bypass for the innominate artery occlusion. When the ischemia in the anterior circulation had existed in patients with multiple cerebrovascular occlusive disease, we first corrected the anterior circulation, and then performed the revascularization for the posterior circulation mentioned above by staged operation, resulting in successful treatment of all patients. We conelude that to determinine surgical indication and select procedures for the subclavian steal syndrome, 123I-IMP-SPECT imaging and 99mTc-HSA accumulation curve of upper extremities are mandatory, and the priority of vascular reconstruction for the subclavian steal syndrome should be first aimed to correct the anterior circulation, then correct the posterior circulation and the circulation of upper extremities.
During the last 6 years, we performed neck clipping on 504 intracranial cerebral aneurysms at our institution. Among them 146 aneurysms were located in the middle cerebral artery. Six aneurysms arose from the origin of the lenticulostriate artery and represented 1.2% of all 504 cerebral aneurysms and 4.1% of 146 middle cerebral aneurysms. Two patients were male, and 4 were female. The age ranged from 46 to 75 years old (average; 59.8 years old). Four patients harbored multiple aneurysms (67%). All 6 aneurysms were clipped within day 3 using lateral trans-Sylvian approach. Postoperative cerebral infarction was noted on CT scan in 3 patients. We discuss the mechanism of postoperative infarction and review some relevant literature.
We report on a 70 year-old-man with mycotic aneurysm. The patient had perianal abscess and splenic abscess before rupture of the aneurysm, but he did not have any other causal disease of mycotic aneurysm. At first, the patient complained of left abdominal pain followed by general convulsion and lost consciousness. He recovered within a short time and then he came to our hospital. On arrival, he was alert and able to walk. He did not have headache. After about half an hour, his blood pressure fell under 90 mmHg suddenly. The duty doctor therefore administered dopamine as intravenously and his blood pressure rose to 140 mmHg, at which point the duty doctor stopped administering dopamine. But about half an later dopamine, the patient complained of severe headache, then developed general convulsion and lost consciousness again. Furthermore, he manifested right hemiparesis. Computed tomography showed a high density area in the sylvian fissure on the left side, and cerebral angiography revealed an aneurysm located along the left middle cerebral arteries and lack of opacification of the left prefrontal artery with delayed retrograde filling. A blood test revealed systemic inflammation. We therefore diagnosed occlusion of the prefrontal artery and subarachnoid hemorrhage caused by rupture of the mycotic aneurysm. During the operation, we found an embolus in the lumen of prefrontal artery located just distal of the aneurysm. A specimen of the aneurysmal wall showed marked infiltration of inflammatory cells. The above, suggested that the first general convulsion was caused by arterial embolism and the second one was caused by the rupture of mycotic aneurysm. In this case, the rupture of mycotic aneurysm was caused by the elevation of systemic blood pressure after arterial occlusion of distal part of the aneurysm
We conducted a nationwide study over a one year period (July 1, 1995-June 30, 1996) to elucidate the incidence, clinical and radiological features, outcome, and factors influencing the poor outcome in intracranial arterial dissection. The subjects of the study were 357 patients with intracranial arterial dissection reported from 208 neurosurgical institutes. Those were divided into two groups: a hemorrhagic group of 206 patients (58%) presenting with subarachnoid hemorrhage, and a nonhemorrhagic group of 151 patients (42%) manifesting brain ischemia, headache or, asymptomatic. In addition, 322 patients (90%) had a single lesion, and 35 (10%) had multiple lesions. Among 322 patients in the single-lesion group, 299 (93%) had a lesion in the vertebrobasilar system, and only 23 (7%) in the carotid system. Results: 1) Age and sex: Patients were younger in the nonhemorrhagic group, and in the group with lesions in the carotid system. Males were predominant in both the hemorrhagic and nonhemorrhagic groups, and in the group with lisions in the vertebrobasilar system. 2) Location of arterial dissection: the vertebral artery was most frequently affected in 84% of the hemorrhagic group, and in 77% of the nonhemorrhagic group. 3) Angiographical findings: Dilatation with or without contrast media retention was the most common finding in both the hemorrhagic and nonhemorrhagic groups. Narrowing or occlusion with or without retention was most prevalent in the carotid system, whereas dilatation with or without retention was most common in the vertebrobasilar system. 4) Treatment: Sixty-one percent of the patients was surgically treated in the hemorrhagic group, while 82%were conservatively managed in the nonhemorrhagic group. 5) Outcome: Fifty-three percent of the patients recovered well, and 27% died in the hemorrhagic group. Seventy-nine percent made a good recovery and only 3%died in the nonhemorrhagic group. The outcome did not significantly differ between those with lesions in the carotid and vertebrobasilar systems. 6) Causes of poor outcome: Rebleeding and primary brain damage were the leading causes of poor outcome in the hemorrhagic group, whereas brain infarction was the main cause in the nonhemorrhagic group. These results were, on the whole, consistent with the data, accumulated from the literature. It could be said that the data in the present study would have established the clinical pictures of the intracranial arterial dissection.
This is Part 2 of our report on a nationwide study of intracranial arterial dissection, carried out from July 1, 1995, through June 30, 1996. In this report, we discuss the treatment and results. Three hundred and fifty-seven patients with intracranial arterial dissection were classified into two groups: a hemorrhagic group of 206 patients (58%) presenting with subarachnoid hemorrhage, and a nonhemorrhagic group of 151 patients (42%) manifesting brain ischemia, headache or, no symptom. Among 322 patients with a single lesion, 299 (93%) lesions were located in the vertebrobasilar system, and only 23 (7%) in the carotid system. Medical treatment, such as anticoagulant therapy, given to the conservtive group presenting brain ischemia was also investigated. Results: 1) Treatment: In the whole series, 61% of the patients in the hemorrhagic group were surgically treated, while 82% in the nonhemorrhagic group was conservatively managed. This difference was statistically significant (p<0.0001). Sixty-one percent and 55% of the patients were conservatively treated in the carotid system and the vertebrobasilar system, respectively. 2) Surgical procedure: In both the hemorrhagic and nonhemorrhagic groups, and in the vertebrobasilar system, proximal occlusion of the involved artery was the leading procedure, and intravascular surgery was the second. On the other hand, wrapping or coating was the main procedure in the carotid system. 3) Outcome: The outcome was better in the surgical group than in the conservative group of the hemorrhagic group, despite the fact that the severity on admission did not differ between the two groups. The outcome did not significantly differ between the surgical and conservative groups in the nonhemorrhagic group, and in both the carotid and the vertebrobasilar systems. Cerebral infarction was the most frequent postoperative intracranial complication in both the hemorrhagic and nonhemorrhagic groups. Anticoagulant and/or antiplatelet drugs were administered in 42% of the patients of the conservative group presenting with brain ischemia. However, the outcome did not significantly differ in the drug-treated group and the group treated without drugs. The present study indicates that conservative treatment has recently been the more frequently chosen option, as compared with the data accumulated from the literature. The outcome might be favorable in the surgical group of the hemorrhagic group.
We conducted neuropsychological testing of 86 patients who had undergone operation for subarachnoid hemorrhage (SAH) due to ruptured aneurysm 6 months to 1.5 years after onset. All patients were assessed as Good Recovery according to the Glasgow Outcome Scale. The battery of neuropsychological tests consisted of the Mini Mental State Examination (MMS), Kohs's block design test, Paired associate learning test, and “Kanahiroi” test. All patients examined by MMS 1.5 years after SAH were normal. Visuoconstructional cognition examined by Kohs's block-design test was impaired in about 40% and long-term memory was impaired in 20-60%. Further, 30% of the patients had frontal dysfunction investigated by “Kanahiroi” test. Multivariate analysis proved significant harmful effects of the neurological grade on onset (Hunt & Kosnik grade) on “Kanahiroi” test and paired associate learning test. In a series of neuropsychological tests, the scores slightly improved by 1 year after SAH, whereas almost none of the patients exhibited improvement in test scores. These findings suggest that neurophycological deficits after SAH was permanent.