We analyzed the efficacy of occlusion of dissection sites using detachable coils for 22 consecutive patients with ruptured dissecting vertebral aneurysms. Over a 36-month period, 22 patients suffering from aneurysms with subarachnoid hemorrhage had dissecting vertebral aneurysms defined by angiography. Sixteen of these 22 patients were treated with platinum coil occlusion of the affected sites as early as possible after diagnosis. In 3 cases involving dominant vertebral arteries, balloon test occlusion with measurement of the stump pressure preceded the embolization. Two cases with hypoplastic vertebral arteries on the contralateral side were followed conservatively. Treatment of the aneurysms was not indicated in the other 4 cases because of intractable elevation of intracerebral pressure and severe brainstem dysfunction. Subsequent rupture occurred in 14 (64%) of the 22 patients, all of which occurred less than 24 hours after the first attack and 3 in an ambulance. Seven (50%) had suffered cardiopulmonary arrest on arrival, but emergency measures allowed recovery in all cases. During balloon occlusion tests of dominant vertebral arteries, mean arterial stump pressure (mean arterial stump pressure ratio %: post-/pre-occlusion mean arterial pressure) was high, ranging from 79mmHg to 100mmHg (postocclusion stump pressure/preocclusion mean arterial pressure ratio of 88% to 94%). In all 16 cases, coil embolization was successfully performed without complications. In 1 case with dissections involving bilateral vertebral arteries, minor rebleeding from a contralateral dissection occurred after embolization. In the other 15 cases, rebleeding did not occur (clinical follow-up: mean 10 months). Radiological findings showed complete occlusion of the dissection site and patency of the non-affected artery (follow-up: mean 7 months). In 6 cases without embolization, only 1 survived with a good outcome, the other 5 cases dying from repeated hemorrhage. The high rate of rerupture during the acute phase with ruptured vertebral dissecting aneurysms requires special attention with regard to cardiopulmonary dysfunction. Retention of stump pressure at the dominant vertebral artery occlusion shows that proximal occlusion does not always achieve immediate cessation of retrograde blood flow to the dissection site. Detachable platinum coil embolization of the dissection site is a more effective treatment than proximal occlusion in ruptured vertebral dissecting aneurysms because of immediate blockage of flow to the affected site. However, in cases with bilateral dissection, hypoplastic contralateral vertebral arteries and dissection including PICA, prior bypass surgery or stent treatment to preserve the affected vertebral artery is needed.
We assessed long-term outcome after surgical revascularization in childhood moyamoya disease. During the past 20 years, 51 children with moyamoya disease were treated in our hospital. All but 1 child underwent surgical revascularization, either indirect bypass surgery or STA-MCA anastomosis combined with indirect bypass surgery. The mean follow-up period was 9.7 years. Surgical revascularization remarkably reduced or completely resolved ischemic attacks, although postoperative incidences of TIA or headache were significantly higher in children who underwent indirect bypass surgery than in those who underwent STA-MCA anastomosis combined with indirect bypass surgery. Postoperative SPECT studies also showed that STA-MCA anastomosis combined with indirect surgery improved hemodynamics in the frontal lobe. The children with TIA had a better intellectual outcome than those with cerebral infarction. If children with TIA underwent surgical revascularization soon after onset, they were able to pursue higher education and careers. Intracranial bleeding has not been observed in any subject during follow-up periods. These results suggest that surgical revascularization can improve long-term outcome in childhood moyamoya disease if the patients undergo the procedure soon after onset.
We examined 258 patients with poor grade subarachnoid hemorrhage (SAH) (Hunt and Kosnik grade IV or V) in this study. Seventy-two patients (27.9%) were over 70 years old. Seventy-four (28.7%) of 258 patients suffered episodes of rebleeding. Of the 74 patients, 54 (73%) were under observation at home or in the primary care hospital without CT scan evaluation because they recovered consciousness after the initial attack. Fifty-seven percent of the rebleeding occurred at home, 28% in the primary care hospital, 9.5% in the ambulance, and 9.5% in our hospital. Eighty-eight patients (34.1%) suffered intracranial hemorrhage (intracerebral hemorrhage and intraventricular hemorrhage), and had to undergo emergency surgery. Sixty-three patients (24.4%) presented respiratory complications: 27 patients (10.5%) suffered from neuronal pulmonary lung edema and 36 patients (14.0%) suffered from aspiration pneumonia. Seven of the patients with neuronal pulmonary lung edema were examined through Swan-Ganz study. These patients showed a remarkably decreased cardiac index, increased SVRI and increased PCWP. Of the 258 patients, 237 presented electrocardiogram disorder. Sixteen of these (6.8%) needed treatment by a cardiologist. Poor grade SAH patients suffer not only from intracranial complications but also from general complications due to a cathecolamine surge after the initial incident. These patients should be rapidly evaluated for treatment to prevent rebleeding, emergency operation and for treatment of general complications.
We report a case of a 71-year-old man who presented a subarachnoid hemorrhage (WFNS grade 1) due to rupture of an aneurysm arising from the hemispheric branch of the superior cerebellar artery (SCA). On the 28th day after admission, the aneurysm was successfully clipped through the infratentorial supracerebellar approach in a Concord position. The patient was discharged with slight cerebellar ataxia 1 month after surgery. We discuss the clinical characteristics of distal SCA aneurysm with a review of literature.
We evaluated granulocyte elastase (PMN-E), a kind of serine protease, in the serum of 48 patients in the acute stage of subarachnoid hemorrhage (SAH). PMN-E on admission was 956.6 ± 1097.8 μg/L in the patients who eventually developed arterial spasm (spasm group, n=16) and 554.5 ± 979.4 μg/L in the non-spasm group (n=32), respectively. PMN-E on day 5 following SAH was 607.6 ± 579.6 μg/L in the spasm group and 307.7 ± 263.5 μg/L in the non-spasm group. The difference was significant between the groups on day 5 (p =0.017). PMN-E on admission was 608.2 ± 990.9 μg/L in the good recovery-moderately disabled group of patients (n=33) according to Glasgow outcome scale, and 831.9 ± 1127.0 μg/L in the severely disabled-dead group (n=15). These results suggest that the neutrophils play an important role in arterial spasm after SAH.
We review intraaneurysmal embolization of Guglielmi detachable coils (GDCs) for middle cerebral artery aneurysm, which is thought to be relatively easy for surgical clipping and relatively difficult for embolization. The subjects of this study are 15 middle cerebral aneurysms in 14 patients treated by intraaneurysmal GDC embolization between January 1996 and December 1998. There were 2 males and 12 females with an average age of 70.6 years. Six aneurysms were ruptured and the others were unruptured. All the ruptured aneurysms were treated in their acute stage with Hunt and Kosnik grades II in 1, III in 1, IV in 3, and V in 1. The patient with H & K grade II was accompanied by idiopathic thrombocytopenic purpura. Spinal drainage was performed in all patients with ruptured aneurysm, and a tissue-type plasminogen activator was administered via the drainage in 4 patients. Glasgow outcome scale at discharge was good recovery in 2, moderate disability in 1, severe disability in 1 and dead in 2. In the patients with unruptured aneurysm, 3 patients were accompanied with renal dysfunction. One aneurysm was treated by neck plasty technique. No patients aggravated clinically. There were no complications either in ruptured and unruptured cases. Although intraaneurysmal GDC embolization is not suitable for middle cerebral artery aneurysms, it is indicated when surgical difficulties are considered such as patients of advanced age, patients with poor grade, and patients with systemic disease.
Recently, many patients with asymptomatic carotid artery stenosis have been found with the increasing availability of MRA and 3D-CTA. There is a high risk of stroke in the future for such asymptomatic patients if they go without treatment. We had 50 CEAs of 49 patients with asymptomatic carotid artery stenosis and 122 CEAs of 122 patients with symptomatic stenosis. Surgical outcome and changes in intraoperative monitorings were compared between asymptomatic and symptomatic patients. There was no significant difference in the risk factors for CEA, such as ischemic heart disease, diabetic mellitus, and hypertension, between the two groups. The intraoperative monitoring such as measurements of blood flow of internal carotid artery, stump pressure, somatosensory evoked potential, and near infrared spectrophotometry were routinely applied to reduce surgical complications. There was also no difference in changes of parameters during CEA between the two groups. Overall mortality was 0, and morbidity was 4/172 (2.3%). Two of 50 CEAs with asymptomatic stenosis had permanent neurological deficits. In symptomatic patients, morbidity was 2/122. Statistically, there was no significant difference of morbidity rate between the two groups. We concluded that morphological evaluation of stenotic lesion, hemodynamic evaluation and intraoperative monitorings are important to reduce perioperative complications in both symptomatic and asymptomatic patients.
We discuss the risk factor of rebleeding from ruptured cerebral aneurysms with the special emphasis on the interval changes of consciousness level. We analyzed 129 patients with subarachnoid hemorrhage from ruptured cerebral aneurysms in this study. We recorded and assessed their consciousness level before and on admission by Japan Coma Scale (JCS) and the presence or absence of rebleeding. Among 71 patients with JCS 100-300 before admission 27 patients (39%) had rebleeding. Among 58 patients with JCS 0-30 before admission, only 1 patient had rebleeding. Therefore, the rebleeding rate of the patients with pre-hospital JCS 0-30 was significantly lower than those with pre-hospital JCS 100-300. On the other hand, the number of the patients with JCS 100-300 on admission was 52, and 17 (32.8%) had rebleeding. Among 77 patients with JCS 0-30 on admission, 11 (14.2%) had rebleeding. A comparison of the rebleeding rate of the patients with JCS 0-30 on admission with that of the patients with pre-hospital JCS 0-30 showed that the rebleeding rate of the patients with admission JCS 0-30 was significantly higher. All 11 patients who had JCS 0-30 on admission and developed rebleeding had pre-hospital JCS 100-300. In other words, none of the patients with both pre-hospital and admission JCS 0-30 had rebleeding. The patients whose consciousness level was once as bad as JCS 100-300 and then recovered to as good as JCS 0-30 had a high risk of rebleeding. Taking the pre-hospital history of patients with subarachnoid hemorrhage in detail provides us important and useful information for preventing rebleeding from ruptured cerebral aneurysms.
Neuroendoscopic evacuation of intracerebral hematoma has been mostly performed using a rigid endoscope system with stereotactic guidance. A major disadvantage of this method is that intraoperative evaluation of the residual hematoma is difficult, and that fine operational movement of the endoscope is limited because of the stereotactic frame fixation. We devised a new echo-guided endoscopic neurosurgery using a peel-off sheath and a steerable fiberscope. This series included 9 patients with putaminal, 7 with subcortical, 1 with thalamic, 1 with cerebellar, and 1 with intraventricular hemorrhage. The operation was performed with the patient under general anesthesia in all but 3 cases. One or 2 burr holes were made in the forehead in 9 cases, at the coronal suture in 5, and as near as possible to the hematoma in 5. The ultrasound probe was utilized to locate the exact position of the hematoma, and to bring a peel-off sheath to the target area. The sheath was successfully located at the appropriate area of the hematoma in all cases. Under strict telescopic monitoring, intracerebral hematomas were successfully evacuated using a rigid endoscope and ordinary suction through the sheath. The tip of the sheath could be easily located at the appropriate position according to the 3-dimensional extension of the hematoma. Furthermore, the steerable fiberscope was used to evaluate the residual hematoma, remove the intraventricular hematoma and perform a third ventriculostomy. An immediate postoperative CT scan revealed that evacuation was over 90% in 13 patients, 70-90% in 3, and less than 70% in 2; the mean evacuation rate was 90.6% (94.9% in 11 recent cases). The mean operation time was 2 hours and 36 minutes. In conclusion, this procedure is safe, minimally invasive, time-saving, and quite effective in hematoma evacuation.
A 62-year-old male presented with a symptomatic porencephalic cyst following removal of a massive subcortical hematoma. He was admitted with progressive disturbance of consciousness and left hemiparesis. A CT scan demonstrated a massive subcortical hematoma in the right temporoparietal region without intraventricular rupture. Gross total removal of the hematoma was achieved without opening of the ventricle. His consciousness level improved promptly but gradually deteriorated again. Follow-up CT and MRI examinations demonstrated development of a cystic lesion at the site of the hematoma. On the 17th postoperative day, dark-brown fluid was stereotaxically aspirated, and his symptoms were gradually improved. This porencephalic cyst formation in the early stage following removal of hematoma is extremely rare in adults. We discuss its possible growth mechanism in detail.
We present two cases of ruptured large aneurysms that present regrowth and recanalization after Guglielmi detachable coil (GDC) treatment. The first patient, a 72-year-old woman, presented with subarachnoid hemorrhage (SAH) secondary to rupture of a 10-mm left internal carotid artery aneurysm with a 5-mm neck. The first GDC embolization was performed at 9 hours after onset, leaving contrast filling of the dome from the distal neck. Follow-up angiography 3 months later revealed aneurysmal regrowth, recanalization and coil compaction. A second embolization was performed, resulting in complete occlusion. However, follow-up angiography 9 months later revealed recanalization again. A third coiling was performed, resulting in complete occlusion. The second patient, a 53-year-old man, presented with SAH secondary to rupture of a 20-mm anterior communicating artery aneurysm with an 8-mm neck. GDC embolization was performed at 3 hours after onset, leaving a residual portion of the aneurysm neck. Ten months later, follow-up angiography demonstrated aneurysmal regrowth, recanalization and coil compaction. Repeat coiling was performed, resulting in residual neck filling. Both patients have lived normal daily lives without rebleedings. Because the large aneurysms with wide neck coiled with GDC have a tendency to regrowth and recanalize, close postoperative angiographic and clinical monitoring of patients with such aneurysms is necessary. If follow-up angiograms show coil compaction inside the aneurysm with re-exposure of portion of the aneurysm to the blood flow, further GDC treatment and/or a surgical approach should be considered.