In preparing for a new grading system for ruptured aneurysm, we have investigated the relationship of the preoperative grades according to various systems to the postoperative results, in 168 patients operated on within 48 hours after the last attack. The grading systems used here were Hunt-Hess system (H-H), Glasgow Coma Scale (GCS) and 3-3-9 system (3-3-9).
1. The results in 39 Grade I patients and those in 44 Grade II patients were equally excellent.
2. The GCS sum scores for 65 Grade III patients varied between 15 and 9. The results were good in patients with a GCS score of 13 or more, and were poor in patients with a GCS score of 12 or less.
3. The 3-3-9 grades for the Grade III patients were between 0 and 20. The results were good in patients in 3-3-9 grade 10, and were poor in grade 20.
4. The GCS sum scores for 18 Grade IV patients were between 12 and 6, and the 3-3-9 grades between 30 and 200. There was no clear distinction between Grade III and IV. The results in Grade IV patients were poor, however the severity of the preoperative grade was not always related to the results.
It is thought that each of the three grading systems, H-H, GCS and 3-3-9, has some defects as a grading system for ruptured aneurysm, which requires us to invent a new system.

View full abstract

Despite the advances in investigation techniques such as computed tomography (CT), etc., the management of individual patients with subarachnoid hemorrhage (SAH) due to aneurysm rupture still depends greatly on assessment of the patient's clinical condition. This is because the likely outcome is closely related to the severity of the patient's clinical state. Several systems for grading patients with SAH have been proposed, among them Hunt's has been mostly used in many neurosurgical centers.
This is a proposal for grading of SAH due to aneurysm rupture based on Hunt's grading.
In this grading, the Glasgow Coma Scale (GCS) and the so-called Japan Coma Scale are used to express the level of consciousness.
This new grading system is clear in description of the patient's condition, will produce less observer variability, and may be useful prognostically.

View full abstract

A new clinical grading system (CEMC-grading) and a scoring system of CT-findings for ruptured intracranial aneurysm have been employed prospectively in Chiba Emergency Medical Center since April, 1980.
This CEMC grading system is a modification of that of Hunt and Hess, and patients are classified according to their Glasgow Coma Scale. Scoring system of CT findings consists of three factors that determine severity of ruptured aneurysm, these are; volume of SAH, existence of ICH and the extent of IVH. As index of blood volume in subarachnoid space, Hounsfield number was measured in 6 cisterns. Zero to 4 points are assigned to specific ranges of Hounsfield number. Total points in 6 cisterns are determined as SAH-score. As for ICH, 0 to 4 points were assigned, and concerning IVH, 0 to 2 points were assigned. Total points of 3 categories is called CT-score of ruptured aneurysm.
Three hundred and thirty-six cases with ruptured aneurysms in the anterior circulation arrived within 72 hours of attack were analyzed using these CEMC-grading and scoring system of CT-findings.
The CEMC-grading as well as the CT-score of ruptured aneurysm were well correlated with the outcome of patients.
And differences in SAH-score were significant between a group with symtomatic vasospasm and a group without symptomatic vasospasm.
This new clinical grading system and a scoring system of CT-findings for ruptured aneurysm were of value as to treat ruptured aneurysm especially in acute stage.

View full abstract

It is well known that Hunt and Kosnik grading in the patients of subarachnoid hemorrhage due to the ruptured aneurysm is fairly related to their outcome. This grading, however, does not include some important factors such as age of the patients, chronological stages, spreads of subarachnoid hemorrhage seen in the CT scan, severity of vasospasm, and so on. Then there have been some gaps between the grade and the outcome, especially in the grade III.
We performed re-evaluation of Hunt and Kosnik grading in concerning about the relationship between the initial grade and the outcome by using multiple variant analysis.
Case materials included 353 cases of ruptured aneurysm. Forty cases were classified into grade III. The outcome was divided into four groups, good, fair, poor, and died. The groups of good and fair were considered to be useful recovery.
In our results, the rates of useful recovery were 87.8% in grade I and II, 65.0% in grade III, and 12.8% in grade IV and V respectively. This results suggested that Hunt and Kosnik grading was useful to predict the prognosis of patients. However, it seemed to be necessary to classify grade III into more detail categories. Then, the factors listed in Table 1 were applied for re-evaluation.
The multiple variant analysis disclosed that following factors were selected to be discussed, which were age of the patients, level of consciousness at admission defined by using III-III-9 method of Japan, severity of subarachnoid hemorrhage seen in the CT scan, intracerebral hematomas, postoperative complication, and size of aneurysms.
In the further multiple variant analysis using the score of each factors, it was suggested that grade III could be divided into two groups.
In the patients, of grade III who have, at least, two of 3 following factors, age younger than 65, level of consciousness better than 3, and size of aneurysms smaller than 10mm in diameter, the rate of useful recovery was calculated to 80% or more.
From these analyses, we conclude that Hunt and Kosnik grading is useful for prediction of prognosis, but it is necessary to design new classification in grade III.

View full abstract

For the comparison of differential effects of various therapeutic modalities on the outcome of subarachnoid hemorrhages (SAH) due to ruptured aneurysms, a need for clinical scales precisely correlated to the severity of SAH has been emphasized. However, it is easily anticipated that such severity-scales must include numerous items because of multiple determinants of the severity of SAH. Severity scales with too many items may be unpractical. Furthermore, the weight of each determinant for the severity is largely unknown. Thus, with the emphasis on objectivity and practicability, we examined in the present study whether coma-scales can be used as a severity scale.
A concept of severity may correspond to the outcome with standard modality of treatments. Thus, we correlated assessments with coma-scales during acute periods after SAH and the outcome. Japan Coma Scale (3-3-9 scale, JCS), Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) were employed. Preliminary results indicated that assessments with coma-scales were positively correlated to the outcome and therefore the severity. It was, however, noted that there existed several factors which differently influenced coma-scales and the actual severity. Reversible deep coma within initial 24 hours after SAH were not correlated to the severity. SAH associated with intraventricular hemorrhages had a tendency to deteriorate the actual severity more than the coma-scales. In contrast, SAH associated with intracerebral hematoma appeared to be reflected more easily to the assessments with coma-scales than the actual severity.
We believe that differential correlation of coma-scales to the actual severity under various pathological states is not a shortcomming of the use of coma-scales as a severity-scale but is rather an advantage that differential weight of each pathological state for the actual severity can be clearly demonstrated. Future studies with larger series of patients, which would identify major factors affecting coma-scales and the actual severity differentially, may facilitate the use of coma-scales as a practical, objective and useful severity-scale in SAH due to ruptured aneurysms.

View full abstract

Among 160 cases of verified ruptured saccular aneurysms, we investigated 82 cases received direct surgery within 72 hours from ictus.
The important factors of neurological and CT findings on admission influencing on operative outcome were analyzed statistically.
To estimate the neurological condition, we used Hunt & Hess' Grading, Japan Coma Scale and Glasgow Coma Scale.
Location of cisternal clot, degree of SAH over the cortex, shape of the third ventricle, ventricular reflux, intracerebral hematoma and intraventricular hematoma were selected as indicators of acute stage of SAH. Based on the statistical analysis of these factors of CT, we devised CT score.
Our “CT score” correlated well with surgical outcome and the severity of clinical vasospasm in comparison with neurological grading system.

View full abstract

An old SAH grading system was formulated based on neurological finding, similar to Hunt's grading system. Recently, symptomatic vasospasm has been reported to be well correlated with amount of hematoma in the basal cistern as seen on CT. CT has become so popular now that almost every neurosurgical institute possesses a CT scanner. It is necessary to formulate a new SAH grading system which also includes CT findings.
239 cases of SAH were admitted to Fujita-Gakuen University Hospital from January 1982 to December 1984.
166 cases of SAH were made an object of this study. CT was taken within 48 hours after the onset and rebleeding did not occur in these cases.
SAH grading scale was formulated as below.
Age was classified into 3 groups as less than 54 year old…… 0 point. 55 to 69 year old 1 point. Over 70 year old…… 2 points.
Conscious level was classified as alert (JCS 0-1, GCS 15)…… 0 point. Somnolence (JCS 2-10, GCS 14-11)…… 1 point. Stupor (JCS 20-30, GCS 10-8)…… 2 points. Semicoma without brain stem sign (JCS 100, GCS 7-6)…… 3 points. Semicoma with brain stem sign(JCS 200, GCS 5-4)…… 4 points. Coma (JCS 300, GCS 3)…… 5 points. CT findings were classified as follow. SAH in the basal cistern was classified into 4 groups. No SAH…… 0 point. A little hematoma in the basal cistern…… 1 point, much hematoma in the basal cistern 2 points. Packed hematoma in the basal cistern…… 3 points.
ICH was classified into 3 groups. No hematoma…… 0 point. A small hematoma without midline shift…… 1 point. A large hematoma with midline shift…… 2 points.
All these factors were considered together for calculating SAH grading scale score. This SAH grading scale was well correlated to outcome. Y=0.855x+1.92 in cases of early operation. Y=0.843x-0.093 in other cases. Thus the outcome is statistically significantly better in early operated cases than that of delayed operated cases.

View full abstract

A new clinical grading system for ruptured cerebral aneurysms(Akita Nohken, 1982) has been used for evaluating operative indications and making the operative timing dicisions. The severity of patient condition is classified by their level of consciousness and signs of herniation. An accompanying conditions, which can include massive subarachnoid hemorrhage (SAH) shown by CT, intracerebral hematoma (ICH) with mass signs, such as midline shift and deformity of the ventricle, and vasospasm (VS) detected in angiography, reveal causes for severity and the pathophysiological condition of the patient.
In this study, a comparison will be made between the new Akita Nohken system and the Hunt and Hess system for grading and classification of ruptured aneurysms, and the clinical outcome of cases so evaluated will be examined. Subjects included 313 cases with ruptured aneurysms of the anterior communicating, internal carotid and middle cerebral arteries admitted within 7 days following the last attack. Excluded were those over 70 years of age, those who died of general complications, those deteriorated by operative or angiographic complications, patients with old strokes, and cases with fatal rebleeding attacks after admission. Two hundred and ninety-six cases were surgical; 17 were non-surgical.
Characteristics of the new classification system can be summarized in that mild cases, such as Grade 1 and 2 in Hunt's classification are placed in Grade 1; and severe cases are classified in detail according to the level of consciousness and signs of cerebral herniation; with labels such as Grade 4, 5 a, 5b and 6. The mortality of all cases was 8.9% and the morbidity was 11.8%. Severity of the clinical grades was well correlated with the clinical outcome. The incidence of accompanying conditions was higher in proportion to a worsening of the clinical grade. The number of cases with more than two accompanying conditions increased in severe cases with Grade 4 or more. “VS” and “SAH” resulted in a poor outcome in grade 2 and 3 patients due to cerebral ischemia following vasospasm. Clinical outcomes were poor in grade 4 and 5a patients with “VS.” Sixteen of 24 cases in Grade 5b and 6 were accompanied by “ICH,” and all of the conservatively treated cases in these grades died. As a result, cases without “VS” should be operated on as early as possible, and operations should be delayed in cases accompanied by “VS.”

View full abstract

Neurological grading (Hunt & Kosnik and others) and CT classification (Fisher and others) were used most popularly to evaluate clinical state and to estimate the prognosis of subarachnoid hemorrhage (SAH). However, there were some cases which the outcome did not corresponds to the neurological grading or CT classification.
From Oct. 1983, we measured regional cerebral blood flow (r-CBF) of 54 cases of acute SAH who arrived at our medical center within 72 hours from last attack.
These 54 cases were divided into 2 groups by their value of mean hemispheric gray matter blood flow (M. F. G.); Group A; 32 cases which M. F. G. were over 50 (ml/100g/min), and Group B; 22 cases which M. F. G. were less than 50. Then, there were clearly difference in prognosis of these 2 groups; 67.4% of group A were recovered to be superior than partially dependent, on the other hand, 84.7% of cases in group B were died or fully dependent.
We considered from those result as follows; adding the value of cerebral circulation damage at acute stage of SAH to neurological grading or CT classification can deduce more correctly valuation of the clinical state and final prognosis of SAH.

View full abstract

Preoperative studies of cerebral blood flow (CBF) and oxygen metabolism were performed in 42 patients with ruptured intracranial aneurysms in the acute stage within 72 hours after subarachnoid hemorrhage.
We evaluated correlations between CBF, oxygen metabolism and preoperative neurological conditions (Hunt and Hess' classification, grade I, II, III)
Measurement of CBF was made by 133Xe inhalation technique (ISI value), and mean CBF was obtained from average value of 7 probes on para-Rolandic area.
Oxygen metabolism (cerebral oxygen utilization; CMRO₂, cerebral oxygen delivery; D-O₂, oxygen extraction fraction; OEF) was calculated based on oxygen content of arterial and jugular blood, and CBF.
The results were as follows.
1) CBF: grade I 46.9±4.0, grade II 36.8±5.0, grade III 25.3±5.0, respectively. The reduction of CBF even in the best clinical condition (grade I & II), but most decrease in CBF was found in grade III patients. Each groups had significant differences in CBF value (P<0.001).
2) CMRO₂: grade I 2.82±0.26, grade II 2.35±0.37, grade III 1.68±0.28, respectively. Significant difference was found between grade I & II (P<0.01) and grade II & III (P<0.001).
3) D-O₂: grade I 7.32±0.89, grade II 5.91±0.80, grade III 3.87±0.74, respectively. There were significant differences between grade I & II, and grade II & III (P<0.001).
4) OEF: grade I 0.39±0.06, grade II 0.40±0.07, grade III 0.44±0.07, respectively. Significant differences were not found, but OEF values were increasing as grades were worsening.
These results indicated that preoperative grade was worse, impairment of CBF and oxygen metabolism were remarkable, and removal of factors deteriorating intracranial environment was thought to be essential.

View full abstract

The problematic points in the superacute stage of subarachnoid hemorrhage patients were studied by classifying the patients into two age groups. The subjects of the present study were 104 patients who were hospitalized within six hours following subarachnoid hemorrhage attack with 38 cases being over 60 years of age (Group A) and 66 cases being less than 60 years of age (Group B). When classified by the grade of Hunt & Kosnik at time of admission, 34 cases belonged to Grades I and II, 28 cases to Grade III, 16 cases to Grade IV, and 26 cases to Grade V. Rerupture within six hours which is the most problematic point was observed in 13 out of 104 cases (12.5%) with the rate in Group B being 12 out of 66 cases (18.2%) which is higher than the rate in Group A of one out of 38 cases (2.6%). In examining the rerupture cases of Group B by grade at time of admission, the rate was two out of 24 cases (8%) belonging to Grades I and II, six out of 22 cases (27%) belonging to Grade III, and four out of eight cases (50%) belonging to Grade IV, demonstrating an elevation in rate with severity of grade. Cerebral angiography was performed on 64 cases within six hours following onset. Rerupture developed prior to angiography in nine cases, during angiography in three cases, and following angiography in one case. It is considered that cerebral angiography within six hours after onset should be avoided, being a risk factor of rerupture.
Early operation within day 2 was conducted on 55 cases. In Group A, early operation was conducted on six out of ten cases (60%) belonging to Grades I and II and on four out of six cases (67%) belonging to Grade III, while in Group B, early operation was conducted on 16 out of 24 cases (67%) belonging to Grades I and II and on 15 out of 22 cases (68%) belonging to Grade III. The reasons why early operation could not be conducted on cases belonging to Grades I and II and Grade III were complication chiefly of the respiratory system in Group A and aggravation of condition following rerupture in Group B. Serum electrolyte imbalance and electrocardiographic abnormality were observed at the high rate in both groups, but these were not fatal. The important problematic points in the superacute stage are regarded to be rerupture in the young age group and complication in the old age group. It is considered that even in the old age group the range of feasibility of early operation can be expanded through the control of complications with the support of all branches of medicine.

View full abstract

We evaluated a relationship between hypoxemia and urinary catecholamine excretion in 34 patients with cerebrovascular diseases. Hypoxemia was induced by an increase in alveolar-arterial oxygen difference (AaDO₂). And AaDO₂ positively correlated with urinary catecholamine excretion. The patients with increased AaDO₂ had an increased intrapulmonary shunt. The maximum diameter of hematoma on CT scan in 20 patients with supratentorial hemorrhage had a significantly positive correlation with AaDO₂. Administration of phentolamine and propranolol decreased the intrapulmonary shunt followed by a decrease in AaDO₂ in patients with intracranial hemorrhage through reducing pulmonary vascular resistance and cardiac output, respectively. Trimethaphan camsilate also decreased these two values without any change in pulmonary vascular resistance or cardiac output.
From these facts, we can speculate that an overactivity of sympathetic nervous system plays an important role in increasing the intrapulmonary shunt through acting on the pulmonary vascular bed directly, through acting on the efferent sympathetic nerves to the pulmonary vascular bed, and/or through increasing cardiac output.

View full abstract

Conventional grading system in subarachnoid hemorrhage (SAH) patients was not really useful in forecasting to what extent delayed vasospasm developed and in assessing the risk for vasospasm (spasm risk). This study is to assess the spasm risk in SAH patients by grading the severity of cisternal high density on CT.
Natural course of vasospasm was difficult to assess in patients with grade IV, V or fatal hemorrhage, and was significantly modified in patients who underwent surgery in the acute or subacute stage of SAH. These patients as well as patients with various complications including rebleeding of the aneurysm were therefore all excluded from this study. And 120 patients with grade I-III on admission within 24 hours of SAH were included who presented natural course of vasospasm either by undergoing uncomplicated delayed operation or by resulting without operation in severe disability or death.
In all patients CT scanning was done within 24 hours of SAH, and severity of subarachnoid hemorrhage was scored from 1 to 4. SAH score 1: mild high density (attenuation number less than 60) in the basal cistern, SAH score 2: moderate (attenuation number 60-69), SAH score 3: local severe (attenuation number 70 or more), SAH score 4: diffuse severe. Intracerebral and intraventricular hemorrhage was not included in this scoring system and discussed separately.
In patients with SAH score 1, no clinical vasospasm was observed in 44/46 (96%) and good recovery from vasospasm obtained in the remaining 2 patients. Patients with SAH score 2 showed no vasospasm in 35/53 (66%), good recovery in 16/53 (30%), and fair recovery in 2 /53 (4%). Patients with SAH score 3 presented fair recovery in 4/15 (27%), severe disability in 2/15 (13%), and death in 9/15 (60%). Patients with SAH score 4 were severely disabled in 1/6 (17%) and dead in 5/6 (83%).
26 patients were associated with intracerebral hemorrhage (ICH) and 13 patients with intraventricular hemorrhage (IVH). ICH patients showed no vasospasm in 14, good recovery in 6, fair recovery in 3, and death in 3. IVH patients presented no vasospasm in 6, good recovery in 3,fair recovery in 1, severe disability in 2, and death in 1. Generally speaking, grade I-III patients with ICH or IVH showed fairly good recovery from vasospasm, and severity of vasospasm in these patients was primarily determined by SAH score.
These results suggested that SAH score is very helpful in assessing spasm risk in SAH patients, and that efficacy of various treatment for vasospasm including that of early operation should be assessed by grading the patients according to the severity of cisternal high density on CT.

View full abstract

The former classification of SAH was based on neurological grading system. Since the incidence of symptomatic vasospasm was well correlated to hematoma in the basal cistern as seen on CT it has been necessary to formulate a new CT grading of SAH. 166 cases of SAH, admitted from January 1982 to December 1984 out of a total of 239 SAH cases admitted to Fujita-Gakuen Univ. Hospital, became the object of this study. CT was taken within 48 hours after the onset and rebleeding did not occur in these cases.
CT grading system was decided as follows grade 1: a little hematoma in the basal cistern grade 2: much hematoma in the basal cistern grade 3: packed hematoma in the basal cistern grade 4: intracerebral or intraventricular hematoma with or without CT grade 1
grade 5: intracerebral or intraventricular hematoma with CT grade 2 or 3
Subgrade was formulated in grade 4 and 5 depending on the size of hematoma and midline shift on CT, namely (a) and (b). 4a or 5a means small hematoma without midline shift, 4b or 5b means large hematoma with midline shift. This grading system was well correlated to the patient's outcome. The difference of outcome between grade 1 and 2, 2 and 3, 3 and 5, 4 and 5, was statistically significant.

View full abstract

Computed tomographic (CT) findings in 150 patients with ruptured cerebral aneurysms which were done a radical operation within 48 hours after last attack, were analyzed for prognostic significance in relation to the surgical results and severity of symptomatic vasospasm. CT findings were classified 4 types according to the extent and degree of subarachnoid bleeding in basal cistern. CT classification were summarized as follows: Grade I: no high density area (HDA), Grade II: HDA visualized in subarachnoid space except basal cistern, Grade IIIa: unilateral thick or bilateral thin HDA visualized in basal cistern, Grade IIIb: bilateral thick HDA in basal cistern, in addition to V: massive intraventricular hematoma, and H: intracerebral hematoma.
The surgical results were Glasgow Outcome Scale (GOS) in five groups at discharge from our hospital.
All out of 5 patients in grade I and 18 in grade II had good recovery (GOS 1, 2) and also 42 out of 48 in grade IIIa were good recovery (86%), however in grade IIIb good recovery were shown only 20%.
The mortality rate was 0%, 0%, 0%, 4%, 39%, 60%, 44% at grade I,II, II+H and/or V, IIIa, IIIa+H and/or V, IIIb, IIIb+H and/or V.
The development rate of symptomatic vasospasm was 0%, 17%, 45%, 80%, at grade I, II, IIIa, IIIb.
There was dirrect correlation between CT classification and surgical results, and between the extent of blood in basal cistern and the severity of symptomatic vasospasm that developed.

View full abstract

Our surgical indication against cerebral aneurysms in acute stages is cases better than comatous stage. Cases showing coma or downhill course are out of indication of immediate operation. At first, these severe cases are treated by the administration of mannitol and recently additional corticosteroid hormone and vitamine E, if necessary, continuous ventricular drainage or aspiration of ventricular hematoma especially in the cases of acute hydrocephalus or ventricular hematoma.
The total number of aneurysm cases admitted to our hospital within 24 hours after hemorrhage was 354 from April, 1978 to December, 1983. The number of grade IV, V cases on admission is 95. Among 91 cases except 4 cases suffered from systemic complications, by these managements 53 cases improved within 48 hours after onset, while 38 cases took a downhill course. Both groups were examined retrospectively in relation to findings of CT scan, sex, age, gradings on admission and sites of ruptured aneurysm. They were devided to 34 cases mainly showing subarachnoid hemorrhage (subarachnoid hemorrhage group) and 57 cases mainly showing intracerebral intraventricular or subdural hematoma (intracranial hematoma group).
In the group of subarachnoid hemorrhage, all of 8 cases with deformity of brain stem died, while 7 of 11 cases without deformity of brain stem and without hydrocephalus recovered within 48 hours after hemorrhage. Moreover, 13 of 14 cases with acute hydrocephalus recovered to grade III or more. The prognosis of cases without deformity of brain stem with or without acute hydrocephalus was significantly better than that with deformity of brain stem.
Cases of grade IV on admission were expected better prognosis than that of grade V, also. However, we could not find relationship between prognosis and age, sex or sites of ruptured aneurysm.

View full abstract

We analyzed CT findings of 95 aneurysmal cases taken within 3 days after the onset of SAH and these findings were classified into 3 types, that is, subarachnoid hemorrhage type, intracerebral hematoma type, and intraventricular hematoma type, from the location of the hematoma after aneurysmal rupture.
CT findings were scored according to the severity of SAH from 0 to 9 in each types. The relationship between CT score, incidence of symptomatic vasospasm and surgical results was studied and the following results were obtained.
(1) CT score correlated well with the severity of clinical grade of Hunt and Kosnik.
(2) The cases, in which CT score was above 3, showed high incidence of symptomatic vasospasm high morbidity and mortality.
(3) In severe SAH, early operation within 3 days was recommended in the aneurysmal surgery, especially within 24 hours after the onset in cases with CT score (s≥5) and within 3 days in cases with CT score (S≥3).
(4) From the above results, CT score may give information for predicting symptomatic vasospasm and deciding the timing of surgery.

View full abstract

We analyzed computed tomogram (CT) of ruptured aneurysms based on the interpretation by eight board-certified neurosurgeons. It was fairly possible to judge the site of aneurysm, development of normal pressure hydrocephalus, later occurrence of vasospasm, and grade or outcome of the patient according to the CT finding. However, symptomatic vasospasm was not markedly predictable (59%) in contrast with the report of Fisher (95%). Most of the cases analyzed had visible subarachnoid clot and were therefore classified in Group 3. This is likely attributed to the improvement in spacial resolution of CT scanners, suggesting that Fisher's classification on CT of subarachnoid hemorrhage should be modified.

View full abstract

For the purpose of evaluating both the systemic and cerebral hemodynamic conditions and the co-relations between them, the authors introduced the cerebro-hemodynamic profile, in which heart rate (HR), mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), right arterial pressure (RAP), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), intracranial pressure (ICP), cerebral perfusion pressure (CPP=MAP-ICP), left ventricular stroke work index (LVSWI), right ventricular stroke work index (RVSWI) and cardiac index (CI) were arranged clockwise from 1 to 12 o'clock as a twelve angled figure (rader chart). In addition to these 12 parameters rCBF and cerebral vascular resistance (CVR) were contained, when rCBF was monitored continuously with temperature-gradient controlled thermoelectrical tissue blood flow meter (TF monitor & WP-6, Unique Med. Co., Ltd.) and CVR was calculated as CPP divided by rCBF. This radar chart was drawn by the signal processor 7 T17 (NEC San-ei) in neurosurgical intensive care unit. To integrate and analyze the 12 or 14 angled figures in critical brain failure proved greatly helpful in generally complicated cases such as hypervolemia in cerebrovascular spasm following aneurysmal rupture, cardiovascular suppressive state in barbiturate coma and so on.

View full abstract

In this study we discussed clinical analysis and management of 31 cases with severe subarachnoid hemorrhages (SAH) in the acute stage and also emphasized the value of CT scan, serial monitoring of intracranial pressure (ICP) and auditory brain stem response (ABR).
They were admitted to our hospital within 3 hours after the attack. Most cases were grade IV or V according to Hunt & Hess. They were divided into three groups on the basis of clinical findings.
In the first group of 20 cases, they were admitted in DOA (dead on arrival) or near DOA. In the second group of 7 cases, they showed signs of acute pulmonary edema at the time of admission. In both groups CT scan showed severe SAH located in the basal cisterns surrounded the brain stem and increased ICP. The major mechanisms leading to acute death or very severe state soon after SAH might be caused by acute brain stem dysfunction and acute increase in ICP by cerebral edema following SAH and secondary cerebral ischemia due to cardiac and respiratory arrest.
In the third group of 4 cases, the level of consciousness improved soon after coma or semicoma by severe SAH with the normalization of ABR. This clinical course also seemed to be associated with acute brain stem dysfunction. In neurosurgical intensive care, serial monitoring of ICP and ABR is important in evaluation of the patients with acute severe SAH.

View full abstract

The authors studied the aneurysmal re-bleeding in 279 patients with ruptured intracranial aneurysm who were admitted within 72 hours after last subarachnoid hemorrhage (SAH), and discussed how to manage the patients in acute stage. The following results were obtained. 1) During first 24-hour hospitalization, re-bleeding occurred in 29 cases (10.4%). 2) The time interval from last SAH was a significant risk factor for re-bleeding. The cases, admitted within 3 hours from last SAH, were easily re-bled (17.6%). Sex, age, site of ruptured aneurysm, number of SAH and surgical grade were not risk factors for re-bleeding. 3) The mortality associated with re-bleeding was 69.0%. Only 10 cases were operated. 4) Re-bleeding took place usually under uncontrolled hypertension and/or after recurrent vomiting and careless positioning. 5) For preventing re-bleeding of aneurysm in acute stage, the patient is necessary to be controlled blood pressure and to be taken sedativa and antiemetic.

View full abstract

This is a report on recurrent bleeding within 24 hours after aneurysmal subarachnoid hemorrhage and is a part of our efforts to find the best procedure for dealing with subarachnoid hemorrhage in the acute phase.
Acute phase surgery was performed on 22 patients following hemorrhage. 5 cases (22.7%) showed recurrent bleeding prior to surgery. Recurrent bleeding occurred within 3.5 to 17 hours after the initial hemorrhage. Following recurrent bleeding, all patients suffered disturbances in consciousness, with 3 patients suffering convulsions. 3 patients suffered recurrent bleeding during transfer for the purpose of neuroradiological examination or surgery. No specific cause could be found for the other cases.
Patients with recurrent bleeding had higher rates of both mortality and morbidity than those not experiencing recurrent bleeding. It would appear that patients with recurrent bleeding need more sedation. Exercising optimum blood pressure control and keeping patients sedated during examinations, in particular during transfer, seem essential for the suitable management of aneurysmal subarachnoid hemorrhage within 24 hours after initial bleeding.

View full abstract

During the past 5 years, we experienced 481 cases of ruptured intracranial aneurysms. Among these, 45 cases (9.4%) had rebleeding, and especially in 30 cases (6.2%), rebleeding occurred within the first 6 hours after the initial subarachnoid hemorrhage. The analysis of these 30 cases led to the following conclusions.
1) The highest incidence of the rebleeding occurred within 4 hours.
2) Distribution of the aneurysm sites was as follows: anterior cerebral complex (A com), 13 cases; middle cerebral artery (MCA), 8 cases; internal carotid artery (IC), 7 cases; and others, 2 cases.
3) 13 patients incurred rebleeding from such causes as transfer (4 cases), neuroradiological examinations (7 cases), and anesthesia (2 cases), whereas, in 17 cases, there were not any special inducements. In 12 patients rebleeding occurred, even though they were kept on absolute rest, and in6 patients rebleeding occurred in spite of treatment of induced systemic arterial hypotension under 140 mmHg. Thus, since the time factor could precipitate rebleeding, early transfer and operation should be considered for minimizing rebleeding soon after an aneurysm rupture.
4) 3 patients had rebleeding while undergoing angiography within 3 hours after the initial rupture. The greatest care must be taken in dealing with this procedure within the first 3 hours.
5) In our series, 11 of 12 reruptured A com aneurysm cases and 5 of 6 reruptured MCA aneurysms had intracerebral hematoma on initial CT-scan following the first attack. On the other hand, IC aneurysms cases with irregular aneurysmal wall and bleb tend to rebleed. Namely, the risk of rebleeding is very high in cases with intracerebral hematoma.
6) The mortality of these rebleeding cases was high (67%). Barbiturate therapy was considered to be effective for prevention of rebleeding.

View full abstract

Three hundred eighty-three cases of subarachnoid hemorrhage due to the rupture of the aneurysm were experienced since 1978. Of these cases 129 (34%) had bleeding twice or more. The period of rebleeding was investigated. It occurred within 6 hours after the first stroke in 48 cases(37%), and the total of rebleeding within 24 hours amounted to 57 cases(44%). Rebleeding within 6 hours showed high frequency.
One hundred eighty-one cases were admitted to our clinic within 6 hours after the first stroke, of whom 57 cases(31%) had rebleeding. On these 57 cases it was studied whether rebleeding occurred before or after admission. It occurred before admission in 19 cases(33.3%) and after that in 36 cases (66.6%). Rebleeding after admission were recognized in various situations, such as immediately after the arrival to our clinic, during consultation, or during CT examination or angiography. The deterioration due to rebleeding under medical facilities must be prevented to the best of our ability. Though our attention is given to sedation (Barbiturate), the control of blood pressure and intracranial pressure, the condition at consultation, and so on, there are still many difficult problems.

View full abstract

We report 42 re-rupture aneurysmal cases. Re-rupture aneurysms have their highest rate (38%) on day 0 and 20 cases out of 42 cases were rebled within day 0 to day 3. 22 cases were rebled during the examinations such as cerebral angiography or CT scanning just after admission. These results suggest that the prevention for re-bleeding is very important from the viewpoint of early surgery. Therefore, we took care of patients under general anesthesia in acute stage and cerebral angiography was examined for 21 cases. Re-bleeding did not occur in this series during the examination.
We recommend that cerebral angiography or CT scanning in case of severe patients (Hunt 3 or 4 )should be performed under general anesthesia by anesthesiologist as soon as possible.

View full abstract

Ten cases of ruptured cerebral aneurysms who developed rebleeding during cerebral angiography (CAG) in acute stage were presented and clinical characteristics of these cases were studied. Among 445 cases of ruptured aneurysms admitted to our department in the last 8 years, 10 cases with rebleeding of the aneurysm during or immediately after CAG were found as an incidence of 2.2%. CAG had been performed within 12 hours after the last subarachnoid hemorrhage (SAH) in all instances and the incidence of rebleeding in 108 cases who had CAG within 12 hours after the last SAH was 9.3%. Female and male ratio was 6 to 4 and the aneurysms were most frequently located at the anterior communicating artery (40%), followed by the internal carotid-posterior communicating, vertebro-basilar and anterior or middle cerebral arteries. Extravasation of the contrast medium from the ruptured aneurysm was found in 3 cases. The surgical risk grade (Hunt and Hess) was grade III or IV in 80% of the cases and the time interval from the last SAH to CAG was 5 hours or less in 70% of the cases. The mortality and morbidity of these 10 cases were poor and the mortality rate was high as 50% although an immediate emergency care was undertaken in all cases. Only two cases who had an emergency radical operation for the ruptured aneurysms showed good recovery.
From these results, it is suggested that the CAG must be performed with great care for the patients with recent SAH within 12 hours, especially within 5 hours after the last SAH, and with high surgical risk grade.

View full abstract

The authors report a study on the rebleeding of cerebral aneurysm in the acute stage, especially during angiography after the first bleeding.
Nine (4.4%) of 204 patients with ruptured aneurysm who were admitted to our hospitals within 6 hours after the first bleeding showed rebleeding during angiography. The incidences of the bleeding were 6 (8.2%) of 73 patients when the angiography was performed within 6 hours after the first bleeding and 3 (9.7%) of 31 patients during next 6 hours. This difference was not significant. In the non-angiography group, the incidence of the rebleeding within 6 hours after the first bleeding was 18.2% (16 out of 88 patients), which was higher than that in the angiography group.
These findings indicate that the angiographic procedure does not lead to a high risk in the acute stage and angiography should be done as early as possible in the patients with ruptured aneurysm in order to perform early operation.

View full abstract

Cerebral angiographies were performed within 3 hours after the rupture in the 96 cases of cerebral aneurysm during the last 4 years. The 5 cases out of these 96 cases showed the rerupture of aneurysm. The 4 cases out of these 5 cases were died and the remained one case was saved from death by the emergency operation. However, the extravasation of contrast material was observed in the all cases. In addition, the site of rerupture observed in the 5 cases was found to be located at the internal carotid artery, especially closely to the injection site, suggesting that the pressure of direct hand-injection rather than the catheter-injection through the femoral artery. Therefore, it is recommended that, in the case of the emergency angiography by the autoinjector set using less sensory incentive contrast material; metrizamide, should be used.

View full abstract

Angiography for patients with ruptured intracranial aneurysms in ultra-acute stage is necessary for early aneurysmal surgery, but risk of rerupture during its procedure is pointed out recently. The purpose of this study is to reveal the response of systemic arterial blood pressure (SABP) during angiography and to discuss the effect of sedation or non-ionized contrast medium for SABP change to reduce the risk of rerupture of aneurysms.
Seventeen patients with ruptured intracranial aneurysms were monitored their SABP by means of intra-arterial catheterization during angiography in acute stage. SABP change after injection of contrast medium of each case varied from 5 to 20% of SABP before injection. Location of aneurysms, neurological grading, interval from the last rupture of aneurysm to angiography had no relation to the degree of SABP changes. SABP changes were reduced obviously by using adequate dose of sedatives and non-ionized cotrast medium (280mgI/ml metrizamide) which is less irritative.
In conclusion, adequate sedation and to use non-ionized contrast medium were useful to reduce the risk of rerupture of aneurysms during angiography in ultra-acute stage. In addition, continuous monitoring of SABP was also useful as a monitor of the general states of the patients, involving the degree of sedation, uncomforts of patients and stress of examinations.

View full abstract

Intracarotid blood pressure was monitored continuously during carotid angiography by small polyethylene tube advanced to the intracavernous carotid artery through 5F introducer sheath placed at the origin of the internal carotid artery. Contrast medium was injected through this introducer sheath. Systemic blood pressure was also measured continuously during the examination.
Injection of contrast media below the rate of 6-8 ml per second did not increase systolic pressure in the carotid artery. However, injection over this rate elevated the pressure up to 20mmHg during the injection. Ionic contrast media elevated the intracarotid pressure for 5-10 seconds after the injection. Non-ionic contrast media produced little change of blood pressure. For the prevention of increased blood pressure during cerebral angiography, it is recommended to inject at lower rate as possible, and to use non-ionic contrast medium. Continuous blood pressure monitoring is also useful, since reaction of blood pressure to any stimulus is very different between individuals.

View full abstract

Recordings of blood pressure were obtained during cerebral angiography, and the blood pressure changes caused by injection of metrizamide and amidotrizoate meglumine were studied. Blood pressure was recorded from brachial artery during carotid angiography, and was recorded from carotid or contralateral brachial artery during retrograde brachial angiography. During carotid angiography, mean elevation of systoric pressure following injection of metrizamide and amidotrizoate meglumine were 7±9mmHg and 25±12mmHg, respectively; and mean elevation of diastoric pressure following injection of metrizamide and amidotrizoate meglumine were 4±5mmHg and 13±9mmHg, respectively. The elevation of blood pressure was statistically less following injection of metrizamide than following injection of amidotrizoate meglumine (p<0.05). During retrograde brachial angiography, blood pressure changes showed same tendency as during carotid angiography, but not showed statistical difference because of paucity of cases.
It is concluded that metrizamide has definite merit for cerebral angiography of the patient with subarachnoid hemorrhage in acute stage because of minimal blood pressure elevation.
During cerebral angiography of the patient with subarachnoid hemorrhage in acute stage, the following care should be taken.
1) use metrizamide
2) inject the least volume of contrast media under the least injection pressure
3) use sufficient analgesics and sedatives

View full abstract

Our experiences of cerebral angiography in acute stage of ruptured aneurysms were 127 cases in 1982-1984 and in only one case rerupture during angiography occurred. Our principle for cerebral angiography in acute stage of ruptured aneurysms is as follows:
1) Control of blood pressure. Systolic pressure should be under 120 using trimetaphan and nifedipine
2) Sedation must be done sufficiently
3) The operator must be skilled in order to minimize the mechanical damage to the patient
4) Direct puncture using teflon needle and slight slow injection by manual
5) Non-ionic contrast medium metrizamide is very useful because of no discomfort and no pain to the patient.

View full abstract

Intraarterial digital subtraction angiography (IA-DSA) was performed in 27 patients of intracranial aneurysms, including 23 cases of ruptured intracranial aneurysms in acute stage, 46 studies with IA-DSA were performed consequently.
Increased spatial resolution of DSA was obtained with intraarterial injection and with high matrix memory. The image quality of aneurysms and their feeders on IA-DSA was either equivalent or excellent, as compared to the conventional carotid or vertebral angiography.
Its high contrast sensitivity enables us to decrease doses and injection speed of contrast medium. Small doses of contrast medium have prevented the patient from burning pain and transient systemic high blood pressure, are inevitable complication of conventional angiography. Also, slow injection reduced the possible raise of local arterial pressure, and accidental flipping out of catheter to the aorta, moreover 4-vessel study by Seldinger's method was easily achieved via the same catheter. The real time display was the valuable tool to make a decision for the angle of X-ray projection.
From above reasons, it was emphasized that IA-DSA is a non-invasive maneuver, and saves the time for angiography, especially harmless for unstable patients of the acute stage of ruptured aneurysms or the state of vasospasm.

View full abstract

Out of 161 cases with ruptured aneurysm operated within 3 days of last bleeding, 96 cases in grade 1-3 without intracerebral and/or intraventricular hematoma and troubled operation were studied for incidence of delayed ischemic symptoms and hydrocephalus.
Based on method of treatment, these were divided into two groups. In group 1 of 47 cases from Jan.'78 to Mar.'83, a simple obliteration for aneurysm was performed and 28% of these were kept under continuous ventricular drainage. In group 2 of 49 cases from Apr.'83 to Apr.'85, Liliequist' membranotomy and extensive removal of cisternal clot were done in all the cases and continuous drainage from the interpeduncular cistern was applied to 85% at the time of clipping for aneurysm.
Results were as follows: Delayed ischemic symptoms occurred in 40.4%of the cases in group 1: 20.0 of cases with MC aneurysm, 41.2% with AC, 60.6% with IC. In group 2, these were seen in 24.5%: 36.8% with MC, 18.8% with AC, 14.3% with IC. The difference in the cases with IC aneurysm was statistically significant (p<0.05), the method used in group 2 was thought to be positive in the cases with AC aneurysm and particularly in IC aneurysm. Shunt operation was necessary in 25.5% of the cases of group 2, compared to only 6.1% of group 2 (p<0.05).
During the term to which group 2 cases belonged, 102 cases of 115 with aneurysmal SAH underwent obliteration for aneurysm (88.7%). Seventy-six cases (74.5% of operated cases) were operated within 3 days of the last bleeding by the above mentioned method in order to prevent rebleeding and reduce postoperative complications. The result was that overall mortality decreased from 35.2% to 20.9% (p<0.05).

View full abstract