Pathogenetic significance of increased levels of interleukin-8 in the peritoneal fluid of patients with endometriosis

BACKGROUND AND PURPOSE: The rationale behind early aneurysm surgery in patients with subarachnoid hemorrhage (SAH) is the prevention of rebleeding as early as possible after SAH. In addition, by clipping the aneurysm as early as possible, one can apply treatment for cerebral ischemia more vigorously (induced hypertension) without the risk of rebleeding. Hypervolemic hemodilution is now a well-accepted treatment for delayed cerebral ischemia. We compared the prospectively collected clinical data and outcome of patients admitted to the intensive care unit in the period 1977 to 1982 with those of patients admitted in the period 1989 to 1992 to measure the effect of the change in medical management procedures on patients admitted in our hospital with SAH. METHODS: We studied 348 patients admitted within 72 hours after aneurysmal SAH. Patients with negative angiography results and those in whom death appeared imminent on admission were excluded. The first group (group A) consisted of 176 consecutive patients admitted from 1977 through 1982. Maximum daily fluid intake was 1.5 to 2 L. Hyponatremia was treated with fluid restriction (<1 L/24 h). Antihypertensive treatment with diuretic agents was given if diastolic blood pressure was >110 mm Hg. Patients in the second group (172 consecutive patients; group B) were admitted from 1989 through 1992. Daily fluid intake was at least 3 L, unless cardiac failure occurred. Diuretic agents and antihypertensive medications were avoided. Cerebral ischemia was treated with vigorous plasma volume expansion under intermittent monitoring of pulmonary wedge pressure, cardiac output, and arterial blood pressure, aiming for a hematocrit of 0.29 to 0.33. Aneurysm surgery was planned for day 12. RESULTS: Patients admitted in group B had less favorable characteristics for the development of cerebral ischemia and for good outcome when compared with patients in group A. Despite this, we found a significant decrease in the frequency of delayed cerebral ischemia in patients of group B treated with tranexamic acid (P=0.00005 by log rank test) and significantly improved outcomes among patients with delayed cerebral ischemia (P=0.006 by chi2 test) and among patients with deterioration from hydrocephalus (P=0.001 by chi2 test). This resulted in a significant improvement of the overall outcome of patients in group B when compared with those in group A (P=0.006 by chi2 test). The major cause of death in group B was rebleeding (P=0.011 by chi2 test). CONCLUSIONS: We conclude that the outcome in our patients with aneurysmal SAH was improved but that rebleeding remains a major cause of death. Patient outcome can be further improved if we can increase the efficacy of preventive measures against rebleeding by performing early aneurysm surgery.     

Folding rate dependence on the chain length of RNA-like heteropolymers

BACKGROUND: Economical studies on surgery of intracranial aneurysms have considered only the significant benefit of surgical approach on unruptured aneurysms and no studies have been performed comparing cost/benefit analysis of early vs delayed surgery. The present study was retrospectively performed in order to verify whether different treatment options in aneurysm surgery have a different cost/benefit ratio. METHODS: We have analysed a series of 137 patients which underwent surgery for intracranial aneurysms (21 unruptured aneurysms, 56 early surgery and 60 delayed surgery). In the analysis we assumed that each state of an operated patient has an assigned quality of life value and an associated medical cost. We expressed the outcome of each patient as the expected length of survival adjusted for quality, and referred to it as "quality-adjusted life years" (QALY). We considered for each patient the direct cost of Hospitalisation (obtained from DRG reimbursement), the Rehabilitation cost and the correction due to QALY adjusted for age and deficit. RESULTS: Significantly higher costs are reported in patients which present as major complication the hydrocephalus and which are treated with nimodipine; moreover, the costs for patients operated for unruptured aneurysms is significantly lower than that of patients which presented with SAH. Meanwhile, the average QALY adjusted for post-operative neurological deficit at three months follow-up is higher in patients operated for unruptured aneurysms than in patients operated after SAH. The cost-effectiveness of different treatment strategies did not significantly differ considering age and neurological deficit adjustment; thus, after SAH, the choice of early or delayed surgery may depend on clinical and logistic conditions related to the neurosurgical department and its organisation, because there is no significant economical advantage leading to recommend early versus delayed surgery. CONCLUSIONS: In conclusion the present data suggest that a decreased length of hospitalisation and a decreased cost for treatment of unruptured aneurysms should justify a more rigorous preventive screening with available non invasive neuroimaging techniques.     

Dermal application of lisuride on parkinsonism induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in the common marmoset and on cases with Parkinson''s disease

BACKGROUND: Follow-up study of patients with surgical repair of aneurysmal subarachnoidal hemorrhage (SAH), looking for clinical outcome predictors. PATIENTS AND METHODS: Sixty two patients consecutively admitted to a teaching hospital, from January 1992 to December 1995 were included in the study. We studied preoperative, intraoperative and postoperative features looking for their relationship with the outcome. The ultimate outcome was evaluated by means of Glasgow Outcome Scale on discharge and 6 months later. RESULTS: Smoking (p = 0.0001) and arterial hypertension (AHT) (p = 0.0186) were more frequent in these patients than in general population, but without relationship to the outcome as with the age of the clinical status on admission. The greatest statistical relationship was found between the level of consciousness on postoperative awakening (measured by the Hunt and Hess scale), and the outcome (p = 2.53 x 10(-8). From our results we made an algorithm that correctly assigned 92% of studied patients to their outcome. CONCLUSIONS: All patients admitted on with aneurysm SAH deserve intensive care treatment besides their clinical grade. The level of consciousness on postoperative awakening was a good outcome predictor.     

Plasma glucose levels and outcome after aneurysmal subarachnoid hemorrhage

Plasma glucose levels were studied in 616 patients admitted within 72 hours after subarachnoid hemorrhage (SAH). Glucose levels measured at admission showed a statistically significant association with Glasgow Coma Scale scores, Botterell grade, deposition of blood on computerized tomography (CT) scans, and level of consciousness at admission. Elevated glucose levels at admission predicted poor outcome. A good recovery, as assessed by the Glasgow Outcome Scale at 3 months, occurred in 70.2% of patients with normal glucose levels (< or = 120 mg/dl) and in 53.7% of patients with hyperglycemia (> 120 mg/dl) (p = 0.002). The death rates for these two groups were 6.7% and 19.9%, respectively (p = 0.001). The association was still maintained after adjusting for age (> or < or = 50 years) and thickness of clot on CT scans (thin or thick) in the subset of patients who were alert/drowsy at admission. Increased mean glucose levels between Days 3 and 7 also predicted a worse outcome; good recovery was observed in 132 (73.7%) of 179 patients who had normal mean glucose levels (< or = 120 mg/dl) and 160 (49.7%) of 322 who had elevated mean glucose levels (> 120 mg/dl) (p < 0.0001). Death occurred in 6.7% and 20.8% of the two groups, respectively (p < 0.0001). It is concluded that admission plasma glucose levels can serve as an objective prognostic indicator after SAH. Elevated glucose levels during the 1st week after SAH also predict a poor outcome. However, a causal link between hyperglycemia and outcome after delayed cerebral ischemia, although suggested by experimental data, cannot be established on the basis of this study.     

Mild hypothermia as a protective therapy during intracranial aneurysm surgery: a randomized prospective pilot trial

OBJECTIVE: To conduct a pilot trial of mild intraoperative hypothermia during cerebral aneurysm surgery. METHODS: One hundred fourteen patients undergoing cerebral aneurysm clipping with (n = 52) (World Federation of Neurological Surgeons score < or =III) and without (n = 62) acute aneurysmal subarachnoid hemorrhage (SAH) were randomized to normothermic (target esophageal temperature at clip application of 36.5 degrees C) and hypothermic (target temperature of 33.5 degrees C) groups. Neurological status was prospectively evaluated before surgery, 24 and 72 hours postoperatively (National Institutes of Health Stroke Scale), and 3 to 6 months after surgery (Glasgow Outcome Scale). Secondary outcomes included postoperative critical care requirements, respiratory and cardiovascular complications, duration of hospitalization, and discharge disposition. RESULTS: Seven hypothermic patients (12%) could not be cooled to within 1 degrees C of target temperature; three of the seven were obese. Patients randomized to the hypothermic group more frequently required intubation and rewarming for the first 2 hours after surgery. Although not achieving statistical significance, patients with SAH randomized to the hypothermic group, when compared with patients in the normothermic group, had the following: 1) a lower frequency of neurological deterioration at 24 and 72 hours after surgery (21 versus 37-41%), 2) a greater frequency of discharge to home (75 versus 57%), and 3) a greater incidence of good long-term outcomes (71 versus 57%). For patients without acute SAH, there were no outcome differences between the temperature groups. There was no suggestion that hypothermia was associated with excess morbidity or mortality. CONCLUSION: Mild hypothermia during cerebral aneurysm surgery is feasible in nonobese patients and is well tolerated. Our results indicate that a multicenter trial enrolling 300 to 900 patients with acute aneurysmal SAH will be required to demonstrate a statistically significant benefit with mild intraoperative hypothermia.     

Surgical outcome of anterior communicating artery aneurysms

During a 6-year period, 65 consecutive patients who had undergone anterior communicating artery aneurysmal surgery were reviewed at a follow-up examination from 6 to 78 months (mean 35 months) after operation. On admission 69% of cases had a good Hunt and Hess scale (grades I to II) and 31% a poor grade (grades III to V). The degree of subarachnoid hemorrhage (SAH) was determined by Fisher's grade. Sixteen (25%) patients were classified in grades I and II. Forty-six percent of cases had pre-existing hypertension. Early surgery (within the first three days after the bleeding) was performed in 17% of cases. Intraoperative rupture of aneurysm occurred in six (9.2%) patients. Symptomatic cerebral vasospasm was diagnosed in 14 (22%) cases, but only 8 (12%) had evidence of low density on the computerized tomographic scan. Hydrocephalus developed in 16 (25%) cases and 10 needed ventriculoperitoneal shunting. The outcome was determined using the activity of daily life. Sixty-five percent of the patients made a good recovery and 13.8% died. The significant poor prognostic factors included a poor pre-operative grade of the Hunt and Hess scale, the presence of symptomatic cerebral vasospasm, and the Fisher's SAH grade of greater than II. Other factors which apparently were not related to the outcome included age, sex, timing of surgery, history of hypertension, intraoperative rupture, and the development of hydrocephalus.     

Effect of ultra-early referral on management outcome in subarachnoid haemorrhage

A study was conducted to clarify whether ultra-early referral of patients with subarachnoid haemorrhage (SAH) is effective for improving the management outcome. The subjects were 455 patients who were admitted within 6 h after initial SAH. Of these patients, 289 were treated surgically, 159 of them within 24 h. At 6 months, 228 patients (50%) had a favourable outcome including good recovery or moderate disability, 37 (8%) had severe disability, and 190 (42%) had an unfavourable outcome including vegetative state or death. Of 214 patients with an admission grade IV or V, 47 (22%) had a favourable outcome. In 10 patients, emergency procedures such as haematoma removal or ventriculostomy were definitely effective, and in 13, early surgery may have been the reason for the improved outcome. However, in 24 patients, the reasons for a favourable outcome were not related directly to ultra-early referral; in 19 of them, there was spontaneous improvement of clinical grade and/or no SAH on computed tomography. Of 218 patients with admission grade I or II, 30 (14%) had an unfavourable outcome, and in 12 of them, this was ascribed to rebleeding. The rebleeding rate and severity of vasospasm were not significantly reduced by surgery carried out within 24 h after SAH, in comparison with surgery carried out between 24 and 48 h, and there was no significant difference in surgical outcome between them. It is concluded that although ultra-early referral of patients with SAH was expected to improve the outcome in emergency cases, no substantial improvement in overall management outcome seems to have been achieved by this policy.     

Outcome after urgent surgery for grade IV subarachnoid hemorrhage

BACKGROUND: Outcome after subarachnoid hemorrhage (SAH) in patients presenting with poor clinical grade has historically been dismal. As a result, many poor-grade patients have been excluded from early, aggressive surgery. We present a consecutive series of 27 patients with acute (less than 24 h since clinical onset) Grade IV SAH treated with early surgery. METHODS: All patients were treated with immediate ventricular drainage, rigid hemodynamic control, early angiography and surgery within 24 h of presentation. Patients were followed for a minimum of 6 months and their outcomes categorized using a four-tiered scale: 1) independent and working, 2) impaired but independent, 3) severely impaired and dependent, and 4) dead. RESULTS: Seven patients died within 48 h of admission. The remaining 20 patients survived to discharge. At the time of discharge eight of these patients were considered to be impaired but independent and twelve were considered severely impaired and dependent. At follow-up, seven patients were independent and working, six were impaired but independent, five were severely impaired and dependent, and two severely impaired patients had subsequently died. CONCLUSIONS: We conclude that urgent surgery for poor-grade SAH can produce quality survival for a higher percentage of patients than is historically reported with delayed surgery.     

Understanding the three national databases on collegiate alcohol and drug use

Early admission and medical treatment can improve prognosis in patients with subarachnoid hemorrhage (SAH). In our Centre in 10 years, 595 patients with SAH have been treated: 422 were admitted within 24 hours (71%) and 498 (84%) within 72 hours. 374 underwent surgical treatment: 283 within 48 hours and 91 underwent late surgery. Thirty-three patients underwent emergency surgery for intracranial hematomas, with a mortality rate of 30%. One hundred eighty-one patients in Hunt-Hess grade I-II underwent early surgery. Mortality rate was 7%. Mortality rate for rebleeding, when surgery was delayed was more than 10%. Patients in Hunt-Hess grade III underwent early surgery in the majority of cases (68 out of 111). Only in 52% of cases surgical result was good. Thirty-four out of 108 in grade IV-V underwent early surgery, with a mortality rate of 45%. The analysis of general results shows that early surgery improves prognosis in Hunt-Hess grade III patients. Also patients in Hunt-Hess grade III-IV-V can take advantage of early surgery. Old age, arterial hypertension and angiographical vasospasm do not worsen prognosis even in patients operated on early. Endovascular treatment even in acute phase has improved results especially in cases of certain aneurysms types such as posterior circulation aneurysms.     

Prognostic factors for adenocarcinoma of the gallbladder: an analysis of 162 cases

We experienced a case with sudden unexpected death caused by rupture of an intracranial aneurysm, which was confirmed by autopsy. Depending on this case, we reported the significance of the cerebellar tonsillar herniation on the cause of sudden death of ruptured cerebral aneurysm. A 58-year-old man was admitted to us for treatment of subarachnoid hemorrhage (SAH). The CT scanning showed diffuse SAH in the whole cistern. Cerebral angiography on admission revealed an aneurysm at the bifurcation of the left middle cerebral artery in association with bleb like configuration. The aneurysmal neck was clipped on the day of admission. The postoperative course was uneventful. In the early morning of postoperative 23rd day, he was found being expired. To clarify the cause of death, an autopsy was done, disclosing diffuse SAH in association with tonsillar herniation more marked on the left. Thus, the distortion of the spinomedullary junction due to asymmetrical herniation was considered to be responsible for unexpected sudden death in this case. Examination of the major cerebral artery disclosed a ruptured anterior communicating artery aneurysm.     

S-100 protein plasma levels after aneurysmal subarachnoid haemorrhage

We investigated the level of S-100 protein in blood as an indicator of brain damage in 71 patients suffering from subarachnoid haemorrhage (SAH) due to ruptured aneurysms. Concentrations of S-100 protein were determined by micro-titre based immunofluorometic assay detecting predominantly S-100b on blood samples obtained 24 hours, 3 days and 7 days after onset of symptoms in patients with SAH and from 120 healthy control subjects. Neurological status was assessed using the Hunt and Hess (HH) scale on admission and by the Glasgow Outcome Scale (GOS) 6 months later. Mean concentrations of S-100 protein in blood were significantly (p < 0.0001) higher in patients 24 hours (0.263 +/- 0.387 microgram/l), 3 days (0.192 +/- 0.288 microgram/l) and 7 days (0.256 +/- 0.442 microgram/l) after onset of SAH symptoms compared to controls (0.050 +/- 0.081 microgram/l). More severe neurological symptoms (higher HH scale scores) on admission correlated with higher S-100 levels on admission (R = 0.70) and Day 3 (R = 0.66) (p < 0.0001). Worse outcome (lower GOS score) 6 months after SAH was also associated with higher plasma concentration of S-100 in the first week after SAH. In summary, this study showed that in patients with SAH due to ruptured aneurysm, S-100 protein levels correlate with early neurological deficit and are as sensitive as HH scores in predicting neurological outcome (GOS scores). Measurement of S-100 protein in blood is a reliable non-invasive method and may be clinically useful to screen for and monitor progression of central nervous system diseases of various origins.     

The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects

Cytokines are considered as mediators of immune and inflammatory responses. Cisternal CSF levels of interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1 (MCP-1) and of the soluble adhesion molecule E-selectin were evaluated in patients operated on for intracranial aneurysms. Cisternal CSF samples were obtained at surgery in 41 selected patients (31 with diagnosis of subarachnoid hemorrhage (SAH) and 10 control patients operated on for incidental unruptured aneurysms); 14 patients were operated within 72 h after SAH (early surgery) and 17 were operated after day 10 after the hemorrhage (delayed surgery). The CSF levels of cytokines were evaluated using radioimmunoassay and their concentrations were related to the timing of surgery, the amount of cisternal subarachnoid blood clots and the onset of clinical and angiographical evidence of arterial vasospasm. Mean cisternal CSF levels of IL-6, IL-8 and AMCP-1 are significantly higher in samples obtained from patients early operated after SAH, while levels of E-selectin were below the threshold value of the method in all 41 cases. In the early operated group 7 patients presented symptomatic vasospasm: levels of IL-8 and MCP-1 were not significantly different were compared to those of uncomplicated cases; on the other hand, significantly higher levels of IL-6 were shown in the subgroup of patients operated within 72 h after SAH and developing vasospasm. Among the patients undergoing delayed surgery 5 presented symptomatic vasospasm, but no significant difference was shown in cisternal CSF levels of cytokines measured. The results of the present study show that in patients with unruptured aneurysms cytokines are present in cisternal CSF in scarce quantities and that in subarachnoid spaces after SAH there is an impressive increase of IL-6, IL-8 and MCP-1. Moreover, the higher cisternal CSF levels of IL-6 found in the early stage after SAH might have a predictive value regarding the occurrence of symptomatic vasospasm.     

The usefulness of magnetic resonance angiography in surgery for intracranial aneurysms that have bled

BACKGROUND: Once it was confirmed that magnetic resonance imaging (MRI) including angiography (MRA) could demonstrate intracranial aneurysms, a study was set up to establish whether satisfactory images could be obtained to plan and execute early surgery on ruptured intracranial aneurysms without recourse to intra-arterial digital subtraction angiography (IA.DSA) in the acute phase of the illness. METHODS: All patients presenting with a subarachnoid haemorrhage (SAH) were considered for MR studies. The patient selection was based on whether they were considered fit enough to tolerate scanning and did not have a known contraindication. A standard protocol was used--a three-dimensional time-of-flight with T1 and T2-weighted sagittal and axial images. If an aneurysm was demonstrated and early surgery was undertaken they were entered into the study. RESULTS: Over a 25-month period, 122 patients were submitted for MR studies, these being selected from over 200 patients presenting with an SAH. Aneurysms were believed to be present in 55 patients who were clinically suitable for early surgery. There were 21 males and 34 females, with an age range of 23-79 years, a mean of 50.5 years. Sixty-three aneurysms in all were demonstrated and 55 of these were surgically dealt with. There were two false positives. CONCLUSION: MRI is the investigation of choice to plan surgery in those patients presenting with an SAH who, on clinical grounds, would be considered suitable for early surgery. The imaging is easily obtained, non-invasive, avoids radiation, and in view of the multiple images obtained is often superior to conventional DSA.     

Cerebrospinal fluid tissue factor and thrombin-antithrombin III complex as indicators of tissue injury after subarachnoid hemorrhage

BACKGROUND AND PURPOSE: No marker that reflects and predicts brain injury due to subarachnoid hemorrhage (SAH) and cerebral vasospasm has been reported. We hypothesized that membrane-bound tissue factor (mTF) and thrombin-antithrombin III complex (TAT) in the cerebrospinal fluid (CSF) of patients with SAH become markers indicating brain injury. To evaluate the hypothesis, we correlated levels of mTF and TAT in the CSF of patients with SAH with clinical severity, the degree of SAH, and outcome. METHODS: We assayed CSF mTF, TAT and myelin basic protein (MBP) in patients with SAH at intervals that included days 0 to 4 and days 5 to 9 after ictus. Classification of clinical severity of disease on admission was based on Hunt and Hess grade, degree of SAH on CT on Fisher's grading, and outcome 3 months after SAH on the Glasgow Outcome Scale. RESULTS: In the interval from days 0 to 4, mTF and TAT correlated with Hunt and Hess and Fisher grades, and occurrence of cerebral infarction due to vasospasm. Only mTF correlated significantly in this period with outcome. TAT, mTF, and MBP all correlated significantly with each other. From days 5 to 9, only mTF correlated with cerebral infarction, infarction volume, MBP levels, and outcome. CONCLUSIONS: Both mTF and TAT reflected brain injury from SAH and predicted vasospasm, though mTF was more sensitive and a better predictor of outcome. Unlike mTF, TAT did not correlate with vasospasm during the interval when it most commonly occurs, which raised doubt about thrombin activation as a cause.     

Complex intracranial aneurysms: combined operative and endovascular approaches

OBJECTIVE: Endovascular management of complex intracranial aneurysms is increasingly being considered as an alternative to standard surgical clipping. However, little attention has been paid to the complementary nature of surgery and endovascular therapy. METHODS: Between September 1992 and May 1997, 12 patients with complex intracranial aneurysms were treated with combined operative and endovascular methods. Seven patients demonstrated subarachnoid hemorrhage (two of Grade II, two of Grade III, and three of Grade IV). Five patients demonstrated unruptured aneurysms, i.e., three giant aneurysms (one vertebrobasilar junction aneurysm, one middle cerebral artery bifurcation aneurysm, and one internal carotid artery-ophthalmic artery aneurysm), one large internal carotid artery-ophthalmic artery aneurysm, and one middle cerebral artery serpentine aneurysm. Management strategies involved either surgery followed by endovascular therapy (S-E; n = 5) or endovascular therapy followed by surgery (E-S; n = 7). S-E paradigms included aneurysm exploration followed by endovascular treatment (S-E1; n = 3), partial aneurysm clipping followed by endovascular aneurysm packing (S-E2; n = 1), and extracranial-to-intracranial bypass followed by endovascular parent vessel occlusion (S-E3; n = 1). E-S paradigms included superselective angiography followed by surgical clipping (E-S1; n = 2), Guglielmi detachable coil partial dome packing followed by delayed surgical clipping (E-S2; n = 2), proximal temporary vessel balloon occlusion followed by aneurysm clipping (E-S3; n = 2), and proximal permanent vessel occlusion followed by surgical aneurysm decompression for mass effect treatment (E-S4; n = 1). RESULTS: Eleven aneurysms (92%) were completely eliminated. The remaining aneurysm was 90% obliterated and remained quiescent at the 34-month follow-up examination, despite presenting with subarachnoid hemorrhage. No patient experienced repeat bleeding (follow-up period, 23+/-28 mo). There were no deaths. One patient achieved a fair outcome (Glasgow Outcome Scale score of III); all other patients experienced excellent outcomes (Glasgow Outcome Scale score of I). In all cases, the aneurysm management paradigm chosen had a positive effect on definitive therapy. CONCLUSION: Several factors can contribute to the complexity of intracranial aneurysms. Management strategies that combine operative and endovascular techniques in a complementary way, for the best possible outcomes for these patients, can be designed accordingly.     

Outpatient adenotonsillectomy. Is it safe in children younger than 3 years?

OBJECTIVE: To evaluate the safety of ambulatory adenotonsillectomy in children younger than 3 years. MATERIALS AND METHODS: The records of 102 children younger than 3 years who underwent adenotonsillectomy as an outpatient procedure were reviewed during a 3-year period. RESULTS: Ten patients (10%) required overnight hospital admission for an average of 1.4 days. Nine patients were admitted directly from the day-stay unit and 1 patient was admitted 48 hours after surgery. The reason for hospital admission was poor oral intake. None of the patients had postoperative bleeding or respiratory problems or required intensive care unit admission. CONCLUSION: The safety of ambulatory adenotonsillectomy depends on judicious selection criteria and can be performed in children younger than 3 years.     

Experience with computed tomographic angiography for the detection of intracranial aneurysms in the setting of acute subarachnoid hemorrhage

OBJECTIVE: To objectively compare computed tomographic angiography (CTA) with selective digital subtraction angiography (DSA) in the detection and anatomic definition of intracranial aneurysms, particularly in the setting of acute subarachnoid hemorrhage (SAH). METHODS: In a blinded prospective study, 40 patients with known or suspected intracranial saccular aneurysms underwent both CTA and DSA, including 32 consecutive patients with SAH in whom CTA was performed after CT images were obtained diagnostic for SAH. The CT angiograms were interpreted for presence, location, and size of the aneurysms, and anatomic features, such as the number of aneurysms lobes, aneurysm neck size (< or = 4 mm), and the number of adjacent arterial branches were suggested. The images obtained with CTA were then compared with the images obtained with DSA, with the later images serving as controls. RESULTS: DSA revealed 43 aneurysms in 30 patients and ruled out intracranial aneurysms in the remaining 10 patients. For aneurysm presence alone, the sensitivity and specificity for CTA was 86 and 90%, respectively. For the presence of an aneurysms, six CT angiogram showed false negative results and one CT angiogram showed a false positive result. False negative results were usually caused by technical problems with the image, tiny aneurysm domes (< 3 mm), and unusual aneurysm locations (i.e., intracavernous carotid or posterior inferior cerebellar artery aneurysms). The results obtained with CTA were, compared with the results obtained with DSA, more than 95% accurate in determining dome and neck size of aneurysm, aneurysm lobularity, and the presence and number of adjacent arterial branches. In addition, CTA provided a three-dimensional representation of the aneurysmal lesion, which was considered useful for surgical planning. CONCLUSION: CTA is useful for rapid and relatively noninvasive detection of aneurysms in common locations, and the anatomic information provided in images showing positive results is at least equivalent to that provided by DSA. In cases of SAH in which the nonaugmented CT and CTA results indicate a clear source of bleeding and provide adequate anatomic detail, we think it is possible to forego DSA before urgent early aneurysm surgery. In all other cases, DSA is indicated.     

Predictive factors for in-hospital mortality and delayed mortality following aneurysmal subarachnoid hemorrhage

It is important to detect predictive factors for in-hospital and delayed mortality of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm. Forty-eight patients with initial bleeding of aneurysmal SAH were referred to our hospital from January 1982 to December 1985. In-hospital mortality was 16.7% (8 to 48), and 15% (6) of forty patients died later during the follow-up period. Using the Kaplan-Meier method we were able to conclude that, cumulatively, there was 70.8% probability that much patients would survive for 10 years. We analysed predictive factors of in-hospital and delayed mortality retrospectively. The most significant predictive factor for in-hospital mortality was SAH grading on admission, and for delayed mortality (29.2%) age on admission was the best predictive factor. In fact, two patients died with cardiac event during the follow-up period. This result suggests that, although the SAH grading on admission was the second most significant factor for delayed mortality, patients who survived in the acute phase had a survival probability similar to those in a normal control group.     

Management of subarachnoid hemorrhage patients who presented with respiratory arrest resuscitated with bystander CPR

BACKGROUND AND PURPOSE: The sudden death rate from aneurysmal subarachnoid hemorrhage (SAH) is 10%. Since 1989, 26 SAH patients who were witnessed to collapse into coma with respiratory arrest and required cardiopulmonary resuscitation (CPR) at the scene survived to reach the hospital and be diagnosed. Although reports on hospital management of grade V SAH suggest improved outcome, no report has previously addressed the issue of respiratory arrest after acute SAH. We analyze our experience with this unique subgroup of aneurysmal SAH patients. METHODS: This is a retrospective analysis of 26 consecutive SAH patients who collapsed at the scene and required CPR for respiratory arrest and survived to reach the hospital and be diagnosed. Statistical analysis was performed using the t test and Mann-Whitney rank-sum test. RESULTS: All patients were grade V on arrival at the emergency department. Twenty-one patients received mouth-to-mouth resuscitation only, and 5 received chest compressions as well. The mean duration of bystander CPR was 12 to 15 minutes. CT scan showed diffuse, thick SAH in all patients, an associated subdural hemorrhage in 2, and an intraparenchymal hemorrhage in 4. After CT scan, an intracranial pressure (ICP) monitor was placed in 24, and 2 were taken to emergency surgery for subdural and intracerebral hemorrhage. ICP was elevated in 24 patients (mean, 54 mm Hg), and a ventriculostomy was placed in all 24. ICP was unresponsive in 12, and all suffered brain death. ICP lessened to < 25 mm Hg in 12, and all underwent angiography. All 12 had an aneurysm and underwent emergency surgical clipping. Time to surgery from SAH was < or = 11 hours in all 12 patients. All were managed with calcium channel blockers and hyperdynamic therapy in addition to aggressive control of ICP. The outcome at 12 months in the 14 surgical cases was normal in 3 patients (21%), good in 2 (14%), vegetative in 1 (7%), and death in 8 (57%). CONCLUSIONS: Aneurysmal SAH patients that present with respiratory arrest present as grade V patients with elevated ICP. Bystander CPR coupled with early retrieval, diagnosis, and therapy can lead to 20% functional survival in what used to be sudden death from aneurysmal SAH.