Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22-51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.     

Sanguineous cerebrospinal fluid in recanalized cerebral infarction

To clarify the causal relationship between spontaneous recanalization of the occluded cerebral artery and development of hemorrhagic infarction, 15 patients with internal carotid or middle cerebral arterial axis occlusion were submitted to consecutive lumbar punctures and follow-up cerebral angiography. Consequently, six of seven recanalized patients had sanguineous cerebrospinal fluid (CSF) on the second or third day after ictus, while only one of eight non-recanalized patients had bloody CSF. It was strongly suggested that recanalization might have an initimate relationship with the development of hemorrhagic infarction.     

Middle cerebral artery dissection

A 12-year-old girl had minor head trauma, with resultant mild headache, one day prior to onset of an apparently generalized tonic clonic seizure, right hemiparesis and dysphasia. A cranial CT scan showed evidence of a left middle cerebral artery infarct. Despite ventilation, fluid restriction, mannitol, thiopental infusion and intracranial pressure monitoring she deteriorated and died. Autopsy demonstrated dissection of the left middle cerebral artery with an intact internal carotid artery and no evidence of vasculitis. Middle cerebral artery dissection in children is very rare. Most reported cases are diagnosed at autopsy. The pathogenesis of cerebral artery dissection may include preceding minor head trauma or exertion and this should be sought for in the history.     

Combined use of duplex imaging and magnetic resonance angiography for evaluation of patients with symptomatic ipsilateral high-grade carotid stenosis

PURPOSE: Advances in cerebral vascular imaging suggest that patients with critical levels of carotid artery stenosis (> 70%) who have symptoms can be identified accurately and necessary information about the intracranial and extracranial circulation obtained before surgery without conventional angiography. We have used carotid duplex imaging in combination with magnetic resonance angiography (MRA) to evaluate 20 patients with symptomatic ipsilateral high-grade carotid stenosis. METHODS: All patients underwent CT and magnetic resonance imaging brain scans, as well as MRA and conventional arteriography of the cerebral circulation. Magnetic resonance angiograms were obtained with two-dimensional phase contrast and time-of-flight techniques. Phase contrast was used for intracranial vascular imaging and for determining qualitative flow velocities and the direction of blood flow in the circle of Willis. Two-dimensional time of flight was used to assess the carotid bifurcations. RESULTS: Twenty patients with symptoms (six with strokes, 11 with transient ischemic attacks, and three with amaurosis fugax) had duplex evidence of high-grade carotid stenoses. Computed tomographic and magnetic resonance brain scans were positive for cerebral infarction in six patients with clinical strokes. Comparison of MRA with conventional angiography was 91% accurate for high-grade stenoses and occlusions (sensitivity 100% and specificity 90% for stenosis; sensitivity/specificity was 100% for complete occlusion). Comparison of duplex imaging with conventional angiography demonstrated 86% accuracy for detection of severe stenosis or occlusion (sensitivity 94% and specificity 89% for stenosis; sensitivity and specificity were 100% for complete occlusion). CONCLUSIONS: This study suggests that combined use of MRA and duplex imaging is accurate for detection and evaluation of high-grade carotid stenoses in patients with symptoms.     

Carotid artery repair for radiation-associated atherosclerosis is a safe and durable procedure

OBJECTIVE: The development of carotid atherosclerosis after neck irradiation is well documented. There has been concern about the safety and durability of carotid artery repair through a radiated field. The objective of this report is to describe the immediate and long-term results of a series of cases collected in a 13-year interval. METHODS: From 1984 to 1997, 24 patients underwent 26 carotid artery operations. All the patients had undergone prior radiation therapy at a mean interval of 17 years, with an average radiation dose of 6300 rad. Severe scarring of the skin or radiation fibrosis were present in two thirds of the patients, with 4 patients having permanent tracheostomies. The indications for carotid surgery included cerebral or monocular transient ischemic attack (58%), asymptomatic high-grade stenosis (27%), prior stroke (12%), and tumor invasion of the carotid artery (4%). General anesthesia was used with selective shunting on the basis of carotid artery back pressure or electroencephalography monitoring. Patch angioplasty closure was used in 79% of the patients. The operations included standard carotid endarterectomy (n = 20), external carotid endarterectomy (n = 2), carotid patch angioplasty alone (n = 2), aortocarotid bypass grafting (n = 1), and carotid interposition grafting (n = 1). Four patients required skin grafting or myocutaneous flaps. RESULTS: No deaths or strokes occurred within 30 days of the operations. Six patients had transient cranial nerve palsy, and two had wound infections. The patients were followed from 1 to 156 months, with six patients being followed for longer than 18 months. No strokes were seen at late follow-up examination. Duplex scan examination documented one occlusion, in a patient with primary closure, and two restenoses, one of which necessitated reoperation. The remainder of the grafts were widely patent. CONCLUSIONS: Carotid surgery after neck irradiation is safe and durable. The long-term patency rates and the protection against subsequent neurologic events are similar to the results obtained in the absence of radiation therapy. Problems of wound healing were not found in this series.     

Rupture of asymptomatic mycotic aneurysm after valve replacement in infective endocarditis

Mycotic cerebral aneurysms (MCA) are one of the most serious complications of infective endocarditis. The rupture of MCA in patients under anticoagulant therapy following valve replacement carries high mortality. We encountered this serious complication in a patient who had no neurologic symptoms. A 12-year-old girl was scheduled for mitral valve replacement (MVR) 5 weeks after antibiotic therapy for infective endocarditis caused by Staphylococcus aureus. Before the surgery, she did not have any neurologic symptoms or abnormal findings in CT scanning examination. The surgery to remove her mitral valve with bacterial vegetations and replace it with an artificial valve proceeded smoothly and she appeared to begin an uneventful postoperative recovery. However, she suddenly began to complain of severe headache and became unconscious on the fifth days after MVR. A CT scan showed cerebral herniation due to a major subdural hematoma. A ruptured MCA was detected in the orbito-frontal artery and clipped in an emergency operation. She was transferred to the intensive care unit and given continuous infusion of barbiturate to prevent increase of her intracranial pressure. CT scanning and arteriography 10 days after the MCA clipping, revealed a new subdural hematoma and MCA just proximal to the previous clip. It is important to bear in mind that patients with infective endocarditis can have mycotic cerebral aneurysms without any clinical neurologic symptoms.     

Angioplasty of the occluded internal carotid artery

PURPOSE: To review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful. METHODS: We reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed. RESULTS: All four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent. CONCLUSION: In acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Anatomical and biomechanical similarity in intracranial environment in identical twins with external hydrocephalus

Identical twins who both presented with progressively enlarging heads in their first year of life are reported. Neuroimaging demonstrated morphological similarities in the cerebral cortex. The CSF space, including ventricular system, and subarachnoid space were dilated, suggesting external hydrocephalus. Cerebral blood flow velocity in the anterior cerebral artery monitored by Doppler sonogram indicated the two had similar flow patterns and velocities. Simultaneous recording of ICP waves and intracranial biomechanical properties, that is, pressure buffering capacity (pressure volume index: PVI) and CSF outflow resistance (Ro) measured by the bolus saline injection technique, objectively indicated that all these biomechanical factors were also quite similar in the twins. These results indicate that identical twins with external hydrocephalus have very similar intracranial environments, both anatomically and biomechanically.     

Insulin-like growth factor binding proteins from adult-hamster pancreatic islets: influence of glucose concentration

The recognized incidence of extra- and intracranial carotid artery dissection has increased concomitantly with the progress and development of diagnostic methods. However, management for this condition is still controversial. We report in the present study the management and long-term follow-up results of 15 patients with carotid artery dissection. Mean age of the patients at onset was 47.8 years old, and male/female ratio was 12:3. Two patients were considered to be traumatic dissections and the other 13 patients were spontaneous dissections. Dissection occurred in 10 patients at the extracranial carotid artery, in 4 at the intracranial carotid artery and in 1 at the middle cerebral artery. Nine of 15 patients demonstrated hemiparesis and 5 complained of headache or facial pain. However, it was not possible to identify a characteristic symptom of dissection. Final diagnosis of dissection was made by cerebral angiography in all patients. Serial angiography was carried out in 10 of those, and 5 of the 10 patients showed some improvements of dissection in the cerebral angiogram. Treatment for those patients was selected according to the neurological and angiographical changes. Five patients were managed conservatively and 10 patients underwent surgical revascularization. During the follow-up period (mean 77.6 months), none of them showed any symptoms of reattack, and all but one, who died of heart failure 193 months after revascularization surgery, have lived independently. Although diagnosis of dissection was difficult because of the lack of characteristic symptom, serial angiography was a useful method for diagnosis and adequate management has led to a good clinical outcome.     

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.     

Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema

OBJECTIVE: The management of malignant posttraumatic cerebral edema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high despite refinements in medical and pharmacological means of controlling elevated intracranial pressure; therefore, a comparison of medical management versus decompressive craniectomy in the management of malignant posttraumatic cerebral edema was undertaken. METHODS: At the University of Virginia Health Sciences Center, 35 bifrontal decompressive craniectomies were performed on patients suffering from malignant posttraumatic cerebral edema. A control population was formed of patients whose data was accrued in the Traumatic Coma Data Bank. Patients who had undergone surgery were matched with one to four control patients based on sex, age, preoperative Glasgow Coma Scale scores, and maximum preoperative intracranial pressure (ICP). RESULTS: The overall rate of good recovery and moderate disability for the patients who underwent craniectomies was 37% (13 of 35 patients), whereas the mortality rate was 23% (8 of 35 patients). Pediatric patients had a higher rate of favorable outcome (44%, 8 of 18 patients) than did adult patients. Postoperative ICP was lower than preoperative ICP in patients who underwent decompression (P = 0.0003). Postoperative ICP was lower in patients who underwent surgery than late measurements of ICP in the matched control population. A statistically significant increased rate of favorable outcomes was seen in the patients who underwent surgery compared to the matched control patients (15.4%) (P = 0.014). All patients who exhibited sustained ICP values above 40 torr and those who underwent surgery more than 48 hours after the time of injury did poorly. Evaluation of the 20 patients who did not fit into either of those categories revealed a 60% rate of favorable outcome and a statistical advantage over control patients (P = 0.0001). CONCLUSION: Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.     

Carotid endarterectomy for asymptomatic carotid artery stenosis: patients with severe bilateral disease a high risk subgroup

Carotid endarterectomy if advised for asymptomatic disease must be associated with a low peri-operative morbidity and mortality and satisfactory long-term results. Over a 12 year period between 1978-1989 181 carotid endarterectomies were performed on 163 patients with asymptomatic carotid artery stenosis. There were 112 males and 51 females with a mean age of 64.9 years. All patients had a high-grade lesion (> 70% stenosis). The combined operative mortality and stroke rate was 2.8%. On long-term follow up six patients suffered a stroke. Only one patient however sustained a stroke in the same territory as the previously operated carotid artery. Four years following surgery 78% of patients were alive. Carotid restenosis or occlusion occurred in 8.3% of the remaining patients, all of whom were asymptomatic. All the immediate postoperative strokes occurred in patients with severe bilateral carotid artery disease. These patients with severe bilateral disease appear to constitute a high risk sub-group for peri-operative stroke. The role of 'normal pressure-hyperperfusion breakthrough' syndrome as the presumed aetiology of two of the postoperative cerebral haemorrhages is discussed.     

Effect of cerebral ischaemia on the cerebrovascular and cardiovascular response to haemorrhage

Reports studying the combination of low blood pressure and cerebral ischaemia are few, and it remains to be determined how cerebral circulatory insufficiency modifies the cerebral perfusion and the central haemodynamic response to blood loss. We hypothesised that occlusion of arteries to the brain modifies the cerebrovascular and cardiovascular responses to blood loss. Continuous measurements of the cerebral microcirculation with laser Doppler microprobes in the cerebral cortex were performed in anaesthetised pigs during cerebral ischaemia and haemorrhagic hypotension. The response to rapid bleeding (25% of the blood volume) was recorded during normal conditions and during cerebral ischaemia induced by bilateral occlusion of the common carotid arteries. During normal conditions haemorrhage caused insignificant decreases in cerebral microcirculation. Haemorrhage during bilateral carotid artery occlusion, however, caused significantly greater changes in cerebral microcirculation and a greater posthaemorrhagic increase in cerebrovascular resistance shortly after the blood loss. Haemorrhage during bilateral carotid artery occlusion also caused greater reductions in cardiac output and arterial pressure than similar blood loss caused during normal conditions. This study showed a disproportionate decrease in cerebral blood flow with haemorrhage during bilateral carotid occlusion, caused by an immediate increase in cerebrovascular resistance. The results suggest that even a moderate blood loss in patients with impaired cerebral circulation could be dangerous, because normal compensatory mechanisms to haemorrhage are impaired.     

Our policy in diagnosis and treatment of hydrocephalus

The authors present the policy they have worked out for hydrocephalus patients with special reference to the pressure measurement and test methods and to rCBF, SPECT and transcranial Doppler sonography (TDC) studies. For diagnosis, the protocol proposed by Gjerris and Borgesen was followed in 75 cases: besides other methods (CT, radionuclide cisternography, MRI) the intracranial pressure waves routinely recorded and analyzed by means of ventricular catheters for 24 h. The patients were roughly divided into groups in terms of diagnosis, baseline pressure, compliance, results of infusion tests and of surgery. In 13 patients the investigations were supplemented by rCBF SPECT and in 42 patients by TCD studies before and after CSF shunting or withdrawal to analyze the acute effects on cerebral circulation. Clinical follow-up shows that need for shunting was indicated fairly well by the common results of baseline ICP, compliance and infusion loading. The rCBF SPECT studies revealed a significant increase of the cerebral perfusion at the basal ganglia after shunting while, on the basis of CBF velocity changes three types of vasoregulatory response could be defined with TCD. In our hands, monitoring of the pressure and craniospinal capacity has proved to be a valuable aid in decisions on surgery; however, for a more precise (and beneficial) appreciation of whether surgery is indicated the vasoregulatory responses should also be taken into account in future.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

En bloc resection of the carotid axis in epidermoid carcinoma of the head and neck. Retrospective analysis of 7 cases

En bloc resection of carotid artery involved by squamous cell carcinoma was performed in 7 patients from 1993 to 1997. Cerebral tolerance was tested with qualitative evaluation of cerebral blood flow during preoperative balloon test occlusion of the internal carotid artery. Four patients later underwent permanent carotid occlusion prior to en bloc resection, 2 patients underwent carotid ligation without reconstruction and one patient underwent carotid resection associated with carotid reconstruction. The preliminary neurovascular and carcinologic results are presented. One patient had definitive stoke postoperatively. Follow-up ranged from 3 to 34 months. Two patients died by the 6th and 26th postoperative month respectively. Among the remaining 5 patients, tumoral recurrence occurred in two. Two patients have survived more than 2 years, but one of them had local recurrence and distant metastases. Considering these data and the review of the literature, selection of patients after carcinologic and cerebral tolerance evaluation is important in order to improve survival and quality of life of these patients.     

Delayed full-thickness grafting of lower leg defects following removal of skin malignancies

Cerebral stroke is a serious complication related to carotid endarterectomy (CEA), being most frequently caused by thromboembolic events and less frequently on account of cerebral haemorrhage. The present series comprised five out of 857 (0.6%) patients who had undergone CEA at Oulu University Hospital between the years 1974 and 1993 and suffered a postoperative stroke four to 13 days after surgery due to intracerebral haemorrhage (IH). Preoperatively, all these patients were neurologically intact, with transient ischaemic attacked (TIA) as the main indication for CEA. All five patients had a history of arterial hypertension treated adequately preoperatively, and one patient had high blood pressure levels after surgery. Critical ipsilateral stenosis of the internal carotid artery (> 90%) was detected in the preoperative angiogram in all five cases. The primary outcome after CEA was uneventful in every case, without any signs of neurological deficiency. The symptoms, comprising severe headache, convulsions and/or hemiparesis occurred suddenly four to 13 days (mean seven days) after CEA. The diagnosis of IH was based on computed tomography (CT) findings. All five patients were treated conservatively. Three of them died. We conclude that even normotensive, neurologically intact patients without demonstrable cerebral infarction or postoperative hypertension may suffer cerebral haemorrhage after the relief of high-grade carotid stenosis. The role of possible insufficiency of the autoregulatory mechanisms of the cerebral vasculature on account of long-standing critical stenosis of the internal carotid artery and subsequent uncontrolled hyperperfusion following CEA are discussed.     

Prenatal diagnosis of 22q11 microdeletion

It has been recognised that the level of superoxide dismutase (SOD) significantly increases in CSF as the result of cerebral ischaemic damage. The aim of this study was to correlate the CSF levels of SOD enzymatic activity to the patterns of subarachnoid haemorrhage with regards to ischaemic complications due to vasospasm. A series of 78 patients operated on for intracranial aneurysms was studied; all patients were monitored with serial TCD measurements every second day after SAH. CSF samples were obtained at surgery by cisternal puncture of the subarachnoid cistern nearest to the aneurysm. SOD activity was assayed spectrophotometrically. Mean cisternal CSF level of SOD in 12 control cases (12.99 +/- 2.33 U/ml) is significantly higher (p < 0.01) than in 26 patients operated on between day 1 and 3 from last SAH episode (4.44 +/- 0.7 U/ml) and in 40 patients treated by delayed surgery (7.64 +/- 0.92 U/ml). In 13 patients presenting neurological deterioration related to arterial vasospasm mean cisternal SOD level was 12.23 +/- 1.86 U/ml; in 27 cases without vasospasm mean level was 5.43 +/- 0.7 U/ml (p < 001). The present results suggest that (a) cisternal CSF levels of SOD significantly decreases after SAH, probably in relation to an impaired synthesis in the brain compartment and that (b) a substantial elevation of SOD levels is evident in patients suffering ischaemic complications vasospasm-related. Biochemical events in the brain compartment could influence the expression and release of anti-oxidant enzymes in CSF after SAH.     

Guidelines for the use of carotid endarterectomy: current recommendations from the Canadian Neurosurgical Society

OBJECTIVE: To assess preoperative diagnosis of intra-abdominal acute diseases manifesting as a RAAA and determine treatment options. DESIGN: Retrospective review, with a mean follow-up period of 4 years. SETTING: Vascular Department, Medical School, University "Federico II" of Naples, Italy. METHODS: In 12 patients (8.7%) with clinical suggestion of RAAA were found other intra-abdominal acute lesions, associated with asymptomatic aortic aneurysm in 10 of them and absence in one; the remainder had an intact common iliac artery aneurysm. Sonography was performed in the operating room in 5 patients (41.6%) in shock, 4 hemodynamically stable patients (33.3%) had CT scanning or MRI investigations, while 3 (25%) underwent surgery directly. INTERVENTIONS: Three patients were not operated; one half of patients were submitted to emergency laparotomy and in the remaining 3 patients a preoperative preparation was made. Simultaneous aneurysm repair and nonvascular procedures were performed in 4 patients; nonvascular operations alone were carried out in 5 patients. 4 patients underwent a successful later treatment of their aneurysms: two aneurysmectomy and two endoluminal stenting were done within 4 months. RESULTS: Weight loss and fever were found at 58.3% and 50% of patients with concomitant intra-abdominal acute diseases; both were present in 41.6%. Noninvasive imaging techniques detected associate lesions in 6 of 8 patients (75%) and absence of aneurysm in one having a bleeding adrenal mass. There were three in-hospital deaths: one patient died of metastatic disease without operation and two after surgery (22.2%). Two late deaths from cancer cachexia occurred at 11 months and 3.6 years. CONCLUSIONS: Atypical findings, such as weight loss and fever may be suggestive of coincident lesions in patients with suspected RAAA. Noninvasive assessment may identify associated diseases simulating aneurysmal rupture, without a delay in the treatment. A selective policy of medical or operative therapy may be effective to minimize risk of complications and mortality rate.     

Comparative susceptibility of 10 antimicrobials against Pseudomonas aeruginosa isolated from complicated urinary tract infection on 1992 & 1993 vs. 1994 & 1995

OBJECTIVES: To describe operative procedures, pathophysiological events, management strategies, and clinical outcomes after acute intraoperative brain herniation during elective neurosurgery. METHODS: Review of clinical diagnoses, operative events, postoperative CT findings, intracranial pressure, and arterial blood pressure changes and outcomes in a series of patients in whom elective neurosurgery had to be abandoned because of severe brain herniation. RESULTS: Acute intraoperative brain herniation occurred in seven patients. In each patient subarachnoid or intraventricular haemorrhage preceded the brain herniation. The haemorrhage occurred after intraoperative aneurysm rupture either before arachnoidal dissection (three) or during clip placement (one); after resection of 70% of a recurrent hemispheric astroblastoma; after resection of a pineal tumour; and after a stereotactic biopsy of an AIDS lesion. In all patients the procedure was abandoned because of loss of access to the intracranial operating site, medical measures to control intracranial pressure undertaken (intravenous thiopentone), an intraventricular catheter or Camino intracranial pressure monitor inserted, and CT performed immediately after scalp closure. The patients were transferred to an intensive care unit for elective ventilation and multimodality physiological monitoring. Using this strategy all patients recovered from the acute ictus and no patient had intracranial pressure > 35 mm Hg. Although one patient with an aneurysm rebled and died three days later the other six patients did well considering the dramatic and apparently catastrophic nature of the open brain herniation. CONCLUSIONS: There are fundamental differences in the pathophysiological mechanisms, neuroradiological findings, and outcomes between open brain herniation occurring in post-traumatic and elective neurosurgical patients. The surprisingly good outcomes in this series may have occurred because the intraoperative brain herniation was secondary to extra-axial subarachnoid or intraventricular haemorrhage rather than intraparenchymal haemorrhage or acute brain oedema. Expeditious abandonment of the procedure and closure of the cranium may also have contributed to the often very satisfactory clinical outcome.