Careful Blood Pressure Control Research Articles

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case.

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature. A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient's blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0. This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Pregnancy and childbirth in women with a kidney transplant (clinical observation)

The number of pregnant women with kidney transplant is growing and will continue to increase in Ukraine and all over the world, taking into account the development of transplantology. Such patients belong to the high-risk group, however, a clear understanding and adequate evaluation of the prognostic factors which are described in the literature will allow to transfer from prohibition and intimidation to the stage of supporting motherhood and providing highly qualified medical care to women with kidney transplants.This article presents two clinical cases of pregnancy and childbirth in women with kidney transplants, which occurred in the Department of Internal Pathology of Pregnant Women of the State Institution “Institute of Pediatrics, Obstetrics and Gynecology named after Acad. O. M. Lukyanova National Academy of Sciences of Ukraine”. Both patients with kidney transplants that functioned for 4 and 5 years, respectively, visited the doctor in early pregnancy.The anamnesis of the first pregnant woman was without peculiarities, while the second patient already had an episode of acute transplant rejection in the anamnesis and organ retransplantation from her mother. In addition, she had viral hepatitis B and C, as well as an insufficient level of immunosuppression. The function of the transplants in both women was satisfactory, each of the persons suffered from secondary nephrogenic anemia. Correction of immunosuppression in both patients was difficult, especially at 28 weeks, which is associated with hemodilution of pregnant women. Both women experienced an episode of urinary tract infection, which is experienced by about 40 % of pregnant kidney recipients.The first pregnant woman was practically healthy at full term pregnancy and had no indications for abdominal operation delivery, however, due to a clinically narrow pelvis she had cesarean section, which is a technically difficult surgery in such cases. In the second patient, the last weeks of pregnancy were complicated by hypertension of non-placental origin and transplant function disorders, which became an indication for cesarean section at 38 weeks. In the postpartum period kidney function began to recover. The condition of both newborns was satisfactory.Therefore, despite the reliable pregnancy outcomes in kidney transplant patients, an increased risk of obstetric complications and adverse perinatal outcomes remains. Interdisciplinary monitoring with timely correction of kidney transplant function disorders, monitoring of immunosuppressive therapy, prevention of premature births, careful control of blood pressure and adequate fetal monitoring allows to hope for favorable obstetric and perinatal outcomes in this group of patients.

Spinal Versus General Anesthesia for Cesarean Delivery in Pregnant Women With Moyamoya Disease: A Retrospective Observational Study

(Anesth Analg. 2022;135:617–624) Moyamoya disease (MMD), a rare cerebrovascular disease causing the vascular network at the brain’s base to be fragile, requiring careful blood pressure control and proactive medical treatment to prevent life-threatening hemorrhage and/or ischemic events. The exact risks pregnancy, labor, and delivery for MMD patients is unknown. The aim of this study was to determine if the choice of spinal anesthesia versus general anesthesia would have a significant effect on the intraoperative mean arterial pressure in MMP patients undergoing cesarean section.

Артеріальна гіпертензія у пацієнтів з гіперурикемією: основи патогенезу, клінічне значення, діагностика, підходи до лікування

Провідною причиною смерті хворих на гіперурикемію є серцево-судинні захворювання. У статті наведений огляд літератури й аналіз механізмів взаємозв’язку артеріальної гіпертензії і гіперурикемії, на підставі яких зроблено висновок про те, що ретельний контроль артеріального тиску, моніторинг ураження органів-мішеней є основою профілактики серцево-судинних захворювань і розвитку кардіоваскулярних катастроф у хворих на гіперурикемію. При проведенні антигіпертензивної терапії у таких пацієнтів необхідно брати до уваги вплив препаратів на показники ліпідного та вуглеводного обміну, рівень сечової кислоти. Ефективність терапії повинна бути достатньою та мати високу антигіпертензивну ефективність.

A rare case of posterior reversible encephalopathy syndrome in a patient with severe leptospirosis complicated with rhabdomyolysis and acute kidney injury; a case report

BackgroundLeptospirosis is a zoonotic spirochetal disease caused by Leptospira interrogans. The clinical presentation ranges from an asymptomatic state to a fatal multiorgan dysfunction. Neurological manifestations including aseptic meningitis, spinal cord and peripheral nerve involvement, cranial neuropathies and cerebellar syndrome are well recognized with varying frequencies among patients with this disease. Posterior reversible encephalopathy syndrome is a very rare occurrence in leptospirosis and only two cases are reported in the medical literature up to now. We report a case of posterior reversible encephalopathy syndrome in a patient with leptospirosis with rhabdomyolysis and acute kidney injury.Case presentationA 21 year-old male presented with fever and oliguric acute kidney injury with rhabdomyolysis. A diagnosis of leptospirosis was made and he was being managed according to the standard practice together with regular hemodialysis. The clinical condition was improving gradually. On day 8 of the illness, he developed headache and sudden painless complete bilateral vision loss followed by several brief generalized tonic clonic seizure attacks. Examination was significant for a Glasgow Coma Scale of 14/15, blood pressure of 150/90 mmHg and complete bilateral blindness. The findings of magnetic resonance imaging of the brain were compatible with posterior reversible encephalopathy syndrome. He was managed with blood pressure control and antiepileptics with supportive measures and standard treatment for leptospirosis and made a complete recovery.ConclusionPosterior reversible encephalopathy syndrome, though very rare with leptospirosis, should be considered as a differential diagnosis in a patient with new onset visual symptoms and seizures, especially during the immune phase. Optimal supportive care together with careful blood pressure control and seizure management would yield a favourable outcome in this reversible entity.

Scalp Arteriovenous Malformation: Double Row Purse String Suture (DROPS) Technique to Decrease Intra-operative Bleeding

Scalp arteriovenous malformations (AVMs) are high flow lesions with complex vascular anatomy. Excessive bleeding is a frequent surgical complication in resection of these lesions, for which many techniques have been suggested. Percutaneous suturing of the feeding vessels along with careful blood pressure control is reported as a method to reduce intra-operative bleeding. Skin shortage is a problem during skin repair and skin graft is often needed, but this problem has not been encountered with the present technique. Scalp AVMs without intracranial involvement are candidates for this technique. Patients are prepared for open surgical resection of the scalp AVM. After routine preparation, a double row of continuous interlocking purse string sutures are placed around the lesion periphery, deep to the galea, to temporarily interrupt the feeding arteries (Fig. 1). Then, the overlying skin is incised and skin flaps created by shaving the nidus from skin and then from the deep fascia in a bloodless field (Fig. 2). Next, the feeding arteries and draining veins are ligated. The skin is closed primarily, covered by a tie over compression wound dressing. Finally, the purse string sutures are removed. There was no need for blood transfusion and no significant change in haemoglobin after the procedure in any of our cases.Figure 2Creation of skin flaps and excised lesion in a bloodless field.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Five patients were operated on using the technique. On long term follow up (mean ± standard deviation 5.5 ± 1.5 years) the cosmetic result was promising, without recurrence. Surgical resection can be performed with confidence in a bloodless field without needing a skin graft. This technique has been used in other body parts, but owing to the bony skull, it is more efficient for scalp AVMs.

Expectant Management of Severe Pre-eclampsia remote from term: Maternal and Perinatal outcome

Background: Management of severe pre eclampsia remote from term remains one of the most difficult challenges in obstetric practice. Expectant management of early onset severe pre eclampsia improves neonatal outcome.
 Methods: A prospective case series extending over five years peiod were recorded to evaluate the maternal and perinatal outcome of expectant management of severe preeclampsia presenting between 24-34 weeks of gestation in a tertiary referral center. All women (n=160) presenting with early onset (24-34 weeks of gestation) severe preeclampsia , where both the mother and the fetus were otherwise stable. Frequent clinical and biochemical monitoring of maternal status with careful blood pressure control. Foetal surveillance included six hourly foetal heart rate monitoring, bi weekly non stress test and weekly USG evaluation.
 Results: Mean number of days of prolongation of gestation was 6 days ( range 1-24days). The largest prolongation of pregnancy was recorded in patients with the lowest gestational age. Conservative management was associated with a 1.63% ( 17/160) intrauterine fetal loss rate. The days of pregnancy prolongation and perinatal mortality were significantly higher among those managed at <30 weeks. Increasing gestational age correlated with a reduction of RDS ( respiratory distress syndrome). Maternal morbidities were significantly higher among those managed at < 32 weeks. But there was no maternal mortality.
 Conclusion: Good perinatal outcome and less risk to mother can be achieved at 30-34 weeks gestation.
 Bangladesh J Obstet Gynaecol, 2017; Vol. 32(2) : 73-78

Renal complications of anaesthesia.

Peri-operative acute kidney injury is common, accounting for 30-40% of all in-hospital cases of acute kidney injury. It is associated with clinically significant morbidity and mortality even with what was hitherto regarded as relatively trivial increases in serum creatinine, and carries over a 12-fold relative risk of death following major abdominal surgery. Comorbid conditions such as diabetes, hypertension, liver disease and particularly pre-existing chronic kidney disease, as well as the type and urgency of surgery, are major risk factors for the development of postoperative acute kidney injury. As yet, there are no specific treatment options for the injured kidney, although there are several modifiable risk factors of which the anaesthetist should be aware. As well as the avoidance of potential nephrotoxins and appropriate volume balance, optimal anaesthetic management should aim to reduce the risk of postoperative renal complications. This may include careful ventilatory management and blood pressure control, as well as appropriate analgesic strategies. The choice of anaesthetic agent may also influence renal outcomes. Rather than concentrate on the classical management of acute kidney injury, this review focuses on the potential development of acute kidney injury peri-operatively, and the means by which this may be ameliorated.

Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Teaching Neuro Images : Combined retinal and cerebral hyperperfusion syndrome after carotid thromboendarterectomy

A 62-year-old man presented with mild left hemiparesis, headache, and blurred vision of his right eye. Ten days before, he had undergone thromboendarterectomy because of subtotal stenosis of his right internal carotid artery. MRI revealed confluent white matter edema together with focal hemorrhage consistent with cerebral hyperperfusion syndrome (CHS; figure 1). Likewise, funduscopy showed small retinal hemorrhages confined to the right eye (figure 2). Under careful blood pressure control, symptoms and brain edema fully resolved within weeks. CHS occurs in around 3% of patients undergoing carotid thromboendarterectomy and can induce severe neurologic deficits.1 Rarely, hyperperfusion also involves the ipsilateral eye.2

Novel drugs and their targets in the potential treatment of diabetic retinopathy

Diabetic retinopathy (DR) is the most common complication of diabetes. It causes vision loss, and the incidence is increasing with the growth of the diabetes epidemic worldwide. Over the past few decades a number of clinical trials have confirmed that careful control of glycemia and blood pressure can reduce the risk of developing DR and control its progression. In recent years, many treatment options have been developed for clinical management of the complications of DR (e.g., proliferative DR and macular edema) using laser-based therapies, intravitreal corticosteroids and anti-vascular endothelial growth factors, and vitrectomy to remove scarring and hemorrhage, but all these have limited benefits. In this review, we highlight and discuss potential molecular targets and new approaches that have shown great promise for the treatment of DR. New drugs and strategies are based on targeting a number of hyperglycemia-induced metabolic stress pathways, oxidative stress and inflammatory pathways, the renin-angiotensin system, and neurodegeneration, in addition to the use of stem cells and ribonucleic acid interference (RNAi) technologies. At present, clinical trials of some of these newer drugs in humans are yet to begin or are in early stages. Together, the new therapeutic drugs and approaches discussed may control the incidence and progression of DR with greater efficacy and safety.

Homozygous lecithin:cholesterol acyltransferase (LCAT) deficiency due to a new loss of function mutation and review of the literature

A case of homozygous familial lecithin:cholesterol acyltransferase (LCAT) deficiency with a novel homozygous LCAT missense mutation (replacement of methionine by arginine at position 293 in the amino acid sequence of the LCAT protein) is reported. The probable diagnosis was suggested by findings of marked high density lipoprotein (HDL) deficiency, corneal opacification, anemia, and renal insufficiency. The diagnosis was confirmed by two dimensional gel electrophoresis of HDL, the measurement of free and esterified cholesterol, and sequencing of the LCAT gene. In our view the most important aspects of therapy to prevent the kidney disease that these patients develop is careful control of blood pressure and lifestyle measures to optimize non HDL lipoproteins. In the future replacement therapy by gene transfer or other methods may become available.

2201 LONG-TERM OUTCOMES OF RENAL ARTERIAL ANEURYSM; A COMPARISON BETWEEN CONSERVATIVE THERAPY AND SURGICAL TREATMENTS IN SINGLE CENTER ANALYSIS

INTRODUCTION AND OBJECTIVES: Since spontaneous rupture risk assumed to be extremely lower in renal arterial aneurysm (RAA), the rarity and variable clinical course has annoyed surgical indication of RAA. Long-term follow-up study of conservative management for RAA has been scarcely reported. The aim of this study was to evaluate long-term outcomes of active surveyllance and surgical repair in patients with RAA. METHODS: The study included 58 patients who were diagnosed as RAA over the past 21 years (male: 17, female: 41). Median age at the time of diagnosis was 62 years (19–85 year range), and the median follow-up period was 69 months (3–216 month range). The conservative group (n 30) included patients who have been followed under strict blood pressure control. The treatment group (n 29) included patients who underwent surgical repair or radiological intervention. Differences between the groups in clinical backgrounds, RAA characteristics, clinical course and renal function were evaluated. Our tentative criteria of patient selection for the conservative group was age at 40 years or older, 20 mm or smaller in maximum aneurysm diameter and high degree of aneurysmal calcification. They had been followed up under careful blood pressure control and evaluated their renal function, RAA image on CT scan / ultrasonogram annually. RESULTS: Twenty-one cases of the treatment group underwent ex-vivo aneurysmal repair, while 4 cases underwent in-situ repair. In the other 4 cases, 2 underwent nephrectomy and 2 underwent trans-arterial embolization. Smoking habits at the time of diagnosis were found in 5 (16.7%) or 15 (51.7%) cases in the conservative or treatment group, respectively (p 0.024). Multiple efferent aneurysmal branches were found in 7 (23.3%) or 16 (55.2%) cases, respectively (p 0.002). Median maximum diameter of aneurysm was significantly lower in conservative group (15 vs. 25mm, p 0.005). All patients were alive except for 2 cases in conservative group, who were died in the other reasons. Increasing in size of RAA was observed in only 2 cases of conservative group. Cumulative postoperative complications (autotransplanted graft dysfunction or post-operative urinary tract complication, et al.) occurred 15/27 (55.6%) in the treatment group. No significant difference was observed in renal function between the two groups. CONCLUSIONS: The conservative approach of RAA could be expanded under appropriate management for hypertension and careful observation for RAA, otherwise surgical repair would be with discretion for obviating the surgical adverse events.

Ischemic Complications Occurring in the Contralateral Hemisphere after Surgical Treatment of Adults with Moyamoya Disease

Direct revascularization surgery is regarded as the most effective method of treatment of adults with moyamoya disease. These patients, however, have a higher risk of perioperative ischemic complications than do patients with atherosclerotic stroke, and are at risk for ischemic complications in the hemisphere contralateral to the one operated on. We investigated the incidence and risk factors for ischemic stroke in the contralateral hemisphere after surgical treatment of adults with moyamoya disease. We retrospectively reviewed the medical records and results of neuroimaging studies on 79 hemispheres of 73 consecutive patients with adult moyamoya disease (mean±SD age, 37.96±11.27 years; range, 18-62 years) who underwent direct bypass surgery over 6 years. Ischemic complications occurred in 4 of 79 (5.1%) contralateral hemispheres, one with Suzuki stage 3 and three with Suzuki stage 4. Three patients showed posterior cerebral artery (PCA) involvement by moyamoya vessels. Advanced stage of moyamoya disease (Suzuki stages 4/5/6; p=0.001), PCA involvement (p=0.001) and postoperative hypotension (mean arterial blood pressure <80% of preoperative mean arterial blood pressure) on the first (p<0.0001) and second (p=0.003) days after surgery were significantly correlated with postoperative contralateral ischemic complications. In patients with advanced moyamoya disease and involvement of the PCA, intentional hypotension can result in ischemic stroke in the hemisphere contralateral to the one operated on. Careful control of perioperative blood pressure is crucial for good surgical results.

Role of clevidipine butyrate in the treatment of acute hypertension in the critical care setting: a review

Acutely elevated blood pressure in the critical care setting is associated with a higher risk of acute end-organ damage (eg, myocardial ischemia, stroke, and renal failure) and perioperative bleeding. Urgent treatment and careful blood pressure control are crucial to prevent significant morbidity. Clevidipine butyrate (Cleviprex) is an ultrashort-acting, third-generation intravenous calcium channel blocker. It is an arterial-selective vasodilator with no venodilatory or myocardial depressive effects. Clevidipine has an extremely short half-life of approximately 1 minute as it is rapidly metabolized by blood and tissue esterases. These metabolites are then primarily eliminated through urine and fecal pathways. The rapid onset and the short duration of action permit tighter and closer adjustment of the blood pressure than is possible with other intravenous agents.

Lacunar stroke

Lacunar infarcts or small subcortical infarcts result from occlusion of a single penetrating artery and account for one quarter of cerebral infarctions. Patients with a lacunar infarct usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria–clumsy hand) and, less frequently, an atypical lacunar syndrome. Hypertension and diabetes mellitus are major risk factors for lacunar stroke. Lacunar infarcts show a paradoxical clinical course with a favorable prognosis in the short term, characterized by a low early mortality and reduced functional disability on hospital discharge, but with an increased risk of death, stroke recurrence and dementia in the mid- and long term. Asymptomatic progression of small-vessel disease is a typical feature of the lacunar infarcts. For this reason, lacunar infarction should be regarded as a potentially severe condition rather than a relatively benign disorder and, therefore, lacunar stroke patients require adequate and rigorous management and follow-up. Antiplatelet drugs, careful blood pressure control, the use of statins and modification of lifestyle risk factors are key elements in secondary prevention after lacunar stroke.

Lacunar infarcts: no black holes in the brain are benign

Lacunar infarcts—small subcortical infarcts that result from occlusion of a single penetrating artery—account for about one quarter of all ischaemic strokes. However, there are many diagnostic pitfalls, and causes other...

Novel Therapeutics for Diabetic Micro- and Macrovascular Complications

Diabetic patients have a two- to four-fold increased risk for the development of microvascular (renal, neuronal and retinal) and macrovascular complications. Unfortunately, these complications may develop in both Type 1 and Type 2 diabetic patients even with careful glycaemic, blood pressure and lipid control. With the worldwide increase in the incidence diabetes, new strategies to prevent the complications are urgently needed. Mediators of vascular damage of diabetes include poor glycemic control, lipoprotein abnormalities, hypertension, oxidative stress, inflammation and advanced glycation end-products (AGEs), which are modified proteins formed by non-enzymatic glycation. AGEs are resistant to enzymatic degradation and therefore very stable, thus their accumulation continues throughout aging. AGE accumulation causes arterial stiffening in the vessel wall, glomerulosclerosis in the kidney, and vascular hyperpermeability in the retina. Through their interaction with their putative receptor the so-called receptor for AGEs (RAGE), AGEs activate endothelial cells and macrophages, generate reactive oxygen species (ROS), induce overexpression of vascular endothelial growth factor (VEGF) and vascular cell adhesion molecule-1 (VCAM-1), and quench nitric oxide (NO). The pharmacological treatment currently available for either Type 1 or Type 2 diabetic patients does not directly address the excess accumulation of AGEs. Novel compounds that inhibit AGE formation, cleave AGE cross-links or reverse their interaction with RAGE are now accessible and could prove useful in meeting this challenge. Other strategies such as inhibition of the hexosamine pathway, vitamin therapy to reduce oxidation and AGE accumulation, reduction of the ROS, or blocking the actions of growth factors or intracellular messengers of cell differentiation are also currently under research. This review will recount recent advances in the development of therapeutic approaches for inhibiting and treating the development of diabetic end-organ damage.

Timing of endovascular repair of blunt traumatic thoracic aortic transections

Patients with blunt traumatic thoracic aortic transection (BTTAT) just distal to the takeoff of the left subclavian artery typically have concomitant injuries that make open emergent surgical repair highly risky. Over the past decade, endovascular repair of the injured thoracic aorta with commercially available and custom-made covered stents has developed as a viable option, with reported decreases in short-term morbidity and mortality. If active extravasation of contrast from the injured thoracic aorta is not appreciated on chest computed tomography scan, other concurrent injuries of the head, abdomen, and extremities can often be repaired with careful control of blood pressure. The timing of endovascular repair of the traumatic thoracic aortic transection, however, often comes into question, particularly with the presence of fever, pneumonia, or bacteremia. We sought to identify a time frame during which endovascular repair of BTTAT could safely be performed. Age, concomitant injuries, time from trauma to repair, type of device, and major outcomes were recorded. Over a 5-year period (January 2000 to March 2005), 51 patients presented with BTTAT. Twenty-seven (52.9%) patients with BTTAT died shortly after arrival. Of the remaining 24, 9 underwent emergent open repair, with 1 intraoperative death. Two delayed open repairs were performed. Thirteen patients with BTTAT underwent delayed endovascular repair. Successful endovascular repair of BTTAT was performed in all 13 patients, with no intraoperative deaths. Seven patients were treated with commercial devices and six with custom-made covered stents. None of the repairs was performed emergently. The timing of repair ranged from 1 day to 7 months (median, 6 days), and all patients were treated aggressively with beta-blockade before surgery. One patient was discharged from the hospital and underwent elective repair at a later date. Three patients died in the postoperative period (30 days): two from multisystem organ failure and one from iliac artery complications encountered at the time of device deployment. The remaining 10 patients were successfully discharged to a rehabilitation facility. The opportunity to successfully perform endovascular repair of BTTAT may be possible many days after the initial injury in the hemodynamically stable trauma patient.

頭蓋内椎骨解離性動脈りゅう出血例の治療成績

The natural history and treatment strategy of intracranial dissecting aneurysm in the vertebrobasilar (V-B) system remains controversial. We report 10 cases of ruptured intracranial dissecting aneurysm in the V-B system and review the literature with focus on the analysis of serial angiographic findings, treatment, and long-term outcome.All patients were conservatively managed under careful blood pressure control, and angiography was carried out depending on the patient's condition. Surgical or endovascular intervention was chosen when morphological changes leading to rebleeding were recognized by follow-up angiography. Craniotomy in 3 patients and coiling in 3 patients was performed. No rebleeding occurred during the follow-up period in any of the 10 patients, and all cases resulted in favorable outcome.These results suggested that ruptured intracranial dissecting aneurysms of the V-B system could be treated conservatively, avoiding rebleeding under careful control of blood pressure in the acute stage. Alternatively, surgical or endovascular treatment should be considered if angiographical changes that may lead to risk of rebleeding are noted.