Incidence Of Clinical Vasospasm Research Articles

Early Experience of Microsurgical Clipping of Ruptured Intracranial Aneurysms

To see the outcome in patients following microsurgical clipping of ruptured intracranial aneurysms and analyze the results. It is a prospective analytical study were demographic data of the patient, initial World Federation of Neurosurgical Societies (WFNS) grade, Fischer’s grade, duration of ictus, intra operative rupture, incidence of clinical vasospasm and Modified Rankin Scale (MRS) at three months were collected and analysis was done using SPSS-20. There were total 19 cases of microsurgical clipping, with mean age 55.4 yrs, where 52.4% were females. Average duration of Ictus was 24.5 hours. Most common WFNS grade on presentation was grade II (42%) and Fischer’s CT grade was IV (58%). Commonest site of aneurysm was A Com (53%) and were 15.8% intraoperatie rupture. Ventriculo-peritoneal (VP) shunt and severe clinical vasospasm both were seen in 10.5%. Overall mortality was 11% and MRS 1 and 2 were obtained in 10% and 58% respectively. Good initial WFNS, internal carotid aneurysm, absence of hydrocephalus and absence of clinical vasospasm were significantly associated with better MRS at three months. Factors associated with better outcome were good initial WFNS, internal carotid aneurysm, absence of hydrocephalus and absence of clinical vasospasm.

The Utility and Benefits of External Lumbar CSF Drainage after Endovascular Coiling on Aneurysmal ubarachnoid Hemorrhage

Cerebral vasospasm still remains a major cause of the morbidity and mortality, despite the developments in treatment of aneurysmal subarachnoid hemorrhage. The authors measured the utility and benefits of external lumbar cerebrospinal fluid (CSF) drainage to prevent the clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage in this randomized study. Between January 2004 and March 2006, 280 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Among them, 107 patients met our study criteria. The treatment group consisted of 47 patients who underwent lumbar CSF drainage during vasospasm risk period (about for 14 days after SAH), whereas the control group consisted of 60 patients who received the management according to conventional protocol without lumbar CSF drainage. We created our new modified Fisher grade on the basis of initial brain computed tomography (CT) scan at admission. The authors established five outcome criteria as follows : 1) clinical vasospasm; 2) GOS score at 1-month to 6-month follow-up; 3) shunt procedures for hydrocephalus; 4) the duration of stay in the ICU and total hospital stay; 5) mortality rate. The incidence of clinical vasospasm in the lumbar drain group showed 23.4% compared with 63.3% of individuals in the control group. Moreover, the risk of death in the lumbar drain group showed 2.1% compared with 15% of individuals in the control group. Within individual modified Fisher grade, there were similar favorable results. Also, lumbar drain group had twice more patients than the control group in good GOS score of 5. However, there were no statistical significances in mean hospital stay and shunt procedures between the two groups. IVH was an important factor for delayed hydrocephalus regardless of lumbar drain. Lumbar CSF drainage remains to play a prominent role to prevent clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage. Also, this technique shows favorable effects on numerous neurological outcomes and prognosis. The results of this study warrant clinical trials after endovascular treatment in patients with aneurysmal SAH.

Intravenous Magnesium versus Nimodipine in the Treatment of Patients with Aneurysmal Subarachnoid Hemorrhage: A Randomized Study

The prophylactic use of nimodipine in patients with aneurysmal subarachnoid hemorrhage reduces the risk of ischemic brain damage. However, its efficacy seems to be rather moderate. The question arises whether other types of calcium antagonists offer better protection. Magnesium, nature's physiological calcium antagonist, is neuroprotective in animal models, promotes dilatation of cerebral arteries, and has an established safety profile. The aim of the current pilot study is to evaluate the efficacy of magnesium versus nimodipine to prevent delayed ischemic deficits after aneurysmal subarachnoid hemorrhage. One hundred and thirteen patients with aneurysmal subarachnoid hemorrhage were enrolled in the study and were randomized to receive either magnesium sulfate (loading 10 mg/kg followed by 30 mg/kg daily) or nimodipine (48 mg/d) intravenously until at least postoperative Day 7. Primary outcome parameters were incidence of clinical vasospasm and infarction. Secondary outcome measures were the incidence of transcranial Doppler/angiographic vasospasm, the neuronal markers (neuron-specific enolase, S-100), and the patients' Glasgow Outcome Scale scores at discharge and after 1 year. One hundred and four patients met the study requirements. In the magnesium group (n = 53), eight patients (15%) experienced clinical vasospasm and 20 (38%) experienced transcranial Doppler/angiographic vasospasm compared with 14 (27%) and 17 (33%) patients in the nimodipine group (n = 51). If clinical vasospasm occurred, 75% of the magnesium-treated versus 50% of the nimodipine-treated patients experienced cerebral infarction resulting in fatal outcome in 37 and 14%, respectively. Overall, the rate of infarction attributable to vasospasm was virtually the same (19 versus 22%). There was no difference in outcome between groups. The efficacy of magnesium in preventing delayed ischemic neurological deficits in patients with aneurysmal subarachnoid hemorrhage seems to be comparable with that of nimodipine. The difference in their pharmacological properties makes studies on the combined administration of magnesium and nimodipine seem promising.

Intracranial aneurysms in patients 18 years of age or under, are they different from aneurysms in adult population?

Intracranial aneurysms are extremely uncommon in the first two decades of life. This study was undertaken to assess the clinicoradiological features and surgical outcome of intracranial aneurysms in patients less than or equal to 18 years of age; and, to highlight the differences between these and intracranial aneurysms seen in adult patients. Twenty-two patients, 18 years of age or under (male:female ratio=1.75:1; mean age 14.18+/-3.8 years, age range 5 to 18 years) and 451 adult patients aged older than 18 years (male:female ratio=1:1.05; mean age 48.21+/-12.71 years, age range, 19 to 81 years) were treated for intracranial aneurysms at our center between January 1991 and July 2003. The univariate statistical analysis was used to compare differences between the two groups. The patients under 18 years constituted 4.6% of the total patient population having intracranial aneurysms. The incidence of associated medical diseases was greater in patients under 18 years than in the adults (9% versus 0.26%, p<0.05). The incidence of seizures was more than double in patients under 18 years (36% versus 17%, p<0.05). The incidence of intracerebral haematoma (ICH; 41% versus 22.5%, p>0.05), intraventricular haemorrhage (IVH; 45% versus 34%, p>0.05), and hydrocephalus (36% versus 25%, p>0.05) were higher in patients under 18 years. In adult patients, anterior communicating artery (AcoA) and in children, ICA bifurcation were the most frequent sites of aneurysm formation respectively (p<0.05). The incidence of giant aneurysms was nearly double in children (13.6% versus 6.5%, p>0.05). The incidence of clinical vasospasm was almost the same in both groups. The overall outcome was favourable in 82% of patients under 18 years and 58.8% in adults. The management mortality in patients under 18 years was 9.1%, while in the adult patients, it was 19%. In patients under 18 years of age, there was a definite male predominance; a higher incidence of seizures; and, the ICA bifurcation formed the most frequent site of intracranial aneurysms. In adults, AcoA a was the commonest site. Rebleeding and delayed ischaemic deficits were the major causes of morbidity. Favorable outcome after surgery in young patients was better in comparison to their adult counterparts.

Surgical experiences of intracranial aneurysms (2500 cases)

Background: The principal role of treatment for ruptured aneurysm has been to obliterate the aneurysal sac and allow preservation of parent vessel parency or collateral flow. It secures the patient's life from the hazards of rebleeding and vasospasm; morbidity and mortality rates are substantially lower. The present study was conducted to evaluate the overall surgical results in 2500 patients with intracranial aneurysm operated on in Paik Hospital from January 1980 to November 18, 2002. It does not include 136 operations conducted at the other hospital. Method: Among these, 818 cases were anterior communicating artery aneurysms, 654 internal carotid artery aneurysms, 642 middle cerebral artery aneurysms, 70 anterior cerebral artery aneurysms and 100 cases of vertebro-basilar artery aneurysms. The male to female ratio was 0.7 to 1. Surgical methods were 2255 clippings, 203 coatings and wrappings, 23 aneurysmorraphy, 19 proximal ligations. Result: Rebleeding occured in 5.2% of the early operation group and 16% of the late operation group. Incidence of clinical vasospasm was 17.2%, and angiographic vasospasm was 24.1%. The percentage of multiple aneurysms was 8.6%; dissecting aneurysm: 4 cases (0.2%); “De Novo” aneurysm: 4 cases (0.2%); lobectomy with the clipping cases: 8 cases (0.32%); incidental aneurysms: 113 cases (4.52%). A total of 88% had an overall favorable surgical result with a 6% mortality rate. The calcium-channel blocker and “Triple-H” therapy did not improve the postoperative mortality but did improve the postoperative morbidity significantly. In the old age group, early operation reduced vasospasm, rebleeding and medical complications. The early surgery group had a 90% favorable outcome and a 5% mortality rate. In the old age group, the favorable outcome was 86% with an 8.3% mortality rate for the within-24-h operation group, favorable outcome was 70.1%, mortality 11.9% in late operation group. In complex artery aneurysm, the use of endovascular treatment increased. Intraoperative angiography reduced residual aneurysm or remained aneurysm in large, giant aneurysms, especially in A. com. artery. Conclusion: In vascular surgery, most people think it is easy to operate the aneurysm, but is actually difficult. The more the aneurysm operations, the more difficult.

Cerebral Vasospasm in Subarachnoid Haemorrhage

In the second and third weeks after a subarachnoid haemorrhage a series of mechanisms causes a decrease of the diameter of the cerebral vessels. These phenomena are globally included in the term “vasospasm”. A certain degree of vasospasm is found in the majority of the patients after a subarachnoid bleeding. This can be detected by instrumental examinations, in particular trans-cranial doppler and angiography. However, only a minor percentage of these patients will suffer clinical consequences. The vasospasm is currently treated by hypertensive-hypervolemic-haemodilution therapy (the so called “HHH” therapy), or may be treated by selective injection of vasoactive substances (Papaverine, nimodipine) or by mechanical dilatation of the involved vessels with balloons, mainly because of an improved medical management and a better monitoring of critical patients the incidence of clinical vasospasm has decreased in the recent years.

Subarachnoid haemorrhage of unknown origin: clinical and tomographical aspects.

65 patients with negative but technically satisfactory 4 vessel angiography - all admitted to our Department in the years 1976-1983 - were evaluated in the present study. CT scan was undertaken in all cases (in 47 cases within 4 days of haemorrhage). Arterial hypertension was present on admission in 9% of cases. The period of follow-up ranged from 4 to 11 years, with a mean of 5.3 years. The study group was compared to a control group, comprising 760 patients with subarachnoid haemorrhage from ruptured aneurysms, admitted during the same period. Clinical grade on admission (Hunt's classification) was better in patients belonging to the study group. The amount of cisternal deposition on CT scan was less significant than in patients with ruptured aneurysms, and the deposition was often atypical (circumpeduncular, ambiental, and/or tentorial). Clinical deterioration associated with vasospasm was observed in 5% of patients in this study and in 27% of patients in the control group. In patients with a consistent or thick cisternal layer (CT scan "at risk") the incidence of clinical vasospasm was 21%, against 47% in controls. One or more rebleedings occurred in 12% of patients in the study group, against 25% of patients in the control group. A significant ventricular dilatation was observed in 15% of patients in the first group (requiring a shunt in 8%), against 25% of patients in the second group (requiring a shunt in 11%). Final outcome was favourable in 95% of patients in this study group and in 63% of patients in the control group, with a mortality rate of 5% in the first group and 32% in the second group.

Cerebral vasospasm following aneurysm rupture. A protocol for therapy and prophylaxis.

A retrospective study was made of 195 patients who had ruptured intracranial aneurysms without significant intracerebral hematomas and who recovered to at least Grade III by Hunt and Hess' classification. The first 121 patients underwent aneurysm surgery 10 days to 2 weeks after subarachnoid hemorrhage (SAH) without repeat preoperative angiography and without special attention to volume replacement or avoidance of hypotension. Vasospasm resulted in cerebral ischemia in 15% of this group, more than half of these postoperatively, and was treated successfully in half the patients with a combination of aminophylline and isoproterenol. The later 74 patients were managed with aggressive maintenance of normal circulating blood volume and preoperative angiography at 2 weeks following SAH. If significant vasospasm persisted on angiography, surgery was delayed an additional week and, if spasm was still present then, aminophylline and isoproterenol was added prophylactically to aggressive volume replacement before surgery. In this second group of patients, the incidence of clinical vasospasm was essentially unchanged; however, it was almost completely limited to the preoperative period, and was more effectively treated with aminophylline and isoproterenol. Postoperative vasospasm was almost completely eliminated from the second group of patients.