Intracranial Rebleeding Research Articles

Modified pedicled temporoparietal fascial flap combined revascularization in adult moyamoya angiopathy

Pedicled temporoparietal fascial flaps (TPFF), which are flexible, thin, and highly vascularized, have been tried for the moyamoya angiopathy (MMA) treatment. To reduce postoperative complications and improve prognosis, we performed surgical modification and followed up to observe the efficacy. From February 2018 and June 2022, the clinical data of 31 adult MMA patients who underwent the modified TPFF combined revascularization were collected. The clinical outcomes and complications of the patients were recorded until the cut-off date of follow-up. The primary endpoints were the magnetic resonance perfusion (MRP), modified Rankin Scale (mRS) scores, and Matsushima Grade; the secondary endpoints were the clinical symptom outcome and Postoperative complications. Descriptive statistics and rank sum test to assess the therapeutic effect of the modified TPFF combined revascularization for adult MMA treatment. The clinical symptoms of MMA were alleviated in 26 patients and disappeared in five. In all patients, MRP showed improvement in cerebral perfusion on the operated side, and no deterioration or new cerebral infarction occurred during follow-up. Postoperative digital subtraction angiography (DSA) showed that the anastomotic site was patent, and the MMA collateral was decreased in all patients. Only 1 case (3%) of Matsushima grade C showed poor collateral compensation. The admission mRS score (1.54±0.66) of the ischemic MMA was significantly reduced compared with ≥6 months postoperatively (0.54±0.72, P<0.01). The admission mRS score (0.57±0.53) of the hemorrhagic MMA was reduced compared with ≥6 months postoperatively (0, P<0.05). Postoperative complications included epileptic seizures in 2 cases, a cerebral hyper-perfusion syndrome in 2 cases, intracranial rebleeding in 2 cases, skin necrosis in 1 case, and skin maceration in 1 case. Modified TPFF combined revascularization might be a feasible and safe surgical technique for MMA, but it is still necessary to increase the sample size and extend the follow-up time to evaluate its efficacy. Ischemic MMA may have a more significant prognostic benefit than hemorrhagic MMA by this surgery.

A Novel Stereotactic Aspiration Technique for Intracerebral Hemorrhage

Minimally invasive surgery is effective and recommended for treatment of intracerebral hemorrhage; however, neurosurgeons in grass-root hospitals in underdeveloped countries lack effective and precise minimally invasive surgery techniques. The aim of this study was to present a technique of computed tomography angiography-based three-dimensional-printed navigation mold-guided stereotactic aspiration and demonstrate its clinical application using a hard needle in a series of patients. The novel stereotactic aspiration technique was performed in 18 patients with spontaneous intracerebral hemorrhage at our center, and clinical outcomes were reported. We compared the volume of hematoma measured by 3 different methods: ABC/2 formula, manual segmentation with OsiriX, and manual segmentation with 3D Slicer. The surgery was completed safely within an average operative time of 15.11 minutes, achieving the goal of <15 mL residual clot volume or >70% clot removal in all patients. No intracranial rebleeding or infection was observed postoperatively. At the end of the 6-month follow-up, 61.11% (11/18) of patients achieved a modified Rankin Scale score <3. There was overall better agreement of hematoma measurement using segmentation with 3D Slicer rather than ABC/2 measurement or hematoma measurement using segmentation with OsiriX. Our novel method of stereotactic aspiration benefited patients in this study with good percent clot removal, few surgery-related complications, and a favorable prognosis. Manual segmentation with 3D Slicer could be used to provide the neurosurgeon with dependable information about hematoma volume. This cheap and convenient technique may be applied in grass-root hospitals in underdeveloped countries. Assessment in multicenter prospective clinical trials is needed.

Effect of D-dimer on the prognosis of patients with aneurysmal subarachnoid hemorrhage based on propensity score matching

Objective: To evaluate the effect of D-dimer on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: A total of 1 658 patients who were first diagnosed with aSAH in West China Hospital of Sichuan University from December 2013 to June 2019 were retrospectively analyzed. All patients were divided into four groups according to the median and quartiles of D-dimer level, including 415 cases, 414 cases, 414 cases, and 415 cases in groups Q1, Q2, Q3, and Q4, respectively. Groups Q2, Q3, Q4, and group Q1 were matched by propensity score matching (PSM), and the correlation between D-dimer and each outcome was analyzed by logistic regression. Since there is no general clinical classification standard for D-dimer, this study attempted to reclassify patients into groups q1 (<0.55 mg/L, 94 cases), q2 (0.55-1.65 mg/L, 435 cases), q3 (1.65-5.50 mg/L, 650 cases) and q4 (>5.50 mg/L, 303 cases) based on 1, 3, 5, 10 times of the upper limit of the current clinical reference value. Results: The age of 1 658 aSAH patients were (57±12) years, including 1 068 males and 590 females. After PSM based on the median and quartiles of D-dimer level, there were 318 cases, 318 cases, 251 cases, and 229 cases in groups Q1, Q2, Q3, and Q4, respectively. Compared with group Q1 (<1.23 mg/L), the risk of in-hospital infection (OR=2.14, 95%CI: 1.47-3.11, P<0.001), pneumonia (OR=2.22, 95%CI: 1.51-3.28, P<0.001), urinary tract infection (OR=1.75, 95%CI: 1.12-2.75, P=0.014) and intracranial rebleeding (OR=3.59, 95%CI: 1.30-9.91, P=0.013) group Q4 (>4.95 mg/L) was higher. Likewise, the risk of adverse outcomes in group Q4 was also higher than that in group Q1, including unfavorable outcome at discharge (OR=2.12, 95%CI: 1.43-3.14, P<0.001), mortality during hospitalization (OR=3.03, 95%CI: 1.26-7.33, P=0.014), mortality within 90 days (OR=2.33, 95%CI:1.29-4.22, P=0.005), mortality within 180 days (OR=1.92, 95%CI: 1.12-3.29, P=0.018), mortality within 1 year (OR=2.07, 95%CI:1.23-3.47, P=0.006) and mortality during the longest follow-up period (OR=1.97, 95%CI:1.26-3.09, P=0.003). After secondary grouping and PSM based on current clinical reference values, there were 90 cases, 87 cases, 90 cases, and 43 cases, respectively in groups q1, q2, q3 and q4. The risk of nosocomial infection (OR=2.26, 95%CI: 1.14-4.45, P=0.019), blood-borne infection (OR=8.86, 95%CI:1.08-72.78, P=0.042), poor prognosis at discharge (OR=4.92, 95%CI: 2.18-11.07, P<0.001), death within 180 days (OR=3.39, 95%CI: 1.04-11.08, P=0.043), death within 1 year (OR=3.23, 95%CI: 1.10-9.49, P=0.033), and death within the longest follow-up period (OR=3.28, 95%CI: 1.34-8.01, P=0.009) was still higher in group q4 than that in group q1. Conclusion: aSAH patients with high D-dimer level have a higher risk of complications and mortality during hospitalization and worse clinical prognosis.

Comparative study on acute management of intracerebral haematoma using local thrombolysis in moyamoya and non-moyamoya patients: a single institution experience

Purpose Spontaneous intracerebral haemorrhage (ICH) is the main presentation in adults with moyamoya disease (MMD), an unusual clinical entity with a poor prognosis. However, optimal management in the acute stage of ICH in patients with MMD remains a challenge. Since minimally invasive surgery (MIS) plus local thrombolysis has emerged as a promising strategy for ICH, we aimed to describe our experience of performing this procedure in this special population in the acute phase, while focusing on its efficacy and safety. Materials and methods The medical data of patients with ICH treated with MIS and local thrombolysis between November 2013 and December 2017 were retrospectively reviewed at our institution. MMD was identified based on the angiographic images. The primary outcome was postoperative intracranial rebleeding. The secondary outcomes were 30-day mortality and 6-month outcome graded using the modified Rankin scale (mRS). Logistic regression was applied to explore independent risk factors for the above outcomes. Results A cohort of consecutive 337 ICH patients was analysed, of whom 14 (4.15%) were diagnosed with MMD. In total, 36 (11.46%) patients experienced postoperative intracranial rehaemorrhage, of which one patient had MMD. No significant difference was found between the patients with and without MMD regarding postoperative rebleeding (9.09% vs. 11.55%, p = 1.000). Additionally, the 30-day mortality of patients with MMD was 21.42% (3/14), which was not significantly different from that of non-MMD patients (10.83%; p = 0.201). Moreover, 53.8% of patients had poor outcomes at the 6-month follow-up among MMD patients, similar to 43.9% of patients without MMD (p = 0.573). The coexistence of MMD failed to show a significant association with postoperative intracranial rebleeding (p = 0.348), 30-day mortality (p = 0.211), or poor outcome at the 6-month follow-up (p = 0.450). Conclusion Our findings suggest that coexistent MMD is not associated with an increased risk of postoperative rebleeding or poor outcome after local thrombolysis for ICH.

INTRACRANIAL EMBOLIZATION: A RARE COMPLICATION

We report a case of a rare complication: aortic pseudoaneurysm rupture after embolization of an intracranial aneurysm in a 62 –year- old patient with spontaneous subarachnoid hemorrhage, presented with chest pain and shortness of breath the fourth day after the procedure. The intracranial aneurysm was embolized with no intraoperative complications, and a postprocedural CT (computed tomography) scan showed no signs of intracranial rebleeding, ischemic lesions, or hydrocephalus. Cardiosurgical treatment was not indicated for the aortic pseudoaneurysm rupture.

A nomogram to predict the risk of postoperative intracranial rebleeding in patients with spontaneous intracranial hematoma.

The 30-day mortality rate of spontaneous cerebral hemorrhage (ICH) is approximately 30-50%. Surgery may improve the prognosis of patients with severe ICH. However, ICH survivors after surgery still face the risks of postoperative intracranial rebleeding (PIB), and clinical tools that accurately predict the risk of PIB occurrence are not available. Therefore, a retrospective study was performed. The population was divided into two groups according to the occurrence of PIB. Univariate and multivariate logistic regression analyses were performed to screen risk factors for PIB. Next, an early PIB risk nomogram prediction model was constructed. In addition, the impact of PIB on the prognosis of ICH was evaluated. In total, 150 ICH patients were continuously enrolled in this study; 21 patients suffered from PIB, and the overall incidence of PIB was 14.0% (21/150). Coronary heart disease history, a lower GCS score, and subarachnoid hemorrhage absence were screened as risk factors for early PIB. The early PIB risk nomogram showed good calibration and discrimination with a concordance index of 0.807 (95% confidence interval (CI), 0.715-0.899), which was confirmed to be 0.788 through bootstrapping validation. In addition, a significant difference in discharged GOS scores (P = 0.043) was observed between the PIB group and the n-PIB group. These results showed that a history of coronary heart disease, a lower GCS score, and absence of subarachnoid hemorrhage were risk factors for early PIB. In addition, the early PIB risk nomogram prediction model exhibits good discrimination and calibration. The occurrence of PIB could reduce the prognosis of ICH patients.

Early prophylactic anticoagulation after subarachnoid hemorrhage decreases systemic ischemia and improves outcome

BackgroundIn neurosurgical perioperative treatment, especially in connection with subarachnoid hemorrhage (SAH), the prophylactic anticoagulation (AC) regimen is still considered controversial. The goal of this retrospective study was to assess how the time point of low-molecular-weight heparin (LMWH) initiation (ToH) affects ischemic and hemorrhagic events after SAH. Methods370 patients who received acute treatment for non-traumatic SAH between 2011 and 2018 were included, and 208 patients were followed up after 12 months. We assessed how the ToH affects ischemic and hemorrhagic events as well as outcome scores. Statistical analysis was performed using the Mann-Whitney U-Test, the chi-squared test, Fisher’s exact test, and univariate binomial logistic regression. P-values below 0.05 were considered statistically significant. ResultsThe incidence of systemic ischemia was 4.6%, cerebral ischemia 33.5%, and intracranial rebleeding 14.6%. Delaying ToH (measured in hours) increases systemic ischemia (p = 0.009). The odds ratio for the impact of delayed anticoagulation on systemic ischemia is 1.013 per hour (95%CI of OR 1.001–1.024). ToH has no influence on cerebral ischemia or intracranial rebleeding. Early anticoagulation was associated with a more favorable Glasgow Outcome Score 12 months after discharge (ToH within 48 h: p = 0.006). ToH did not affect mortality or readmission rates. ConclusionsInitiating prophylactic AC with LMWH later than 48 h after aneurysm repair or admission impairs outcomes 12 months after discharge. It might be safe for patients with non-traumatic SAH to be anticoagulated with prophylactic doses of heparin within 24 h after admission or the treatment of source of bleeding (SoB). Early AC with prophylactic LMWH does not promote rebleeding.

Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis

ObjectiveThis study was performed to explore the efficacy and safety of different surgical interventions in patients with spontaneous supratentorial intracranial hemorrhage (SSICH) and determine which intervention is most suitable for such patients. Patients and MethodsWe searched the PubMed, Medline, OVID, Embase, and Cochrane Library databases. The quality of the included studies was assessed. Statistical analyses were performed using the software Stata 13.0 and RevMan 5.3. ResultsEndoscopic surgery (ES), minimally invasive surgery combined with urokinase (MIS + UK), minimally invasive surgery combined with recombinant tissue plasminogen activator (MIS + rt-PA), and craniotomy were associated with higher survival rates and a lower risk of intracranial rebleeding than standard medical care (SMC) in patients with SSICH, especially in younger patients with few comorbidities. The order from highest to lowest survival rate was ES, MIS + UK, MIS + rt-PA, craniotomy, and SMC. The order from lowest to highest intracranial rebleeding risk was ES, MIS + UK, craniotomy, MIS + rt-PA, and SMC. Additionally, compared with SMC, all four surgical interventions (ES, MIS + rt-PA, MIS + UK, and craniotomy) improved the prognosis and reduced the proportion of patients with serious disability. The order from most to least favorable prognosis was MIS + rt-PA, ES, MIS + UK, craniotomy, and SMC. The order from highest to lowest proportion of patients with serious disability was ES, MIS + rt-PA, MIS + UK, craniotomy, and SMC. ConclusionsThis study revealed that the efficacy and safety of different surgical interventions (ES, MIS + UK, MIS + rt-PA, craniotomy) were superior to those of SMC in the patients with SSICH, especially in younger patients with few comorbidities. Among them, ES was the most reasonable and effective intervention. ES was found not only to improve the survival rate and prognosis but also to have the lowest risk of intracranial rebleeding and the lowest proportion of patients with serious disability.

Clinical study on the treatment of severe intraventricular hemorrhage by using neuroendoscopy combinedwith ventricular irrigation

Objective To explore the efficacy of neuroendoscopy combined with ventricular irrigation in the treatment of severe intraventricular hemorrhage. Methods A retrospective study was conducted on 145 cases of severe intraventricular hemorrhage admitted to Department of Neurosurgery at Harrison International Peace Hospital Affiliated to Hebei Medical University from January 2015 to November 2017. Among them, 65 cases were treated by neuroendoscopy combined with ventricular irrigation (neuroendoscope group) and 80 were treated with external ventricular drainage (drilling drainage group). The hospital stay length, recovery time of cerebrospinal fluid, intracranial infection rate, hematoma clearance and rebleeding rate at 6h post operation were compared between the 2 groups. After 6 months of follow-up, the occurrence of hydrocephalus was assessed according to CT examination and the patient's outcome was assessed according to the activity of daily living (ADL) score. The Bsrsel index≥90% indicated that the patient had a good outcome. Results Compared with the drilling drainage group, the recovery time of cerebrospinal fluid after neuroendoscopy was shortened (3.9±0.9 min vs. 4.6±1.1 min, P=0.034), the clearance rate of hematoma was significantly higher [23.1%(15/65) vs. 2.5%(2/80), P 0.05). After 6 months, the rate of good outcome in the neuroendoscopy group was better than in the drilling drainage group [50.8%(33/65) vs. 28.8%(23/80), P=0.001]. The occurrence rate of hydrocephalus [4.6%(3/65) vs. 16.3%(13/80)] and mortality rate [4.6%(3/65) vs. 15.0%(12/80)] were lower than those in the drilling drainage group(both P<0.05). Conclusion Neuroendoscopy combined with ventricular irrigation could effectively improve clinical efficacy, reduce complications and improve the outcome of severe ventricular hemorrhage, which might be worthy of clinical promotion. Key words: Natural cavity endoscopic; Neurosurgery; Treatment results; Severe intraventricular hemorrhage; Ventricular irrigation

Is it dangerous to treat spontaneous intracerebral hemorrhage by minimally invasive surgery plus local thrombolysis in patients with coexisting unruptured intracranial aneurysms?

ObjectivesLimited evidence supports the presumed increased frequency of hemorrhage caused by the unruptured intracranial aneurysms which coexist in patients with spontaneous intracerebral hemorrhage treated with minimally invasive surgery plus local thrombolysis. Subsequently, we sought to determine the safety of local thrombolysis for this particular subset of patients. Patients and MethodsWe reviewed the medical records of patients treated with minimally invasive surgery plus local thrombolysis for intracerebral hemorrhage between November 2013 to December 2015 in an intensive care unit of a tertiary care hospital. Depending upon the vascular images, unruptured intracranial aneurysms were identified. The primary outcome was any of postoperative intracranial rebleeding. The second outcome included the 30-day death and 6-month follow up graded by Modified Rank Scale. Blind abstractors reviewed the medical data and binary logistic regression was performed to investigate the risk factors of poor prognosis. ResultsWe identified a cohort of consecutive 188 patients, of whom 23 (12.2%) harbored unruptured intracranial aneurysms. There were 28 aneurysms documented in this study, among which 3 were in the posterior circulation. And in total, 20 (11.3%) cases suffered from postoperative hematoma growth, of which 4 were with aneurysms. Additionally,the 30-day mortality after stroke in patients with aneurysms was 8.69% (2/23), comparable to 13.33% in without (22/165,p = 0.744). The proportion of the favorable outcome at 6-month follow-up in patients with aneurysms was comparable to that in without (47.8% versus 48.5%,p = 1.000) Insignificant associations were demonstrated between the unruptured intracranial aneurysms and postoperative intracranial rehemorrhage (p = 0.092), 30-day death(p = 0.588) and poor long-term prognosis (p = 0.332), respectively. ConclusionOur findings suggest that unruptured intracranial aneurysms seem to represent no increased risks of poor outcome after local thrombolysis for intracerbral hematomas.

The effect of hypertonic saline and mannitol on coagulation in moderate traumatic brain injury patients

BackgroundHyperosmolar therapy, using either hypertonic saline (HTS) or mannitol (MT), is considered the treatment of choice for intracranial hypertension, a disorder characterized by high intracranial pressure (ICP). However, hyperosmolar agents have been postulated to impair coagulation and platelet function. The aim of this study was to identify whether HTS and MT could affect coagulation in moderate traumatic brain injury (TBI) patients. MethodsIn this prospective and randomized double-blind study, we included adult patients with moderate TBI. Patients were divided into two groups according to the type of hypertonic solution administered. Group A patients received 20% MT and group B patients received 3% HTS. Rotational thromboelastometry (ROTEM) parameters were used to assess coagulation and platelet function. ResultsROTEM parameters included CT (clotting time), CFT (clot formation time), maximum clot firmness (MCF) measured by MCF (EXTEM and INTEM), MCF (FIBTEM) and standard coagulation tests (p>0.05). No significant differences were found between the two groups. Moreover, ROTEM parameters did not show significant changes at different time points after administration of the hyperosmolar solutions (p>0.05). Conclusions Overall, use of 3% HTS and 20% MT for the control of ICP did not significantly affect patients' coagulation function. Therefore, hyperosmotic solution is safe and does not increase the risk of intracranial rebleeding.

Influences of shallow sputum suction method for mechanical ventilation on prognosis in patients with cerebral hemorrhage

Objective To explore the influences of shallow sputum suction method for mechanical ventilation on prognosis in patients with cerebral hemorrhage. Methods The study investigated 60 patients with cerebral hemorrhage who used closed endotracheal suction for mechanical ventilation. The participants were divided into the intervention group (n=30) and the control group (n=30) using the random number table. The intervention group received the shallow sputum suction method while the control group received conventional deep sputum suction method. The blood pressure, heart rate, blood oxygen saturation, and the incidence of airway mucosa injury bleeding and intracranial re-bleeding caused by sputum suction were compared between the two groups. Results In the intervention group, the heart rate increased (13.4±6.1) times/min, the blood pressure increased (15.3±8.6)mmHg, and one case (3.3%) of airway mucosa injury bleeding caused by sputum suction. In the control group, the heart rate increased (15.6±5.8) times/min, the blood pressure increased (18.9±9.8)mmHg, and eight cases (26.7%) of airway mucosa injury bleeding caused by sputum suction. There were significant differences between the two groups (P<0.05). Conclusions The application of the shallow sputum suction can effectively reduce the fluctuation of blood pressure and airway mucosa injury, as well as can decrease the incidence of the intracranial re-bleeding in patients with cerebral hemorrhage who used closed endotracheal suction for mechanical ventilation. Key words: Cerebral hemorrhage; Mechanical ventilation; Shallow sputum suction; Closed endotracheal suction; Airway injury

Long term outcome after conservative and surgical treatment of haemorrhagic moyamoya disease

ObjectiveTo investigate the long term outcomes after conservative and surgical treatment for haemorrhagic moyamoya disease.Methods97 consecutive patients with haemorrhagic moyamoya disease from 1997 to 2009 were enrolled in this study...

Prevention and Treatment of Venous Thromboembolism in Patients with Acute Intracerebral Hemorrhage

Deep venous thrombosis and pulmonary emboli are common preventable causes of morbidity and mortality in patients with acute intracerebral hemorrhage (ICH). The frequency of venous thromboembolism (VTE) in patients with acute ICH ranges from 0.5 to 13% in scant reports. The dilemma in the prevention and treatment of these complications is to reduce the morbidity of VTE without increasing the risk of intracranial rebleeding. There is a paucity of information about this issue, and the applicability of the recommendations for patients with ischemic stroke to those with ICH is unclear. From the available literature, the recommendations for prevention of VTE in patients with ICH are early mobilization, adequate hydration, pneumatic compression stockings, and (in stable patients) low-dose subcutaneous heparins. Considering the treatment of VTE in patients with ICH, placement of an inferior vena caval filter is the most frequent expert recommendation. While existing data are sparse and not sufficient to recommend modifications to current options, the way is open for randomized trials to test early use of antithrombotic agents for VTE in acute ICH patients.

Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms.

Recurrent hemorrhage in the case of incompletely treated aneurysms is well known. The authors present a series of patients in whom rebleeding occurred in spite of totally occluded aneurysms. During a period of 12 years, 1170 patients with intracranial aneurysms were treated using either clipping (n=727) or coiling (n=443). In 11 of them, intracranial rebleeding occurred, in seven of whom routine post-treatment angiography revealed total aneurysm occlusion before the appearance of rehemorrhage. Further analysis focused on these seven patients. Their recurrent aneurysm ruptures happened with a mean latency of 9.5 months (range 21 h-48 months) from initial treatment. All aneurysms belonged to the anterior circulation. Three patients underwent primary clipping, and four experienced coiling first. The intracranial hemorrhages appeared mainly as intracerebral hematomas. The angiographically documented recurrent aneurysm configurations were caused by clip slippage (n=2), coil compaction (n=3), or coil migration/dislocation (n=1). In one case with primary surgery, clip slippage was possible but not confirmed by intraoperative view, because the patient died before therapeutic intervention. Two patients did not undergo therapy because of their poor clinical condition and died. Four of the remaining patients underwent clipping of the recurrent lesions, and one had recoiling. Final outcome was excellent/good in only two patients. The mainly poor outcome after rebleeding was caused by the high incidence of intracerebral hemorrhage.

Mechanism of intracranial rebleeding in Moyamoya disease

Intracranial hemorrhage is the major catastrophic event in the natural course of Moyamoya disease, and outcome of the patients with rebleeding is very poor. However, the mechanism underlying intracranial rebleeding is not well elucidated. We retrospectively analyzed 15 patients who bled two times or more among 46 bled patients with Moyamoya disease. The results indicated that there were two different types in the manner of rebleeding. One group consisted of seven cases, which bled two times or more at the same site than the original bleeding site. In four of these seven cases, a ruptured aneurysm was identified at the distal part of collateral vessel or on the major vessel. In the other three cases, no source of bleeding was identified. In all of these cases, rebleeding occurred within 2 months after the initial insult except for one case. Another group consisted of eight cases, which bled repeatedly but at different sites from the initial bleeding site. In any of these cases, neither aneurysms nor other vascular abnormalities were identified. In all of these cases, rebleeding occurred more than 2 months after the initial bleeding. The present result indicated that intracranial bleeding might occur as a result of rupture of a tiny aneurysm at the periphery of collateral vessels. These aneurysms may be blown out after the initial bleeding. When they persist after the event, they may rupture again in a fairly short interval. In other cases, bleeding occur at different sites from the initial site. They are considered to be a result of ruptured weak Moyamoya vessels which are forced to act as collateral pathways and are under unusually increased hemodynamic stress.

P-1-134 - Efficacy of direct revascularization to prevent intracranial rebleeding in Moya-Moya disease

P-1-134 - Efficacy of direct revascularization to prevent intracranial rebleeding in Moya-Moya disease

Intracranial rebleeding in moyamoya disease

Cerebral ischaemia and intracranial haemorrhage are the major catastrophic events in the natural course of moyamoya disease. To prevent cerebral ischaemia extracranial/intracranial (EC/IC) bypass surgery has been done and the results of the surgery have been well documented. However, the mechanism(s) underlying intracranial bleeding and the therapeutic modalities used to prevent bleeding have not been well elucidated. We have retrospectively analysed 45 cases with intracranial haemorrhage among 192 patients with moyamoya disease treated and followed at our institute. Analysis of the initial patients with haemorrhage did not provide any new information other than the already reported theories about the origin and mechanism of bleeding. Analysis of 15 patients in whom haemorrhage occurred at least twice suggested that there were two different mechanisms of rebleeding. One group consisted of 7 cases, where haemorrhages were confined to the original bleeding site. In 3 of these 7 cases a small aneurysm was identified at the periphery of a moyamoya vessel. In 1 case a ruptured aneurysm was found on a major vessel. In 3 other cases no source of bleeding was identified. In all but 1 of these cases rebleeding occurred within 2 months after the initial ictus. The second group consisted of 8 cases where haemorrhage occurred repeatedly but at variable sites. In none of these cases were aneurysms or other vascular abnormalities identified to suggest the source of bleeding and in all of these cases rebleeding occurred more than 2 months after the initial ictus. In moyamoya disease intracranial bleeding may occur as a result of rupture of a tiny aneurysm situated at the periphery of the moyamoya vessels and which may have been destroyed after the initial bleeding. If the aneurysms persist after rupture they may re-rupture after a fairly short interval. In other cases bleeding occurs at different sites from the initial haemorrhage; these are considered to be a result of rupture of weak moyamoya vessels which are forced to act as collateral pathways and are under unusually increased haemodynamic stress. EC/IC bypass surgery is considered to be effective for the prevention of rebleeding in both groups of patients but in selected cases. Direct surgery is recommended when a peripheral aneurysm is found on a moyamoya vessel which has bled once.

Management of intracranial hemorrhage associated with anticoagulant therapy

Intracranial hemorrhage may be a particularly devastating complication of anticoagulant therapy. Very few accounts have reported data on the duration of anticoagulant discontinuation following intracranial hemorrhage or the intensity of anticoagulation during treatment for it, although we must adequately manage such a complication. We analyzed the management of warfarin-related intracranial hemorrhages in 27 patients with cardiac diseases. We evaluated the degree of anticoagulation using the thrombotest. Anticoagulants were stopped as soon as the diagnosis of intracranial hemorrhage was established by computed tomographic scan. Mechanical valve prosthesis patients, who required intensive long-term anticoagulant therapy, constituted the majority of our series (74.1%). Intraoperative hemostasis was brought under control despite low thrombotest values (13%-68%) at the time of surgery except for the acute subdural hematoma (SDH) patients with cerebral contusion. Early resumption of anticoagulant therapy (within 3 days) did not cause intracranial rebleeding in any operative patient. All the chronic SDH patients and some of the subcortical hematoma patients had a good outcome. All three patients with acute SDH and contusion, however, had a fatal outcome because of intracranial rebleeding within a short period of time or ineffective intraoperative hemostasis. The patients with anticoagulant-related intracranial hemorrhage may undergo surgery with thrombotest values approximately between 20% and 60%, and anticoagulants can be resumed after an interval of 3 days. Aggressive surgery should particularly be performed in patients with anticoagulation-related chronic SDH or subcortical hemorrhage, as in the cases of anticoagulant-unrelated intracranial hemorrhage.

Occlusive Cerebrovascular Disease with Moyamoya Vessels and Intracranial Hemorrhage during Pregnancy

A 24-year-old female in the sixth month of pregnancy developed headache and vomiting caused by an intraventricular hemorrhage from moyamoya vessels. Superficial temporal artery-middle cerebral artery bypass surgery was performed when she was in the seventh month of pregnancy in order to prevent intracranial rebleeding or a cerebrovascular ischemic attack during labor and delivery. The patient delivered successfully at full term, without complications. The clinical features and management of patients with such rare occurrences during pregnancy are discussed and seven previously reported cases are reviewed.