Postoperative Cerebral Hemorrhage Research Articles

The Dilator-Dotter technique can successfully treat tandem lesions of posterior circulation.

In this study, we applied the Dilator-Dotter technique, a catheter-based angioplasty, to cross through severely stenotic or occluded vertebral arteries during mechanical thrombectomy, and we explored its efficacy and safety in treating tandem lesions of posterior circulation. We performed a retrospective analysis of patients with acute stroke caused by tandem lesions of posterior circulation treated with the Dilator-Dotter technique and thrombectomy between July 2017 and December 2021. In addition to collecting clinical, radiographic, and procedural data from patient records, we also collected information about surgical complications and outcome. We enrolled 9 patients for this study. In all cases, the vertebral artery (VA) on the affected side was crossed through via the Dilator-Dotter technique, and mechanical thrombectomy was successfully performed. The average time from groin puncture to revascularization (TICI 2B-3) was 26 minutes (range 16-50 minutes). Eight patients (89%) achieved complete recanalization with TICI 3, and only 1 patient suffered from thrombus escape to the posterior cerebral artery. Eight patients underwent VA stenting, while the remaining patient was excluded from this procedure because a postoperative brain CT scan recorded obvious staining of the contrast medium within the infarcted area. Five patients had modified Rankin Scale scores ≤ 3 at the 3-month follow-up examination, and 2 patients died due to postoperative cerebral hemorrhage and severe ischemia. The Dilator-Dotter technique may represent a safe and effective treatment for tandem lesions of posterior circulation. Using this method, the lesions can be rapidly recanalized and treated.

Retracted: Influence of Optimal Management of Hyperglycemia and Intensive Nursing on Blood Glucose Control Level and Complications in Patients with Postoperative Cerebral Hemorrhage.

[This retracts the article DOI: 10.1155/2022/8553539.].

Endovascular intervention vs. microsurgery on the prognosis of anterior circulation blood blister-like aneurysm: A cohort study.

There are no universally acknowledged standardized treatment strategies for blood blister-like aneurysms (BBAs). This study compared the prognosis of patients with BBA who underwent craniotomy microsurgery vs. endovascular intervention. This retrospective cohort study included patients with BBA treated between September 2009 and August 2020 at Sichuan Provincial People's Hospital affiliated to the Sichuan Academy of Medical Science. Patients were divided into the microsurgery and endovascular groups. The preoperative Hunt-Hess grade and modified Fisher grade were collected. The intraoperative and postoperative complications (including intraoperative aneurysm rupture and hemorrhage, postoperative cerebral hemorrhage, and BBA recurrence) were recorded. Seventy-two patients were included: 28 and 44 in the microsurgery and endovascular groups, respectively. Only the preoperative Fisher grade was different between the two groups (P = 0.041). The proportion of patients with good outcomes was lower in the microsurgery group (28.6%) than in the endovascular group (72.7%), and the mortality rate was higher in the microsurgery group (32.1%) than in the endovascular group (11.4%) (P < 0.05). After adjustment for the modified Fisher grade, the multivariable analysis showed that compared with craniotomy microsurgery, an endovascular intervention was associated with the prognosis of patients with BBA (OR = 0.128, 95%CI: 0.040-0.415, P < 0.001). The rate of complications (intraoperative hemorrhage, cerebral infarction, and recurrence) was higher in the microsurgery group than in the endovascular group. In patients with BBA, an endovascular intervention appears to be associated with a better prognosis compared with craniotomy microsurgery.

Influence of Optimal Management of Hyperglycemia and Intensive Nursing on Blood Glucose Control Level and Complications in Patients with Postoperative Cerebral Hemorrhage.

Background Cerebral hemorrhage, also known as hemorrhagic stroke, is a common clinical cerebrovascular disease, accounting for about 10%-30% of stroke, with high morbidity and mortality. Objective To observe the effect of optimal management of hyperglycemia and intensive nursing on blood glucose control level and complications in patients with postoperative cerebral hemorrhage. Methods One hundred and eight patients with postoperative cerebral hemorrhage comorbid with stress hyperglycemia admitted to our neurosurgery department from February 2019 to February 2022 were selected and divided into a general group of 54 cases and an optimized group of 54 cases by simple random method. The general group was managed with conventional care, while the optimized group developed optimized management of hyperglycemia for intensive care. The indexes related to blood glucose control, electrolytes, National Institutes of Health Stroke Scale (NIHSS) scores, Barthel Index (BI) scores, and time to achieve blood glucose standard, insulin pumping time, patient satisfaction, and prognosis were compared between the two groups. Results Before intervention, there was no statistical significance in the comparison of blood glucose control-related indicators and electrolytes between the two groups (P > 0.05). After 7 d and 14 d of intervention, the fasting blood glucose and 2 h postprandial blood glucose in the two groups were lower than before, while K+ and Na+ were higher than before (P < 0.05). The blood glucose indexes at the same time point in the optimized group were found to be lower than those in the general group by statistical analysis, but electrolytes were not statistically significant when compared with the general group (P > 0.05). In the optimized group, the time to achieve blood glucose standard (6.59 ± 1.94) d and insulin pumping time (7.14 ± 1.89) d were shorter than those in the general group [(7.48 ± 2.12) d and (8.58 ± 2.14) d], insulin dosage (748.85 ± 63.61) U was less than that in the general group (923.54 ± 84.14) U, and the incidence of hypoglycemia (3.70%) was lower than that in the general group (16.67%), and the satisfaction rate (92.59%) was higher than that of the general group (77.78%), which was statistically significant (P < 0.05). Before intervention, there was no significant difference in NIHSS score and BI score between the two groups (P > 0.05). After 7 d and 14 d of intervention, the NIHSS scores of the two groups were lower than before, while the BI scores were higher than before, and the NIHSS scores of the optimized group at the same time point were all lower than those of the general group, and the BI scores were higher than those of the general group (P < 0.05). The incidence of pulmonary infection (11.11%) and rebleeding (7.41%) in the optimized group were lower than those in the general group (25.93% and 22.22%), while deep vein thrombosis, multiple organ dysfunction syndrome (MODS), and death within 28 d was not statistically significant when compared with the general group (P > 0.05). Conclusion Optimal management of hyperglycemia and intensive nursing can effectively control the blood sugar level of patients after cerebral hemorrhage, reducing insulin dosage, and the occurrence of hypoglycemia, pulmonary infection, and rebleeding.

Long-Term Outcomes of Preoperative Atrial Fibrillation in Cardiac Surgery.

BackgroundAtrial fibrillation (Afib) is a marker of increased cardiovascular morbidity and mortality. Owing to the increased prevalence of Afib in patients undergoing cardiac surgery, assessing the effect of Afib on postsurgical outcomes is important. We aimed to analyze the effect of preoperative Afib on clinical outcomes in patients undergoing cardiac surgery using a large surgical database.MethodsThis retrospective cohort study was based on the national health claims database established by the National Health Insurance Service of the Republic of Korea from 2009 to 2015. Diagnosis and procedure codes were used to identify diseases according to the International Statistical Classification of Diseases, 10th revision.ResultsWe included 1,037 patients (0.1%) who had undergone cardiac surgery from a randomized 1,000,000-patient cohort, and 15 patients (1.5%) treated with isolated surgical Afib ablation were excluded. Of these 1,022 patients, 412 (39.7%), 303 (29.2%), and 92 (9.0%) underwent coronary artery bypass, heart valve surgery, and Cox-maze surgery, respectively. Preoperative Afib was associated with higher patient mortality (p=0.028), regardless of the surgical procedure. Patients with preoperative Afib (n=190, 18.6%) experienced a higher cumulative risk of overall mortality (hazard ratio [HR], 1.435; 95% confidence interval [CI], 1.263–2.107; p=0.034). Subgroup analysis revealed a reduced risk of overall mortality with Cox-maze surgery in Afib patients (HR, 0.500; 95% CI, 0.266–0.938; p=0.031). Postoperative cerebral ischemia or hemorrhage events were not related to Afib.ConclusionPreoperative Afib was independently associated with worse long-term postoperative outcomes after cardiac surgery. Concomitant Cox-maze surgery may improve the survival rate.

Abstract 10951: Clinical Outcome of Maze Procedure for Atrial Fibrillation Combined with Mitral Valve Disease and Tricuspid Regurgitation

Introduction: The surgical strategy for atrial fibrillation (AF) combined with mitral valve (MV) disease are still controversial whether biatrial or left atrial maze procedure should be performed concomitantly. Hypothesis: Our retrospective study aimed to evaluate the long-term results of two kinds of maze procedure combined with MV surgery and identify the factors involved in AF recurrence. Methods: We enrolled 88 patients from January 2010 to December 2020 who underwent MV surgery with maze procedure concomitantly. The patients were divided into two groups; biatrial maze, group F: n=42 and left atrial maze, group L: n=46). Primary endpoint was AF recurrence and we also evaluated early and late complication and preoperative and operative factors related to AF recurrence. The average follow-up term was 2.8 years. Results: Preoperative factors of long-standing AF and TR grade were significantly higher in group F than group L (P=0.004, 0.02, respecively). Consequently, tricuspid annuloplasty (TAP) was performed significantly frequent in group F than group L (P=0.002). We encountered 2 hospital deaths (4.4%) due to postoperative cerebral hemorrhage and AMI in group L. There was 1 case (2.2%) required pacemaker implantation (PMI) during hospitalization in group L and 3 cases (7.1%) requiring PMI in Group F in late-period. The AF recurrence rates at 1 and 5-year follow-ups between Group F and Group L were not significantly different (24.4% and 28.4% vs. 22.9% and 32.4%, P =0.79). However, the AF recurrence rate in group L with TAP is significant high than those of the other groups (group F 24.4% and 28.4%, group L with TAP 44.3% and 56.7%, and group L without TAP 7.7% and 14.3% at 1 and 5 years, respectively p =0.005). Subject with group L with TAP were associated with a high risk of AF recurrence, with an adjusted OR of 2.4 (95% CI: 1.31-4.45, P =0.005). Conclusions: Our study demonstrated that both concomitant maze procedure was effective for preventing AF recurrence. However, it is also revealed that left atrial maze with TAP significantly increased AF recurrence. It was suggested that preoperative right atrial load was involved in primary occurrence of AF and left atrial maze alone might not control AF recurrence in such situation.

Complications in Staged Late Titanium Cranioplasty and Ventriculoperitoneal Shunting for Patients with Traumatic Brain Injury

Hydrocephalus is a common complication following decompressive craniectomy. Ventriculoperitoneal shunt (VPS) is required for some patients before receiving a cranioplasty (CP). The presence of a VPS is regarded as a risk factor for overall CP complications. A retrospective survey was conducted on 176 patients with traumatic brain injury who underwent late (>3 months) titanium CP (Ti-CP) in our hospital from April 2014 to July 2018. Thirteen patients (7.4%) had preoperative VPS. Propensity score matching was performed for these 13 patients with a ratio of 1:5. A total of 78 patients were selected. Preoperative clinical parameters and postoperative complications were analyzed. The period of postoperative follow-up ranged from 3 to 63 months (mean 21.3 ± 17.0 months). The overall complication rate was greater in the VPS group (P= 0.010). These patients were more likely to develop a sunken skin flap (P < 0.001). The rate of postoperative cerebral hemorrhage was greater in the VPS group. Logistic analysis showed that preoperative VPS was an independent risk factor for postoperative extradural collection (odds ratio 17.714, P < 0.001). VPS was not related to postoperative infection and seizure. Postoperative drainage duration longer than 2.5 days significantly increased the risk of postoperative infection (odds ratio 7.715, P= 0.023). The presence of a VPS significantly increased the risk of extradural collection in patients with traumatic brain injury who underwent late Ti-CP. It also was related to postoperative hemorrhage. The sunken skin flap in patients with VPS increased surgical difficulty and the likelihood of extradural accumulation. Preoperative VPS was not related to postoperative infection and seizure in Ti-CP.

Observation of curative effect of point electric stimulation for urinary incontinence after postoperative cerebral hemorrhage

Objective To study the effect of point electric stimulation for urinary incontinence after postoperative cerebral hemorrhage. Methods Eighty patients with urinary incontinence after postoperative cerebral hemorrhage were randomly divided into treatment group and control group(n=40 case). Point electric stimulation was given to the treatment group, and Oxybutynin hydrochloride sustained release tablets was given orally to the control group. Index of urinary diary and bladder capacity in both groups before treatment and after 3 weeks of treatment were observed. Results After 3 weeks of treatment,the total effective rate(87.2% vs. 65.8%, χ2=4.916) in the treatment group were better than the control group (P<0.05). The times of voided (10.15 ± 2.21 times/24 h vs. 18.63 ± 3.42 times/24 h, t=12.956), the times of urinary incontinence (2.18 ± 1.04 times/24 h vs. 6.19 ± 2.16 times/24 h, t=10.421), the average voided volume (293.38 ± 16.32 ml vs. 180.82 ± 15.43 ml, t=31.083), the initial sensory capacity of bladder (276.73 ± 20.95 ml vs. 186.43 ± 21.14 ml, t=18.825), the maximum capacity of bladder (492.81 ± 23.72 ml vs. 293.81 ± 24.46 ml, t=36.244), the residual urine volume(13.25 ± 5.83 ml vs. 34.63 ± 6.25 ml, t=15.527) in the treatment group were significantly better than those in the control group (P<0.01). Conclusions The treatment of point electric stimulation can reduce the symptoms of urinary incontinence. Key words: Point; Electric stimulation; Cerebral hemorrhage; Urge incontinence; Postoperative complications

The observation of the effect of continuous intracranial pressure monitoring application on postoperative hypertension cerebral hemorrhage

Objective To explore the clinical application and the related nursing experience of continuous intracranial pressure monitoring postoperative hypertension cerebral hemorrhage. Methods A retrospective analysis of 80 cases of hypertensive cerebral hemorrhage patients from May 2013 to August 2016 in our department was performed.Patients were divided into the experimental group and the control group, according to whether ICP monitor were implanted.The control group received conventional treatment and nursing, while the experimental group received ICP monitoring at the same time.The amount of dehydrating agent and prognosis of the two groups were compared. Results The amount of dehydrating agent and the postoperative GOS scores of the experimental group were significantly better than that of the control group (P 0.05). Conclusions Postoperative ICP monitoring and careful nursing for patients with hypertension cerebral hemorrhage can reduce the amount of dehydrating agent, and improve GOS scores, the prognosis and survival quality of patients. Key words: Continuous intracranial pressure monitoring; Hypertensive cerebral hemorrhage; Clinical application; Nursing

Extended endoscopic endonasal approach for pituitary adenoma: a single-center experience of 171 patients

BackgroundPituitary adenoma (PA) is a common intracranial tumor and surgical treatment is considered to be the best treatment for most patients. The extended endoscopic endonasal approach (EEEA) has been used to treat increasing numbers of patients with PA in recent years. We conducted this study to evaluate the safety and efficacy of this approach for PA resection.MethodsWe performed a retrospective analysis of all patients who underwent an EEEA to remove PA by a binostril, four-handed technique between October 2013 and April 2016 in our department. The medical information of the patients including gender, age, tumor size, hormone level, clinical outcome, and complications were collected and analyzed.ResultsFrom a total of 593 pituitary adenoma surgeries, 171 patients (101 male and 70 female, mean age 47.4 ± 12.8 years) underwent EEEA, including 96 with functional adenomas (56.14%) and 75 with nonfunctional adenomas (43.86%). The most common symptoms were headache and vision change. Gross total resection was achieved in 126 patients (73.68%). Common complications were hyposmia or anosmia, diabetes insipidus, hypopituitarism, postoperative cerebrospinal fluid leak, cerebral hemorrhage, and epistaxis. The mean duration of follow-up was 14.6 months (range: 6–31 months).ConclusionsThe application of EEEA for PA resection by a binostril, four-handed technique provided great surgical freedom with minimal invasion, and resulted in few complications. EEEA is a secure and effective surgical method that could be used for the majority of PAs.

Endoscopic Endonasal Surgery for Suprasellar Meningiomas: Experience with 75 Cases

Objective: Endoscopic endonasal surgery (EES) has been recently introduced in the treatment of skull base meningiomas. Study Design: Retrospective review. Methods: Retrospective chart review of 75 patients with suprasellar meningiomas who underwent EES. Results: Most patients presented with visual loss (81.3%). Tumors extended into the optic canal(s) in 26.7%. Complete tumor resection (Simpson grade I) was achieved in 81.4% of the 70 patients in whom it was the goal (76% overall). In cases with optic canal invasion, complete resection was 90%. Tumor size, configuration, and vascular encasement were significant factors affecting the degree of resection (p < 0.0001). Vision was improved/normalized in 85.7% of the cases. Postoperative visual deterioration occurred in two patients (3.6%). Complications included CSF leak (16.1% in recent years) resulting in meningitis in four cases. One patient had an intraoperative vascular injury resulting in neurological deficits. Another elderly patient died within a month after EES from multisystem organ failure. No patient developed postoperative cerebral contusions, hemorrhage, or seizures. During a mean follow-up period of 29 months (range, 1-98 months), one patient underwent repeat EES for progression of residual tumor. Conclusions: EES is an effective and safe approach for the treatment of suprasellar meningiomas with excellent visual outcomes regardless of tumor location and extension into the optic canals.

Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients

Following the introduction of the neurosurgical microscope, the outcomes in suprasellar meningioma surgery were dramatically improved. More recently, the neurosurgical endoscope has been introduced as a visualization option during removal of skull base tumors, both transcranially and endonasally. The authors retrospectively reviewed the effectiveness of endoscopic endonasal surgery (EES) in the management of suprasellar meningiomas. Between 2002 and 2011, 75 patients (81.3% female) with suprasellar meningiomas underwent EES at the University of Pittsburgh Medical Center. The authors present the results of EES and analyze the resection rates, visual outcome, and complications. Seventy-one patients presented with primary tumors, whereas 4 were previously treated elsewhere. Their mean age was 57.3 years (range 36-88 years), and most patients presented with visual loss (81.3%). Tumors occupied the tuberculum sellae (86.7%) and planum sphenoidale (50.7%), with extension into the optic canals in 26.7% (unilateral in 21.3% and bilateral in 5.3%) and the pituitary fossa (9.3%). Gross-total tumor resection (Simpson Grade I) was achieved in 76% of the cases in the whole cohort and in 81.4% of the patients in whom it was the goal of surgery. Tumor location and extension into the optic canals was not a limitation for total resection. Tumor size, configuration, and vascular encasement were significant factors that influenced the degree of resection (p < 0.0001). Vision was improved or normalized in 85.7% of the cases. Visual deterioration following EES occurred in 2 patients (3.6%). Complications included postoperative CSF leaks (25.3% overall, 16.1% in recent years) resulting in meningitis in 4 cases. One patient had an intraoperative injury of the artery of Heubner resulting in associated neurological deficit. Another elderly patient died within 1 month after EES due to cerebral vasospasm and multisystem impairment. No patient developed postoperative cerebral contusions, hemorrhage, or seizures. During a mean follow-up period of 29 months (range 1-98 months), 4 patients have shown recurrence, but only 1 required repeat EES. With the goal of gross-total tumor resection and visual improvement, EES can achieve very good results, (comparable to microscopic approaches) for the treatment of suprasellar meningiomas. Avoidance of brain and optic nerve retraction, preservation of the vascularization of the optic apparatus, and wide decompression of the optic canals are the main advantages of EES for the treatment of suprasellar meningiomas, while CSF leaks remain a disadvantage.

The Management of Vertebrobasilar Dissecting Aneurysm Using Endovascular Embolization

To explore the imaging features of the vertebrobasilar artery dissecting aneurysm (VBA-DA) and to evaluate the effect of endovascular treatments. Five patients with VBA-DA undergoing endovascular treatments were retrospectively studied. Stent-alone technique was used to treat two of the patients, stent-assisted coil embolization of aneurysm in one patient, coil embolization of parent artery in the other patient, and stent-assisted coil embolization of parent artery in the last patient. Postoperative angiography revealed complete occlusion of aneurysm in two patients and delayed image development in three patients. One patient suffered postoperative cerebral hemorrhage without any neurological deficits. Five patients achieved favorable outcomes on both the imaging results and clinical recovery during a mean follow-up of 20.2 months (range 6-90 months). The string sign pearl and string sign and double-lumen sign are typical imaging features of VBA-DA. Treatment modality is determined by the imaging results. Endovascular embolization is a minimally-invasive, safe, effective, and reliable intervention for managing VBA-DA.

Management of infectious endocarditis with mycotic aneurysm evaluated by brain magnetic resonance imaging†

Cerebral complications of infective endocarditis (IE) [particularly, mycotic aneurysm, visualized as a hypointense spot on T2*-weighted brain magnetic resonance imaging (MRI)] are associated with a high incidence of postoperative cerebral or subarachnoid hemorrhage. We have adopted a policy of performing elective open heart surgery after performing a MRI enhanced by gadolinium in such patients whenever possible after improvement in inflammatory findings around a cerebral aneurysm. Fifty-six patients (35 men and 21 women, mean age 56 years) diagnosed with active-phase IE between January 2000 and December 2010 were analysed retrospectively. Six patients who had not undergone MRI were excluded. The remaining patients were classified into four groups according to preoperative brain MRI findings-Group A (n = 13): cerebral haemorrhage, cerebral infarction, abscess and encephalitis; Group B (n = 7): simple or multiple black dots ( = hypointensive spots) with cerebral haemorrhage or cerebral infarction; Group C (n = 15): simple or multiple black dots alone; Group D (n = 15): no abnormal MRI findings. None of the 12 patients who successfully underwent elective surgery in Groups B and C developed postoperative cerebral complications. Brain MRI is an important tool for the detection of asymptomatic intracranial abnormalities associated with IE and evaluation of the preoperative bleeding risk of patients. Patients with contrast enhancement around black dots are at high risk for bleeding, and performing open heart surgery in such patients whenever possible after the improvement of inflammatory findings reduces the potential risk of cerebral haemorrhage.

Acute Care Skills in Anesthesia Practice

A recurring initiative in graduate education is to find more effective methods to assess specialists' skills. Life-sized simulators could be used to assess the more complex skills expected in specialty practice if a curriculum of relevant exercises were developed that could be simply and reliably scored. The purpose of this study was to develop simulation exercises and associated scoring methods and determine whether these scenarios could be used to evaluate acute anesthesia care skills. Twenty-eight residents (12 junior and 16 senior) managed three intraoperative and three postoperative simulation exercises. Trainees were required to make a diagnosis and intervention in a simulation encounter designed to recreate an acute perioperative complication. The videotaped performances were scored by six raters. Three raters used a checklist scoring system. Three faculty raters measured when trainees performed three key diagnostic or therapeutic actions during each 5-min scenario. These faculty also provided a global score using a 10-cm line with scores from 0 (unsatisfactory) to 10 (outstanding). The scenarios included (1) intraoperative myocardial ischemia, (2) postoperative anaphylaxis, (3) intraoperative pneumothorax, (4) postoperative cerebral hemorrhage with intracranial hypertension, (5) intraoperative ventricular tachycardia, and (6) postoperative respiratory failure. The high correlation among all of the scoring systems and small variance among raters' scores indicated that all of the scoring systems measured similar performance domains. Scenarios varied in their overall difficulty. Even though trainees who performed well on one exercise were likely to perform well in subsequent scenarios, the authors found that there were considerable differences in case difficulty. This study suggests that simulation can be used to measure more complex skills expected in specialty training. Similar to other studies that assess a broad content domain, multiple encounters are needed to estimate skill effectively and accurately.

脳卒中治療の中・長期予後 高齢者脳動脈りゅう手術症例の長期予後 健康寿命の視点から

We analyzed the surgical results of patients in their 70s suffering from ruptured aneurysms to clarify the possible factors related to poor outcomes. We also investigated the active life expectancy for patients with good recovery on discharge.Over a period of 21 years (1978-1998), we surgically treated 144 patients with ruptured aneurysms who were 70 years of age or older. Seventy-nine patients (54.9%) obtained a good recovery, 45 (31.3%) were in a disabled condition, and 20 (13.8%) died. The main reason for disability and death was assessed retrospectively. Moreover, we conducted a follow-up study, including interviews, to determine survival rate, quality of life, active life expectancy, incidence of ADL disability and duration of ADL disability for patients with good recovery on discharge.Factors of poor outcome for patients in their 70s with ruptured aneurysms were aging itself, a poor grade of SAH, and the aneurysm location (especially distal ACA). Misdiagnoses, operative troubles, postoperative cerebral hemorrhage and infarction were other factors influencing poor outcomes.For patients having a good recovery on discharge, independence with meaningful activity can extend to 6 years after discharge. The overall incidence of ADL disability for patients in their 70s was 2.4 times higher than that of aged people in Sendai City; however, the duration of ADL disability was shorter than that reported in the Japan control study.

Surgical management in the patient with congenital factor XII deficiency: Report of a case

A rare case of blood coagulation disorder, congenital factor XII deficiency, detected in a patient with mandibular osteomyelitis is presented. Routine laboratory tests showed prolonged clotting and activated partial thromboplastin time. Detailed investigations for the intrinsic and extrinsic pathways of coagulation, fibrinolytic system, kinin-kallikrein system, and complement system were performed because factor XII is known as an activator of these systems. No hemorrhagic or thromboembolic complication occurred during and after surgery. Substitution therapy with fresh forzen plasma was not necessary. Magnetic resonance imaging and electrocardiography were used to examine the possible occurrence of postoperative cerebral hemorrhage or myocardial infarction.

Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators.

Controversy continues about the pathogenesis of perioperative stroke in carotid endarterectomy and the use of shunting. The purpose of this study was to determine, using transcranial Doppler ultrasonography, the severity of ischemia during clamping of the carotid artery as a basis for analysis of complications in patients operated on with and without shunting. In a retrospective study, 11 centers contributed 1,495 carotid endarterectomies monitored with transcranial Doppler. The cases were divided into groups with severe, mild, and no ischemia, and each group was subdivided according to shunt use. The perioperative rate of severe stroke attributable to intraoperative ischemia, in addition to total perioperative stroke, was determined for each subgroup. Severe ischemia occurred in 7.2% of our cases but cleared spontaneously in about half of these. In those with persisting ischemia the rate of severe stroke was very high, while shunting protected against stroke in such cases. If ischemia did not occur, the stroke rate was higher with shunting, although not so high as in unshunted cases with severe ischemia. Slightly more than one third of the severe strokes were due to postoperative cerebral hemorrhage or carotid thrombosis, unrelated to clamp-induced ischemia or shunting. Carotid endarterectomy complications might be reduced by selectively shunting only for severe persisting ischemia. Monitoring of cerebral ischemia would be essential to selective shunting.

Surgical risk of hemorrhage in cerebral amyloid angiopathy.

Cerebral amyloid angiopathy is increasingly recognized as a cause of lobar cerebral hemorrhage in normotensive elderly individuals. Isolated reports have suggested that neurosurgical intervention entails a high risk of precipitated hemorrhage. We identified 16 pathologically confirmed cases of cerebral amyloid angiopathy. Fourteen of these patients presented with lobar cerebral hemorrhage. Fifteen neurosurgical procedures in eight patients included eight clot evacuations, three abscess drainage procedures, two ventriculoperitoneal shunts, one biopsy, and one lobectomy. Recurrent postoperative cerebral hemorrhage was seen in four patients at 2 days, 9 days, 6 weeks, and 10 months, but surgery was thought to have precipitated the cerebral hemorrhage in only one patient. Recurrent cerebral hemorrhage also was seen in two of the eight nonoperated cases. Recurrent cerebral hemorrhage is characteristic of cerebral amyloid angiopathy, but we conclude that neurosurgical intervention, particularly evacuation of hematomas, is not associated with major risk of precipitated hemorrhage.

CEREBRAL HEMORRHAGE IN CAROTID ARTERY SURGERY.

Introduction In the course of evaluating surgical treatment in 900 patients with internal carotid artery stenosis or occlusion, we have encountered six who developed postoperative cerebral hemorrhage. It appears to us that a report of this complication is of special importance in view of the increasing use of this mode of therapy. We believe that there is a particular group of patients in whom the timing of operation for re-establishing adequate blood flow is an important consideration. In all of these six cases, the vessel operated upon was found to be patent, either by postoperative arteriog raphy or at autopsy. All of the patients were conscious after surgery and were showing clinical improvement and were well enough to be out of bed before complication occurred. One of them was on his way home after being discharged from the hospital. As yet, we do not have a definitive explanation for this