Surgery For Subarachnoid Hemorrhage Research Articles

Craniotomy Clipping for Cerebral Aneurysms

Preoperative simulation is essential to safely complete neurosurgical procedures. A vascular-oriented approach is important in cerebrovascular disorder surgery, considering anatomical variations among individuals. Particularly, subarachnoid hemorrhage surgery requires a detailed simulation of a safe dissection procedure, considering the rupture point of the aneurysm, and combined computed tomography or magnetic resonance imaging images with cerebral angiography can be useful. We present a case of subarachnoid hemorrhage and introduce the preoperative simulation performed at our hospital.

Subarachnoid Hemorrhage Following Drainage of Chronic Subdural Hematoma: A Case Report

Background: Acute subarachnoid hemorrhage (SAH) is a rare but severe complication after burr hole surgery for Subarachnoid hemorrhage (CSDH). Case presentation: An 86-year-old male was found fainted. Computed tomography (CT) scans showed a right fronto-temporo-parietal CSDH with a shift in the midline structures. Under local anesthetic with medical sedation a closed-system drainage of the hematoma was performed via one burr hole. Two days after surgery the patient complained of headache and a subsequent CT scan revealed SAH. The presence of intracranial aneurysms was excluded by CT angiogram. The patient survived with medical management.

Contrast-Induced Acute Kidney Injury in Patients Followed at the Intensive Care Unit after Aneurysmal Subarachnoid Haemorrhage (Fisher Grade IV) Surgery:A Retrospective Study

Background: Contrast-enhanced imaging studies are widely used to diagnose and follow up acute cerebrovascular diseases. Exposure to contrast media may lead to nephropathy. This study investigated the incidence of contrast-induced acute kidney injury during intensive care follow-up of patients who underwent aneurysmal subarachnoid haemorrhage surgery and the impact of this condition on patient outcomes.
 Material and Methods: Patients >18 years of age with no known renal injury and admitted to the intensive care unit after Fisher Grade IV aneurysmal subarachnoid haemorrhage and surgery between January 2017 and June 2022 were retrospectively analysed. Renal injury was defined as a renal injury occurring within 48 hours of exposure to contrast media in line with the Kidney Disease Improving Global Outcomes criteria.
 Results: Among the 85 patients with subarachnoid haemorrhage who received at least one contrast medium, the mean age was 55, and 40% were female. 11.8% of the patients were found to have early acute kidney injury and were non-oliguric. At 48 hours, six, three, and one patients had Stage 1, 2, and 3 injuries, respectively. None of the patients required renal replacement therapy. Patients received a mean of 2 mL/kg/h saline infusion after contrast media administration and had a mean arterial pressure of 93.6 mmHg. There was no association between acute kidney injury and comorbidities, Glasgow coma scale, or APACHE II scores.
 Conclusions: The study found that the incidence of contrast-induced acute kidney injury was low and transient in patients followed at the ICU after aneurysmal subarachnoid haemorrhage (Fisher Grade IV) surgery. Adequate hydration and hemodynamic stability were found to be effective in reducing acute kidney injury in these patients.

Effects of postoperative lateral positioning on outcomes of patients with subarachnoid hemorrhage

Purpose: This study was conducted to investigate the effects of postoperative lateral positioning on the patients’ outcomes with subarachnoid hemorrhage. 
 Materials and Methods: This study, which is a randomized controlled intervention study, was conducted with 42 (experimental group: 21, control group: 21) patients who underwent subarachnoid hemorrhage surgery in the neurosurgery intensive care unit of a university hospital and met the sampling criteria. In the study, "Patient Descriptive Information Form" and "Patient Results Form" were used as data collection tools. A total of 42 patients operated on for subarachnoid hemorrhage were included in the study. While the patients in the intervention group were placed in the left lateral, right lateral, and semi-fowler position (30 degrees) every 2 to 4 hours for the first 72 hours, those in the control group were routinely placed in the semi-fowler position (20 to 45 degrees). 
 Results: The power of hydrogen value and partial oxygen pressure and arterial oxygen saturation at the 48th hour in the intervention group were statistically significantly higher than the control group at the 72nd hour. In the intervention group, a slight decrease was observed only in the heart rate at 72 hours, which was near normal.
 Conclusion: Lateral and semi-fowler positions with a 2 to 4 hour interval contributed to improved oxygenation and prevented secondary complications of subarachnoid hemorrhage.

Timing of aneurysm treatment in subarachnoid hemorrhage and grade of functional capacity at discharge: a retrospective cohort study

BackgroundAneurysmal subarachnoid hemorrhage (SAH) is a vascular pathology with high morbidity and mortality that requires timely management to reduce the risk of complications. However, the ideal time for aneurysm clipping is still controversial. This study aimed to compare the degree of functional capacity at discharge of patients who underwent surgery for rupture of a cerebral aneurysm at different periods of time until surgery.Results132 patients who underwent surgery for SAH due to aneurysm rupture were included. The mean age was 52.5 years and 69.7% of participants were female. At admission, 96.2% were given a score of 1–3 on the World Federation of Neurological Surgeons scale and 79.6% received a score of 1–2 on the Hunt Hess scale. 8.3% of cases underwent surgery within the first 3 days of bleeding. The average time from clinical manifestation to surgical intervention was 7.1 days. At discharge 77.27% of patients presented good functional capacity. After adjusting for confounders, multivariate analysis showed a trend towards increased, albeit not statistically significant, risk in patients undergoing surgery at between 4 and 10 days (RR = 2.95 95% CI 0.80–10.87) and at > 10 days after SAH (RR = 2.65. 95% CI 0.72–9.79).ConclusionsDespite the trend towards a higher probability of presenting poor functional capacity at discharge in patients undergoing aneurysm clipping more than 3 days after SAH, the differences were not statistically significant. There is a need for prospective randomized studies evaluating the best time to clip aneurysms, since aneurysm clipping is still a routine procedure in many countries.

Pretreatment with Clodronate Improved Neurological Function by Preventing Reduction of Posthemorrhagic Cerebral Blood Flow in Experimental Subarachnoid Hemorrhage.

Brain perivascular macrophages (PVMs) are potential treatment targets for subarachnoid hemorrhage (SAH), and previous studies revealed that their depletion by clodronate (CLD) improved outcomes after experimental SAH. However, the underlying mechanisms are not well understood. Therefore, we investigated whether reducing PVMs by CLD pretreatment improves SAH prognosis by inhibiting posthemorrhagic impairment of cerebral blood flow (CBF). In total, 80 male Sprague-Dawley rats received an intracerebroventricular injection of the vehicle (liposomes) or CLD. Subsequently, the rats were categorized into the prechiasmatic saline injection (sham) and blood injection (SAH) groups after 72h. We assessed its effects on weak and severe SAH, which were induced by 200- and 300-µL arterial blood injections, respectively. In addition, neurological function at 72h and CBF changes from before the intervention to 5min after were assessed in rats after sham/SAH induction as the primary and secondary end points, respectively. CLD significantly reduced PVMs before SAH induction. Although pretreatment with CLD in the weak SAH group provided no additive effects on the primary end point, rats in the severe SAH group showed significant improvement in the rotarod test. In the severe SAH group, CLD inhibited acute reduction of CBF and tended to decrease hypoxia-inducible factor 1α expression. Furthermore, CLD reduced the number of PVMs in rats subjected to sham and SAH surgery, although no effects were observed in oxidative stress and inflammation. Our study proposes that pretreatment with CLD-targeting PVMs can improve the prognosis of severe SAH through a candidate mechanism of inhibition of posthemorrhagic CBF reduction.

A Case of Subarachnoid Haemorrhage and Postop Cerebral Vasospasm Successfully Healed Using Yoga Prana Vidya Energy Healing Techniques as Complementary Therapy

Introduction: Subarachnoid haemorrhage (SAH) refers to the bleeding in the space surrounding the brain and its membrane and occurs usually due to the bulging or ruptures in the blood vessels of the brain. Following SAH, cerebral vasospasm can occur which can lead to sudden death or brain damage if not treated correctly and immediately. This paper presents a case of a 35 years old male patient with SAH & cerebral vasospasm, who completely recovered after a successful surgery, and using Yoga Prana Vidya Healing techniques as complementary therapy. Method: This paper uses case study method going through patient medical records, YPV healers’ records and patient feedback. Results: The patient recovered within 4 hours from a complicated 7+ hours of SAH surgery, was able to recognize people and respond to body movements and also use the washroom comfort ability by himself. Within 14 days of YPV healing, the patient was discharged from the hospital and within 2 months of the surgery the patient resumed office and started leading normal life. Conclusion: It is observed that with Yoga Prana Vidya, which is a no-touch no-drug and distant healing modality, faster and complete recovery of patients takes place when used complementarily to medical and surgical treatments such as this case. YPV Healing techniques have been known to increase the life energy or prana in the energy body of a person thereby helping them with a speedy recovery. There is a great scope for further research on this topic using appropriate methodology and sample size.

Edaravone Dexborneol Treatment Attenuates Neuronal Apoptosis and Improves Neurological Function by Suppressing 4-HNE-Associated Oxidative Stress After Subarachnoid Hemorrhage.

Edaravone dexborneol is a novel neuroprotective drug that comprises edaravone and (+)-borneol in a 4:1 ratio. Phase II and III studies have demonstrated that Chinese patients treated with edaravone dexborneol within 48 h of AIS onset have better functional outcomes than those treated with edaravone alone. However, the effect of edaravone dexborneol on subarachnoid hemorrhage (SAH) has not yet been elucidated. This study aimed to investigate the therapeutic effects of edaravone dexborneol on SAH-induced brain injury and long-term behavioral deficits and to explore the possible mechanisms. The experimental rat SAH model was induced by an intraluminal puncture of the left middle cerebral artery (MCA). Edaravone dexborneol or edaravone at a clinical dose was infused into the tail vein for 3 days post-SAH surgery. Behavioral outcomes were assessed by a modified Garcia scoring system and rotarod, foot-fault, and corner tests. Immunofluorescence, Western blot, and ELISA methods were used to evaluate neuronal damage and oxidative stress. Our results showed that a post-SAH therapeutic regimen with edaravone dexborneol helped improve neurological function up to 21 days after SAH surgery and demonstrated a greater beneficial effect than edaravone alone, accompanied by an obvious inhibition of neuronal apoptosis in the CA1 hippocampus and basal cortex regions. Mechanistically, edaravone dexborneol not only suppressed the lipid peroxidation product malondialdehyde (MDA) but also improved the total antioxidant capability (TAC) 3 days after SAH. Notably, edaravone dexborneol treatment significantly inhibited the expression of another lipid peroxidation product, 4-hydroxynonenal (4-HNE), in the CA1 hippocampus and basal cortex, which are vital participants in the process of neuronal oxidative damage and death after SAH because of their acute cytotoxicity. Together, our results demonstrate that edaravone dexborneol confers neuroprotection and stabilizes long-term behavioral ability after SAH injury, possibly by suppressing 4-HNE-associated oxidative stress. These results may help develop new clinical strategies for SAH treatment.

Burrowing behaviour of rats: Strain differences and applicability as well-being parameter after intracranial surgery.

In mice, burrowing is considered a species-typical parameter for assessing well-being, while this is less clear in rats. This exploratory study evaluated burrowing behaviour in three rat strains during training and in the direct postoperative phase after complex intracranial surgery in different neuroscience rat models established at Hannover Medical School or Aachen University Hospital. Male Crl:CD (SD; n = 18), BDIX/UlmHanZtm (BDIX; n = 8) and RjHan:WI (Wistar; n = 35) rats were individually trained to burrow gravel out of a tube on four consecutive days. Thereafter, BDIX rats were subjected to intracranial injection of BT4Ca cells and tumour resection (rat glioma model), SD rats to injection of 6-hydroxydopamine (6-OHDA) or vehicle (rat Parkinson's disease model) and Wistar rats to endovascular perforation or sham surgery (rat subarachnoid haemorrhage (SAH) model). Burrowing was retested on the day after surgery. During training, BDIX rats burrowed large amounts (mean of 2370 g on the fourth day), while SD and Wistar rats burrowed less gravel (means of 846 and 520 g, respectively). Burrowing increased significantly during training only in Wistar rats. Complex surgery, that is, tumour resection (BDIX), 6-OHDA injection (SD) and endovascular perforation or sham surgery for SAH (Wistar) significantly reduced burrowing and body weight, while simple stereotactic injection of tumour cells or vehicle did not affect burrowing. Despite the training, burrowing differed between the strains. In the direct postoperative phase, burrowing was reduced after complex surgery, indicating reduced well-being. Reduced burrowing was accompanied with postoperative weight loss, a validated and recognised quantitative measure for severity assessment.

Modified Glasgow coma scale for predicting outcome after subarachnoid hemorrhage surgery

There are many grading scales that attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH). Most scales used to assess outcome are based on the neurological status of the patient. Here, we propose a new scale for aSAH patients that combines the Glasgow Coma Scale (GCS) and the modified Fisher scale (mFS).Five hundred ninety-seven patients with aSAH who were treated at our institution between January 2008 and December 2017 were retrospectively analyzed. Initial GCS score, Hunt and Hess scale, World Federation of Neurosurgical Societies scale, mFS, and modified Rankin Scale were obtained by reviewing data. Incidence of vasospasm was investigated. Factors found to be significant on a multivariable regression analysis were used to develop a scale that was compared with other grading systems using the area under the curve (AUC) calculated from receiver operating characteristic curve.The GCS score and mFS were related to outcomes in patients with aSAH. A simple score, which we call the GCS-F score, was calculated using these initial data. The GCS-F score had an AUC of 90.5% for unfavorable outcome prediction, and 88.4% for in-hospital mortality prediction. On the receiver operating characteristic curve analysis for vasospasm, the AUC for World Federation of Neurosurgical Societies, mFS and GCS-F scores were 0.912, 0.704, and 0.936, respectively.A simple arithmetic combination of the GCS score and mFS, the GCS-F score, includes the radiographic status as well as the clinical status of the patient, so that the state of the patient can be known in more detail than other single scales. The GCS-F score may be a useful scale for predicting outcome and the occurrence of vasospasm in patients with aSAH.

Role of Endothelial Nitric Oxide Synthase in Isoflurane Conditioning-Induced Neurovascular Protection in Subarachnoid Hemorrhage.

BackgroundDelayed cerebral ischemia remains a common and profound risk factor for poor outcome after subarachnoid hemorrhage (SAH). The aim of our current study is to define the role of endothelial nitric oxide synthase (eNOS) in isoflurane conditioning‐induced neurovascular protection after SAH.Methods and ResultsTen‐ to 14‐week‐old male wild‐type mice (C57BL/6) as controls and eNOS knockout male mice (strain # 002684) were obtained for the study. Animals underwent either sham surgery, SAH surgery, or SAH with isoflurane conditioning. Anesthetic post conditioning was performed with isoflurane 2% for 1 hour, 1 hour after SAH. Normothermia was maintained with the homeothermic blanket. In a separate cohort, nitric oxide synthase was inhibited by a pan nitric oxide synthase inhibitor, L‐nitroarginine methyl ester. Vasospasm measurement was assessed 72 hours after SAH and neurological function was assessed daily. Isoflurane‐induced changes in the eNOS protein expression were measured. eNOS protein expression was significantly increased by isoflurane conditioning in naïve mice as well as mice subjected to SAH. Vasospasm of the middle cerebral artery and neurological deficits were evident following SAH versus sham surgery, both in wild‐type mice and eNOS knockout mice. Isoflurane conditioning attenuated vasospasm and neurological deficits in wild‐type mice. This delayed cerebral ischemia protection was lost in L‐nitroarginine methyl ester ‐administered mice and eNOS knockout mice.ConclusionsOur data indicate isoflurane conditioning provides robust protection against SAH‐induced vasospasm and neurological deficits, and that this delayed cerebral ischemia protection is critically mediated via isoflurane‐induced augmentation of eNOS.

An Evaluation of the Practice for the Requisition of Blood Products and its Utilization in Neurosurgical Patients Undergoing Elective Surgery at a Tertiary Care Hospital.

Background:Neurosurgical procedures are associated with profound blood loss that necessitates need for intraoperative and postoperative blood transfusion. Excessive ordering of blood based on physicians' habitual practice may lead to unintentional misuse of blood bank services. For the optimal use of blood resources, transfusion practices have to be appropriate.Aims:The aim of this study is to study the cross match to transfusion ratio and to review the blood utilization practices (transfusion index and maximal surgical blood order schedule) in elective neurosurgical procedures.Settings and Design:A prospective, observational study comprising 740 patients undergoing elective neurosurgical procedures.Materials and Methods:Blood requisition forms and patient records were analyzed of patients undergoing elective neurosurgical procedures from December 2017 to December 2018. A review and note was made of the patient's age, sex, and diagnosis. The number of units prepared, cross matched, and transfused were noted.Statistical Analysis:Statistical analysis was performed with the IBM SPSS software version 21.0. Blood utilization indices were computed and expressed as percentage.Results:A total of 740 patients underwent elective surgical procedures. Among these, 346 patients were requested to prepare 614 units of blood. Out of these 740 patients, there were 56 patients who were in the pediatric age group. A total of 178 units were transfused in 102 patients. One hundred and forty-two units were transfused in the intraoperative period, whereas as 36 units were transfused in the postoperative period.Conclusion:There is an efficient usage of blood for patients undergoing surgery for meningiomas, posterior fossa tumors, spinal dysraphism, and craniovertrebral junctional anomalies. However, the blood resources were poorly utilized in patients undergoing surgery for subarachnoid hemorrhage and pituitary tumors. A revision of blood transfusion policy within the hospital is needed.

Effects of Single Dose of Dexamethasone on Perioperative Blood Glucose Levels in Patients Undergoing Surgery for Supratentorial Tumors - An Observational Study.

Introduction:Dexamethasone is commonly administered in intracranial tumors to reduce the cerebral edema. Its administration may be associated with hyperglycemia. The primary objective of this study was to study the magnitude of rise in blood sugar levels following the administration of a single 10 mg dose of dexamethasone.Methods:Seventy patients who underwent various neurosurgical procedures were enrolled in the study. Group D (n = 35 undergoing surgery for intracranial tumors) were administered injection dexamethasone 10 mg while as Group P (n = 35 undergoing surgery for subarachnoid hemorrhage) received placebo. Blood samples were obtained through the arterial line at baseline (before dexamethasone administration), 60, 120, 180, and 240 min after the dexamethasone administration and blood glucose concentrations noted.Results:Glucose concentrations were significantly increased in patients who received dexamethasone compared with those who received placebo (P < 0.05). Blood glucose concentrations at different time intervals were greater when compared with the baseline blood sugar levels in both the placebo and dexamethasone group (P < 0.05). The arterial blood glucose concentration in those who received 10 mg dexamethasone (n = 35) increased from 95.29 ± 13.69 mg.dl−1 to 139.97 ± 10.34 mg.dl−1 over 4 h, compared with a change from 94.74 ± 10.05 mg.dl−1 to 122.34 ± 10.68 mg.dl−1 in those who received placebo (n = 35) (P < 0.05).Conclusion:The administration of a single intravenous dose of 10-mg dose dexamethasone caused a significant increase in the blood glucose concentrations at different point intervals when compared with the placebo over a 4-h period. We recommend intensive monitoring of the blood sugar levels during the intraoperative period to prevent the development of severe hyperglycemia and its associated complications.

Rupture of cerebral aneurysm during pregnancy: a case report

The most common cause of subarachnoid hemorrhage at the period of pregnancy and during puerperium is rupture of an intracranial aneurysm. It is five times more common in pregnant women than in non-pregnant women. This pathology is more common in primiparous women and in the third trimester of pregnancy. A 37-year-old woman who was admitted to the emergency department with sudden-onset headache and loss of consciousness was diagnosed with intracranial hemorrhage due to middle cerebral artery aneurysm rupture. The patient, who gave birth with emergency cesarean delivery, underwent surgery for subarachnoid hemorrhage. The case is presented here because of its rarity.

Monitoring in the treatment of patients with aneurysmal and nonaneurysmal subarachnoid haemorrhage in terms of nursing care and therapy

Monitoring in the treatment of patients with aneurysmal and nonaneurysmal subarachnoid haemorrhage in terms of nursing care and therapy

Minocycline protects against delayed cerebral ischemia after subarachnoid hemorrhage via matrix metalloproteinase-9 inhibition.

ObjectiveDelayed cerebral ischemia (DCI) is an independent risk factor for poor outcome after aneurysmal subarachnoid hemorrhage (SAH) and is multifactorial in etiology. While prior studies have suggested a role for matrix metalloproteinase‐9 (MMP‐9) in early brain injury after SAH, its contribution to the pathophysiology of DCI is unclear.MethodsIn the first experiment, wild‐type (WT) and MMP‐9−/− mice were subjected to sham or endovascular perforation SAH surgery. In separate experiments, WT and MMP‐9−/−mice were administered vehicle or minocycline either pre‐ or post‐SAH. All mice underwent assessment of multiple components of DCI including vasospasm, neurobehavioral function, and microvessel thrombosis. In another experiment, rabbits were subjected to sham or cisterna magna injection SAH surgery, and administered vehicle or minocycline followed by vasospasm assessment.Results MMP‐9 expression and activity was increased after SAH. Genetic (MMP‐9−/− mice) and pharmacological (pre‐SAH minocycline administration) inhibition of MMP‐9 resulted in decreased vasospasm and neurobehavioral deficits. A therapeutically feasible strategy of post‐SAH administration of minocycline resulted in attenuation of multiple components of DCI. Minocycline administration to MMP‐9−/− mice did not yield additional protection. Consistent with experiments in mice, both pre‐ and post‐SAH administration of minocycline attenuated SAH‐induced vasospasm in rabbits.Interpretation MMP‐9 is a key player in the pathogenesis of DCI. The consistent attenuation of multiple components of DCI with both pre‐ and post‐SAH administration of minocycline across different species and experimental models of SAH, combined with the excellent safety profile of minocycline in humans suggest that a clinical trial in SAH patients is warranted.

379 Matrix Metalloproteinase-9

Abstract INTRODUCTION Delayed cerebral ischemia (DCI) is an independent risk factor for poor outcome after subarachnoid hemorrhage (SAH) and is multi-factorial in etiology. A few prior studies have suggested a key role for matrix metalloproteinase-9 (MMP-9) in the pathogenesis of early brain injury (EBI) after SAH. In contrast, the role of MMP-9 in DCI is poorly understood. In this study, we examined the contribution of MMP-9 to DCI after SAH. METHODS Wild type (WT) and MMP-9-/− mice were subjected to sham or endovascular perforation SAH surgery. Daily neurobehavioral assessments were performed, and vasospasm was assessed on post-SAH Day 3. MMP-9 expression and activity were also assessed. In separate experiments, WT mice or MMP-9-/− were administrated vehicle or Minocycline and subjected to vasospasm, neurobehavioral, and microthrombi assessments. In another experiment, male New Zealand White rabbits were subjected to sham surgery or cisterna magna injection SAH, and administered vehicle or Minocycline, followed by vasospasm assessment on post-SAH day 3. RESULTS &gt;SAH resulted in a significant increase in MMP-9 expression and activity. Genetic inhibition of MMP-9 (MMP-9-/− mice) and pharmacological inhibition of MMP-9 (pre-SAH Minocycline administration) resulted in significantly decreased vasospasm and neurobehavioral deficits after SAH. Post-SAH administration of Minocycline resulted in significant attenuation of multiple components of DCI including vasospasm, microthrombosis and neurobehavioral deficits. Consistent with experiments in mice both pre- and post-SAH administration of Minocycline attenuated vasospasm in rabbits. CONCLUSION Our study provides definitive mechanistic evidence that MMP-9 is a key player in the pathogenesis of DCI after SAH. We observed consistent attenuation of SAH-induced neurovascular deficits with both pre- and post-SAH administration of minocycline across different species and experimental models of SAH, and against multiple components of DCI. The excellent safety profile of minocycline in humans and promising results in experimental SAH studies suggest that a clinical trial in SAH patients is warranted.

Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal.

In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25ml (p=0.047, Mann-Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.

くも膜下出血術後7 日目にたこつぼ型心筋障害を発症し1 年以上左室収縮障害が遷延した1 例

くも膜下出血の術後7 日目にたこつぼ型心筋障害を発症し，その後1 年以上左室収縮障害が遷延した症例を経験した．症例は67 歳の女性で前交通動脈瘤の破裂によるくも膜下出血を発症し，同日動脈瘤クリッピング術を施行した．術後7 日目に突然胸部不快感を訴え，急性心不全状態となった．心電図検査，経胸壁超音波検査，冠動脈造影の結果たこつぼ型心筋障害と診断した．心筋逸脱酵素が高値を示し過換気負荷試験が陽性のため，冠攣縮が原因の急性心筋梗塞を合併したと考えた．くも膜下出血は順調に回復したが，たこつぼ型心筋障害は左室壁運動・心機能障害は改善なく，1 年後も同様の所見が継続した．たこつぼ型心筋障害にもかかわらず，左室壁運動・心機能障害が1 年以上継続した理由として冠攣縮による急性心筋梗塞が合併したためと考えた．

頭蓋形成術直後の予期せぬ合併症について(Unexpected complications immediately after cranioplasty)

要旨頭蓋形成術直後に脳浮腫と脳出血を認めた症例を報告する。症例は84歳，男性。くも膜下出血に対し開頭クリッピング術，外減圧術が施行され，第58病日に頭蓋形成術が施行された。術中は問題なく手術が終了したが，術直後の頭部CTにて脳浮腫，脳出血を認めた。その後浮腫は進行したが追加手術を施行することなく，浮腫は改善し神経症状は術前と変わらないまで改善し安定した。手術前後でperfusion MRIを施行し，病側の脳血流量・脳血液量が健側比で上昇を認め，無症候性のsinking skin flap syndrome（SSFS）であったと考えられた。頭蓋形成術直後に脳浮腫や脳出血を呈する原因は再灌流，自動調整能の低下，SSFS，皮下ドレーンによる陰圧，静脈鬱滞，正中偏位からの復元による血管損傷，アレルギー反応が原因と考えられる。この合併症による致死率は高い。頭蓋形成術は比較的容易な手術であり，合併症の多くは痙攣，感染，硬膜外血腫であるが，脳浮腫や脳出血が生じることも念頭に置き，術前に十分な説明をする必要があると考えられた。