Underwent Hematoma Evacuation Research Articles

Computed tomography angiography based emergency microsurgery for massive intracranial hematoma arising from arteriovenous malformations

Digital subtraction angiography (DSA) and magnetic resonance angiography are the imaging modalities for the detection of intracranial arteriovenous malformations. However, these modalities are time consuming and cannot be used in emergency conditions. Computed tomography angiography (CTA) has also been shown to reliably detect vascular disorders such as cerebral arteriovenous malformations (AVMs). The purpose of this study was to evaluate the usefulness CTA in the surgical treatment of AVMs and the hematoma evacuation. Case records of 18 patients with massive intracranial hematoma secondary to AVMs were retrospectively reviewed. All patients had emergent brain CT and CTA. Follow-up DSA was performed two to three weeks after surgery. The outcome was assessed using Glasgow Outcome Scale (GOS). Results : Emergent CTA demonstrated AVMs and defined the feeding arteries, abnormal vascular nest, and draining veins in all the patients. Fourteen patients underwent hematoma evacuation and total resection of the AVMs, and four patients had hematoma evacuation and a partial resection. Follow-up DSA demonstrated complete resection of AVM in 14/18 patients and partial resection in 4 patients. There were no deaths and none of the patients had rebleeding in the follow up. A GOS scores during follow-up were: GOS 3 in 12 patients, GOS 4 in 4 patients and GOS 2 in 2 patients. CTA can be a reliable and rapid diagnostic tool for detecting underlying AVM in patients presenting with intracranial hematoma and for the pretreatment planning of emergency craniotomy.

Neurosurgical Outcomes After Intracerebral Hemorrhage: Results of the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST)

The value of neurosurgical interventions after spontaneous intracerebral hemorrhage (SICH) is uncertain. We evaluated clinical outcomes in patients diagnosed with SICH within 3 hours of symptom onset who underwent hematoma evacuation or external ventricular drainage (EVD) of the hematoma in the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). FAST was a randomized, multicenter, double-blind, placebo-controlled trial conducted between May 2005 and February 2007 at 122 sites in 22 countries. Neurosurgical procedures (hematoma evacuation and external ventricular drainage) performed at any point after hospital admission were prospectively recorded. Clinical outcomes evaluated were post-SICH disability, as assessed by the modified Rankin Scale; neurologic impairment, as assessed by the National Institutes of Health Stroke Scale; and mortality at 90 days after SICH onset. The impact of neurosurgical procedures on clinical outcomes was evaluated using multivariate logistic regression analysis, controlling for relevant baseline characteristics. Fifty-five of 821 patients underwent neurosurgery. Patients who underwent hematoma evacuation or EVD were on average younger, had greater baseline neurologic impairment, and lower levels of consciousness compared with patients who did not undergo neurosurgery. After adjusting for these differences and other relevant baseline characteristics, we found that neurosurgery was generally associated with unfavorable outcomes at day 90. Among the patients who underwent hematoma evacuation, those with lobar ICH had less ICH expansion than those with deep gray matter ICH, and the smaller expansion was associated with lower mortality. ICH volume was substantially decreased in patients who underwent hematoma evacuation between 24 and 72 hours after hospital admission, and this was associated with better clinical outcome. In conclusion, a small number of patients who underwent neurosurgery in FAST exhibited no overall clinical benefit from neurosurgical intervention, although outcomes varied by type of surgery, time of surgery, and hematoma location. Our findings support the need for further research into the value of neurosurgery in patients with SICH.

出血発症の重症脳／硬膜動静脈奇形に対する超急性期治療

As most of cerebral arteriovenous malformations (AVMs) and dural AVMs (dAVM) are electively treated, their urgent treatment has been rarely reported. We therefore sought to evaluate the clinical characteristics and treatment strategy for comatose patients with AVM/dAVM transported by ambulance. Within the past 10 years, 36 patients with AVM/dAVM (30 AVM and 6 dAVM, 21 men and 15 women with an average age of 48.6 years) have arrived at our institution. Among these, 23 patients had a Glasgow Coma Scale (GCS) grade of 6 or less and 16 patients presented with pupillary abnormality. The average amount of intracerebral hematoma was 44.2 ml. The AVM was removed after cerebral angiography in 19 patients, whereas 8 underwent hematoma evacuation and 3 underwent ventricular drainage prior to angiography. An AVM was simultaneously extirpated in 6 patients at the initial craniotomy without angiography, 4 of which were preoperatively diagnosed as hypertensive cerebral hemorrhage. The Spetzler-Martin Grade was I in 9, II in 16, III in 4 and V in 1 patient, respectively. The AVM/dAVM was extirpated in 32 patients. The average time from arrival to emergency surgery was 213 minutes. Massive cerebral hematoma tended to be caused by small AVM. Their modified Rankin Scale assessed at discharge was 0 in 3, 1 in 6, 2 in 2, 3 in 1, 4 in 4, 5 in 12, 6 in 6 patients, respectively. Poor outcome was related to older age, poor GCS and Apache II score, and large amount of hematoma volume. Prompt resuscitation and surgical decompression along with neurointensive care appeared to be mandatory to save these AVM/dAVM patients showing impending herniation.

ＣＴ ａｎｇｉｏｇｒａｐｈｙで破裂性中大脳動脈瘤が疑われた高血圧性脳内出血の１例

A 73-year-old male presented with hypertensive intracerebral hemorrhage that mimicked middle cerebral artery aneurysm on CT angiography. Nonenhanced CT showed hemorrhage in the right basal ganglia with extension to the sylvian fissure. CT angiography (CTA) revealed an aneurysm-like enhancement adjacent to the right M3 branch to M4. The location of the lesion was atypical and the neck was obscure for a middle cerebral artery aneurysm. On CTA performed 1.5 hour after initial CTA, the aneurysm-like enhancement had vanished. The patient underwent hematoma evacuation by craniotomy. No aneurysm was found in an intraoperative view or on digital subtraction angiography performed after the operation. We considered the aneurysm-like enhancement on CTA as contrast extravasation in the acute stage of hypertensive intracerebral hemorrhage.

Apoptosis as a Form of Cell Death in Intracerebral Hemorrhage

The goals of this study were to identify and quantify the presence of programmed cell death (apoptosis) in intracerebral hemorrhage (ICH) among human subjects. Recent evidence from laboratory models suggests that cell death in the perihematoma region may involve apoptosis. Retrospective clinical and histological analyses were performed for patients with spontaneous ICH who underwent surgical evacuation. Quantification of apoptotic cells was performed in sections obtained from the perihematoma region from 12 patients with ICH and stained with the terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling method. Necrosis was identified on the basis of morphological criteria, using hematoxylin and eosin staining. Evidence of apoptosis was present in surgical specimens obtained from 10 of the 12 patients. The mean number of apoptotic cells in the perihematoma region in each patient specimen was 38% (range, 0-90%). For five patients, more than one-half of the total cells observed were apoptotic. Apoptosis was observed in specimens obtained within 1 day, 2 days, and 5 days after the onset of symptoms. No terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling-positive cells were observed in specimens from the two patients with cerebellar hematomas. The mean proportion of necrotic cells in the perihematoma region in each patient specimen was 25% (range, 0-100%). There was a prominent excess of apoptotic cells, in comparison with necrotic cells, for 6 of the 12 patients who underwent hematoma evacuation. For five other patients, similar proportions of apoptotic and necrotic cells were observed. Necrosis was the predominant finding for only one patient, who underwent late surgical evacuation on Day 5. These observations suggest that apoptosis represents a prominent form of cell death associated with ICH in the perihematoma region. Further studies are required to define the mediators of apoptosis in ICH.

Acute subdural hematoma caused by ruptured cerebral aneurysms: diagnostic and therapeutic pitfalls

On rare occasions, rupture of a cerebral aneurysm causes acute subdural hematoma (SDH) in addition to subarachnoid hemorrhage (SAH). The frequency of SDH resulting from aneurysmal rupture is summarized, and its clinical and radiological characteristics, as well as potential pitfalls in the diagnosis and the management of this life-threatening condition are described. Among 641 patients with nontraumatic SAH treated between 1992 and 2000, 12 patients (1.9%) presented with SDH due to aneurysmal rupture. The SAH grade on admission was grade II in one patient, grade IV in three patients, and grade V in eight patients. Four underwent both hematoma evacuation and clipping of the aneurysm, four underwent hematoma evacuation alone, and the other four patients were treated conservatively. The outcome was good recovery in two patients, severe disability in one patient, and death in nine patients. Patients with a good outcome had a better SAH grade on admission, smaller midline shift, and smaller SDH volume on the initial CT scan, and they had been treated by both SDH evacuation and clipping of the aneurysm. Emergency one-stage operations may be beneficial for aneurysmal SDH patients who are in good SAH grade, or those who are in poor SAH grade but show some neurological recovery after resuscitation. It should also be mentioned that there are cases of aneurysmal SDH without recognizable SAH on the CT scans, and that a case of aneurysmal SDH may present as a case of ‘head trauma’ after an accident, because of the disturbance of consciousness resulting from aneurysmal rupture.