Acute hydrocephalus after aneurysmal subarachnoid hemorrhage

Review of the literature regarding the relationship of rebleeding and external ventricular drainage in patients with subarachnoid hemorrhage of aneurysmal origin

Acute hydrocephalus is a well-documented complication of subarachnoid hemorrhage. The insertion of external ventricular drainage (EVD) has been the standard of care in the management of this complication, aiming primarily at immediate improvement of the clinical condition of these patients, making them more suitable candidates for surgical or endovascular intervention. In our current communication, we review the pertinent literature regarding the relationship of rebleeding and EVD. Several studies have implicated a significantly increased risk of rebleeding in patients with EVD, compared with patients without it. Abrupt lowering of the intracranial pressure could lead to rebleeding due to decreased transmural pressure or removal of the clot sealing the previously ruptured aneurysm. However, a variety of parameters that could affect the rebleeding rate, such as the timing of surgery, the timing and duration of drainage, the size of the aneurysm, as well as the severity of the initial hemorrhage, do not seem to have been adequately explored in the majority of these studies. In addition, a number of clinical trials have failed to provide evidence for the negative role of EVD in the development of rebleeding. Conclusively, further long-term multi-center studies are required in order to establish the exact nature of the relationship between EVD and rebleeding after aneurysmal subarachnoid hemorrhage.

Fenestration of the Lamina Terminalis as a Valuable Adjunct in Aneurysm Surgery

OBJECTIVE:

Hydrocephalus, vasospasm, and frontobasal injury are common complications after aneurysmal subarachnoid hemorrhage (SAH) from anterior communicating artery aneurysms. Previous studies have suggested that fenestration of the lamina terminalis (FLT) during surgery may be associated with reduced rates of shunt-dependent hydrocephalus and vasospasm. We report 106 patients affected by anterior communicating artery aneurysms and Fisher Grade 3 aneurysmal SAH and the affect of FLT on shunt-dependent hydrocephalus, vasospasm, and frontobasal injury.

METHODS:

During a 3-year period, 53 patients underwent FLT and 53 did not. We prospectively evaluated admission and discharge clinical grades, hydrocephalus at admission, occurrence of clinical vasospasm, need for interventional vasospasm therapy, frontobasal hypodensity incidence, and permanent ventriculoperitoneal shunting requirement. Follow-up ranged from 3 to 35 months (mean, 17.9 mo).

RESULTS:

Shunting incidence after aneurysmal SAH with hydrocephalus was 4.25% in patients who underwent FLT and 13.9% in patients who did not (P< 0.001). Clinical cerebral vasospasm occurred in 29.6% of patients who underwent FLT and in 54.7% of patients who did not (P< 0.001). Frontobasal hypodensity was identified postoperatively in 0% of patients who underwent FLT and in 5% of patients who did not. Good outcome was reported in 69.81% of patients who underwent FLT and in 33.96% of patients who did not (P< 0.001). Poor outcome was associated with higher Hunt and Hess grades, need for ventricular drainage, elevated intracranial pressure, and multiple interventional vasospasm therapies. No complications were linked to FLT.

CONCLUSION:

FLT was associated with statistically significant decreases in shunting rates, incidence of vasospasm, and better outcomes. We recommend its routine use in patients with Fisher Grade 3 anterior communicating artery aneurysmal SAH.

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

OBJECT

This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms.

METHODS

In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization.

CONCLUSIONS

Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

Poor-grade aneurysmal subarachnoid hemorrhage: relationship of cerebral metabolism to outcome

OBJECT

The majority of patients with poor-grade subarachnoid hemorrhage (SAH), that is, World Federation of Neurosurgical Societies (WFNS) Grades IV and V, have high morbidity and mortality rates. The objective of this study was to investigate cerebral metabolism in patients with low- compared with high-grade SAH by using bedside microdialysis and to evaluate whether microdialysis parameters are of prognostic value for outcome in SAH.

METHODS

A prospective investigation was conducted in 149 patients with SAH (mean age 50.9 +/- 12.9 years); these patients were studied for 162 +/- 84 hours (mean +/- standard deviation). Lesions were classified as low-grade SAH (WFNS Grades I-III, 89 patients) and high-grade SAH (WFNS Grade IV or V, 60 patients). After approval by the local ethics committee and consent from the patient or next of kin, a microdialysis catheter was inserted into the vascular territory of the aneurysm after clip placement. The microdialysates were analyzed hourly for extracellular glucose, lactate, lactate/pyruvate (L/P) ratio, glutamate, and glycerol. The 6- and 12-month outcomes according to the Glasgow Outcome Scale and functional disability according to the modified Rankin Scale were assessed. In patients with high-grade SAH, cerebral metabolism was severely deranged compared with those who suffered low-grade SAH, with high levels (p < 0.05) of lactate, a high L/P ratio, high levels of glycerol, and, although not significant, of glutamate. Univariate analysis revealed a relationship among hyperglycemia on admission, Fisher grade, and 12-month outcome (p < 0.005). In a multivariate regression analysis performed in 131 patients, the authors identified four independent predictors of poor outcome at 12 months, in the following order of significance: WFNS grade, patient age, L/P ratio, and glutamate (p < 0.03).

CONCLUSIONS

Microdialysis parameters reflected the severity of SAH. The L/P ratio was the best metabolic independent prognostic marker of 12-month outcome. A better understanding of the causes of deranged cerebral metabolism may allow the discovery of therapeutic options to improve the prognosis, especially in patients with high-grade SAH, in the future.

An overview of new pharmacological treatments for cerebrovascular dysfunction after experimental subarachnoid hemorrhage

Cerebral vasospasm and the resulting cerebral ischemia occurring after subarachnoid hemorrhage (SAH) are still responsible for the considerable morbidity and mortality in patients affected by cerebral aneurysms. Mechanisms contributing to the development of vasospasm, abnormal reactivity of cerebral arteries and cerebral ischemia after SAH have been intensively investigated in recent years. It has been suggested that the pathogenesis of vasospasm is related to a number of pathological processes, including endothelial damage, smooth muscle cell contraction resulting from spasmogenic substances generated during lyses of subarachnoid blood clots, changes in vascular responsiveness and inflammatory or immunological reactions of the vascular wall. A great deal of experimental and clinical research has been conducted in an effort to find ways to prevent these complications. However, to date, the main therapeutic interventions remain elusive and are limited to the manipulation of systemic blood pressure, alteration of blood volume or viscosity, and control of arterial dioxide tension. Even though no single pharmacological agent or treatment protocol has been identified which could prevent or reverse these deadly complications, a number of promising drugs have been investigated. Among these is the hormone erythropoietin (EPO), the main regulator of erythropoiesis. It has recently been found that EPO produces a neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is systemically administered. This topic review collects the relevant literature on the main investigative therapies for cerebrovascular dysfunction after aneurysmal SAH. In addition, it points out rHuEPO, which may hold promise in future clinical trials to prevent the occurrence of vasospasm and cerebral ischemia after SAH.

Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial

OBJECT

The goal of this study was to compare rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage (SAH) in a prospective, randomized trial.

METHODS

Between December 2001 and December 2002, 81 patients with aneurysmal SAH in whom external ventricular drains (EVDs) had been placed were enrolled in the study: 41 patients were randomized to the rapidly weaned group and 40 were randomized to the gradually weaned group. The two groups were well matched with respect to age, sex, posterior aneurysm location, Fisher grade, Hunt and Hess grade, intraventricular hemorrhage on admission, and hydrocephalus on admission. Rapid weaning was defined as weaning that occurred within 24 hours with immediate closure of the EVD, whereas gradual weaning took place over a 96-hour period with daily, sequential height elevations of the EVD system followed by drain closure for 24 hours. All patients in whom EVD weaning failed underwent shunt placement. Rates of shunt implantation, days in the intensive care unit (ICU), and overall duration of hospitalization were compared. There was no significant difference in rates of shunt implantation between the rapidly weaned (63.4%) and gradually weaned (62.5%) groups. Nevertheless, patients in the gradually weaned group spent a mean of 2.8 more days in the ICU (p = 0.0002) and 2.4 more days in the hospital (p = 0.0314) than patients in the rapidly weaned group.

CONCLUSIONS

Compared with rapid weaning, gradual, multistep EVD weaning provided no advantage to patients with aneurysmal SAH in preventing the need for long-term shunt placement and prolonged ICU and hospital stays.

Acute Syringomyelia: Case Report

OBJECTIVE AND IMPORTANCE

Syringomyelia is generally regarded as a chronic, slowly progressive disorder. We describe a case of acute dilation of the central canal of the spinal cord that presented with rapidly progressive segmental signs.

CLINICAL PRESENTATION

A 29-year-old female patient who had previously undergone surgical treatment for a Chiari I malformation, syringomyelia, and hydrocephalus presented with an 8-day history of headaches, progressive paraparesis, and urinary retention. Magnetic resonance imaging scans demonstrated panventricular hydrocephalus in association with a holocord syrinx that extended to the obex. Magnetic resonance imaging scans that had been coincidentally obtained just 3 days before the onset of symptoms had revealed no evidence of hydrocephalus or syringomyelia.

INTERVENTION

The patient underwent emergency revision of a failed ventriculoperitoneal shunt. Postoperatively, there was prompt resolution of the syringomyelia, hydrocephalus, and associated neurological deficits.

CONCLUSION

Among patients with communicating syringomyelia, the central canal of the spinal cord participates as a “fifth ventricle” and can undergo rapid dilation in association with acute hydrocephalus. Appropriate treatment in such cases involves placement of a ventriculoperitoneal shunt.

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion.

METHODS

Seven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system.

RESULTS

Overall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P < 0.001), 2) female sex (P = 0.015), 3) poor admission Hunt and Hess grade (P < 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P < 0.001), 5) intraventricular hemorrhage (P < 0.001), 6) radiological hydrocephalus at the time of admission (P < 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P = 0.046), 8) clinical vasospasm (P < 0.001), and 9) endovascular treatment (P = 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus.

CONCLUSION

The results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

[A study of 234 patients with subarachnoid hemorrhage of aneurysmic and cryptogenic origin]

INTRODUCTION

Subarachnoidal hemorrhage (SAH) is a medical emergency in all the patients. There are some known risk factors and, some complications associated to subarachnoid hemorrhage due to aneurysm rupture, being the rebleeding the main cause of mortality.

POPULATION AND METHODS

We performed a retrospective study of 234 patients with non traumatic SAH treated in the Hospital Clínic i Provincial of Barcelona from January 1993 to December 1999. Diagnosis of SAH was done by CT, and ethiological diagnosis by brain angiography. We pay attention to previous pathological history, Hunt-Hess, WFNS and Fisher scales, and we divided our population in two groups depending on the treatment (surgery or embolization). We analyzed SAH complications and GOS at discharge and in a year.

RESULTS

Population main age was 53.67 years-old (16-88 years-old). The relationship between male:female was 1:1.4. Almost out of 37% of the patients had previous history of high blood pressure, out of 25.9% were smokers. We saw a bleeding predominance within active hours (from 8:00 to 22:00), mostly during the morning (from 8:00 to 14:00). Between the complications associated to SAH, 45 patients (out of 19.2%) suffered clinical vasospasm, 24 patients (out of 10.25%) rebleeded, 61 patients (out of 26%) had some degree of hydrocephallus post-SAH, and 38 patients (out of 16.23%) had seizures. In 31 cases the bleeding pattern in CT scan was non-perimesencephalic (out of 62% of the 50 patients with negative angiography) and, in 19 cases (out of 38%) was perimesencephalic one. Patients with angiography had 150 aneurysms from anterior circulation and, 12 from posterior circulation. We performed surgery in ninety eight patients, and embolization in 38. We found among embolized patients a worse clinical status and massive hemorrhages than in surgery ones, and, those patients had higher mortality rates and severe sequelae.

DISCUSSION

We noticed that sex, pathological history and bleeding timing rates similar than previously published, either than SAH complications. We deeply analyzed those patients with negative angiography and their bleeding pattern, finding that a perimesencephalic bleeding pattern could be caused by an aneurysm, as nowadays publications point out. Due to the above reason we tried to perform a second angiography to every patient with a negative first one. We want to highlight among treated patients, those embolized had a most severe clinical status and then their prognosis and mortality rate was higher. Finally, surgical group, had a high rate of ischemic complications, and most part of this patients group didn't get a control angiography, thus lead us to change our policy, seeing the final results.

CONCLUSIONS

This study has been specially self-helpful in order to analyze our medical policy in front of this entity, and in this way, to elaborate a protocol of treatment taking account nowadays tendencies and our experience.

Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Associations among various factors and the occurrence of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) were evaluated retrospectively in 897 patients enrolled in the North American study of tirilazad mesylate.

METHODS

Patients were assessed for hydrocephalus in a blinded fashion. Assessment of hydrocephalus was made on the basis of 3-month follow-up computed tomographic studies or, for those without a 3-month follow-up scan, on the basis of the latest computed tomographic studies obtained at least 10 days after SAH. Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or prior placement of a ventricular shunt. Univariate analysis was performed to assess relationships among various factors and hydrocephalus. Factors statistically associated with the occurrence of hydrocephalus were analyzed further using logistic regression analysis.

RESULTS

Overall, 25.9% of the 897 patients developed hydrocephalus. Statistically significant associations among the following factors and hydrocephalus were observed (P value; risk coefficient): 1) severity of 3-month post-SAH Glasgow Outcome Scale (0.0001; 2.00); 2) increased ventricular size at admission (0.0001; 2.78); 3) neurological grade severity at admission (0.0274; 1.26); 4) preexisting hypertension (0.0284; 1.66); 5) alcoholism (0.0066; 2.30); 6) female sex (0.0056; 0.49); 7) increased aneurysm size (0.0239; 0.56); 8) pneumonia (0.0299; 1.78); 9) meningitis (0.0290; 5.86); and 10) intraventricular hemorrhage at admission (0.0414; 1.64).

CONCLUSION

Hydrocephalus seems to have a multifactorial etiology. Knowledge of risk factors related to the occurrence of hydrocephalus may help guide neurosurgeons in the long-term care of patients who have experienced aneurysmal SAH.

Development of obstructive hydrocephalus with lumboperitoneal shunting following subarachnoid hemorrhage

Hydrocephalus is a frequent complication of subarachnoid hemorrhage (SAH). The optimum method of treating hydrocephalus in this setting has not been determined. We review our experience with patients developing communicating hydrocephalus secondary to SAH and subsequently treated with lumboperitoneal (LP) shunts. Following hospitalization for the treatment of SAH, patients who developed clinical symptoms and radiologic signs of hydrocephalus were treated with (ventriculoperitoneal) VP or LP shunting. Eighteen patients received an LP shunt, of which seven (28%) developed a non-communicating or obstructive hydrocephalus. These seven patients underwent replacement with a VP shunt and have not had further complications. In the setting of post-SAH communicating hydrocephalus, obstructive hydrocephalus may develop after LP shunt placement. Patients who develop this complication and have their LP shunts converted to VP shunts have a favorable prognosis.

Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient

Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.

Patients in poor neurological condition after subarachnoid hemorrhage: early management and long-term outcome

We report management and outcome data on 118 patients that presented to our emergency room over a 4 year interval (1990-1994) in poor neurological condition after subarachnoid hemorrhage. All patients were treated following a strict protocol. After initial evaluation, patients underwent a head computerized tomography (CT) scan to try to understand the mechanism of coma. If CT did not show destruction of vital brain areas, a ventriculostomy was inserted and ICP measured. If ICP was less than 20 mm Hg, or if standard treatment of increased ICP was able to lower the ICP to a value less than 20 mmHg, patients were evaluated with cerebral angiogram to determine the location of the ruptured aneurysm. The lesion was then treated by craniotomy for aneurysm clipping or endovascular obliteration. Postoperative monitoring for vasospasm with clinical exam and transcranial doppler studies was performed routinely. If vasospasm developed, this was managed aggressively with hypertensive, hypervolemic and hemodilutional therapy and, at times, endovascular treatment with angioplasty or papaverine. Outcome was measured at 1 year or more after treatment. Among patients who met criteria for aneurysm treatment, 47% had excellent or good neurologic outcome. There was a 30% mortality rate in these patients. In patients with high ICP, poor brainstem function or destruction of vital brain areas on CT, comfort measures only were offered and almost all died. It is concluded that an approach of early aneurysm obliteration and aggressive medical and endovascular management of vasospasm is warranted in patients in poor neurological conditions after subarachnoid hemorrhage.

The safety of intraoperative lumbar subarachnoid drainage for acutely ruptured intracranial aneurysm: technical note

Recently, some concern has arisen regarding the safety of intraoperative spinal drainage for brain relaxation in aneurysm surgery, due to anecdotal association with both aneurysmal rebleeding and increases in symptomatic vasospasm. To address these concerns, we reviewed our experience with frequent spinal drainage and early surgery in 432 consecutive cases of surgically treated aneurysmal subarachnoid hemorrhage. Unless contraindicated by mass effect or associated pathology, all grade I-III patients referred within 14 days were treated with spinal drainage at surgery. In this cohort (n = 314), there were no cases of meningitis or nerve root injury. Only one case of intraoperative rebleeding could be associated with spinal drain placement (0.3%). In grade IV-V patients, 47% required preoperative ventriculostomy, and 11% were ineligible for spinal drainage due to mass effect. There were, however, no complications related to spinal drainage in the remaining 23 patients. Permanently-shunted hydrocephalus (8%) and symptomatic vasospasm (19%) were infrequent overall. When analyzed by grade, spinal drains were generally associated with equal or reduced incidence of these developments when compared to patients without spinal drainage. We conclude that brain relaxation can be safely and effectively obtained using intraoperative spinal drains during early aneurysm surgery.

The relationship of subarachnoid hemorrhage and the need for postoperative shunting

The incidence of chronic hydrocephalus requiring shunting after aneurysmal subarachnoid hemorrhage (SAH) is not precisely known. The authors investigated whether the need for ventriculoperitoneal (VP) shunting can be predicted by initial Hunt and Hess grade or Fisher computerized tomography score. One hundred eight patients who presented with SAH and underwent 116 surgical procedures for aneurysm clipping were evaluated retrospectively to determine the incidence of chronic hydrocephalus. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after the original hemorrhage and that required shunting. All SAH patients were managed in a similar fashion with induced hypervolemia, relative hemodilution, and hypertension complemented by a course of calcium channel blockers. The majority of patients underwent perioperative extracranial ventricular drainage to allow intraoperative brain relaxation and to assist intracranial pressure management. The overall mortality rate of the study group was 17%. Of the surviving patients, 20% underwent VP shunt placement secondary to chronic hydrocephalus. There were no statistically significant relationships between chronic hydrocephalus and patient age or gender, aneurysm type and size, or use of a perioperative drain. There was a high clinical correlation between chronic hydrocephalus and admission Hunt and Hess grades and Fisher grades (p < 0.05). All of the patients who survived a second bleeding episode and almost 46% of the patients who presented with intraventricular hemorrhage required placement of a VP shunt. The authors present predictive tables of chronic hydrocephalus based on the patient's admission Hunt and Hess grade and Fisher classification.

Cerebral vasospasm after subarachnoid haemorrhage of unknown aetiology: a clinical and transcranial Doppler study

Sixteen patients (6 women, 10 men; mean age: 52.5 years) suffering from spontaneous subarachnoid haemorrhage (SAH) of unknown origin underwent a protocol of initial and then weekly computed tomography (CT), initial four-vessel digital subtraction angiography (DSA) and at least one control pancerebral DSA. Fourteen patients had magnetic resonance imaging before undergoing first control DSA. All patients had calcium-antagonists (Nimodipine) via a central venous catheter, were kept on the neurosurgical intensive care unit and followed daily with transcranial Doppler ultrasonography (TCD). One patient (6.3%) developed moderate and 5 (31.1%) developed severe cerebral vasospasm as documented with TCD and exhibited deterioration of their level of consciousness. These 6 patients were treated with induced hypertension, hypervolaemia and haemodilution. Their blood flow velocities were elevated for a mean of 8 (5-17) days with a peak after 12.5 (9-17) days following SAH. No complications due to treatment were noted. One patient of the non-vasospastic group died of pulmonary embolism, another patient had an ischaemic incident during angiography, which has led to permanent disability. On follow-up 2-24 months after SAH 14 patients had returned to their premorbid state. It is concluded that patients suffering from SAH of unknown origin should undergo repeated angiographic investigation and subsequent daily monitoring of their neurologic status including daily TCD recordings so that haemodynamic treatment can be established in the event of cerebral vasospasm, which may occur in up to one third of these patients.

[Subarachnoid hemorrhage caused by aneurysm rupture. Surgery or embolization?]

Traditionally the aneurysms of the circle of Willis have been an indication for neurosurgery. New technologies of endovascular treatment with electrically detachable coils resulted in a different therapeutical concept since four years. A series including 140 patients has been treated in our institution from 1 January 1992 to 31 December 1994, 94 of them presenting with a subarachnoid haemorrhage. Out of these 140 patients, 84 were treated with surgery, 51 with the endovascular technique, five with surgery after incomplete or unsuccessful endovascular treatment. Surgery was indicated in patients presenting early after bleeding, devoid of vasospasm, with a favourable Hunt and Hess grading and in aneurysms located in the anterior part of the circle of Willis. Endovascular treatment was indicated in patients admitted with delay, with severe vasospasm, a poor Hunt and Hess grading and in all aneurysms of the vertebrobasilar arterial network. Age was of less importance in comparison to the status of the vessels for selection of the method of treatment. Giant aneurysms are difficult to treat as surgery is faced with the size of the aneurysmal itself and endovascular technique with the width of the aneurysmal neck.

Amount of subarachnoid blood and vasospasm: current aspects. A transcranial Doppler study

Subsequent to admission after aneurysmal subarachnoid haemorrhage (SAH), 120 patients (74 women and 46 men) underwent microsurgical clipping of a total of 158 cerebral aneurysms within 96 hours after the bleed. Their mean age was 46 (20-91) years. Computed tomography (CT) findings were graded according to the modified Fisher scale and all patients had daily transcranial doppler (TCD) recordings of their basal cerebral arteries. In 19% of SAH was grade I on CT, in 44% grade II and in 37% grade III. The rate of patients who developed severe vasospasm as documented by TCD (mean blood flow velocities exceeding 160 cm/s on 2 or more consecutive days) was 39% for grade I patients, 26% for grade II patients and 34% for patients with SAH grade III on the initial CT. There was no difference in the rate of occurrence of severe vasospasm, when the patients were split into 2 groups according to the time of performance of the initial CT scan-within 24 hours, and 48-80 hours after SAH, respectively. It is concluded that the amount of subarachnoid blood on the initial CT scan should no longer be used as the indicator for occurrence and severity of the multifactorial entity vasospasm.

Our policy in diagnosis and treatment of hydrocephalus

The authors present the policy they have worked out for hydrocephalus patients with special reference to the pressure measurement and test methods and to rCBF, SPECT and transcranial Doppler sonography (TDC) studies. For diagnosis, the protocol proposed by Gjerris and Borgesen was followed in 75 cases: besides other methods (CT, radionuclide cisternography, MRI) the intracranial pressure waves routinely recorded and analyzed by means of ventricular catheters for 24 h. The patients were roughly divided into groups in terms of diagnosis, baseline pressure, compliance, results of infusion tests and of surgery. In 13 patients the investigations were supplemented by rCBF SPECT and in 42 patients by TCD studies before and after CSF shunting or withdrawal to analyze the acute effects on cerebral circulation. Clinical follow-up shows that need for shunting was indicated fairly well by the common results of baseline ICP, compliance and infusion loading. The rCBF SPECT studies revealed a significant increase of the cerebral perfusion at the basal ganglia after shunting while, on the basis of CBF velocity changes three types of vasoregulatory response could be defined with TCD. In our hands, monitoring of the pressure and craniospinal capacity has proved to be a valuable aid in decisions on surgery; however, for a more precise (and beneficial) appreciation of whether surgery is indicated the vasoregulatory responses should also be taken into account in future.

Medical and surgical management of intracranial aneurysms

OBJECTIVE

To examine the medical and surgical aspects of intracranial aneurysms, including the pathogenesis, clinical manifestations, management of subarachnoid hemorrhage (SAH), and indications for surgical intervention.

DESIGN

This review presents the classification of intracranial aneurysms, defines specific aneurysms, and analyzes the Mayo Clinic experience with surgical treatment of cerebral aneurysms.

MATERIAL AND METHODS

Intracranial aneurysms are classified by cause, size, site, and shape. The clinical grading systems for SAH, the most common manifestation, are as follows: modified Botterell, Hunt and Hess, and World Federation of Neurological Surgeons. Surgical options are direct clipping, interventional neuroradiologic treatment, proximal ligation or trapping of aneurysms, and wrapping or coating of aneurysms. Although the timing of surgical intervention after SAH is controversial, it should be based on the clinical grade, site of the aneurysm, and patient's medical condition.

RESULTS

The frequency of intracranial aneurysms is estimated to be 1 to 8% in the general population, and 90% of patients have SAH. After SAH, 8 to 60% of patients die before they get to a hospital. After hospitalization, the mortality rate is 37%, severe disability is 17%, and outcome is favorable in 47%. The current trend for surgical treatment is early after SAH. The Mayo Clinic experience with 1,947 patients who underwent surgical treatment because of aneurysmal SAH or for aneurysmal repair between 1969 and 1990 is as follows: 1,445 had an excellent outcome, 231 had a good outcome, 171 had a poor outcome, and 100 died.

CONCLUSION

Aggressive management can be beneficial for many patients with severe neurologic injury after SAH by preventing rerupture of the aneurysm, attenuating the severity and sequelae of vasospasm, and decreasing the surgical complications.

Emergency ventriculostomy-experience with a new screw device: technical note

Emergency situations, such as acute hydrocephalus or ventricular hemorrhage, require immediate and reliable treatment by ventriculostomy. The method used has to be standardized, applicable in a fast manner, and associated with only minimum risk of infection. We present a recently developed set for external ventriculostomy, which meets the above-standing requirements, and which consists of a screw with self-biting thread, a metal cannula, and a special screwdriver. Ventriculostomy can be performed easily within 2 minutes, and the system can be fixed rigidly to the skull of the patient for a period of up to several weeks. Exchange of the cannula is possible within 1 minute. The system has been used in 90 cases so far, with a rate of possible infection of 1.1%.

Shunt-dependent hydrocephalus after subarachnoid haemorrhage and aneurysm surgery: timing of surgery is not a risk factor

Early hydrocephalus is a risk factor of shunt-dependent late hydrocephalus (SDHC). In the CT era 1980-1990 we had 835 consecutive patients operated on because of aneurysm and subarachnoid haemorrhage (SAH); 294 had an early hydrocephalus and 67 finally required a shunt. There were 14 patients with normal early CT and SDHC, in all 81 patients needed a shunt (10%). Patients with shunt did worse, they were older (53 vs 49) than the non-shunted group and there was a female preponderance. Pre-operative Grade correlated significantly with the need for a shunt operation; no one in Grade I developed SDHC, incidence in Grades III and IV was high (18% and 10%, respectively). Location was important; in vertebrobasilar area 28% and in anterior communicating area 14% but in middle cerebral area only 4% of the patients had SDHC. The amount of cisternal bleeding correlated significantly with SDHC; in 155 patients with non detectable or minimal cisternal blood only one developed SDHC, with severe cisternal bleeding the incidence was 16%. Ventricular bleeding increased the risk of SDHC, but intracerebral haematoma did not. Timing of surgery had no correlation with the risk of SDHC. Postoperative complications, haematomas and infections increased the risk of late SDHC. Delayed ischaemia correlated with the risk, but so did the treatment with nimodipine. Severe bleeding was the common predictor for the risk of SDHC. Location of the bleeding and postoperative problems are the other major causes. Outcome is, however, not so gloomy; 54% of patients with SDHC are independent one year later.

Traumatic subarachnoid haemorrhage: analysis of 89 cases

Between 1985 and 1990, 2056 patients with head injuries were treated in the Department of Neurosurgery at the Izmir State Hospital. Among them, 89 patients with traumatic subarachnoid haemorrhage (TSAH) were analysed retrospectively. It was noted that focal or global contusion accompanying TSAH was the most common pathology which could be detected in computer tomographic (CT) imaging. CT did not show any other intracranial lesion in 13 cases. Vasospasm developed in one patients and hydrocephalus in two others in the acute stage. Considering the relationship between the severity of a subarachnoid haemorrhage detected on CT and the mortality rate, it was seen that the mortality rate was higher in patients who suffered diffuse subarachnoid haemorrhage with intracerebral or intraventricular clots.

Outcome of patients with aneurysmal and presumed aneurysmal bleeding. A hospital study based on 100 consecutive cases in a neurological clinic

One hundred patients with spontaneous subarachnoid hemorrhage due to aneurysm or presumed aneurysm consecutively admitted to a neurological clinic and subjected to CCT during the first 72 hours were examined retrospectively. The outcome after two months as defined by the Glasgow Outcome Scale (GOS) was relatively good: 23% of the patients suffered management mortality (GOS I) (postoperative lethality 8%), 3% showed GOS-Grade II, 14% grade III, 17% grade IV, and 43% grade V. The extent of intracranial hemorrhage correlated well with the initial Hunt-Hess Grade which, in turn, had a strong influence on case fatality and the degree of disability. Lethal factors were: 1. massive subarachnoid hemorrhage together with a massive ventricular hemorrhage (p < 0.001), 2. massive subarachnoid hemorrhage together with an intracerebral hematoma > 20 ml (p < 0.05). Case fatality was lower when angiography was negative. In our study rebleeding (12%) and delayed cerebral ischemia (DCI) (18%) were less frequent and the lethality due to acute hydrocephalus (5%) and delayed cerebral ischemia (5%) was less pronounced than in comparable studies. The degree of disability (GOS) was directly related to the amount of intracranial blood, to the development of acute or chronic hydrocephalus, delayed cerebral ischemia and rebleeding. DCI occurred in 60% of patients with marked hydrocephalus. Rebleeding was more frequent in patients with acute hydrocephalus. Hydrocephalus, DCI, and rebleeding were associated with a poorer initial grade on the Hunt and Hess Scale.

Subacute hydrocephalus after experimental subarachnoid hemorrhage: its prevention by intrathecal fibrinolysis with recombinant tissue plasminogen activator

It is investigated whether intrathecal fibrinolysis may prevent subacute hydrocephalus after subarachnoid hemorrhage (SAH). In 19 cats, SAH was induced by the intracisternal infusion of 1 ml/kg body weight of fresh autologous blood at a rate of 0.6 ml/min. Eleven of those animals were treated by intrathecal fibrinolysis performed 24 hours after experimental SAH by intracisternal infusion of 3 mg of recombinant tissue plasminogen activator. Included were eight animals suffering from experimental SAH and four healthy animals retained for control. A computed tomographic scan performed 24 hours after the SAH displayed an acute hydrocephalus from the experimental procedure. Cerebrospinal fluid outflow resistance was 71 +/- 5.0 mm Hg/ml/min in the healthy animals, 265 +/- 19.8 mm Hg/ml/min in the nontreated animals 7 days after SAH, and 151 +/- 6.4 mm Hg/ml/min in the recombinant tissue plasminogen activator-treated animals 7 days after SAH (mean +/- standard deviation; changes significant with P less than 0.01). Postmortem planimetry of both lateral ventricles gives a mean of 3.7 +/- 2.7 mm2 in the healthy animals, 11.1 +/- 3.9 mm2 in the nontreated group after SAH (P less than 0.01), and 3.5 +/- 1.1 mm2 in the animals treated with recombinant tissue plasminogen activator. Intracranial pressure monitoring demonstrated marked intracranial pressure waves only in the nontreated animals after SAH. It is concluded that intrathecal fibrinolysis may prevent subacute hydrocephalus after experimental SAH.

Distribution of cisternal blood in patients with acute hydrocephalus after subarachnoid hemorrhage

The distribution of cisternal blood in relation to the development of acute hydrocephalus was studied in 246 consecutive patients with aneurysmal subarachnoid hemorrhage who were admitted within 72 hours. Patients with evidence on the initial computed tomograph (CT) of subarachnoid hemorrhage caused by other than a ruptured aneurysm and patients with a negative angiography were excluded. Acute hydrocephalus (defined as a bicaudate index, measured on the initial CT or on a repeat CT within 1 week after subarachnoid hemorrhage, exceeding the 95th percentile for age) was found on the initial CT in 50 (20%) of the 246 patients and on a repeat CT in 9 other patients. Ventricular blood was found significantly more often in patients with acute hydrocephalus than in those in whom acute hydrocephalus did not develop (28 of 59 [47%] versus 58 of 187 [31%]; chi 2 = 4.634, p = 0.031). When the analysis was restricted to the 86 patients with ventricular blood, no significant differences were found in the total amount of cisternal blood and in the distribution of cisternal blood between patients with and without hydrocephalus. In contrast, among the 160 patients without ventricular blood, hydrocephalus was associated with a slightly higher total amount of cisternal blood (Wilcoxon's rank sum test, p = 0.023), and significantly more patients with acute hydrocephalus had a higher score in both ambient cisterns than patients without acute hydrocephalus (20 of 31 [65%] versus 41 of 129 [32%]; chi 2 = 10.007, p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Results of routine ventriculostomy with external ventricular drainage for acute hydrocephalus following subarachnoid haemorrhage

We reviewed the results of ventriculostomy with external ventricular drainage in patients with acute hydrocephalus complicating subarachnoid haemorrhage. Of 194 consecutive patients with subarachnoid haemorrhage admitted during the past eight years, 52 (27%) developed hydrocephalus within 72 hours of the ictus. Patients with acute hydrocephalus were in grades III to V (Hunt and Hess) at the time of evaluation and all patients with hydrocephalus underwent ventriculostomy within 24 hours of diagnosis. Twenty-six patients improved within 24 hours of cerebrospinal fluid drainage and 17 of these patients underwent surgery, nine of whom did well (Glasgow Outcome Scale 1 and 2). All 18 patients who did not improve within this period, including one who worsened, died. In eight patients the response to ventriculostomy was considered as undetermined, because of the proximity of the drain insertion to a definitive surgical procedure, and all of them had an excellent outcome (Glasgow Outcome Scale 1). Of 32 patients in grades IV and V, 17 did not improve and all of them died. Eight of the 15 patients in these grades, who were in the improved or undetermined categories, did well. Five patients (10%) developed meningitis. All patients with this complication had drainage for more than four days. Seven patients (14%) had a rebleed during the drainage. All except one patient with a rebleed had no surgery or delayed surgery and in six of them recurrent haemorrhages occurred after more than 24 hours of drainage. We conclude that routine ventriculostomy with external ventricular drainage should be considered for all patients with altered sensorium and acute hydrocephalus following subarachnoid haemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of ventricular drainage to aneurysmal rebleeding

Given the widespread use of continuous external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage (SAH), this investigation was undertaken to define the relationship of ventricular drainage to aneurysmal rebleeding. A historical cohort study of 128 patients with confirmed aneurysmal SAH was performed using a multivariate stepwise logistic regression analysis to examine the relationship between aneurysmal rerupture and ventricular drainage, while controlling for important clinical and radiological independent variables. The variables for ventricular drainage selected in the regression analysis were clinical grade, aneurysm size, and presence of hydrocephalus. The rate of rerupture was significantly higher in cases with ventricular drainage (odds ratio 5.31:1, p less than 0.05), poor clinical grade (odds ratio 4.90:1, p less than 0.02), and large aneurysm size (odds ratio 11.25:1, p less than 0.01). The significant effect of ventricular drainage was limited to patients with hydrocephalus. The increased risk of aneurysmal rebleeding in patients undergoing ventricular drainage may result from both: 1) a rise in aneurysmal transmural pressure, since intracranial pressure is lowered by ventricular drainage; and 2) an association between ventricular drainage and a more severely disrupted aneurysm which is more prone to rebleed as part of its natural history. This study found an increased risk of aneurysmal rebleeding among patients undergoing ventricular drainage, particularly in the presence of hydrocephalus.

Dilatation of the temporal horn in subarachnoid haemorrhage

CT studies of 50 patients with spontaneous subarachnoid haemorrhage (SAH) and 100 randomly selected patients were reviewed with regard to the size of the frontal and temporal horns of the lateral ventricles. The temporal horn was classified into four grades, based on the size of its posterior portion at the level of the midbrain. The horn was clearly visible in 66% of patients with SAH, but in only 2% of controls. In the SAH group, the temporal horn tended to dilate sooner than the frontal horn after haemorrhage and could be seen clearly in a larger proportion of patients. Thus, assessment of the size of the temporal horn appears to be a simple and sensitive method for assessing ventricular dilatation. In addition, dilatation of the temporal horn may prove to be an important indirect sign suggesting SAH in patients in whom no high density clot is seen on CT.

Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar puncture

Computed tomography demonstrated acute hydrocephalus less than or equal to 72 hours after subarachnoid hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. With the exception of three patients, all 104 patients received antifibrinolytic treatment. Delayed clinical deterioration from acute hydrocephalus occurred in seven (29%) of the 24 patients with acute hydrocephalus on admission and in six (8%) of the remaining 80 patients. Serial lumbar puncture was performed in 17 patients. Twelve (71%) of the 17 patients treated with serial lumbar puncture, including 10 (77%) of the 13 patients with delayed deterioration from acute hydrocephalus after admission, achieved improvement in the level of consciousness. Four of these 17 patients (4% of all 104 patients) required an internal shunt. No patient deteriorated from coning following serial lumbar puncture. The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic patients with serial lumbar puncture was not higher than the rate in those without hydrocephalus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage.

Ventriculoperitoneal shunt in cryptococcal meningitis with hydrocephalus

Fourteen patients with cryptococcal meningitis were reviewed. All patients had a ventriculoperitoneal shunt for hydrocephalus. Early recognitions and prompt relief of hydrocephalus were useful for eight patients who showed rapid deterioration of consciousness or signs of cerebral herniation. There was no surgical response in four patients who had had weeks of confusion or mental change. It seems, therefore, that the duration of disturbance of consciousness or change of mentality before shunting is critical in determination of the outcome of the treatment. Ventricular shunting was effective in relieving papilledema in five patients. However, the surgery did not prevent the development of papilledema to optic atrophy and subsequent blindness in two patients. Hence, in addition to hydrocephalus with increased intracranial pressure, conditions such as direct invasion of the optic pathways by Cryptococcus neoformans or optochiasmatic arachnoiditis may be responsible for the visual failure. Ventricular shunting was also helpful in restoring paraparesis in one patient. Of the cerebrospinal fluid determinations, low protein concentration was a favorable indicator for surgery. Of the seven patients who received the surgical procedure before the start of antifungal therapy, four showed a significant improvement despite active infection of the central nervous system. None of the seven patients deteriorated because of the surgical operation. Thus, active stage of cryptococcal meningitis does not contraindicate the necessity of shunting, and premedication with antifungal drugs is unnecessary. Also, no shunt-related morbidity and mortality was seen in this study.

Management morbidity and mortality of poor-grade aneurysm patients

Preliminary experience with the occasional good survival of patients in Hunt and Hess Grade IV or V with aneurysmal subarachnoid hemorrhage (SAH) led to a prospective management protocol employed during a 2 1/2-year period. The protocol utilized computerized tomography (CT) scanning to diagnose SAH and to obtain evidence for irreversible brain destruction, consisting of massive cerebral infarction with midline shift or dominant basal ganglia or brain-stem hematoma. These patients, along with those who exhibited poor or absent intracranial filling on CT or angiography, were excluded from active treatment and given supportive care only. All other patients had immediate ventriculostomy placement and, if intracranial pressure (ICP) was controllable (less than or equal to 30 cm H2O without an intracranial clot or less than or equal to 50 cm H2O in the presence of a clot), went on to have craniotomy for aneurysm clipping. Aggressive postoperative hypertensive, hypervolemic, hemodilutional therapy was subsequently employed. Of 54 patients with poor-grade aneurysms, ventriculostomy was placed in 47 (87.0%) and yielded high ICP's in the overwhelming majority, with the mean ICP being 40.2 cm H2O. Nineteen poor-grade aneurysm patients received no surgical treatment and survived a mean of 31.8 hours with 100% mortality. Thirty-five patients underwent placement of a ventriculostomy, craniotomy for aneurysm clipping and intracranial clot evacuation, and postoperative hypertensive, hypervolemic, hemodilutional therapy. The outcome at 3 months of the 35 patients who were selected for active treatment was good in 19 (54.3%), fair in four (11.4%), poor in four (11.4%), and death in eight (22.9%). It is concluded that poor-grade aneurysm patients usually present with intracranial hypertension, even those without an intracranial clot. Based on radiographic rather than neurological criteria, a portion of these patients can be selected for active and successful treatment. Increased ICP can be present without ventriculomegaly, and immediate ventriculostomy should be performed. As long as ICP is controllable, craniotomy and postoperative intensive care can effect a favorable outcome in a significant percentage of these patients.

Progression of acute hydrocephalus in subarachnoid haemorrhage: a case report documented by serial CT scanning

A patient with a perimesencephalic subarachnoid haemorrhage gradually developed, within the first day, progressively impaired consciousness, small non-reactive pupils, and defective upward gaze. Three successive CT scans showed progressive enlargement of the lateral and third ventricles. Ventricular shunting resulted in complete recovery.

Management of cerebral aneurysms: further facts and additional myths

In 1985 we reviewed 17 misconceptions or myths surrounding the treatment of aneurysmal subarachnoid hemorrhage that may contribute to the dismal outcome from these lesions. Since that time, significant new data, or facts, have become available regarding the influence of early aneurysm surgery on rebleeding, the efficacy of treatments for symptomatic arterial narrowing, improvements in surgical techniques such as temporary arterial clipping, and measures to protect the brain from ischemic injury. However, additional myths have become apparent which continue to limit our ability to improve the outcome of these patients. We review these facts and myths and discuss management of the patient with aneurysmal subarachnoid hemorrhage.