Acute hydrocephalus after aneurysmal subarachnoid hemorrhage

Management problems in acute hydrocephalus after subarachnoid hemorrhage

In a consecutive series of 473 patients admitted within 72 hours after a subarachnoid hemorrhage, 91 (19%) had hydrocephalus on the initial computed tomogram. Consciousness was unimpaired in 25 of the 91 (28%). In 11 more patients acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. Thirty-eight (8%) of all 473 patients subsequently showed clinical deterioration because of acute hydrocephalus; 11 of these 38 had fluctuations in the level of consciousness. Of the 66 patients with acute hydrocephalus and impaired consciousness on admission, 26 (39%) spontaneously improved within 24 hours. Ventricular drainage was performed in 32 (31%) of the 102 patients with acute hydrocephalus (7% of all 473 patients). Consciousness improved after ventricular drainage in 25 (78%) of the 32 patients. Ventriculitis developed in 12 of the 24 patients with external drainage, mainly after greater than 3 days of drainage, and in none of the eight patients with an internal shunt. Among the 340 patients with aneurysmal subarachnoid hemorrhage and no long-term tranexamic acid treatment, the frequency of rebleeding in patients with ventricular drainage (43% of 23) was significantly higher than in hydrocephalic patients without drainage (15% of 52 patients; chi 2 = 5.009, p = 0.025) and patients without acute hydrocephalus (20% of 265 patients; chi 2 = 5.521, p = 0.019). We conclude that spontaneous improvement occurs in half of the patients with acute hydrocephalus and impaired consciousness on admission, which is usually apparent within 24 hours, and that the outcome of patients who need ventricular drainage will improve if rebleeding and infection after insertion of the ventricular drain can be prevented.

The risk of ischaemic brain damage during the use of self-retaining brain retractors

Self-retaining brain retractors (SRBR) are commonly used during intracranial surgery and they are indispensable during microneurosurgery. To evaluate limitations in the employment of SRBR, as well animal as human studies have been performed. In the animal studies, male Wistar rats were used for measurements of regional cerebral blood flow (rCBF) changes during brain retractor pressure (BRP) provided by lead weights. These weights, corresponding to different levels of mm Hg, were applicated for different periods of time on the parietal cortex after craniotomy. In one part of the animal studies different profiles of the application surface of the weights were evaluated. For measurement of the rCBF (n = 41) autoradiography with carbon-14(14C)iodoantipyrine was used as described by Gjedde et al (1980). A neuropathological method (n = 30) was used to reveal possible brain damage after graded BRP. In the rats the thresholds of rCBF, regional cerebral perfusion pressure (rCPP) and time were 20-25 ml/100 g/min, 20 mm Hg and 7-10 minutes respectively. In the human studies only alert patients without neurological deficits (except defects of the visual fields) and in whom preoperative CT-scans did not disclose any sign of infarction were included. BRP beneath as well the tip as the centre of the SRBR and the MABP were recorded continuously. Patients with peroperative complications were excluded. During the operations induced hypotension (n = 20) and mannitol (n = 6) were administrated. The patients (n = 23) had a 3-month follow-up examination. In man the thresholds of rCPP and time were found to be 10 mm Hg and 6-8 minutes, respectively. Other authors have found a rCBF threshold of 10-13 ml/100 g/min (Astrup 1982, Iannotti & Hoff 1983). It is concluded that the results obtained in the rat studies are comparable to the human situation if reservations are made concerning the differences in the thresholds of rCBF and rCPP. The time threshold of cerebral ischaemia seems to be rather equal in rat and in man. If these thresholds are reached, intermittent BRP is absolutely recommendable. It was also found that the most easily-handled retractors, those with a flat profile, did not decrease the rCBF further than other types of retractors.

Early aneurysm surgery: a 7 year clinical practice report

One hundred and fifty patients with intracranial aneurysms, operated on consecutively in the early stage in our department, were re-evaluated retrospectively. Seven surgeons operated on 159 aneurysms in 150 patients. Seventy-nine percent of the patients were in grades I-III (scale of Hunt and Hess), 21% in grades IV-V. Seventy-one percent had a severe haemorrhage (classification of Fisher et al.), 21% had an intracerebral haematoma. Intraoperative CSF drainage was an almost indispensable tool while postoperative external drainage did not prove to be helpful in preventing vasospasm and/or hydrocephalus. Induced hypotension was abandoned in favour of temporary clipping. Thirteen percent of the patients suffered a permanent or fatal immediate postoperative deterioration, while 11% developed delayed neurological deficits. Five percent were related to vasospasms alone, they were all transient. Five percent had vasospasm combined with other complications. One of them had permanent and the other one fatal deficits. One percent deteriorated due to embolism or occluded vessels. The results improved with the introduction of the calcium channel blocker nimodipine, induced hypertension and transcranial Doppler sonographic control of the vasospasm. Patients in good preoperative condition had a good early outcome in 69%. The result was fair in 21% and poor in 4%, while 6% of the patients died. In the poor condition group 22% of the patients made a good, 13% a fair, and 59% a poor recovery, 16% of whom died.(ABSTRACT TRUNCATED AT 250 WORDS)

Referral pattern of patients with aneurysmal subarachnoid hemorrhage

The referral pattern of 334 patients admitted to a neurosurgical clinic with aneurysmal subarachnoid hemorrhage (SAH) was analyzed. Forty-nine percent of the patients were admitted after the day following the SAH. Failure of patients to seek prompt medical care was a cause of delay in 29 patients and of physician diagnostic errors in 95 patients. Common misdiagnoses included migraine, mental exhaustion, sinusitis, and influenza. A delay at the referring hospital was observed in 97 patients. Early intervention is important for the optimal management of patients with SAH. Educating the public, medical students, and physicians about the signs and symptoms of SAH and the importance of prompt therapy is likely to improve overall outcome after aneurysmal rupture.