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Zhang M, Wang X. Rupture of a previously undiagnosed intracranial aneurysm during endoscopic dacryocystorhinostomy: A case report. Clin Case Rep 2023; 11:e6749. [PMID: 36694636 PMCID: PMC9842777 DOI: 10.1002/ccr3.6749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/16/2022] [Accepted: 12/01/2022] [Indexed: 01/18/2023] Open
Abstract
Endoscopic endonasal dacryocystorhinostomy (EE-DCR) is an effective treatment for dacryocystitis. Aneurysmal rupture is generally not considered a complication of EE-DCR under general anesthesia. Here, we present a patient with intracerebral and subarachnoid hemorrhage secondary to the rupture of an undiagnosed intracranial aneurysm during EE-DCR. Clinicians should be aware of such fatal complications when using any vasoconstrictor intraoperatively.
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Affiliation(s)
- Meng‐Qiu Zhang
- Department of AnesthesiologyWest China Hospital, Sichuan UniversityChengduChina
| | - Xin Wang
- Department of AnesthesiologyGuizhou Provincial People's HospitalGuiyangChina
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Pavesi G, Nasi D, Moriconi E, Stanzani R, Puzzolante A, Lucchesi L, Cavallo SM, Iaccarino C. Management and safety of intraoperative ventriculostomy during early surgery for ruptured intracranial aneurysms. Acta Neurochir (Wien) 2022; 164:2909-2916. [PMID: 36008637 DOI: 10.1007/s00701-022-05346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Brain edema and/or acute hydrocephalus are common features that limit working space during early surgery of aneurysmal subarachnoid hemorrhage (aSAH). Intraoperative ventriculostomy offers an immediate brain relaxation. However, management and complications related to the routine use of intraoperative external ventricular drainage (iEVD) are not well investigated. METHODS We retrospectively reviewed all patients who were treated with pterional craniotomy and clipping for ruptured anterior circulation aneurysms in our center between 2012 and 2019. We included in this study all patients submitted to iEVD using the Paine's point on the side of craniotomy. Indication for positioning of an iEVD was given in all cases whenever initial cisternal dissection was hampered by the lack of cerebrospinal fluid (CSF) circulation due to SAH and/or hydrocephalus. RESULTS In the study period, 162 patients with aSAH underwent surgical clipping. In 103 patients, an iEVD was used. The overall rate of iEVD-related complications was 6.7%, including 3 cases of catheter misplacement, one case of catheter obstruction, one case of related hemorrhage, and 2 cases of infection. The rate of shunt-dependent hydrocephalus was 16.5% (17/103 patients). CONCLUSION In our experience, iEVD is a safe technique that facilitates dissection during early surgery for intracranial ruptured aneurysms, without requiring an additional burr hole procedure.
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Affiliation(s)
- Giacomo Pavesi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Davide Nasi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy.
| | - Elisa Moriconi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Riccardo Stanzani
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Annette Puzzolante
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Lucio Lucchesi
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Selene Marika Cavallo
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Via Pietro Giardini, 1355-41126, Modena, Località Baggiovara, Italy
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Liu T, Wu L, Xue R, Ding H. Efficacy and safety of tranexamic acid in aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials. Am J Emerg Med 2021; 50:646-653. [PMID: 34879481 DOI: 10.1016/j.ajem.2021.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Tranexamic acid, as a traditional hemostatic agent, is commonly used to treat or prevent excessive blood loss. However, the role of tranexamic acid in promoting good clinical outcomes and reducing mortality and risk of adverse events during the treatment of aneurysmal subarachnoid hemorrhage remains unclear. METHODS In strict accordance with the inclusion and exclusion criteria, Cochrane Library, Embase, Web of Science, and PubMed databases were assessed for randomized controlled trials (published between 1980 and 2021). Data were analyzed using STATA 16.0 and RevMan 5.3. In addition, the fixed-effects model (M-H method) and effect size (risk difference; RD) were used as a pooled measure to combine data. We also performed a post hoc sensitivity analysis and subgroup analysis to evaluate each outcome with low heterogeneity. RESULTS A meta-analysis revealed that although tranexamic acid was related to less rebleeding (RD = -0.06; 95% CI [-0.09, -0.03]; P = 0.0006), there is evidence that it has no an effect on good clinical outcomes or mortality (RD = -0.01; 95% CI [-0.05, 0.02]; P = 0.51; RD = 0.00; 95% CI [-0.03, 0.04]; P = 0.91). Tranexamic acid was associated with increased hydrocephalus (RD = 0.04; 95% CI [0.01, 0.08]; P = 0.02) and seizure (RD = 0.04; 95% CI [0.00, 0.08]; P = 0.05). The incidence of thromboembolic complications or delayed cerebral ischemia was not different in the two groups (RD = -0.01; 95% CI [-0.04, 0.03]; P = 0.62; RD = 0.00; 95% CI [-0.03, 0.03]; P = 0.96), and significant drug-related overall adverse events were identified (RD = 0.02; 95% CI [0.00, 0.04]; P = 0.03). CONCLUSIONS These findings indicate that the routine use of tranexamic acid is not suggested for patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China.
| | - Lingqin Wu
- Zhoushan Women and Children Hospital, Zhoushan 330902, China
| | - Renmin Xue
- Department of Cell Biology, Capital Medical University, Beijing 100069, China
| | - Huiru Ding
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Garg K, Gupta D, Singh M, Chandra PS, Kale SS. Comparison of a bolt-connected external ventricular drain with a tunneled external ventricular drain - a narrative review and meta-analysis. Neurosurg Rev 2021; 45:937-949. [PMID: 34490538 DOI: 10.1007/s10143-021-01639-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 01/15/2023]
Abstract
External ventricular drain (EVD) is one of the most commonly performed neurosurgical procedures. EVD can be associated with high rates of complications like misplacement, iatrogenic hemorrhage, and CSF infection. Several modifications have been proposed in the EVD insertion techniques to decrease the risk of these complications. Bolt-connected EVD, one of these modifications which involves insertion of a bolt in the burr hole, has been proposed to have better chances of optimal placement of EVD tip, lesser risk of CSF infection, and accidental pullout. A comprehensive search of different databases was performed to retrieve studies comparing the bolt-connected EVD with tunneled EVD and meta-analysis was done. Seven studies met inclusion criteria and were included in the meta-analysis. Our analysis revealed that bolt-connected EVD is associated with significantly better chances of optimal placement than traditional tunneled EVD (MH OR-1.65, 95% CI 1.14 to 2.40, p = 0.008). We also observed that bolt-connected EVD is associated with significantly decreased risk of CSF infection (MH OR-0.60, 95% CI 0.39 to 0.94, p = 0.026), EVD malfunction (MH OR-0.31, 95% CI 0.16 to 0.58, p = 0.0003), and accidental disconnection (MH OR-0.09, 95% CI 0.03 to 0.26, p < 0.0001) as compared to traditional tunneled EVD. The difference between the two techniques was not statistically significant for complications, multiple punctures done for insertion of EVD, iatrogenic intracranial, and need of reoperation. Bolt-connected external ventricular drain is associated with significantly more chances of optimal placement and lesser chances of accidental discontinuation and CSF infection than tunneled EVD. There was no statistically significant difference noted between the two techniques for multiple punctures done for insertion of EVD, iatrogenic intracranial hemorrhage and need of reoperation. However, most of the included studies were retrospective. Thus, the results from the meta-analysis should be interpreted with caution as further prospective high-quality studies are needed.
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Affiliation(s)
- Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Majovsky M, Netuka D, Lipina R, Mraček J, Beneš V. Pineal Apoplexy: A Case Series and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg 2021; 83:31-38. [PMID: 34077982 DOI: 10.1055/s-0041-1723813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pineal apoplexy is a rare condition, with unknown incidence and clinical significance. To elucidate this clinical condition, we analyzed our own case series and performed a review of the literature. METHODS We enrolled all patients with a hemorrhagic pineal apoplexy who were referred to our department between January 2000 and January 2020. Hemorrhagic pineal apoplexy was defined as the presence of fluid-fluid levels inside the pineal cyst (PC) on an axial or sagittal magnetic resonance scan. In one patient, after PC apoplexy, we performed a circadian melatonin sampling from peripheral blood to determine the function of the pineal gland. The PubMed database was searched for publications using the terms "pineal" and "apoplexy." RESULTS Eight patients were enrolled, of which three patients underwent surgical treatment and five patients were managed conservatively. One patient was tested for circadian melatonin secretion. Results confirmed melatonin secretion with preserved physiologic circadian rhythm.Our search of the literature led us to 31 studies that comprised 30 patients with apoplectic PC, 9 with apoplectic pineal tumor, and 1 with bleeding into the normal pineal gland. Most patients presented with headache, nausea, and vomiting, less frequently with acute hydrocephalus and gaze palsy. Twenty patients with a PC underwent resection or aspiration. Two patients underwent shunt placement as the only procedure and five received both shunt and surgical removal. Six patients with a PC were observed without surgical treatment. All the nine patients with a pineal tumor were operated on. In indicated cases, four patients received radiation therapy and one received chemotherapy. CONCLUSION Clinical significance of hemorrhagic pineal apoplexy ranges from an asymptomatic course to rapid deterioration and death. In patients with mild symptoms, observation is indicated, whereas surgical treatment is reserved for severe cases presenting with obstructive hydrocephalus and includes cerebrospinal fluid diversion, resection of apoplectic pineal lesions, or both.
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Affiliation(s)
- Martin Majovsky
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - Radim Lipina
- Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Mraček
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, University Hospital Pilsen - Pilsen, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
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Ohbuchi H, Hagiwara S, Arai N, Yoneyama T, Takahashi Y, Inazuka M, Kubota Y, Chernov M, Kasuya H. Optimal timing and safety of the external ventricular drainage in patients with high-grade aneurysmal subarachnoid hemorrhage treated with endovascular coiling. J Clin Neurosci 2021; 88:63-69. [PMID: 33992206 DOI: 10.1016/j.jocn.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The presented retrospective analysis has evaluated the optimal timing and safety of external ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). The study cohort comprised 102 patients, 49 of whom underwent EVD at 3-120 h (mean, 16 h) after the clinical onset of aSAH, either before (N = 27) or after (N = 22) ruptured aneurysm coiling. Among those treated with EVD, favorable and fair outcomes at discharge (modified Rankin Scale [mRS] scores 0-3) were noted in 14 (29%) and unfavorable (mRS scores 4-6) in 35 (71%). The former was more common among women (P = 0.019) and patients without chronic arterial hypertension (P = 0.028). The cut-off value for optimal timing of EVD was defined at 13 h after the onset of aSAH. Favorable and fair outcomes were more frequent after early (≤13 h; N = 30) than late (>13 h; N = 19) EVD (40% vs. 11%; P = 0.026), whereas did not differ significantly between those in whom such procedure was done before or after ruptured aneurysm coiling (19% vs. 41%; P = 0.083). In the entire study cohort, 2 patients had re-rupture of the aneurysm, and while both of them were treated with EVD, neither case of complication was directly associated with the procedure and, in fact, preceded it. In conclusion, EVD for management of acute hydrocephalus in patients with high-grade aSAH should be preferably applied within 13 h after the clinical onset of stroke, which may be considered sufficiently safe regardless whether it is performed before or after ruptured aneurysm coiling.
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Affiliation(s)
- Hidenori Ohbuchi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo.
| | - Shinji Hagiwara
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Naoyuki Arai
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Taku Yoneyama
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Takahashi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo; Department of Neurosurgery, Moriya Daiichi General Hospital, Ibaraki, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Kubota
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Mikhail Chernov
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
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Konovalov A, Shekhtman O, Pilipenko Y, Okishev D, Ershova O, Oshorov A, Abramyan A, Kurzakova I, Eliava S. External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review. Cureus 2021; 13:e12951. [PMID: 33643744 PMCID: PMC7885737 DOI: 10.7759/cureus.12951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction The placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH. Materials and methods From 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded. Results Among the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15). Conclusion EVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.
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Affiliation(s)
- Anton Konovalov
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Oleg Shekhtman
- Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Yury Pilipenko
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Dmitry Okishev
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Olga Ershova
- Epidemiology and Public Health, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Andrey Oshorov
- Internal Medicine: Critical Care, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Arevik Abramyan
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Irina Kurzakova
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Shalva Eliava
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
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Sun J, Wang Z, Su P, Liu J, Li J, Ma G, Cen J, Chang Q, Liu X, Zhao N. [Long-term clinical outcomes of patients with aneurysmal subarachnoid hemorrhage in Yunnan Province]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1353-1358. [PMID: 32990220 DOI: 10.12122/j.issn.1673-4254.2020.09.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) after surgeries in Yunnan Province. METHODS We retrospectively analyzed the demographic features, vascular risk factors, severity at admission, and aneurysm locations in 85 patients with aSAH receiving surgical interventions in Yunnan Province. All the patients were treated by aneurysm clipping or coiling and followed up for clinical outcomes and recovery of daily activities evaluated by modified Rankin Scale (mRS) and Activities of Daily Living (ADL) scale, respectively. RESULTS Thirty-four of the patients (40.0%) underwent aneurysm clipping and 51 (60.0%) underwent aneurysm coiling. During a median follow- up period of 66.23 months (IOR, 12.03 months), 84.7% of the patients had low mRS scores, and 78.8% lived independently. The WFNS grade at admission was significantly correlated with the follow-up mRS scores (95%CI: 1.48-19.09, P=0.011) and ADL (95%CI: 2.55-28.77, P < 0.001). Multivariate analysis showed that age (95%CI: 1.02-1.23, P=0.017; 95%CI: 1.00-1.15, P=0.038) and a high WFNS grade at admission (95%CI: 2.19-141.48, P=0.007; 95%CI: 2.84-82.61, P=0.002) were independent predictors of both mRS and ADL scores at follow-up. There was no significant difference in clinical outcomes or the length of hospital stay between the two treatment strategies (P > 0.05), but the cost of hospitalization was significantly higher in coiling group than in the clipping group (P < 0.001). CONCLUSIONS Both aging and a high WFNS grade at admission are associated with a poor prognosis of aSAH, for which aneurysm clipping and coiling have similar long- term outcomes, but for patients with a high WFNS score, aneurysm clipping is favored over coiling in terms of health economics.
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Affiliation(s)
- Jie Sun
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Zeyi Wang
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Ping Su
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Jun Liu
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Junyan Li
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Gang Ma
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Jianchang Cen
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Qian Chang
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Xinghai Liu
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Nan Zhao
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
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Tasiou A, Brotis AG, Paschalis T, Tzerefos C, Kapsalaki EZ, Giannis T, Tzannis A, Fountas KN. Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience. Int J Neurosci 2020; 132:38-50. [PMID: 32746674 DOI: 10.1080/00207454.2020.1801676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Thanasis Paschalis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Eftychia Z Kapsalaki
- Department of Neuroradiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Theofanis Giannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alkiviadis Tzannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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Abstract
Subarachnoid hemorrhage is an often devastating intracranial hemorrhage resulting from acute bleeding into the subarachnoid space. Although its overall incidence is less than that of acute ischemic stroke, sub-arachnoid hemorrhage carries increased risks of both mortality and disability. Although many patients with subarachnoid hemorrhage are transferred to specialty centers, they might initially present to small community-based hospitals. Treatment for these patients is complex, requiring specialized care and knowledge, and various complications can occur quickly and without warning. Therefore, all members of the health care team who care for these patients must understand proper management. Nurses in the intensive care unit play an important role in influencing outcomes, as they are best positioned to recognize neurological decline and provide rapid intervention. This article discusses the anatomy relevant to, and the epidemiology and pathophysiology of, subarachnoid hemorrhage and provides an overview of current evidence and clinical guidelines for managing this brain injury.
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Affiliation(s)
- Bryan Boling
- Bryan Boling is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky. Tasha R. Groves is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky
| | - Tasha R. Groves
- Bryan Boling is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky. Tasha R. Groves is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky
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The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts. Neurosurg Rev 2019; 43:739-747. [DOI: 10.1007/s10143-019-01116-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/07/2019] [Accepted: 05/17/2019] [Indexed: 11/27/2022]
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Lim YC, Shim YS, Oh SY, Kim MJ, Park KY, Chung J. External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications. Neurointervention 2019; 14:35-42. [PMID: 30636388 PMCID: PMC6433188 DOI: 10.5469/neuroint.2018.01067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/02/2019] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of this study was to report the authors’ experience with external ventricular drainage (EVD) before endovascular treatment (EVT) in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its relation to hemorrhagic complications.Materials and Methods Between March 2010 and December 2017, a total of 122 patients were recruited who had an aSAH, underwent EVT to secure the ruptured aneurysm, and had EVD performed within 72 hours of rupture. The pre-embo EVD group (n=67) comprised patients who underwent EVD before EVT, and the post-embo EVD group (n=55) comprised those who underwent EVD after EVT. Results Overall, EVD-related hemorrhage occurred in 18 patients (14.8%): six (8.9%) in the pre-embo EVD group and 12 (21.8%) in the post-embo EVD group (P=0.065). No rebleeding occurred between EVD and EVT in the pre-embo EVD group. Clinical outcomes at discharge did not differ significantly between groups (P=0.384). At discharge, the final modified Rankin Scale score in patients who experienced pre-embo rebleeding was better in the pre-embo EVD group than in the post-embo EVD group (P=0.041). Current use of an antiplatelet agent or anticoagulant on admission (odds ratio [OR], 2.928; 95% confidence interval [CI], 1.234–7.439; P=0.042) and stent use (OR, 2.430; 95% CI, 1.524–7.613; P=0.047) remained independent risk factors for EVD-related hemorrhagic complications. Conclusion EVD before EVT in patients with aSAH in acute period did not increase the rate of rebleeding as well as EVD-related hemorrhagic complications. Thus, performing EVD before EVT may be beneficial by normalizing increased intracranial pressure. Especially in patients with rebleeding before the ruptured aneurysm is secured, pre-embo EVD may improve clinical outcomes at discharge.
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Affiliation(s)
- Yong Cheol Lim
- Department of Neurosurgery, Ajou University Hospital, Ajou University College of Medicine, Suwon, Korea
| | - Yu Shik Shim
- Department of Neurosurgery, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Se-Yang Oh
- Department of Neurosurgery, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Myeong Jin Kim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Keun Young Park
- Department of Neurosurgery, Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
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Safety and Feasibility of Out-of-Bed Mobilization for Patients With External Ventricular Drains in a Neurosurgical Intensive Care Unit. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2018. [DOI: 10.1097/jat.0000000000000085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Increased rate of ventriculostomy-related hemorrhage following endovascular treatment of ruptured aneurysms compared to clipping. Acta Neurochir (Wien) 2018; 160:545-550. [PMID: 29362932 DOI: 10.1007/s00701-018-3471-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/16/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Acutely ruptured aneurysms can be treated by endovascular intervention or via surgery (clipping). After endovascular treatment, the risk of thromboembolic complications is reduced by the use of anticoagulative agents, which is not required after clipping. The aim of the study is to investigate the rate of ventriculostomy-related hemorrhage after endovascular treatment and clipping. METHODS A consecutive series of 99 patients treated for a ruptured aneurysm which required an external ventricular drainage between 2010 and 2015 were included. Their CT scans were investigated retrospectively for ventriculostomy-related hemorrhage. Furthermore, the extent of bleeding, the rate of revision surgery, and the rate of bacterial ventriculitis have been analyzed. RESULTS Ventriculostomy-related hemorrhage was observed in 20 of 45 patients after endovascular treatment compared to 7 of 54 patients after clipping (chi-squared test, p < 0.001). Revision surgery was indicated in 75%. In 50% of these patients, revision surgery was required more than once and nearly 50% developed additional cerebral infections. Intraventricular or intracerebral extension of the bleeding was observed only in the endovascular treatment group (chi-squared test, p = 0.003). Glasgow outcome scale showed a significant better outcome in the surgical group (t test, p = 0.005). CONCLUSIONS Ventriculostomy-related hemorrhage is an underestimated complication after endovascular treatment leading to revision surgeries, bacterial infections, and may have a negative impact on long-term outcome. The probability of occurrence is increased when anticoagulation is performed by heparin in combination with antiplatelet drugs as compared to heparin alone. Lumbar drainage should be considered as an alternative for treatment of acute hydrocephalus in patients with Hunt and Hess grade 1-3.
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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16
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Aneurysm rebleeding after placement of external ventricular drainage: a systematic review and meta-analysis. Acta Neurochir (Wien) 2017; 159:695-704. [PMID: 28243810 DOI: 10.1007/s00701-017-3124-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The association between external ventricular drainage (EVD) and aneurysm rerupture is still a controversial issue. We performed a systematic review and meta-analysis of published series reporting data of EVD placement in aneurysmal subarachnoid hemorrhage (SAH) with the aim to evaluate the relationship between ventricular drainage and aneurysm rebleeding. METHOD PRISMA/MOOSE guidelines were followed. The Newcastle-Ottawa Scale was used to assess the quality of the studies. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on series reporting patients with EVD placement and aneurysmal SAH. The reported studies were analyzed with a primary aim to calculate the strength of the association (odds ratio) between rebleeding and EVD placement in patients with SAH. RESULTS Our systematic review included 16 articles with a total of 6804 patients with SAH of which 595 (8.7%) had aneurysmal rebleeding. Ventricular drainage was inserted in 19% of patients. Rebleeding occurred in 18.8% (95% CI = 16.4-20.6%) of patients requiring EVD and in 6.4% (95% CI = 5.8-7.1%) of patients who did not require EVD (OR = 3.92, p < 0.0001). The mean time between EVD placement and rebleeding was 1 h (range, 0-8 h). The maximal aneurysm diameter of patients with rerupture was larger when compared with patients without rerupture (9.9 mm vs. 7.5 mm; p < 0.04). High Fisher grades (III-IV) were present in 75% of patients with rerupture and in 60% of patients without aneurysmal rerupture (p < 0.0001). CONCLUSIONS Our study conclusively defined an association between EVD and rebleeding. However, the effective role of EVD in aneurysm rebleeding is insufficiently investigated in the literature. Other significant factors of rebleeding are usually observed in patients requiring ventricular drainage. According to our findings, a causal relationship between EVD and aneurysm rebleeding could be a plausible hypothesis, at least in certain cases.
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Abstract
Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.
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Effects of lumbar drainage on CSF dynamics in subarachnoid hemorrhage condition: A computational study. Comput Biol Med 2016; 77:49-58. [DOI: 10.1016/j.compbiomed.2016.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 11/24/2022]
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Hybrid Operating Room for Combined Neuroendovascular and Endoscopic Treatment of Ruptured Cerebral Aneurysms with Intraventricular Hemorrhage. World Neurosurg 2016; 89:727.e9-727.e12. [PMID: 26802870 DOI: 10.1016/j.wneu.2016.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 01/10/2016] [Accepted: 01/11/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intraventricular hemorrhages (IVHs) caused by ruptured cerebral aneurysms often have poor outcomes. Treatment challenges include comorbidities, increased intracranial pressure caused by IVH, and risk of rebleeding. CASE DESCRIPTION Two cases of severe IVH accompanied by acute hydrocephalus caused by ruptured aneurysm were treated with coil embolization followed by endoscopic hematoma evacuation as a single treatment session in a hybrid operating room (OR) equipped with a multipurpose angio biplane system. The first case was an 84-year-old woman with a ruptured basilar top aneurysm, who presented with Hunt and Hess (H&H) grade 5 subarachnoid hemorrhage (SAH) with packed IVH. The second case was a 43-year-old man with a ruptured anterior communicating artery aneurysm who presented with H&H grade 5 SAH with packed IVH. In both cases, endovascular coil embolization was performed first to prevent intraoperative bleeding. The coiled aneurysms suddenly appeared on the screen of the endoscope during the hematoma removal, which could have led to massive rebleeding if not treated previously. Neither patient needed a reinsertion of the ventricular drainage or developed chronic hydrocephalus during hospitalization. The hybrid OR enabled the 2 treatment approaches to be performed without the need to transfer the patient, thereby minimizing the transition time between the modalities. Intraoperative cone-beam computed tomography contributed to the evaluation of residual clots. CONCLUSIONS A hybrid OR may contribute to a combined neuroendoscopic and endovascular treatment for ruptured cerebral aneurysms with severe intraventricular hemorrhage.
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Kirmani AR, Sarmast AH, Bhat AR. Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surg Neurol Int 2015; 6:188. [PMID: 26759733 PMCID: PMC4697206 DOI: 10.4103/2152-7806.172533] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022] Open
Abstract
Background: External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management. Methods: During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy. Results: The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring. Conclusions: The use of EVD should be undertaken only in situation where it is absolutely necessary and ventriculostomy should be kept only for the duration required, and this should be monitored on a daily basis, given the exponential increase in infection after 5 days.
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Affiliation(s)
- Altaf Rehman Kirmani
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif Hussain Sarmast
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Bhat
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Miyagi N, Uchikado H, Aoki T, Sakata K, Hirohata M, Morioka M. Nontraumatic aneurysm rupture following an endoscopic third ventriculostomy and ventricular drainage: Case report of a rare complication. Surg Neurol Int 2015; 6:80. [PMID: 26009704 PMCID: PMC4439787 DOI: 10.4103/2152-7806.157303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/19/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Although endoscopic third ventriculostomy is a safe procedure, the authors report a case of aneurysmal subarachnoid hemorrhage as an unusual and serious complication of an endoscopic third ventriculostomy and ventricular drainage. CASE DESCRIPTION A 60-year-old male presented with obstructive hydrocephalus caused by midbrain tumors was admitted to our hospital. Endoscopic third ventriculostomy and external ventricular drainage were successfully performed. Two days after the operation, he became comatose, and a computed tomography (CT) scan revealed a diffuse subarachnoid hemorrhage. Emergency cerebral angiogram showed an aneurysm of the left internal carotid artery. Endovascular coil embolization of the ruptured aneurysm was then performed. CONCLUSION The rupture of the aneurysm may have been induced by excessive cerebrospinal fluid drainage after the endoscopic third ventriculostomy. Planning for intracranial endoscopic procedures should consider that rupture of an unknown previously unruptured aneurysm is a possible complication.
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Affiliation(s)
- Naohisa Miyagi
- Department of Neurosurgery, Nakagami Hospital, Okinawa, Japan
| | | | - Takachika Aoki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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de Andrade AF, Paiva WS, Neville IS, Noleto GS, Alves Junior A, Sandon LHD, Bor-Seng-Shu E, Amorim RL, Teixeira MJ. Monoblock external ventricular drainage system in the treatment of patients with acute hydrocephalus: a pilot study. Med Sci Monit 2014; 20:227-32. [PMID: 24509952 PMCID: PMC3933296 DOI: 10.12659/msm.890080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system. Material/Methods 46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system. Results The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors. Conclusions Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.
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Affiliation(s)
- Almir Ferreira de Andrade
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gustavo Sousa Noleto
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Aderaldo Alves Junior
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz Henrique Dias Sandon
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Robson Luis Amorim
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurological Surgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Iwaasa M, Ueba T, Nonaka M, Okawa M, Abe H, Higashi T, Inoue T. Safety and feasibility of combined coiling and neuroendoscopy for better outcomes in the treatment of severe subarachnoid hemorrhage accompanied by massive intraventricular hemorrhage. J Clin Neurosci 2013; 20:1264-8. [PMID: 23830690 DOI: 10.1016/j.jocn.2012.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/18/2012] [Accepted: 09/26/2012] [Indexed: 10/26/2022]
Abstract
Subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) is associated with poor outcomes. The aim of this study was to evaluate the safety and feasibility of combined coiling and neuroendoscopy for treating severe SAH with massive IVH. Between April 2008 and June 2011, 49 patients with a severe SAH were treated at the Department of Neurosurgery, Fukuoka University, Japan; 10 of these patients had a massive IVH with a ruptured aneurysm. All 10 patients (three men and seven women; mean age, 63.1±8.5 years) were treated with coiling and neuroendoscopic removal of the IVH within 2 days of onset. Coiling was successfully performed at a mean volume embolization ratio of 21.8±5.5%. Neuroendoscopic removal of the IVH reduced the mean Graeb score from 10.5±2.0 to 4.8±2.5 (p=0.005). All external drains were removed on day 3. No rebleeding or acute hydrocephalus was noted. The Glasgow Outcome Scale scores at discharge indicated two patients with good recovery, three with moderate disability, four in a vegetative state, and one dead. A good modified Rankin Scale (mRS) score (0-2) at least 6 months later (mean follow-up period, 15.4±9.2 months) was observed for five patients (50%), and a poor mRS score (3-6) was observed for the remaining four patients. Neuroendoscopically removing the IVH from all of the ventricles between the lateral and the fourth ventricle and coiling the ruptured aneurysm is a safe, feasible approach for treating severe SAH with massive IVH.
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Affiliation(s)
- Mitsutoshi Iwaasa
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jounan-ku, Fukuoka City, Fukuoka 814-0180, Japan
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Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJP, Quinn AC, Ross SA. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke 2012; 43:677-82. [PMID: 22282887 DOI: 10.1161/strokeaha.111.625731] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A single-center prospective randomized controlled trial has been conducted to determine if lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage reduces the prevalence of delayed ischemic neurological deficit and improves clinical outcome. METHODS Patients with World Federation of Neurological Surgeons Grade 1 to 3 aneurysmal subarachnoid hemorrhage and modified Fisher Grades 2, 3, 4, and 3+4 were randomized to either the study group of standard therapy plus insertion of a lumbar drain or the control group of standard therapy alone. The primary outcome measure was the prevalence of delayed ischemic neurological deficit. RESULTS Two hundred ten patients with aneurysmal subarachnoid hemorrhage (166 female, 44 male; median age, 54 years; interquartile range, 45-62 years) were recruited into the control (n=105) and study (n=105) groups of the trial. World Federation of Neurological Surgeons grade was: 1 (n=139), 2 (n=60), and 3 (n=11); Fisher grade was: 2 (n=87), 3 (n=85), and 4 (n=38). The prevalence of delayed ischemic neurological deficit was 35.2% and 21.0% in the control and study groups, respectively (P=0.021). The prevalence of a modified Rankin Scale score of 4, 5, or 6 at Day 10 and 6 months, respectively, was 62.5% and 18.6% in the control group and 44.8% and 19.8% in the study group (P=0.009 and 0.83, respectively). CONCLUSIONS Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage has been shown to reduce the prevalence of delayed ischemic neurological deficit and improve early clinical outcome but failed to improve outcome at 6 months after aneurysmal subarachnoid hemorrhage. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov. Unique identifier: NCT00842049.
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Affiliation(s)
- Yahia Z Al-Tamimi
- Department of Neurosurgery, Level G Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds, West Yorkshire, UK LS1 3EX.
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Risk Factors Related to Aneurysmal Rebleeding. World Neurosurg 2011; 76:292-8; discussion 253-4. [DOI: 10.1016/j.wneu.2011.03.025] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 12/28/2010] [Accepted: 03/22/2011] [Indexed: 11/17/2022]
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Hemorragia subaracnoidea aneurismática: Guía de tratamiento del Grupo de Patología Vascular de la Sociedad Española de Neurocirugía. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70007-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Gigante P, Hwang BY, Appelboom G, Kellner CP, Kellner MA, Connolly ES. External ventricular drainage following aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2010; 24:625-32. [DOI: 10.3109/02688697.2010.505989] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pavesi G, Amistà P, Munari M, Gardiman MP. Intraventricular hemorrhage caused by peripheral anterior choroidal artery aneurysm rupture. A case report. Neuroradiol J 2008; 21:717-20. [PMID: 24257017 DOI: 10.1177/197140090802100518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 09/07/2008] [Indexed: 11/16/2022] Open
Abstract
Intraventricular hemorrhage is a severe ictal event secondary to several pathological conditions (anticoagulation therapies, hypertension, post-surgical, traumatic, neoplastic, vascular malformations), leading to blockage of CSF flow and possible hydrocephalus, often justifying surgical intervention. We describe an uncommon source of intraventricular hemorrhage in a 54-year-old woman caused by a peripheral anterior choroidal artery aneurysm rupture.
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Affiliation(s)
- G Pavesi
- Neurosurgery, Padua City Hospital; Padua Italy -
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Freiman TM, Spiegelberg A. Mounting device for external cerebrospinal fluid drainage: the Freiburg Stativ. Acta Neurochir (Wien) 2008; 150:1081-5. [PMID: 18802662 DOI: 10.1007/s00701-008-0023-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 07/14/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND External drainage of cerebrospinal fluid (CSF) is one of the most common neurosurgical procedures. It is important to maintain a stable drainage rate, but with the commonly available mountings for CSF drainage this can be difficult to achieve. The drainage rate is dependent on the height-difference between the CSF space and the drip chamber of the device. Most mountings for open CSF drainage cannot be satisfactorily fixed at the bed of the patient; especially if the head of the bed is moved, there is a risk of over- or underdrainage. MATERIALS AND METHODS We have therefore constructed a mounting for open CSF drainage which allows appropriate adjustment of the rate of CSF outflow, even if the patient's head part of the bed is moved. FINDINGS The device was easily mountable or exchangeable at any hospital bed and served equally well for ventricular or for lumbar drainage. CONCLUSION We think that this device can help to reduce serious complication of over- or underdrainage in external CSF drainage.
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Stefini R, Ghitti F, Bergomi R, Catenacci E, Latronico N, Mortini P. Uncommon presentation of ruptured intracranial aneurysm during surgical evacuation of chronic subdural hematoma: case report. ACTA ACUST UNITED AC 2008; 69:89-92; discussion 92. [PMID: 17586010 DOI: 10.1016/j.surneu.2006.11.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Accepted: 11/28/2006] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are many factors that predispose an aneurysm to rupture, but there are few real, demonstrable causes that lead to rupture of the aneurysmal sac with a precise cause-effect mechanism. CASE DESCRIPTION We report a 74-year-old male patient with chronic subdural hematoma after head trauma, who underwent surgery for evacuation of the hematoma. During surgery, there was sudden copious loss of blood from the drainage tubes that were positioned subdurally. Immediate cerebral computed tomography scan and angiography revealed a subarachnoid hemorrhage at the level of the basal cisterns from a ruptured basilar apex aneurysm. We discuss the cause-effect relationship between the surgery with its positioning of subdural drains and the rupture of a previously unrecognized cerebral aneurysm. CONCLUSIONS The rupture of an unknown, previous "unruptured" aneurysm after craniotomy with subdural positioning of drainage, must be considered a possible complication.
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Affiliation(s)
- Roberto Stefini
- Department of Neurosurgery, University of Brescia, 25100 Brescia, Italy.
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Abstract
Subarachnoid haemorrhage accounts for only 5% of strokes, but occurs at a fairly young age. Sudden headache is the cardinal feature, but patients might not report the mode of onset. CT brain scanning is normal in most patients with sudden headache, but to exclude subarachnoid haemorrhage or other serious disorders, a carefully planned lumbar puncture is also needed. Aneurysms are the cause of subarachnoid haemorrhage in 85% of cases. The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping). Another complication is delayed cerebral ischaemia; the risk is reduced with oral nimodipine and probably by maintaining circulatory volume. Hydrocephalus might cause gradual obtundation in the first few hours or days; it can be treated by lumbar puncture or ventricular drainage, dependent on the site of obstruction.
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Affiliation(s)
- Jan van Gijn
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, 3584CX Utrecht, Netherlands.
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Longatti P, Fiorindi A, Di Paola F, Curtolo S, Basaldella L, Martinuzzi A. Coiling and neuroendoscopy: a new perspective in the treatment of intraventricular haemorrhages due to bleeding aneurysms. J Neurol Neurosurg Psychiatry 2006; 77:1354-8. [PMID: 16835289 PMCID: PMC2077420 DOI: 10.1136/jnnp.2006.090142] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intraventricular haemorrhages (IVHs) caused by bleeding aneurysms are critical conditions that often carry a severe prognosis. Two main problems must be urgently dealt with: the secondary damage caused by intraventricular clotting and the risk of early rebleeding. A protocol of ultra-early endoscopic ventricular evacuation, after securing the aneurysm with coils, is proposed to solve this challenge in the acute phase and within a few hours of onset. METHODS Ten consecutive patients presenting with haematocephalus from aneurysm rupture were treated in our institute with coiling and endoscopic clot aspiration extended to the whole ventricular system. The only inclusion criteria were the presence of a massive IVH and an aneurysm appropriate for coiling. Computed tomography scans obtained before (within 4 h of symptom onset in all patients) and immediately after surgery were compared for Graeb score and ventriculocranial ratio (VCR); the Glasgow Outcome Scale (GOS) was assessed at 1 year. RESULT All patients were treated within 2 days of onset. The procedure resulted in a mean 58% removal of ventricular blood and decrease of hydrocephalus; the mean (standard deviation (SD)) Graeb score reduced from 11.5 (0.7) to 4.7 (2.2) (p<0.001) and mean ventriculocranial ratio from 0.26 (0.06) to 0.17 (0.05) (p<0.001). No rebleeding or delayed hydrocephalus needing shunt was observed. Mortality at 1 year was 30%; marked disability (GOS = 3) and good recovery (GOS = 5) were observed in 40% and 30% of patients, respectively. CONCLUSIONS Early neuroendoscopic removal of blood casting from the lateral to the fourth ventricle after coiling of bleeding aneurysms is a feasible approach, allowing in most instances the rapid improvement of the IVH.
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Affiliation(s)
- P Longatti
- Department of Neurosurgery, Treviso Hospital-Padova University, Treviso, Italy
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Hellingman CA, van den Bergh WM, Beijer IS, van Dijk GW, Algra A, van Gijn J, Rinkel GJE. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 2006; 38:96-9. [PMID: 17122426 DOI: 10.1161/01.str.0000251841.51332.1d] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cerebrospinal fluid drainage is often indicated in patients with acute hydrocephalus after aneurysmal subarachnoid hemorrhage but is believed to increase the risk of rebleeding. We studied the risk of rebleeding in patients with subarachnoid hemorrhage during treatment for acute hydrocephalus. METHODS We included patients with hydrocephalus treated with external ventricular drainage or lumbar punctures within 4 days after the hemorrhage and before aneurysm occlusion. Each treated patient was matched with a control patient with untreated hydrocephalus and a control patient without ventricular enlargement. Patients and controls were matched for interval since subarachnoid hemorrhage, duration of exposure, use of tranexamic acid, clinical condition on admission, and age. We used Cox regression to calculate hazard ratios and we adjusted for rebleeding that had occurred before starting the cerebrospinal fluid drainage. RESULTS In the group treated with external ventricular drainage, rebleeding occurred in seven of 34 patients (21%) with treatment, in seven of 34 controls (21%) with untreated hydrocephalus, and in six of 34 controls (18%) without hydrocephalus. In the group treated with one or more lumbar punctures, rebleeding occurred in one of 21 patients (5%) with treatment, in three of 21 controls (14%) with untreated hydrocephalus, and in none of the 21 controls without hydrocephalus. The hazard ratios for rebleeding were 1.0 (95% CI: 0.4 to 2.7) for external ventricular drainage treatment and 0.7 (95% CI: 0.1 to 6.4) for lumbar puncture treatment. CONCLUSIONS This study does not confirm an importantly increased risk of rebleeding during external ventricular drainage or lumbar punctures for acute hydrocephalus after aneurysmal subarachnoid hemorrhage.
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