Bleeding patterns from ruptured intracranial aneurysms: an autopsy series of 205 patients

Subarachnoid Hemorrhage From Ruptured Aneurysms at the Internal Carotid Artery-Posterior Communicating Artery Bifurcation Not Detectable on Preoperative Imaging Studies

Since subarachnoid hemorrhage (SAH) due to the re-rupture of cerebral aneurysms severely worsens the prognosis, an accurate initial diagnosis is essential. Computed tomography (CT) and magnetic resonance imaging (MRI) usually detect aneurysmal subarachnoid hemorrhage (aSAH). However, in rare cases, its identification on CT- and MRI scans is difficult, and a cerebrospinal fluid (CSF) examination is required. We present preoperative imaging and intraoperative findings in patients whose aSAH detection necessitated a CSF examination. Of 225 aSAH patients who underwent preoperative imaging studies at our institution between April 2010 and August 2019, 3 females (1.3%, mean age 57.3 years) harbored undetectable aSAH due to the rupture of an internal carotid artery-posterior communicating artery (ICA-PcomA) aneurysm. The aneurysmal orientation was inferolateral. Intraoperatively, the anterior petroclinoid ligament hampered the detection of the aneurysms that firmly adhered to the surrounding arachnoid membrane. Sustained arterial pulsation and successive minor hemorrhage can lead to the gradual adhesion of an ICA-PcomA aneurysm to the surrounding arachnoid membrane and explain their atypical rupture undetectable on imaging studies and the development of acute subdural hematoma without SAH.

Acute subdural hematomas secondary to aneurysmal subarachnoid hemorrhage confer poor prognosis: a national perspective

BACKGROUND

Aneurysmal ruptures typically cause subarachnoid bleeding with intraparenchymal and intraventricular extension. However, rare instances of acute aneurysmal ruptures present with concomitant, non-traumatic subdural hemorrhage (SDH). We explored the incidence and difference in outcomes of SDH with aneurysmal subarachnoid hemorrhage (aSAH) as compared with aSAH alone.

METHODS

Retrospective cohort study from 2012 to 2015 from the National (Nationwide) Inpatient Sample (NIS) (20% stratified sample of all hospitals in the United States). NIS database (2012 to September 2015) queried to identify all patients presenting with aSAH. From this population, the patients with concomitant SDH were identified.

RESULTS

A total of 10 075 patients with both cerebral aneurysms and aSAH were included. Of these, 335 cases of concomitant SDH and aSAH were identified. There was no significant change in the rate of SDH in aSAH over time. SDH with aSAH patients had a mortality of 24% compared with 12% (p=0.003) in the SAH only group, and only 16% were discharged home vs 37% (p=0.003) in the SAH group.

CONCLUSIONS

There is a 3.5% incidence of acute SDH in patients presenting with non-traumatic aSAH. Patients with SDH and aSAH have nearly double the mortality, higher rate of discharge to nursing home and rehabilitation, and a significantly lower rate of discharge to home and return to routine functioning. This information is useful in counseling and prognostication of patients with concomitant SDH and aSAH.

A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase

Objective

Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase.

Materials and Methods

We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%).

Results

In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality.

Conclusion

If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms.

Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm

BACKGROUND

Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage.

METHODS

Case report and review of the literature.

RESULTS

We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence.

CONCLUSIONS

Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.

Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms

OBJECTIVE

Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures.

METHODS

A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10-82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome.

RESULTS

The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome.

CONCLUSIONS

Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

Outcome after emergency surgery without angiography in patients with intracerebral haemorrhage after aneurysm rupture

BACKGROUND

Patients with large intracerebral haematomas (ICH) from aneurysm rupture often present in a poor clinical condition and have a poor prognosis. Time delay for preoperative angiography might in some cases be unappealing. We evaluated the outcome after immediate haematoma removal and aneurysm occlusion without preoperative angiography.

METHODS

We retrospectively identified 13 consecutive patients. We recorded clinical data and evaluated mortality and morbidity with the Glasgow Outcome Score (GOS) and Telephone Interview of Cognitive Status (TICS).

FINDINGS

At follow up seven of thirteen patients had favourable outcome assessed by GOS. Three patients had severe disability and three patients died. None of the survived patients interviewed had impaired cognition.

CONCLUSIONS

In patients presented in a critical state with aneurysmal ICH, emergency haematoma removal and aneurysm clipping without the delay for diagnostic angiography may be life saving and a satisfactory outcome can be accomplished.

Role of transcranial Doppler in neurocritical care

Transcranial Doppler has several practical applications in neurocritical care. It has its main application in the diagnosis and monitoring of vasospasm in patients with subarachnoid hemorrhage. In addition, it holds promise for the detection of critical elevations of intracranial pressure. Its ability to measure CO2 reactivity and autoregulation may ultimately allow intensivists to optimize cerebral perfusion pressure and ventilatory therapy for the individual patient. Transcranial Doppler findings of brain death are well described and can be useful as a screening tool.

Posterior temporal haematoma associated with anterior communicating artery aneurysm rupture

We report the case of a 68-year-old man who presented with symptoms suggesting an intracranial haemorrhage. A computed tomography scan showed subarachnoid haemorrhage associated with a remote posterior temporal intracerebral haematoma. Angiography revealed the presence of an anterior communicating artery aneurysm, which was subsequently clipped. Possible causes for the association of a distant intracerebral haematoma with rupture of an anterior communicating artery aneurysm are discussed. This uncommon association should be recognised to avoid incorrect identification of the origin of haemorrhage.

Ruptured intrasellar superior hypophyseal artery aneurysm presenting with pure subdural haematoma. Case report

SUMMARY

Subdural haemorrhage from a ruptured intracranial aneurysm is a well-known entity when associated with subarachnoid haemorrhage. However, haemorrhage confined only to the subdural space is rare because there are limited anatomical sites where extravasation can be purely subdural. We report the rare case of a patient who suffered pure subdural haematoma after the rupture of a left superior hypophyseal artery aneurysm located within the sella turcica. The patient was treated with endovascular coil embolization of the aneurysm. Angiography immediately after treatment and one month later revealed complete obliteration of the aneurysm. Six months after treatment, the patient remained symptom free.

GDC Embolization of Intracranial Aneurysms with SAH and Mass Effect by Subdural Haematoma. A Case Report and Review

SUMMARY

A 43-year-old woman was brought to the emergency room due to the sudden onset of severe headache and stuporous consciousness. She had no history of head injury. Computerized tomography scan revealed subarachnoid haemorrhage and left SDH with midline shift of about 10 mm. Cerebral angiography demonstrated anterior communicating artery and right middle cerebral artery bifurcation aneurysms. Her family refused operation due to her religion never to permit blood transfusion. So just aneurysm coiling and medical ICP control was planned. Guglielmi detachable coil (GDCs) embolization of the two aneurysms was successfully performed. She made a neurological recovery after embolization without evacuation of the SDH. She was discharged from hospital with no neurological deficit on day 21. We report our experience of successful GDC embolization on multiple aneurysms without craniotomy even in the selected case of mass effect.

Acute pure spontaneous subdural haematoma from ruptured intracranial aneurysms

SUMMARY

Acute subdural haematoma (ASDH) is rarely caused by an aneurysmal rupture. We report four cases of pure acute subdural haematomas caused by ruptured intracranial aneurysms. Aneurysms were localized in the posterior communicating artery in two cases, in the anterior communicating artery in one case and in the middle cerebral artery in one other case. Possible mechanisms for this type of aneurysmal bleeding are discussed. A good prognosis for these patients can be expected with rapid evacuation of the haematoma (in case of high intracranial pressure and midline structure shift), and treatment of the aneurysm (surgical clipping or endovascular treatment). Our report demonstrates the utility of angiography in the evaluation of nontraumatic acute subdural haematomas. Angiography has to be performed before haematoma evacuation or just after if the patient requires urgent surgery in case of intracranial hypertension. Aneurysms may require surgical clipping or endovascular treatment.

Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases

During a six-year (1986-1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery. Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8%) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2%). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6%). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%). We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.

Recurrent aneurysmal subarachnoid haemorrhage: bleeding pattern and incidence of posthaemorrhagic ischaemic infarction

This report is based on a consecutive series of 162 patients with aneurysmal subarachnoid haemorrhage (SAH), including 22 patients (14%) with recurrent SAH, who were treated within 72 h after the most recent bleed. Of the 22 patients with recurrent haemorrhage: 68% were in poor clinical condition (Hunt & Hess grade 4-5); 73% presented with intracerebral haemorrhage (ICH); 41% developed delayed ischaemic infarctions from chronic arterial spasm; 14% made a good recovery, while 41% died. Of the 140 patients with a single bleed: 34% were in poor clinical condition (Hunt & Hess grade 4-5); 33% presented with ICH; 22% developed delayed ischaemic infarctions; 53% made a good recovery, while 19% died. Our results suggest that a high incidence of intracerebral haemorrhage in conjunction with a more severe course of chronic arterial spasm substantially contributes to the high morbidity and mortality associated with recurrent SAH. In poor grade patients not suitable for acute open surgery, endovascular treatment should receive consideration for the prevention of early rebleeding.

Acute subdural haematoma from ruptured intracranial aneurysms

Acute subdural haematoma (SDH) secondary to a ruptured intracranial aneurysm is a rare event. Out of a total of 292 patients with a verified aneurysm (period 1986-1992) in five cases SDH was the diagnosis on CT-evaluation. One patient was in such a bad condition that no treatment was indicated. The remaining four patients were operated on: craniotomy and haematoma evacuation in two cases, craniotomy for haematoma evacuation and aneurysm clipping in the other two cases. Two patients died and two achieved a good outcome.

Intracerebral hematoma in patients with ruptured cerebral aneurysms

BACKGROUND

Intracerebral hematoma from ruptured aneurysms is one of the unfavorable factors for outcome in patients with subarachnoid hemorrhage. In this study, the clinical characteristics of intracerebral hematoma in patients with ruptured aneurysms were examined.

METHODS

The subjects were 512 patients who had been admitted by day 3 after aneurysmal rupture without episodes of rebleeding before the initial computed tomography (CT) scan. They were divided into two groups according to the findings of initial CT; groups 1 and 2 comprised patients with and without intracerebral hematoma, respectively.

RESULTS

Of the 512 patients, intracerebral hematoma was observed in 98 (19%). The incidence of intracerebral hematoma was higher in patients with distal anterior cerebral and middle cerebral artery aneurysms, compared with those at other sites (both, p < 0.01). Interhemispheric, callosal, and temporal lobe/sylvian hematomas were observed more frequently in patients with anterior communicating, distal anterior cerebral, and middle cerebral artery aneurysms, respectively, than in those with aneurysms at other sites. The incidence of rebleeding was 22% in group 1 and 14% in group 2 (p < 0.05). Clinical grades on admission were higher and outcome at 6 months after onset was less favorable in group 1 than in group 2 (both, p < 0.01). The larger the intracerebral hematoma, the higher was the clinical grade and the less favorable the outcome. However, when comparing management and surgical outcome under the same clinical grades, there was no significant difference between the two groups.

CONCLUSIONS

There was a close correlation between the site of hematoma and that of the ruptured aneurysm. Poor outcome in patients with intracerebral hematoma seems to be related to severity of clinical grade on admission.

Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study

Multiple intracranial aneurysms (MIA) have been detected in up to one-third of patients with cerebral aneurysms. Three main external factors influence these figures as follows: the quality of angiographies, the quantity of vessels studied, and referral policy. In a 1-year prospective study, we determined the incidence of MIA in a defined catchment area in East Finland by investigating all of the patients with intracranial aneurysms with panangiography. In 114 unselected patients, a total of 170 intracranial aneurysms were detected, and, of these, 39 (34%) harbored MIA. In contrast to most other reports, there was a male predominance in patients with MIA, and half of these men had hypertension. Intracavernous carotid and pericallosal aneurysms were more frequent in patients with MIA. The number of asymptomatic vertebrobasilar aneurysms was extremely low, and most of the nonruptured aneurysms were found in bilateral carotid angiograms. In spite of the active search, the proportion of vertebrobasilar aneurysms remained at 6%. Although our surgical policy was most active, one-third of the asymptomatic aneurysms remained untreated, mainly because of the poor condition of the patient.

The prognostic significance of intracerebral haematoma as shown on CT scanning after aneurysmal subarachnoid haemorrhage

In a prospective study of 1076 consecutive patients with aneurysmal subarachnoid haemorrhage (SAH), CT was carried out in 815 patients. CT visible intracerebral haematoma (ICH) was found in 42.6% of the 815 patients. There were no differences in age, pre-existing hypertension or sex between patients with or without ICH. Patients with ICH were in poorer clinical condition on admission, and had a poorer mental outcome and a higher mortality at the 2-year follow-up examination compared with patients without ICH. Of the 491 operated patients, there were in every group according to the clinical condition on admission fewer patients with a normal mental outcome and more fatal cases if an ICH was present after aneurysm rupture. This indicates that the acute brain dysfunction from SAH complicated by ICH is more likely to be followed by permanent cerebral damage compared to the corresponding acute cerebral dysfunction from SAH without ICH.

Acute subdural haematoma secondary to ruptured intracranial aneurysm: diagnosis and management

Acute subdural haematoma secondary to a ruptured intracranial aneurysm may lead to coma or sudden death. We describe five cases encountered in our department over the last 3 years emphasizing the differential diagnosis and approaches to management.

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.

Ruptured intracranial aneurysms: an autopsy study of 133 patients

The autopsy findings of 133 patients with ruptured intracranial aneurysms were reviewed: 24 (18%) had multiple aneurysms. Intraventricular hemorrhage was seen in 53 patients (40%), and intracerebral hematoma was seen in 52 (39%). Intraventricular hemorrhage was seen most frequently in patients with anterior communicating artery aneurysms [21 of 40 (53%)]. Intracerebral hematoma occurred most frequently in patients with middle cerebral artery aneurysms [11 of 28 (39%)]. Hemorrhages arising from anterior communicating artery aneurysms had two types of penetration routes into the lateral ventricle. The first was through the inferomedial portion of the frontal lobe, and the second was through the corpus callosum. The second type was poorly visualized in horizontal sections of the brain. Of 40 patients with anterior communicating artery aneurysms, the first type of penetration route was observed in 15, and the second type was found in 3. The second type is rare, and if the hemorrhage is not massive, it may be overlooked in axial computed tomography scans. Of the 109 ruptured aneurysms, 18 (17%) were 4 mm or less in diameter, 50 (46%) were 5-9 mm in diameter, and 41 (38%) were 10 mm or larger in diameter. In the 21 patients with multiple aneurysms, unruptured aneurysms were smaller than ruptured aneurysms in 17 of 27 (63%), equal size in 9 (33%), and larger in 1 (4%). Regarding rerupture, the larger the ruptured aneurysms were, the higher the percentage of rerupture, that is, 11% of 18 ruptured aneurysms of 4 mm or less in diameter, 32% of 50 of 5-9 mm in diameter, and 37% of 41 of 10 mm or larger in diameter had reruptured. It seems that the larger the size of the aneurysm, the higher the risk of rerupture as well as of initial rupture.

Ruptured middle cerebral aneurysm with accumulation of subarachnoid blood within convexity arachnoid cyst

A case of acute rupture of a right middle cerebral bifurcation aneurysm with extravasation of blood into a distant arachnoid cyst is reported.

Ruptured intracerebral aneurysm resulting in a subdural hematoma

We present the case of a 28-year-old woman whose clinical presentation was that of an intracerebral hemorrhage with rapid neurologic deterioration. A nonenhanced computed tomography scan demonstrated an acute subdural hematoma with no evidence of blood in the subarachnoid space. The patient subsequently herniated and died 24 hours after admission.

Intracranial hematomas following aneurysmal rupture: experience with 309 cases

Three hundred and nine consecutive cases of intracranial hematomas due to aneurysmal rupture--representing 34% of the total number of patients with aneurysms observed in a 12-year period--were evaluated; of these, 211 were submitted to computed tomography scan. Hematomas were present on admission in 71% of patients and occurred at rebleeding in 29%. Ruptured middle cerebral artery aneurysms caused an intracranial hematoma more frequently than aneurysms in other locations. Ventricular hematomas were frequently observed--especially at rebleeding--in cases with anterior communicating artery aneurysms. Basal ganglia hematomas were detected in eight cases with internal carotid bifurcation aneurysms and in three with middle cerebral artery aneurysms. Subdural hematomas were observed in 32 cases, mainly due to ruptured middle-cerebral-artery and internal-carotid-artery aneurysms. As for clinical evolution, a rapid deterioration was observed in 39% of cases and a chronic course in 46%; a subacute deterioration was far less frequent. Delayed deterioration from vasospasm was observed in 8% of cases, and appeared to be related to the amount of subarachnoid bleeding associated with the hematoma. One hundred and forty-two patients were submitted to surgical treatment (evacuation of hematoma together with exclusion of aneurysm); deep coma, poor medical condition, stabilized neurological disability, or combinations of these factors accounted for the high number of patients not operated upon. Regardless of treatment, 24% of patients showed good results and 58% died. Presence of a large hematoma, ventricular hemorrhage, and shift of the ventricles represented significant risk factors, associated with a poor prognosis. A comparison between two groups of patients admitted within 3 days of hemorrhage--47 operated on early, and 149 with delayed treatment--showed that better results were achieved by early operations, especially for cases in Hunt's grades IV and V.

Successful treatment of a basilar aneurysm presenting as a brainstem hemorrhage

A case of large brainstem hemorrhage resulting from a basilar artery aneurysm is reported. This extremely rare disorder is fatal in a large majority of cases, and has usually been reported after autopsy. This case presents a successful recovery after clipping the aneurysm.

Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases

Intraventricular hemorrhage (IVH) from aneurysm rupture is generally considered to be of grave prognostic significance. Ninety-one cases have been studied retrospectively from seven medical centers. The overall mortality rate was 64%. The dramatically poor condition of these patients leads to their rapid admission to the hospital. Eighty-seven percent were admitted on Day 0 or 1, and more than half were classified neurologically as Grade 4 or 5. A multiple regression analysis explained 56% of the variance in survival, using the variables of ventriculocranial ratio (VCR), day of admission, diastolic blood pressure, location of aneurysm, associated intracerebral hematoma, age, grade on admission, sex, and systolic blood pressure. No patient with a VCR of more than 0.25, as calculated from the initial computerized tomography (CT) scan, survived. No patient whose smallest VCR was 0.23 or more survived. This ratio can be simply measured with a millimeter ruler from the CT scan. Patients with IVH usually had enlarged ventricles, even initially. The overall results suggest that early management of intracranial hypertension should be more generally considered, although even when this was done the prognosis was still guarded. The timing of surgery was not an important determinant of outcome, although a significant number of patients died awaiting surgery.

Clinical - radiological correlates in intracerebral hematomas due to aneurysmal rupture

In this series of intracerebral hematomas from aneurysmal rupture, gathered from several neurosurgical services, certain morphological features were studied in detail. Patients with very large hematomas tended to have poor neurological grades on admission to hospital and their immediate discharge outlook was correspondingly poor. Ruptured middle cerebral and pericallosal artery aneurysms were relatively common causes of intracerebral hematomas. Patients with temporal lobe hematoma did relatively well; those with parietal hematoma did poorly. The larger the hematoma the less chance there was of developing cerebral vasospasm but the more likely was pre-operative brain herniation. The survival was more closely linked to size and location of the hematoma than to the location of aneurysm or the degree of midline shift.

Superior sagittal sinus thrombosis followed by subdural hematoma

A case of superior sagittal sinus thrombosis followed by a subdrual hematoma is reported. A 33-year-old woman, who presented with serious neurological deficits, made a remarkable recovery with mild residual. She had a thin subdural fluid collection, which eventually developed into a subdural hematoma. After evacuation of the hematoma, she had no neurological deficits. Treatment of cerebral venous and dural sinus thrombosis is discussed.