A study of blood coagulation and fibrinolytic system in spontaneous subarachnoid hemorrhage. Correlation with hunt-hess grade and outcome

BACKGROUND

Subarachnoid hemorrhage (SAH) has been studied from various standpoints with the purpose of discovering criteria that might be useful in predicting the prognosis. In the literature a high incidence of coagulative and fibrinolytic disorders has been reported in SAH patients. A prospective study was performed to evaluate hemostatic plasmatic parameters in SAH patients.

METHODS

Hemostatic plasmatic parameters were prospectively studied in 76 patients with SAH. Both the coagulative (PT, APTT, fibrinogen, thrombin/antithrombin complex: TAT, and modified antithrombin III: MAT) and fibrinolytic (D-dimer) plasmatic systems were evaluated. Von Willebrand factor was also tested.

RESULTS

PT, APTT, and fibrinogen were within normal limits. High TAT levels were associated with clinical outcome since 16 patients out of 27 (59%) with unfavorable outcomes displayed TAT levels >20 ngzaq/L, as compared with 10 patients out of 38 (26%) with favorable outcomes. Plasmatic D-dimer, an index of subarachnoid clot lysis, was invariably found to be elevated. Nevertheless, very high levels (>1000 mcg/mL) were found in 16 patients out of 22 (73%) with unfavorable outcomes but in only 9 patients out of 38 (26%) with favorable outcomes. Significant D-dimer elevation showed a strong association with severe delayed ischemic deficit (DID). Patients were also tested for von Willebrand factor, displaying a specific increase in all cases.

CONCLUSION

The study provides evidence for an early activation of the coagulation and fibrinolytic system following SAH. Increase of plasmatic TAT parallels clinical outcome. A generalized increase of D-dimer was observed as well and D-dimer levels in the high range were associated with clinical outcome and poor results with DID. Our analysis shows close statistical significance between plasma levels of TAT, D-dimer, and outcome. A similar statistical significance has been found when comparing other known prognostic factors such as clinical and cerebral computerized tomography scan (CT) grade and outcome.

Minor head injuries: one year experience according to the new Italian guideline

BACKGROUND

The data concerning a consecutive series of 4,536 adult patients suffering from minor head injuries treated at the Department of Neurosurgery over a period of one year are reported.

METHOD

The patients' age, sex and the circumstances of the injury have been taken into consideration. The patients, according to the new method, were divided into four groups. Group 0 (3,864 patients) included all patients with Glasgow Coma Scale (GCS) score 15. They did not present any clinical features such as loss of consciousness (LOC), post-traumatic amnesia (PTA), headache or vomiting. No risk factors (RF) such as coagulopaties, alcoholism, drug abuse, epilepsy, previous neurological treatment or disabled elderly patients were detected. Group 1 (600 patients) included patients with GCS score 15. The patients presented one or more clinical features (LOC, PTA, headache, vomiting). No RF were presented. Group 2 (24 patients) included patients with GCS score 14 with or without clinical features (LOC, PTA, headache, vomiting) and with or without RF. Group 0-1R (48 patients) included patients with GCS score 15 with or without clinical features (LOC, PTA, headache, vomiting). All of them presented RF. The presence of focal neurological signs, open injury and GCS score < or = 13 were considered criteria for exclusion.

FINDINGS

All the patients from groups 1, 0-1R, 2 and 187 patients from group 0 underwent CT scan for a total of 859 exams which are analyzed and discussed. 458 patients were admitted and are divided as follows: 216 from group 0, 192 from group 1, 26 from group 0-1R and all the 24 belonging to group 2. Six patients were treated surgically (3 extradural haematomas, 2 lobe contusions, 1 acute subdural haematoma) and one of them (0.02% of the total) died (extradural haematoma). The patients who were not admitted were sent home with an information sheet after at least a six hour observation period.

INTERPRETATION

The authors draw the conclusion that they have evaluated the applicability and efficacy of guidelines, developed by the study group on head injury of the Italian Society of Neurosurgery. A critical part of our guidelines is not only to identify all the intracranial lesions, but to identify patients harbouring relevant intracranial mass before clinical deterioration.

Extradural low cervical chordoma. Case report

Chordoma of the mobile segments of the spine are infrequent lesions and especially rare are those located in the lower part of the cervical spine. We present the case of a cervical chordoma located in the C6 vertebral body diagnosed by means of magnetic resonance imaging and operated on by an anterior approach. The authors discuss the clinical and neuroradiological features of this disease also analysing some controversial therapeutic aspects.

Association of elevated levels of prothrombin fragment 1+2 and Arg506 to Gln mutation in patients with a history of ischemic stroke

BACKGROUND

Recent findings have indicated the association between APC-resistance and cerebrovascular disease. These reports prompted us to investigate whether resistance to APC could be found in patients suffering from stroke.

METHODS

Therefore, we studied APC-resistance in 50 young adults (< or =45 yrs) with a history of ischemic stroke. Eleven out of fifty cerebrovascular subjects showed APC-resistance, while 2 had PC deficiency and 3 PS deficiency. No deficiencies in the anticoagulant protein AT III and in fibrinolytic proteins were found. The family history demonstrated a distribution of APC-resistance compatible with dominant autosomal inheritance. The plasma concentration of prothrombin fragment 1+2 (F1+2), which is a marker of hypercoagulable states, was also measured in patients and family members of resistant subjects (n = 38).

RESULTS

DNA analysis showed factor V R506Q mutation (Leiden mutation) in 11 patients and their relatives with poor response to activated protein C detected by APTT tests. Of 11 investigated subjects with APC-resistance, 9 were heterozygotes and 2, with the lowest APC-ratio values, were homozygotes for factor V mutation. Among 38 relatives, 22 showed a poor response to APC and according to the APC-ratio values, 18 were heterozygotes and 4 homozygotes for FV Leiden mutation. The mutation, in heterozygous form, was also found in 2% of our normal population (n = 100). The plasma concentration of F1+2 was significantly higher both in 11 individuals carrying the FV:Q506 mutation and in 39 patients without APC-resistance compared to that found in the control group. However, the patients with FV:Q506 mutation showed the highest values in F1+2. In the studied family members F1+2 plasma levels were within normal values.

CONCLUSIONS

Our findings indicate a possible involvement of APC-resistance in the pathogenesis of cerebral thrombosis in young adults and agree with the hypothesis that individuals with APC-resistance have an imbalance between pro-and anti-coagulant forces leading to increased thrombin generation and a hypercoagulable state.

[Reasons in favor of lumbar puncture diagnosis (or lavage)]

In patients with strong suspicion of SAH, CT is the initial diagnostic procedure of choice. A lumbar puncture (LP) should be done if a CT is not available. If the patient has no focal deficit or papilloedema there is a little risk in LP. When a CT is negative there can be indication to do a LP: small leaks can be overlooked by CT, and they are often important premonitory events preceding larger and severe haemorrhages. The accuracy of CT in documenting SAH diminishes after 24 hours: thereafter, diagnosis is often dependent on LP. In some cases LP can be useful because the procedure may alleviate headache and remove some blood. LP can also quantify cerebro-spinal fluid (CSF) pressure, provide a baseline for future CSF determination, and allow the study of some parameters like arachidonate metabolites, lactic acid, fibrinogen degradation products (FDP) and thrombin-antithrombin complex (TAT).

Activated protein C resistance due to a factor V mutation associated with familial ischemic stroke

Recent findings have indicated the association between activated protein C (APC)-resistance and cerebrovascular disease. These reports prompted us to investigate whether resistance to APC could be found in patients suffering from transient ischaemic attacks or stroke. Therefore, we studied APC-resistance in 14 young adults belonging to three different families with a history of transient ischemic attacks (TIAs) and stroke. Nine out of fourteen subjects showed APC-resistance but no deficiencies in the anticoagulant proteins AT III, PC and PS. The family history demonstrated a distribution of APC-resistance compatible with dominant autosomal inheritance. A rapid screening method to detect factor V R506Q (Leiden) mutation without sequencing or restriction enzyme digestion has been set-up after biochemical analyses. DNA analysis showed a guanine to adenine transition at nucleotide 1,691 in patients and their relatives with poor response to activated protein C detected by APTT tests. Of 14 investigated subjects and their family members, 5 were normals, 6 were heterozygotes and 3 were homozygotes for factor V mutation. The mutation, in heterozygous form, was also found in 1.3% of our normal population (n = 75). Our findings indicate a possible involvement of APC-resistance in the pathogenesis of arterial thrombosis in young adults.

Cervical myelopathy caused by median disc herniation: analysis of the complications following anterior discectomy with and without Fusion Report of 90 cases

Between 1980 and 1992 about 400 patients underwent anterior cervical discectomy with or without intersomatic fusion at the Department of Neurosurgery of CTO Hospital (Rome) and Nuovo Pellegrini Hospital (Naples). Among them 90 patients were selected (50 from CTO and 40 from Nuovo Pellegrini Hospital). Clinical evaluation of postoperative results were assessed according to Odom's grading system and postoperative complications were discussed. No difference was observed in patients who underwent anterior cervical discectomy with and without fusion; however, postoperative complications were frequently observed in patients who underwent fusion. In conclusion, we consider the anterior microdiscectomy as the treatment of choice for the removal of soft disc herniations with or without osteophytosis even at two level disc. If cervical myelopathy is expression of one or more disc herniations, maybe calcified and associated with marked osteoarthrosic degenerative phenomena, we favour the evacuation of the herniated disc and the removal of osteophytes with Cloward's or Smith-Robinson's techniques.

Familial coagulation-inhibiting and fibrinolytic protein deficiencies in juvenile transient ischaemic attacks

The aim of this study was to investigate the role of natural cascade inhibitors in Juvenile Transient Ischemic Attacks. Fifty patients with anterior or posterior brain attacks were studied. One hundred healthy subjects matched for sex and age were randomly assigned to a control group. All had a physical examination and radiologic work-up. Computerized tomography showed no ischaemia either with or without contrast medium. Digital angiography of epiaortic and intracerebral vessels was unremarkable patients non controls ever had war-farin therapy. Antithrombin III, protein C and plasminogen were determined by functional methods. Protein S was assayed by a functional clotting method based on prolonged PT. The activated protein C resistance test was performed and a poor response to activated protein C was verified in patients. Our findings show protein S, protein C and antithrombin III type I deficiency with a functional activity < 70% compared to controls. Eight of fifty patients (16%) had low protein S levels, 5 (10%) had low protein C, 2 (4%) had low antithrombin III and 1 (2%) plasminogen deficiency. A significant (p < 0.01) difference in activated protein C ratio was seen for controls and patients. These results suggest that screening for natural anticoagulants in young people suffering from transient ischemic attacks could be beneficial and should be encouraged.

Intraradicular and intradural lumbar disc herniation: experiences with nine cases

BACKGROUND

Intraradicular or intradural disc herniation is a very rare complication of spinal degenerative processes. The aim of our study is to analyze the clinical spectrum, the mechanism, and the treatment of this acute spinal pathology.

METHODS

Retrospective clinical examination was performed in nine personal cases of intradural disc herniation: among these, six were associated with lateral perforation, the remaining three with intradural herniation and ventral perforation. A review of the literature concerning mainly the frequency pathogenesis and diagnosis of intradural disc herniation has also been done.

RESULTS

Nine cases of intradural herniations comprise 1.51% of the 593 cases of ruptured lumbar disc that underwent surgery from 1980 to 1992. The site most frequently involved is at level L4-L5, and 30% of patients have previously undergone surgery for lumbar disc herniation. Most patients reported in literature and in our present series have been complaining of a chronic history of sciatica, complicated later by bilateral neurologic signs. In the present series, diagnosis was obtained by means of myelography and computerized tomography; magnetic resonance imaging was performed in one case. All patients underwent surgery, reporting excellent results in five cases and good results in the other four. Surgery was performed either with an interlaminar approach or with a bilateral laminectomy in cases of ventral perforation.

CONCLUSIONS

There is no typical neuroradiologic picture of intraradicular herniation, while a total or subtotal block is frequently observed in intradural ventral perforations. Dural perforation is often an unexpected intraoperative finding. Surgical treatment is always necessary. Favorable results are obtained if surgical treatment is carried out before the neurologic deficit becomes too pronounced.

Cavernous angioma of the diencephalon

A case of cavernous angioma of the diencephalon presenting with subarachnoid hemorrhage in a 19 years old woman is reported. Pertinent literature is reviewed. Clinical data, Computerized Tomography (CT) and pre and post operative Magnetic Resonance (MR) imaging are presented and discussed. The problems of diagnosis and treatment of cavernous angiomas localized in critical areas of the brain are also discussed.

Monitoring of fibrin and fibrinogen degradation products (FDP) in the cerebrospinal fluid of patients with subarachnoid haemorrhage due to ruptured aneurysm. Report of 55 cases

Fibrin and fibrinogen degradation products in the cerebrospinal fluid (CSF-FDP) were first studied in a group of 29 patients observed during the first and the second week after subarachnoid hemorrhage (SAH), then in a second group of 26 patients for a total of 55 patients. In the latter group only the first FDP value obtained as soon as possible after SAH was taken in consideration. In the whole series of 55 patients several noteworthy factors were found: 1) FDP determination should be performed as soon as possible after SAH; 2) CSF-FDP at or above 40, 80 micrograms/ml was found both in the patients with severe neurological deficits and in those with cerebral ischemia (statistically significant); 3) the significance of CSF-FDP in patients who rebled was also evaluated. In conclusion CSF-FDP could be considered useful in predicting cerebral ischemia.

Congenital deficiency of factor VII in subarachnoid hemorrhage

BACKGROUND

Factor VII is essential for coagulation activation by the extrinsic pathway. Hemorrhages of the central nervous system in patients with congenital factor VII deficiency seem to have a higher incidence compared with other congenital coagulopathies. The purpose of this paper is to report two rare cases of subarachnoid hemorrhage and factor VII deficiency.

CASE DESCRIPTION

Two cases of women affected by a congenital deficiency of factor VII and subarachnoid hemorrhage are reported. Diagnosis was obtained by cerebral computer tomography; cerebral pan-angiography was normal. Complete coagulation studies were performed showing prothrombin time prolongation and factor VII deficiency. In one patient, family studies revealed the existence of a similar coagulation disorder.

CONCLUSIONS

We suggest routine coagulation studies in all patients with subarachnoid hemorrhage. Determination of factor VII activity might be performed in patients with normal activated partial thromboplastin time and prolonged prothrombin time.

Large anterior communicating artery aneurysm with temporal hemianopsia. Case report

Giant or large anterior communicating artery (ACOA) aneurysms producing bitemporal hemianopsia are extremely rare. A case is presented of an ACOA aneurysm measuring 2 X 1.4 cm with the patient having had a post-traumatic amaurosis of the left eye for many years. Then he had a subarachnoid hemorrhage and subsequently developed impaired vision in the right eye and temporal hemianopsia. The aneurysm was visible on C.T. but disappeared on post-operative scans. Visual acuity improved radically after treatment with neck ligation and opening of the sac.

Primary non traumatic intracranial hemorrhage: 139 consecutive cases treated at an emergency regional hospital

We review 139 consecutive cases of primary non-traumatic intracranial hemorrhage observed at the Neurosurgical Division of Pellegrini Hospitals, Naples. We excluded 20 similar cases which were not thoroughly studied. In the region Campania, which has almost five and a half million inhabitants, there are four emergency centres for neurosurgical patients one of which is at the Pellegrini Hospitals in Naples. In our series of 139 patients, 68 (48.92%) had an intracerebral hematoma (CH); while 71 (51.07%) patients had a subarachnoid hemorrhage (SAH). Thirteen cases out of 68 were added to the 71 cases with SAH because they had an arterial aneurysm or an arteriovenous malformation (AVM) which had ruptured both in the subarachnoid space and in the brain. The most frequent cause of CH was arterial hypertension. Out of 84 patients with SAH, 57 (67.85%) had a vascular malformation. Age, sex, presence of vasospasm, gravity of hemorrhage and interval between hemorrhage and neurosurgical observation were studied. Out of 139 cases, 68 (48.92%) were surgically treated. In conclusion, out of 68 operated patients, 48 (70.58%) survived and 20 died; while, out of 71 non-operated patients, 24 (23.80%) survived and 47 died. The survival rate of patients with aneurysms operated on after 14 days from the hemorrhage is 90.47%. The survival rate in patients with CH operated on after the fifth day is 89.47%.

Space occupying contusions of cerebral lobes after closed brain injury: considerations about 51 cases

Fifty one cases of space occupying contusions of the brain have been treated between 1967 and 1974. These represented 2.4% of all head injuries. Forty four were surgically treated and only clinically. The total mortality was 50.9% being 91.4% in patients above 50 years of age and 41% in patients below 50. In 66.6% of patients the lesions were localized in the temporal lobes, and two patients had localized cerebellar contusions. Surgery was performed in 44 patients. There were 13 craniectomies and 31 craniotomies. The operative mortality was 54.5%. Mortality was 65.2% in patients operated on within 24 hours of injury, and 12.5% in those operated on more than 72 hours after trauma. Twenty five patients (20 treated surgically and 5 managed clinically) were examined one year after injury. Eighty four percent were in either good or excellent condition.

The use of antifibrinolytic drugs in aneurysmal subarachnoid hemorrhage

Antifibrinolytic drugs have been investigated in a series of 58 patients with recent aneurysmal subarachnoid hemorrhage. It is concluded that tranexamic acid (AMCA) provides a rational method for reducing the frequency of recurrences, and that antifibrinolytic treatment is a preliminary to surgical intervention. In the present series, ischemic complications, which often follow aneurysmal hemmorrhage, seem to be of a more serious nature. There is evidence also that hydrocephalus due to adhesive arachnoiditis is a rare occurrence. The last 20 patients of the present series have been treated with very low doses of AMCA associated with parotid kallikrein inhibitor (Trasylol); this dosage has been effective in preventing recurrence and has appeared to be freer from severe side effects.