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Circumstances Precipitating Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

To determine the precipitating factors of aneurysmal rupture, the medical records of 425 consecutive patients with aneurysmal subarachnoid hemorrhage were reviewed. As for the time of onset, a significantly higher incidence was found between 06.00 and 09.00 h and 18.00 and 21.00 h. Aneurysmal rupture occurred most frequently during talking, watching TV or staying home without any strenuous physical activity.

Masayuki Matsuda; Michiaki Ohashi; Akihiko Shiino; Kenichi Matsumura; Jyoji Handa



Hemorrhagic stroke: aneurysmal subarachnoid hemorrhage.  


Non-traumatic subarachnoid hemorrhage (SAH) represents approximately 5-6% of all strokes. Morbidity and mortality rates remain high, but accurate diagnosis using clinical assessment and neuroimaging, critical care management, and early treatment using either surgical or interventional techniques have improved overall outcomes. This, the fifth in a Missouri Medicine series on stroke, summarizes the clinical and imaging aspects of making the diagnosis of SAH, critical care management of the patient, treatment options, and factors important in prognosis. PMID:21568235

Martin, Coleman O; Rymer, Marilyn M


Seizures and anticonvulsants after aneurysmal subarachnoid hemorrhage.  


Seizures and seizure-like activity may occur in patients experiencing aneurysmal subarachnoid hemorrhage. Treatment of these events with prophylactic antiepileptic drugs remains controversial. An electronic literature search was conducted for English language articles describing the incidence and treatment of seizures after aneurysmal subarachnoid hemorrhage from 1980 to October 2010. A total of 56 articles were included in this review. Seizures often occur at the time of initial presentation or aneurysmal rebleeding before aneurysm treatment. Seizures occur in about 2% of patients after invasive aneurysm treatment, with a higher incidence after surgical clipping compared with endovascular repair. Non-convulsive seizures should be considered in patients with poor neurological status or deterioration. Seizure prophylaxis with antiepileptic drugs is controversial, with limited data available for developing recommendations. While antiepileptic drug use has been linked to worse prognosis, studies have evaluated treatment with almost exclusively phenytoin. When prophylaxis is used, 3-day treatment seems to provide similar seizure prevention with better outcome compared with longer-term treatment. PMID:21751102

Lanzino, Giuseppe; D'Urso, Pietro Ivo; Suarez, Jose



Pituitary deficiency after aneurysmal subarachnoid hemorrhage  

PubMed Central

OBJECTIVE: Aneurysmal subarachnoid hemorrhage puts patients at high risk for the development of pituitary insufficiency. We evaluated the incidence of pituitary dysfunction in these patients and its correlation with clinical outcome. METHODS: Pituitary function was tested in 66 consecutive patients in the first 15 days after aneurysmal subarachnoid hemorrhage. The following were measured in all patients: thyroid-stimulating hormone, free thyroxine, triiodothyronine, luteinizing hormone, follicle-stimulating hormone, total testosterone (in males), estradiol (in females), prolactin, serum cortisol, plasma adrenocorticotropic hormone, growth hormone and insulin growth factor. RESULTS: The endocrine assessment was made at a mean of 7.4 days (standard deviation ±6.6) after subarachnoid hemorrhage. Forty-four (66.7%) female and 22 (33.3%) male patients were evaluated. Thirty-nine patients (59.1%) had some type of pituitary dysfunction. Follicle-stimulating hormone/luteinizing hormone deficiency was the most frequent disorder (34.8%), followed by growth hormone/insulin growth factor (28.7%), adrenocorticotropic hormone (18.1%) and thyroid-stimulating hormone (9%). Seventeen (25.7%) patients showed deficiencies in more than one axis. A greater incidence of hormone deficiency was observed in patients with a Glasgow Coma Scale score ?13 (t test, p?=?0.008), Hunt-Hess grade ?4 (t test, p<0.001), or Fisher grade 4 (t test, p?=?0.039). Hormone deficiency was not significantly associated (p>0.05) with increased hospitalization or clinical outcome. CONCLUSION: Pituitary dysfunction was identified in a substantial portion of patients with previous aneurysmal subarachnoid hemorrhage, but no association was found between this dysfunction and poor clinical outcome.

Pereira, Julio Leonardo Barbosa; de Albuquerque, Lucas Alverne Freitas; Dellaretti, Marcos; de Carvalho, Gervasio Teles Cardoso; Jr, Gerival Vieira; Brochado, Vitor Michelstaedter; Drummond, Austen Venancio; de Morais, Joyce Espeschit; Ferreira, Leticia Maia; Miranda, Paulo Augusto Carvalho; de Sousa, Atos Alves



Myocardial stunning secondary to aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

BackgroundAlthough subarachnoid hemorrhage (SAH) is often associated with electrocardiographic abnormalities, profound effects on cardiac performance are rare.CASE DESCRIPTIONA 57-year-old woman who developed loss of consciousness, respiratory distress, severe hypotension, and left ventricular hypokinesis with minimal coronary artery disease is described. Despite normal appearance of the coronary arteries on angiography, left ventricle function was so severely depressed that she required intra-aortic

Jill W Donaldson; Michael B Pritz



Iatrogenic dural arteriovenous fistula and aneurysmal subarachnoid hemorrhage.  


The authors present the case of a patient who presented acutely with aneurysmal subarachnoid hemorrhage (SAH) and a contralateral iatrogenic dural arteriovenous fistula (DAVF). Diagnostic angiography was performed, revealing a right-sided middle cerebral artery (MCA) aneurysm and a left-sided DAVF immediately adjacent to the entry of the ventriculostomy and bur hole site. A craniotomy was performed for clipping of the ruptured MCA aneurysm, and the patient subsequently underwent endovascular obliteration of the DAVF 3 days later. The authors present their treatment of an iatrogenic DAVF in a patient with an aneurysmal SAH, considerations in management options, and a literature review on the development of iatrogenic DAVFs. PMID:22537118

Vadivelu, Sudhakar; Xin, Xin; Loven, Tina; Restrepo, Guillermo; Chalif, David J; Setton, Avi



Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

OBJECTIVESWe studied the incidence of myocardial injury in aneurysmal subarachnoid hemorrhage (SAH) using the more sensitive cardiac troponin I (cTnI) assay, correlated changes in cTnI with creatine kinase, MB fraction (CK-MB), myoglobin, and catecholamine metabolite assays, and examined the predictive value of changes in cTnI for myocardial dysfunction.BACKGROUNDMyocardial injury in aneurysmal SAH as evidenced by elevated CK-MB fraction has been

Nilesh Parekh; Bala Venkatesh; David Cross; Anne Leditschke; John Atherton; William Miles; Adam Winning; Alan Clague; Claire Rickard



Mechanisms in neurogenic stress cardiomyopathy after aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

Cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH) is often referred to as “neurogenic stunned myocardium,”\\u000a which does not accurately reflect the suspected pathophysiology. We propose an alternativeterminology,” neurogenic stress\\u000a cardiomyopathy,” as a more appropriate label based on our review of the current literature. This article will review the distinctive\\u000a characteristics of SAH-induced cardiac dysfunction, hypotheses to explain the pathophysiology, and

Vivien H. Lee; Jae K. Oh; Sharon L. Mulvagh; Eelco F. M. Wijdicks



Risk Factors for Aneurysmal Subarachnoid Hemorrhage in Aomori, Japan  

Microsoft Academic Search

Background and Purpose—Japan is known to have an incidence of aneurysmal subarachnoid hemorrhage (SAH) as high as that in Finland, where SAH is especially common. However, the risk factors for SAH in Japan are unknown. The purpose of this study was to identify the risk factors and then examine their possible roles in cases of SAH in Japan. Methods—Case-control data

Hiroki Ohkuma; Hidefumi Tabata; Shigeharu Suzuki; Shafiqul Islam



Arteriovenous fistula after ventriculostomy in aneurysmal subarachnoid hemorrhage.  


A 66-year-old woman was found unresponsive after complaining of severe headache several days prior. She was comatose upon initial evaluation and a cranial CT revealed diffuse subarachnoid hemorrhage. A right posterior communicating artery aneurysm (figure, A, arrow) was successfully treated with endovascular embolization. Conventional angiography performed 7 days following ventriculostomy placement for hydrocephalus demonstrated interval development of a traumatic arteriovenous fistula (AVF) filling by the middle meningeal artery (figure, C, D, arrow). The AVF was treated with intra-arterial embolization. Ventriculostomy-associated AVF has rarely been reported.(1) Outcomes of untreated iatrogenic AVF are unknown, but could lead to hemorrhagic complications. PMID:23733553

Meisel, Karl; Yee, Alan; Stout, Charles; Kim, Warren; Cooke, Daniel; Halbach, Van



Aneurysmal Subarachnoid Hemorrhage in Third and Fourth Decades of Life  

PubMed Central

Objective The aim of this study was to compare clinical characteristics of ruptured aneurysms in young adults, of the third and fourth decades of life, and to compare several clinical characteristics affecting the outcome of patients. Methods We retrospectively investigated 1459 patients who underwent surgery and endovascular treatment for ruptured cerebral aneurysms from June 1992 to December 2010 and compared clinical characteristics. We also reviewed pre-existing medical conditions and perioperative complications. Results Among 1459 patients, there were 21 patients (1.44%) in the third decade and 104 patients (7.13%) in the fourth decade of life. Within two age groups, 88 (70.4%) were male and 37 (29.6%) were female, a ratio of 2.37 : 1. In both groups, we observed the anterior cerebral artery (ACA) aneurysm with the most frequency (p=0.028). In general, favorable outcome was achieved in both age groups (90.5% and 81.7%, respectively). An initial univariate analysis showed Hunt-Hess grade, Fisher grade, location of aneurysm, and rebleeding significantly associated with outcome after aneurysm rupture. Further, multivariate analysis demonstrated that only Hunt-Hess grade (grade 4-5) was a risk factor for the outcome (odds ratio=9.730, 95% confidence interval 2.069-45.756, p=0.004). Conclusion The incidence of subarachnoid hemorrhage (SAH) was higher in the male population of the third and fourth decades of life. Aneurysms on the ACA were most frequently occurred in both age groups and the outcome of aneurysmal SAH among the third and fourth decades was favorable. Multivariate analysis revealed that high Hunt-Hess grade was a risk factor for patient's outcome.

Kim, Su-Yong; Park, In Sung; Hwang, Jae Ha; Hwang, Soo Hyun; Han, Jong Woo



Multivariate Analysis of Predictors of Cerebral Vasospasm Occurrence After Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH

Claire Charpentier; Gerard Audibert; Francis Guillemin; Thierry Civit; Xavier Ducrocq; Serge Bracard; Henri Hepner; Luc Picard; Marie Claire Laxenaire


Incidence of Recurrent Subarachnoid Hemorrhage After Clipping for Ruptured Intracranial Aneurysms  

Microsoft Academic Search

Background and Purpose—Because intracranial aneurysms develop during life, patients with subarachnoid hemorrhage (SAH) and successfully occluded aneurysms are at risk for a recurrence. We studied the incidence of and risk factors for recurrent SAH in patients who regained independence after SAH and in whom all aneurysms were occluded by means of clipping. Methods—From a cohort of patients with SAH admitted

Marieke J. H. Wermer; Paut Greebe; Ale Algra; Gabriel J. E. Rinkel



Cisternal irrigation therapy with urokinase and ascorbic acid for prevention of vasospasm after aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

BACKGROUNDCisternal irrigation therapy with urokinase and ascorbic acid was introduced to prevent symptomatic vasospasm after aneurysmal subarachnoid hemorrhage (SAH). To dissolve and wash out the subarachnoid clot, cisternal irrigation with urokinase is used. Ascorbic acid is added to degenerate oxy-hemoglobin, one of the strongest spasmogenic substances, into verdohemelike products, which are nonspasmogenic. The efficacy and safety of this therapy were

Namio Kodama; Tatsuya Sasaki; Masahisa Kawakami; Masahiro Sato; Jun Asari



Early posttraumatic subarachnoid hemorrhage due to dissecting aneurysms in three children.  


Subarachnoid hemorrhage (SAH) due to a ruptured saccular aneurysm is uncommon in children. Pediatric traumatic aneurysms have been reported relatively frequently, tending to bleed after an interval of weeks after head injury. The authors describe three children with acute SAH after head injury caused by intracranial dissecting aneurysms. When head trauma in children is complicated by SAH in basal cisterns, dissecting aneurysms should be considered and treated, because rebleeding may occur. PMID:16301503

Kneyber, M C J; Rinkel, G J E; Ramos, L M P; Tulleken, C A F; Braun, K P J



A Case of Cerebral Aneurysmal Subarachnoid Hemorrhage in Fabry's Disease.  


We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH originated from a saccular aneurysm of the right posterior communicating artery. The patient was treated by an endovascular coil embolization of aneurysm. Postoperatively the patient recovered favorably without any neurological deficit. During her admission, the patient had a sign of proteinuria in urine analysis. The pathologic findings of kidney needle biopsy implied nephrosialidosis (mucolipidosis of lysosomal stroage disease), which is consistent with a Fabry's disease. It is uncommon that Fabry's disease is presented with aneurysmal SAH, especially in middle-aged patients, but could be a clinical concern. Further investigations are needed to reveal risk factors, vascular anatomy, and causative mechanisms of Fabry's disease with aneurysmal SAH. PMID:23634271

Chang, Youn Hyuk; Hwang, Sung-Kyun




Microsoft Academic Search

A 67-year-old Korean woman attended our hospital complaining of a severe headache. A brain computed tomography scan showed conglomerated, high-density, calcified nodules in the left temporo-occipito-parietal area and high-density subarachnoid hemorrhage in the basal cisterns. Magnetic resonance imaging of the brain shows multiple conglomerated iso- or low-signal intensity round nodules with peripheral rim enhancement. She underwent craniotomies to clip the



Dissecting aneurysm of the anterior cerebral artery with severe subarachnoid hemorrhage during treatment for cerebral infarction.  


Intracranial dissecting aneurysms cause ischemia, but anticoagulation or antiplatelet agents are administered to most ischemic patients without angiographical investigation. A 55-year-old woman succumbed to a subarachnoid hemorrhage (SAH) during antiplatelet therapy for ischemia caused by a dissecting aneurysm at the anterior cerebral artery, which was identified by conventional angiography on day 11 after admission. The authors emphasize that all dissecting aneurysms manifesting ischemic attack can cause hemorrhage. Therefore, emergency angiography is recommended for patients with ischemia complaining of a headache. If dissection is identified, it may be better to regulate the blood pressure of the patient strictly without anticoagulation or antiplatelet therapy. PMID:12793716

Yamada, Shoko M; Nakane, Makoto; Aoki, Makoto; Nakayama, Hitoshi



Giant intrasellar aneurysm presenting with panhypopituitarism and subarachnoid hemorrhage: case report and literature review  

Microsoft Academic Search

A 52-year-old woman was admitted to our hospital presenting with subarachnoid hemorrhage, left ophthalmoplegia, and right hemiparesis. Previous symptoms and signs suggested the presence of panhypopituitarism. A giant intracranial aneurysm of the internal carotid artery, diagnosed by magnetic resonance imaging, showed the characteristic flow void phenomenon with black appearance. Analysis of endocrine function disclosed panhypopituitarism and hyperprolactinemia. After proximal balloon

J. M. Fernandez-Real; M. Fernández-Castañer; C. Villabona; E. Sagarra; J. M. Gómez-Sáez; J. Soler



Electrocardiographic changes in subarachnoid hemorrhage secondary to cerebral aneurysm. Report of 70 cases  

Microsoft Academic Search

Electrocardiographic (ECG) alterations in the course of sub-arachnoid hemorrhage (SAH) have frequently been reported. The most frequent anomalies reported were lengthening of the QT interval, very negative or positive deep T waves, elevation or depression of the ST segment and the presence of U waves. We report 70 cases of SAH secondary to rupture of intracranial aneurysm (part of a

M. Salvati; F. Cosentino; M. Artico; M. Ferrari; D. Franchi; M. Domenicucci; E. Ramundo Orlando; L. Tacconi



Hyperglycemia in aneurysmal subarachnoid hemorrhage: a potentially modifiable risk factor for poor outcome  

Microsoft Academic Search

Hyperglycemia after aneurysmal subarachnoid hemorrhage (aSAH) occurs frequently and is associated with delayed cerebral ischemia (DCI) and poor clinical outcome. In this review, we highlight the mechanisms that cause hyperglycemia after aSAH, and we discuss how hyperglycemia may contribute to poor clinical outcome in these patients. As hyperglycemia is potentially modifiable with intensive insulin therapy (IIT), we systematically reviewed the

Nyika D Kruyt; Geert Jan Biessels; J Hans DeVries; Merel J A Luitse; Marinus Vermeulen; Gabriel J E Rinkel; W Peter Vandertop; Yvo B Roos



Cervical Sympathetic Block to Reverse Delayed Ischemic Neurological Deficits After Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Methods—Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block

Miriam M. Treggiari; Jacques-André Romand; Jean-Baptiste Martin; Alain Reverdin; Daniel A. Rüfenacht; Nicolas de Tribolet


Simvastatin Reduces Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Results of a Pilot Randomized Clinical Trial  

Microsoft Academic Search

Background and Purpose—Cerebral vasospasm remains a major source of morbidity after aneurysmal subarachnoid hemorrhage (SAH). We demonstrate that simvastatin reduces serum markers of brain injury and attenuates vasospasm after SAH. Methods—Patients with angiographically documented aneurysmal SAH were randomized within 48 hours of symptom onset to receive either simvastatin (80 mg daily; n19) or placebo (n20) for 14 days. Plasma alanine

John R. Lynch; Haichen Wang; Matthew J. McGirt; James Floyd; Allan H. Friedman; Alexander L. Coon; Robert Blessing; Michael J. Alexander; Carmelo Graffagnino; David S. Warner; Daniel T. Laskowitz



Subarachnoid hemorrhage  


... snapping feeling in the head. Other symptoms: Decreased consciousness and alertness Eye discomfort in bright light ( photophobia ) ... time, the outlook is much worse. Changes in consciousness and alertness due to a subarachnoid hemorrhage may ...


Recognition and evaluation of nontraumatic subarachnoid hemorrhage and ruptured cerebral aneurysm.  


Swift diagnosis and treatment are critical for good outcomes in patients with nontraumatic subarachnoid hemorrhage, which is usually caused by a ruptured aneurysm. This type of stroke often results in death or disability. Rates of misdiagnosis and treatment delays for subarachnoid hemorrhage have improved over the years, but these are still common occurrences. Subarachnoid hemorrhage can be more easily diagnosed in patients who present with severe symptoms, unconsciousness, or with thunderclap headache, which is often accompanied by vomiting. The diagnosis is more elusive in patients who present in good condition, yet these patients have the best chance for good outcome if they are correctly diagnosed at the time of presentation. Physicians should be alert for warning headaches, which are often severe, and headaches that feel different to the patient. Other symptoms may include nausea, vomiting, impaired consciousness, nuchal rigidity, orbital pain, focal neurologic deficits, dysphasia, lightheadedness, and dizziness. The most important risk factors for subarachnoid hemorrhage include cigarette smoking, hypertension, heavy alcohol use, and personal or family history of aneurysm or hemorrhagic stroke. The first step in the diagnostic workup is noncontrast computed tomography of the head. If computed tomography is negative or equivocal, a lumbar puncture should be performed. Subsequent imaging may include computed tomographic angiography, catheter angiography, and magnetic resonance angiography. PMID:24134085

Cohen-Gadol, Aaron A; Bohnstedt, Bradley N



Subarachnoid and intraventricular hemorrhage due to ruptured aneurysm after combined spinal-epidural anesthesia.  


A patient received combined spinal-epidural anesthesia for a scheduled total knee arthroplasty. After an injection of spinal anesthetic and ephedrine due to a decrease in blood pressure, the patient developed a severe headache. The patient did not respond to verbal command at the completion of the operation. A brain CT scan revealed massive subarachnoid and intraventricular hemorrhages, and a CT angiogram showed a ruptured aneurysm. Severe headaches should not be overlooked in an uncontrolled hypertensive patient during spinal anesthesia because it may imply an intracranial and intraventricular hemorrhage due to the rupture of a hidden aneurysm. PMID:20376909

Chun, Duk-Hee; Kim, Na-Young; Shin, Yang-Sik



The utility of cone beam volume CT in the evaluation of thrombosed intracranial aneurysms in subarachnoid hemorrhage.  


Thrombosed aneurysms are difficult to visualize with digital subtraction angiography. We report a case of subarachnoid hemorrhage from a thrombosed ruptured aneurysm which was undetected on digital subtraction angiography but was visualized with cone beam volume CT. To our knowledge, this is the first report highlighting the utility of cone beam volume CT in identifying such aneurysms. PMID:23345628

Shah, Shreyansh; Murthy, Santosh B; Hannawi, Yousef; Rao, Chethan P Venkatasubba



Treatment of a cerebral dissecting aneurysm in anterior circulation: report of 11 subarachnoid hemorrhage cases.  


This report presents 8 cases of internal carotid artery aneurysms, 1 case of a middle cerebral artery aneurysm, and 2 cases of anterior cerebral artery aneurysms, together with a discussion of the treatment of aneurysms in anterior circulation. All cases showed subarachnoid hemorrhage. Two of the 8 internal carotid artery aneurysms were trapped with a low-flow bypass; however, both patients died of an immediate hemodynamic infarction or vasospasm-induced infarction. Five of the 8 internal carotid artery aneurysms were trapped after revascularization with high flow bypass. Four of those patients were self-supporting at discharge, but one patient was discharged in a vegetative state due to the sacrifice of arterial branches which were included in the dissecting portion. One case of the dissecting aneurysm in the M2 portion of the middle cerebral artery was trapped after low-flow bypass. This patient was self-supporting at discharge. In 2 cases of anterior cerebral artery aneurysms, the lesions were first wrapped with Bemsheets, and then the aneurysmal clip was applied on the wrapped dome. Trapping following high-flow bypass is the best method for treating a dissecting aneurysm in the internal carotid artery. Trapping also can be used to treat a dissecting aneurysm of the middle cerebral artery, after low-flow bypass. Clipping on the wrapped aneurysm can also be performed successfully in the anterior cerebral artery aneurysm. PMID:23092105

Oyama, Hirofumi; Kito, Akira; Maki, Hideki; Hattori, Kenichi; Noda, Tomoyuki; Wada, Kentaro



Circulatory and vascular changes after aneurysmal subarachnoid hemorrhage.  


Delayed cerebral ischemia (DCI) is a major complication that afflicts approximately 30% of patients who suffer an aneursymal subarachnoid hemorrhage (SAH). DCI is often associated with neurological infarction, poor outcome and mortality. Though the pathogenesis of DCI is not yet clear, it is traditionally been attributed to angiographic vasospasm. Unfortunately, clinical trials based on this premise have mostly been disappointing, predominantly unable to prevent ischemic damage and improve patient outcome despite reducing angiographic vasospasm. More recently, increasing concern that vasospasm could not fully account for DCI development has incited novel proposals as to the pathogenesis of DCI. A general theme exists among these theories (microcirculatory constriction, cortical spreading depression, blood brain barrier breakdown, microthrombosis) in that a majority seems to revolve around dysfunction and changes to the microvasculature. This purpose of this review was then to juxtapose macrovascular and microvascular changes after SAH, and provide an overview of current and prospective treatments. PMID:22198585

Wan, H; Loch Macdonald, R



Clinical Outcome Prediction in Aneurysmal Subarachnoid Hemorrhage Using Bayesian Neural Networks with Fuzzy Logic Inferences  

PubMed Central

Objective. The novel clinical prediction approach of Bayesian neural networks with fuzzy logic inferences is created and applied to derive prognostic decision rules in cerebral aneurysmal subarachnoid hemorrhage (aSAH). Methods. The approach of Bayesian neural networks with fuzzy logic inferences was applied to data from five trials of Tirilazad for aneurysmal subarachnoid hemorrhage (3551 patients). Results. Bayesian meta-analyses of observational studies on aSAH prognostic factors gave generalizable posterior distributions of population mean log odd ratios (ORs). Similar trends were noted in Bayesian and linear regression ORs. Significant outcome predictors include normal motor response, cerebral infarction, history of myocardial infarction, cerebral edema, history of diabetes mellitus, fever on day 8, prior subarachnoid hemorrhage, admission angiographic vasospasm, neurological grade, intraventricular hemorrhage, ruptured aneurysm size, history of hypertension, vasospasm day, age and mean arterial pressure. Heteroscedasticity was present in the nontransformed dataset. Artificial neural networks found nonlinear relationships with 11 hidden variables in 1 layer, using the multilayer perceptron model. Fuzzy logic decision rules (centroid defuzzification technique) denoted cut-off points for poor prognosis at greater than 2.5 clusters. Discussion. This aSAH prognostic system makes use of existing knowledge, recognizes unknown areas, incorporates one's clinical reasoning, and compensates for uncertainty in prognostication.

Lo, Benjamin W. Y.; Macdonald, R. Loch; Baker, Andrew; Levine, Mitchell A. H.



Fusiform Lenticulostriate Artery Aneurysm with Subarachnoid Hemorrhage: The Role for Superselective Angiography in Treatment Planning  

PubMed Central

Summary Aneurysms of the lenticulostriatal perforating arteries are rare and either involve the middle cerebral artery-perforator junction or are located distally in basal ganglia. We describe a rare ruptured fusiform lenticulostriatal perforating artery aneurysm arising from a proximal M2 MCA branch, discerned on superselective microcatheter angiography, presenting solely with subarachnoid hemorrhage (SAH). A 50-year-old previously healthy man presented with diffuse SAH and negative CT angiogram. Cerebral angiogram demonstrated a 2 mm fusiform aneurysm presumably arising from the right lateral lenticulostriate perforator but the exact origin of the perforator was unclear. Superselective angiography was required to precisely delineate the aneurysm and its vessel of origin and directly influenced treatment planning (surgical trapping). Superselective microcatheter angiography provides both an option for endovascular therapy as well as more accurate delineation for surgical planning for these rare aneurysms.

Kochar, P.S.; Morrish, W.F.; Hudon, M.E.; Wong, J.H.; Goyal, M.



Cocaine Use Is an Independent Risk Factor for Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—Although acute cocaine use has been temporally associated with aneurysmal subarachnoid hemorrhage (aSAH), the prevalence of vasospasm and the clinical outcome of patients experiencing aSAH associated with cocaine exposure are unclear. We have analyzed this patient population in our institution to address these issues. Methods—Between 1992 and 1999, 440 patients presented to our institution with aSAH. This sample

James E. Conway; Rafael J. Tamargo



Spinal syringomyelia following subarachnoid hemorrhage  

Microsoft Academic Search

Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated

Kinya Nakanishi; Takuya Uchiyama; Naoki Nakano; Norihito Fukawa; Kimito Yamada; Tomonari Yabuuchi; Amami Kato


Elevated Cardiac Troponin I and Functional Recovery and Disability in Patients After Aneurysmal Subarachnoid Hemorrhage  

PubMed Central

Background Patients with aneurysmal subarachnoid hemorrhage experience myocardial injury at the time of rupture, but its effect on functional recovery and disability is unclear. Objective To describe the prevalence of myocardial injury, as indicated by high serum levels of cardiac troponin I (?0.3 ng/mL), within the first 5 days after aneurysmal subarachnoid hemorrhage and the effect of the injury on 3-month functional recovery and disability. Methods In a prospective longitudinal study, 239 patients with Hunt/Hess grade 3 or greater and/or Fisher grade 2 or greater at admission had serum level of troponin I measured on days 0 to 5. Patients were interviewed at 3 months to evaluate functional recovery (Glasgow Outcome Scale) and functional disability (Modified Rankin Scale). Statistics included ?2 analysis, t tests, and binary logistic regression. Results Troponin values were elevated in 33.5% of the patients, and few patients in either group had a history of coronary artery disease (7.4% with troponin levels ? 0.3 ng/mL vs 2.7% with levels <0.3 ng/mL, P = .12). Higher troponin levels were significantly related to age and Hunt/Hess and Fisher grades, but not race, and were significantly associated with poorer functional recovery (P <.001) and more functional disability (P <.001). Even after controls for age, race, and more severe Hunt/Hess grades, higher levels remained a significant predictor of poorer functional recovery (P = .04) and disability (P= .01). Conclusion Elevated levels of cardiac troponin I after aneurysmal subarachnoid hemorrhage are common in patients with no cardiac history, are associated with severity of the hemorrhage, and are independently predictive of poorer functional recovery and increased disability.

Miketic, Joyce K.; Hravnak, Marilyn; Sereika, Susan M.; Crago, Elizabeth A.



Dissection aneurysm of the radiculomedullary branch of the artery of Adamkiewicz with subarachnoid hemorrhage.  


A 60-year-old female presented with sudden onset of severe headache and back pain, followed by nausea. The initial head computed tomography (CT) scan revealed posterior fossa subarachnoid hemorrhage (SAH). Spinal T(2)-weighted magnetic resonance imaging demonstrated SAH, and a homogeneous and slightly low signal intensity mass at T11. Spinal angiography in the early arterial phase revealed a small pearl and string-like aneurysm of the proximal radiculomedullary artery on the left side at the T12 level. Forty days after the onset of SAH, CT angiography demonstrated complete occlusion of the dissecting aneurysm and the preserved anterior spinal artery. The present case of ruptured dissecting aneurysm of the radiculomedullary branch of the artery of Adamkiewicz with SAH underwent subsequent spontaneous occlusion, indicating that the wait-and-see strategy may be justified and will provide adequate treatment. PMID:21946730

Iihoshi, Satoshi; Miyata, Kei; Murakami, Tomohiro; Kaneko, Takahisa; Koyanagi, Izumi



Solitary ruptured aneurysm of the spinal artery of adamkiewicz with subarachnoid hemorrhage.  


Spinal subarachnoid hemorrhage (SAH) due to solitary spinal aneurysm is extremely rare. A 45-year-old female patient visited the emergency department with severe headache and back pain. Imaging studies showed cerebral SAH in parietal lobe and spinal SAH in thoracolumbar level. Spinal angiography revealed a small pearl and string-like aneurysm of the Adamkiewicz artery at the T12 level. One month after onset, her back pain aggravated, and follow-up imaging study showed arachnoiditis. Two months after onset, her symptoms improved, and follow-up imaging study showed resolution of SAH. The present case of spinal SAH due to rupture of dissecting aneurysm of the Adamkiewicz artery underwent subsequent spontaneous resolution, indicating that the wait-and-see strategy may provide adequate treatment option. PMID:24044082

Son, Seong; Lee, Sang-Gu; Park, Cheol-Wan



Spontaneous thrombosis of basilar artery aneurysm after subarachnoidal hemorrhage in a patient with thrombophilia and recurrent deep venous thrombosis.  


We report a patient with combined thrombophilia--protein C deficiency and mild hyperhomocysteinemia with total spontaneous thrombosis of a basilar tip aneurysm after subarachnoid hemorrhage, without neurological deficit. At admission, the patient had headache, drowsiness, and nausea, with no neurological deficit. Computed tomography (CT) did not show the presence of subarachnoid blood, and magnetic resonance examination revealed discrete remains of a subarachnoid hemorrhage in projections of temporal, frontal and occipital lobes, with no vascular abnormalities. Initial angiography showed a small basilar tip aneurysm and the patient was scheduled for endovascular treatment. A second angiography, performed before the planned endovascular treatment, did not show the aneurysm and complete thrombosis was suspected. A follow-up angiogram, 6 months after this event, showed preserved posterior cerebral circulation with no aneurysm present. The patient was discharged in good condition, without neurological deterioration. We did not find any previous reports of similar conditions. PMID:20547547

Vulekovic, Petar; Karan, Mladen; Kojadinovic, Zeljko; Papic, Vladimir; Djilvesi, Djula; Mitic, Gorana



Criteria for the diagnosis of noninfectious and infectious complications after aneurysmal subarachnoid hemorrhage in DISCHARGE-1.  


Patients with aneurysmal subarachnoid hemorrhage (aSAH) frequently develop secondary noninfectious and infectious complications that have an important impact on clinical course and outcome. We here report on criteria for the diagnosis of the most important complications after aSAH based on clinical status, neuroimaging, and laboratory tests, including cerebrospinal fluid parameters. These criteria will be used for a retrospective analysis of aSAH patients who were recruited at the Charité Berlin for the CoOperative Study on Brain Injury Depolarisations (COSBID) before the Depolarisations in Ischaemia after Subarachnoid Haemorrhage-1 (DISCHARGE-1) trial started. Moreover, they serve for the survey of complications in DISCHARGE-1. We also report on a customized, Web-based database that has been developed for the documentation of the clinical course after aSAH. This database is used for the COSBID outcome study on aSAH and for DISCHARGE-1. PMID:22890662

Drenckhahn, Christoph; Brabetz, Claudia; Major, Sebastian; Wiesenthal, Dirk; Woitzik, Johannes; Dreier, Jens P



Subarachnoid Hemorrhage  


... into the compartment surrounding the brain, the subarachnoid space and is therefore also known as a subarachnoid ... leak into the CSF (cerebrospinal fluid) in the space around the brain (subarachnoid space). The pool of ...


Genetic determinants of cerebral vasospasm, delayed cerebral ischemia, and outcome after aneurysmal subarachnoid hemorrhage  

PubMed Central

Despite extensive effort to elucidate the cellular and molecular bases for delayed cerebral injury after aneurysmal subarachnoid hemorrhage (aSAH), the pathophysiology of these events remains poorly understood. Recently, much work has focused on evaluating the genetic underpinnings of various diseases in an effort to delineate the contribution of specific molecular pathways as well as to uncover novel mechanisms. The majority of subarachnoid hemorrhage genetic research has focused on gene expression and linkage studies of these markers as they relate to the development of intracranial aneurysms and their subsequent rupture. Far less work has centered on the genetic determinants of cerebral vasospasm, the predisposition to delayed cerebral injury, and the determinants of ensuing functional outcome after aSAH. The suspected genes are diverse and encompass multiple functional systems including fibrinolysis, inflammation, vascular reactivity, and neuronal repair. To this end, we present a systematic review of 21 studies suggesting a genetic basis for clinical outcome after aSAH, with a special emphasis on the pathogenesis of cerebral vasospasm and delayed cerebral ischemia. In addition, we highlight potential pitfalls in the interpretation of genetic association studies, and call for uniformity of design of larger multicenter studies in the future.

Ducruet, Andrew F; Gigante, Paul R; Hickman, Zachary L; Zacharia, Brad E; Arias, Eric J; Grobelny, Bartosz T; Gorski, Justin W; Mayer, Stephan A; Connolly, E Sander



Timing of symptomatic vasospasm in aneurysmal subarachnoid hemorrhage: the effect of treatment modality and clinical implications.  


A better prediction of the time course of symptomatic vasospasm (SVSP) might have a significant impact on the management and prevention of delayed neurologic ischemic deficit (DIND). We studied the influence of the treatment for ruptured aneurysm on SVSP timing. We retrospectively analyzed data of consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) admitted in our center between 1999 and 2005, treated within 72 hours of the rupture by surgical clipping or endovascular coiling and in accordance with our neuroscience unit protocol. We analyzed the presence of SVSP and recorded the timing of occurrence after the aneurysmal repair intervention. Data on demographics, premorbid conditions, time elapsed from the subarachnoid hemorrhage onset and intervention, and clinical and radiologic characteristics at admission were collected. The first occurrence of postintervention SVSP was recorded and compared between the 2 treatment groups using a proportional hazards regression model, including significant covariates. Of the 67 patients analyzed, 21 (31%) underwent endovascular coiling and 46 (69%) underwent surgical clipping. The baseline variables were similar in the 2 groups. The median time from the procedure to clinical vasospasm was 4 days in the coiled patients and 7 days in the clipped patients. In a proportional hazards model regression analysis including age, sex, Fisher and Hunt-Hess grades, time between onset to procedure, and intervention type, only intervention type emerged as a significant predictor of time to SVSP after intervention (likelihood ratio chi2 = 16.8; P < .00). Treatment modality of ruptured intracranial aneurysm may influence the timing of SVSP occurrence. PMID:20189086

Ionita, Catalina C; Baker, John; Graffagnino, Carmelo; Alexander, Michael J; Friedman, Allan H; Zaidat, Osama O



[Spontaneous subarachnoid hemorrhage].  


The diagnosis, management and long-term implications of non-traumatic subarachnoid hemorrhage continue to be a multidisciplinary challenge. Often, the patients present to emergency or primary care physicians not particularly experienced in the differential diagnosis of headache. In most cases of a proven hemorrhage (aneurysm rupture in 85%), further treatment will require the discussion between experienced neurosurgeons and neuroradiologists whether to "clip or coil". Thus, subarachnoid hemorrhage is the first cerebrovascular disorder where a multidisciplinary approach has become the evidence-based standard of care. Patients with this condition are relatively young, and the survivors have a good life expectancy. Their neurologic, cognitive and psychiatric morbidity, risk of recurrent bleeding and elevated risk of other vascular diseases remain underestimated tasks for long-term care. PMID:22349626

Steinmetz, H



Quantitative Regional Cerebral Blood Flow Measurement Techniques Improve Noninvasive Detection of Cerebrovascular Vasospasm after Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Adequate therapy of vasospasm (VS) in patients suffering from aneurysmal subarachnoid hemorrhage critically depends upon early and reliable diagnosis of cerebral hypoperfusion. The objective of the present study was to evaluate the usefulness of quantitative regional blood flow (rCBF) analysis as an adjunct in noninvasive prediction of VS. Therefore, 33 transcranial Doppler sonography (TCD) studies assuming cerebrovascular VS (TCD flow

P. Horn; P. Vajkoczy; C. Bauhuf; E. Münch; C. Poeckler-Schoeniger; P. Schmiedek



Spontaneous bilateral carotid and vertebral artery dissections associated with multiple disparate intracranial aneurysms, subarachnoid hemorrhage and spontaneous resolution  

Microsoft Academic Search

Spontaneous bilateral carotid and vertebral artery dissections (CADs and VADs) are rare. A 29-year-old female presented with a collapse, 4 weeks after a sudden onset of severe neck and shoulder pain. CT scan revealed diffuse subarachnoid hemorrhage (SAH) and early hydrocephalus. Angiography revealed bilateral CADs and VADs, along with multiple fusiform and saccular aneurysms. Systemic vessels – including the renal

Laurence A. G. Marshman; Luke Ball; Changez K. Jadun



[A case of HELLP syndrome resulting in eclampsia with non-aneurysmal subarachnoid hemorrhage].  


It is known that hemorrhagic stroke at the perinatal period are caused by specifics conditions like eclampsia as well as by the existing abnormal vessels. We treated a case of HELLP syndrome resulting in eclampsia with non-aneurysmal, convexity subarachnoid hemorrhage. A 34-year-old female, who had been pointed out to have a high level of urinal protein at the 37th week, was seen in the emergency department because of severe headache, vomiting and respiratory discomfort. Her systolic blood pressure was over 190mmHg, and caesarean section was selected. On the way to the operating room, she had a generalized convulsion with loss of consciousness. The delivery was carried out. The CT immediately after the caesarean section revealed faint and localized subarachnoid hemorrhage in the bilateral convexity areas. Additionally, the FLAIR image of MRI demonstrated increased intensity in the bilateral cerebellar hemispheres, basal ganglion and subcortical area, suggesting vasogenic edema. The patient had a good clinical course and the abnormal signal of MRI also recovered by treatment with oral iron and zinc. Here, we report a speculation for the mechanism of this case and precautions against stroke in the perinatal period. PMID:23378389

Yoshikane, Tsutomu; Miyazaki, Takeshi; Aoki, Showa; Kambara, Mizuki; Hagiwara, Shinya; Miyazaki, Kohji; Akiyama, Yasuhiko



Absence of Alpha1 Antitrypsin Deficiency Alleles (S and Z) in Japanese and Korean Patients With Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—A possible association has been proposed for the formation of intracranial aneurysm (IA) and deficiency alleles (S and Z )o f the1-antitrypsin (AAT) gene. We extensively screened this gene in Japanese and Korean patients with aneurysmal subarachnoid hemorrhage. Methods—Seven allelic variants, including S and Z alleles, were genotyped by direct sequencing of genomic DNA obtained from 195 and

Taku Yoneyama; Hidetoshi Kasuya; Hiroyuki Akagawa; Hideaki Onda; Toshiaki Nakajima; Tomokatsu Hori; Ituro Inoue; Jung-Chung Lee; Tae-Ki Yang; Chul-Jin Kim


The safety and feasibility of continuous intravenous magnesium sulfate for prevention of cerebral vasospasm in aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

Introduction: Cerebral vasospasm in aneurysmal subarachnoid hemorrhage (SAH) is associated with poor outcome. The safety and feasibility\\u000a of continuous high-dose intravenous magnesium sulfate (MgSO4) for the prevention of cerebral vasospasm and ischemic cerebral injury has not been well studied.\\u000a \\u000a \\u000a Methods: Patients presenting to our center within 72 hours of aneurysmal SAH (confirmed by computed tomography [CT] scanning and cerebral\\u000a angiography)

Abutaher M. Yahia; Jawad F. Kirmani; Adnan I. Qureshi; Lee R. Guterman; L. Nelson Hopkins



Detection of Circle of Willis Aneurysms in Patients with Acute Subarachnoid Hemorrhage: A Comparison of CT Angiography and Digital Subtraction Angiography  

Microsoft Academic Search

POBJECTIVE. The purpose of this study was to compare CT angiography with dig- ital subtraction angiography (DSA) in the detection and measurement of intracranial aneurysms in patients with acute subarachnoid hemorrhage. SUBJECTS AND METHODS. Thirty consecutive patients with recent subarachnoid hemorrhage shown by unenhanced CT scanning or lumbar puncture were studied with CT angiography and DSA. Using a shaded surface

Pedro T. Vieco; William P. Shuman; Cordell E. Gross


Current concepts of pathophysiology and management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage.  


Approximately 10 in 100,000 persons suffer rupture of a saccular intracranial aneurysm annually, and roughly 60% of these will survive the initial catastrophe in reasonable neurological condition. Of the many ensuing complications of aneurysmal subarachnoid hemorrhage, the most frustrating continues to be a form of delayed-onset cerebral arterial narrowing known as vasospasm. Because it is caused by thick subarachnoid blood clots coating the adventitial surface of cerebral arteries, the distribution and severity of vasospasm correlates closely with location and volume of subarachnoid hematoma as visualized on computed tomography (CT). Critical vasospasm causes cerebral ischemia and infarction: the "second stroke." It is now know that vasospasm represents sustained arterial contraction rather than structural thickening of the vessel wall with lumen encroachment. A large body of evidence points to oxyhemoglobin, released from lysing erythrocytes, as the principal component of blood clot responsible for this contraction. The precise mechanism by which oxyhemoglobin causes prolonged vascular smooth muscle cell constriction has not yet been established, but possibilities include secondary generation of vasoactive free radicals, lipid peroxides, eicosanoids, bilirubin, and endothelin. Vasospasm treatments are directed at preventing or reversing arterial narrowing, or at preventing or reversing cerebral ischemia. Several treatments from the latter category, namely, hypertensive, hypervolemic hemodilutional therapy and the calcium channel blocker nimodipine, have proven moderately effective and are in widespread clinical use. It has also been possible to mechanically dilate vasospastic vessels with transluminal angioplasty improving cerebral blood flow to ischemic brain. However we are still in need of an effective agent to prevent arterial narrowing, and several hopeful candidates in this category of treatment are clot lytic agent tissue plasminogen activator (rt-PA) and an inhibitor of iron-dependent peroxidation, 21-aminosteroid U74006F (tirilazad mesylate). PMID:1772740

Findlay, J M; Macdonald, R L; Weir, B K



Hyperglycemia in aneurysmal subarachnoid hemorrhage: a potentially modifiable risk factor for poor outcome  

PubMed Central

Hyperglycemia after aneurysmal subarachnoid hemorrhage (aSAH) occurs frequently and is associated with delayed cerebral ischemia (DCI) and poor clinical outcome. In this review, we highlight the mechanisms that cause hyperglycemia after aSAH, and we discuss how hyperglycemia may contribute to poor clinical outcome in these patients. As hyperglycemia is potentially modifiable with intensive insulin therapy (IIT), we systematically reviewed the literature on IIT in aSAH patients. In these patients, IIT seems to be difficult to achieve in terms of lowering blood glucose levels substantially without an increased risk of (serious) hypoglycemia. Therefore, before initiating a large-scale randomized trial to investigate the clinical benefit of IIT, phase II studies, possibly with the help of cerebral blood glucose monitoring by microdialysis, will first have to improve this therapy in terms of both safety and adequacy.

Kruyt, Nyika D; Biessels, Geert Jan; DeVries, J Hans; Luitse, Merel J A; Vermeulen, Marinus; Rinkel, Gabriel J E; Vandertop, W Peter; Roos, Yvo B



[Blood blister-like aneurysm on the posterior wall of the internal carotid artery causing subarachnoid hemorrhage: a case report].  


We report a case of blood blister-like aneurysm(BBA)on the posterior wall of the internal carotid artery(ICA)causing subarachnoid hemorrhage(SAH). A 45-year-old man suffering from SAH(WFNS grade 5)was referred to our hospital. 3D-CT angiography showed a BBA on the posterior wall of the ICA. The aneurysm had been enlarged for a few days. Therefore we performed coil embolization. Four weeks after the operation, the aneurysm was found to have regrown. In the second operation the aneurysm was successfully treated by the ICA proximal occlusion with extracranial-intracranial bypass. Postoperative follow-up cerebral angiography detected no aneurysm. To our knowledge, BBA on the posterior wall of the ICA is rare. Radical surgery with bypass should be performed as soon as possible when the BBA is found to regrow. We discuss the clinical characteristics with a review of the literature. PMID:23459520

Koguchi, Motofumi; Suzuyama, Kenji; Uchiyama, Taku; Okamoto, Hiroaki; Takase, Yukinori; Kawashima, Masatou; Matsushima, Toshio



Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages  

PubMed Central

Objective: We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm. Case Description: A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss. Conclusion: We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.

Defillo, Archie; Nussbaum, Eric S.; Zelensky, Andrea; Nussbaum, Leslie



Preventing Vasospasm Improves Outcome After Aneurysmal Subarachnoid Hemorrhage: Rationale and Design of CONSCIOUS2 and CONSCIOUS3 Trials  

Microsoft Academic Search

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a frequent but unpredictable complication associated\\u000a with poor outcome. Current vasospasm therapies are suboptimal; new therapies are needed. Clazosentan, an endothelin receptor\\u000a antagonist, has shown promise in phase 2 studies, and two randomized, double-blind, placebo-controlled phase 3 trials (CONSCIOUS-2\\u000a and CONSCIOUS-3) are underway to further investigate its impact on vasospasm-related outcome after

R. Loch Macdonald; Randall T. Higashida; Emanuela Keller; Stephan A. Mayer; Andy Molyneux; Andreas Raabe; Peter Vajkoczy; Isabel Wanke; Aline Frey; Angelina Marr; Sébastien Roux; Neal F. Kassell



CSF 20-HETE is associated with delayed cerebral ischemia and poor outcomes after aneurysmal subarachnoid hemorrhage  

PubMed Central

Background and Purpose Delayed cerebral ischemia (DCI) is a major complication after aneurysmal subarachnoid hemorrhage (aSAH) that is manifested by changes in cerebral blood flow (CBF) accompanied by neurological decline and results in long-term functional and neuropsychological (NP) impairment. Preclinical evidence has demonstrated that the arachidonic acid metabolite, 20-hydroxyeicosatetraenoic acid (20-HETE), affects cerebral microvascular tone and CBF after aSAH. The purpose of this study was to determine if CSF 20-HETE levels were associated with DCI and long term NP outcomes in aSAH patients. Methods CSF samples collected twice daily through 14 days after hemorrhage on 108 acute, adult aSAH patients. Samples were analyzed for 20-HETE via HPLC MSQ single quadrupole mass spectrometry. DCI was defined as the presence of impaired CBF (angiographic vasospasm, elevated transcranial Dopplers, abnormal CT or MR perfusion scans) accompanied by neurological deterioration. Outcomes including death and neuropsychological testing were completed at 3 months after hemorrhage. Results and Conclusions Detectible 20-HETE levels were observed in 31% of patient samples and were associated with severity of hemorrhage (Hunt&Hess p=0.04; Fisher p=0.05). Detection of 20-HETE was not associated with angiographic vasospasm (p=0.34), however, detectible 20-HETE was significantly associated with DCI (p=0.016). Our data also suggests that detectable 20-HETE was associated with decreased performance in 5 NP domains. These results provide the first clinical evidence that CSF 20-HETE concentrations are associated with DCI and poor outcomes and provide impetus for future studies to elucidate the clinical utility of inhibiting 20-HETE formation as a novel therapeutic intervention in patients with aSAH.

Crago, Elizabeth A.; Thampatty, Bhavani P.; Sherwood, Paula R.; Kuo, Chie-Wen J.; Bender, Catherine; Balzer, Jeffrey; Horowitz, Michael; Poloyac, Samuel M.



[Cerebral aneurysm and subarachnoid hemorrhage revealed by a Tako Tsubo syndrome].  


Cerebral hemorrhage is usually associated to many cardiac disorders, mimicking acute coronary syndrome. We relate a case of a postmenopausal woman presenting at emergency room for acute coronary syndrome and whose evaluation revealed a subarachnoidal hemorrhage, normal coronary arteries, and a typical Tako Tsubo aspect on echocardiography with apical ballooning and hyperkinesis with basal hypokinesis. PMID:20003960

Hamdan, R; Kadri, Z; Kassab, R; Abou Jaoudé, S



EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial  

PubMed Central

Background Aneurysmal subarachnoid hemorrhage (SAH) may be complicated by delayed cerebral ischemia, which is a major cause of unfavorable clinical outcome and death in SAH-patients. Delayed cerebral ischemia is presumably related to the development of vasospasm triggered by the presence of blood in the basal cisterns. To date, oral application of the calcium antagonist nimodipine is the only prophylactic treatment for vasospasm recognized under international guidelines. In retrospective trials lumbar drainage of cerebrospinal fluid has been shown to be a safe and feasible measure to remove the blood from the basal cisterns and decrease the incidence of delayed cerebral ischemia and vasospasm in the respective study populations. However, the efficacy of lumbar drainage has not been evaluated prospectively in a randomized controlled trial yet. Methods/Design This is a protocol for a 2-arm randomized controlled trial to compare an intervention group receiving early continuous lumbar CSF-drainage and standard neurointensive care to a control group receiving standard neurointensive care only. Adults suffering from a first aneurysmal subarachnoid hemorrhage whose aneurysm has been secured by means of coiling or clipping are eligible for trial participation. The effect of early CSF drainage (starting < 72 h after securing the aneurysm) will be measured in the following ways: the primary endpoint will be disability after 6 months, assessed by a blinded investigator during a personal visit or standardized telephone interview using the modified Rankin Scale. Secondary endpoints include mortality after 6 months, angiographic vasospasm, transcranial Doppler sonography (TCD) mean flow velocity in both middle cerebral arteries and rate of shunt insertion at 6 months after hospital discharge. Discussion Here, we present the study design of a multicenter prospective randomized controlled trial to investigate whether early application of a lumbar drainage improves clinical outcome after aneurysmal subarachnoid hemorrhage. Trial registration Identifier: NCT01258257



Evidence that a Panel of Neurodegeneration Biomarkers Predicts Vasospasm, Infarction, and Outcome in Aneurysmal Subarachnoid Hemorrhage  

PubMed Central

Biomarkers for neurodegeneration could be early prognostic measures of brain damage and dysfunction in aneurysmal subarachnoid hemorrhage (aSAH) with clinical and medical applications. Recently, we developed a new panel of neurodegeneration biomarkers, and report here on their relationships with pathophysiological complications and outcomes following severe aSAH. Fourteen patients provided serial cerebrospinal fluid samples for up to 10 days and were evaluated by ultrasonography, angiography, magnetic resonance imaging, and clinical examination. Functional outcomes were assessed at hospital discharge and 6–9 months thereafter. Eight biomarkers for acute brain damage were quantified: calpain-derived ?-spectrin N- and C-terminal fragments (CCSntf and CCSctf), hypophosphorylated neurofilament H, 14-3-3 ? and ?, ubiquitin C-terminal hydrolase L1, neuron-specific enolase, and S100?. All 8 biomarkers rose up to 100-fold in a subset of patients. Better than any single biomarker, a set of 6 correlated significantly with cerebral vasospasm, brain infarction, and poor outcome. Furthermore, CSF levels of 14-3-3?, CCSntf, and NSE were early predictors of subsequent moderate-to-severe vasospasm. These data provide evidence that a panel of neurodegeneration biomarkers may predict lasting brain dysfunction and the pathophysiological processes that lead to it following aSAH. The panel may be valuable as surrogate endpoints for controlled clinical evaluation of treatment interventions and for guiding aSAH patient care.

Siman, Robert; Giovannone, Nicholas; Toraskar, Nikhil; Frangos, Suzanne; Stein, Sherman C.; Levine, Joshua M.; Kumar, Monisha A.



Critical care management of subarachnoid hemorrhage  

Microsoft Academic Search

Successful critical care management of patients with aneurysmal subarachnoid hemorrhage requires a thorough understanding\\u000a of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article\\u000a reviews the natural history of aneurysmal subarachnoid hemorrhage and strategies for disease management in the acute setting.\\u000a Available tools for monitoring brain function are discussed.

Joshua M. Levine



Terson's syndrome as the initial symptom of subarachnoid hemorrhage caused by ruptured vertebral artery aneurysm. Case report.  


A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm. PMID:16861828

Inoue, Tomohiro; Tsutsumi, Kazuo; Shigeeda, Takashi



Sentinel Headache and the Risk of Rebleeding After Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—The clinical significance of sentinel headaches in patients with subarachnoid hemorrhage (SAH) is still unknown. We investigated whether patients with a sentinel headache (SH) have a higher rate of rebleeding after SAH. Methods—An SH was defined as a sudden, severe, unknown headache lasting 1 hour with or without accompanying symptoms, not leading to a diagnosis of SAH in

Jurgen Beck; Andreas Raabe; Andrea Szelenyi; Joachim Berkefeld; Rudiger Gerlach; Matthias Setzer; Volker Seifert



Relationship between Angiographic Vasospasm and Regional Hypoperfusion In Aneurysmal Subarachnoid Hemorrhage  

PubMed Central

Background Angiographic vasospasm frequently complicates subarachnoid hemorrhage (SAH) and has been implicated in the development of delayed cerebral ischemia. Whether large-vessel narrowing adequately accounts for the critical reductions in regional cerebral blood flow (CBF) underlying ischemia is unclear. We sought to clarify the relationship between angiographic vasospasm and regional hypoperfusion. Methods 25 patients with aneurysmal SAH underwent cerebral catheter angiography and 15O-PET imaging within 1 day of each other (median of 7 days after SAH). Severity of vasospasm was assessed in each intracranial artery while cerebral blood flow (CBF) and oxygen extraction fraction (OEF) were measured in 28 brain regions distributed across these vascular territories. We analyzed the association between vasospasm and perfusion and compared frequency of hypoperfusion (CBF < 25 ml/100g/min) and oligemia (low oxygen delivery with OEF ? 0.5) in territories with vs. without significant vasospasm. Results 24% of 652 brain regions were supplied by vessels with significant vasospasm. CBF was lower in such regions (38.6±12 vs. 48.7±16 ml/100g/min) while OEF was higher (0.48±0.19 vs. 0.37±0.14, both p<0.001). Hypoperfusion was seen in 46 regions (7%) but 66% of these were supplied by vessels with no significant vasospasm; 24% occurred in patients without angiographic vasospasm. Similarly, oligemia occurred more frequently outside territories with vasospasm. Conclusions Angiographic vasospasm is associated with reductions in cerebral perfusion. However, regional hypoperfusion and oligemia frequently occurred in territories and patients without vasospasm. Other factors in addition to large-vessel narrowing must contribute to critical reductions in perfusion.

Dhar, Rajat; Scalfani, Michael T; Blackburn, Spiros; Zazulia, Allyson R; Videen, Tom; Diringer, Michael



Role of Endothelin-1 in Human Aneurysmal Subarachnoid Hemorrhage: Associations with Vasospasm and Delayed Cerebral Ischemia  

PubMed Central

Background Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathogenesis of vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. The aim of this study was to investigate the relationship between cerebrospinal fluid (CSF) ET-1 levels and angiographic vasospasm and DCI. Methods Patients with aSAH were consented (n = 106). Cerebral vasospasm was determined by angiography. DCI was determined by transcranial Doppler (TCD) results and/or angiogram results with corresponding clinical deterioration. CSF ET-1 levels over 14 days after the initial insult was quantified by ELISA. ET-1 analysis included a group-based trajectory analysis and ET-1 exposure rate during 24, 48, and 72 h prior to, as well as 72 h post angiography, or clinical deterioration. Results Trajectory analysis revealed two distinct groups of subjects with 56% of patients in the low ET-1 trajectory group (mean at day 1 = 0.31 pg/ml; SE = 0.04; mean at day 14 = 0.41 pg/ml; SE = 0.15) and 44% of patients in the high ET-1 trajectory group (mean at day 1 = 0.65 pg/ml; SE = 0.08; mean at day 14 = 0.61 pg/ml; SE = 0.06). Furthermore, we observed that ET-1 exposure rate 72 h before angiography and clinical spasm was a significant predictor of both angiographic vasospasm and DCI, whereas, ET-1 exposure after angiography and clinical spasm was not associated with either angiographic vasospasm or DCI. Conclusion Based on these results we conclude that ET-1 concentrations are elevated in a sub-group of patients and that the acute (72 h prior to angiography and clinical neurological deterioration), but not chronic, elevations in CSF ET-1 concentrations are indicative of the pathogenic alterations of vasospasm and DCI in aSAH patients.

Thampatty, Bhavani P.; Sherwood, Paula R.; Gallek, Matthew J.; Crago, Elizabeth A.; Ren, Dianxu; Hricik, Allison J.; Kuo, Chien-Wen J.; Klamerus, Megan M.; Alexander, Sheila A.; Bender, Catherine M.; Hoffman, Leslie A.; Horowitz, Michael B.; Kassam, Amin B.; Poloyac, Samuel M.



Spinal syringomyelia following subarachnoid hemorrhage.  


Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated at Kinki University School of Medicine. Two of the 198 patients had syringomyelia following aneurysmal SAH; thus the rate of syringomyelia associated with aneurysmal SAH was 1.0%. Patient 1 was a 54-year-old woman who presented with back pain, back numbness and gait disturbance 20 months after SAH. Her MRI revealed syringomyelia of the spinal cord from C2 to T10. She underwent shunting of the syrinx to the subarachnoid space. Patient 2 was a 49-year-old man, who was admitted to the hospital with headache, diplopia, hoarseness, dysphagia and ataxia five months after SAH. MRI revealed syringomyelia from the medulla oblongata to C6, and an enlargement of the lateral and fourth ventricles. After foramen magnum decompression and C1 laminectomy, a fourth ventricle-subarachnoid shunt was placed by insertion of a catheter. Spinal arachnoiditis and spinal syringomyelia are rare but important chronic complications after SAH. PMID:22285478

Nakanishi, Kinya; Uchiyama, Takuya; Nakano, Naoki; Fukawa, Norihito; Yamada, Kimito; Yabuuchi, Tomonari; Kato, Amami



Location and Size of Ruptured Intracranial Aneurysm and Serious Clinical Outcomes Early after Subarachnoid Hemorrhage: A Population-Based Study in Australasia  

Microsoft Academic Search

Background: It is uncertain whether the location and size of a ruptured intracranial aneurysm (IA) independently influences the outcome of subarachnoid hemorrhage (SAH). Objective: To determine the independent relationship of location and size of a ruptured IA with serious clinical outcomes after SAH in an Australasian population-based study. Methods: From 432 first-ever cases of primary SAH registered prospectively over 12

Ivy Shiue; Hisatomi Arima; Graeme J. Hankey; Craig S. Anderson



Differential Regulation of Matrix-Metalloproteinases and Their Tissue Inhibitors in Patients with Aneurysmal Subarachnoid Hemorrhage  

PubMed Central

Background Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are involved in vascular remodeling, (neuro)inflammation, blood-brain barrier breakdown and neuronal apoptosis. Proinflammatory mechanisms are suggested to play an important role during early brain injury and cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). This study aimed to analyze MMP-3, MMP-9, TIMP-1 and TIMP-3 in patients with SAH and their respective association with cerebral vasospasm (CVS). Methods Blood samples were collected in 20 SAH patients on days 1 to 7, 9, 11, 13 and 15 and 20 healthy age and gender matched volunteers. Serum MMPs and TIMPs were analyzed using enzyme-linked immunosorbent assay. Doppler sonographic CVS was defined as a mean blood flow velocity above 120 cm/sec in the middle cerebral artery. When discharged from hospital and at 6 month follow-up neurological outcome was evaluated using the Glasgow Outcome Score and the modified Rankin Scale. Results MMP-9 was higher in SAH patients compared to healthy controls (p<0.001). Patients with CVS (n?=?11) had elevated MMP-9 serum levels compared to patients without CVS (n?=?9, p<0.05). Higher MMP-9 was observed in the presence of cerebral ischemia associated with cerebral vasospasm (p<0.05). TIMP-1 was increased in patients with SAH on day 4 (p<0.05). There was an imbalance of the MMP-9/TIMP-1 ratio in favor of MMP-9 in SAH patients, in particular those with CVS (p<0.001). MMP-3 and TIMP-3 were significantly lower in SAH patients throughout day 4 and day 7, respectively (p<0.05). We did not find an association between MMP-, TIMP levels and neurological outcome after 6 months. Conclusions MMP-3 and -9 are differentially regulated in SAH patients with both enzymes showing peak levels correlating with the development of CVS. The inhibitors TIMP-1 and -3 were low during the acute phase after SAH and increased later on which might suggest a preponderance of pro-inflammatory mechanisms.

Fischer, Marlene; Dietmann, Anelia; Beer, Ronny; Broessner, Gregor; Helbok, Raimund; Pfausler, Bettina; Schmutzhard, Erich; Lackner, Peter



Nonthyroidal illness syndrome in patients with subarachnoid hemorrhage due to intracranial aneurysm.  


We have previously reported that subarachnoid hemorrhage due to ruptured intracranial aneurysm (SH) is associated with changes in the hormonal profile in the first 24 hours after the event. We proposed that the hormonal changes observed are due to the intense stress to which the patients are exposed. However, the thyroidal hormonal profile is indicative of the presence of a nonthyroidal illness syndrome (NTIS). In this paper, we examined whether the change in the thyroid hormone profile is compatible with a NTIS. Two groups of patients were included in the study: A) 30 patients with SH (21 females and 9 males; 41.7+/-11.4 years) and B) a control group including 25 patients with benign diseases of the spine (BDS) (lumbar disc hernia or stable spinal trauma) (8 females and 17 males; 41.3+/-14.2 years). In a subgroup of eight patients of each group serum triiodothyronine (T3) and reverse T3 levels were measured. The blood samples were obtained between 8:00 and 9:00 AM. The following results were obtained: The SH group had smaller serum T3 and free T4 levels than the BDS group (p<0.05): T3 (ng/mL): SH = 58.7+/-1.1 and BDS = 74.5+/-13.9; free T4 (ng/dL): SH = 0.9+/-0.2 and BDS = 1.1+/-0.3. There was no significant difference in the serum levels of total thyroxine (T4) and thyroid-stimulating hormone (TSH) between the two groups: T4 ( microg/dL): SH = 6.9+/-1.1 and BDS = 7.4+/-2.1; TSH ( microUI/mL): SH = 1.5+/-0.8 and BDS = 1.8+/-1,0. In the sample of eight patients of each group we had the following results: T3 (ng/mL): SH = 66.8+/-3.8 and BDS = 77.2+/-1.1 (p <0.05); reverse T3 (ng/dL): SH = 32.8+/-8 and BDS = 24.7+/-2.2 (NS); T3/ reverse T3 ratio: SH = 2.6+/-0.3 and BDS = 3.3+/-0.4 (NS). Thyreoglobulin and microsomal antibodies were not detectable, except in one patient in the SH group. In conclusion, the SH patients present serum levels of T3 and free T4 significantly lower than that of BDS patients; the thyroidal hormone profile suggests that SH patients have developed the nonthyroidal illness syndrome. PMID:15122429

Casulari, Luiz Augusto; Mangieri, Paola; Naves, Luciana A; Suzuki, Kunio; Ferreira, Moema; Domingues, Lucilia



Long-term Cognitive Deficits in Patients with Good Outcomes after Aneurysmal Subarachnoid Hemorrhage from Anterior Communicating Artery  

PubMed Central

Aim To evaluate long-term cognitive consequences of subarachnoid hemorrhage with good outcome and the opinion of patients and their relatives about these consequences. Methods The study included 10 patients surgically treated for subarachnoid hemorrhage due to the rupture of aneurysm of the anterior communicating artery 2 or more years earlier, and 10 age- and sex-matched healthy controls. The preoperative and postoperative course in the patients was uneventful. Clinical and psychosocial factors and cognitive status of the patients were assessed by use of checklists and neuropsychological tests for executive functions, attention, and memory, and event-related potential recordings (waves P3a and P3b) with tree-stimulus auditory oddball paradigm, which was also performed in healthy controls. Results The number of reported cognitive problems negatively correlated with the patients’ level of community integration (? range, -0.22 to -0.75). The average neuropsychological results ranged between the 12th and 46th percentile. Impaired results were found in 7 patients across different tests and were most frequent for visual memory, followed by verbal memory and executive functions. A clear decline in cognitive functioning was observed in 3 patients. Neither P3a nor P3b wave could be found in 3 patients. In comparison with controls, patients had significantly longer P3b wave latencies (364 vs 334 ms; Mann-Whitney U test, P?=?0.025). We found statistically non-significant, but still prominent negative correlations between the sustained attention results and latencies of P3a (??=?-0.58; P?=?0.172) and P3b (??=?-0.58; P?=?0.172) waves. Conclusion Despite good outcome after subarachnoid hemorrhage, persistent cognitive consequences were still manifest, limiting the patients' psychosocial functioning. The correlation between neuropsychological and neurophysiological measures indicated frontal lobe damage, which in some patients persisted for years after the hemorrhage.

Ravnik, Janez; Starovasnik, Barbara; Sesok, Sanja; Pirtosek, Zvezdan; Svigelj, Viktor; Bunc, Gorazd; Bosnjak, Roman



The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage.  


Delayed cerebral ischemia remains a severe potential complication of aneurysmal subarachnoid hemorrhage (SAH) possibly leading to death and disability. We evaluated a semiquantitative and visual analysis of perfusion computed tomography (PCT) as a predictor of clinically relevant vasospasm (CRV) in patients with aneurysmal SAH. Thirty-eight patients with aneurysmal SAH were analyzed yielding 145 PCT scans. PCT, clinical examination, and transcranial Doppler ultrasound (TCD) were performed on days 3, 7, 10, and 14 after hemorrhage. Cerebral blood flow, cerebral blood volume, and time to peak (TTP) were analyzed semiquantitatively using six regions of interest, and visually for signs of cerebral hypoperfusion. CRV was defined as secondary cerebral infarction (CI) seen on cranial computed tomography scans and/or delayed neurological deterioration (DND). CI occurred in 13 (34.2 %) and DND in 11 patients (28.9 %). With TCD as pretest, TTP had a sensitivity of 90 % and a specificity of 72 % (cutoff value, 0.963) as predictor for CI. TTP's sensitivity as predictor for DND was 90 % with a specificity of 61.1 % (cutoff value, 0.983). Visual analysis of TTP showed a negative predictive value of 100 % with a positive predictive value of 52 %. TTP is a sensitive and specific perfusion parameter in predicting CI in patients with SAH. Its use in the clinical setting may optimize the early treatment of patients at risk for vasospasm before the onset of clinical deterioration, especially when applying TCD as pretest. Further investigation in a larger patient population is required. PMID:23104502

Hickmann, Anne-Katrin; Langner, Sönke; Kirsch, Michael; Baldauf, Jörg; Müller, Cornelia; Khaw, Alexander; Schroeder, Henry W S



Relationship between plasma high mobility group box-1 protein levels and clinical outcomes of aneurysmal subarachnoid hemorrhage  

PubMed Central

Background High-mobility group box 1 (HMGB1), originally described as a nuclear protein that binds to and modifies DNA, is now regarded as a central mediator of inflammation by acting as a cytokine. However, the association of HMGB1 in the peripheral blood with disease outcome and cerebrovasospasm has not been examined in patients with aneurysmal subarachnoid hemorrhage. Methods In this study, 303 consecutive patients were included. Upon admission, plasma HMGB1 levels were measured by ELISA. The end points were mortality after 1?year, in-hospital mortality, cerebrovasospasm and poor functional outcome (Glasgow Outcome Scale score of 1 to 3) after 1?year. Results Upon admission, the plasma HMGB1 level in patients was statistically significantly higher than that in healthy controls. A multivariate analysis showed that the plasma HMGB1 level was an independent predictor of poor functional outcome and mortality after 1?year, in-hospital mortality and cerebrovasospasm. A receiver operating characteristic curve showed that plasma HMGB1 level on admission statistically significantly predicted poor functional outcome and mortality after 1?year, in-hospital mortality and cerebrovasospasm of patients. The area under the curve of the HMGB1 concentration was similar to those of World Federation of Neurological Surgeons (WFNS) score and modified Fisher score for the prediction of poor functional outcome and mortality after 1?year, and in-hospital mortality, but not for the prediction of cerebrovasospasm. In a combined logistic-regression model, HMGB1 improved the area under the curve of WFNS score and modified Fisher score for the prediction of poor functional outcome after 1?year, but not for the prediction of mortality after 1?year, in-hospital mortality, or cerebrovasospasm. Conclusions HMGB1 level is a useful, complementary tool to predict functional outcome and mortality after aneurysmal subarachnoid hemorrhage. However, HMGB1 determination does not add to the accuracy of prediction of the clinical outcomes.



Is the circulating plasma volume sufficiently maintained? Fluid management of an aneurysmal subarachnoid hemorrhage in the acute phase.  


Cerebral vasospasm is a well-known cause of mortality and morbidity following aneurysmal subarachnoid hemorrhage (SAH). Prevention of symptomatic cerebral vasospasm is the basic management after SAH. Numerous pharmaceutical therapies and endovascular treatments are available against cerebral vasospasm, but none of them have so far proven to improve the outcome. We have focused on maintaining the circulation volume in order to prevent cerebral vasospasm. But to maintain the central venous pressure, huge infusion volume was required, and hyponatremia was frequently observed due to natriuresis and osmotic diuresis. Excessive natriuresis and diuresis cannot be managed through sodium and water replacement, since sodium replacement induces further natriuresis and diuresis (desalination), and water replacement induces hyponatremia. We therefore administered fludrocortisone and hydrocortisone to inhibit excessive natriuresis and diuresis. The efficacy of sodium reabsorption therapy is extremely high to maintain the circulation volume that might have a therapeutic effect to prevent cerebral vasospasm. In this article, we review our institution's experience regarding the management of patients with aneurysmal SAH and also discuss the importance of water and sodium balance when managing such patients. PMID:22989722

Mori, Tatsuro; Katayama, Yoichi; Igarashi, Takahiro; Moro, Nobuhiro; Kojima, Jun; Hirayama, Teruyasu



The Use of Cardiac Troponin-I (cTnI) to Determine the Incidence of Myocardial Ischemia and Injury in Patients with Aneurysmal and Presumed Aneurysmal Subarachnoid Hemorrhage  

Microsoft Academic Search

Summary   A prospective single center study was performed to determine the minimal preoperative incidence of unrecognized cardiac injury\\u000a in patients suffering aneurysmal and presumed aneurysmal subarachnoid hemorrhage (SAH). When caring for such patients in the\\u000a pre- and post operative period clinicians must be aware of the possibility of cardiac injury even when a history of previous\\u000a cardiac symptomatology is not

M. B. Horowitz; D. Willet; J. Keffer



Nonaneurysmal Subarachnoid Hemorrhage after Udenafil Intake.  


We report a 67-year-old man who presented with severe headache after taking 50 mg of udenafil, a new phosphodiesterase 5 inhibitor. Computed tomographic imaging of the brain revealed a small amount of acute subarachnoid hemorrhage localized around basal cisterns (anterior to midbrain and pons). There were no aneurysms in the cerebral arteries, although vein of Galen stenosis was suspected after magnetic resonance venography. This case anecdotally suggests that phosphodiesterase 5 inhibition might trigger perimesencephalic subarachnoid hemorrhage with venous hypertension possibly associated with vein of Galen stenosis. PMID:23643478

Bae, Eun-Kee; Ahn, Jong-Hyeon; Park, Jeong-Jin



Cerebral microdialysis for detection of bacterial meningitis in aneurysmal subarachnoid hemorrhage patients: a cohort study  

PubMed Central

Introduction Bacterial meningitis (BM) is a severe complication in patients with aneurysmal subarachnoid haemorrhage (SAH). Clinical signs of meningitis are often masked by SAH-related symptoms, and routine cerebrospinal fluid (CSF) analysis fails to indicate BM. Microdialysis (MD) is a technique for monitoring cerebral metabolism in patients with SAH. A cohort study was performed to investigate the value of MD for the diagnosis of BM. Methods Retrospectively, 167 patients with SAH in an ongoing investigation on cerebral metabolism monitored by MD were analysed for the presence of BM and related MD changes. Diagnosis of BM was based on microbiological CSF culture or clinical symptoms responding to antibiotic treatment, combined with an increased CSF cell count and/or fever. Levels of MD parameters before and after diagnosis of BM were analysed and compared with the spontaneous course in controls. Results BM developed in 20 patients, of which 12 underwent MD monitoring at the time of diagnosis. A control group was formed using 147 patients with SAH not developing meningitis. On the day BM was diagnosed, cerebral glucose was lower compared with the value three days before (p = 0.012), and the extent of decrease was significantly higher than in controls (p = 0.044). A decrease in cerebral glucose by 1 mmol/L combined with the presence of fever ? 38°C indicated BM with a sensitivity of 69% and a specificity of 80%. CSF chemistry failed to indicate BM, but the cell count increased during the days before diagnosis (p < 0.05). Conclusions A decrease in MD glucose combined with the presence of fever detected BM with acceptable sensitivity and specificity, while CSF chemistry failed to indicate BM. In patients with SAH where CSF cell count is not available or helpful, MD might serve as an adjunct criterion for early diagnosis of BM.

Schlenk, Florian; Frieler, Katja; Nagel, Alexandra; Vajkoczy, Peter; Sarrafzadeh, Asita S



Analysis of subarachnoid hemorrhage according to the Japanese Standard Stroke Registry Study--incidence, outcome, and comparison with the International Subarachnoid Aneurysm Trial.  


The data for subarachnoid hemorrhage (SAH) from the Japanese Standard Stroke Registry Study (JSSRS) were analyzed to evaluate the incidence of SAH according to age, neurological grading and outcome, and outcome of surgical clipping, for comparison with the International Subarachnoid Aneurysm Trial (ISAT). From the ISSRS data, the peak incidence of SAH was the sixth decade in males and the eighth decade in females. The overall mortality was 22%, and good outcome, better than 2 on the modified Rankin Scale (mRS), at discharge was achieved in 58% of cases. Radical treatment was performed in 62.6% of all SAH cases, 58.7% with surgical clipping and 3.2% with endovascular coiling. Poor outcome, worse than 3 on the mRS, occurred in 26.6% of patients under 60 years, 47.3% between 60-69 years, 54.2% between 70-79 years, and 72.9% 80 years or over. From the ISAT data, 88% of patients were in grades 1-2 of the World Federation of Neurological Surgeons (WFNS) grading system in both surgical clipping and endovascular coiling groups, 94% in grades 1-3, and 98% in grades 1-4. Poor outcome, worse than 3 on the mRS, at 2 months occurred in 25.4% and 36.4% of patients with endovascular coiling and surgical clipping, respectively. Limiting the patients in the JSSRS to WFNS grades 1-2 showed poor outcome, worse than 3 on the mRS, occurred in 12.8%, and in grades 1-3 and 1-4 occurred in only 16.3% and 23.0%, respectively. PMID:15200066

Ikawa, Fusao; Ohbayashi, Naohiko; Imada, Yasutaka; Matsushige, Toshinori; Kajihara, Yosuke; Inagawa, Tetsuji; Kobayashi, Shotai



The German database on hypopituitarism after traumatic brain injury and aneurysmal subarachnoid hemorrhage - description, objectives and design.  


Within the last years, a number of clinical studies have addressed the topic of hypothalamo-pituitary dysfunction following traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH). Clinical studies oftentimes reflect the investigation of highly selective patient groups, very standardized test procedures and may be influenced by a publication bias. Epidemiological data on the prevalence and incidence of hypopituitarism after TBI and SAH in the general population still do not exist. Moreover, very little is known about risk factors and clinical characteristics of pituitary impairment after brain damage. Epidemiologic surveys which aggregate information of many different treatment centers become an increasingly important means of bridging the gap between standardized study situations and clinical practice. Therefore, a multi-center, structured data assessment to create a national registry of TBI and SAH patients has been established in 2005. The Structured Data Assessment of Hypopituitarism after TBI and SAH is coordinated by the Department of Endocrinology, Max-Planck-Institute in Munich with participation of at present 13 neurosurgical, rehabilitation and endocrinological centers in Germany and one Austrian center. Within this database, a large scope of very detailed, clinical, endocrine and outcome information is collected. It also offers the possibility of long-term follow up of the recorded patients. This is the first report of the registry describing goals, organization, methodology, funding and the descriptive data of the first 1,242 patients entered until November 20th, 2008. PMID:20533178

Kreitschmann-Andermahr, I; Hartmann, Y; Poll, E; Schneider, H J; Buchfelder, M; Stalla, G K



Structured assessment of hypopituitarism after traumatic brain injury and aneurysmal subarachnoid hemorrhage in 1242 patients: the German interdisciplinary database.  


Clinical studies have demonstrated that traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH) are frequent causes of long-term disturbances of hypothalamo-pituitary function. This study aimed to assess the prevalence and associated factors of post-traumatic hypopituitarism in a large national registry of patients with TBI and SAH. Data were collected from 14 centers in Germany and Austria treating patients for TBI or SAH and performing endocrine assessments. Data were collected using a structured, internet-based study sheet, obtaining information on clinical, radiological, and hormonal parameters. A total of 1242 patients (825 TBI, age 43.5±19.7 years; 417 SAH, age 49.7±11.8 years) were included. We studied the prevalence of hypopituitarism reported based on different definitions of laboratory values and stimulation tests. Stimulation tests for the corticotropic and somatotropic axes were performed in 26% and 22% of the patients, respectively. The prevalence of hypopituitarism in the chronic phase (at least 5 months after the event) by laboratory values, physician diagnoses, and stimulation tests, was 35%, 36%, and 70%, respectively. Hypopituitarism was less common in the acute phase. According to the frequency of endocrine dysfunction, pituitary hormone secretion was impaired in the following sequence: ACTH, LH/FSH, GH, and TSH. TBI patients with abnormal stimulation tests had suffered from more severe TBI than patients with normal stimulation tests. In conclusion, our data confirm that hypopituitarism is a common complication of TBI and SAH. It is possible that patients with a higher likelihood of hypopituitarism were selected for endocrine stimulation tests. PMID:21671796

Schneider, Harald J; Schneider, Manfred; Kreitschmann-Andermahr, Ilonka; Tuschy, Ulrich; Wallaschofski, Henri; Fleck, Steffen; Faust, Michael; Renner, Caroline I E; Kopczak, Anna; Saller, Bernhard; Buchfelder, Michael; Jordan, Martina; Stalla, Günter K



Parenteral diclofenac infusion significantly decreases brain-tissue oxygen tension in patients with poor-grade aneurysmal subarachnoid hemorrhage  

PubMed Central

Introduction Diclofenac, a nonsteroidal antiinflammatory drug, is commonly used as antipyretic therapy in intensive care. The purpose of this study was to investigate the effects of parenteral diclofenac infusion on brain homeostasis, including brain-tissue oxygen tension (PbtO2) and brain metabolism after aneurysmal subarachnoid hemorrhage (aSAH). Methods We conducted a prospective, observational study with retrospective analysis of 21 consecutive aSAH patients with multimodal neuromonitoring. Cerebral perfusion pressure (CPP), mean arterial pressure (MAP), intracranial pressure (ICP), body temperature, and PbtO2 were analyzed after parenteral diclofenac infusion administered over a 34-minute period (20 to 45 IQR). Data are given as mean ± standard error of mean and median with interquartile range (IQR), as appropriate. Time-series data were analyzed by using a general linear model extended by generalized estimation equations (GEEs). Results One-hundred twenty-three interventions were analyzed. Body temperature decreased from 38.3°C ± 0.05°C by 0.8°C ± 0.06°C (P < 0.001). A 10% decrease in MAP and CPP (P < 0.001) necessitated an increase of vasopressors in 26% (n = 32), colloids in 33% (n = 41), and crystalloids in 5% (n = 7) of interventions. PbtO2 decreased by 13% from a baseline value of 28.1 ± 2.2 mm Hg, resulting in brain-tissue hypoxia (PbtO2 <20 mm Hg) in 38% (n = 8) of patients and 35% (n = 43) of interventions. PbtO2 <30 mm Hg before intervention was associated with brain-tissue hypoxia after parenteral diclofenac infusion (likelihood ratio, 40; AUC, 93%; 95% confidence interval (CI), 87% to 99%; P < 0.001). Cerebral metabolism showed no significant changes after parenteral diclofenac infusion. Conclusions Parenteral diclofenac infusion after aSAH effectively reduces body temperature, but may lead to CPP decrease and brain-tissue hypoxia, which were both associated with poor outcome after aSAH.



Aneurysmal subarachnoid hemorrhage (aSAH) results in low prevalence of neuro-endocrine dysfunction and NOT deficiency.  


Neuro-endocrine deficiencies have been argued to be common sequelae after aneurysmal subarachnoid hemorrhage (aSAH). As this, however, does not resemble our clinical experience, we studied the incidence of neuro-endocrine and neuropsychological deficits after aSAH. Twenty-six patients (20 females) were prospectively screened for neuro-endocrine and neuropsychological deficits 3, 6 and 12 months after aSAH. GH, IGF-1, prolactin, LH, FSH, estradiol, testosterone, ACTH as well as cortisol during ACTH-stimulation were assessed. Neuropsychological analysis covered verbal comprehension, short term and working memory, visuospatial construction, figural memory, psychomotor speed, attention, and concentration. During the study period 5 individuals demonstrated neuro-endocrine dysfunction. Hypogonadotrophic hypogonadism resolved spontaneously in 2 patients and central hypothyroidism in one of these patients during the study. After 12 months three patients presented low IGF-1 levels. 73.9% of our cohort was affected by neuropsychological deficits during follow-up. At 3, 6 and 12 months the prevalences were 56.5, 52.6 and 42.1%, respectively. Interestingly, all patients with neuro-endocrine dysfunction presented impaired clinical outcome with a GOS 4 at some time point of the study (GOS 4 vs. 5, 45.5% vs. 0, P = 0.007). We found a low prevalence of neuro-endocrine and a high prevalence of neuropsychological deficits in patients 3, 6 and 12 months after aSAH without significant interrelation. Spontaneous recovery of neuro-endocrine alterations most likely presents an adaption to or dysfunction after severe illness. This hypothesis is strengthened by the fact that only patients with inferior clinical outcome after aSAH as assessed by GOS demonstrated neuro-endocrine dysfunction. PMID:22038031

Lammert, Alexander; Bode, Hinrich; Hammes, Hans-Peter; Birck, Rainer; Fatar, Marc; Zohsel, Katrin; Schmieder, Kirsten; Schubert, Gerrit Alexander; Thomé, Claudius; Seiz, Marcel



[Comparison of 2 consecutive series of aneurysmal subarachnoid hemorrhage with or without nimodipine and study of the temperature curve].  


A total of 210 consecutive patients with aneurysmal subarachnoid hemorrhage (S.A.H.) of any clinical grade admitted from January 1985 through May 1990 were retrospectively studied to determine the effect of intravenous Nimodipine on survival and functional results and to analyse temperature curve as a prognosis factor. The 106 patients admitted from January 1985 through November 1987 constituted the reference series termed G1. The 104 patients admitted from December 1987 through May 1990 and treated with intravenous Nimodipine constituted the series termed G2. Of the 210 patients, 172 (82%) could be operated on with a similar mean operative delay in both series (G1 = 9.5 days, G2 = 9.8 days). Of the 210 patients, 153 (73%) survived with an average follow-up of 111 weeks for G1 and of 64 weeks for G2. Nimodipine treatment was associated with a significant increase of survival (11.8%, P = 0.05) which was not the result of improved operative technique but of a lower incidence of deaths caused by postoperative vasospasm (G1 = 5 deaths, G2 = 0 deaths, P = 0.05) and by rebleeding (G1 = 15 deaths, G2 = 5 deaths, P = 0.03). No significant difference between the two series G1 and G2 was observed regarding functional results in the 153 survivors, frequency and seriousness of clinical signs of vasospasm during the waiting phase for surgery, radiologic signs of vasospasm on initial and second angiography, cerebral infarctus on second C.T.-Scan. Analysis of temperature curves of the 210 patients revealed that a delayed fever with a plateau pattern was associated with a higher incidence of vasospasm, rebleeding, and deaths.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:8295647

Rousseaux, P; Gomis, P; Bazin, A; Peruzzi, P; Scherpereel, B; Bernard, M H; Bertault, R; Graftieaux, J P



[Traumatic basal subarachnoid hemorrhage].  


Massive subarachnoid hemorrhage may occur on a traumatic basis. The injury is most often sustained by a blow with a clenched fist against the posterolateral part of the cranial basis, but the injury may also occur in relation to an accident. The condition is rare, most often occurring in alcohol intoxicated men. The victim typically collapses immediately and usually dies within a few minutes. The origin of the bleeding may be the vertebral artery on the neck or the intercranial basal brain arteries. In some cases the origin of the bleeding cannot be located. The pathogenetic mechanisms have been a subject of discussion. The damage to the artery may occur in relation to a fracture of the transverse process of the atlas or in relation to subluxations in the cervical vertebral column. The arterial rupture may occur in both normal and abnormal arteries. In many of the cases the trauma may be very slight. This has, of course, important legal implications. PMID:12772392

Lundgaard, Peter; Leth, Peter Mygind; Gregersen, Markil



The Role of Lumbar Drainage to Prevent Shunt-Dependent Hydrocephalus after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage in Good-Grade Patients  

PubMed Central

Objective To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients. Methods One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms. Results One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure. Conclusion Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.

Yong, Cho In; Hwang, Sung-Kyun



Acute Hydrocephalus After Subarachnoid Hemorrhage  

Microsoft Academic Search

BackgroundAcute hydrocephalus as a consequence of subarachnoid hemorrhage is a relatively frequent problem. It is associated with more neurologic impairment and mortality than subarachnoid hemorrhage without hydrocephalus. A review of the literature was done to determine its frequency of presentation, the associated causes of morbidity and mortality, its clinical presentation, and treatment options.MethodsA search was done through the Med-Line system

Oscar Suarez-Rivera



Spinal subarachnoid hemorrhage accompanied with intraventricular hemorrhage  

PubMed Central

Spinal hematoma is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated in some studies. A 66-year-old man referred to our hospital because of acute onset paraplegia and incontinency started 3 h before admission. With impression of spinal hemorrhage, emergent cervicothoracic spinal MRI performed. On magnetic resonance imagination (MRI) mixed hyper/iso intense lesion in anterior subarachnoid space from C7 to T5 was seen. On brain A computerised tomography (CT) scan, subarachnoid hemorrhage and intraventricular hemorrhage in posterior parts of brain was seen. Unfortunately, the patient died 10 days later. About our patient, severe back pain accompanying by immediate paraplegia, sphincter disturbances, sensory level, and prominent meningeal signs guided us clinically to spinal subarachnoid hemorrhage. Further brain CT scan revealed diffusion of blood to brain subarachnoid space and ventricles. An outstanding finding on brain CT was the presence of blood only in posterior horn of lateral ventricles and dorsal fissures of brain supporting our theory that blood has diffused from spinal subarachnoid space to dorsal subarachnoid space of brain because of supine position of patient. In this patient anticoagulation may be the only sinister factor for developing complications.

Fatehi, Farzad; Basiri, Keivan; Ghorbani, Askar



Effect of Clazosentan in Patients with Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized Controlled Trials  

PubMed Central

Background Cerebral vasospasm is the most important potentially treatable cause of mortality and morbidity following aneurysmal subarachnoid hemorrhage (aSAH). Clazosentan, a selective endothelinreceptor antagonist, has been suggested to help reduce the incidence of vasospasm in patients with aSAH. However, the results were controversial in previous trials. This meta-analysis attempts to assess the effect of clazosentan in patients with aSAH. Methodology/Principal Findings We systematically searched Pubmed, Embase, and the Cochrane Library from their inception until June, 2012. All randomized controlled trials (RCTs) related to the effect of clazosentan in aSAH were included. The primary outcomes included the incidence of angiographic vasospasm, new cerebral infarction (NCI), delayed ischemic neurological deficits (DIND), and vasospasm-related morbidity/mortality (M/M); the second outcomes included the occurrence of rescue therapy, all-cause-mortality, and poor outcome. 4 RCTs were included with a total of 2156 patients. The risk of angiographic vasospasm (relative risk [RR]?=?0.58; 95% CI, 0.48 to 0.71), DIND (RR?=?0.76; 95% CI, 0.62 to 0.92), and vasospasm-related M/M (RR?=?0.80; 95% CI, 0.67 to 0.96) were statistically significantly reduced in the clazosentan group. Patients treated with clazosentan had a reduced occurrence of rescue therapy (RR?=?0.62; 95% CI, 0.49 to 0.79). However, no statistically significant effects were observed in NCI (RR?=?0.74; 95% CI, 0.52 to 1.04), mortality (RR?=?1.03; 95% CI, 0.71 to 1.49), and poor outcome (RR?=?1.12; 95% CI, 0.96 to 1.30). Conclusions/Significance Our pooling data supports that clazosentan is probably effective in preventing the occurrence of angiographic vasospasm, vasospasm-related DIND, vasospasm related M/M, and rescue therapy. However, no evidence lends significant supports to the benefits of clazosentan in decreasing the occurrence of NCI, mortality or improving the functional outcome.

Li, Wei-Qing; Huang, Cheng-Guang; Lu, Yi-Cheng; Hou, Li-Jun



Magnesium and the inflammatory response: potential pathophysiological implications in the management of patients with aneurysmal subarachnoid hemorrhage?  


Cerebral vasospasm and delayed cerebral ischemia remain an unsolved problem in patients with aneurysmal subarachnoid hemorrhage (SAH). In theory, high-dose magnesium sulfate (MgSO(4)) therapy offers vascular and neuroprotective benefits and is therefore currently under evaluation. The intensity of the inflammatory response after SAH is associated with the outcome. The aim of the current study was to evaluate a possible link between the inflammatory response and MgSO(4) therapy, since magnesium (Mg(2+)) has anti-inflammatory properties. In 15 patients with SAH, inflammatory cytokine levels in the cerebrospinal fluid (CSF) and peripheral blood were determined daily using an enzyme-linked immunosorbent assay between day 4 and day 12. Eight patients were treated with standard therapy alone (group 1) and seven patients were treated with an additional, high-dose of MgSO(4) (group 2). Serum Mg(2+) levels in group 2 were significantly higher compared to group 1: 1.48 ± 0.04 mmol/L versus 0.90 ± 0.01 mmol/L, ?<0.001. Interleukin-6 (IL-6) in the CSF was significantly lower in group 2 compared to group 1: 6680 ± 989 vs.11079 ± 1277 pg/mL, ? = 0.021. A trend towards lower systemic IL-6 levels was found in group 2: 58 ± 7 versus 104 ± 21 pg/mL, ? = 0.052. Systemic IL-1? levels were significantly lower in group 2: 0.66 ± 0.11 and 0.15 ± 0.01 pg/mL (?<0.001), while the CSF levels did not differ. Tumor necrosis factor-? levels did not differ between the two groups. Although there were more patients with favorable outcome in group 2, the difference was not statistically significant. This was probably due to the small sample size. The results indicate a suppression of inflammatory cytokine release, in particular IL-6, in patients treated with high-dose MgSO(4). These results call for further studies of the effect of Mg(2+) on the inflammatory signaling pathway with regard to delayed cerebral ischemia following SAH. PMID:22966500

Muroi, Carl; Burkhardt, Jan-Karl; Hugelshofer, Michael; Seule, Martin; Mishima, Kenichi; Keller, Emanuela



An Unusual Cause of Subarachnoid Hemorrhage  

PubMed Central

A 47-year-old man presented to our hospital with collapse secondary to a subarachnoid hemorrhage. A careful history taking revealed symptoms of anaphylaxis before his collapse. This case illustrates an unusual cause of subarachnoid hemorrhage.



Spinal vascular malformations in non-perimesencephalic subarachnoid hemorrhage  

Microsoft Academic Search

Objective\\u000a   In patients with non-traumatic subarachnoid hemorrhage (SAH) and no evidence for a cerebral aneurysm on angiography, a frequent\\u000a cause of the hemorrhage is perimesencephalic hemorrhage or other cerebral vascular pathology. In some patients no cause is\\u000a found. The exact incidence of a spinal vascular malformation (SVM) as the origin for the SAH is not known. We assessed the\\u000a occurrence

M. R. Germans; F. A. Pennings; M. E. S. Sprengers; W. P. Vandertop



[Bilateral abducens nerve palsies in treated cases of subarachnoid hemorrhage].  


Isolated abducens nerve palsies associated with the rupture of intracranial aneurysms have rarely been reported. We report two cases of isolated bilateral abducens nerve palsies occurring after subarachnoid hemorrhage due to the rupture of an intracranial aneurysm. Case 1: A 49-year-old woman had bilateral abducens nerve palsies following subarachnoid hemorrhage due to the rupture of the left vertebral artery-posterior inferior cerebellar artery aneurysm. Case 2: A 55-year-old man had bilateral abducens nerve palsies following subarachnoid hemorrhage due to dissecting aneurysm of the right vertebral artery. Case 1 and 2 were treated with surgical clipping of the aneurysm and internal occlusion of the parent artery. In both cases, bilateral abducens nerve palsies achieved almost full recovery several months after treatment. It is speculated that the main causes of palsies are compression and stretching of the bilateral abducens nerves by a thick clot in the prepontine cistern. Although most of the abducens palsies may be reversible and have good prognosis, it is important that they are kept in mind as isolated symptoms of subarachnoid hemorrhage. PMID:22824578

Saito, Hisayasu; Nakayama, Naoki; Takikawa, Shugo; Ushikoshi, Satoshi; Shinbo, Daisuke; Kuroda, Satoshi; Houkin, Kiyohiro



Cardiac manifestations of subarachnoid hemorrhage.  


Subarachnoid hemorrhage (SAH) is a devastating condition. It carries a high mortality rate, with 12% of patients dying before reaching the hospital. Aside from its neurological morbidities, SAH is associated with significant medical complications. Cardiac manifestations are common and can impact morbidity and mortality in SAH patients. This article will discuss the cardiac manifestations of SAH. PMID:21438809

Behrouz, Réza; Sullebarger, John T; Malek, Ali R



Symptomatic Tarlov Cyst Following Spontaneous Subarachnoid Hemorrhage  

PubMed Central

Most of Tarlov or perineurial cysts remain asymptomatic throughout the patient's life. The pathogenesis is still unclear. Hemorrhage has been suggested as one of the possible causes and trauma with resultant hemorrhage into subarachnoid space has been suggested as an origin of these cysts. However, Tarlov cysts related to spontaneous subarachnoid hemorrhage has not been reported. The authors report a case of Tarlov cyst which was symptomatic following spontaneous subarachnoid hemorrhage.

Kong, Woo Keun; Hong, Seung-Koan



Symptomatic tarlov cyst following spontaneous subarachnoid hemorrhage.  


Most of Tarlov or perineurial cysts remain asymptomatic throughout the patient's life. The pathogenesis is still unclear. Hemorrhage has been suggested as one of the possible causes and trauma with resultant hemorrhage into subarachnoid space has been suggested as an origin of these cysts. However, Tarlov cysts related to spontaneous subarachnoid hemorrhage has not been reported. The authors report a case of Tarlov cyst which was symptomatic following spontaneous subarachnoid hemorrhage. PMID:22053232

Kong, Woo Keun; Cho, Keun-Tae; Hong, Seung-Koan



Neurological and neurobehavioral assessment of experimental subarachnoid hemorrhage  

Microsoft Academic Search

About 50% of humans with aneurysmal subarachnoid hemorrhage (SAH) die and many survivors have neurological and neurobehavioral dysfunction. Animal studies usually focused on cerebral vasospasm and sometimes neuronal injury. The difference in endpoints may contribute to lack of translation of treatments effective in animals to humans. We reviewed prior animal studies of SAH to determine what neurological and neurobehavioral endpoints

Hyojin Jeon; Jinglu Ai; Mohamed Sabri; Asma Tariq; Xueyuan Shang; Gang Chen; R Loch Macdonald



Acute Subarachnoid Hemorrhage and Cardiac Abnormalities: Takotsubo Cardiomyopathy or Neurogenic Stunned Myocardium? a case report  

Microsoft Academic Search

INTRODUCTION: Cardiac abnormalities can be seen with subarachnoid hemorrhage. To date, there have been isolated case reports of transient left ventricular apical ballooning cardiomyopathy, also known as Takotsubo cardiomyopathy in patients suffering from subarachnoid hemorrhage. CASE PRESENTATION: An adult female was brought to the emergency department with somnolence. A 3 × 3 mm ruptured basilar aneurysm was found and successfully

C Franco; B Khaled; L Afonso; M Raufi



Subarachnoid hemorrhage and cerebral vasospasm - Literature review  

PubMed Central

Subarachnoid hemorrhage represents a serious disease with high mortality and morbidity. Two important areas are becoming the central research interest of subarachnoid hemorrhage: cerebral vasospasm and early brain injury. The authors have reviewed the major contributions in experimental subarachnoid hemorrhage documented in the medical literature in the past 5 years. Treatments interfering with nitric oxide - or endothelin-pathways continue to show antispasmotic effects in experimental models of subarachnoid hemorrhage. Inflammation and oxidative stress play a vital role in the pathophysiology of cerebral vasospasm. Apoptosis, a relevant cause of early brain injury after subarachnoid hemorrhage, also underline the etiology of cerebral vasospasm. Future research studies will continue to elucidate the pathophysiological pathways and treatment modalities targeting cerebral vasospasm and early brain injury, enabling an improvement in outcome for patients with subarachnoid hemorrhage.

Ciurea, AV; Palade, C; Voinescu, D; Nica, DA



Subarachnoid Hemorrhage as a Presentation of Basilar Artery Dissection  

Microsoft Academic Search

Introduction  Subarachnoid hemorrhages caused by intracranial dissections are rare. The management of dissections in these cases not clear.\\u000a \\u000a \\u000a \\u000a Methods  Case report.\\u000a \\u000a \\u000a \\u000a Results  An 82-year-old woman presented with acute drowsiness and vomiting. CT scan demonstrated extensive subarachnoid hemorrhage\\u000a and hydrocephalus that subsequently required placement of ventriculoperitoneal shunt. Angiography revealed extensive basilar\\u000a artery dissection and no aneurysms. The dissection did not produce a critical stenosis

Alexander Y. Zubkov; Amit N. Sanghvi; Harry J. Cloft; Eelco F. M. Wijdicks; Alejandro A. Rabinstein



Aneurysm in the brain  


... part of the face or body Seizures Stroke Subarachnoid hemorrhage ... Heart Association Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special ...


Subarachnoid hemorrhage due to retained lumbar drain.  


Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging. PMID:21905770

Guppy, Kern H; Silverthorn, James W; Akins, Paul T



Influence of Fever and Hospital-Acquired Infection on the Incidence of Delayed Neurological Deficit and Poor Outcome after Aneurysmal Subarachnoid Hemorrhage  

PubMed Central

Although fever and infection have been implicated in the causation of delayed neurological deficits (DND) and poor outcome after aneurysmal subarachnoid hemorrhage (SAH), the relationship between these two often related events has not been extensively studied. We reviewed these events through of our retrospective database of patients with SAH. Multivariate logistic regression was used to determine independent predictors of DND and poor outcome. A total of 186 patients were analyzed. DND was noted in 76 patients (45%). Fever was recorded in 102 patients (55%); infection was noted in 87 patients (47%). A patient with one infection was more likely to experience DND compared to a patient with no infections (adjusted OR 3.73, 95% CI 1.62, 8.59). For those with more than two infections the likelihood of DND was even greater (adjusted OR 4.24, 95% CI 1.55, 11.56). Patients with 1-2 days of fever were less likely to have a favorable outcome when compared to their counterparts with no fever (adjusted OR 0.19, 95% CI 0.06, 0.62). This trend worsened as the number of days febrile increased. These data suggest that the presence of infection is associated with DND, but that fever may have a stronger independent association with overall outcome.

Douds, G. Logan; Tadzong, Bi; Agarwal, Akash D.; Krishnamurthy, Satish; Lehman, Erik B.; Cockroft, Kevin M.



Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm  

Microsoft Academic Search

.   This study was performed to analyze the effect of intraventricular hemorrhage (IVH) on 14-day mortality, outcome at 6 months,\\u000a and the occurrence of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Clinical grade of subarachnoid\\u000a hemorrhage and the distribution of extravasated blood were evaluated in 219 patients with ruptured aneurysms. Computed tomographic\\u000a scans performed within 72 h of hemorrhage were

L. Mayfrank; B. Hütter; Y. Kohorst; I. Kreitschmann-Andermahr; V. Rohde; A. Thron; J. Gilsbach



“Triple-H” therapy for cerebral vasospasm following subarachnoid hemorrhage  

Microsoft Academic Search

The combination of induced hypertension, hypervolemia, and hemodilution (triple-H therapy) is often utilized to prevent and\\u000a treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Although this paradigm has gained widespread acceptance\\u000a over the past 20 years, the efficacy of triple-H therapy and its precise role in the management of the acute phase of SAH\\u000a remains uncertain. In addition, triple-H therapy

Kendall H. Lee; Timothy Lukovits; Jonathan A. Friedman



Acute Focal Neurological Deficits in Aneurysmal Subarachnoid Hemorrhage Relation of Clinical Course, CT Findings, and Metabolite Abnormalities Monitored With Bedside Microdialysis  

Microsoft Academic Search

Background and Purpose—We sought (1) to identify early metabolic markers for the development of (ir)reversible neurological deficits and cerebral infarction in subarachnoid hemorrhage (SAH) patients by using the microdialysis technique and (2) to evaluate the influence of intracerebral hemorrhage (ICH) on microdialysis parameters. Methods—We performed a prospective study of 44 SAH patients with acute focal neurological deficits (AFND) occurring acutely

Asita Sarrafzadeh; Daniel Haux; Oliver Sakowitz; Goetz Benndorf; Harry Herzog; Ingeborg Kuechler; Andreas Unterberg


Aneurysmal Subarachnoid Haemorrhage in Pregnancy: A Case Series  

PubMed Central

Summary Pregnancy is a recognized risk factor for aneurysmal subarachnoid hemorrhage (SAH). Headache is very frequent in normal pregnancy and it is a common sign shared between several intracranial diseases. We present a case series of 10 women in the third trimester of pregnancy admitted to our intensive care unit (ICU) with neurological signs and symptoms. 4 of these patients were diagnosed with SAH. Data in this study suggest that a timely diagnosis and an appropriate treatment is crucial for mother and baby.

Guida, Maurizio; Altieri, Roberto; Palatucci, Valeria; Visconti, Federica; Pascale, Renato; Marra, Marialuisa; Locatelli, Giampiero; Saponiero, Renato; Tufano, Rosalba; Bifulco, Francesca; Piazza, Ornella



Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report  

Microsoft Academic Search

BackgroundVertebral artery dissecting aneurysm is now increasingly recognized as a cause of posterior circulation stroke in young adults. Here, we report a case of bilateral VADA with SAH, treated by bilateral coil occlusion using GDCs.

Akihiro Inoue; Kanehisa Kohno; Akihiko Takechi; Keiji Kohno; Toshinori Matsushige; Tetsuji Takeda



Cerebral Energy Metabolism after Subarachnoid Hemorrhage.  

National Technical Information Service (NTIS)

The purpose of this study was to determine the effects of subarachnoid hemorrhage (SAH) on cerebral blood flow and cerebral oxidative metabolism. Average total hemispheric flow was measured utilizing a polarographic technique and the metabolic consumption...

J. M. Fein



The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed aneurysmal subarachnoid hemorrhage.  


A prospective single center study was performed to determine the minimal preoperative incidence of unrecognized cardiac injury in patients suffering aneurysmal and presumed aneurysmal subarachnoid hemorrhage (SAH). When caring for such patients in the pre- and post operative period clinicians must be aware of the possibility of cardiac injury even when a history of previous cardiac symptomatology is not present. Forty-seven consecutive patients suffering from SAH over a five-month period underwent serum measurements of the cardiac muscle marker troponin I (cTnI) immediately upon admission. Repeat studies, if possible, were done 24 hours later. EKG was performed in all patients and was available for review in 44 of the 47 cases. Echocardiography was performed in four of eight patients with elevated cTnI levels. Signs and symptoms relating to cardiac ischemia were recorded by the patients' physicians and nurses. Eight individuals (17%) had elevations in cardiac troponin I levels. Because surgical treatment is generally carried out as soon as possible following the hemorrhage, many patients with normal troponin I levels within twenty-four hours of their hemorrhage were operated upon before a repeat enzyme could be obtained or possibly before elevations could be recorded. In addition, a number of patients were referred to our center several days post-hemorrhage at a time when marker levels may have normalized. Therefore, the 17% incidence of elevated cTnI may be an underestimate. Only two of the eight patients had clinical abnormalities in cardiac function. Four patients with elevated levels had echocardiograms, three of which were abnormal. One additional patient died of a myocardial infarction before an echocardiogram could be obtained. EKG was abnormal in six of the seven patients with elevated troponin who had tracings available for review. Recordings consistent with recent myocardial ischemia were present in four of these. Of the 39 patients with negative troponin I levels, 37 had EKG available for review. None had recordings clearly consistent with recent myocardial ischemia although 13 were suggestive of ischemic changes. None of these 39 patients had pre- or post-operative clinical changes in cardiac function. Elevations in troponin I appeared to be unrelated to the patient's Hunt and Hess grade or Fisher score although our numbers were too small to draw any meaningful conclusions. PMID:9522914

Horowitz, M B; Willet, D; Keffer, J



Ventricular Arrhythmia Risk After Subarachnoid Hemorrhage  

PubMed Central

Introduction Cardiac morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH) are attributable to myocardial injury, decreased ventricular function, and ventricular arrhythmia (VA). Our objective was to test the relationships between QTc prolongation, VA, and survival after SAH. Methods In 200 subjects with acute aneurysmal SAH, electrocardiograms, echocardiograms, and telemetry were evaluated. Serum electrolytes and troponin were also evaluated. Results Initial QTc (mean 460 ± 45 ms) was prolonged (?470 ms) in 38% of subjects and decreased on follow-up (469 ± 49 initial vs. 435 ± 31 ms follow-up; N = 89; P < 0.0001). VA was present in 14% of subjects, 52% of subjects with VA had QTc ? 470 ms, and initial QTc trended toward longer duration in subjects with VA (474 ± 61 vs. 457 ± 42 ms; P = 0.084). Multivariate analysis demonstrated significant predictors of VA after SAH were increasing age (OR 1.3/5 years; P = 0.025), increasing stroke severity (OR 1.8; P = 0.009), decreasing heart rate (OR 0.5/10 beats/min; P= 0.006), and the absence of angiotensin converting enzyme inhibitor or angiotensin II receptor antagonist use at SAH onset (OR 0.10; P = 0.027). All-cause mortality was 19% (25/135) at 3 months and subjects with VA had significantly higher mortality than those without VA (37% vs. 16%; P = 0.027). Conclusions These data demonstrate that QTc prolongation and arrhythmias are frequently noted after SAH, but arrhythmias are often not associated with QTc prolongation. In addition, the presence of VA identified subjects at greater risk of mortality following their SAH.

Frangiskakis, J. Michael; Hravnak, Marilyn; Crago, Elizabeth A.; Tanabe, Masaki; Kip, Kevin E.; Gorcsan, John; Horowitz, Michael B.; Kassam, Amin B.; London, Barry



Thrombosed vertebral artery aneurysm presenting with hemorrhage and bulbar compression: report of two cases  

Microsoft Academic Search

Bulbar compression by vertebral artery (VA) aneurysm is extremely rare and only reported in a few cases. We report two cases with thrombosed VA aneurysm compressing medulla oblongata; one presented with bulbar apoplexy hemorrhage and the other with subarachnoid hemorrhage (SAH). A 61-year-old male (case 1) presented with consciousness disturbances, left hemiplegia, and subsequent respiratory arrest. He was subjected to

Shin-ichiro Shiraishi; Miki Fujimura; Hiroyuki Kon; Osamu Motohashi; Motonobu Kameyama; Kiyoshi Ishii; Takehide Onuma



[The Factors which Affect the Neurological Condition in Subarachnoid Hemorrhage].  


The factors which were related to the neurological condition were analyzed in 233 cases of subarachnoid hemorrhage. Bivariate analysis and multiple(binomial)logistic regression analysis were performed as for Hunt & Kosnik grade, modified Rankin Scale at discharge and modified Rankin Scale in the out-patient department to detect the factors which were related to the neurological condition. Hematoma-filled intraventricular hemorrhage, intracerebral hemorrhage with midline shift, acute subdural hematoma and aneurysm of the vertebrobasilar system were the representative factors which caused poor neurological condition. Hunt & Kosnik grade was poor when rebleeding occurred or hematoma was formed in the sylvian fissure. Hunt & Kosnik grade and modified Rankin Scale at discharge tended to be poor in the cases with acute hydrocephalus. The elevation of intracranial pressure was the major factor in neurological deterioration. PMID:24091459

Oyama, Hirofumi; Wada, Kentaro; Kito, Akira; Maki, Hideki; Noda, Tomoyuki



Aneurysmal subarachnoid haemorrhage in pregnancy: a case series.  


Pregnancy is a recognized risk factor for aneurysmal subarachnoid hemorrhage (SAH). Headache is very frequent in normal pregnancy and it is a common sign shared between several intracranial diseases. We present a case series of 10 women in the third trimester of pregnancy admitted to our intensive care unit (ICU) with neurological signs and symptoms. 4 of these patients were diagnosed with SAH. Data in this study suggest that a timely diagnosis and an appropriate treatment is crucial for mother and baby. PMID:23905045

Maurizio, Guida; Roberto, Altieri; Valeria, Palatucci; Federica, Visconti; Renato, Pascale; Marialuisa, Marra; Giampiero, Locatelli; Renato, Saponiero; Rosalba, Tufano; Francesca, Bifulco; Piazza, Ornella



[Brain natriuretic peptide in subarachnoid hemorrhage].  


Because of the known correlation between the brain natriuretic peptide (BNP) level and the severity of cardiac failure, cardiac function assessment often involves measuring BNP levels. In addition, BNP is produced in the hypothalamus; high BNP levels are reported in patients with subarachnoid hemorrhage (SAH), although the details of this mechanism remain to be clarified. Furthermore, there are unconfirmed reports of high BNP levels during follow up in cases of post-SAH cerebral vasospasm (CVS). In the present study, we retrospectively investigated the correlation between plasma BNP levels and severity of SAH at onset and the utility of the BNP level as a predictor for CVS. Of 149 SAH cases treated as inpatients at our institution between November 2008 and March 2010, our subjects comprised 28 SAH cases in which the plasma BNP level was measured at the time of hospitalization (?48 hours after SAH onset). There was no significant correlation between BNP levels and SAH severity at the onset, but BNP levels tended to be high in cases accompanied by intracerebral hematoma, particularly in patients with an anterior communicating aneurysm rupture. This is thought to be the result of direct damage to the hypothalamus. The cases with normal BNP levels at the onset of SAH were apt to have favorable outcomes. The incidence of delayed ischemic neurological deficit (DIND) was investigated in 15 cases in which the BNP level was measured multiple times during follow up. The ratio of BNP at SAH onset compared to at days 3 to 7 of the illness was not significant; however, BNP levels tended to be high in cases with DIND complications. BNP levels may constitute a useful early marker for CVS, despite BNP susceptibility to surgical invasion and perioperative management. PMID:23180743

Kawamura, Yoichiro; Inoue, Kohei; Sakai, Hideki; Nakashima, Susumu



Effect of recombinant human erythropoietin on cerebral ischemia following experimental subarachnoid hemorrhage  

Microsoft Academic Search

Erythropoietin exerts a neuroprotective effect during cerebral ischemia. We investigated the effect of systemic administration of recombinant human erythropoietin in a rabbit model of subarachnoid hemorrhage-induced acute cerebral ischemia. The animals were divided into three groups: group 1, subarachnoid hemorrhage; group 2, subarachnoid hemorrhage plus placebo; group 3, subarachnoid hemorrhage plus recombinant human erythropoietin (each group, n=8). Experimental subarachnoid hemorrhage

Concetta Alafaci; Francesco Salpietro; Giovanni Grasso; Alessandra Sfacteria; Marcello Passalacqua; Antonio Morabito; Eliana Tripodo; Gioacchino Calapai; Michele Buemi; Francesco Tomasello



Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey  

Microsoft Academic Search

ABSTRACT: INTRODUCTION: Anemia is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether this association can be modified with more aggressive use of red blood cell (RBC) transfusions. The degree to which restrictive thresholds have been adopted in neurocritical care patients remains unknown. METHODS: We performed a survey of North American academic neurointensivists, vascular

Andreas H Kramer; Michael N Diringer; Jose I Suarez; Andrew M Naidech; Loch R Macdonald; Peter D Le Roux



Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring  

Microsoft Academic Search

The neurologic morbidity of delayed ischemic deficits from vasospasm following aneurysmal subarachnoid hemorrhage (SAH) continues to be the most debilitating complication from this devastating illness. Neurologic critical care is focused on recognition and treatment of these secondary insults but often the treatment is withheld until an irreversible deficit becomes manifest. Continuous EEG (cEEG) monitoring provides a unique potential to recognize

Paul M. Vespa; Marc R. Nuwer; Csaba Juhász; Michael Alexander; Valeriy Nenov; Neil Martin; Donald P. Becker



Effect of Hypervolemic Therapy on Cerebral Blood Flow After Subarachnoid Hemorrhage A Randomized Controlled Trial  

Microsoft Academic Search

Background and Purpose—Cerebral blood flow (CBF) is reduced after subarachnoid hemorrhage (SAH), and symptomatic vasospasm is a major cause of morbidity and mortality. Volume expansion has been reported to increase CBF after SAH, but CBF values in hypervolemic (HV) and normovolemic (NV) subjects have never been directly compared. Methods—On the day after aneurysm clipping, we randomly assigned 82 patients to

Laura Lennihan; Stephan A. Mayer; Matthew E. Fink; Avis Beckford; Myunghee C. Paik; Haiying Zhang; Ya-Chi Wu; Louise M. Klebanoff; Eric C. Raps; Robert A. Solomon


Cerebral Vasospasm with Ischemia following a Spontaneous Spinal Subarachnoid Hemorrhage  

PubMed Central

Cerebral vasospasm is a well-known consequence of aneurysmal subarachnoid hemorrhage (SAH) triggered by blood breakdown products. Here, we present the first case of cerebral vasospasm with ischemia following a spontaneous spinal SAH. A 67-year-old woman, who was on Coumadin for atrial fibrillation, presented with chest pain radiating to the back accompanied by headache and leg paresthesias. The international normalized ratio (INR) was 4.5. Ten hours after presentation, she developed loss of movement in both legs and lack of sensation below the umbilicus. Spine MRI showed intradural hemorrhage. Her coagulopathy was reversed, and she underwent T2 to T12 laminectomies. A large subarachnoid hematoma was evacuated. Given her complaint of headache preoperatively and the intraoperative finding of spinal SAH, a head CT was done postoperatively that displayed SAH in peripheral sulci. On postoperative day 5, she became obtunded. Brain MRI demonstrated focal restricted diffusion in the left frontoparietal area. Formal angiography revealed vasospasm in anterior cerebral arteries bilaterally and right middle cerebral artery. Vasospasm was treated, and she returned to baseline within 48 hours. Spontaneous spinal SAH can result in the same sequelae typically associated with aneurysmal SAH, and the clinician must have a degree of suspicion in such patients. The pathophysiological mechanisms underlying cerebral vasospasm may explain this unique case.

Shakur, Sophia F.; Farhat, Hamad I.



Worst Headache of Life: Evaluation of Nontraumatic Subarachnoid Hemorrhage.  

National Technical Information Service (NTIS)

While the 'worst headache of life' has a differential diagnosis, acute subarachnoid hemorrhage must be the primary diagnostic consideration. Approximately l%-4% of patients presenting to the emergency department with severe headache have subarachnoid hemo...

P. M. Sherman



Cauda equina syndrome resulting from lumbar arachnoiditis after intracranial subarachnoid hemorrhage: a case report.  


Spinal arachnoiditis is a known but very rare late complication of subarachnoid hemorrhage (SAH). Since 1943, 17 cases of spinal arachnoiditis after intracranial hemorrhage have been reported internationally. The vast majority of these cases were related to aneurysmal SAH. All previously published cases have involved spinal arachnoiditis at the cervical and thoracic levels. In this report, we present an adult woman with lumbar spinal arachnoiditis causing cauda equina syndrome as a result of posterior circulation aneurysmal SAH. We believe this is the first reported case of this specific condition causing cauda equina syndrome. PMID:23790823

Whetstone, Kirk E; Crane, Deborah A



Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage  

PubMed Central

Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.

Keyrouz, Salah G; Diringer, Michael N



Pharmacological treatment of delayed cerebral ischemia and vasospasm in subarachnoid hemorrhage  

PubMed Central

Subarachnoid hemorrhage after the rupture of a cerebral aneurysm is the cause of 6% to 8% of all cerebrovascular accidents involving 10 of 100,000 people each year. Despite effective treatment of the aneurysm, delayed cerebral ischemia (DCI) is observed in 30% of patients, with a peak on the tenth day, resulting in significant infirmity and mortality. Cerebral vasospasm occurs in more than half of all patients and is recognized as the main cause of delayed cerebral ischemia after subarachnoid hemorrhage. Its treatment comprises hemodynamic management and endovascular procedures. To date, the only drug shown to be efficacious on both the incidence of vasospasm and poor outcome is nimodipine. Given its modest effects, new pharmacological treatments are being developed to prevent and treat DCI. We review the different drugs currently being tested.



Fatal subarachnoid hemorrhage during sexual anal self-stimulation in a female: a case report.  


Sudden death after sexual activity is a well-known entity, but it is rare in females. Herein we present a case of fatal, massive subarachnoid hemorrhage from a ruptured berry-shaped aneurysm, during sexual anal self-stimulation. A 39-year-old woman was found dead on a couch, with the wooden handle of a spring twirl whisk inserted inside her anus and rectum as a dildo-like object. External examination was unremarkable with no signs of injuries. Intracranial examination showed a massive subarachnoid hemorrhage, up to 6 mm in thickness, especially around the brainstem and the inferior side of the brain. After removing the blood clots, the saccular aneurysm was found at the site of the bifurcation of the left internal carotid. In this case study, we underline the utility of forensic autopsy, as well as death scene investigation, in reconstructing the mechanism of death, as well as the dynamics of the event. PMID:22104332

Nikoli?, Slobodan; Živkovi?, Vladimir



Does 16-detector computed tomography improve detection of non-traumatic subarachnoid hemorrhage in the Emergency Department?  


The diagnosis of subarachnoid hemorrhage remains difficult to establish, yet the sensitivity of increasingly available 16-detector computed tomography (CT) has not been evaluated. The objective of this study was to estimate the sensitivity of 16-detector CT for the diagnosis of non-traumatic subarachnoid hemorrhage in the Emergency Department (ED). A retrospective review was performed in an academic tertiary care hospital. Patients presenting to the ED from September 2003 through December 2004 with symptoms suggestive of subarachnoid hemorrhage and having a final diagnosis of non-traumatic subarachnoid hemorrhage were eligible for study. Diagnosis was established by positive 16-detector CT examination of the brain, or spinal fluid analysis. Patient demographics and results of CT, angiogram, and spinal fluid analysis were reviewed. Sensitivity of 16-detector CT was calculated by comparing CT results and cerebral angiogram results. Refined Wilson Simple Asymptotic 95% confidence intervals were calculated. Sixty-one consecutive patients met the study criteria and had a final diagnosis of non-traumatic subarachnoid hemorrhage. One of these patients did not have subarachnoid hemorrhage identified by 16-detector CT, but had a positive lumbar puncture and an aneurysm confirmed on cerebral angiography. Sensitivity of 16-detector CT for subarachnoid hemorrhage was 97% (95% confidence interval 84-100%). Sixteen-detector CT did not improve detection of non-traumatic subarachnoid hemorrhage when compared with studies using single-detector CT. If there is high clinical suspicion for non-traumatic subarachnoid hemorrhage and non-contrast 16-detector CT scan is negative, further evaluation is suggested. PMID:18572343

Lourenco, Ana P; Mayo-Smith, William W; Tubbs, Robert J; Sidman, Robert



Beneficial effects of systemic administration of recombinant human erythropoietin in rabbits subjected to subarachnoid hemorrhage  

Microsoft Academic Search

Cerebral vasospasm and ischemic damage are important causes of mortality and morbidity in patients affected by aneurysmal subarachnoid hemorrhage (SAH). Recently, i.p. administration of recombinant human erythropoietin (r-Hu-EPO) has been shown to exert a neuroprotective effect during experimental SAH. The present study was conducted to evaluate further the effect of r-Hu-EPO administration after SAH in rabbits on neurological outcome, degree

Giovanni Grasso; Michele Buemi; Concetta Alafaci; Alessandra Sfacteria; Marcello Passalacqua; Alessio Sturiale; Gioacchino Calapai; Gionata de Vico; Giuseppe Piedimonte; Francesco M. Salpietro; Francesco Tomasello



Unfractionated Heparin: Multitargeted Therapy for Delayed Neurological Deficits Induced by Subarachnoid Hemorrhage  

Microsoft Academic Search

Aneurysmal subarachnoid hemorrhage (SAH) is associated with numerous “delayed neurological deficits” (DNDs) that have been\\u000a attributed to multiple pathophysiological mechanisms, including ischemia, microthrombosis, free radical damage, inflammation,\\u000a and vascular remodeling. To date, effective prophylactic therapy for SAH-induced DNDs has been elusive, due perhaps to the\\u000a multiplicity of mechanisms involved that render typical, single-agent therapy seemingly futile. We hypothesized that heparin,

J. Marc SimardDavid Schreibman; David Schreibman; E. Francois Aldrich; Bernadette Stallmeyer; Brian Le; Robert F. James; Narlin Beaty



Severe aortic stenosis and subarachnoid hemorrhage: Anesthetic management of lethal combination  

PubMed Central

Despite advances in various modalities of management, subarachnoid hemorrhage (SAH) continues to be associated with high mortality, which is further increased by associated comorbidities. Aortic stenosis (AS) is one such disease which can further complicate the course of SAH. We recently managed a known patient of severe AS, who presented with aneurysmal SAH. Patient was planned for eurovascular intervention. With proper assessment and planning, patient was managed with favorable outcome despite the restrictions faced in the neurovascular intervention laboratory.

Sharma, Rakesh; Mehta, Yatin; Sapra, Harsh



Metamorphosis of Subarachnoid Hemorrhage Research: from Delayed Vasospasm to Early Brain Injury  

Microsoft Academic Search

Delayed vasospasm that develops 3–7 days after aneurysmal subarachnoid hemorrhage (SAH) has traditionally been considered\\u000a the most important determinant of delayed ischemic injury and poor outcome. Consequently, most therapies against delayed ischemic\\u000a injury are directed towards reducing the incidence of vasospasm. The clinical trials based on this strategy, however, have\\u000a so far claimed limited success; the incidence of vasospasm is reduced

Fatima A. Sehba; Ryszard M. Pluta; John H. Zhang



Extradural vertebral artery dissecting aneurysm causing subarachnoid haemorrhage  

Microsoft Academic Search

The authors report the case of a 37-year-old man who presented with subarachnoid haemorrhage (SAH) after rupture of an extradural vertebral artery dissecting aneurysm. The patient underwent a left lateral suboccipital craniotomy with removal of the medial part of the occipital condyle and the fusiform dilatation was coated. The angiograms 3 months after surgery showed aneurysm resolution and normal vessel

Javier Fandino; Yasuhiro Yonekawa; Werner W Wichmann; Peter Roth



[Two cases of spinal arteriovenous malformation presenting with subarachnoid hemorrhage].  


Two cases of spinal arteriovenous malformation (AVM) with subarachnoid hemorrhage (SAH) are reported. The first case is that of a 14-year-old boy who was transferred to our hospital with a sudden onset of headache. Neurological examination revealed no motosensory deficit, but a brain CT showed a slight diffuse SAH. A left vertebral angiogram demonstrated intramedullary AVM in the cervical region of the spinal cord. This AVM was therefore occluded using a solid embolization material. The patient was then discharged without neurological deficit. The second case is that of a 67-year-old man who visited our hospital with a sudden onset of headache. Neurological examination revealed no motor or sensory deficit, but a brain CT showed SAH, which was dominant in the posterior fossa. Initial cerebral angiography demonstrated no abnormality such as cerebral aneurysm or AVM except for laterality of the C1 radiculo-meningeal artery. A second angiogram on day 11 demonstrated spinal arteriovenous fistula (AVF), which was fed by the left radiculo-meningeal artery and drained to the posterior spinal vein. Embolization for the AVF was performed using liquid material. He was then discharged without neurological deficit. These two cases revealed non-specific SAH symptoms and were indistinguishable from other ruptured aneurysms. Although the brain CT can show a slight SAH or posterior fossa dominant SAH, repeated angiography may be necessary to verify and conclude the diagnosis of spinal AVM. PMID:15352630

Hayashi, Kentaro; Takahata, Hideaki; Nakamura, Minoru



Recent advances in diagnostic approaches for sub-arachnoid hemorrhage  

PubMed Central

Sub-arachnoid hemorrhage (SAH) has been easily one of the most debilitating neurosurgical entities as far as stroke related case mortality and morbidity rates are concerned. To date, it has case fatality rates ranging from 32-67%. Advances in the diagnostic accuracy of the available imaging methods have contributed significantly in reducing morbidity associated with this deadly disease. We currently have computed tomography angiography (CTA), magnetic resonance angiography (MRA) and the digital subtraction angiography (DSA) including three dimensional DSA as the mainstay diagnostic techniques. The non-invasive angiography in the form of CTA and MRA has evolved in the last decade as rapid, easily available, and economical means of diagnosing the cause of SAH. The role of three dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional “gold standard” DSA. The most recent addition has been the introduction of the fourth dimension to the established 3D-CT angiography (4D-CTA). At many centers, DSA is still treated as the first choice of investigation. Although, CT angiography still has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. We study the recent advances in the diagnostic approaches to SAH with special emphasis on 3D-CTA and 4D-CTA as the upcoming technologies.

Kumar, Ashish; Kato, Yoko; Hayakawa, Motoharu; Junpei, ODA; Watabe, Takeya; Imizu, Shuei; Oguri, Daikichi; Hirose, Yuichi



Time-course of cerebral perfusion and tissue oxygenation in the first 6 h after experimental subarachnoid hemorrhage in rats  

Microsoft Academic Search

Present knowledge about hemodynamic and metabolic changes after subarachnoid hemorrhage (SAH) originates from neuromonitoring usually starting with aneurysm surgery and animal studies that have been focusing on the first 1 to 3 h after SAH. Most patients, however, are referred to treatment several hours after the insult. We examined the course of hemodynamic parameters, cerebral blood flow, and tissue oxygenation

Thomas Westermaier; Alina Jauss; Jörg Eriskat; Ekkehard Kunze; Klaus Roosen



Thrombosed vertebral artery aneurysm presenting with hemorrhage and bulbar compression: report of two cases.  


Bulbar compression by vertebral artery (VA) aneurysm is extremely rare and only reported in a few cases. We report two cases with thrombosed VA aneurysm compressing medulla oblongata; one presented with bulbar apoplexy hemorrhage and the other with subarachnoid hemorrhage (SAH). A 61-year-old male (case 1) presented with consciousness disturbances, left hemiplegia, and subsequent respiratory arrest. He was subjected to controlled ventilation, and computed tomography (CT) scan showed bulbar hemorrhage. Magnetic resonance imaging (MRI) and digital subtraction angiogram (DSA) revealed fusiform right VA aneurysm with partial thrombosis and bulbar compression. Intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) relieved his clinical symptom including respiratory disturbance. Three months after the onset, he remained moderately disabled. A 76-year-old male (case 2) presented with severe headache and subsequent respiratory disturbance. CT scan on admission showed subarachnoid hemorrhage with acute hydrocephalus. Ventricular drainage rapidly improved consciousness while respiratory disturbance persisted over several days. MRI and DSA suggested spontaneous thrombosis of the right VA dissection with bulbar compression. He showed gradual recovery of his respiration over a week. After ventriculo-peritoneal shunting, he was transferred with moderate disability. These results suggest that the elimination of the pulsatile effect of VA aneurysm adjacent to medulla oblongata can improve symptoms caused by aneurysm-related compression. Early diagnosis and appropriate treatment such as intra-aneurysmal embolization for ameliorating the blood flow inside the aneurysm can relieve mass effect and clinical symptoms. PMID:15708227

Shiraishi, Shin-ichiro; Fujimura, Miki; Kon, Hiroyuki; Motohashi, Osamu; Kameyama, Motonobu; Ishii, Kiyoshi; Onuma, Takehide



Brainstem control of cerebral blood flow and application to acute vasospasm following experimental subarachnoid hemorrhage  

PubMed Central

Symptomatic ischemia following aneurysmal subarachnoid hemorrhage is common but poorly understood and inadequately treated. Severe constriction of the major arteries at the base of the brain, termed vasospasm, traditionally has been thought to be a proximal event underlying these ischemias, although microvascular changes also have been described. The vast majority of studies aimed at understanding the pathogenesis of ischemic deficits and vasospasm have focused on the interaction of the “spasmogen” of the extravasated blood with the smooth muscle and endothelium of the arteries. This has led to a comparative neglect of the contribution of the central nervous system to the maintenance of cerebral perfusion. In the present study, we focused on the role of the rostral ventromedial medulla (RVM) in modulating cerebral perfusion at rest and following an experimental subarachnoid hemorrhage in the rat. Changes in cerebral blood flow (CBF) were measured using laser-Doppler flowmetry and three-dimensional optical microangiography. Focal application of a GABAA receptor agonist and antagonist were used to respectively inactivate and activate the RVM. We show here that the RVM modulates cerebral blood flow under resting conditions, and further, contributes to restoration of cerebral perfusion following a high-grade subarachnoid hemorrhage. Failure of this brainstem compensatory mechanism could be significant for acute perfusion deficits seen in patients following subarachnoid hemorrhage.

Cetas, Justin S.; Lee, Delaina R.; Alkayed, Nabil J.; Wang, Ruikang; Iliff, Jeffrey J.; Heinricher, Mary M.



Atypical megadolichoectasia manifesting as brain infarction rapidly followed by fatal subarachnoid hemorrhage.  


A 71-year-old female, without medical or family history for cerebrovascular disease, presented with basilar and bilateral carotid dolichoectasia manifesting as dysarthria and hemisensory disturbance, which resolved spontaneously within a day. She suffered brainstem infarction 28 months later, manifesting as drowsiness, dysarthria, and right hemiparesis. Her consciousness level progressively deteriorated to stupor within 4 days. Computed tomography taken on the 5th day confirmed cerebellar infarct in the perfusion area of the superior cerebellar artery but did not show subarachnoid hemorrhage. She died of acute respiratory failure on the 7th day. Autopsy demonstrated a tear in the lateral wall of the broad-based aneurysm on the ectatic basilar artery and diffuse subarachnoid hemorrhage. Vertebrobasilar ectasia is a dynamic vasculopathy that may rapidly progress in the affected basilar artery following an indolent clinical course. The prognosis for patients with vertebrobasilar ectasia may depend mainly on the pathological changes in the basilar artery. PMID:19226335

Tsutsumi, Satoshi; Yasumoto, Yukimasa; Ito, Masanori



[A case of Churg-Strauss syndrome with subarachnoid hemorrhage and left phrenic nerve paralysis].  


A 60-year-old woman was given a diagnosis of Churg-Strauss syndrome (CSS) in 2000 because of peripheral blood eosinophilia, eosinophilic pneumonia, asthma, polyarticular pain, and limb numbness. She was treated with prednisolone (PSL), and the above symptoms improved but then relapsed on tapering of PSL. In September 2009, after 7 days of tapering of PSL to 5mg/day, the patient developed a subarachnoid hemorrhage and was admitted. MRA and cerebral angiography revealed no aneurysm; the source of bleeding could not be determined, but her symptoms indicated a benign course. A chest X-ray 27 days after admission showed left diaphragmatic elevation, and left phrenic nerve paralysis was diagnosed by a phrenic nerve stimulation test. Peripheral blood eosinophilia had progressed gradually during the admission period, and although it is rare for subarachnoid hemorrhage and phrenic nerve paralysis to be associated with CSS, we regarded these as vasculitis symptoms related to CSS. PMID:22073608

Shimizu, Kyoko; Ohoba, Hiromi; Shimada, Hiroyuki; Inoue, Yukihisa; Jinn, Yasuto; Yoshimura, Nobuyuki



Recent advances in diagnostic approaches for sub-arachnoid hemorrhage.  


Sub-arachnoid hemorrhage (SAH) has been easily one of the most debilitating neurosurgical entities as far as stroke related case mortality and morbidity rates are concerned. To date, it has case fatality rates ranging from 32-67%. Advances in the diagnostic accuracy of the available imaging methods have contributed significantly in reducing morbidity associated with this deadly disease. We currently have computed tomography angiography (CTA), magnetic resonance angiography (MRA) and the digital subtraction angiography (DSA) including three dimensional DSA as the mainstay diagnostic techniques. The non-invasive angiography in the form of CTA and MRA has evolved in the last decade as rapid, easily available, and economical means of diagnosing the cause of SAH. The role of three dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional "gold standard" DSA. The most recent addition has been the introduction of the fourth dimension to the established 3D-CT angiography (4D-CTA). At many centers, DSA is still treated as the first choice of investigation. Although, CT angiography still has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. We study the recent advances in the diagnostic approaches to SAH with special emphasis on 3D-CTA and 4D-CTA as the upcoming technologies. PMID:22347331

Kumar, Ashish; Kato, Yoko; Hayakawa, Motoharu; Junpei, Oda; Watabe, Takeya; Imizu, Shuei; Oguri, Daikichi; Hirose, Yuichi



Chronic Hydrocephalus after Experimental Subarachnoid Hemorrhage  

PubMed Central

Chronic communicating hydrocephalus is a significant health problem affecting up to 20% of survivors of spontaneous subarachnoid hemorrhage (SAH). The development of new treatment strategies is hampered by the lack of well characterized disease models. This study investigated the incidence of chronic hydrocephalus by evaluating the temporal profile of intracranial pressure (ICP) elevation after SAH, induced by endovascular perforation in rats. Twenty-five adult male Sprague-Dawley rats (260–320g) were subjected to either endovascular perforation or sham surgery. Five animals died after SAH induction. At 7, 14 and 21 days after surgery ICP was measured by stereotaxic puncture of the cisterna magna in SAH (n=10) and SHAM (n=10) animals. On day 21 T-maze test was performed and the number of alterations and latency to decision was recorded. On day 23, samples were processed for histological analyses. The relative ventricle area was evaluated in coronal Nissl stained sections. On day 7 after surgery all animals showed normal ICP. The absolute ICP values were significantly higher in SAH compared to SHAM animals on day 21 (8.26±4.53 mmHg versus 4.38±0.95 mmHg) but not on day 14. Observing an ICP of 10mmHg as cut-off, 3 animals showed elevated ICP on day 14 and another animal on day 21. The overall incidence of ICP elevation was 40% in SAH animals. On day 21, results of T-maze testing were significantly correlated with ICP values, i.e. animals with elevated ICP showed a lower number of alterations and a delayed decision. Histology yielded a significantly higher (3.59 fold increased) relative ventricle area in SAH animals with ICP elevation compared to SAH animals without ICP elevation. In conclusion, the current study shows that experimental SAH leads to chronic hydrocephalus, which is associated with ICP elevation, behavioral alterations and ventricular dilation in about 40% of SAH animals.

Lackner, Peter; Vahmjanin, Alexander; Hu, Qin; Krafft, Paul R.; Rolland, William; Zhang, John H.



Thrombus formation in a dilated torcula following aneurysmal subarachnoid haemorrhage.  


A case of thrombus formation occurring within a dilation of the dural venous sinuses following aneurysmal sub-arachnoid haemorrhage is presented. Acute neurological deterioration accompanied propagation of the thrombus. The patient was anticoagulated on day 5 post-SAH with no haemorrhagic complications and made a full recovery. The optimum time to commence anticoagulation is not clear and is discussed. PMID:23451941

Haynes, H R; Visca, A; Renowden, S; Malcolm, G



The distribution of intravenous nicardipine in rat brain after subarachnoid hemorrhage  

SciTech Connect

The distribution of intravenously injected nicardipine in rat brain was investigated, as well as the influence of subarachnoid hemorrhage on its distribution. Autoradiographic studies demonstrated the accumulation of {sup 3}H-nicardipine only in the ventricles and subarachnoid spaces around pial vessels in normal brains. Thirty minutes after subarachnoid hemorrhage, the concentration of {sup 3}H-nicardipine was higher in the ventricles and in the subarachnoid space than that found in normal brains. It is concluded that nicardipine penetrates into the subarachnoid spaces and ventricles from pial vessels and/or choroid plexus, and that subarachnoid hemorrhage increases the penetration of nicardipine from vessels into the subarachnoid space.

Tsukahara, T.; Arista, A.; Kassell, N.F. (Univ. of Virginia School of Medicine, Charlottesville (USA))



Subarachnoid Hemorrhage Misdiagnosed as an Acute ST Elevation Myocardial Infarction  

PubMed Central

Without significant coronary artery stenosis, ischemic electrocardiographic change including ST segment elevation, segmental wall motion abnormality and elevated serum cardiac-specific markers (creatine kinase-MB, Troponin-T) may develop after central nervous system injuries such as subarachnoid, intracranial or subdural hemorrhage. Misdiagnosing these patients as acute myocardial infarction may result in catastrophic outcomes. By reporting a case of a 55-year old female with subarachnoid hemorrhage mimicking acute ST elevation myocardial infarction, we hope to underline that careful attention of neurologic abnormality is critical in making better prognosis.

Heo, Woon Je; Jeong, Woo Shin; Jeong, Mi Yeon; Lee, Sang Hyuk; Seo, Jeong Yeun; Jo, Sang Won



Transdermal Nicotine Replacement Therapy in Cigarette Smokers with Acute Subarachnoid Hemorrhage  

Microsoft Academic Search

Background  We evaluated the safety of nicotine replacement therapy (NRT) in active smokers with acute (aneurysmal) subarachnoid hemorrhage\\u000a (SAH).\\u000a \\u000a \\u000a \\u000a \\u000a Methods  A retrospective observational cohort study was conducted in a prospectively collected database including all SAH patients\\u000a admitted to an 18-bed neuro-ICU between January 1, 2001 and October 1, 2007. Univariate and multivariable models were constructed,\\u000a employing stepwise logistic regression. The primary endpoint

David B. SederJ; J. Michael Schmidt; Neeraj Badjatia; Luis Fernandez; Fred Rincon; Jan Claassen; Errol Gordon; Emmanuel Carrera; Pedro Kurtz; Kiwon Lee; E. Sander Connolly; Stephan A. Mayer



Acute Subarachnoid Hemorrhage and Cardiac Abnormalities: Takotsubo Cardiomyopathy or Neurogenic Stunned Myocardium? a case report  

PubMed Central

Introduction Cardiac abnormalities can be seen with subarachnoid hemorrhage. To date, there have been isolated case reports of transient left ventricular apical ballooning cardiomyopathy, also known as Takotsubo cardiomyopathy in patients suffering from subarachnoid hemorrhage. Case presentation An adult female was brought to the emergency department with somnolence. A 3 × 3 mm ruptured basilar aneurysm was found and successfully embolized. Two days after the patient developed acute heart failure. Troponin-I was elevated to 4.2 (normal <0.4). On ECG, new symmetric T wave inversion in V3, V4, V5 with prolonged QT were evident. Transthoracic echocardiogram showed severe systolic dysfunction with an ejection fraction of 20% and akinetic apex along with the distal left ventricular segments, consistent with Takotsubo cardiomyopathy. Myocardial contrast echocardiography showed a decrease in capillary blood flow and volume in the akinetic areas with delayed contrast replenishment, sparing the basal segments. A repeat study 2 weeks later showed near normalization of the perfusion parameters. The patient improved with medical management. A repeat echocardiogram, a month later revealed an ejection fraction of 45% with no identifiable wall motion abnormality. Conclusion Our case, as well as others reported previously, supports the diagnosis of Takotsubo cardiomyopathy in patients with Subarachnoid Hemorrhage who fulfill the clinical and imaging description of this syndrome.



Alpha 1-antitrypsin activity in subarachnoid hemorrhage.  


An altered equilibrium of protease/protease-inhibitor factors may be involved in the pathogenesis of aneurysm rupture: alpha 1-antitrypsin (alpha 1-AT) represents the most relevant inhibitor of elastase, a proteolytic enzyme enhancing catabolic processes of collagen metabolism. In the present study we test the hypothesis whether the activity of alpha 1-AT is altered in SAH patients; 5 cases with unruptured intracranial aneurysm and 27 patients with diagnosis of aneurysm SAH were included in the study. Blood samples were obtained immediately at admission. As control samples we consider the 5 cases of unruptured aneurysm, 15 cases of unruptured aortic aneurysms and 10 patients with non-vascular CNS diseases. Measurement of alpha 1-AT level was determined by immunoturbidimetric method. Serum levels of alpha 1-AT are significantly lower in patients admitted within 72 hours after SAH, if compared to patients admitted in a delayed phase. The linear relationship between alpha 1-AT and collagenase inhibitory percentage capacity (CIC) was shown to be different in the 4 subgroups considered, and so were the mean % CIC values in the between-groups comparison, except for unruptured aneurysm vs controls. The alpha 1-AT CIC in patients with SAH is shown to be the lowest when compared to controls and unruptured aneurysms (p = 0.0001). PMID:8684266

Tartara, F; Gaetani, P; Tancioni, F; Guagliano, A; Klersy, C; Forlino, A; Marzatico, F; Rodriguez y Baena, R



Alpha1-antitrypsin activity in subarachnoid hemorrhage  

Microsoft Academic Search

An altered equilibrium of protease\\/protease-inhibitor factors may be involved in the pathogenesis of aneurysm rupture: ?1-antitrypsin (?1-AT) represents the most relevant inhibitor of elastase, a proteolytic enzyme enhancing catabolic processes of collagen metabolism. In the present study we test the hypothesis whether the activity of ?1-AT is altered in SAH patients; 5 cases with unruptured intracranial aneurysm and 27 patients

Fulvio Tartara; Paolo Gaetani; Flavio Tancioni; Alberto Guagliano; Catherine Klersy; Antonella Forlino; F. Marzatico; Riccardo Rodriguez y Baena



Comparison of Intracerebral Hemorrhage and Subarachnoid Hemorrhage in Patients with Autosomal-Dominant Polycystic Kidney Disease  

Microsoft Academic Search

Background\\/Aims: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are two subtypes of hemorrhagic stroke that may cause severe complications in patients with autosomal-dominant polycystic kidney disease (ADPKD). The differences in clinical features between SAH and ICH associated with ADPKD are not known. Methods: Among 647 ADPKD patients hospitalized between 1997 and 2007 in our hospital, 11 with ICH (1.7%) and

Ming-Yang Chang; Chi-Man Kuok; Yung-Cheng Chen; Shan-Jin Ryu; Ya-Chung Tian; Yah-Huei Wu-Chou; Fang-Ji Tseng; Chih-Wei Yang



Rebleeding and Ischemia after Acute Endovascular Treatment of Ruptured Dissecting Subarachnoid Vertebral Artery Aneurysms  

PubMed Central

Summary Dissection aneurysms of the vertebral artery represent 3.2% of all cerebral aneurysms and 28% of intracranial dissection aneurysms. Dissection of the vertebral artery in its intracranial segment (V4) usually causes a subarachnoid hemorrhage (SAH) from subadventiatial extension of the vessel wall hematoma. Rarely (one case in seven), the symptomatology is characterized by brain stem ischemia from the vertebral artery and/or postero-inferior cerebellar artery occlusive dissection. The high rebleeding (18-33% with a 10+/-5 day interval between the first and the second bleeding) and mortality (>45%) rates 1,13 of this disease prompt emergency treatment usually consisting in endovascular coiling of the dissection aneurysm and/or the dissected segment of the parent vessel. Herein we report our experience in endovascular coiling of acutely ruptured dissecting aneurysms of the vertebral artery dissection in V4 segment. We focus the discussion on the risk of rebleeding and the ischemic complications that my occur after endovascular or surgical treatment

Mangiafico, S.; Padolecchia, R.; Cellerini, M.; Puglioli, M.; Villa, G.; Nistri, M.



[Spinal subarachnoid hemorrhage due to neurinoma of the cauda equina].  


A case of neurinoma of the cauda equina which showed spinal subarachnoid hemorrhage was reported. A 39-year-old man was admitted to our hospital because of left lumboischialgia, on August 7, 1987. Myelography disclosed a round mass at L2, and cerebrospinal fluid was slightly xanthochromic. MRI demonstrated a round isointensity mass by T1 weighted image, and slightly high intensity by T2 weighted image. On August 26, 1987, the patient developed sudden onset of headache, but his headache disappeared under medication. On August 27, 1987, laminectomy L1-3 and total removal of the tumor were carried out. At operation, marked subarachnoid hemorrhage was discovered. He was discharged with slight hypesthesia of the dermatome of left S2. PMID:2674761

Furuno, M; Nishiura, I; Koyama, T



Bevacizumab for glioblastoma multiforme after traumatic subarachnoid hemorrhage.  


We present a patient with a glioblastoma multiforme treated with bevacizumab who suffered a traumatic subarachnoid hemorrhage (SAH). Trascranial doppler revealed no evidence of vasoconstriction, which has been previously described in a bevacizumab-treated patient. Bevacizumab was resumed five weeks after the SAH without recurrence of bleeding or vasoconstriction. To our knowledge this is the first report of resumption of bevacizumab after SAH. PMID:22721885

Lukas, Rimas V; Goldenberg, Fernando; Nicholas, Martin K



Intracranial vertebral artery dissection with subarachnoid hemorrhage following child abuse.  


Child abuse is often suspected based on particular patterns of injury. We report a case of intracranial vertebral artery dissection with subarachnoid hemorrhage (SAH) in a 3-month-old boy following child abuse. The mechanisms of injury and the clinical and imaging findings are discussed. This particular pattern of injury has rarely been reported in association with child abuse. We hope to raise physician awareness of child abuse when faced with these imaging findings. PMID:17453187

Nguyen, Pamela H; Burrowes, Delilah M; Ali, Saad; Bowman, Robin M; Shaibani, Ali



Intracranial vertebral artery dissection with subarachnoid hemorrhage following child abuse  

Microsoft Academic Search

Child abuse is often suspected based on particular patterns of injury. We report a case of intracranial vertebral artery dissection\\u000a with subarachnoid hemorrhage (SAH) in a 3-month-old boy following child abuse. The mechanisms of injury and the clinical and\\u000a imaging findings are discussed. This particular pattern of injury has rarely been reported in association with child abuse.\\u000a We hope to

Pamela H. Nguyen; Delilah M. Burrowes; Saad Ali; Robin M. Bowman; Ali Shaibani



Myocardial Injury and Left Ventricular Performance After Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—Electrocardiographic abnormalities and elevations of the creatine kinase myocardial isoenzyme (CK-MB) occur frequently after subarachnoid hemorrhage. In some patients, a reversible and presumably neurogenic form of left ventricular dysfunction is demonstrated by echocardiography. It is not known whether cardiac injury of this type adversely affects cardiovascular hemodynamic performance. Methods—We retrospectively studied 72 patients admitted to our neuro-ICU for

Stephan A. Mayer; Julie Lin; Shunichi Homma; Robert A. Solomon; Laura Lennihan; David Sherman; Matthew E. Fink; Avis Beckford; Louise M. Klebanoff


[Two cases showing subarachnoid hemorrhage from angioblastic meningioma and vascular hamartoma (author's transl)].  


As a causative factor in spontaneous subarachnoid hemorrhage, vascular anomalies, especially aneurysm or arteriovenous malformation, have been generally recognized. On the other hand, subarachnoid hemorrhage from brain tumor and cryptic vascular malformation are rare. We experienced two cases showing subarachnoid hemorrhage from angioblastic meningioma and vascular hamartoma as an initial symptom. Case 1: A 48-year-old woman, who complained of severe headache and vomiting on Feb. 10th, 1972, gradually became lethargic. Lumbar puncture revealed moderately hemorrhagic C.S.F.. On the fifth day after the onset, she was admitted to our hospital. On admission she showed disorientation and disturbance of resent memory. Aphasia and agnosia were slightly observed. On ophthalmologic examination right homonymous lower quadrant hemianopsia was observed. The carotid angiogram showed slight square shift of the anterior cerebral artery to the right side, elevation of the middle serebral artery and a homogeneous tumor stain in the occipital region in capillary phase. A walnut sized tumor invading the middle portion of the left lateral sinus and showing firm adhesion to the tentrium was found. There was an intracerebral hematoma behined the tumor. The tumor, the tentrium and the lateral sinus were extirpated en bloc and the intracerebral hematoma was aspirated. Histologically, the tumor was angioblastic meningioma. Case 2: A 7-year-old boy, who complained of severe abrupt headache, nuchal pain and vomiting on Sept. 17th, 1972, became gradually lethargic. Lumbar puncture revealed hemorrhagic C.S.F., On the tenth day after the onset, he was admitted to our hospital. He showed confusion and agitation. The carotid angiogram showed an unrolling of the pericallosal artery, but no findings of space taking lesions. An air study indicated a globular filling defect protruding into the anterior horn of the right lateral ventricle. The tumor located in the laterobasal wall of the anterior horn was removed picemiel by transventricular approach. Histologically, the tumor was vascular hamartoma. Furthermore, we discussed various brain tumors showing subarachnoid hemorrhage as an initial symptom, its frequency and bleeding mechanism on the literature. PMID:988494

Shinmura, F; Yamamoto, I; Koba, T; Miwa, T



Roller coaster-associated subarachnoid hemorrhage--report of 2 cases.  


The most common neurological injuries associated with roller coaster rides are subdural hematoma and cervical artery dissection. We report two cases of roller-coaster associated subarachnoid hemorrhage (SAH). A 40-year-old healthy man developed a strong, holocephalic headache during a roller coaster ride. SAH Hunt & Hess grade II and Fisher grade 3 was diagnosed. An underlying aneurysm of the anterior communicating artery was successfully treated with coil embolization. A 41-year-old female (smoker, otherwise healthy) experienced a sudden, strong headache and diplopia during a roller coaster ride. A perimesencephalic SAH (Hunt & Hess grade II, Fisher grade 3) was disclosed by a CT scan. No aneurysm was detected on angiography. Both patients were discharged without neurological disability. In conclusion, SAH is a rare but relevant differential diagnosis in cases of acute headache during roller coaster rides. Both aneurysmal and non-aneurysmal perimesencephalic SAH can occur. A combination of mechanical factors and excessive blood pressure rises in vulnerable persons is discussed. PMID:22177088

Rutsch, Sebastian; Niesen, Wolf-Dirk; Meckel, Stephan; Reinhard, Matthias



Spinal arachnoiditis as a consequence of aneurysm-related subarachnoid haemorrhage.  


Only a few case reports currently exist regarding symptomatic spinal arachnoiditis following aneurysm-related subarachnoid haemorrhage. We present three patients who developed symptomatic spinal arachnoiditis following spontaneous aneurysm rupture. Following initial aneurysm and subarachnoid haemorrhage management (including ventriculo-peritoneal shunt placement), all three patients developed gradually worsening neurological abnormalities, and subsequent imaging demonstrated spinal arachnoiditis. Despite spinal decompression, all three patients experienced progressively worsening neurological decline. PMID:23374556

van Heerden, Jolandi; McAuliffe, William



Pseudo-subarachnoid hemorrhage and death after a bee sting.  


We report a case of a 33-year-old woman who developed severe brain edema and pseudo-subarachnoid hemorrhage (SAH) at 36-hour follow-up after successful cardiopulmonary resuscitation for anaphylactic shock as a result of a bee sting. The patient died on the sixth day of the follow-up due to multiple organ failure and brain herniation. Our case suggests that the SAH-like indings on computed tomography scanning were not a new complication ("real" SAH) arising from the bee sting; rather, it was a pseudo-SAH related to prolonged cardiopulmonary resuscitation). PMID:23348190

Yasar Tekelioglu, Umit; Demirhan, Abdullah; Akkaya, Akcan; Gurel, Kamil; Ocak, Tarik; Duran, Arif; Kocoglu, Hasan



Predictors Analysis of Symptomatic Cerebral Vasospasm After Subarachnoid Hemorrhage  

Microsoft Academic Search

\\u000a \\u000a Purpose: Symptomatic cerebral vasospasm (SCVS) is still lacking in reliable early warning methods and often diagnosed after clinical\\u000a deterioration of neurological function, making prevention and treatment extremely passive. This study investigates the risk\\u000a factors relevant to SCVS after subarachnoid hemorrhage (SAH) in order to provide useful information for clinical work.\\u000a \\u000a \\u000a \\u000a Materials and Methods: Clinical data of 211 patients with SAH

L. Yin; C. Y. Ma; Z. K. Li; D. D. Wang; C. M. Bai


[Ruptured dissecting aneurysm of the vertebral artery concurrent with contralateral intracerebellar hemorrhage].  


A case of a dissecting vertebral aneurysm concurrent with contralateral cerebellar hemorrhage is reported. A 69-year-old man was referred to our hospital for treatment of subarachnoid hemorrhage (SAH). On admission, CT scanning showed SAH and left cerebellar hematoma. Angiography was performed and it revealed a dissecting aneurysm of the right vertebral artery. Proximal clipping of the right vertebral dissecting artery was performed through right suboccipital craniotomy. During the operation, the cerebellar hemisphere gradually became firm, but the operation was finished without any complications. After the operation, the patient's consciousness level decreased from somnolence to semicomatose for a period of 2 hours 30 min. CT scanning showed the left cerebellar hematoma expanding. The cerebellar hematoma was evacuated immediately by midline suboccipital craniectomy, and the patient's consciousness level improved. In such a case, care must be taken to discover the cause of the expansion and to prevent concurrent hematoma during the operation. Through this case, discussion was held concerning the pitfalls of treatment of aneurysmal subarachnoid hemorrhage concurrent with intracerebral hematoma in the remote region. PMID:11260895

Ochiai, H; Yamakawa, Y; Kawasoe, T



Has admission blood pressure any prognostic value in patients with subarachnoid hemorrhage: an emergency department experience.  


Hypertension is a well-known risk factor for the development and rupture of cerebral aneurysms. The authors conducted a study to investigate the prognostic value of admission blood pressure (BP) on prognosis in patients with subarachnoid hemorrhage (SAH). Two hundred patients with SAH were divided into two groups according to Hunt Hess score (good prognosis: 1 to 3, and poor prognosis: 4 and 5) and according to death in hospital (surveyed and died). The prognostic factors of SAH and BP changes according to Hunt Hess scores in the acute stages of the event were evaluated. Admission mean arterial BP values of the patients who died in hospital were significantly lower than in the patients who were surveyed (P=.026). The admission mean arterial BP values were found to be lower in the poor prognostic patients (Hunt Hess score of 4 and 5) (P<.001). Decreased admission BP values were found to be associated with poor prognosis and mortality. PMID:24088282

Duran, Latif; Balci, Kemal; Kati, Celal; Akdemir, H?z?r Ufuk; Kocabicak, Ersoy; Do?ruel, Canan



Subarachnoid hemorrhage and negative angiography: clinical course and long-term follow-up.  


The aim of this study was to investigate the long-term natural history of nontraumatic angiogram-negative subarachnoid hemorrhage with typical pretruncal (P-SAH) and diffuse (D-SAH) pattern of hemorrhage. A retrospective review of 102 patients who experienced angiographically negative SAH at our institution was undertaken (11.6% of 882 spontaneous SAH). Follow-ups were obtained at 7.9 to 16 years. In the D-SAH group, 11 patients (13.9%) out of 79 had an aneurysm, and four (5.1%) had rebleeding episodes. In the P-SAH group, the second angiography was negative in all of the 23 cases, and no rebleeding episodes were recorded. The long-term follow-up confirms that P-SAH is a benign disease. A second angiography could not be necessary. D-SAH is probably due to an aneurysm that thrombose early after the bleeding. At short-term follow-up, the sack could frequently recanalize and rebleed, whereas a late follow-up shows that rebleeding is very rare. PMID:21607573

Fontanella, Marco; Rainero, Innocenzo; Panciani, Pier Paolo; Schatlo, Bawarjan; Benevello, Chiara; Garbossa, Diego; Carlino, Christian; Valfrè, Walter; Griva, Federico; Bradac, Gianni Boris; Ducati, Alessandro



Endovascular Treatment of Unruptured Intracranial Aneurysms  

Microsoft Academic Search

BACKGROUND AND PURPOSE: Intracranial aneurysms are common, with an overall fre- quency ranging from 0.8% to 10%. Because prognosis after subarachnoid hemorrhage is still very poor, treatment of unruptured aneurysms, either neurosurgically or endovascularly, has been advocated. However, risk of rupture and subsequent subarachnoid hemorrhage needs to be con- sidered against the risks of elective treatment. We analyzed the technical

Isabel Wanke; Arnd Doerfler; Uwe Dietrich; Thomas Egelhof; Beate Schoch; Dietmar Stolke; Michael Forsting



Deaths from cerebrovascular diseases correlated to month of birth: elevated risk of death from subarachnoid hemorrhage among summer-born  

NASA Astrophysics Data System (ADS)

It has been suggested that maternal nutrition, and fetal and infant growth have an important effect on the risk of cardiovascular disease in adult life. We investigated the population-based distribution of deaths from cerebrovascular diseases (ICD9 codes 430, 431, or 434) in Japan in 1986-1994 as a function of birth month, by examining death-certificate records. For a total of 853 981 people born in the years 1900-1959, the distribution of the number of deaths according to the month of birth was compared with the distribution expected from the monthly numbers of all births for each sex and for the corresponding birth decade. For those born between 1920 and 1949, there were significant discrepancies between the actual numbers of deaths from subarachnoid hemorrhage (ICD9 430) and the numbers expected, and these differences were related to the month of birth. Those born in summer, June-September, consistently had an elevated risk of death, particularly men, where the excess risk was 8%-23%. This tendency was also observed, less distinctly but significantly, for deaths from intracerebral hemorrhage (ICD9 431), but was not observed for those dying from occlusion of the cerebral arteries (ICD9 434). The observation that the risk of dying from subarachnoid hemorrhage was more than 10% higher among those born in the summer implies that at least one in ten deaths from subarachnoid hemorrhage has its origin at a perinatal stage. Although variations in hypertension in later life, which could possibly be ''programmed'' during the intra-uterine stages, could be an explanation for this observation, the disease-specific nature of the observation suggests the involvement of aneurysm formation, which is a predominant cause of subarachnoid hemorrhage.

Nonaka, K.; Imaizumi, Y.


Disordered cerebro-vascular physiology in aneurysmal subarachnoid haemorrhage.  


The technical problems of surgery for anterior circle aneurysm have in large measure been solved. The problem of reduced perfusion to the brain which characterises the patient with aneurysmal subarachnoid haemorrhage in a poor clinical condition demands more subtle physiological handling. It appears likely that maintenance of an intact cell membrane and blood brain barrier may be aided by the exhibition of pre and post-operative steriods, and that concentration on regional perfusion should be the main aim in post-operative management of such cases. This demands maintenance of adequate blood volume, avoidance of platelet stickiness, and utilisation of the pathological paralysis of autoregulation to improve flow to ischaemic zones by hypertensive agents if necessary. The possibility that early operation with evacuation of blood from the basal cisterns may in the end prevent the vascular damage and disordered vaso-reactivity which encourages the development of transient ischaemic deficits, is a concept which has to be actively pursued. The problem is a continuing one which has bedevilled aneurysm surgery for 25 years, but the omens suggest that a solution is appreciably nearer at hand. PMID:665340

Symon, L



Characteristics of intracranial aneurysms and subarachnoid haemorrhage in patients with polycystic kidney disease  

Microsoft Academic Search

.   Background and Purpose: Subarachnoid haemorrhage is a common cause of death in patients with autosomal dominant polycystic kidney disease (ADPKD),\\u000a but little is known about specific characteristics of subarachnoid haemorrhage and intracranial aneurysms in this group of\\u000a patients. We performed a systematic review on site, size and number of aneurysms, age at time of rupture, gender, and family\\u000a history

Esther W. Gieteling; Gabriel J. E. Rinkel



[Endovascular treatment of vasospasm following subarachnoid aneurysmal haemorrhage].  


An endovascular treatment of vasospasm following a subarachnoid aneurysmal haemorrhage is to be implemented if the patient presents clinical or biological symptoms arguing for brain ischemia in conjunction with increased Doppler velocities despite well controlled systemic haemodynamic. Treatment might be either pharmacological or haemodynamic. Calcium and phosphodiesterase inhibitors can be administered. The former could also provide a neuroprotective effect as compared to the latter. In Europe, nimodipine is widely used whereas nicardipine and verapamil are the major molecules administered in North America where iv nimodipine is not FDA approved. Papaverine is less used nowadays because of its short duration of action and of the risk of aggravation of raised intracranial pressure. Balloon angioplasty has a long lasting effect but can be applied only to proximal spasm. Complications of its use are rare but life threatening. In some cases, both the pharmacological approach and the mechanical approach are used in combination. PMID:17935940

Abdennour, L; Lejean, L; Bonneville, F; Boch, A-L; Puybasset, L



Effect of Prophylactic Transluminal Balloon Angioplasty on Cerebral Vasospasm and Outcome in Patients With Fisher Grade III Subarachnoid Hemorrhage Results of a Phase II Multicenter, Randomized, Clinical Trial  

Microsoft Academic Search

Background and Purpose—Cerebral vasospasm continues to be a major cause of poor outcome in patients with ruptured aneurysms. Prophylactic Transluminal Balloon Angioplasty (pTBA) appeared to prevent delayed ischemic neurological deficit in a pilot study. A phase II multicenter randomized clinical trial was subsequently designed. Methods—One hundred and seventy patients with Fisher Grade III subarachnoid hemorrhage were enrolled in the study.

Marike Zwienenberg-Lee; Jonathan Hartman; Nancy Rudisill; Lori Kennedy Madden; Karen Smith; Joseph Eskridge; David Newell; Bon Verweij; M. Ross Bullock; Andrew Baker; William Coplin; Robert Mericle; Jian Dai; David Rocke; J. Paul Muizelaar



Subarachnoid hemorrhage in a 13-year-old girl.  


At 5:20 pm, a local flight team was activated to respond for an interfacility transfer of a 13-year-old girl with a subarachnoid hemorrhage. In the history obtained, the patient's parents noted that she had not been feeling well for the past several days. She had been complaining of intermittent dizziness and a persistent headache. Until the onset of these prodromal events, she had been active with no medical history. That afternoon, the child was playing with her friends at the school playground. As the group was walking home, they noticed that the patient was not with them. They subsequently returned and found her lying face-down in the bushes, unresponsive, with agonal respirations. PMID:20826349

Tilney, Peter


Subarachnoid Hemorrhage Mimicking Leakage of Contrast Media After Coronary Angiography  

PubMed Central

We report a patient who developed subarachnoid hemorrhage (SAH) just after coronary angiography (CAG) with non-ionic contrast media (CM) and minimal dose of heparin. The 55-year-old man had a history of acute ST elevation myocardial infarction that had been treated with primary percutaneous coronary intervention and was admitted for a follow-up CAG. The CAG was performed by the transradial approach, using 1000 U of unfractionated heparin for the luminal coating and 70 mL of iodixanol. At the end of CAG, he complained of nausea and rapidly became stuporous. Brain CT showed a diffusely increased Hounsfield unit (HU) in the cisternal space, similar to leakage of CM. The maximal HU was 65 in the cisternal space. No vascular malformations were detected on cerebral angiography. The patient partially recovered his mental status and motor weakness after 2 days. Two weeks later, subacute SAH was evident on magnetic resonance imaging. The patient was discharged after 28 days.

Oh, Min Seok; Kwon, Jee Eun; Kim, Kyung Jun; Jo, Joon Hwan; Min, Yun Ju; Byun, Jun Soo; Kim, Kyung Tae; Kim, Sang Wook



Musical murmurs in human cerebral arteries after subarachnoid hemorrhage.  


A transcranial ultrasonic method for the recording of murmurs from cerebral vessels is described. Using the new approach the authors have observed musical murmurs of pure tone quality in 15 patients with increased flow velocities in the cerebral arteries after spontaneous subarachnoid hemorrhage (SAH). The frequency range of the pure tones was from 140 to 820 Hz, corresponding to flow velocities between 73 and 215 cm/sec. The musical murmurs occurred as a transitional state between silent flow and the well known phenomenon of bruit. They were observed between the 4th and the 20th day after SAH. The most likely cause of the musical murmur is a periodic shedding of vortices in the cerebral arteries, commonly referred to as "a von Kármán vortex street." Clinically the presence of musical murmurs indicated that pathologically increased blood velocities were present in the artery under investigation. This probably reflected the degree of spasm. PMID:6689725

Aaslid, R; Nornes, H



Prevention and treatment of medical and neurological complications in patients with aneurysmal subarachnoid haemorrhage  

Microsoft Academic Search

Treatment of patients with aneurysmal subarachnoid haemorrhage not only involves securing the aneurysm by endovascular coiling or surgical clipping but also prevention and treatment of the medical and neurological complications of the bleed. These acutely ill patients should be looked after in specialised centres by a multidisciplinary team that is available 24 h a day, 7 days a week. No

G J E Rinkel; C J M Klijn



[Vertebral artery dissection without subarachnoid hemorrhage studied by serial angiography].  


We presented six cases we have encountered of vertebral artery dissection without subarachnoid hemorrhage followed by serial angiography. All six patients suffered from severe headache and/or nuchal pain at onset. Pain was acute at onset, with severe intensity and sharp quality and was located unilaterally on the dissection side. Only two patients showed neurological deficits. CT scan disclosed no abnormalities in any of the cases and angiography performed at the acute stage showed varied findings. The so-called pearl and string sign, which has been considered the most common finding of this disorder, was observed in only two cases. The definite diagnosis was able to be finally made by serial angiography. During the first few months after onset, dynamic changes of angiographical findings were demonstrated in all cases. During these periods, although transient deterioration of the angiographical findings was shown in four cases, spontaneous healing or improvement was finally recognized in all cases except one which progressed to total occlusion. In contrast to this, in the chronic stage, no changes of angiographical findings occurred in any of the cases. All six patients were treated non-surgically. All showed almost total recovery from symptoms and returned to their previous life styles. There were no cases of recurrent deterioration of symptoms in spite of the changes indicated by the angiographical findings. Our experience with these patients suggests that the actual incidence of vertebral artery dissection without subarachnoid hemorrhage may be much higher than is usually thought, and that the natural course of this disorder seems to be usually favorable. However, longer follow-up study and an analysis of a larger number of cases are required to identify the true incidence and the natural course of this disorder. In addition, we would like to emphasize that accurate diagnosis is most important. If it is clinically suspected, careful investigations including serial angiography should be carried out for the diagnosis of this disorder. PMID:8692370

Akiyama, Y; Itoh, T; Kumai, J; Iwamuro, Y; Miyake, H; Nishikawa, M



Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts?  


A 69-year-old woman presenting with short lasting recent episodes of visual impairment was treated uneventfully with a flow diverter covering the neck of a large paraophthalmic aneurysm. As angiography showed immediate flow reduction we abstained from additional coiling which was initially planned. Eleven days later CT demonstrated nearly complete thrombosis of the aneurysm. Twenty days after treatment the patient suffered a lethal subarachnoid hemorrhage after rupture of the aneurysm. All available data were reviewed and beside hemodynamic factors instability of the intra-aneurysmal thrombus is discussed as a possible cofactor leading to this disastrous event. PMID:20339842

Turowski, Bernd; Macht, Stephan; Kulcsár, Zolt; Hänggi, Daniel; Stummer, Walter



Delayed cerebral ischemia and spreading depolarization in absence of angiographic vasospasm after subarachnoid hemorrhage  

PubMed Central

It has been hypothesized that vasospasm is the prime mechanism of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Recently, it was found that clusters of spreading depolarizations (SDs) are associated with DCI. Surgical placement of nicardipine prolonged-release implants (NPRIs) was shown to strongly attenuate vasospasm. In the present study, we tested whether SDs and DCI are abolished when vasospasm is reduced or abolished by NPRIs. After aneurysm clipping, 10 NPRIs were placed next to the proximal intracranial vessels. The SDs were recorded using a subdural electrode strip. Proximal vasospasm was assessed by digital subtraction angiography (DSA). 534 SDs were recorded in 10 of 13 patients (77%). Digital subtraction angiography revealed no vasospasm in 8 of 13 patients (62%) and only mild or moderate vasospasm in the remaining. Five patients developed DCI associated with clusters of SD despite the absence of angiographic vasospasm in three of those patients. The number of SDs correlated significantly with the development of DCI. This may explain why reduction of angiographic vasospasm alone has not been sufficient to improve outcome in some clinical studies.

Woitzik, Johannes; Dreier, Jens P; Hecht, Nils; Fiss, Ingo; Sandow, Nora; Major, Sebastian; Winkler, Maren; Dahlem, Yuliya A; Manville, Jerome; Diepers, Michael; Muench, Elke; Kasuya, Hidetoshi; Schmiedek, Peter; Vajkoczy, Peter



Partly reversible central auditory dysfunction induced by cerebral vasospasm after subarachnoid hemorrhage.  


The authors describe a rare case of central auditory dysfunction induced by cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). A 55-year-old woman who was admitted after aneurysmal SAH developed cerebral vasospasm on Day 3 affecting mainly the right middle cerebral artery (MCA) and partly the left MCA. The vasospasm became refractory to conventional therapy and was ultimately improved by intraarterial infusion of nimodipine in the right MCA and angioplasty. Severe auditory dysfunction was apparent from Day 10 as the patient was not reactive to speech or environmental sounds. Brain MRI on Day 17 demonstrated infarcted areas mainly in the right hippocampus, medial occipital lobe, and thalamus. The patient underwent further examination using audiometry, speech testing, auditory evoked potentials, functional MRI, and cerebral PET. The initial diagnosis was extended nonverbal agnosia and total pure word deafness. The central auditory dysfunction improved over 6 months, with persisting hyperacusis, tinnitus, and amusia. Central auditory dysfunction is a rare complication after SAH. While cortical deafness may be associated with bilateral lesions of the temporal cortex, partly reversible central auditory dysfunction was observed in this patient after prominently unilateral right temporal lesions. The role of the interthalamic connections can be discussed, as well as the possibility that a less severe vasospasm on the left MCA could have transiently impaired the left thalamocortical auditory pathways. PMID:23971951

Ponzetto, Ester; Vinetti, Marco; Grandin, Cécile; Duprez, Thierry; van Pesch, Vincent; Deggouj, Naïma; Lhommel, Renaud; Hantson, Philippe



Delayed cerebral ischemia and spreading depolarization in absence of angiographic vasospasm after subarachnoid hemorrhage.  


It has been hypothesized that vasospasm is the prime mechanism of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Recently, it was found that clusters of spreading depolarizations (SDs) are associated with DCI. Surgical placement of nicardipine prolonged-release implants (NPRIs) was shown to strongly attenuate vasospasm. In the present study, we tested whether SDs and DCI are abolished when vasospasm is reduced or abolished by NPRIs. After aneurysm clipping, 10 NPRIs were placed next to the proximal intracranial vessels. The SDs were recorded using a subdural electrode strip. Proximal vasospasm was assessed by digital subtraction angiography (DSA). 534 SDs were recorded in 10 of 13 patients (77%). Digital subtraction angiography revealed no vasospasm in 8 of 13 patients (62%) and only mild or moderate vasospasm in the remaining. Five patients developed DCI associated with clusters of SD despite the absence of angiographic vasospasm in three of those patients. The number of SDs correlated significantly with the development of DCI. This may explain why reduction of angiographic vasospasm alone has not been sufficient to improve outcome in some clinical studies. PMID:22146193

Woitzik, Johannes; Dreier, Jens P; Hecht, Nils; Fiss, Ingo; Sandow, Nora; Major, Sebastian; Winkler, Maren; Dahlem, Yuliya A; Manville, Jerome; Diepers, Michael; Muench, Elke; Kasuya, Hidetoshi; Schmiedek, Peter; Vajkoczy, Peter



Orbital apex syndrome due to aspergillosis with subsequent fatal subarachnoid hemorrhage  

PubMed Central

Background: Orbital apex syndrome has been described previously as a syndrome involving damage to the oculomotor nerve (III), trochlear nerve (IV), abducens nerve (VI), and ophthalmic branch of the trigeminal nerve (V1), in association with optic nerve dysfunction. It may be caused by inflammatory, infectious, neoplastic, iatrogenic, or vascular processes. Case Description: A 73-year-old female having hypertension and rheumatoid arthritis stage 4 under long-term corticosteroid therapy presented to us with the right side orbital apex syndrome. Her magnetic resonance imaging (MRI) of orbit showed progression of a lesion at the right orbital apex and adjacent right superior orbital fissure with mild extension to the right posterior ethmoid sinus. She underwent endoscopic endonasal transethmoid approach with the removal of the lesion. The pathology showed a picture of fungal infection and the culture of the specimen proved Aspergillus fumigatus. Her postoperative course was smooth until 5 days after surgery, when she suffered a massive spontaneous subarachnoid hemorrhage resulting from a ruptured aneurysm, which was proven by computed tomography angiography (CTA) of brain. Unfortunately, she expired due to central failure. Conclusion: In cases of immunocompromised patients having orbital apex syndrome, fungal infection should be kept in mind. One of the most lethal but rare sequels of CNS fungal infection is intracranial aneurysms. Early diagnosis and radical resection, combined with antifungal medications is the key to save this particular group of patients.

Yip, Chi-Man; Hsu, Shu-Shong; Liao, Wei-Chuan; Chen, Jun-Yih; Liu, Su-Hao; Chen, Chih-Hao



[New trends in neuromonitoring patients with with aneurysmal subarachnoid haemorrhage].  


Neurointensive care of patients with subarachnoid haemorrhage is based on the theory that clinical outcome is the consequence of the primary haemorrhage and a number of secondary insults in the acute post haemorrhage period. Several neuromonitoring techniques have been introduced or accomplished into clinical practice in the last decade with the purpose of monitoring different but related aspects of brain physiology, such as cerebral blood flow (CBF), pressure within the cranial cavity, metabolism, and oxygenation. The aim of these techniques is to obtain information that can improve knowledge on brain pathophysiology, and especially to detect secondary insults which may cause permanent neurological damage if undetected and untreated in "real time", at the time when they can still be managed. These techniques include intracranial pressure (ICP) measurements, jugular venous oxygen saturation, near-infrared spectroscopy, brain tissue monitoring, and transcranial Doppler. The available devices are limited because they measure a part of complex process indirectly. Expense, technical difficulties, invasiveness, limited spatial or temporal resolution and the lack of sensitivity add to the limitation of any individual monitor. These problems have been partially addressed by the combination of several monitors known as multimodality monitoring. In this review, we describe the most common neuromonitoring methods in patients with subarachnoidal hemorrhage that can assess nervous system function, cerebral haemodynamics and cerebral oxygenation. PMID:18792577

Dostani?, M M; Stosi?, M M; Milakovi?, B D; Baljozovi?, B V; Jovanovi?, I B; Koji?, Z Z; Marinkovi?, D M; Markovi?, D J; Mili?, I S



Acute Microvascular Changes after Subarachnoid Hemorrhage and Transient Global Cerebral Ischemia  

PubMed Central

Subarachnoid hemorrhage and transient global cerebral ischemia result in similar pathophysiological changes in the cerebral microcirculation. These changes include microvascular constriction, increased leukocyte-endothelial interactions, blood brain barrier disruption, and microthrombus formation. This paper will look at various animal and preclinical studies that investigate these various microvascular changes, perhaps providing insight in how these microvessels can be a therapeutic target in both subarachnoid hemorrhage and transient global cerebral ischemia.

Tso, Michael K.; Macdonald, R. Loch



Traumatic subarachnoid hemorrhage and the COL3A1 gene: emergence of a potential causal link  

Microsoft Academic Search

We describe two previously unreported associations in four cases. The first two cases demonstrate an association between segmental\\u000a mediolytic arteriopathy and vascular Ehlers-Danlos syndrome. The second two cases illustrate an association between vascular\\u000a Ehlers-Danlos syndrome and traumatic subarachnoid hemorrhage. In case 1, there was acute subarachnoid hemorrhage and mesenteric\\u000a artery dissection. In case 2, there was an acute mesenteric artery

Michael J. Pickup; Michael S. Pollanen



Fatal subarachnoid hemorrhage following traumatic rupture of the internal carotid artery.  


Traumatic subarachnoid hemorrhage (TSAH) is a life-threatening intracranial bleed often associated with violent assault or motor vehicle accidents. The vast majority of TSAH is associated with rupture of the vertebral artery, although rare cases of traumatic aneurysm of the internal carotid artery (ICA) have been reported. A 27-year-old man was found bleeding and unresponsive following a violent altercation in which he received repeated blows to the head and neck. CT scan showed acute SAH, and death ensued within 24 h. Autopsy revealed generalized bruising of the face, a complete midline mandibular fracture, and massive basal SAH resulting from traumatic rupture of the right terminal internal carotid artery at the origin of the middle cerebral artery. Anterior and posterior neck dissection revealed focal hemorrhage associated with the right neural arch of the first cervical vertebra (C1). Autopsy findings were consistent with TSAH resulting from rupture of the ICA following blunt force trauma to the head. The rupture site in TSAH can be difficult to locate, and injury to the ICA may be overlooked if not routinely examined. Dissection of the neck and skull base is required to ensure accurate identification of the site of vascular injury. PMID:22824587

Salvatori, Marcus; Kodikara, Sarathchandra; Pollanen, Michael



New decision analytical models for management of intracranial aneurysms  

Microsoft Academic Search

This thesis addresses decision analysis, cost-effectiveness models and the analysis of heterogeneity, applied to intracranial aneurysms and subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a subset of stroke that usually occurs at relatively young age and has poor prognosis. Although, the risk of SAH can be reduced by screening for and preventive treatment of unruptured aneurysms, these strategies are not without

H. Koffijberg



Safety and pharmacokinetics of sodium nitrite in patients with subarachnoid hemorrhage: a Phase IIA study.  


Object Intravenous sodium nitrite has been shown to prevent and reverse cerebral vasospasm in a primate model of subarachnoid hemorrhage (SAH). The present Phase IIA dose-escalation study of sodium nitrite was conducted to determine the compound's safety in humans with aneurysmal SAH and to establish its pharmacokinetics during a 14-day infusion. Methods In 18 patients (3 cohorts of 6 patients each) with SAH from a ruptured cerebral aneurysm, nitrite (3 patients) or saline (3 patients) was infused. Sodium nitrite and saline were delivered intravenously for 14 days, and a dose-escalation scheme was used for the nitrite, with a maximum dose of 64 nmol/kg/min. Sodium nitrite blood levels were frequently sampled and measured using mass spectroscopy, and blood methemoglobin levels were continuously monitored using a pulse oximeter. Results In the 14-day infusions in critically ill patients with SAH, there was no toxicity or systemic hypotension, and blood methemoglobin levels remained at 3.3% or less in all patients. Nitrite levels increased rapidly during intravenous infusion and reached steady-state levels by 12 hours after the start of infusion on Day 1. The nitrite plasma half-life was less than 1 hour across all dose levels evaluated after stopping nitrite infusions on Day 14. Conclusions Previous preclinical investigations of sodium nitrite for the prevention and reversal of vasospasm in a primate model of SAH were effective using doses similar to the highest dose examined in the current study (64 nmol/kg/min). Results of the current study suggest that safe and potentially therapeutic levels of nitrite can be achieved and sustained in critically ill patients after SAH from a ruptured cerebral aneurysm. Clinical trial registration no.: NCT00873015 ( ). PMID:23706046

Oldfield, Edward H; Loomba, Johanna J; Monteith, Stephen J; Crowley, R Webster; Medel, Ricky; Gress, Daryl R; Kassell, Neal F; Dumont, Aaron S; Sherman, Craig



[Forensic medical assessment of the role of the injury and pathology in the development of basal subarachnoidal hemorrhage].  


The comparative analysis of clinical and pathomorphological forensic medical literature and the original investigations of basal subarachnoidal hemorrhage carried out by the author during 25 years provided a basis for morphological diagnostics of traumatic and non-traumatic subarachnoidal hemorrhage with special reference to variants of forensic medical assessment of the role of injuries and pathologies in the development of basal subarachnoidal hemorrhage. PMID:23888498

Popov, V L


Detection of CT occult aneurismal subarachnoid hemorrhage using a novel spectrophotometric analysis of cerebral spinal fluid  

NASA Astrophysics Data System (ADS)

In North America, approximately 30,000 people annually suffer an aneurismal subarachnoid hemorrhage (SAH). Using computerized tomography (CT), the blood is generally not visible after 12 hours. Currently lumbar puncture (LP) results are equivocal for diagnosing SAH largely because of technical limitations in performing a quick and objective evaluation. Having ruptured once, an aneurysm is statistically more likely to rupture again. Therefore, for those individuals with a sentinel (or warning) hemorrhage, detection within the first 12 hours is paramount. We present a diagnostic technology based on visible spectroscopy to quickly and objectively assess low-blood volume SAH from a diagnostic spinal tap. This technology provides clinicians, with the resources necessary for assessing patients with suspected aneurismal SAH beyond the current 12-hour limitation imposed by CT scans. This aids in the improvement of patient care and results in rapid and appropriate treatment of the patient. To perform this diagnosis, we quantify bilirubin and hemoglobin in human CSF over a range of concentrations. Because the bilirubin and hemoglobin spectra overlap quantification is problematic. To solve this problem, two algorithmic approaches are presented: a statistical or a random stochastic component known as Partial Least Square (PLS) and a control theory based mathematical model. These algorithms account for the noise and distortion from blood in CSF leading to the quantification of bilirubin and methemoglobin spectroscopically. The configurations for a hardware platform is introduced, that is portable and user-friendly composed of specific components designed to have the sensitivity and specificity required. This aids in measuring bilirubin in CSF, hemorrhagic-CSF and CSF-like solutions. The prototype uses purpose built algorithms contained within the platform, such that physicians can use it in the hospital and lab as a point of care diagnostic test.

Salgaonkar, Vasant A.; Bhadri, Prashant R.; Huang, Jian; Kumar, Alla S.; Pyne, Gail J.; Caffery, James, Jr.; Clark, Joseph F.; Shukla, Rakesh; Beyette, Fred R., Jr.



Subarachnoid and Intracerebral Hemorrhage in Patients with Churg-Strauss Syndrome: Two Case Reports  

PubMed Central

Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis of the small and medium vessels, associated with extravascular eosinophilic granulomas, peripheral eosinophilia, and asthma. The exact etiology of CSS is unknown. This syndrome commonly affects the lungs, peripheral nerves, skin, heart, and gastrointestinal tract, but rarely the central nervous system. Subarachnoid and intracerebral hemorrhage in CSS patients is extremely rare; however, clinicians should consider that CSS may be a cause of intracranial hemorrhage and its high rate of mortality and morbidity. The authors report on two cases of subarachnoid and intracerebral hemorrhage with CSS and discuss a brief review of CSS.

Go, Myeong Hoon; Park, Jeong Un; Kang, Jae Gyu



Dynamic alterations of cerebral pial microcirculation during experimental subarachnoid hemorrhage.  


The study aimed to investigate the involvement of cerebral microcirculation turbulence after subarachnoid hemorrhage (SAH). Wistar rats were divided into non-SAH and SAH groups. Autologous arterial hemolysate was injected into rat's cisterna magna to induce SAH. Changes of pial microcirculation within 2 h were observed. It was found that there were no obvious changes of the diameters, flow velocity, and fluid state of microvessels in non-SAH group. With the exception of rare linear-granular flow in A4 arteriole, linear flow was observed in most of the arterioles. There was no blood agglutination in any of the arterioles. After SAH, abnormal cerebral pial microcirculation was found. Spasm of microvessels, decreased blood flow, and agglutination of red blood cells occurred. Five minutes following the induction of SAH, the diameters of the arterioles and venules significantly decreased. The decreased diameters persisted for 2 h after cisternal injection. Decreased flow velocity of venules was found from 5 to 90 min after induction of SAH. Spasm of the basilar artery and increased brain malondialdehyde were also found after SAH. We concluded that cerebral microcirculation turbulence plays an important role in the development of secondary cerebral ischemia following SAH. PMID:18821009

Sun, Bao-Liang; Zheng, Cheng-Bi; Yang, Ming-Feng; Yuan, Hui; Zhang, Su-Ming; Wang, Le-Xin



Zinc protoporphyrin aggravates cerebral ischemic injury following experimental subarachnoid hemorrhage.  


This study was aimed to evaluate the influence of an antagonist of heme oxygenase, zinc protoporphyrin IX (ZnPPIX), on the production of endogenous carbon monoxide (CO) and the secondary cerebral injury after subarachnoid hemorrhage (SAH). Wistar rats were divided into non-SAH, SAH, and ZnPPIX groups. Autologus arterial hemolysate was injected into rat cisterna magna to induce SAH. CO and cyclic guanosine monophosphate (cGMP) levels in the brain, and lactate dehydrogenase (LDH) activity in serum were determined 24 hours and 72 hours after cisternal injection. It was found that 24 hours and 72 hours after SAH, the CO contents in SAH group were increased by 20.76% and 37.36%, respectively. CO content in ZnPPIX group was statistically lower than that in SAH group. No obvious change of cGMP content in SAH group was found. However, cGMP content in ZnPPIX group was lower than that in SAH group. Serum LDH activity increased significantly after induction of SAH. LDH activity in ZnPPIX group increased to a greater extent. It was concluded that ZnPPIX aggravates the cerebral injury secondary to experimental SAH by inhibiting the production of endogenous CO. The activation of HO/CO pathway is an intrinsic protective mechanism against cerebral ischemic injury after SAH. PMID:16543643

Sun, Bao-Liang; An, Wei; Xia, Zuo-Li; Zheng, Cheng-Bi; Li, Wen-Xia; Yang, Ming-Feng; Zhao, Tong; Ye, Wen-Jing



Shunt-dependent hydrocephalus following subarachnoid hemorrhage correlates with increased S100B levels in cerebrospinal fluid and serum.  


Posthemorrhagic hydrocephalus requiring permanent ventriculoperitoneal shunt placement is a major complication of aneurysmal subarachnoid hemorrhage (SAH). High S100B serum and cerebrospinal fluid (CSF) levels are considered to reflect the severity of brain injury. We prospectively assessed whether S100B levels in serum and CSF were predictive parameters for permanent shunt requirement following aneurysmal SAH. In patients suffering from aneurysmal SAH and treated with an external ventricular drain (EVD), S100B levels in serum and CSF were measured daily as long as the EVD was in place. S100B levels of patients who passed their EVD challenge were compared with those patients who required a permanent ventriculoperitoneal shunt placement. Out of 68 patients included in the study, 43 patients (63.2%) passed the EVD challenge and in 25 patients (36.8%) permanent ventriculoperitoneal shunting was performed. Group comparison revealed that in patients who required shunt placement, S100B was significantly higher in CSF (p < 0.05 at days 2, 4, 6, 10; p < 0.005 at days 1, 3, 5, 7, 8, 9) and serum (p < 0.05 at days 4-7) compared with patients who could be weaned from the EVD. Assessment of S100B levels in CSF and serum may be useful as a predictive parameter for shunt dependency in patients with posthemorrhagic hydrocephalus following aneurysmal SAH. PMID:22327696

Brandner, S; Xu, Y; Schmidt, C; Emtmann, Irene; Buchfelder, Michael; Kleindienst, Andrea



Reduced Ca2+ spark activity after subarachnoid hemorrhage disables BK channel control of cerebral artery tone.  


Intracellular Ca(2+) release events ('Ca(2+) sparks') and transient activation of large-conductance Ca(2+)-activated potassium (BK) channels represent an important vasodilator pathway in the cerebral vasculature. Considering the frequent occurrence of cerebral artery constriction after subarachnoid hemorrhage (SAH), our objective was to determine whether Ca(2+) spark and BK channel activity were reduced in cerebral artery myocytes from SAH model rabbits. Using laser scanning confocal microscopy, we observed ?50% reduction in Ca(2+) spark activity, reflecting a decrease in the number of functional Ca(2+) spark discharge sites. Patch-clamp electrophysiology showed a similar reduction in Ca(2+) spark-induced transient BK currents, without change in BK channel density or single-channel properties. Consistent with a reduction in active Ca(2+) spark sites, quantitative real-time PCR and western blotting revealed decreased expression of ryanodine receptor type 2 (RyR-2) and increased expression of the RyR-2-stabilizing protein, FKBP12.6, in the cerebral arteries from SAH animals. Furthermore, inhibitors of Ca(2+) sparks (ryanodine) or BK channels (paxilline) constricted arteries from control, but not from SAH animals. This study shows that SAH-induced decreased subcellular Ca(2+) signaling events disable BK channel activity, leading to cerebral artery constriction. This phenomenon may contribute to decreased cerebral blood flow and poor outcome after aneurysmal SAH. PMID:20736958

Koide, Masayo; Nystoriak, Matthew A; Krishnamoorthy, Gayathri; O'Connor, Kevin P; Bonev, Adrian D; Nelson, Mark T; Wellman, George C



Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients.  


We have reviewed initial diagnostic features, treatment, and outcome in 29 patients with acute subarachnoid hemorrhage due to non-traumatic vertebrobasilar artery dissection diagnosed in our hospital between 1993 and 2003. The dissections occurred in the vertebral artery in 19 patients, the posterior inferior cerebellar artery (PICA) in two patients, the basilar artery in four patients, and in the vertebral artery extending into the PICA in four patients. A pseudoaneurysm was found in 20 patients. Clinical manifestations typically included sudden onset of moderate to severe headache, nuchal rigidity, and drowsiness. Fourteen patients were treated conservatively. Fifteen patients underwent endovascular treatment with either parent artery occlusion (13 patients) or aneurysmal coil occlusion with preservation of the parent artery (2 patients). Re-bleeding occurred within 12 days and before treatment in nine patients. Eight of these had a pseudoaneurysm. No patient bled after endovascular treatment. Poor grade and early re-bleeding were associated with less favorable outcome. Outcome at 6 months did not differ significantly between endovascular and conservative treatment. Altogether, good recovery was achieved for 16 patients, moderate disability was seen in one, severe disability in four, and eight patients (27%) died. The absence of bleeding subsequent to endovascular treatment in this study suggests that endovascular treatment may be a rational approach in these patients at high risk of re-bleeding, especially those with a pseudoaneurysm. PMID:15711986

Ramgren, B; Cronqvist, M; Romner, B; Brandt, L; Holtås, S; Larsson, E-M



Unfractionated Heparin: Multitargeted Therapy for Delayed Neurological Deficits Induced by Subarachnoid Hemorrhage  

PubMed Central

Aneurysmal subarachnoid hemorrhage (SAH) is associated with numerous “delayed neurological deficits” (DNDs) that have been attributed to multiple pathophysiological mechanisms, including ischemia, microthrombosis, free radical damage, inflammation, and vascular remodeling. To date, effective prophylactic therapy for SAH-induced DNDs has been elusive, due perhaps to the multiplicity of mechanisms involved that render typical, single-agent therapy seemingly futile. We hypothesized that heparin, which has multiple underappreciated salutary effects, might be useful as a multitargeted prophylactic agent against SAH-induced DNDs. We performed a comprehensive review of the literature to evaluate the potential utility of heparin in targeting the multiple pathophysiological mechanisms that have been identified as contributing to SAH-induced DNDs. Our literature review revealed that unfractionated heparin can potentially antagonize essentially all of the pathophysiological mechanisms known to be activated following SAH. Heparin binds >100 proteins, including plasma proteins, proteins released from platelets, cytokines, and chemokines. Also, heparin complexes with oxyhemoglobin, blocks the activity of free radicals including reactive oxygen species, antagonizes endothelin-mediated vasoconstriction, smooth muscle depolarization, and inflammatory, growth and fibrogenic responses. Our review suggests that the use of prophylactic heparin following SAH may warrant formal study.

Schreibman, David; Aldrich, E. Francois; Stallmeyer, Bernadette; Le, Brian; James, Robert F.; Beaty, Narlin



Subarachnoid hemorrhage model in the rat: modification of the endovascular filament model.  


The present study describes modifications to the endovascular filament model of subarachnoid hemorrhage (SAH) in rats. Specifically, we sought to improve the percentage yield of SAH, reduce mortality rates and better simulate human cerebral aneurysmal rupture. Instead of using a 4-0 prolene suture to induce SAH in the existing endovascular filament model, a hollow and flexible polyetrafluoroethylene (PTFE) tube was maneuvered into the proximal anterior cerebral artery (ACA) to ensure that advancement occurred without producing trauma to the vessels. SAH was induced by advancing a tungsten wire through this tube, perforating the ACA at the desired location. These modifications produced significant improvements over the endovascular filament model. Mortality rate declined from 46 to 19%, and SAH was produced more frequently. With the prolene suture, only 48% of our attempts produced a SAH, and unsuccessful attempts typically resulted in an acute subdural hematoma (ASDH). In contrast, the wire/tubing technique was 90% successful at inducing SAH, and led to a significant reduction of ASDH incidence from 44 to 6%. Additionally, the modified technique produced vasospasm in basilar and middle cerebral arteries post-SAH as well as pseudoaneurysms in the proximal ACA which indicated the location of vessel perforation. PMID:18562012

Park, Ik-Seong; Meno, Joseph R; Witt, Cordelie E; Suttle, Timothy K; Chowdhary, Abhineet; Nguyen, Thien-Son; Ngai, Al C; Britz, Gavin W



Syringomyelia and arachnoid cysts associated with spinal arachnoiditis following subarachnoid hemorrhage.  


A 66-year-old woman with primary Sjogren syndrome developed syringomyelia following two episodes of subarachnoid hemorrhage (SAH) due to the rupture of basilar artery aneurysms. Gait disturbance and abnormal sensation with pain over the foot and abdomen appeared 3 years after the last SAH. Magnetic resonance (MR) imaging revealed a syringomyelia throughout the thoracic cord, from the T2 to T11 levels. In addition, the thoracic cord was compressed by multiple arachnoid cysts in the ventral side of spinal cord. Computed tomography myelography revealed complete block of cerebrospinal fluid (CSF) flow at the T7 level. Surgery for microlysis of the adhesions and restoration of the CSF flow pathway was performed. Postoperatively, leg motor function slowly improved and she could walk unaided. However, abdominal paresthesia was persisted. Postoperative MR imaging revealed diminished size of the syrinxes. We should recognize syringomyelia and arachnoid cysts due to adhesive arachnoiditis as a late complication of SAH. Microlysis of the adhesions focusing on the lesion thought to be the cause of the symptoms is one of the choices to treat massive syringomyelia and arachnoid cysts associated with arachnoiditis following SAH. PMID:23006888

Ishizaka, Shunsuke; Hayashi, Kentaro; Otsuka, Munehiro; Fukuda, Shuji; Tsunoda, Keishi; Ushijima, Ryujiro; Kitagawa, Naoki; Suyama, Kazuhiko; Nagata, Izumi



Cerebrospinal fluid ferritin level, a sensitive diagnostic test in late-presenting subarachnoid hemorrhage.  


The workup of patients with suspected subarachnoid hemorrhage (SAH) presenting late is complicated by a loss of diagnostic sensitivity of computed tomography (CT) brain imaging and cerebrospinal fluid (CSF) bilirubin levels. In this prospective longitudinal study of CSF ferritin levels in SAH, serial CSF samples from 14 patients with aneurysmal SAH requiring extraventricular drainage (EVD) were collected. The control group comprised 44 patients presenting with headache suspicious of SAH. Nine patients underwent a traumatic spinal tap. CSF ferritin levels were significantly higher in the patients with SAH compared with controls (P < .0001). The upper reference range of CSF ferritin is 12 ng/mL, and there was no significant difference between the traumatic and normal spinal taps (mean, 9.0 ng/mL vs 3.9 ng/mL; P = .59). CSF ferritin levels increased after SAH, from an average of 65 ng/mL on day 1 to 1750 ng/mL on day 11 (P < .01). Both the Fisher and Columbia CT scores were significantly correlated with CSF ferritin level. The increase in CSF ferritin level after SAH and possibly may provide additional diagnostic information in patients with suspected SAH who present late to the clinic. PMID:20719531

Petzold, Axel; Worthington, Viki; Appleby, Ian; Kerr, Mary E; Kitchen, Neil; Smith, Martin



Diagnostic value of a ghrelin test for the diagnosis of GH deficiency after subarachnoid hemorrhage  

PubMed Central

Objective To determine the diagnostic value of a ghrelin test in the diagnosis of GH deficiency (GHD) shortly after aneurysmal subarachnoid hemorrhage (SAH). Design Prospective single-center observational cohort study. Methods A ghrelin test was assessed after the acute phase of SAH and a GH-releasing hormone (GHRH)–arginine test 6 months post SAH. Primary outcome was the diagnostic value of a ghrelin test compared with the GHRH–arginine test in the diagnosis of GHD. The secondary outcome was to assess the safety of the ghrelin test, including patients' comfort, adverse events, and idiosyncratic reactions. Results Forty-three survivors of SAH were included (15 males, 35%, mean age 56.6±11.7). Six out of 43 (14%) SAH survivors were diagnosed with GHD by GHRH–arginine test. In GHD subjects, median GH peak during ghrelin test was significantly lower than that of non-GHD subjects (5.4 vs 16.6, P=0.002). Receiver operating characteristics analysis showed an area under the curve of 0.869. A cutoff limit of a GH peak of 15??g/l corresponded with a sensitivity of 100% and a false-positive rate of 40%. No adverse events or idiosyncratic reactions were observed in subjects undergoing a ghrelin test, except for one subject who reported flushing shortly after ghrelin infusion. Conclusion Owing to its convenience, validity, and safety, the ghrelin test might be a valuable GH provocative test, especially in the early phase of SAH.

Blijdorp, K; Khajeh, L; Ribbers, G M; Sneekes, E M; Heijenbrok-Kal, M H; van den Berg-Emons, H J G; van der Lely, A J; van Kooten, F; Neggers, S J C M M



MR angiography in patients with subarachnoid hemorrhage: adequate to evaluate vasospasm-induced vascular narrowing?  


The diagnosis of cerebral vasospasm (CVS) following subarachnoid hemorrhage (SAH) is still challenging. We evaluate the accuracy of time of flight MR angiography (TOF-MRA) to assess the arterial diameters of the circle of Willis in SAH patients with suspected CVS. MR examinations (1.5 Tesla) including 3D TOF-MRA with maximum intensity projections (MIP) and digital subtraction angiography (DSA) were performed within 24 h in 21 patients with acute aneurysmal SAH and suspicion of CVS. Arterial diameters of the circle of Willis including the distal internal carotid artery (ICA) were measured as ratios to the extradural ICA in standard projections. The diagnosis of CVS was established by comparing the luminal size of baseline and follow-up DSA. The correlation between the arterial ratios measured on MIP angiograms and on follow-up DSA was assessed with Pearson's linear regression analysis. Arterial ratios on MIP angiograms were categorized as correct, overestimated, and underestimated compared to the ratios on follow-up DSA. Pearson's correlation coefficient between the ratios of MIP angiograms and DSA was r?=?0.5799 and the regression coefficient was b?=?0.4775. Highest correlation was found for the category of severe CVS (r?=?0.8201). Of all MIP angiograms, 34.9% showed consistent results compared to the DSA, while 44.2% of MIP images overestimated the vascular narrowing. Standard MIP angiograms from TOF-MRA are not accurate to assess vascular narrowing in patients with suspected CVS after aneurysmal SAH. The multifocal arterial stenoses in CVS may induce severe changes in blood flow dynamics, which compromise the diagnostic accuracy of the TOF-MRA. PMID:20532584

Hattingen, Elke; Blasel, Stella; Dumesnil, Richard; Vatter, Hartmut; Zanella, Friedhelm E; Weidauer, Stefan



Permanent cerebrospinal fluid diversion in subarachnoid hemorrhage: Influence of physician practice style  

PubMed Central

Background: Acute hydrocephalus (HCP) after aneurysmal subarachnoid hemorrhage (SAH) often persists. Our previous study described factors that singly and combined in a formula correlate with permanent CSF diversion. We now aimed to determine whether the same parameters are applicable at an institution with different HCP management practice. Methods: We reviewed records of 181 consecutive patients who presented with SAH and received an external ventricular drain (EVD) for acute HCP. After exclusion and inclusion criteria were met, 71 patients were analyzed. Data included admission Fisher and Hunt and Hess grades, aneurysm location, treatment modality, ventricle size, CSF cell counts and protein levels, length of stay (LOS) in the hospital, and the presence of craniectomy. Outcome measures were: (1) initial EVD challenge outcome; (2) shunting within 3 months; and (3) LOS. Results: Shunting correlated with Hunt and Hess grade, CSF protein, and the presence of craniectomy. The formula derived in our previous study demonstrated a weaker correlation with initial EVD challenge failure. Several parameters that correlated with shunting in the previous study were instead associated with LOS in this study. Conclusions: The decision to shunt depends on management choices in the context of a disease process that may improve over time. Based on the treatment strategy, the shunting rate may be lowered but LOS increased. Markers of disease severity in patients with HCP after SAH correlate with both shunt placement and LOS. This is the first study to directly evaluate the effect of different practice styles on the shunting rate. Differences in HCP management practices should inform the design of prospective studies.

Esposito, Domenic P.; Goldenberg, Fernando D.; Frank, Jeffrey I.; Ardelt, Agnieszka A.; Roitberg, Ben Z.



Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage  

PubMed Central

Objective: Rebleeding of an aneurysm is a leading cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated the risk factors associated with rebleeding, few data on complications of rebleeding, including its effect on the development of delayed cerebral ischemia (DCI), are available. Methods: A nested case-control study was performed on patients with rebleeding and control subjects matched for modified Fisher scale, Hunt-Hess grade, age, and sex previously entered into a prospective database. Rebleeding was defined as new hemorrhage apparent on repeat CT with or without new symptoms. Incidence and time course of DCI and hospital complications were compared. A secondary analysis of DCI and hospital complications was also performed on subjects surviving to postbleed day 7. Results: We identified 120 patients with rebleeding and 359 control subjects from 1996 to 2011. The rebleeding rate was 8.6%. In both the primary and secondary analyses, there was no difference in the incidence of DCI or its time course (29% vs 27%, p = 0.6; 7 ± 5 vs 7 ± 6 days, p = 0.9 for primary analysis; 39% vs 31%, p = 0.1, 7 ± 5 vs 7 ± 6 days, p = 0.6 for the secondary analysis). In a multivariate logistic regression model, rebleeding was associated with the complications of hyponatremia, respiratory failure, and hydrocephalus. Patients with rebleeding had higher rates of mortality, brain death, and poor outcomes. Conclusions: Rebleeding after SAH is associated with multiple medical and neurologic complications, resulting in higher morbidity and mortality, but is not associated with change of incidence or timing of DCI.

Lord, A.S.; Fernandez, L.; Schmidt, J.M.; Mayer, S.A.; Claassen, J.; Lee, K.; Connolly, E.S.



Triple-H therapy in the management of aneurysmal subarachnoid haemorrhage  

Microsoft Academic Search

Cerebral vasospasm is a recognised but poorly understood complication for many patients who have aneurysmal subarachnoid haemorrhage and can lead to delayed ischaemic neurological deficit (stroke). Morbidity and mortality rates for vasospasm are high despite improvements in management. Since the middle of the 1970s, much has been written about the treatment of cerebral vasospasm. Hypervolaemia, hypertension, and haemodilution (triple-H) therapy

Jon Sen; Antonio Belli; Helen Albon; Laleh Morgan; Axel Petzold; Neil Kitchen



Subarachnoid Hemorrhage in Type 1 Diabetes: A prospective cohort study of 4,083 patients with diabetes.  


OBJECTIVE To estimate for the first time the incidence of subarachnoid hemorrhage (SAH) in type 1 diabetes. RESEARCH DESIGN AND METHODS Using the nationwide Finnish Diabetic Nephropathy (FinnDiane) Study cohort of 4,083 patients with type 1 diabetes (mean age of 37.4 ± 11.8 years at enrollment), we analyzed the incidence of first-ever SAH events. RESULTS During the follow-up time of 36,680 person-years (median 9.4 years), 15 patients with type 1 diabetes experienced an aneurysmal or nonaneurysmal SAH, and thus the crude incidence of SAH was 40.9 (95% CI 22.9-67.4) per 100,000 person-years. One patient had a verified aneurysmal SAH, and four patients died suddenly of an SAH, which was most likely caused by an aneurysm. SAHs in 10 out of 15 patients were classified as nonaneurysmal SAH, and thus the crude incidence of nonaneurysmal SAH was 27.3 (13.1-50.1) per 100,000 person-years. None of the nonaneurysmal SAHs were fatal. In univariate analysis, current smokers had a hazard ratio of 4.82 (95% CI 1.31-17.81) for nonaneurysmal SAH. CONCLUSIONS The incidence of nonaneurysmal SAH is high among patients with type 1 diabetes. Our findings suggest that nonaneurysmal SAH is a distinct new microvascular complication in type 1 diabetes. PMID:23877984

Korja, Miikka; Thorn, Lena M; Hägg, Stefanie; Putaala, Jukka; Liebkind, Ron; Harjutsalo, Valma; Forsblom, Carol M; Gordin, Daniel; Tatlisumak, Turgut; Groop, Per-Henrik



Accumulation of intimal platelets in cerebral arteries following experimental subarachnoid hemorrhage in cats  

SciTech Connect

From 2 hours to 23 days following experimental subarachnoid hemorrhage, the accumulation of indium-111-labeled platelets on the intimal surface of the middle cerebral artery was studied in 23 cats. Subarachnoid hemorrhage was produced by transorbital rupture of the right middle cerebral artery. Of the 23 cats, 17 exhibited right middle cerebral artery/left middle cerebral artery radioactivity ratios of greater than 1.25. When these results were compared with those of 12 control cats, 0.001 less than p less than 0.005 (chi2 test). Thus, the results from the control and experimental groups are significantly different and indicate early (after 2 hours) preferential accumulation of intimal platelets in the ruptured right middle cerebral artery compared with the unruptured left middle cerebral artery and new platelet deposition continuing for up to 23 days. However, the experimental group did not reveal a clear pattern for platelet accumulation following subarachnoid hemorrhage. There was no simple correlation between the magnitude of the radioactivity ratios and the time after hemorrhage when the cats were killed although the ratios for 2 hours to 7 days seemed greater than those for 8 to 23 days. Assuming the pivotal role of platelets in the angiopathy of subarachnoid hemorrhage, the administration of antiplatelet agents as soon as possible following its occurrence may be of value.

Haining, J.L.; Clower, B.R.; Honma, Y.; Smith, R.R.



Contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty: a case report  

PubMed Central

Introduction Subarachnoid hemorrhage is one of the most feared acute neurologic events. Accurate diagnosis of subarachnoid hemorrhage is essential, and computed tomography of the brain is the first diagnostic imaging study. However, in rare circumstances, a similar appearance may occur in the absence of blood in the subarachnoid space. The contrast enhancement of subarachnoid space is a rare complication after lumbar percutaneous epidural neuroplasty, with, to the best of our knowledge, no previous report in the literature. Case presentation A 42-year-old Korean male patient, who underwent a spinal operation five years previously at the level of L4 to S1, visited our clinic with persistent and aggravating low back pain. An imaging study revealed the focal and diffuse disc protrusion at the level of L4/5 and L5/S1. The clinician decided to perform a lumbar percutaneous epidural neuroplasty. During the procedure, dural adhesion was suspected at the previously operated level, and the neuroplasty catheter was malpositioned into the intradural space on the first attempt. After the catheter was repositioned, the scheduled epidural neuroplasty was completed. Our patient had no definite abnormal neurological signs. But, after a day, our patient complained of severe headache with sustained high blood pressure without neurological disorientation. Computed tomography of his brain showed a subarachnoid hemorrhage-like appearance with intracranial air. Sequential angiography, subtractional magnetic resonance imaging and examination of the cerebrospinal fluid revealed no abnormalities. Follow-up computed tomography after one day revealed no definite intracranial hemorrhage, and our patient was discharged with improved low back pain without neurological deficit. Conclusion We report a rare case of contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty. The physician should keep in mind a rare case like this, and the supine position with head elevation is necessary to avoid a similar complication after lumbar percutaneous epidural neuroplasty.



Risk of cardiovascular events and death in the life after aneurysmal subarachnoid haemorrhage: a nationwide study.  


BACKGROUND AND AIM: The increased mortality rates of survivors of aneurysmal subarachnoid haemorrhage have been attributed to an increased risk of cardiovascular events in a registry study in Sweden. Swedish registries have however not been validated for subarachnoid haemorrhage and Scandinavian incidences of cardiovascular disease differ from that in Western European countries. We assessed risks of vascular disease and death in subarachnoid haemorrhage survivors in the Netherlands. METHODS: From the Dutch hospital discharge register, we identified all patients with subarachnoid haemorrhage admission between 1997 and 2008. We determined the accuracy of coding of the diagnosis subarachnoid haemorrhage for patients admitted to our centre. Conditional on survival of three-months after the subarachnoid haemorrhage, we calculated standardized incidence and mortality ratios for fatal or nonfatal vascular diseases, vascular death, and all-cause death. Cumulative risks were estimated with survival analysis. RESULTS: The diagnosis of nontraumatic subarachnoid haemorrhage was correct in 95·4% of 1472 patients. Of 11?263 admitted subarachnoid haemorrhage patients, 6999 survived more than three-months. During follow-up (mean 5·1 years), 874 (12·5%) died. The risks of death were 3·3% within one-year, 11·3% within five-years, and 21·5% within 10 years. The standardized mortality ratio was 3·4 (95% confidence interval: 3·1 to 3·7) for vascular death and 2·2 (95% confidence interval: 2·1 to 2·3) for all-cause death. The standardized incidence ratio for fatal or nonfatal vascular diseases was 2·7 (95% confidence interval: 2·6 to 2·8). CONCLUSIONS: Dutch hospital discharge and cause of death registries are a valid source of data for subarachnoid haemorrhage, and show that the increased mortality rate in subarachnoid haemorrhage survivors is explained by increased risks for vascular diseases and death. PMID:22973950

Nieuwkamp, Dennis J; Vaartjes, Ilonca; Algra, Ale; Rinkel, Gabriel J E; Bots, Michiel L



Early Brain Injury: A Common Mechanism in Subarachnoid Hemorrhage and Global Cerebral Ischemia  

PubMed Central

Early brain injury (EBI) has become an area of extreme interest in the recent years and seems to be a common denominator in the pathophysiology of global transient ischemia and subarachnoid hemorrhage (SAH). In this paper, we highlight the importance of cerebral hypoperfusion and other mechanisms that occur in tandem in both pathologies and underline their possible roles in triggering brain injury after hemorrhagic or ischemic strokes.

Macdonald, R. Loch



Intra-Aortic Balloon Pump Counterpulsation in the Setting of Subarachnoid Hemorrhage, Cerebral Vasospasm, and Neurogenic Stress Cardiomyopathy. Case Report and Review of the Literature  

Microsoft Academic Search

Background  The management of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) can be often complicated\\u000a by the presence of stunned myocardium and left ventricular failure. Vasopressors and inotropes are commonly used to optimize\\u000a mean arterial pressure (MAP) and cerebral perfusion pressure (CPP). Intra-aortic balloon counterpulsation pump (IABP) may\\u000a be indicated in the management of these patients.\\u000a \\u000a \\u000a \\u000a \\u000a Methods  We report the case

Christos Lazaridis; Gustavo Pradilla; Paul A. Nyquist; Rafael J. Tamargo



Cardiac manifestations after subarachnoid hemorrhage: A systematic review of the literature  

Microsoft Academic Search

Cardiac alterations associated with subarachnoid hemorrhage (SAH) have been recognized and frequently reported. We systematically reviewed the literature on MEDLINE using the key words: SAH + (heart, cardiac, electrocardiogram, cardiac enzymes, troponin, myoglobin, echocardiography, scintigraphy, Holter, and regional wall motion abnormalities) and included all articles describing cardiac abnormalities in the course of SAH whether spontaneous or secondary. The diagnosis of

Yasser L. Sakr; Issam Ghosn; Jean Louis Vincent



Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients  

Microsoft Academic Search

We have reviewed initial diagnostic features, treatment, and outcome in 29 patients with acute subarachnoid hemorrhage due to non-traumatic vertebrobasilar artery dissection diagnosed in our hospital between 1993 and 2003. The dissections occurred in the vertebral artery in 19 patients, the posterior inferior cerebellar artery (PICA) in two patients, the basilar artery in four patients, and in the vertebral artery

B Ramgren; M Cronqvist; B Romner; L Brandt; S Holtås; E-M Larsson



Spinal tumors and subarachnoid hemorrhage: pathogenetic and diagnostic aspects in 5 cases  

Microsoft Academic Search

The authors report 5 cases of spinal tumor associated with subarachnoid hemorrhage. Histologically, the tumor was an ependymoma in 2 cases, a neurinoma in 2 cases and a hemangioblastoma in 1 case. The pathogenetic and diagnostic characteristics of these 5 cases are analyzed in the light of other published reports.

Luigi Cervoni; Carmine Franco; Paolo Celli; Aldo Fortuna



Plasma Concentrations of Brain Natriuretic Peptide in Patients With Subarachnoid Hemorrhage  

Microsoft Academic Search

Background and Purpose—Hyponatremia after subarachnoid hemorrhage (SAH) is commonly associated with diuresis and natriuresis, but the causes are still controversial. We investigated whether brain natriuretic peptide (BNP) was related to such hyponatremia. Methods—Plasma BNP concentrations were measured by immunoradiometric assay in 18 patients at 0 to 2 days (period 1), 7 to 9 days (period 2), and .14 days (period

Mamoru Tomida; Masaaki Muraki; Kenichi Uemura; Kenji Yamasaki


Expression of monocyte chemoattractant protein-1 in the cerebral artery after experimental subarachnoid hemorrhage  

Microsoft Academic Search

Monocyte chemoattractant protein-1 (MCP-1) is a potent chemokine that plays an important role in the recruitment of macrophages. Although previous studies have demonstrated that MCP-1 has been shown to be involved in the damaging inflammatory processes associated with stroke, infection, neoplasia, and others in the central nervous system, the role of MCP-1 in the cerebral artery after experimental subarachnoid hemorrhage

Hua Lu; Ji-Xin Shi; Hui-Lin Chen; Chun-Hua Hang; Han-Dong Wang; Hong-Xia Yin



Microvascular Endothelial Dysfunction and its Mechanism in a Rat Model of Subarachnoid Hemorrhage  

Microsoft Academic Search

After subarachnoid hemorrhage (SAH), large cerebral arteries are prone to vasospasm. Using a rat model of SAH, we examined whether cortical microvessels dem- onstrate vasomotor changes that may make them prone to spasm and whether endothelial dysfunction may ac- count for any observed changes. Two days after percu- taneous catheterization into the cisterna magna, 0.3 mL of autologous blood was

Kyung W. Park; Caroline Metais; Hai B. Dai; Mark E. Comunale; Frank W. Sellke



Regional Patterns of Left Ventricular Systolic Dysfunction After Subarachnoid Hemorrhage: Evidence for Neurally Mediated Cardiac Injury  

Microsoft Academic Search

Although left ventricular (LV) dysfunction has been described after subarachnoid hemorrhage (SAH), its pathophysiology, regional distribution, and reversibility remain uncertain. To test the hypothesis that regional wall motion patterns in SAH patients do not match the typical patterns observed in coronary artery disease, a segmental wall motion analysis was performed in 30 SAH patients with LV dysfunction. Both regional (n

Jonathan G Zaroff; Guy A Rordorf; Christopher S Ogilvy; Michael H Picard



The Effect of Intracisternal Phentolamine on Cerebral Blood Flow after Simulated Subarachnoid Hemorrhage.  

National Technical Information Service (NTIS)

The hydrogen clearance method was used to measure total and focal blood flow (CBF) in the monkey before and for 5 hours after a simulated subarachnoid hemorrhage (SAH). Some monkeys also received 0.2-1.0 mg/kg phentolamine intracisternally 3 hours after S...

A. N. Martins N. Newby T. F. Doyle A. I. Kobrine A. Ramirez



The Effect of a Simulated Subarachnoid Hemorrhage on Cerebral Blood Flow in The Monkey.  

National Technical Information Service (NTIS)

The hydrogen clearance method was used to measure local and total cerebral blood flow (CBF) in the rhesus monkey before and for 5 hours after a simulated subarachnoid hemorrhage (SAH). CBF remained stable after SAH unless SAH was associated with a fall in...

A. N. Martins T. F. Doyle N. Newby A. I. Kobrine A. Ramirez



Association of early post-procedure hemodynamic management with the outcomes of subarachnoid hemorrhage patients.  


Post-procedure hemodynamic management for aneurysmal subarachnoid hemorrhage is controversial because of the paucity of studied patients. Using a Japanese administrative database, we tested whether increased albumin, catecholamine, and volumes of fluid administered between the procedure and the 4th post-procedure day would be associated with outcomes of mortality, consciousness deterioration at discharge and re-intubation between the 5th and 14th post-procedure days. Across 550 hospitals, 5,400 patients were identified who received clipping, wrapping and endovascular coiling within 48 h after admission in 2010. Patient characteristics and the administration of albumin, catecholamine, and volume of fluid normalized by body weight were analyzed among the groups and categorized according to the presence of albumin and catecholamine administered between the procedure and the 4th post-procedure day. The association of early hemodynamic management with outcomes was measured using logistic regression models, through controlling for the preference of early administration of albumin and catecholamine. For the patients, 9.3 % received albumin only, 14.4 % catecholamine only, and 4.9 % both between the procedure and the 4th post-procedure day, while 16.5 % received albumin or catecholamine on other days. Variation in albumin and catecholamine administration was observed. Higher normalized fluid volume, commenced before the 4th post-procedure day, was associated with increased mortality and re-intubation (although with decreased complications), and vice versa between the 4th and 14th post-procedure days. Catecholamine administration was associated with worsened outcomes. Hypervolemic and hypertensive therapies commenced before the 4th post-procedure day require further research to determine whether their associations with outcomes in this administrative data base are causal or not. PMID:23096067

Kuwabara, Kazuaki; Fushimi, Kiyohide; Matsuda, Shinya; Ishikawa, Koichi B; Horiguchi, Hiromasa; Fujimori, Kenji



Cranial base approaches to intracranial aneurysms in the subarachnoid space.  


The use of cranial base approaches to aneurysm surgery is illustrated by means of patient examples. Over a 9-year period, cranial base approaches were used to expose and treat 38 aneurysms involving the anterior communicating artery complex, proximal internal carotid artery, basilar artery, or vertebral artery. The approaches included orbital osteotomy, orbitozygomatic osteotomy, petrous apicectomy, presigmoid petrosectomy, and extreme lateral transcondylar methods. Complications related to the approaches included one partial ptosis and two cerebrospinal fluid leaks, which resolved with treatment. The technique of three-dimensional computed tomographic angiography was useful in delineating the vascular anatomy and its relation to the cranial base structures. This helped the surgeon plan the appropriate approach to the aneurysm. Cranial base approaches, used selectively, can provide improved exposure of deep-seated aneurysms and large or giant aneurysms, while minimizing brain retraction. PMID:7800139

Sekhar, L N; Kalia, K K; Yonas, H; Wright, D C; Ching, H



Subarachnoid haemorrhage with bilateral intracranial vertebral artery dissecting aneurysms treated by staged endovascular stenting.  


Bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid haemorrhage (SAH) are an exceedingly rare and deadly clinical dilemma. Prompt intervention in the case of unilateral VADAs is advocated to prevent rebleed; however, in the case of bilateral VADAs, the optimal therapeutic intervention is unclear. We describe the case of a patient presenting with SAH with bilateral VADAs treated by staged endovascular stenting. This led to resolution of the aneurysms with patency of both vertebral arteries. Stent-based therapy of the symptomatic aneurysm followed by staged stenting of the asymptomatic, contralateral aneurysm appears to be a viable treatment option. This method allows the ability to preserve flow in both vertebral arteries with minimal changes in flow characteristics that may threaten the contralateral, asymptomatic VADA, and appears to be the ideal treatment in these rare cases. PMID:23417929

Wilkinson, David Andrew; Wilson, Thomas J; Stetler, William R; Pandey, Aditya S



Induced hypertension for the treatment of cerebral ischemia after subarachnoid hemorrhage. Direct effect on cerebral blood flow  

SciTech Connect

The best treatment for symptomatic cerebral ischemia from presumed vasospasm after aneurysmal subarachnoid hemorrhage remains a matter of controversy. A direct effect of any treatment modality on regional cerebral blood flow has never been documented. In a series of 43 patients operated on for ruptured anterior circulation aneurysms, five patients (11.6%) developed clinical signs of cerebral ischemia postoperatively. In four of those patients, the diagnosis of vasospasm was made with measurements of cerebral blood flow (133Xe inhalation or intravenous injection, 10-16 detectors, cerebral blood flow infinity). Treatment with induced arterial hypertension with phenylephrine was instituted. Hemodilution was instituted in one patient; the other three patients already had hematocrits in the range of 33. Within 1 hour, the cerebral blood flow measurement was repeated to document the effect of treatment. The average pretreatment hemispherical blood flow on the operated side was 18.8 mL/100 g per minute, on the contralateral side 21.0 mL/100 g per minute. With treatment these flows increased to 30.8 and 35.8 mL/100 g per minute, respectively. There was also an immediate and obvious positive clinical effect in all patients. The role of measurement of cerebral blood flow in the clinical management of vasospasm is discussed. We stress the theoretical and practical advances of measurements of cerebral blood flow over cerebral angiography, especially in comatose patients.

Muizelaar, J.P.; Becker, D.P.



Transcranial Cerebral Oximetry Related to Transcranial Doppler After Aneurysmal Subarachnoid Haemorrhage  

Microsoft Academic Search

Summary  ?Noninvasive methods for detecting cerebral artery vasospasm, still a serious complication following aneurysmal subarachnoid\\u000a haemorrhage, are of vital interest. Up-to-date transcranial Doppler ultrasound (TCD) has proved to be sensitive in detecting\\u000a vasospasm in the middle cerebral artery, but has less accuracy for other cerebral arteries. Transcranial cerebral oximetry\\u000a (TCCO) is a new noninvasive technique which may increase the reliability for

A. Ekelund; P. Kongstad; H. Säveland; B. Romner; P. Reinstrup; K.-A. Kristiansson; L. Brandt



A Severe Vicious Cycle in Uncontrolled Subarachnoid Hemorrhage: the Effects on Cerebral Blood Flow and Hemodynamic Responses upon Intracranial Hypertension  

Microsoft Academic Search

In subarachnoid hemorrhage (SAH), Cushing postulated that the increase in systemic arterial pressure (SAP) in response to elevation of intracranial pressure (ICP) was beneficial to cerebral perfusion. However, in uncontrolled SAH, the increased SAP may cause more bleeding into the subarachnoid space and further increase the ICP. We created an animal model to simulate SAH by connecting a femoral arterial

Chain-Fa Su; Yi-Ling Yang; Ming-Che Lee; Hsing I Chen


A novel intravital method to evaluate cerebral vasospasm in rat models of subarachnoid hemorrhage: a study with synchrotron radiation angiography.  


Precise in vivo evaluation of cerebral vasospasm caused by subarachnoid hemorrhage has remained a critical but unsolved issue in experimental small animal models. In this study, we used synchrotron radiation angiography to study the vasospasm of anterior circulation arteries in two subarachnoid hemorrhage models in rats. Synchrotron radiation angiography, laser Doppler flowmetry-cerebral blood flow measurement, [(125)I]N-isopropyl-p-iodoamphetamine cerebral blood flow measurement and terminal examinations were applied to evaluate the changes of anterior circulation arteries in two subarachnoid hemorrhage models made by blood injection into cisterna magna and prechiasmatic cistern. Using synchrotron radiation angiography technique, we detected cerebral vasospasm in subarachnoid hemorrhage rats compared to the controls (p<0.05). We also identified two interesting findings: 1) both middle cerebral artery and anterior cerebral artery shrunk the most at day 3 after subarachnoid hemorrhage; 2) the diameter of anterior cerebral artery in the prechiasmatic cistern injection group was smaller than that in the cisterna magna injection group (p<0.05), but not for middle cerebral artery. We concluded that synchrotron radiation angiography provided a novel technique, which could directly evaluate cerebral vasospasm in small animal experimental subarachnoid hemorrhage models. The courses of vasospasm in these two injection models are similar; however, the model produced by prechiasmatic cistern injection is more suitable for study of anterior circulation vasospasm. PMID:22428033

Cai, Jun; Sun, Yuhao; Yuan, Falei; Chen, Lujia; He, Chuan; Bao, Yuhai; Chen, Zuoquan; Lou, Meiqing; Xia, Weiliang; Yang, Guo-Yuan; Ling, Feng



A Novel Intravital Method to Evaluate Cerebral Vasospasm in Rat Models of Subarachnoid Hemorrhage: A Study with Synchrotron Radiation Angiography  

PubMed Central

Precise in vivo evaluation of cerebral vasospasm caused by subarachnoid hemorrhage has remained a critical but unsolved issue in experimental small animal models. In this study, we used synchrotron radiation angiography to study the vasospasm of anterior circulation arteries in two subarachnoid hemorrhage models in rats. Synchrotron radiation angiography, laser Doppler flowmetry-cerebral blood flow measurement, [125I]N-isopropyl-p-iodoamphetamine cerebral blood flow measurement and terminal examinations were applied to evaluate the changes of anterior circulation arteries in two subarachnoid hemorrhage models made by blood injection into cisterna magna and prechiasmatic cistern. Using synchrotron radiation angiography technique, we detected cerebral vasospasm in subarachnoid hemorrhage rats compared to the controls (p<0.05). We also identified two interesting findings: 1) both middle cerebral artery and anterior cerebral artery shrunk the most at day 3 after subarachnoid hemorrhage; 2) the diameter of anterior cerebral artery in the prechiasmatic cistern injection group was smaller than that in the cisterna magna injection group (p<0.05), but not for middle cerebral artery. We concluded that synchrotron radiation angiography provided a novel technique, which could directly evaluate cerebral vasospasm in small animal experimental subarachnoid hemorrhage models. The courses of vasospasm in these two injection models are similar; however, the model produced by prechiasmatic cistern injection is more suitable for study of anterior circulation vasospasm.

Yuan, Falei; Chen, Lujia; He, Chuan; Bao, Yuhai; Chen, Zuoquan; Lou, Meiqing; Xia, Weiliang; Yang, Guo-Yuan; Ling, Feng



Hyperbaric Oxygen for Cerebral Vasospasm and Brain Injury Following Subarachnoid Hemorrhage  

Microsoft Academic Search

The impact of acute brain injury and delayed neurological deficits due to cerebral vasospasm (CVS) are major determinants\\u000a of outcomes after subarachnoid hemorrhage (SAH). Although hyperbaric oxygen (HBO) had been used to treat patients with SAH,\\u000a the supporting evidence and underlying mechanisms have not been systematically reviewed. In the present paper, the overview\\u000a of studies of HBO for cerebral vasospasm

Robert P. Ostrowski; John H. Zhang


Arginine vasopressin as a supplementary vasopressor in refractory hypertensive, hypervolemic, hemodilutional therapy in subarachnoid hemorrhage  

Microsoft Academic Search

Introduction  Hypertensive, hypervolemic, and hemodilutional (HHH) therapy for vasospasm in subarachnoid hemorrhage (SAH) refractory to\\u000a phenylephrine requires high doses of catecholamines, leading to adverse adrenergic effects. Arginine vasopressin (AVP) has\\u000a been shown to stabilize advanced shock states while facilitating reduction of catecholamine doses, but its use has never been\\u000a reported in SAH. In this retrospective study, we investigated the hemodynamic effects

Susanne Muehlschlegel; Martin W. Dunser; Andrea Gabrielli; Volker Wenzel; A. Joseph Layon



Alpha Lipoic Acid Alleviates Oxidative Stress and Preserves Blood Brain Permeability in Rats with Subarachnoid Hemorrhage  

Microsoft Academic Search

The neuroprotective effect of alpha lipoic acid (ALA; 100 mg\\/kg, po), a dithiol antioxidant, on experimentally induced subarachnoid\\u000a hemorrhage (SAH) was assessed in Wistar albino rats. Neurological examination scores recorded at the 48th h of SAH induction\\u000a were increased in SAH groups, which were accompanied with significant increases in the formation of reactive oxygen species,\\u000a DNA fragmentation ratios, malondialdehyde levels and myeloperoxidase

Mehmet ErsahinHale; Hale Z. Toklu; ?ule Çetinel; Meral Yüksel; Can Erzik; M. Zafer Berkman; Berrak Ç. Ye?en; Göksel ?ener



Mechanisms of hyperbaric oxygen-induced neuroprotection in a rat model of subarachnoid hemorrhage  

Microsoft Academic Search

Acute cerebral ischemia occurs after subarachnoid hemorrhage (SAH) because of increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP). The effect of hyperbaric oxygen (HBO) on physiological and clinical outcomes after SAH, as well as the expressions of hypoxia-inducible factor-1? (HIF-1?) and its target genes, such as BNIP3 and VEGF was evaluated. Eighty-five male SD rats (300 to 350

Robert P Ostrowski; Austin R T Colohan; John H Zhang



Risk Factors for Subarachnoid Hemorrhage An Updated Systematic Review of Epidemiological Studies  

Microsoft Academic Search

Background and Purpose—After a 1996 review from our group on risk factors for subarachnoid hemorrhage (SAH), much new information has become available. This article provides an updated overview of risk factors for SAH. Methods—An overview of all longitudinal and case-control studies of risk factors for SAH published in English from 1966 through March 2005. We calculated pooled relative risks (RRs)

Valery L. Feigin; Gabriel J. E. Rinkel; Carlene M. M. Lawes; Ale Algra; Derrick A. Bennett; Jan van Gijn; Craig S. Anderson



Heme-oxygenase-1 induction in glia throughout rat brain following experimental subarachnoid hemorrhage  

Microsoft Academic Search

The heme released following subarachnoid hemorrhage is metabolized by heme-oxygenase (HO) to biliverdin and carbon monoxide (CO) with the release of iron. The HO reaction is important since heme may contribute to vasospasm and increase oxidative stress in cells. HO is comprised of at least two isozymes, HO-2 and HO-1. HO-1, also known as heat shock protein HSP32, is inducible

Paul Matz; Christopher Turner; Philip R. Weinstein; Stephen M. Massa; S. Scott Panter; Frank R. Sharp



Association Between Subarachnoid Hemorrhage Outcomes and Number of Cases Treated at California Hospitals  

Microsoft Academic Search

Background and Purpose—Studies of several complex medical conditions have shown that outcomes are better at hospitals that treat more cases. We tested the hypothesis that patients with subarachnoid hemorrhage treated at high-volume hospitals have better outcomes. Methods—Using a database of all admissions to nonfederal hospitals in California from 1990 to 1999, we obtained discharge abstracts for patients with a primary

Naomi S. Bardach; Shoujun Zhao; Daryl R. Gress; Michael T. Lawton; S. Claiborne Johnston



Amelioration of Vasospasm After Subarachnoid Hemorrhage in Transgenic Mice Overexpressing CuZn-Superoxide Dismutase  

Microsoft Academic Search

Background and Purpose—To clarify the effect of superoxide dismutase (SOD) on vasospasm after subarachnoid hemorrhage (SAH), we investigated sequential changes in arterial diameter after SAH in transgenic mice overexpressing CuZn-SOD (SOD-1). Methods—SOD-transgenic mice and nontransgenic littermates (35 to 40 g) were subjected to SAH produced by endovascular perforation of left anterior cerebral artery. At 4 hours and 1, 3, 7,

Hideyuki Kamii; Ichiro Kato; Hiroyuki Kinouchi; Pak H. Chan; Charles J. Epstein; Atsushi Akabane; Hiroshi Okamoto; Takashi Yoshimoto


[Recommendations for the management of patients with aneurysmal subarachnoid hemorrhage].  


After SAH, primary and secondary complications are frequent and often require neurosurgical interventions to avoid secondary brain damage. The authors of the present paper have summarized the available data about the treatment modalities often used for patients with SAH. The present recommendations have been developed as a neurosurgical and neuroanestesiological consensus. Evidence from prospective, randomized, double blind, placebo-controlled studies support grade A recommendations (standard) for the prophylaxis and treatment of cerebral vasospasm with oral Nimodipine in good grade patients. For intravenous Nimodipine or for oral nimodipine treatment in poor grade patients, available data only support grade C recommendations (options). Despite the lack of data supporting standards (grade A) or guidelines (grade B), avoidance and rigorous treatment of hypotension and hypovolemia remains the mainstay in the prophylaxis and treatment of a delayed ischemic neurological deficit (DIND). Prophylactic hypervolemia or prophylactic hypertension and hypervolemia was shown to be ineffective in reducing symptomatic vasospasm and improving outcome (grade B). Therapeutic hypertensive hypervolemic hemodilution is recommended as a treatment of symptomatic vasospasm but no prospective studies are available (grade C recommendation). Suggested target values for moderate triple-H-therapy are CPP 80- 120 mmHg (MAP 90-130), CVP > 7 mmHg and Hk 0.25-0.40. Balloon angioplasty should be considered for treatment of DIND cause by focal, proximal cerebral vasospasm. There is no evidence supporting the routine use of antifibrinolyticals, steroids or anticonvulsive prophylaxis. Clinical data indicate that current prophylaxis and treatment of cerebral vasospasm is still insufficient and aggressive triple-H-therapy is associated with an increased incidence of complications. PMID:15846536

Raabe, A; Beck, J; Berkefeld, J; Deinsberger, W; Meixensberger, J; Schmiedek, P; Seifert, V; Steinmetz, H; Unterberg, A; Vajkoczy, P; Werner, C



Risk factors for aneurysmal subarachnoid haemorrhage: the Troms? study  

PubMed Central

Methods: The Tromsø health study is a population based survey of risk factors for cardiovascular disease in 27 161 subjects. 26 cases of aneurysmal SAH were identified in which risk factors were registered before the bleeding. Four age and sex matched controls were selected for each case. A backward logistic regression analysis was conducted and odds ratios (ORs) for significant risk factors were calculated. Systolic and diastolic blood pressure, cigarette smoking habits, serum concentrations of lipoproteins, body mass index, and coffee consumption were analysed. Results: The crude annual incidence rate of aneurysmal SAH was 8.84/100 000 population. The proportion of current smokers was significantly (p = 0.003) higher in patients with SAH (73.1%) than in controls (41.3%). Drinking more than five cups of coffee per day was more common among patients (85%) than controls (59%) (p = 0.004). Mean (SD) systolic blood pressure was higher (p = 0.017) in patients (154.0 (32.5)) than in controls (136.3 (23.3)). Regression analysis showed that cigarette smoking (p = 0.04), systolic blood pressure (p < 0.0001), and coffee consumption (p = 0.004) were independent risk factors for SAH. The OR of current smokers versus never smokers was 4.55 (95% confidence interval (CI) 1.08 to 19.30) and the OR of drinking more than five cups of coffee a day was 3.86 (95% CI 1.01 to 14.73). The OR of an increase in systolic blood pressure of 20 mm Hg was 2.46 (95% CI 1.52 to 3.97). Conclusions: Cigarette smoking and hypertension are significant independent risk factors for aneurysmal SAH. A high coffee consumption may also predispose patients to aneurysmal SAH.

Isaksen, J; Egge, A; Waterloo, K; Romner, B; Ingebrigtsen, T



Natural history, epidemiology and screening of unruptured intracranial aneurysms  

Microsoft Academic Search

IntroductionThe prevalence of unruptured intracranial aneurysms is around 2%; most of these aneurysms are small and located in the anterior circulation. Unruptured intracranial aneurysms may give rise to subarachnoid hemorrhage in the near or distant future and sometimes, these lesions warrant preventive intervention.

G. J. E. Rinkel



Femoral access in 100 consecutive subarachnoid hemorrhage patients: the "craniotomy" of endovascular neurosurgery  

PubMed Central

Background Femoral access is a fundamental element of catheter-based cerebral angiography. Knowledge of location of the common femoral artery (CFA) bifurcation is important as the risk of retroperitoneal bleeding is increased if the puncture is superior to the inguinal ligament and there is an increased risk of thrombosis and arteriovenous fistula formation if the puncture is distal into branch vessels. We sought to characterize the location of the CFA bifurcation along with the presence of significant atherosclerosis or iliac tortuosity in a contemporary series of subarachnoid hemorrhage (SAH) patients. Findings The records of a prospective single-center aneurysm database were reviewed to identify 100 consecutive SAH patients. Using an oblique femoral arteriogram, the presence of significant atherosclerosis, iliac tortuosity, and the CFA bifurcation were assessed. The CFA bifurcation was graded according to its position with respect to the femoral head: below (grade 1), lower half (grade 2), and above the upper half (grade 3). We found a CFA bifurcation grade 1 in 50 patients (50%, mean age 51.2 years), grade 2 in 40 patients (40%, mean age 55.5 years), and grade 3 in 10 patients (10%, mean age 58.2 years). Whereas 30 of 90 patients with CFA grades I or II were male (33%), only 10% with grade 3 were male (1 of 10, p = 0.12). Mean age for significant atherosclerosis was 65.5 +/- 2.6 years versus 50.9 +/- 1.6 years (p < 0.001) without, and iliac tortuosity was 64.9 +/- 2.4 years versus 50.3 +/- 1.6 years (p < 0.001) without. Conclusions Although a requisite element of endovascular treatment in SAH patients, femoral access can be complicated by a high common femoral artery bifurcation and the presence of atherosclerotic disease and/or iliac artery tortuosity. In this study, we found a grade 3 (above the femoral head) CFA bifurcation in 10% patients, with 90% of these patients being female. We also found the presence of atherosclerotic disease and iliac tortuosity to be significantly more likely in patients older than 65 years of age.



Cerebrospinal Fluid Catecholamine Levels as Predictors of Outcome in Subarachnoid Hemorrhage  

PubMed Central

Objective Subarachnoid hemorrhage (SAH) is associated with marked sympathetic activation at the time of ictus. The purpose of this study is to determine whether early central catecholamine levels measured from cerebrospinal fluid (CSF) relate to outcome in patients with SAH. Methods Observational study of consecutive SAH grade 3–5 patients who underwent ventriculostomy placement, but did not undergo open craniotomy for aneurysm obliteration. CSF samples were obtained during the first 48 h following symptom onset and assayed for catecholamine levels. Statistical analyses were performed to determine whether the levels predicted mortality by day 15 or mortality/disability by day 30. Results For the 102 patients included, mean age was 58, and 73% were female ? 21% experienced day-15 mortality, and 32% experienced mortality/disability by day 30. Early mortality was related to Hunt-Hess (H/H) grade (p < 0.001), neurogenic cardiomyopathy (NC) (p = 0.003), cerebral infarction (p = 0.001), elevated intracranial pressure (ICP) (p = 0.029), epinephrine (EPI) level (p = 0.002) and norepinephrine/3,4-dihydroxyphenylglycol (NE/DHPG) ratio (p = 0.003). Mortality/disability was related to H/H grade (p < 0.001), NC (p = 0.018), infarction (p < 0.001), elevated ICP (p = 0.002), EPI (p = 0.004) and NE/DHPG (p = 0.014). Logistic regression identified age [OR 1.09 (95% CI 1.01–1.17)], H/H grade [9.52 (1.19–77)], infarction [10.87 (1.22–100)], ICP elevation [32.26 (2–500)], EPI [1.06 (1.01–1.10)], and (inversely) DHPG [0.99 (0.99–1.00)] as independent predictors of early mortality. For mortality/disability, H/H grade [OR 21.74 (95% CI 5.62?83)], ICP elevation [18.52 (1.93–166)], and EPI [1.05 (1.02–1.09)] emerged as independent predictors. Proportional-hazards analysis revealed age [HR 1.041 (95% CI 1.003–1.08)], H/H grade [6.9 (1.54–31.25)], NC [4.31 (1.5–12.35)], and EPI [1.032 (1.009–1.054)] independently predicted early mortality. Conclusions CSF catecholamine levels are elevated in SAH patients who experience early mortality or disability. EPI may potentially serve as useful index of outcome in this population of patients with SAH.

Moussouttas, Michael; Huynh, Thanh T.; Khoury, John; Lai, Edwin W.; Dombrowski, Keith; Pello, Scott; Pacak, Karel



Detection and Characterization of Very Small Cerebral Aneurysms by Using 2D and 3D Helical CT Angiography  

Microsoft Academic Search

BACKGROUND AND PURPOSE: Many cases of subarachnoid hemorrhage are due to rupture of small cerebral aneurysms. Our purpose was to evaluate the usefulness of helical CT angiography (CTA) in the detection and characterization of very small (<5 mm) intracranial aneurysms. METHODS: One hundred eighty consecutive patients underwent CTA for suspected intra- cranial aneurysms. All aneurysms prospectively detected by CTA were

J. Pablo Villablanca; Reza Jahan; Parizad Hooshi; Silvester Lim; Gary Duckwiler; Aman Patel; James Sayre; Neil Martin; John Frazee; John Bentson; Fernando Vinuela



Recurrent non-aneurysmal subarachnoid haemorrhage in Takayasu arteritis: is the cause immunological or mechanical?  


Aneurysmal subarachnoid haemorrhage (SAH) is rarely associated with Takayasu's arteritis (TA). The present report describes a 21-year-old woman with recurrent SAH and TA. In addition, she also had recurrent spells of postural weakness in the bilateral lower limb occurring at the same time. Sequential CT of the head and MRI showed bilateral cortical SAH. Vascular imaging with MR angiogram and CT angiogram showed bilateral subclavian arteries and left common carotid artery occlusion with multiple hypertrophied collaterals vessels in the neck. There was no evidence of aneurysms in the intracranial vasculature in the conventional angiogram. The CT angiogram of the aorta showed severe stenosis of the abdominal aorta above the renal arteries. The patient was treated with immunomodulatory therapy and had a favourable outcome without further recurrence at end of 1 year of follow-up. A review of the literature showed 21cases with aneurysmal SAH and three cases non-aneurysmal SAH in patients with TA have been reported. Various factors are responsible for the reorganisation of the intracranial of the arteries in patients with chronic vasculitis in the presence of extracranial stenosis and occlusion, which could possibly explain the SAH in absence of aneurysm in patients with TA. PMID:23771963

Shuaib, Umar Ashfaq; Kate, Mahesh; Homik, Joanne; Jerrakathil, Thomas



Imaging findings in spinal subarachnoid hemorrhage in patient with hemophilia A: an unusual cause for back pain  

Microsoft Academic Search

Back pain and presentation with spinal canal hemorrhage in hemophilia is not common; however, these are significant clinical\\u000a issues and may lead to significant neurological issues and morbidity. We present an interesting case of severe back pain in\\u000a a young patient with moderate hemophilia A. Imaging confirmed subarachnoid hemorrhage in the spinal canal without intracranial\\u000a hemorrhage. To the best of

Arabinda Kumar Choudhary; Bhawna Jha



Automatic detection of the existence of subarachnoid hemorrhage from clinical CT images.  


Subarachnoid hemorrhage (SAH) is a medical emergency which can lead to death or severe disability. Misinterpretation of computed tomography (CT) in patients with SAH is a common problem. How to improve the accuracy of diagnosis is a great challenge to both the clinical physicians and medical researchers. In this paper we proposed a method for the automatic detection of SAH on clinical non-contrast head CT scans. The novelty includes approximation of the subarachnoid space in head CT using an atlas based registration, and exploration of support vector machine to the detection of SAH. The study included 60 patients with SAH and 69 normal controls from clinical hospitals. Thirty patients with SAH and 30 normal controls were used for training, while the rest were used for testing to achieve a testing sensitivity of 100% and specificity of 89.7%. The proposed algorithm might be a potential tool to screen the existence of SAH. PMID:20827565

Li, Yonghong; Wu, Jianhuang; Li, Hongwei; Li, Degang; Du, Xiaohua; Chen, Zhijun; Jia, Fucang; Hu, Qingmao



Glycyrrhizic acid confers neuroprotection after subarachnoid hemorrhage via inhibition of high mobility group box-1 protein: A hypothesis for novel therapy of subarachnoid hemorrhage.  


Subarachnoid hemorrhage usually results in poor clinical outcome and devastating neurological deficits. The early brain injury and delayed vasospasm after subarachnoid hemorrhage (SAH) are involved in the poor prognosis to the patients, while the mechanisms have not been well elucidated. Previous studies found an up-regulation of Toll-like receptor 4 (TLR4), inflammatory factors and high-mobility group box 1 (HMGB1) in the cortex after SAH. Increased inflammatory response contributes to the early brain injury and delayed vasospasm after SAH. Moreover, we found that the inflammatory response could be induced and amplified following recombinant HMGB1 (rHMGB1) addition in cultured neurons. Based on the latest researches in this field, we raised a hypothesis that HMGB1, a prototypical member of damage-associated molecular pattern (DAMP) family, could be passively released from the damaged neuroglia cells and hemotocyte lysis after SAH. Extracellular HMGB1 initiated the inflammation through its receptors. The inflammatory mediators then acted on the neurocytes to make them actively release HMGB1 continuously, manifesting an double phases. HMGB1 might be the key factor to induce sterile inflammation, and thus be one of the origin of early brain injury and delayed vasospasm after SAH. Inhibition of extracellular HMGB1 activities might be a novel therapeutic target for SAH to reduce the damaging inflammatory response. Glycyrrhizic acid (GA) which was extracted from liquorice and confirmed as a nature inhibitor of HMGB1 with little side-effects could inhibit extracellular HMGB1 cytokine activities and reduce the level of inflammatory response, thus alleviating early brain injury and cerebrovasospasm. GA might be a new novel therapy of SAH for better outcomes. PMID:23932051

Sun, Qing; Wang, Fan; Li, Wei; Li, Weide; Hu, Yang-Chun; Li, Song; Zhu, Jian-Hong; Zhou, Mengliang; Hang, Chun-Hua



Nicardipine in the treatment of aneurysmal subarachnoid haemorrhage: a meta-analysis of published data.  


Nicardipine is a dihydropyridine-type Ca(2+) channel blocker with a powerful antihypertensive activity and a unique cerebrovascular profile. Recent studies have examined nicardipine for the treatment of patients with aneurysmal subarachnoid haemorrhage (SAH), but have shown inconsistent results. In the current study, a meta-analysis was performed to assess the clinical effectiveness of nicardipine in the prevention of cerebral vasospasm in patients who had suffered from aneurysmal SAH. Medline, EMBASE, and PubMed databases were searched for the controlled trials evaluating nicardipine for treating SAH after a ruptured aneurysm, without language restrictions. Moreover, a manual search of the bibliographies of relevant articles was also conducted. Two researchers of the present study independently performed the literature search and the data extraction. The meta-analyses were performed using the software RevMan 4.2.10 (provided by the Cochrane Collaboration, Oxford, UK). Five published manuscripts involving 1,154 patients were included in this meta-analysis. Nicardipine infusion reduced the risk of poor outcome (death, vegetative state, or dependency) and mortality, with an odds ratio (OR) of 0.58 [95 % confidence interval (CI) 0.37-0.90] and 0.45 (95 % CI 0.15-1.29), respectively. This meta-analysis suggests that nicardipine therapy reduces the likelihood of poor outcome and mortality in patients after aneurysmal SAH. PMID:23111775

Huang, Ren-qiang; Jiang, Fu-gang; Feng, Zi-min; Wang, Tian-yi



Results of Direct Surgery for Aneurysmal Subarachnoid Haemorrhage: Outcome of 2055 Patients who Underwent Direct Aneurysm Surgery and Profile of Ruptured Intracranial Aneurysms  

Microsoft Academic Search

Summary  \\u000a ?Background and Purpose. The purpose of this study is to evaluate the therapeutic value of our surgical treatment of subarachnoid haemorrhage in\\u000a a large series with standardized surgical principles.\\u000a \\u000a \\u000a \\u000a ?Methods. Results of 2055 direct operations on ruptured intracranial aneurysms, treated in our institutions, where surgical indications,\\u000a instruments and techniques were standardized, between 1988 and 1998, were retrospectively evaluated and

M. Osawa; K. Hongo; Y. Tanaka; Y. Nakamura; K. Kitazawa; S. Kobayashi



Spontaneous intracranial hypotension presenting as pseudo-subarachnoid hemorrhage on CT scan.  


We report a 20-year-old man who suffered from severe headache. A brain CT scan revealed that he had diffuse brain swelling and increased attenuation of the basal cisterns and Sylvian fissure. Subarachnoid hemorrhage (SAH) was diagnosed but the results of CT angiography and conventional arterioangiography were negative. His headache relapsed and remitted several times during the following months. Brain MRI demonstrated brain sagging with a crowded foramen magnum. Spontaneous intracranial hypotension (SIH) was finally diagnosed and his headache subsided after application of an epidural blood patch. Pseudo-SAH on CT scan is an unusual manifestation of SIH that often results in delay of diagnosis and adequate treatment. PMID:21745742

Koh, Elly; Huang, Shih-Hao; Lai, Yen-Jun; Hong, Chien-Tai



Myocardial Dysfunction in Subarachnoid Hemorrhage: Prognostication by Echo Cardiography and Cardiac Enzymes. A Prospective Study  

Microsoft Academic Search

\\u000a \\u000a Background  The myocardial dysfunction in nontraumatic sub-arachnoid hemorrhage (SAH) is not well understood. Borderline elevations of\\u000a cardiac biomarkers, electrocardiographic repolarization abnormalities and systolic dysfunction have been reported but the\\u000a clinical significance of these abnormalities is uncertain.\\u000a \\u000a \\u000a \\u000a \\u000a Methods  Patients without history of cardiac disease were prospectively evaluated for cardiac dysfunction. Myocardial regional wall\\u000a motion and left ventricular ejection fraction (LVEF) were serially studied

Prasad Vannemreddy; Prasanna Venkatesh; Kumar Dinesh; Pratap Reddy; Anil Nanda


Recurrent subarachnoid hemorrhage associated with a new transthyretin variant (Gly53Glu).  


CNS involvement is rare in systemic amyloidoses due to transthyretin (TTR) mutation and manifests as a combination of dementia, seizures, and myelopathy. The authors report two French siblings who experienced recurrent subarachnoid hemorrhages as the main clinical feature. Brain specimens showed that the leptomeningeal vessels walls were thickened by amyloid deposits, and sequencing of the TTR exons showed a heterozygous single base-pair transition from G to A (codon 53), resulting in a glycine for glutamic acid substitution (G53E). PMID:11445644

Ellie, E; Camou, F; Vital, A; Rummens, C; Grateau, G; Delpech, M; Valleix, S



Endoscopic third ventriculostomy for hydrocephalus after perimesencephalic subarachnoid hemorrhage: initial experience in three patients  

Microsoft Academic Search

Background  To review the outcome after endoscopic third ventriculostomy (ETV) for symptomatic, persistent hydrocephalus in three patients\\u000a with perimesencephalic angiographically negative subarachnoid hemorrhage (PNH) who were dependent on an external ventricular\\u000a drain (EVD).\\u000a \\u000a \\u000a \\u000a \\u000a Methods  All patients initially presented with severe headache, nuchal rigidity, confusion and lethargy (Hunt-Hess Grade II or III),\\u000a and persistent, EVD-dependent hydrocephalus. Cranial CT images in each revealed acute

Walter Grand; Andrea J. Chamczuk; Jody Leonardo; Kenneth V. Snyder


The Familial Intracranial Aneurysm (FIA) study protocol  

Microsoft Academic Search

BACKGROUND: Subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms (IAs) occurs in about 20,000 people per year in the U.S. annually and nearly half of the affected persons are dead within the first 30 days. Survivors of ruptured IAs are often left with substantial disability. Thus, primary prevention of aneurysm formation and rupture is of paramount importance. Prior studies indicate

Joseph P Broderick; Laura R Sauerbeck; Tatiana Foroud; John Huston; Nathan Pankratz; Irene Meissner; Robert D Brown Jr



Management of 12 patients with ruptured and unruptured intracranial vertebral artery dissecting aneurysms  

Microsoft Academic Search

Vertebral artery dissecting aneurysms (VADA) are challenging disorders for neurosurgeons. Between December 2005 and May 2010, we treated 12 patients for DA of the intracranial VA. Three were treated by open surgery, seven underwent endovascular manipulation, and two were conservatively managed. Nine patients presented with subarachnoid hemorrhage from the ruptured aneurysm, and of these, two experienced abrupt re-hemorrhage and three

Wandong Su; Shouzhong Gou; Shilei Ni; Gang Li; Yuguang Liu; Shugan Zhu; Xingang Li


[Arterial aneurysms as cause of gushing post-tonsillectomy hemorrhage].  


Aneurysms of the external carotid artery can be causally for threatening late hemorrhage secondary to tonsillectomy. On the bases of typical, extended and finally dramatic bleeding course in a child the "clinical look" and the sensitivity should be raised for this bleeding cause. Characteristic after apparently inconspicuous post-operative first phase is late signal bleeding with little loss of blood which are replaced after following intervals free of bleeding from bleeding as flood with massive loss of blood. Then vessel-imaging (Angio-MRI or CT) is urgently indicated. By confirmation of the suspicion diagnosis the interventional angiography is the therapy of the choice, although after successful embolisation a fine-meshed postcontrol is necessary, because therapy failures are possible how the described case points. The highest security offers the surgical exploration with aimed vessel stopping. PMID:16142624

Hoff, M; Graumüller, S; Pau, H W



Heart rate variability, norepinephrine and ECG changes in subarachnoid hemorrhage patients.  


While electrocardiographic abnormalities in subarachnoid hemorrhage patients have been known since 1947, the provocative mechanism has not yet been satisfactorily explained. The purpose of this study was to evaluate with some tests, the role of autonomic nervous system in provoking the electrocardiographic abnormalities in 22 patients with subarachnoid hemorrhage. The standard electrocardiographic tracings and one-channel computer-based electrocardiographic tracings for spectral analysis of heart rate variability were made. Blood samples for plasma norepinephrine concentrations were taken. Statistically significant parasympathetic hyperactivation between Days 4 and 6 after sudden onset of the disease was found. In standard electrocardiographic tracings in almost all patients transient repolarisation changes and in one patient transient premature ventricular complexes were observed. Plasma norepinephrine concentrations did not parallel electrocardiographic abnormalities. No statistically significant correlation was found among tests of autonomic nervous system activity. Electrocardiographic abnormalities in our group of patients were transient, functional and observed only in the acute phase. They were probably not dependent on elevated plasma norepinephrine concentration. Spectral analysis of heart rate variability failed to explain the role of the autonomic nervous system in provoking the cardiac abnormalities. PMID:8891057

Svigelj, V; Grad, A; Kiauta, T



Automated detection of intracranial aneurysms based on parent vessel 3D analysis  

Microsoft Academic Search

The detection of brain aneurysms plays a key role in reducing the incidence of intracranial subarachnoid hemorrhage (SAH) which carries a high rate of morbidity and mortality. The majority of non-traumatic SAH cases is caused by ruptured intracranial aneurysms and accurate detection can decrease a significant proportion of misdiagnosed cases. A scheme for automated detection of intracranial aneurysms is proposed

Alexandra Lauric; Eric Miller; Sarah Frisken; Adel M. Malek



Small, Asymptomatic, Unruptured Intracranial Aneurysm Found by three-dimensional CT Angiography  

Microsoft Academic Search

Many asymptomat ic, unruptured intracra - nial aneurysms (UIAs) are found by MR angi - ography or CT angiography during the physical checkup. The International Study of Unruptured Intracranial Aneurysms (ISUIA) emphasize that among patients with unruptured aneurysms and no history of subarachnoid hemorrhage, aneu - rismal size at the time of discovery is the most important variable determining the

Chih-Dong Ya



Intraventricular fibrinolysis for severe aneurysmal intraventricular hemorrhage: a randomized controlled trial and meta-analysis.  


The aim of this study was to assess the safety and efficacy of intraventricular fibrinolysis (IVF) for aneurysmal subarachnoid hemorrhage (aSAH) with severe intraventricular hemorrhage (IVH). In this randomized controlled trial, between 2005 and 2009, patients with aSAH and severe IVH were randomly assigned into two groups: one treated with external ventricular drainage (EVD) combined with intraventricular recombinant tissue plasminogen activator (rt-PA) and the second with EVD alone. The primary end-point was mortality rate within the first 30 days. We performed meta-analysis including all published articles that compared IVF + EVD to EVD alone in patients with aSAH IVH. Eleven patients were included in the rt-PA group, eight in the control group. At 30 days, mortality rate was lower in the rt-PA group (45.5 vs. 62.5 %), but results were not statistically significant (p?=?0.65). Clearance of third and fourth ventricles was obtained previously in the rt-PA group (4.25 days) compared to the control group (10.67 days) (p?=?0.001). There was no statistically significant difference concerning the occurrence of complications. The meta-analysis showed a better survival rate with IVF without raised statistical significance (odds ratio?=?0.32 [95 % confidence interval, 0.10-1.03]). This study shows that IVF is as safe as EVD alone for aSAH with severe IVH. It accelerates blood clot resolution in the ventricular system. Mortality rate could be improved by IVF but without significant results. Because of the severity and rarity of this pathology, a multicenter study is required. Clinical Trial Registration Information: (NCT00823485). PMID:23636409

Litrico, Stephane; Almairac, Fabien; Gaberel, Thomas; Ramakrishna, Rohan; Fontaine, Denys; Sedat, Jacques; Lonjon, Michel; Paquis, Philippe



Use of 31P Magnetic Resonance Spectroscopy to Study the Effect of Cortical Magnesium and Energy Metabolism after Subarachnoid Hemorrhage  

Microsoft Academic Search

Background: Flow metabolism coupling ensures adequate cerebral oxygenation. When subarachnoid hemorrhage (SAH) occurs, the flow metabolism coupling lost its balance and results in cerebral ischemia and infarction second to cortical magnesium and energy metabolism alternation. During chronic vasospasm, change in cortical energy metabolism is coupled with change in cerebral blood flow after SAH. Methods: What kind of noninvasive technique can

Heping Yang; Xiangqi Tang; Lihua Tan; Liuwang Zeng; Zhiping Hu



Perigraft Hemorrhage after Abdominal Aortic Aneurysm Repair in a Heart Transplant Patient  

PubMed Central

Spontaneous perigraft hemorrhage can occur years after a successful aortic aneurysm repair. Such hemorrhage can result, in part, from inadequate graft healing. Herein, we describe the case of a heart transplant recipient who underwent an abdominal aortic aneurysm repair that was complicated by an acute perigraft leak 6 weeks later. Apparently, suppression of the patient's immune system impaired proper healing of the graft–aortic anastomosis site. In patients who have a compromised immune system, an additional 4-0 polypropylene pledgeted suture line should be placed for reinforcement during abdominal aortic aneurysm repair. Postoperatively, patients who are given immunosuppressive therapy should undergo careful, long-term monitoring.

Akay, Mehmet H.; Nabzdyk, Christoph S.; Gregoric, Igor D.; Frazier, O. H.



Isoflurane delays the development of early brain injury after subarachnoid hemorrhage through sphingosine-related pathway activation in mice  

PubMed Central

Objective Isoflurane, a volatile anesthetic agent, has been recognized for its potential neuroprotective properties and has antiapoptotic effects. We examined whether isoflurane posttreatment is protective against early brain injury (EBI) after subarachnoid hemorrhage (SAH) and determined whether this effect needs sphingosine-related pathway activation. Design Controlled in vivo laboratory study. Setting Animal research laboratory. Subjects 179 eight-week-old male CD-1 mice weighing 30 to 38 g. Interventions SAH was induced in mice by endovascular perforation. Animals were randomly assigned to sham-operated, SAH-vehicle, and SAH+2% isoflurane. Neurobehavioral function and brain edema were evaluated at 24 and 72 hours. The expression of sphingosine kinase (SphK), phosphorylated Akt (p-Akt) and cleaved caspase-3 was determined by Western blotting and immunofluorescence. Neuronal cell death was examined by terminal deoxynucleotidyl transferase-mediated uridine 5?-triphosphate-biotin nick end-labeling staining. Effects of a SphK inhibitor DMS, or a sphingosine 1 phosphate receptor inhibitor VPC23019 on isoflurane’s protective action against post-SAH EBI were also examined. Measurements and Main Results Isoflurane significantly improved neurobehavioral function and brain edema at 24 hours but not 72 hours after SAH. At 24 hours, isoflurane attenuated neuronal cell death in the cortex, associated with an increase in SphK1 and p-Akt, and a decrease in cleaved caspase-3. The beneficial effects of isoflurane were abolished by DMS and VPC23019. Conclusions Isoflurane posttreatment delays the development of post-SAH EBI through antiapoptotic mechanisms including sphingosine-related pathway activation, implying its use for anesthesia during acute aneurysm surgery or intervention.

Altay, Orhan; Hasegawa, Yu; Sherchan, Prativa; Suzuki, Hidenori; Khatibi, Nikan H.; Tang, Jiping; Zhang, John H.



Impact of anesthesia on pathophysiology and mortality following subarachnoid hemorrhage in rats  

PubMed Central

Background Anesthesia is indispensable for in vivo research but has the intrinsic potential to alter study results. The aim of the current study was to investigate the impact of three common anesthesia protocols on physiological parameters and outcome following the most common experimental model for subarachnoid hemorrhage (SAH), endovascular perforation. Methods Sprague-Dawley rats (n = 38) were randomly assigned to (1) chloral hydrate, (2) isoflurane or (3) midazolam/medetomidine/fentanyl (MMF) anesthesia. Arterial blood gases, intracranial pressure (ICP), mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), and regional cerebral blood flow (rCBF) were monitored before and for 3 hours after SAH. Brain water content, mortality and rate of secondary bleeding were also evaluated. Results Under baseline conditions isoflurane anesthesia resulted in deterioration of respiratory parameters (arterial pCO2 and pO2) and increased brain water content. After SAH, isoflurane and chloral hydrate were associated with reduced MAP, incomplete recovery of post-hemorrhagic rCBF (23 ± 13% and 87 ± 18% of baseline, respectively) and a high anesthesia-related mortality (17 and 50%, respectively). Anesthesia with MMF provided stable hemodynamics (MAP between 100-110 mmHg), high post-hemorrhagic rCBF values, and a high rate of re-bleedings (> 50%), a phenomenon often observed after SAH in humans. Conclusion Based on these findings we recommend anesthesia with MMF for the endovascular perforation model of SAH.



Clipping of a vertebral artery aneurysm behind the hypoglossal nerve under the monitoring of lower cranial nerves  

Microsoft Academic Search

Under an operative view, an aneurysm of the vertebral artery is located behind the lower cranial nerves. To prevent neurological deficits we employed electrophysiological monitoring while clipping an aneurysm of the vertebral artery. A 64-year-old woman had suffered a sudden severe headache in the morning. Computed tomography (CT) revealed a subarachnoid hemorrhage (SAH) and CT angiography revealed an aneurysm at

Mami Ishikawa; Gen Kusaka; Kouichi Takashima; Haruna Kamochi; Soji Shinoda



Evaluation of the Circle of Willis with Three-dimensional CT Angiography in Patients with Suspected Intracranial Aneurysms  

Microsoft Academic Search

PURPOSE: To determine the usefulness of CT angiography in the setting of suspected acute subarachnoid hemorrhage or intracranial aneurysm. METHODS: We prospectively studied 68 patients suspected of having subarachnoid hemorrhage or an intracranial aneurysm with noncon- trast CT of the head followed immediately by contrast-enhanced helical CT of the circle of Willis with three-dimensional reconstruction. Twenty-seven patients with CT findings

Ronald A. Alberico; Mahendra Patel; Sean Casey; Betsy Jacobs; William Maguire; Robert Decker


Delayed cerebral ischemia after subarachnoid hemorrhage: from vascular spasm to cortical spreading depolarizations.  


Non-traumatic subarachnoid hemorrhage (SAH) represents about 5 to 6% of the overall incidence of stroke and is associated with high morbidity and mortality. Despite the substantial research and clinical efforts, delayed cerebral ischemia (DCI) is still the major complication after SAH and represents an important factor for severe neurological deficits. Cerebral vasospasm (VSP) has been recognised for a long time as an important underlying pathophysiologic cause of DCI, but it is now clearer that the mechanisms underlying DCI are multifactorial. Among other pathomechanisms proposed, ischemia-producing cortical spreading depolarizations (CSDs) are likely to be involved in DCI development. Understanding the plethora of different pathophysiological derangements after SAH is very important for the development of new therapies, in order to abolish secondary ischemic brain injuries early-on and improve patients' outcome. In this review, we strive to summarise the mechanisms and therapeutic developments of DCI. PMID:22873726

Zheng, Zelong; Sanchez-Porras, Renan; Santos, Edgar; Unterberg, Andreas W; Sakowitz, Oliver W



Correlation of Head Trauma and Traumatic Aneurysms  

PubMed Central

Summary Subarachnoid hemorrhage following severe trauma to the head is relatively common. In most cases the bleed originates from superficial veins and occasionally from arteries. Following the replacement of cerebral angiography with CT in the diagnostic evaluation of head traumas fewer traumatic aneurysms have been observed. This may indicate that some traumatic aneu-rysms are missed if angiographic procedures are not performed in patients with severe head injury. Trauma patients admitted to our institution are submitted to CT including a bone algorithm. In case of subarachnoid hemorrhage, especially in the basal cisterns, CT- angiography is performed. Digital subtraction angiography is performed as well in cases with uncertain interpretations. During one year 81 patients were admitted with subarachnoid hemorrhage following head trauma. Thirteen (16%) of them underwent CT-angiography and in five (6.2%) with SAH in the basal cistern traumatic aneurysms were found. Four of these cases had a skull base fracture including fractures through the clivus. Four cases were embolized and one very small extradural aneurysm is still not treated. One small pericallosal aneurysm was operated. A traumatic aneurysm should always be suspected n patients with skull base fractures and subarachnoid hemorrhage in the basal cisterns.

Nakstad, P.Hj.; Gjertsen, ?.; Pedersen, H.Kr.



Mild Intraoperative Hypothermia During Surgery for Intracranial Aneurysm  

Microsoft Academic Search

background Surgery for intracranial aneurysm often results in postoperative neurologic deficits. We conducted a randomized trial at 30 centers to determine whether intraoperative cool- ing during open craniotomy would improve the outcome among patients with acute aneurysmal subarachnoid hemorrhage. methods A total of 1001 patients with a preoperative World Federation of Neurological Surgeons score of I, II, or III (\\

Michael M. Todd; Bradley J. Hindman; William R. Clarke; J. C. Torner



Hypercholesterolemia increases vasospasm resulting from basilar artery subarachnoid hemorrhage in rabbits which is attenuated by Vitamin E  

PubMed Central

Background: Aneurysm rupture results in subarachnoid hemorrhage (SAH) with subsequent vasospasm in the cerebral and cerebellar major arteries. In recent years, there has been increasing evidence that hypercholesterolemia plays a role in the pathology of SAH. It is known that hypercholesterolemia is one of the major risk factors for the development of atherosclerosis. Among the factors that have been found to retard the development of atherosclerosis is the intake of a sufficient amount of Vitamin E. An inverse association between serum Vitamin E and coronary heart disease mortality has been demonstrated in epidemiologic studies. Therefore, we tested, in an established model of enhanced cholesterol feed in rabbits, the effects of hypercholesterolemia on vasospasm after SAH by using computed tomography (CT) angiograms of the rabbit basilar artery; in addition, we tested the effects of Vitamin E on these conditions, which have not been studied up to now. Methods: In this study rabbits were divided into 3 major groups: control, cholesterol fed, and cholesterol + Vitamin E fed. Hypercholesterolemia was induced by a 2% cholesterol-containing diet. Three rabbit groups were fed rabbit diet; one group was fed a diet that also contained 2% cholesterol and another group was fed a diet containing 2% cholesterol and they received i.m. injections of 50 mg/kg of Vitamin E. After 8 weeks, SAH was induced by the double-hemorrhage method and distilled water was injected into cisterna magna. Blood was taken to measure serum cholesterol and Vitamin E levels. Basilar artery samples were taken for microscopic examination. CT angiography and measurement of basilar artery diameter were performed at days 0 and 3 after SAH. Results: Two percent cholesterol diet supplementation for 8 weeks resulted in a significant increase in serum cholesterol levels. Light microscopic analysis of basilar artery of hypercholesterolemic rabbits showed disturbances in the subendothelial and medial layers, degeneration of elastic fibers in the medial layer from endothelial cell desquamation, and a reduction of waves in the endothelial layer. However, the cholesterol + Vitamin E group did not exhibit these changes. The mean diameter of the basilar artery after SAH induction in the cholesterol-treated group was decreased 47% compared with the mean diameter of the control group. This value was less affected in cholesterol + Vitamin E-treated rabbits, which decreased 18% compared with the mean diameter of the control group. Conclusions: Hypercholesterolemia-related changes in the basilar artery aggravate vasospasm after SAH. Adding Vitamin E to cholesterol-treated rabbits decreased the degree of vasospasm following SAH in the rabbit basilar artery SAH model. We suggest that Vitamin E supplements and a low cholesterol diet may potentially diminish SAH complicated by vasospasm in high-risk patients.

Sasani, Mehdi; Yazgan, Burak; Celebi, Irfan; Aytan, Nurgul; Catalgol, Betul; Oktenoglu, Tunc; Kaner, Tuncay; Ozer, Nesrin Kartal; Ozer, Ali Fahir



Suppression of the Rho/Rho-Kinase Pathway and Prevention of Cerebral Vasospasm by Combination Treatment with Statin and Fasudil After Subarachnoid Hemorrhage in Rabbit.  


The Rho/Rho-kinase pathway is considered important in the pathogenesis of sustained smooth muscle cell contraction during cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). The aims of this study were to investigate whether combination treatment, with pitavastatin as an inhibitor of RhoA and fasudil as an inhibitor of Rho-kinase, prevents the cerebral vasospasm. SAH was simulated using the double-hemorrhage rabbit model, and pitavastatin, or fasudil, or both (combination treatment) were administrated. The basilar artery (BA) cross-sectional area only in the combination treatment group was statistically larger than in the SAH group (p?

Naraoka, Masato; Munakata, Akira; Matsuda, Naoya; Shimamura, Norihito; Ohkuma, Hiroki



Depletion of Ly6G/C+ cells ameliorates delayed cerebral vasospasm in subarachnoid hemorrhage  

PubMed Central

Background The etiology of delayed cerebral vasospasm (DCV) after aneurismal subarachnoid hemorrhage (SAH) has remained elusive. Growing evidence supports a role for inflammation in the pathogenesis of DCV. We showed that CSF neutrophils predict which patients will develop DCV. Methods We evaluated a murine model of SAH to test the hypothesis that myeloid cells are required for the cerebral damage associated with DCV. Results SAH was associated with decreased middle cerebral artery caliber on day 1 which normalized at day 3 and recurred at day 6. In addition, behavioral testing with a Barnes maze showed executive dysfunction that progressively worsened after the seventh day post hemorrhage. To test the role of innate immune responses, we administrated a myeloid cell-depleting monoclonal antibody against Ly6G/C prior to experimental SAH. Myeloid cell depletion ameliorated angiographic vasospasm measured by MCA vessel caliber and normalized behavioral testing. Conclusion Our findings support the role of Ly6G/C+ cells in the development of DCV after SAH and suggest that immune modulation of neutrophils or other Ly6G/C+ cells may be a strategy for the prevention of DCV.

Altay, Tamer; Smithason, Saksith; Moore, Shari Korday; Ransohoff, Richard M.



The impact of experimental preconditioning using vascular endothelial growth factor in stroke and subarachnoid hemorrhage.  


Vascular endothelial growth factor (VEGF) stimulating angiogenesis was shown to be a potential novel therapeutic approach for the treatment of ischemic vascular diseases. The goal of the present study was to examine whether transfection of VEGF before occurrence of major stroke (part I) and cerebral vasospasm after experimental subarachnoid hemorrhage (SAH; part II) develops neuroprotective qualities. A total of 25 (part I) and 26 (part II) brains were analyzed, respectively. In part one, a significant reduction of infarct volume in the VEGF-treated stroke animals (43% reduction, P < 0.05) could be detected. In part two, significant vasospasm was induced in all hemorrhage groups (P < 0.02). Analyzing microperfusion, a significant higher amount of perfused vessels could be detected (P < 0.01), whereas no significant effect could be detected towards macroperfusion. Histologically, no infarctions were observed in the VEGF-treated SAH group and the sham-operated group. Minor infarction in terms of vasospasm-induced small lesions could be detected in the control vector transduced group (P = 0.05) and saline-treated group (P = 0.09). The present study demonstrates the preconditioning impact of systemic intramuscular VEGF injection in animals after major stroke and induced severe vasospasm after SAH. PMID:23634319

Eicker, Sven Oliver; Hoppe, Moritz; Etminan, Nima; Macht, Stephan; Perrin, Jason; Steiger, Hans-Jakob; Hänggi, Daniel



[Blood flow in cerebral aneurysms].  


Saccular aneurysm of the cerebral arteries occur in 1 to 5% of the population; the major risk of this disease is aneurysm rupture causing subarachnoid hemorrhage associated with a mortality rate of 50 to 60%. Two methods exist to treat cerebral aneurysms: neurosurgical clipping at the base of the aneurysm and endovascular introduction of a platin coils. Both methods have advantages and disadvantages. With the knowledge of the flow in an aneurysm it is easier to choose the appropriate method. In this study we simulated the flow in four different aneurysms. The shape of the aneurysms are gained from computertomographic data. The simulated flow in four aneurysms shows the great variability of possible flow patterns. PMID:12451841

Kertzscher, U; Goubergrits, L; Spuler, A; Affeld, K



An audit of aneurysmal subarachnoid haemorrhage: earlier resuscitation and surgery reduces inpatient stay and deaths from rebleeding.  

PubMed Central

OBJECTIVE--To audit the outcome in patients with subarachnoid haemorrhage (SAH) after a change in management strategy. METHODS--A retrospective analysis of patients with aneurysmal subarachnoid haemorrhage over a 20 month period (phase 1) was followed by a prospective analysis of patients presenting during the next 20 months (phase 2) in which a protocol driven management regime of immediate intravenous fluid resuscitation and earlier surgery was pursued. Patients in this phase were grouped into those receiving early (within four days of subarachnoid haemorrhage) and late (after four days of subarachnoid haemorrhage) surgery. In phase 1, 75 out of a total of 92 patients underwent surgery on (median) day 12. From phase 2, 109 patients out of a total of 129 underwent surgery on (median) day 4, 58 of which had their surgery within 4 days of the subarachnoid haemorrhage. Patients in each phase/group were well matched for demographic features, site of aneurysm, and severity of subarachnoid haemorrhage. RESULTS--The surgical morbidity and mortality were no different in the two phases (P < 0.92; chi2 test). The management outcomes in the two phases of the study were also no different (P < 0.52). However, there was a significant reduction in the rebleed rate in patients undergoing surgery within four days of the subarachnoid haemorrhage in phase 2 (P < 0.0001) with an associated trend towards reduced incidence of postoperative ischaemia (P = 0.06) and mortality (P = 0.11). Operating earlier in phase 2 of the trial resulted in a lower total hospital inpatient stay of 15.8 (95% CI 13.1-18.5) days for survivors compared with 25.7 (95% CI 21.6-29.8) days in the late group (P < 0.00001; t test). CONCLUSIONS--surgical morbidity and mortality seemed independent of the timing of aneurysm surgery. Early surgery within four days was associated with a highly significant reduction in rebleed rate, and in the duration of total hospital inpatient stay. Images

Whitfield, P C; Moss, H; O'Hare, D; Smielewski, P; Pickard, J D; Kirkpatrick, P J



From multidimensional neuropsychological outcomes to a cognitive complication rate: The International Subarachnoid Aneurysm Trial  

PubMed Central

Background The neuropsychological arm of the International Subarachnoid Aneurysm Trial (N-ISAT) evaluated the cognitive outcome of 573 patients at 12 months following subarachnoid haemorrhage (SAH). The assessment included 29 psychometric measures, yielding a substantial and complex body of data. We have explored alternative and optimal methodologies for analysing and summarising these data to enable the estimation of a cognitive complication rate (CCR). Any differences in cognitive outcome between the two arms of the trial are not however reported here. Methods All individual test scores were transformed into z-scores and a 5th percentile cut-off for impairment was established. A principal components analysis (PCA) was applied to these data to mathematically transform correlated test scores into a smaller number of uncorrelated principal components, or cognitive 'domains'. These domains formed the basis for grouping and weighting individual patients' impaired scores on individual measures. In order to increase the sample size, a series of methods for handling missing data were applied. Results We estimated a 34.1% CCR in all those patients seen face-to-face, rising to 37.4% CCR with the inclusion of patients who were unable to attend assessment for reason related to the index SAH. This group demonstrated significantly more self and carer/relative rated disability on a Health Related Quality of Life questionnaire, than patients classified as having no functionally significant cognitive deficits. Conclusion Evaluating neuropsychological outcome in a large RCT involves unique methodological and organizational challenges. We have demonstrated how these problems may be addressed by re-classifying interval data from 29 measures into a dichotomous CCR. We have presented a 'sliding scale' of undifferentiated individual cognitive impairments, and then on the basis of PCA-derived cognitive 'domains', included consideration of the distribution of impairments in these terms. In order to maximize sample size we have suggested ways for patients who did not complete the entire protocol to be included in the overall CCR. ISAT trial registration ISRCTN49866681

Scott, Richard B; Eccles, Fiona; Lloyd, Andrew; Carpenter, Katherine



Predictors of Subarachnoid Hemorrhage in Acute Ischemic Stroke with Endovascular Therapy  

PubMed Central

Background and Purpose Subarachnoid hemorrhage (SAH) is a potential hemorrhagic complication after endovascular intracranial recanalization. The purpose of this study was to describe the frequency and predictors of SAH in acute ischemic stroke patients treated endovascularly, and its impact on clinical outcome. Methods Acute ischemic stroke (AIS) patients treated with primary mechanical thrombectomy, intra-arterial thrombolysis (IAT), or both were analyzed. Post-procedural CT and MR images were reviewed to identify the presence of SAH. We assessed any decline in the National Institutes of Health Stroke Scale (NIHSS) score 3 hours post-intervention and outcomes at discharge. Results One hundred twenty-eight patients were treated by primary thrombectomy with Merci Retriever devices, while 31 were treated by primary IAT. Twenty patients experienced SAH- eight with pure SAH, and twelve with co-existing parenchymal hemorrhages. SAH was numerically more frequent with primary thrombectomy than IAT groups (14.1% versus 6.5%, p=0.37). On multivariate analysis, independent predictors of SAH were hypertension (OR 5.39; p=0.035), distal middle cerebral artery (MCA) occlusion (OR 3.53; p=0.027), use of rescue angioplasty after thrombectomy (OR 12.49; p=0.004), and procedure-related vessel perforation (OR 30.72; p<0.001). Patients with extensive SAH or co-existing parenchymal hematomas tended to have more neurologic deterioration at 3 hours (28.6% versus 0%; p=0.11), to be less independent at discharge (modified Rankin Scale ? 2, 0% versus 15.4%; p=0.5); and to more often die during hospitalization (42.9% versus 15.4%; p=0.29). Conclusions Procedure-related vessel perforation, rescue angioplasty after thrombectomy with Merci devices, distal MCA occlusion, and hypertension were independent predictors of SAH following endovascular therapy for AIS. Only extensive SAH or SAH accompanied by severe parenchymal hematomas may worsen clinical outcome at discharge.

Shi, Zhong-Song; Liebeskind, David S; Loh, Yince; Saver, Jeffrey L; Starkman, Sidney; Vespa, Paul M; Gonzalez, Nestor R.; Tateshima, Satoshi; Jahan, Reza; Feng, Lei; Miller, Chad; Ali, Latisha K; Ovbiagele, Bruce; Kim, Doojin; Duckwiler, Gary R; Vinuela, Fernando



Intracisternal infusion of magnesium sulfate solution improved reduced cerebral blood flow induced by experimental subarachnoid hemorrhage in the rat  

Microsoft Academic Search

Magnesium has neuroprotective and antivasospastic properties in the presence of subarachnoid hemorrhage (SAH). The present\\u000a study investigated the effect of intracisternal administration of magnesium on cerebral vasospasm in the experimental SAH\\u000a rat model. The rat double-SAH model (0.2 mL autologous blood injected twice into the cisterna magna) was used. Normal saline\\u000a (SAH group, N?=?8) or 10 mmol\\/L magnesium sulfate in normal saline

Kentaro Mori; Masahiro Miyazaki; Junko Iwata; Takuji Yamamoto; Yasuaki Nakao



Role of ERK1\\/2 and vascular cell proliferation in cerebral vasospasm after experimental subarachnoid hemorrhage  

Microsoft Academic Search

Background  Although there are still some unresolved aspects, current research has revealed that vascular cell proliferation probably\\u000a plays an important part in the pathological formation process of cerebral vasospasm. Using a “two-hemorrhage” model of subarachnoid\\u000a hemorrhage (SAH), this study investigated the function of ERK1\\/2 and vascular wall cell proliferation in pathological development\\u000a of cerebral vasospasm.\\u000a \\u000a \\u000a \\u000a Methods  Fifty rabbits were randomly divided into

Duo Chen; Jian-Jun Chen; Qiang Yin; Jun-Hong Guan; Yun-Hui Liu



Does Isolated Traumatic Subarachnoid Hemorrhage Affect Outcome in Patients With Mild Traumatic Brain Injury?  


BACKGROUND:: The importance of isolated traumatic subarachnoid hemorrhage (SAH) in relation to functional outcome in patients with mild traumatic brain injury (TBI) has not been frequently studied. The aim of this study was to compare the impact of isolated SAH with normal computed tomographic (CT) scan on outcome of patients with mild TBI. METHODS:: This is a retrospective study of clinical records and CT scans of all patients with mild TBI (Glasgow Coma Scale score ?13) evaluated from January 1, 2010, to March 15, 2010, at our institution. The patients were divided into 2 groups: isolated SAH and normal CT scan. The telephonic Glasgow Outcome Scale-Extended, Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ), and Rivermead Head Injury Follow-up Questionnaire (RHFUQ) scores were used to assess outcome after 1 year of injury. Independent sample t test in SPSS was used to assess difference in outcome. RESULTS:: A total of 1149 patients with mild TBI were evaluated during study period. Among them, 34 (2.9%) patients had isolated SAH. Twenty-eight patients were male and 6 were female, with a mean age of 36.5 years. Subarachnoid hemorrhage was cortical in 19 (55.9%) patients, interhemispheric in 3 (8.8%) patients, Sylvian fissure in 2 (5.9%) patients, and basal cisternal in 1 (2.9%) patient. Nine (26.5%) patients had SAH at multiple locations. The mean RPCSQ and RHFUQ scores for patients with isolated SAH were 1.38 ± 2.40 and 1.11 ±3.305, respectively. The mean RPCSQ and RHFUQ scores for patients with normal CT scans were 0.40 ± 1.549 and 0.533 ± 1.59, respectively. There was no significant difference in the outcome scores between the SAH and the normal CT scan groups (RHFUQ, P = .45; RPCSQ, P = .248). CONCLUSION:: In our study sample of patients with mild TBI, there is no difference in outcome of patients with isolated SAH compared with those with normal CT scans 1 year after injury. PMID:22832372

Deepika, Akhil; Munivenkatappa, Ashok; Devi, Bhagavatula Indira; Shukla, Dhaval



Feasibility and methodology of optical coherence tomography imaging of human intracranial aneurysms: ex vivo pilot study  

NASA Astrophysics Data System (ADS)

Rupture of intracranial aneurysm is a common cause of subarachnoid hemorrhage. An aneurysm may undergo microscopic morphological changes or remodeling of the vessel wall prior to rupture, which could potentially be imaged. In this study we present methods of tissue sample preparation of intracranial aneurysms and correlation between optical coherence tomography imaging and routine histology. OCT has a potential future in the assessment of microscopic features of aneurysms, which may correlate to the risk of rupture.

Vuong, Barry; Sun, Cuiru; Khiel, Tim-Rasmus; Gardecki, Joseph A.; Standish, Beau A.; da Costa, Leodante; de Morais, Josaphat; Tearney, Guillermo J.; Yang, Victor X. D.



Bath-related thunderclap headache associated with subarachnoid and intracerebral hemorrhage.  


Purpose: Bath-related thunderclap headache (BRTH) is a rare and usually benign condition. We report a case of episodic explosive thunderclap headache (TH) provoked by showering water, with the complications of cortical subarachnoid hemorrhages (SAH) and delayed intracerebral hemorrhage (ICH). Case Report: A 56-year-old premenopausal woman, without chronic illness or headache history, suffered from 4 episodes of severe explosive TH within 11 days. Two of these attacks were provoked by hot water and 1 by cold water. A small acute SAH was found in the left high frontal cortex on brain computed tomography (CT) performed 7 days after the first attack (day 7). Brain magnetic resonance imaging (MRI) and angiography (MRA) on day 9 disclosed a new acute SAH in the right frontal cortex but with no apparent vasoconstriction. CT angiography (CTA) on day 12 first revealed vasoconstriction in the M2 segment of right middle cerebral artery (MCA), and found a new ICH in the right anterior frontal lobe. Conventional angiography on day 14 revealed partial remission of vasoconstriction with only mild short segmental narrowing at the proximal M1 segment of right MCA. The patient had no clinical neurological deficit. She was free of headache at day 11 when she started taking nimodipine. Conclusion: Reversible cerebral vasoconstriction syndrome (RCVS) presented with BRTH is rare and is not always that benign as was once thought. The delayed ICH and the short-period of vasoconstriction in this patient extended our knowledge that the time course of the complications and the duration of vasospasm in RCVS could vary widely among patients. Nimodipine is probably effective in both relieving symptoms and reversing vasoconstriction. PMID:24030092

Jhang, Kai-Ming; Lin, Chun-Hsiang; Lee, Kwo-Whei; Chen, Yen-Yu



Acute hypoperfusion immediately after subarachnoid hemorrhage: a xenon contrast-enhanced CT study.  


The acute neurological deficit present immediately after subarachnoid hemorrhage (SAH) correlates with overall outcome. Only limited data are available to quantify changes in cerebral perfusion in this acute phase, and this study sought to characterize those changes within the first 12 h post-SAH. Xenon contrast-enhanced CT scanning was performed in 17 patients (Hunt and Hess grade [HH] 1-3, n = 9; HH 4-5, n = 8) within 12 h after SAH. Cerebral blood flow (CBF) was analyzed in all cortical and central vascular regions of interest (ROI), as well as infratentorial ROI. Hemodynamic stress distribution (central/cortical ROI) was also calculated. Asymptomatic patients without perfusion deficits served as controls (n = 5), and Glasgow Outcome Scale score (GOS) was determined 3 months after the event. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were within normal limits in all patients. CBF was significantly reduced in all patients with SAH (34 mL/100 g x min) compared to controls (67 mL/100 g x min; p < 0.001). Patients in better clinical condition (HH 1-3) presented with significantly less reduction of CBF (41 mL/100 g x min) compared to patients with more severe hemorrhage (HH 4-5: 24 mL/100 g x min; p < 0.001), and had better outcomes. Changes in perfusion were more pronounced in supratentorial than in infratentorial ROI. Hemodynamic stress distribution was most pronounced in patients with higher HH grade (p < 0.05). The first 12 h after SAH are characterized by persistent, severe reduction of CBF, which in turn correlates with HH grade, but is independent of ICP or CPP. Acute peripheral vasospasm of the microvasculature, not detectable by conventional angiography, may account for this early phase of prolonged hypoperfusion. PMID:19929373

Schubert, Gerrit Alexander; Seiz, Marcel; Hegewald, Aldemar Andrés; Manville, Jérôme; Thomé, Claudius



Effects of meteorological factors on the onset of subarachnoid hemorrhage: a time-series analysis.  


Previous studies have suggested a possible association between meteorological factors and the onset of subarachnoid hemorrhage (SAH). We aimed to investigate the relationship between the onset of SAH and meteorological factors based on an hourly time-series analysis. We collected hourly data on transportation of patients with SAH using the ambulance records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected hourly meteorological data for Tokyo from the Japan Meteorological Agency during the same period. We performed a time-series analysis using the autoregressive integrated moving average (ARIMA) model to control for autocorrelations in the time-series data. There were 1729 patients with SAH (mean age 63.3 years; 60.2% women). We identified two circadian patterns in the onset of SAH: a daily peak at 10 am (p<0.001) and a seasonal peak in February (p<0.001). Based on the ARIMA time-series analysis, significant risk factors associated with the onset of SAH included: low temperature on the previous day (lag time 17h; p=0.005) and on the onset day (lag time 0h; p<0.001); high barometric pressure on the onset day (lag time 0h; p=0.001). Humidity was not associated with the onset of SAH. Among meteorological factors, low temperature and high barometric pressure may be risk factors for the onset of SAH. PMID:18617401

Abe, Toshikazu; Ohde, Sachiko; Ishimatsu, Shinichi; Ogata, Hiromitsu; Hasegawa, Takahiro; Nakamura, Tomohiko; Tokuda, Yasuharu



Changes in responsiveness of the canine basilar artery to endothelin-1 after subarachnoid hemorrhage  

SciTech Connect

The effect of endothelin-1 (ET-1) on the basilar arteries from control and subarachnoid hemorrhage (SAH) dogs were examined. The maximal contraction of the basilar artery in response to ET-1 was markedly decreased in the SAH group. Treatment with 10{sup {minus}8}M phorbol 12-myristate 13-acetate (PMA) reduced the contractile responses to ET-1 in the basilar arteries from control dogs. ET-1-induced contractions of the basilar arteries from control dogs were similar to those in strips from SAH dogs by the treatment with 10{sup {minus}8}M PMA. Ca{sup 2+}-induced contraction of the basilar arteries which were depolarized with isotonic K{sup +} were significantly attenuated in SAH dogs. Treatment with PMA also reduced the contractile responses to Ca{sup 2+} in the basilar arteries from control dogs. These results indicate that decreased contractile responses of the basilar arteries to ET-1 and Ca{sup 2+} in the SAH group may be related to changes in the activity of the protein kinase C in vascular smooth muscle.

Kamata, Katsuo; Nishiyama, Hiroshi; Kasuya, Yutaka (Taisho Pharmaceutical Co. Ltd., Saitama (Japan)); Miyata, Noriyuki (Hoshi Univ., Tokyo (Japan))



[Odontoid fracture: Long-term subarachnoid hemorrhage after anterior screw fixation. Case report and literature review].  


Odontoid fractures have been classified by Anderson and D'Alonzo into three main categories. The most unstable injuries, type II fractures involve the base of the odontoid peg at the junction with the C2 body. Due to the proximity of vital neural structures, fracture of the odontoid process may result in instability and fatal neurological damage. Treatment aims to re-establish stability of the atlanto-axial complex by restoring the odontoid process. This may be achieved by conservative or surgical treatment. Anterior screw fixation of the odontoid peg is an interresting alternative surgical option but this technique has a significant complication rate. However, vascular injury is very rare with three case reported in the literature: one case of an intracranial vertebral artery (VA) injury, one case of a cervical internal carotid artery (ICA) injury and one case of anterior pseudoaneurysm of the spinal artery branch. We report a new case of long term vascular injury after screw fixation revealed by a subarachnoid hemorrhage. We discuss the incidence, the mechanisms of injury and the conditions necessary for the occurrence of this complication. PMID:22683208

Le Corre, M; Suleiman, N; Lonjon, N



Genetic elimination of eNOS reduces secondary complications of experimental subarachnoid hemorrhage.  


Delayed complications of subarachnoid hemorrhage (SAH) such as angiographic vasospasm, cortical spreading ischemia, microcirculatory dysfunction, and microthrombosis are reported in both patients and animal models of SAH. We demonstrated previously that SAH is associated with increased oxidative stress in the brain parenchyma, and that this correlates with dysfunction of endothelial nitric oxide synthase (eNOS) (homodimeric uncoupling). Uncoupling of eNOS exacerbated oxidative stress and enhanced nitric oxide (NO) depletion, and was associated with multiple secondary complications such as microthrombosis, neuronal apoptosis, and release of reactive oxygen species. Thus, we hypothesized that genetic abbrogation of eNOS would confer a beneficial effect on the brain after SAH. Using a prechiasmatic injection model of SAH, we show here that eNOS knockout (KO) significantly alleviates vasospasm of the middle cerebral artery and reduces superoxide production. Endothelial nitric oxide synthase KO also affected other nitric oxide synthase isoforms. It significantly increases neuron nitric oxide synthase expression but has no effect on inducible nitric oxide synthase. Endothelial nitric oxide synthase KO decreases Zn(2+) release after SAH, reduces microthrombi formation, and prevent neuronal degeneration. This work is consistent with our findings where, after SAH, increased oxidative stress can uncouple eNOS via Zn(2+) thiolate oxidation, or theoretically by depletion or oxidation of tetrahydrobiopterin, resulting in a paradoxical release of superoxide anion radical, further exacerbating oxidative stress and microvascular damage. PMID:23549379

Sabri, Mohammed; Ai, Jinglu; Lass, Elliot; D'abbondanza, Josephine; Macdonald, R Loch



Pharmacologic reduction of angiographic vasospasm in experimental subarachnoid hemorrhage: systematic review and meta-analysis.  


Animal models have been developed to simulate angiographic vasospasm secondary to subarachnoid hemorrhage (SAH) and to test pharmacologic treatments. Our aim was to evaluate the effect of pharmacologic treatments that have been tested in humans and in preclinical studies to determine if animal models inform results reported in humans. A systematic review and meta-analysis of SAH studies was performed. We investigated predictors of translation from animals to humans with multivariate logistic regression. Pharmacologic reduction of vasospasm was effective in mice, rats, rabbits, dogs, nonhuman primates (standard mean difference of -1.74; 95% confidence interval -2.04 to -1.44) and humans. Animal studies were generally of poor methodologic quality and there was evidence of publication bias. Subgroup analysis by drug and species showed that statins, tissue plasminogen activator, erythropoietin, endothelin receptor antagonists, calcium channel antagonists, fasudil, and tirilazad were effective whereas magnesium was not. Only evaluation of vasospasm >3 days after SAH was independently associated with successful translation. We conclude that reduction of vasospasm is effective in animals and humans and that evaluation of vasospasm >3 days after SAH may be preferable for preclinical models. PMID:22534672

Zoerle, Tommaso; Ilodigwe, Don C; Wan, Hoyee; Lakovic, Katarina; Sabri, Mohammed; Ai, Jinglu; Macdonald, R Loch



CSF and Serum Biomarkers Focusing on Cerebral Vasospasm and Ischemia after Subarachnoid Hemorrhage  

PubMed Central

Delayed cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) remain severe complications after subarachnoid hemorrhage (SAH). Although focal changes in cerebral metabolism indicating ischemia are detectable by microdialysis, routinely used biomarkers are missing. We therefore sought to evaluate a panel of possible global markers in serum and cerebrospinal fluid (CSF) of patients after SAH. CSF and serum of SAH patients were analyzed retrospectively. In CSF, levels of inhibitory, excitatory, and structural amino acids were detected by high-performance liquid chromatography (HPLC). In serum, neuron-specific enolase (NSE) and S100B level were measured and examined in conjunction with CVS and DCI. CVS was detected by arteriography, and ischemic lesions were assessed by computed tomography (CT) scans. All CSF amino acids were altered after SAH. CSF glutamate, glutamine, glycine, and histidine were significantly correlated with arteriographic CVS. CSF glutamate and serum S100B were significantly correlated with ischemic events after SAH; however, NSE did not correlate neither with ischemia nor with vasospasm. Glutamate, glutamine, glycine, and histidine might be used in CSF as markers for CVS. Glutamate also indicates ischemia. Serum S100B, but not NSE, is a suitable marker for ischemia. These results need to be validated in larger prospective cohorts.

Jung, Carla S.; Lange, Bettina; Zimmermann, Michael; Seifert, Volker



Inhibition of Rho kinase by Hydroxyfasudil Attenuates Brain Edema after Subarachnoid Hemorrhage in Rats  

PubMed Central

The blood-brain barrier (BBB) disruption and brain edema are important pathophysiologies of early brain injury after subarachnoid hemorrhage (SAH). This study is to evaluate whether Rho kinase (Rock) enhances BBB permeability via disruption of tight junction proteins during early brain injury. Adult male rats were assigned to five groups; sham-operated, SAH treated with saline, a Rock inhibitor hydroxyfasudil (HF) (10mg/kg) treatment at 0.5 hours after SAH, HF treatment at 0.5 and 6 hours (10mg/kg, each) after SAH, and another Rock inhibitor Y27632 (10mg/kg) treatment at 0.5 hrs after SAH. The perforation model of SAH was performed and neurological score and brain water content were evaluated 24 and 72 hours after surgery. Evans blue extravasation, Rock activity assay, and Western blotting analyses were evaluated 24 hours after surgery. Treatment of HF significantly improved neurological scores 24 hours after SAH. Single treatment with HF and Y27632, and two treatments with HF reduced brain water content in the ipsilateral hemisphere. HF reduced Evans blue extravasation in the ipsilateral hemisphere after SAH. Rock activity increased 24 hours after SAH, and HF reversed the activity. SAH significantly decreased the levels of tight junction proteins, occludin and zonula occludens-1 (ZO-1), and HF preserved the levels of occluding and ZO-1 in ipsilateral hemisphere. In conclusion, HF attenuated BBB permeability after SAH, possibly by protection of tight junction proteins.

Fujii, Mutsumi; Duris, Kamil; Altay, Orhan; Soejima, Yoshiteru; Sherchan, Prativa; Zhang, John H.



L-arginine improves cerebral blood perfusion and vasomotion of microvessels following subarachnoid hemorrhage in rats.  


The purpose of this study is to investigate the effect of L-arginine (L-Arg) on cerebral blood perfusion and vasomotion (perfusion motion) in microvessels following subarachnoid hemorrhage (SAH). Rat noncraniotomy SAH models were used and animals were divided into sham-operated, saline-treated, and L-Arg-treated groups. L-Arg was injected intraperitoneally 30 minutes before the operation and repeated every 6 hours, with a single dose of 0.5 g/kg bw. Dynamic changes in regional cerebral blood flow (CBF) and vasomotion within 24 hours were measured using a laser Doppler flow-meter probe. Serum nitric oxide (nitrite/nitrate) and plasma endothelin-1 levels were also measured at different time points within 24 hours. Morphologic changes in neurons in the hippocampus CA1 region were examined. SAH gave rise to an immediate and persistent decrease in CBF in saline-treated rats. Abnormal vasomotions with decreased frequency and amplitude were observed. Serum nitric oxide decreased, while plasma endothelin-1 increased significantly. Neurons in the hippocampus CA1 region were severely damaged. The above pathological alterations in the L-Arg-treated group were alleviated. It was concluded that L-Arg, which increases cerebral blood perfusion and improves vasomotions of microvessels by enhancing nitric oxide levels and decreasing endothelin-1 levels in blood, exerts a protective effect on secondary cerebral ischemic injury following experimental SAH. PMID:14724366

Sun, Bao-Liang; Zhang, Su-Ming; Xia, Zuo-Li; Yang, Ming-Feng; Yuan, Hui; Zhang, Jian; Xiu, Rui-Juan



Endovascular Treatment of Intracranial Ruptured Aneurysms Associated with Arteriovenous Malformations: a Clinical Analysis of 14 Hemorrhagic Cases  

PubMed Central

Summary This study investigated and summarized endovascular therapeutic strategies for intracranial ruptured aneurysms associated with arteriovenous malformations (AVMs). Between June 2005 and June 2009, we identified 16 aneurysms in 14 hemorrhagic cases of intracranial AVM using digital subtraction angiography (DSA). Of the 16 aneurysms, 14 were ruptured and two were unruptured. Aneurysms were classified as types I to IV, and were treated. Aneurysm treatment was followed by AVM treatment via various therapies, including embolization, gamma knife radiotherapy, or follow-up and observation to reduce the risk of aneurysm rupture or intracranial hemorrhage. Over a follow-up period ranging from six months to one year, none of the patients had aneurysm ruptures or intracranial hemorrhage. Most (13/14) patients had a Glasgow Outcome Scale (GOS) score of 5, and one patient had a score of 4. Sixteen aneurysms were treated successfully, as confirmed by DSA examination, and no AVMs re-grew. Clinical therapeutic strategies for intracranial ruptured aneurysms associated with AVMs should include aneurysm treatment first to reduce the risk of rupture and intracranial hemorrhage, eventually leading to a better prognosis.

Yu, J.-L.; Yang, S.; Luo, Q.; Wang, H.-L.; Wang, B.; Qu, Y.-Y.; Xu, K.



Numerical simulation of aneurysm hemodynamics  

NASA Astrophysics Data System (ADS)

Rupture of intracranial aneurysms is the leading cause of spontaneous subarachnoid hemorrhage, with high rates of morbidity and mortality. Numerical simulations of flow in a variety of two-dimensional and three-dimensional saccular aneurysm geometries were performed to evaluate possible sites and mechanisms for aneurysm growth and rupture. The governing equations were solved in their finite volume formulation for both steady and pulsatile flows. Recirculation zones and secondary flows were observed in aneurysms and arteries. Regions of elevated and oscillating shear stress were observed, often at the aneurysm's distal shoulder. The influence of several geometric factors, including vessel curvature, branching angle, and aneurysm shape, on flow patterns and fluid mechanical forces was studied, with the goal of assessing the risks posed by given aneurysm geometry.

MacVicar, Stephen; Huynh, Sophia; Rossmann, Jenn



Heritability of Intracerebral Hemorrhagic Lesions and Cerebral Aneurysms in the Rat  

Microsoft Academic Search

Background and Purpose—Under certain conditions, the Brown Norway (BN) rat is susceptible to intracerebral hemorrhagic vascular (ICV) lesions within the cerebral cortex, whereas the Long-Evans (LE) rat is prone to develop aneurysms in the circle of Willis. The incidence of these 2 pathological phenotypes was studied in progeny of different BNXLE crosses to determine their heritability in these new rat

Michele Coutard; Wei Huang; Mary Osborne-Pellegrin


Hematoma in the splenium of the corpus callosum in the subacute stage of subarachnoid hemorrhage--three case reports.  


Three patients developed hemorrhage in the splenium of the corpus callosum 2 weeks after the onset of subarachnoid hemorrhage (SAH) associated with acute hydrocephalus. Computed tomography performed a few days after the onset showed a low density area in the splenium of corpus callosum in all three patients, and preventive measures against symptomatic vasospasm were begun, including vasodilator administration. Computed tomography showed hemorrhage in the splenium of the corpus callosum 17 to 22 days after onset of SAH, manifesting as mental deterioration or headache. Antivasospasm agents were immediately discontinued, and strict blood control measures were instituted. Splenial hematoma is another potential cause of neurological deterioration after surgery for SAH, in addition to vasospasm, hydrocephalus, and rebleeding. PMID:20339269

Sorimachi, Takatoshi; Yajima, Naoki; Sasaki, Osamu; Koike, Tetsuo; Fujii, Yukihiko



Open surgical management of a ruptured intracranial aneurysm in Klippel-Trenaunay-Weber (KTW) syndrome.  


A 24-year-old man with a history of Klippel-Trenaunay-Weber syndrome presented with severe headache and neck pain. Work-up revealed subarachnoid hemorrhage and evidence of multiple intracranial aneurysms. The patient was treated with open surgical clipping of his ruptured aneurysm and is currently doing well. PMID:23314873

Smitherman, Adam Derik; Woodall, Michael Neil; Alleyne, Cargill H; Rahimi, Scott Y



Cognitive domain deficits in patients with aneurysmal subarachnoid haemorrhage at 1 year  

PubMed Central

Background Cognitive domain deficits can occur after aneurysmal subarachnoid haemorrhage (aSAH) though few studies systemically evaluate its impact on 1-year outcomes. Objective We aimed to evaluate the pattern and functional outcome impact of cognitive domain deficits in aSAH patients at 1?year. Methods We carried out a prospective observational study in Hong Kong, during which, 168 aSAH patients (aged 21–75?years and had been admitted within 96?h of ictus) were recruited over a 26-month period. The cognitive function was assessed by a domain-specific neuropsychological assessment battery at 1?year after ictus. The current study is registered at of the US National Institutes of Health (NCT01038193). Results Prevalence of individual domain deficits varied between 7% to 15%, and 13% had two or more domain deficits. After adjusting for abbreviated National Institute of Health Stroke Scale and Geriatric Depressive Scale scores, unfavourable outcome (Modified Rankin Scale 3–5) and dependent instrumental activity of daily living (Lawton Instrumental Activity of Daily Living<15) were significantly associated with two or more domain deficits and number of cognitive domain deficits at 1?year. Two or more domain deficits was independently associated with age (OR, 1.1; 95% CI 1.1 to 1.2; p<0.001) and delayed cerebral infarction (OR, 6.1; 95% CI 1.1 to 33.5; p=0.036), after adjustment for years of school education. Interpretation In patients with aSAH, cognitive domain deficits worsened functional outcomes at 1?year. Delayed cerebral infarction was an independent risk factor for two or more domain deficits at 1?year.

Wong, George Kwok Chu; Lam, Sandy Wai; Ngai, Karine; Wong, Adrian; Siu, Deyond; Poon, Wai Sang; Mok, Vincent





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Intracranial vasospasm with subsequent stroke after traumatic subarachnoid hemorrhage in a 22-month-old child.  


Clinical and radiographic evidence of subarachnoid hemorrhage (SAH)-related vasospasm is rare in children and has not been reported in infants. In this report the authors present the case of a 22-month-old child who developed clinically symptomatic, radiographically identifiable vasospasm after traumatic SAH. To the authors' knowledge, this is the first report of vasospasm associated with SAH in a child this young. This 22-month-old boy fell and had a dense SAH. He had a history of surgically corrected craniosynostosis and nonsymptomatic ventriculomegaly. The boy was evaluated for occult vascular lesions using imaging; none were found and normal vessel caliber was noted. Ten days later, the child developed left-sided weakness and a right middle cerebral artery infarct was identified. Evaluation disclosed significant intracranial vasospasm. This diagnosis was supported by findings on CT angiography, transcranial Doppler ultrasonography, MR imaging, and conventional angiography. The child was treated using intraarterial verapamil with a good result, as well as with conventional intensive care measures to reduce vasospasm. This report documents the first known case of intracranial vasospasm with stroke after SAH in a patient under the age of 2 years. This finding is important because it demonstrates that the entity of SAH-associated vasospasm can affect the very young, widening the spectrum of ages susceptible to this condition. This case is also important because it demonstrates that even very young children can respond to conventional therapeutic interventions such as intraarterial verapamil. Thus, clinicians need to be alert to the possibility of vasospasm as a potential diagnosis when evaluating young children with SAH. PMID:19338410

Nahed, Brian V; Ferreira, Manuel; Naunheim, Matthew R; Kahle, Kristopher T; Proctor, Mark R; Smith, Edward R



Family and friends' fears of recurrence: impact on the patient's recovery after subarachnoid hemorrhage.  


Object Patients with subarachnoid hemorrhage (SAH) and their close friends and family may be excessively fearful that the patient will have a recurrence, and such fears could play a critical role in the poor recovery shown by many patients The authors examined whether these fears could account for significant variance in psychosocial outcomes. Methods The authors prospectively studied a sample of 69 patients with SAH alongside their spouse, other family member, and/or close friend identified as their significant other (SO). The patient/SO pairs were assessed at 13 months postictus for their fears of recurrence and for health-related quality of life on the 8 domains of the 36-Item Short Form Health Survey. Results The SOs were found to be significantly more fearful of SAH recurrence than the patients. The SO's fears also explained unique variance in the patient's recovery on 4 of the 36-Item Short Form Health Survey domains over and above the patient's own fears, demographic and/or neurological variables, and the patient's history of psychiatric or neurological problems. The domains affected reflected activity-based and functional aspects of the patient's quality of life as opposed to more general characteristics of their emotional well-being or physical health state. Conclusions The patient's recovery may be compromised if their spouse, close family, and/or friends are excessively fearful about their suffering a recurrence. Perhaps the SO's fears cause them to be overprotective of the patient and to restrict their day-to-day activities. Attention must therefore be given to the experience of having a loved one suffer from an SAH, and alleviating the caregiver's fears could help to promote a better outcome for the patient. PMID:23876000

Covey, Judith; Noble, Adam J; Schenk, Thomas



Adenosine A2A receptors in early ischemic vascular injury after subarachnoid hemorrhage  

PubMed Central

Object The role of adenosine A2A receptors (A2AR) in the early vascular response after subarachnoid hemorrhage (SAH) is not known. In other forms of cerebral ischemia both activation and inhibition of A2AR is reported to be beneficial. However, these studies mainly used pharmacological receptor modulation and most of the agents available exhibit low specificity. We used adenosine A2A receptor knockout mice to study the role of A2AR in the early vascular response to SAH. Method SAH was induced in the wild type (WT; C57BL/6) and A2AR knockout mice (A2AR-KO) by endovascular puncture. Cerebral blood flow (CBF), intracranial pressure (ICP) and blood pressure (BP) were recorded, cerebral perfusion pressure (CPP) was deduced. Animals were sacrificed at 1, 3 and 6 hours after SAH or sham surgery. Coronal brain sections were immunostained for collagen-IV; major protein of basal lamina. The internal diameter of major cerebral arteries and the area fraction of collagen-IV positive microvessels (<100?m) were determined. Results Initial ICP rise and CPP fall at SAH induction was similar but CBF fall was significantly smaller in A2AR-KO as compared to WT cohorts. The internal diameter of major cerebral vessels decreased progressively after SAH. The extent of diameter reduction was significantly less in A2AR-KO than in WT mice. Collagen-IV immunostaining decreased progressively after SAH. The decrease was significantly less in A2AR-KO than in WT. Conclusion Our results demonstrate that global inactivation of A2AR decreases the intensity of the early vascular response to SAH. Early inhibition of A2AR after SAH might reduce cerebral injury.

Sehba, Fatima A.; Flores, Rowena; Muller, Artur; Friedrich, Victor; Chen, Jiang-Fan; Britz, Gavin W.; Winn, H. Richard; Bederson, Joshua B.



Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage.  


Object Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm. Methods The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group). Results After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21-11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13-1.45, p = 0.177). Conclusions Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 ( ). PMID:23957382

Olson, Daiwai M; Zomorodi, Meg; Britz, Gavin W; Zomorodi, Ali R; Amato, Anthony; Graffagnino, Carmelo



Urea for treatment of acute SIADH in patients with subarachnoid hemorrhage: a single-center experience  

PubMed Central

Background Hyponatremia occurring as a result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cerebral salt wasting syndrome is a common complication in patients with subarachnoid hemorrhage (SAH). The efficacy and safety of urea as treatment for SIADH-induced hyponatremia has not been reported in this population. Methods This is a retrospective analysis of all patients admitted to our department for nontraumatic SAH between January 2003 and December 2008 (n?=?368). All patients with SIADH-induced hyponatremia (plasma sodium??20 mEq/L, and osmolality?>?200 mOsm/kg; absence of overt dehydration or hypovolemia; no peripheral edema or renal failure; no history of adrenal or thyroid disease) routinely received urea per os when hyponatremia was associated with clinical deterioration or remained less than 130 mEq/L despite saline solution administration. Results Forty-two patients developed SIADH and were treated with urea. Urea was started after a median of 7 (IQR, 5–10) days and given orally at doses of 15–30 g tid or qid for a median of 5 (IQR, 3–7) days. The median plasma sodium increase over the first day of treatment was 3 (IQR, 1–6) mEq/L. Hyponatremia was corrected in all patients, with median times to Na+ >130 and >135 mEq/L of 1 (IQR, 1–2) and 3 (IQR, 2–4) days, respectively. Urea was well tolerated, and no adverse effects were reported. Conclusions Oral urea is an effective and well-tolerated treatment for SIADH-induced hyponatremia in SAH patients.



Can S100B Predict Cerebral Vasospasms in Patients Suffering from Subarachnoid Hemorrhage?  

PubMed Central

Background: Protein S100B has proven to be a useful biomarker for cerebral damages. Increased levels of serum and cerebrospinal fluid (CSF) S100B have been shown in patients suffering subarachnoid hemorrhage (SAH), severe head injury and stroke. In patients with SAH, the course of S100B levels has been correlated with neurological deficits and outcome. Cerebral vasospasm is a major contributor to morbidity and mortality. The primary aim of this study was to investigate the potential of S100B protein as a predictor of cerebral vasospasm in patients with severe SAH. Materials and Methods: Patients with SAH, Fisher grade 3 and 4, were included in the study. Five samples of CSF and serum S100B were collected from each patient. The first sample (baseline sample) was drawn within the first 3?days following ictus and the following four samples, once a day on days 5–8, with day of ictus defined as day 1. Clinical suspicion of cerebral vasospasm confirmed by computed tomography angiography was used to diagnose cerebral vasospasm. Results: A total of 18 patients were included. Five patients (28%) developed cerebral vasospasm, two (11%) developed ventriculitis. There were no significant differences between S100B for those with and without vasospasm. Serum S100B levels in patients with vasospasm were slightly lower within the first 5?days following ictus, compared to patients without vasospasm. Two out of five patients had elevated and increasing serum S100B prior to vasospasm. Only one showed a peak level of S100B 1?day before vasospasm could be diagnosed. Due to the low number of patients in the study, statistical significance could not be reached. Conclusion: Neither serum nor CSF S100B can be used as predictor of cerebral vasospasm in patients suffering from SAH.

Amiri, Moshgan; Astrand, Ramona; Romner, Bertil



Potential contribution of SOCC to cerebral vasospasm after experimental subarachnoid hemorrhage in rats.  


Cerebral vasospasm (CVS) is the most treatable component of subarachnoid hemorrhage (SAH), which can be reduced by endothelin receptor antagonists. Endothelin-evoked vasospasm is considered to be mediated by Ca(2+) influx in the smooth muscle through voltage-dependent Ca(2+) channel (VDCC) and nonselective cation channels (NSCC). Because VDCC antagonists such as nimodipine have been shown to be relatively less effective than the endothelin receptor antagonists, it is assumed that NSCC maybe a more important component in mediating Ca(2+) influx during CVS. In this study, we used the basilar arteries from a "two-hemorrhage" rat model of SAH to investigate expressions of transient receptor potential channel 1 (TRPC1), transient receptor potential channel 3 (TRPC3) and stromal interaction molecule 1 (STIM1), which are considered as the promising candidates constituting NSCC. To investigate the possible role of NSCC in phenotypic switching, we performed immunohistochemical staining to examine expressions of SM?-actin and PCNA, markers of smooth muscle phenotypic switching. We found that the basilar arteries exhibited vasospasm after SAH and that vasospasm became more severe on days 5 and 7 after SAH. Elevated mRNA and protein expressions of TRPC1 and STIM1 were detected after SAH and peaked on days 5 and 7, which was in a parallel time course to the development of cerebral vasospasm. The mRNA and protein expressions of TRPC3 were not changed in the SAH group when compared with those in the control. Results of immunohistochemical staining with anti-PCNA and anti-SM?-actin antibodies also showed enhanced expression of PCNA and disappearance of SM?-actin from day 1 to day 7. Taken together, the above results supported a novel mechanism that the components of store-operated calcium channels, TRPC1 and STIM1 mediated the Ca(2+) influx and phenotypic switching in smooth muscle cells, which promoted the development of vasospasm after SAH. TRPC3, which is a component of receptor-operated calcium channels, was not involved in the above-mentioned mechanism. PMID:23542055

Song, Jin-Ning; Yan, Wen-Tao; An, Ji-Yang; Hao, Guang-Shan; Guo, Xiao-Ye; Zhang, Ming; Li, Yu; Li, Dan-Dong; Sun, Peng



Successful treatment of a blood blister-like aneurysm of the internal carotid artery by trapping with a high-flow bypass  

Microsoft Academic Search

Treatment of blood blister-like aneurysms of the internal carotid artery (ICA) is difficult because the wall of the aneurysm is fragile and there is a high risk of rebleeding. There has been no consensus on the best way to treat these aneurysms. A 32-year-old woman presented with subarachnoid hemorrhage (SAH) caused by a ruptured blood blister-like aneurysm of the ICA.

Akitsugu Kawashima; Yoshikazu Okada; Takakazu Kawamata; Hideaki Onda; Osami Kubo; Tomokatsu Hori



Likelihood of aneurysmal subarachnoid haemorrhage in patients with normal unenhanced CT, CSF xanthochromia on spectrophotometry and negative CT angiography.  


Background: Patients with suspected subarachnoid haemorrhage, a normal noncontrast computed tomography (CT) and cerebrospinal fluid (CSF) evidence of haemoglobin breakdown products often undergo CT angiography (CTA). If this is normal, then invasive catheter angiography may be offered. In current clinical practice, haemoglobin breakdown products are detected by spectrophotometry rather than visible xanthochromia, and CTA is performed on multidetector scanners. The aim of this study was to determine if such patients should still have a catheter angiography, given the associated risks. Methods: Patients positive for CSF spectrophotometry (n=26) were retrospectively identified from the clinical biochemistry information system and imaging data from the electronic radiology records were reviewed. Discharge letters were consulted to relate the biochemistry and radiology results to the final diagnosis. Results: 15 patients with CT angiography were found. Nine patients had normal CT angiography. No causative aneurysms had been missed. One patient had small, coincidental aneurysms missed on initial reading of the CTA. Conclusion: The likelihood of a clinically significant aneurysm in a patient who is CT negative, lumbar puncture positive and CTA negative is low. Double reporting of negative CT angiograms may be advisable. PMID:24087797

Rana, A K; Turner, H E; Deans, K A



A severe vicious cycle in uncontrolled subarachnoid hemorrhage: the effects on cerebral blood flow and hemodynamic responses upon intracranial hypertension.  


In subarachnoid hemorrhage (SAH), Cushing postulated that the increase in systemic arterial pressure (SAP) in response to elevation of intracranial pressure (ICP) was beneficial to cerebral perfusion. However, in uncontrolled SAH, the increased SAP may cause more bleeding into the subarachnoid space and further increase the ICP. We created an animal model to simulate SAH by connecting a femoral arterial catheter to the subarachnoid space. The global cerebral blood flow (CBF) was measured with a venous outflow method. The purposes were to observe the CBF change under the simulated SAH, and to evaluate the effects of an adrenergic blocker and a vasodilator. In addition, spectral analysis of the aortic pressure and flow was employed for the analysis of hemodynamic changes at various ICP levels. When the femoral arterial blood was allowed to flow into the subarachnoid space, the ICP was elevated. The Cushing response to increased ICP caused an increase in SAP. A vicious cycle was generated between ICP and SAP. The CBF under the vicious cycle was greatly depressed. The dog developed pulmonary edema (PE) within 5 mins. An alpha-adrenergic blocker (phentolamine) and a vasodilator (nitroprusside) were beneficial to the reduction of SAP and ICP, improvement of CBF, and prevention of PE. Hemodynamic analysis revealed that graded increases in ICP caused increases in SAP, total peripheral resistance, arterial impedance, and pulse reflection with decreases in stroke volume, cardiac output and arterial compliance. The hemodynamic changes may contribute to acute left ventricular failure that leads to pressure and volume loading in the lung circulation, and finally acute PE. PMID:16900706

Su, Chain-Fa; Yang, Yi-Ling; Lee, Ming-Che; Chen, Hsing I



Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: A Natural History  

PubMed Central

Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high-mortality rate when ruptured. The authors report a case of a 54-year-old man who presented with infective endocarditis of the mitral valve and acute stroke. He subsequently developed subarachnoid hemorrhage during antibiotic treatment, and a large intracranial aneurysm was discovered on CT Angiography. His lesion quickly progressed into an intraparenchymal hemorrhage, requiring emergent craniotomy and aneurysm clipping. Current recommendations on the management of intracranial Mycotic Aneurysms are based on few retrospective case studies. The natural history of the patient's ruptured aneurysm is presented, as well as a literature review on the management and available treatment modalities.

Kuo, Isabel; Long, Theodore; Nguyen, Nathan; Chaudry, Bharat; Karp, Michael; Sanossian, Nerses



De Novo aneurysms in long-term follow-up CT-angiography of patients with clipped intracranial aneurysms  

PubMed Central

Abstract: Background: This study was conducted to evaluate the de Novo aneurysm formation in the long-term follow-up of patients with clipped intracranial aneurysms. Methods: A total of 459 patients underwent the clipping of ruptured cerebral aneurysms in our institution during 1997 -2008. Of them, 119 patients were available in good condition and agreed to undergo 64 detector row computed tomography (CT) angiography. In addition, 8 patients with subarachnoid hemorrhage (SAH) underwent CT angiography. Results: The mean ± SD interval from surgery was 7.2±2.3 years for CT-angiography controlled patents. De novo aneurysms were detected in 5 of 119 (4.5%) patients and 4 of 8 patients with new subarachnoid hemorrhage. A history of multiple aneurysms was associated with the de novo aneurysm formation (p less than 0.001). Conclusions: The risk of the de novo aneurysm formation in patients with clipped aneurysm is significant in long term follow-up. CT-angiography can be used as a non-invasive method for detection of de novo aneurysms in these patients. Keywords: Cerebral aneurysm, Ct-angiography, De Novo aneurysm, Surgical clipping

Zali, Alireza; Jalili Khoshnood, Reza; Zarghi, Afsaneh



High Risk of New Episode of Symptomatic Vasospasm in Unaffected Arteries in Subarachnoid Hemorrhage Patients Receiving Targeted Endovascular Treatment for Symptomatic Focal Vasospasm.  


BACKGROUND: There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE: To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS: We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ?50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS: Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS: High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session. PMID:23463421

Tekle, Wondwossen G; Chaudry, Saqib A; Hassan, Ameer E; Qaiser, Habib; Grigoryan, Mikayel; Rodriguez, Gustavo J; Qureshi, Adnan I



A modified double injection model of cisterna magna for the study of delayed cerebral vasospasm following subarachnoid hemorrhage in rats  

PubMed Central

Delayed cerebral vasospasm following subarachnoid hemorrhage (SAH) is a serious medical complication, characterized by constriction of cerebral arteries leading to varying degrees of cerebral ischemia. Numerous clinical and experimental studies have been performed in the last decades; however, the pathophysiologic mechanism of cerebral vasospasm after SAH still remains unclear. Among a variety of experimental SAH models, the double hemorrhage rat model involving direct injection of autologous arterial blood into the cisterna magna has been used most frequently for the study of delayed cerebral vasospasm following SAH in last years. Despite the simplicity of the technique, the second blood injection into the cisterna magna may result in brainstem injury leading to high mortality. Therefore, a modified double hemorrhage model of cisterna magna has been developed in rat recently. We describe here step by step the surgical technique to induce double SAH and compare the degree of vasospasm with other cisterna magna rat models using histological assessment of the diameter and cross-sectional area of the basilar artery.



Increase ICAM-1 and LFA-1 expression by cerebrospinal fluid of subarachnoid hemorrhage patients: involvement of TNF-?.  


Subarachnoid hemorrhage (SAH) is a frequent occurrence in cerebrovascular accidents, and inflammation occurs in the subarachnoid space after SAH. Arachnoid cells have the capability to present antigens and active T-lymphocytes after stimulation by cerebrospinal fluid (CSF). However, the effect of CSF on T-lymphocytes and arachnoid cell adhesion was not clearly understood. In this study, we used ELISA to detected tumor necrosis factor-? (TNF-?) content in CSF of SAH patients. CSF or recombinant TNF-? were applied on arachnoid cells and T-lymphoctes, and RT-PCR and western blotting were performed to determine the expression of intercellular adhesion molecule-1 (ICAM-1) in arachnoid cells and Lymphocyte Function-Associated Antigen-1 (LFA-1) in T-lymphocytes, respectively. Meanwhile, the Matrix Metal Proteinase-9 (MMP-9) expression in these cells was also determined. We found that the content of TNF-? in the CSF was significantly increased in the CSF of SAH patients (from 22 ± 8 pg/mL of healthy people to 436-450 pg/mL of SAH patients). Treatement with CSF could increase the expression of ICAM-1 in arachnoid cells and that of LFA-1 in T-lymphocytes, mainly through the increased levels of TNF-?. We also found that the co-culture of arachnoid cells and T-lymphocytes increased the expression of MMP-9 in both cells through the interaction of ICAM-1 of and LFA-1. All of these results suggested that arachnoid cells are involved in the T-lymphocytes invasion in the subarachnoid space after SAH. PMID:23548604

Xie, Xin; Wu, Xiaokang; Cui, Jihong; Li, Hongmin; Yan, Xingrong



Subarachnoid hemorrhage in the rat: cerebral blood flow and glucose metabolism during the late phase of cerebral vasospasm  

SciTech Connect

A double-isotope technique for the simultaneous measurement of CBF and CMRglu was applied to a subarachnoid hemorrhage (SAH) model in the rat. Cisternal injection of 0.07 ml blood caused a rather uniform 20% reduction in CBF together with an increase in glucose utilization of 30% during the late phase of vasospasm. In one-third of the SAH animals, there were focal areas where the flow was lowered to 30% of the control values and the glucose uptake increased to approximately 250% of control. We suggest that blood in the subarachnoid space via a neural mechanism induces the global flow and metabolic changes, and that the foci are caused by vasospasm superimposed on the global flow and metabolic changes. In the double-isotope autoradiographic technique, (/sup 14/C)iodoantipyrine and (/sup 3/H)deoxyglucose were used for CBF and CMRglu measurements, respectively, in the same animal. In half of the sections, the (/sup 14/C)iodoantipyrine was extracted using 2,2-dimethoxypropane before the section was placed on a /sup 3/H- and /sup 14/C-sensitive film. The other sections were placed on x-ray film with an emulsion insensitive to /sup 3/H. The validity of the double-isotope method was tested by comparing the data with those obtained in animals receiving a single isotope. The CBF and metabolic values obtained in the two groups were similar.

Delgado, T.J.; Arbab, M.A.; Diemer, N.H.; Svendgaard, N.A.



Coil embolization of intracranial aneurysm in polyarteritis nodosa. A case report and review of the literature.  


Polyarteritis nodosa (PAN) is a rare multisystem disease characterized by systemic necrotizing arteritis of small and medium size arteries. The skin, joints, kidneys, gastrointestinal tract and peripheral nerves are most commonly involved. Although aneurysms are commonly seen in the visceral vessels, intracranial aneurysms are rare with 15 reported cases. The intracranial aneurysms are usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. The aneurysms were usually small, although large cavernous aneurysms were reported in one case. Treatment guidelines are not clear regarding the management of these cases. Most patients were treated conservatively by medical management with surgical excision performed in only two cases and coiling done in one patient with cavernous aneurysms. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported. We describe the case of a 22-year-old woman, a known case of PAN who presented with subarachnoid hemorrhage. Cerebral angiogram showed a ruptured right middle cerebral artery bifurcation aneurysm along with unruptured left middle cerebral, right posterior communicating and left posterior inferior cerebellar artery aneurysms. Her previous abdominal angiogram had revealed multiple aneurysms in visceral arteries. Successful coil embolization of the ruptured right MCA bifurcation aneurysm was performed with preservation of the parent vessel. The patient made a complete recovery and was placed on medical treatment for PAN. Follow-up MR angiography at three months revealed stable occlusion of the embolized aneurysm with no change in the unruptured aneurysms. Although rare, PAN can be associated with intracranial aneurysms which can cause subarachnoid or parenchymal hemorrhage. Selected cases can be treated safely by coil embolization. PMID:23693044

Gupta, V; Chinchure, S D; Goe, G; Jha, A N; Malviya, S; Gupta, R



From GWAS to the clinic: risk factors for intracranial aneurysms  

Microsoft Academic Search

Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm is a devastating subset of stroke, occurring in relatively\\u000a young people (mean age around 50 years) of whom around a third die within the initial weeks after the bleed. Environmental\\u000a and genetic risk factors both have a role in SAH. A recent genome-wide association study of intracranial aneurysms in Finnish,\\u000a Dutch and

Ynte M Ruigrok; Gabriel JE Rinkel



[Problems of surgical treatment for multiple intracranial aneurysms].  


A series of 105 patients presenting with multiple aneurysms and subarachnoid hemorrhage (SAH) were operated on for ruptured and unruptured aneurysms between 1976 and 1984. Clinical factors other than the severity of SAH affecting the outcomes included: 1) Misdiagnosis of the location of a ruptured aneurysm among multiple aneurysms resulted in poor outcomes because of multiple surgical approaches or rebleeding during the acute period. 2) Combinations of aneurysmal locations requiring multiple surgical approaches, such as interhemispheric and transsylvian, during the acute stage caused worse outcomes than with multi-stage surgeries. If an unruptured aneurysm could not be reached during the initial exposure, multi-stage surgery was safe if the ruptured aneurysm had been clipped during the acute period. 3) Complications occurring during unruptured aneurysm surgery. The patient's age, the location and size of the unruptured aneurysms were significant factors in the clinical prognosis. Surgery for unruptured aneurysm caused 1.8% morbidity in patients between 28 and 55 years, but 18.0% morbidity in patients over 56 years of age. Surgery for internal carotid artery aneurysms resulted in 14.8% overall morbidity. Surgery for middle cerebral and anterior cerebral artery aneurysms caused below 5% morbidity. Postoperative morbidity in patients with aneurysms less than 5 mm in diameter was 1.3%, and with aneurysms measuring 10 mm or more, 20%. The optimum treatment for multiple aneurysms with SAH should be based on all factors of the patient's condition, including the unruptured aneurysms. PMID:1726249

Nemoto, M; Yasui, N; Suzuki, A; Sayama, I



Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage:case report and literature review  

Microsoft Academic Search

BACKGROUNDTraumatic false aneurysms of the meningeal arteries are rare. We report an unusual case of an intracerebral hematoma caused by the rupture of a traumatic aneurysm of the middle meningeal artery.CASE DESCRIPTIONA 64-year-old woman suffered a massive spontaneous intracerebral fronto-temporal hemorrhage. Cerebral angiogram revealed a pseudoaneurysm of the middle meningeal artery. At operation, a skull fracture was discovered in the

Michaël Bruneau; Thierry Gustin; Khalid Zekhnini; Claude Gilliard



Renal angiomyolipoma with coexistent hemorrhagic aneurysm formation and fatty thrombus in inferior vena cava: a rare presentation.  


Angiomyolipoma (AML) is known as the most common benign mesenchymal tumor of kidney. Usually AMLs present as benign lesions without local invasion or complication. However, few cases of renal AML have been reported with complications such as tumor thrombus extension into inferior vena cava (IVC) or hemorrhagic aneurysm formation. We report a complicated case of renal AML with CT and angiography evidence of hemorrhagic aneurysm formation and IVC thrombus, treated by a combination of selective arterial embolization, radical nephrectomy and thrombectomy. Radiologists and clinicians should be aware that AMLs could have such aggressive behaviors. PMID:22450723

Li, Hao-ming; Yeh, Lee-ren; Lu, Kevin



Effect of subarachnoid hemorrhage on contractile responses and noradrenaline release evoked in cat cerebral arteries by histamine  

SciTech Connect

This study analyzes the changes induced by subarachnoid hemorrhage (SAH) on the contractile responses and the noradrenaline release evoked in cat cerebral arteries by histamine. The dose-dependent vasoconstriction induced by histamine on the cerebral arteries of normal cats was significantly reduced by diphenhydramine and phentolamine. When SAH was produced 3 and 7 days before the experiment, the histamine-induced vasoconstriction also decreased. Thereafter, a tendency to normalization in the contractile vascular responses was observed such that in 15 days after the hemorrhage it was not significantly different from that found in controls animals. The decrease in the contractile responses to histamine provoked by SAH was similar to that seen after pretreatment with intracisternal injections of 6-hydroxydopamine. The amount of radioactivity released by histamine following preincubation with /sup 3/H-noradrenaline from the cerebral arteries of cats exposed to SAH 3, 7, and 15 days before the experiment was significantly reduced when compared with controls. Moreover, the basal level of tritium release and the radioactivity retained at the end of the experiment were also decreased after SAH. Results indicate histamine releases noradrenaline from cat cerebral arteries, and SAH produce a transient denervation of the perivascular adrenergic nerve endings, which explained by the impairment of the indirect adrenergic mechanism involved in the overall contractile response elicited by this amine in cerebral arteries. Histamine does not seem to play a significant role in the production of the cerebral vasospasm occurring after SAH.

Lobato, R.D.; Marin, J.; Salaices, M.; Rico, M.L.; Sanchez, C.F.



Protein therapy using heme-oxygenase-1 fused to a polyarginine transduction domain attenuates cerebral vasospasm after experimental subarachnoid hemorrhage  

PubMed Central

A sequence of 11 consecutive arginine residues (11R) is one of the best protein transduction domains for introducing proteins into cell membranes. Heme-oxygenase-1 (HO-1) is involved in heme catabolism and reduces the contractile effect of hemoglobin after subarachnoid hemorrhage (SAH). Therefore, we constructed 11R-fused HO-1 protein to achieve successful transduction of the protein into the cerebral arteries and examined the therapeutic effect of the 11R-HO-1 protein for cerebral vasospasm (CV) after SAH. We injected the 11R-HO-1 protein into the cisterna magna of male rats and, several hours after the injection, performed immunofluorescence staining and western blotting analysis of the rat basilar arteries (BAs) to determine transduction efficacy. We also assessed intraarterial HO-1 activity as cGMP (cyclic guanosine 3?, 5?-cyclic monophosphate) accumulation in SAH and determined whether protein transduction of 11R-HO-1 quantified the therapeutic effect in a rat double-hemorrhage model of SAH. The BAs expressed significantly more HO-1 in the group injected with 11R-HO-1 (3.56±0.54 (11R-HO-1) versus control (saline)), and transduction of 11R-HO-1 resulted in higher activity (>3.25-fold) in rat BAs with SAH. Moreover, the results of the rat double-hemorrhage model showed that the 11R-HO-1 protein significantly attenuated CV after SAH (317.59±23.48??m (11R-HO-1) versus 270.08±14.66??m (11R-fused enhanced green fluorescent protein), 252.05±13.95??m (saline), P<0.01).

Ogawa, Tomoyuki; Hanggi, Daniel; Wu, Yumei; Michiue, Hiroyuki; Tomizawa, Kazuhito; Ono, Shigeki; Matsui, Hideki; Date, Isao; Steiger, Hans-Jakob



Recurrent Meningitis and Subarachnoid Hemorrhage Due to Salmonella in an HIV+ Patient: Case Report and Mini-Review of the Literature.  


Meningitis due to non-typhi salmonella is infrequent in HIV-positive adults.We report a case of a patient with >300 CD4+ cells/mm3 who presented with five episodes of recurrent meningitis, focal subarachnoid hemorrhage and cerebral vasculitis ultimately attributed to Salmonella choleraesuis infection. Even within the cART era invasive salmonellosis can occur in unusual ways in HIV-infected patients. PMID:21772932

Belloso, Waldo H; Romano, Marina; Greco, Graciela S; Davey, Richard T; Perelsztein, Ariel G; Sánchez, Marisa L; Ajzenszlos, Martín R; Otegui, Inés M



ERK1\\/2 inhibition attenuates cerebral blood flow reduction and abolishes ETB and 5HT1B receptor upregulation after subarachnoid hemorrhage in rat  

Microsoft Academic Search

Upregulation of endothelin B (ETB) and 5-hydroxytryptamine 1B (5-HT1B) receptors via transcription has been found after experimental subarachnoid hemorrhage (SAH), and this is associated with enhanced phosphorylation of the mitogen-activated protein kinase (MAPK) extracellular signal-regulated kinase (ERK1\\/2). In the present study, we hypothesized that inhibition of ERK1\\/2 alters the ETB and 5-HT1B receptor upregulation and at the same time prevents

Saema A S Beg; Jacob A Hansen-Schwartz; Petter J Vikman; Cang-Bao Xu; Lars I H Edvinsson; SAS Beg



Duret hemorrhage: demonstration of ruptured paramedian pontine branches of the basilar artery on minimally invasive, whole body postmortem CT angiography.  


A 25 year old male died suddenly and unexpectedly. Postmortem CT scanning revealed marked raised intracranial pressure with brainstem compression due to subarachnoid, subdural and parenchymal hemorrhage. A hyperdense mass at the termination of the right internal carotid artery was thought to represent an aneurysm. Postmortem, whole body CT angiography failed to fill the aneurysm but did demonstrate multiple central pontine linear enhancing structures in continuity with the mid basilar artery and small foci of contrast leak into the adjacent mid pontine parenchyma. Autopsy confirmed subarachnoid hemorrhage, a thrombosed and ruptured proximal right middle cerebral artery aneurysm and Duret hemorrhages in the mid pons. This finding supports the theory that Duret hemorrhages occur as a result of perforating pontine branch of the basilar arterial rupture but does not exclude the contribution of venous congestion. PMID:22484970

Chew, Ka Lip; Baber, Yeliena; Iles, Linda; O'Donnell, Christopher



Thoraco-lumbar artery aneurysms associated with a metameric paraspinal lesion presenting with retroperitoneal hemorrhage: Endovascular management  

PubMed Central

Background: Retroperitoneal hemorrhage is a life-threatening condition. This is the first reported case of rupture of one of multiple thoraco-lumbar artery aneurysms associated with a metameric paraspinal vascular lesion. Case Description: A 77-year-old female patient presented to the emergency room with a new onset of left-sided low back pain shooting down the leg associated with weakness, numbness, and inability to walk. On physical examination, there was a notable left paraspinal swelling with a harsh bruit audible in the same area, left flank ecchymosis and a positive straight leg raising test. A computed tomography (CT) scan showed a large retroperitoneal hematoma. Digital subtraction angiography showed a large left paraspinal high-flow arteriovenous lesion, with large arterial aneurysms of the left T11, T12, and L1 segmental arteries. The patient was successfully treated with endovascular aneurysm embolization using coils and Onyx-34. Six months following the procedure, the patient had fully recovered, and a follow-up angiogram showed no residual or recurrent aneurysms. Conclusion: Thoraco-lumbar artery aneurysms have never previously been described in association with a metameric paraspinal vascular malformation. We report a case of retroperitoneal hemorrhage due to rupture of one of several high-flow artery aneurysms of a paraspinal arteriovenous malformation (AVM). The diagnosis was made on CTA, MRI, and angiography, and the lesion was successfully treated by transarterial embolization.

Santillan, Alejandro; Zink, Walter; Patsalides, Athos; Gobin, Y. Pierre



Dysphagia due to Retropharyngeal Abscess that Incidentally Detected in Subarachnoid Hemorrhage Patient  

PubMed Central

Cerebral hemorrhage is one of the most common causes of dysphagia. In many cases, dysphagia gets better once the acute phase has passed. Structural lesions such as thyromegaly, cervical hyperostosis, congenital web, Zenker's diverticulum, neoplasm, radiation fibrosis, and retropharyngeal abscess must be considered as other causes of dysphagia as well. Retropharyngeal abscess seldom occur in adults and if it does so, a search for a prior dental procedure, trauma, head and neck infection is needed. The symptoms may include neck pain, dysphagia, sore throat, and in rare cases, dyspnea accompanied by stridor. We present a case and discuss a patient who had dysphagia and neck pain after a cerebral hemorrhage. Testing revealed a retropharyngeal abscess. The symptoms were successfully treated after the administration of antibiotics.

Lee, Jung Hwan; Kwon, Bum Sun; Ryu, Ki Hyung; Lee, Ho Jun; Park, Young Geun; Chang, Ji Hea; Sim, Kyoung Bo



Changes in trace elements of cerebrospinal fluid after subarachnoid hemorrhage, and effects of trace elements on vasospasm  

NASA Astrophysics Data System (ADS)

Various causal factors have been proposed for cerebral vasospasm after subarachnoid hemorrhage (SAH), such as serotonin, acetylcholine, angiotensin, thrombin and thromboxane A2. However, none of them explain the whole pathomechanism of vasospasm. To evaluate the role of trace elements on vasospasm, we have examined these sequential changes in the cerebrospinal fluid (CSF) after SAH by PIXE, and have investigated the relation between trace elements and vasospasm. We obtained the CSF samples from cisternal drainage in patients with SAH who underwent radical surgery within 48h from the onset. The drainage was placed into basal cisterns at the end of the operation. Three sampling times (3-5, 7-9 and 12-14days from the onset) has been scheduled because vasospasm is likely to occur from day 4 to day 14 after the onset. In this study, we focused on the levels of Mg, Ca, Mn, Al, Zn, P, Pb, Sr, Br, Co, Cu, Si, Ti, Mn, Co, Cu, Zn, Br, Sr, Mo and Pb, and we found a significantly lower level of Mg in the CSF of patients with vasospasm on days 7-9 after the onset. These results suggest that Mg in the CSF may ameliorate vasoconstriction due to Ca in the pathomechanism of vasospasm.

Sato, N.; Kuroda, K.; Suzuki, M.; Ogawa, A.; Sera, K.



Brain edema formation correlates with perfusion deficit during the first six hours after experimental subarachnoid hemorrhage in rats  

PubMed Central

Background Severe brain edema is observed in a number of patients suffering from subarachnoid hemorrhage (SAH). Little is known about its pathogenesis and time-course in the first hours after SAH. This study was performed to investigate the development of brain edema and its correlation with brain perfusion after experimental SAH. Methods Male Sprague–Dawley rats, randomly assigned to one of six groups (n = 8), were subjected to SAH using the endovascular filament model or underwent a sham operation. Animals were sacrificed 15, 30, 60, 180 or 360 minutes after SAH. Intracranial pressure (ICP), mean arterial blood pressure (MABP), cerebral perfusion pressure (CPP) and bilateral local cerebral blood flow (LCBF) were continuously measured. Brain water content (BWC) was determined by the wet/dry-weight method. Results After SAH, CPP and LCBF rapidly decreased. The decline of LCBF markedly exceeded the decline of CPP and persisted until the end of the observation period. BWC continuously increased. A significant correlation was observed between the BWC and the extent of the perfusion deficit in animals sacrificed after 180 and 360 minutes. Conclusions The significant correlation with the perfusion deficit after SAH suggests that the development of brain edema is related to the extent of ischemia and acute vasoconstriction in the first hours after SAH.



Global cerebral atrophy after subarachnoid hemorrhage: a possible marker of acute brain injury and assessment of its impact on outcome.  


There is a correlation between poor neuropsychological outcome and focal regions of atrophy in patients with subarachnoid hemorrhage (SAH). No study has investigated the impact of global brain atrophy on outcome after SAH. In other neurological disorders, such as multiple sclerosis, a correlation has been found between global atrophy and outcome. This analysis of patients entered into a randomized clinical trial of clazosentan in patients with SAH (CONSCIOUS-1) investigated the relationship between global cerebral atrophy, clinical factors, and outcome.The 413 patients in the CONSCIOUS-1 study underwent cranial computed tomography (CT) on admission and 6 weeks after SAH. After patients with large clip/coil artefacts and those with infarctions on CT were excluded, 97 patients remained and had voxel-based volumetric measurements of the baseline and 6-week CT scans. The percentage difference in volume between times was taken and analysed against clinical variables. Relationships were modeled using univariate and multivariate analysis.Age, female gender, and higher body temperature during the patient's stay in the intensive care unit were significantly correlated with brain atrophy. Greater brain atrophy significantly correlated with poor outcome (modified Rankin scale), more severe neurological deficits on the National Institute of Health Stroke Scale (NIHSS), and poorer health status (EQ-5D). PMID:22890637

Tam, Alan K H; Ilodigwe, Don; Li, Zeyu; Schweizer, Tom A; Macdonald, R Loch



The proposal of subgroups for grade V on World Federation of Neurologic Surgeons Grading for subarachnoid hemorrhage.  


Aim: Some of cases suffering from subarachnoid hemorrhages (SAHs) in grade V on World Federation of Neurologic Surgeons (WFNS) grading can gain a good prognosis. The outcome of patients of SAH in grade V on WFNS grading in their institute was here investigated. Methods: Between April 2007 and July 2012, consecutive 37 patients had SAH diagnosed on CT scan and were classified in grade V on WFNS grading in Kosei General Hospital. There were seventeen male and twenty female patients. We were assigned to patients with spontaneous respiration and without oculomotor palsy (N group, N.=11), and patients with oculomotor palsy (O group, N.=26). Patients were evaluated by mRS. Results: The prognosis in N group was significantly better than in O group (P<0.001). Conclusion: Surgical treatments should be considered for SAH patients without oculomotor palsy. It is necessary to make subgroups in grade V on WFNS grading in order to decide operative indication and evaluate the treatment results of SAH in grade V. PMID:24091433

Nakagawa, M; Sugiu, K; Tokunaga, K; Sakamoto, C; Fujiwara, K



Effects of blockade of cerebral lymphatic drainage on regional cerebral blood flow and brain edema after subarachnoid hemorrhage.  


The study was designed to observe the influence of blockade of cerebral lymphatic drainage on the regional cerebral blood flow (rCBF) and brain edema after experimental subarachnoid hemorrhage (SAH). Wistar rats were divided into non-SAH, SAH, and SAH plus cervical lymphatic blockade (SAH + CLB) groups. Autologous arterial hemolysate was injected into rat's cisterna magna to induce SAH. The rCBF was recorded continuously by a laser Doppler flowmeter. Intracranial pressure (ICP) was also monitored. After 24 hours and 72 hours of SAH, the rats were sacrificed and the brain was harvested for water content detection. It was found that there was no obvious change of rCBF and brain water content during the experiment in non-SAH group. An immediate and persistent drop in rCBF was found in SAH group. The drop in rCBF was more obvious in SAH + CLB group. CLB also worsened the SAH-induced increase in ICP. The brain water content 24 hours and 72 hours after induction of SAH in SAH group increased significantly. CLB led to a further increase of brain water content. In conclusion, blockade of cerebral lymphatic drainage pathway deteriorates the secondary cerebral ischemia and brain edema after SAH. PMID:16543641

Sun, Bao-Liang; Xia, Zuo-Li; Wang, Jing-Ru; Yuan, Hui; Li, Wen-Xia; Chen, Yu-She; Yang, Ming-Feng; Zhang, Su-Ming



A postmarketing surveillance study of fasudil treatment after aneurysmal subarachnoid hemorrhage  

Microsoft Academic Search

BackgroundThe aim of the present study was, first, to assess safety of fasudil (Eril; Asahi Kasei Pharma Corp, Tokyo, Japan) and, second, to investigate whether the effects of fasudil in the phase 3 trial could be reproduced in a PMS study.

Yoshio Suzuki; Masato Shibuya; Shin-ichi Satoh; Yuka Sugimoto; Kintomo Takakura



MR angiography as a screening tool for intracranial aneurysms: feasibility, test characteristics, and interobserver agreement  

Microsoft Academic Search

OBJECTIVE. MR angiography may be an appropriate tool to screen for unruptured in- tracranial aneurysms. Feasibility, test characteristics, and interobserver agreement in evalua- tion of MR angiograms were assessed by members of the MARS (Magnetic resonance Angiography in Relatives of patients with Subarachnoid hemorrhage) Study Group. SUBJECTS AND METHODS. We screened 626 first-degree relatives of a consecutive series of I

Theodora W. M. Raaymakers; P. C. Buys; B. W. J. M. Verbeeten; L. M. P. Ramos; T. D. Witkamp; F. J. H. Hulsmans; W. P. T. M. Mali; A. Algra; G. J. Bonsel; P. M. M. Bossuyt; C. M. Vonk; E. Buskens; M. Limburg; Gijn van J; J. M. T. Gorissen; P. Greebe; K. W. Albrecht; C. A. Tulleken; G. J. E. Rinkel



Effects of the selective endothelin A (ET A ) receptor antagonist Clazosentan on cerebral perfusion and cerebral oxygenation following severe subarachnoid hemorrhage – preliminary results from a randomized clinical series  

Microsoft Academic Search

Summary  \\u000a Objective. To study the effects of clazosentan, a new selective endothelin receptor subtype A antagonist, on cerebral perfusion and\\u000a cerebral oxygenation following severe aneurysmal subarachnoid haemorrhage (aSAH).\\u000a \\u000a \\u000a Methods. All 12 patients treated at our institution in the context of a phase IIa, multicenter, randomized trial on clazosentan’s\\u000a safety and efficacy in reducing the incidence of angiographic cerebral vasospasm were

M. Barth; H.-H. Capelle; E. Münch; C. Thome ´; F. Fiedler; P. Schmiedek; P. Vajkoczy



Prediction of rebleeding from angiographic features in vertebral artery dissecting aneurysms  

Microsoft Academic Search

To identify patient characteristics and angiographic features that predict high risk for rebleeding in vertebral artery (VA) dissecting aneurysms. We analyzed 62 patients treated for subarachnoid hemorrhage (SAH) from VA dissecting aneurysms (male: female, 46:16; mean age, 51.7??±??8 years). Univariate and multivariate stepwise logistic regression analyses were performed to assess relationships between rebleeding rate and age, gender, history of hypertension, sidedness

Teruhide Takagi; Masakazu Takayasu; Yoshio Suzuki; Jun Yoshida



Pathogenesis of the "sentinel headache" preceding berry aneurysm rupture.  

PubMed Central

Pathologic examination in a case of fatal intracerebral hemorrhage from a berry aneurysm showed that the "sentinel" or warning headache in this patient was due to the leakage of blood into the subarachnoid space through a previous small tear in the wall of her saccular aneurysm. Oribital pain, transient, dysphasia, dizziness and, later, meningismus might have prompted the performing of a lumbar puncture to determine the presence of blood in the cerebrospinal fluid. This type of event is the likely pathogenetic mechanism for the premonitory headache that may precede a lethal rupture of a saccular aneurysm. Images FIG. 1 FIG. 2 FIG. 3 FIG. 4

Ball, M. J.



Stent-assisted coil embolization of intracranial wide-necked aneurysms.  


The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent2 was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required. PMID:16028036

Lee, Young-Jun; Kim, Dong Joon; Suh, Sang Hyun; Lee, Seung-Koo; Kim, Jinna; Kim, Dong Ik



Incidental finding of tumor while investigating subarachnoid hemorrhage: ethical considerations and practical strategies.  


High-resolution neuroimaging modalities are used often in studies involving healthy volunteers. Subsequently, a significant increase in the incidental discovery of asymptomatic intracranial abnormalities raised the important ethical issues of when follow-up and treatment may be necessary. We examined the literature to establish a practical set of criteria for approaching incidental findings. Our objective is to develop an algorithm for when follow-up may be important and to provide recommendations that would increase the likelihood of follow-up. A systematic literature search was performed using the PubMed and MEDLINE databases to identify articles describing brain tumors and intracranial aneurysms. The treatment algorithm we present suggests that incidental intracranial masses suspicious for glioma should be biopsied or resected, while other masses are to be followed with serial imaging based on the expected growth pattern. Lack of follow-up can result in adverse outcomes that can be mitigated by using technology to facilitate communication and improve follow-up care. The importance of training physicians to be good communicators is also stressed. New technology including automated telephone systems, texting and email will improve access to patients and hopefully encourage compliance and follow-up. PMID:23065539

Drazin, Doniel; Spitler, Kevin; Cekic, Milos; Patel, Ashish; Hanna, George; Shirzadi, Ali; Chu, Ray



Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after subarachnoid hemorrhage  

PubMed Central

Background: Monitoring of cardiac output (CO) is important for promising safe approach to goal-directed hemodynamic therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), but is often precluded by the invasiveness and complexity of ongoing monitoring modalities. We examined the clinical utility of less-invasive management using an uncalibrated arterial pressure waveform-derived cardiac output (APCO) monitor with refined algorithm (Third-generation FloTrac/Vigileo, Edwards, Irvine, CA, USA) during hyperdynamic therapy for post-SAH DCI, compared with transpulmonary thermodilution (PiCCO, Pulsion, Munich, Germany) as a reference technique. Methods: Forty-five patients who underwent surgical clipping within 24 h of SAH onset and subsequently developed clinical deterioration attributable to DCI were investigated. Validation of the APCO-derived cardiac index (CI) during dobutamine-induced hyperdynamic therapy was compared with a reference CI analyzed by transpulmonary thermodilution in 20 patients. In a subsequent trial of 48 cases, the overall clinical results from patients managed with each device were compared. Results: The APCO underestimated CI with an overall bias ± SD of 0.33 ± 0.26 L/min/m2 compared with transpulmonary thermodilution, resulting in an error of 14.9%. The trends of CI for both techniques at each dobutamine dose were similar (r2= 0.77; P < 0.0001). No statistically significant differences were observed between the device groups for frequencies of neurological improvement, cerebral infarction, cardiopulmonary complications, or functional outcomes at 3 months. Conclusions: These data suggest that the refined APCO tends to underestimate CI compared with reference transpulmonary thermodilution during hyperdynamic therapy with dobutamine for reversing DCI, but may be acceptable in this select category of patients to obtain comparable clinical results.

Mutoh, Tatsushi; Ishikawa, Tatsuya; Kobayashi, Shinya; Suzuki, Akifumi; Yasui, Nobuyuki



Intracisternal infusion of magnesium sulfate solution improved reduced cerebral blood flow induced by experimental subarachnoid hemorrhage in the rat.  


Magnesium has neuroprotective and antivasospastic properties in the presence of subarachnoid hemorrhage (SAH). The present study investigated the effect of intracisternal administration of magnesium on cerebral vasospasm in the experimental SAH rat model. The rat double-SAH model (0.2 mL autologous blood injected twice into the cisterna magna) was used. Normal saline (SAH group, N=8) or 10 mmol/L magnesium sulfate in normal saline (SAH + MG group, N=8) was infused into the cisterna magna at 1.5 microL/min for 30 min on day 5. Control rats without SAH also received intracisternal infusion of normal saline (control group, N=6). Local cerebral blood flow (CBF) at 24 locations and the weighted average were quantitatively measured by the autoradiographic technique using [(14)C]iodoantipyrine during infusion. The weighted average CBF was significantly reduced (P<0.01, Student's t-test) in the SAH group (0.78+/-0.16 mL g(-1) min(-1)) compared to the control group (1.0+/-0.15 mL g(-1) min(-1)) and was significantly improved (P<0.01, Student's t-test) in the SAH + MG group (0.98+/-0.18 mL g(-1) min(-1)). Local CBF was significantly reduced (P<0.05, unpaired t test) in 16 locations in the SAH group and significantly improved (P < 0.05, unpaired t test) in 12 locations in the SAH + MG group. Intracisternal infusion of magnesium sulfate significantly improved reduced CBF induced by experimental SAH in the rat. PMID:18253770

Mori, Kentaro; Miyazaki, Masahiro; Iwata, Junko; Yamamoto, Takuji; Nakao, Yasuaki



Melatonin alleviates secondary brain damage and neurobehavioral dysfunction after experimental subarachnoid hemorrhage: possible involvement of TLR4-mediated inflammatory pathway.  


Previous studies proved that melatonin protected against secondary brain damage by modulating oxidative stress after experimental subarachnoid hemorrhage (SAH), but it has not been evaluated yet about its effects on inflammatory pathway and secondary cognitive dysfunction in SAH model. This study was undertaken to evaluate the influence of melatonin on toll-like receptor 4 (TLR4) signaling pathway and neurobehavioral tests after SAH. Adult SD rats were divided into four groups: control group (n = 20), SAH group (n = 20), SAH+vehicle group (n = 20), and SAH+melatonin group (n = 20). The rat SAH model was induced by injection of 0.3 mL fresh arterial, nonheparinized blood into the prechiasmatic cistern in 20 s. In SAH+melatonin group, melatonin was administered i.p. at 150 mg/kg at 2 and 24 hr after the induction of SAH. Cognitive and memory changes were investigated in the Morris water maze. Treatment with melatonin markedly decreased the expressions of TLR4 pathway-related agents, such as high-mobility group box 1 (HMGB1), TLR4, nuclear factor-?B (NF-?B), myeloid differentiation factor 88 (MyD88), interleukin-1? (IL-1?), tumor necrosis factor-? (TNF-?), interleukin-6 (IL-6), and inducible nitric oxide synthase (iNOS). Administration of melatonin following SAH significantly ameliorated spatial learning and memory deficits in this prechiasmatic blood injection model. Staining of apoptosis and necrosis indicated that fewer positive cells appeared in melatonin-treated group than SAH+vehicle group. In conclusion, melatonin may attenuate neurobehavioral dysfunction in this SAH model, and melatonin exhibits neuroprotection possibly not only through anti-oxidative pathway but also anti-inflammatory signaling after experimental SAH. PMID:24007200

Wang, Zhong; Wu, Lingyun; You, Wanchun; Ji, Chengyuan; Chen, Gang



Targeted over-expression of endothelin-1 in astrocytes leads to more severe brain damage and vasospasm after subarachnoid hemorrhage  

PubMed Central

Background Endothelin-1 (ET-1) is a potent vasoconstrictor, and astrocytic ET-1 is reported to play a role in the pathogenesis of cerebral ischemic injury and cytotoxic edema. However, it is still unknown whether astrocytic ET-1 also contributes to vasogenic edema and vasospasm during subarachnoid hemorrhage (SAH). In the present study, transgenic mice with astrocytic endothelin-1 over-expression (GET-1 mice) were used to investigate the pathophysiological role of ET-1 in SAH pathogenesis. Results The GET-1 mice experienced a higher mortality rate and significantly more severe neurological deficits, blood–brain barrier breakdown and vasogenic edema compared to the non-transgenic (Ntg) mice following SAH. Oral administration of vasopressin V1a receptor antagonist, SR 49059, significantly reduced the cerebral water content in the GET-1 mice. Furthermore, the GET-1 mice showed significantly more pronounced middle cerebral arterial (MCA) constriction after SAH. Immunocytochemical analysis showed that the calcium-activated potassium channels and the phospho-eNOS were significantly downregulated, whereas PKC-? expression was significantly upregulated in the MCA of the GET-1 mice when compared to Ntg mice after SAH. Administration of ABT-627 (ETA receptor antagonist) significantly down-regulated PKC-? expression in the MCA of the GET-1 mice following SAH. Conclusions The present study suggests that astrocytic ET-1 involves in SAH-induced cerebral injury, edema and vasospasm, through ETA receptor and PKC-mediated potassium channel dysfunction. Administration of ABT-627 (ETA receptor antagonist) and SR 49059 (vasopressin V1a receptor antagonist) resulted in amelioration of edema and vasospasm in mice following SAH. These data provide a strong rationale to investigate SR 49059 and ABT-627 as therapeutic drugs for the treatment of SAH patients.



Concurrent basilar artery double fenestration with aneurysm and vertebral artery dissection: case report and literature review of rare cerebrovascular abnormalities.  


Many disorders can cause aneurysm and/or dissection of the cerebral arteries, including fibromuscular dysplasia (FMD), connective tissue disorders, cerebral vasculitis, infection, and vascular malformations. Arterial fenestration is a rare congenital finding that can also cause aneurysms, and can rarely dissect and bleed. Treatment of aneurysm and dissection with subarachnoid hemorrhage can be very complicated, and requires case-by-case analysis of the risks and benefits of antithrombotic therapy. To the authors' knowledge, no case of double fenestration of the basilar artery has been reported. This report presents a case of concurring vertebral artery dissection and double fenestration of the basilar artery with aneurysm. The fenestration and FMD are considered possible main contributing causes of this presentation. A literature review of cerebrovascular fenestration and FMD is provided and the relationship between the 2 is considered. Lastly, the use of antithrombotic therapy in the setting of subarachnoid hemorrhage, dissection, and stent placement is discussed. PMID:23548267

Stark, Madeline M; Skeik, Nedaa; Delgado Almandoz, Josser E; Crandall, Benjamin M; Tubman, David E



Gender Differences in Cerebral Aneurysm Location  

PubMed Central

Background and Purpose: A limited number of studies consisting predominantly of ruptured aneurysms have looked at differences in anatomical distribution of aneurysms between male and females. Unlike all other causes of stroke, subarachnoid hemorrhages (SAH) occur more often in women and are thought to be a result of both hormonal influences and variation in wall shear stress. This paper retrospectively looks at a cohort of largely unruptured intracranial aneurysms to determine if there exists a gender discrepancy in the anatomic distribution of cerebral aneurysms. Methods: A retrospective review of consecutive patients with ruptured and unruptured intradural saccular cerebral aneurysms treated endovascularly was performed. Results: Six hundred eighty-two aneurysms were treated. Seventy-two percentage of the patients were women and 27% of patients presented with SAH. Among women, most aneurysms were located along the ICA (54%) while men the ACA (29%, compared to 15% in women), a discrepancy evident in both unruptured and ruptured groups. Females tended to present later in life (59 vs. 55?years), with multiple aneurysms (11 vs. 6% in men), and with SAH (28 vs. 23% in men) – the majority of these ruptured aneurysms were located at the ICA (42%), while men at the ACA (47%). Additionally, the majority (68%) of ruptured ICA aneurysms were PCOM. Conclusion: Understanding the natural history of aneurysms is imperative in treating incidentally found aneurysms. Significant differences exist between the genders in relation to aneurysm location, the most pronounced at the ICA and ACA. Previously described hormonal and hemodynamic theories behind cerebral aneurysm pathogenesis seem like plausible reasons to explain these differences.

Ghods, Ali J.; Lopes, Demetrius; Chen, Michael



Management of Patients Presenting with Acute Subdural Hematoma due to Ruptured Intracranial Aneurysm  

PubMed Central

Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establish reliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm rupture results in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determining initial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and the mixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinical and radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmal subarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past 20 years are discussed and summarized in a proposed treatment flowchart.

Marbacher, Serge; Tomasi, Ottavio; Fandino, Javier



Acute formation of a pseudoaneurysm adjacent to a previously clipped anterior communicating artery aneurysm  

PubMed Central

Background: Cerebral pseudoaneurysms, especially of the anterior communicating artery (ACoA), are rare. Case Description: Herein, the authors report a 66-year-old patient who underwent successful clip ligation of a small ruptured ACoA aneurysm. Eighteen days after surgery, he suffered from another episode of subarachnoid hemorrhage due to the rupture of a newly formed pseudoaneurysm adjacent to the previously clipped aneurysm. This pseudoaneurysm was treated through clip ligation as well. Conclusion: A pseudoaneurysm may rarely form adjacent to a previously clipped cerebral aneurysm and should be included in the differential diagnosis of recurrent subarachnoid hemorrhage. Potential mechanisms of formation and management strategies for this challenging problem will be discussed.

Shoja, Mohammadali M.; Tubbs, R. Shane; Cohen-Gadol, Aaron A.



Time evolution and hemodynamics of cerebral aneurysms  

NASA Astrophysics Data System (ADS)

Cerebral aneurysm rupture is a leading cause of hemorrhagic strokes. Because they are being more frequently diagnosed before rupture and the prognosis of subarachnoid hemorrhage is poor, clinicians are often required to judge which aneurysms are prone to progression and rupture. Unfortunately, the processes of aneurysm initiation, growth and rupture are not well understood. Multiple factors associated to these processes have been identified. Our goal is to investigate two of them, arterial hemodynamics (using computational fluid dynamics) and the peri-aneurysmal environment, by studying a group of growing cerebral aneurysms that are followed longitudinally in time. Six patients with unruptured untreated brain aneurysms which exhibited growth during the observation period were selected for the study. Vascular models of each aneurysm at each observation time were constructed from the corresponding computed tomography angiography (CTA) images. Subsequently, models were aligned, and geometrical differences quantified. Blood flow was modeled with the 3D unsteady incompressible Navier-Stokes equation for a Newtonian fluid, and wall shear stress distribution and flow patterns were calculated and visualized. Analysis of the simulations and changes in geometry revealed asymmetric growth patterns and suggests that areas subject to vigorous flows, i.e. relative high wall shear stress and concentrated streamlines patterns; correspond to regions of aneurysm growth. Furthermore, in some cases the geometrical evolution of aneurysms is clearly affected by contacts with bone structures and calcifications in the wall, and as a consequence the hemodynamics is greatly modified. Thus, in these cases the peri-aneurysmal environment must be considered when analyzing aneurysm evolution.

Sforza, Daniel M.; Putman, Christopher; Tateshima, Satoshi; Viñuela, Fernando; Cebral, Juan



Recommendations for the Management of Patients With Unruptured Intracranial Aneurysms A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association  

Microsoft Academic Search

neurysmal subarachnoid hemorrhage (SAH) has a 30- day mortality rate of 45%, with approximately half the survivors sustaining irreversible brain damage. 1 On the basis of an annual incidence of 6 per 100 000, '15 000 Americans will have an aneurysmal SAH each year. Population-based incidence rates vary considerably from 6 to 16 per 100 000, with the highest rates

Joshua B. Bederson; Issam A. Awad; David O. Wiebers; David Piepgras; E. Clarke; Thomas Brott; George Hademenos; Douglas Chyatte; Robert Rosenwasser; Cynthia Caroselli



Reactive oxygen species modulate growth of cerebral aneurysms: a study using the free radical scavenger edaravone and p47phox?\\/? mice  

Microsoft Academic Search

Cerebral aneurysm (CA) is a relatively common disease and can cause a catastrophic subarachnoid hemorrhage with a high mortality and morbidity rate. Despite its clinical and social importance, the detailed mechanism of CA formation remains to be elucidated, resulting in the absence of effective medical treatment against CAs. Recent studies revealed that chronic inflammation in arterial walls by hemodynamic force

Tomohiro Aoki; Masaki Nishimura; Hiroharu Kataoka; Ryota Ishibashi; Kazuhiko Nozaki; Nobuo Hashimoto



Combined clinical and computational information in complex cerebral aneurysms: application to mirror cerebral aneurysms  

NASA Astrophysics Data System (ADS)

Although the incidence of ruptured cerebral aneurysms is relatively small, when rupture occurs, morbidity and mortality are exceptionally high. The understanding of the pathological and physiological forces driving aneurysmal pathogenesis and progression is crucial. In this paper we analyze the occurrence of mirror cerebral aneurysms in 8 patients and speculate on the effect of haemodynamics on the localization and course of the disease. By mirror cerebral aneurysms we indicate two aneurysms in the same patient and at the same location in the cerebral vasculature but symmetrically with respect to a sagittal plane. In particular we focus on cases of mirror cerebral aneurysms where only one of the two aneurysms presented subarachnoid hemorrhage (SAH). Anatomical information is extracted from 3D rotational angiography (3DRA) images and haemodynamic information is obtained through blood flow simulation in patientspecific anatomical models. The distribution of Wall Shear Stress (WSS) and the flow patterns through the vessels and inside the aneurysms are reported. By combining clinical observations on asymmetry of the cerebral vasculature and aneurysmal shape and size with computed information on blood flow patterns we explore the causes behind a specific localization and a different outcome of disease progression.

Radaelli, Alessandro G.; Sola Martínez, Teresa; Vivas Díaz, Elio; Mellado, Xavier; Castro, Marcelo A.; Putman, Christopher M.; Guimaraens, Leopoldo; Cebral, Juan R.; Frangi, Alejandro F.



Endovascular and Surgical Management of Vertebral Artery Dissecting Aneurysms Presenting With Subarachnoid Haemorrhage: Medium-term Experience  

Microsoft Academic Search

Introduction: Dissecting aneurysms of the vertebral artery are associated with a high incidence of rebleeding and mortality if untreated. Current endovascular alternatives to surgery are being evaluated. Materials and Methods: We conducted a retrospective review of our experience with endovascular as well as surgical treatments of dissecting vertebral artery aneurysms in 6 patients. Three patients were treated with a combination

K Sheah; W Lim; Chumpon Chan


[Surgical and endovascular treatment for superior cerebellar artery aneurysms: report of two cases].  


Aneurysms located on the superior cerebellar artery (SCA) are uncommon and their presentation, natural history, and clinical management are poorly understood. Reports related to the endovascular or surgical management of SCA aneurysms are rare. Herein, we report two cases of SCA aneurysm. The first is that of a 70-year-old woman who presented with subarachnoid hemorrhage (SAH). Surgical treatment (neck clipping) of the ruptured SCA aneurysm was performed, and the flow of the parent artery disappeared. The second is that of a 69-year-old woman with an unruptured SCA aneurysm who underwent endovascular surgery to occlude the parent artery. Neither patients exhibited any additional neurological deficits. SCA aneurysms often have either relatively wide or undefinable necks, so it is difficult to preserve the parent artery. According to several surgical reports, occlusion of the SCA appears well tolerated for a variety of reasons. PMID:23269255

Haruma, Jun; Sugiu, Kenji; Shimazu, Yosuke; Michiue, Hiroyuki; Tokunaga, Koji; Date, Isao



Risk of Hemorrhage in Combined Neuroform Stenting and Coil Embolization of Acutely Ruptured Intracranial Aneurysms  

PubMed Central

Summary Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial due to the necessity of anticoagulation and antiplatelet medications. We report our experience using the Neuroform stent in the management of 41 aneurysms in 40 patients over a period of three years. For aneurysms whose open surgical risk remains excessive with a morphology that would preclude complete embolization, the risks of stenting may be warranted.

Jankowitz, B.; Thomas, A.J.; Vora, N.; Gupta, R.; Levy, E.; Yamamoto, J.; Kassam, A.; Gologorsky, Y.; Panapitiya, N.; Sandhu, E.; Crago, E.; Hricik, A.; Lee, K.; Gallek, M.; Jovin, T.; Horowitz, M.



Subarachnoid hemorrhage in the rat: cerebral blood flow and glucose metabolism after selective lesions of the catecholamine systems in the brainstem  

SciTech Connect

A double-isotope autoradiographic technique was used to evaluate CBF and glucose metabolism 2 days after a subarachnoid hemorrhage (SAH) in rats with lesions in the lower brainstem. Lesioning in the mesencephalon of the ascending catecholamine pathways from locus ceruleus and from the A1 and A2 nuclei, or lesioning in the medulla oblongata of the ascending fibers from A1 and A2, prevents the development of the global changes in flow and metabolism seen in normal animals post SAH. Also the focal low-flow areas with markedly elevated deoxyglucose uptake, which can develop in normal animals 2 days post SAH, were not seen in the lesioned animals after the SAH. The findings indicate that the A1 and A2 nuclei, which project to the hypothalamus-pituitary, are essential for the flow and metabolic changes after an SAH. The lesions per se did not change baseline flow and metabolism as compared with sham-lesioned animals.

Delgado, T.J.; Diemer, N.H.; Svendgaard, N.A.



Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery  

PubMed Central

OBJECTIVE—To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome.?METHODS—A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded.?RESULTS—The proportion of patients that was operated on early—that is, within three days after SAH—was 55%. Thirty seven of all 102admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome.?CONCLUSIONS—In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.??

Roos, Y; Beenen, L; Groen, R; Albrecht, K; Vermeulen, M



Distal aneurysms of basilar perforating and circumferential arteries. Report of three cases.  


Distal aneurysms of basilar perforating and circumferential arteries are exceedingly rare. The authors encountered one patient with a distal basilar perforating artery aneurysm and two with aneurysms arising from circumferential branches of the basilar artery (BA). The diagnostic features, microsurgical treatment, and outcomes in these three patients are described. The first patient, a 27-year-old man, presented with an angiogram-negative subarachnoid hemorrhage (SAH), and subsequent readmission for a new hemorrhage revealed a centrally thrombosed aneurysm arising from a basilar apex perforating artery. The second patient, a 68-year-old man, presented for follow-up evaluation 2 months after an angiogram-negative SAH, and an aneurysm was identified on a circumferential artery originating from the BA trunk. The third patient, a 2-year-old boy, presented with blunt head trauma and a pseudoaneurysm arising from a basilar apex circumferential artery. All three aneurysms were managed microsurgically with aneurysm trapping, via either an orbitozygomatic or an extended retrosigmoid approach. Occlusion of the distal perforating or circumferential artery was well tolerated in all cases, with no neurological sequelae resulting from surgery. Features common to all three aneurysms were dolichoectatic morphology, intraluminal thrombus, and SAH. These aneurysms may be difficult to diagnose given their small size and delayed filling on angiographic studies. Consequently, their presence in cases of angiogram-negative SAH may be underestimated. These aneurysms are not amenable to endovascular treatment, but excellent results can be obtained with microsurgical exposure and trapping. PMID:17886568

Sanchez-Mejia, Rene O; Lawton, Michael T



Glue Embolization of Ruptured Anterior Thalamoperforating Artery Aneurysm in Patient with Both Internal Carotid Arteries Occlusion  

PubMed Central

Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.

Lee, Jae Il; Ko, Jun Kyeung; Lee, Tae Hong



Relationship between presence of vasoconstrictor activity in cerebrospinal fluid and time after subarachnoid haemorrhage from rupture of cerebral arterial aneurysms.  

PubMed Central

The relationship between clinical condition and vasoconstrictor factors in cerebrospinal fluid was studied in 19 patients for up to six weeks after subarachnoid haemorrhage. Vasoconstrictor activity was assayed biologically. Sixteen of 19 patients improved as vasoconstrictor activity declined; this pattern was not significantly influenced by surgery. Serial angiography was performed on three patients and a qualitative relationship was shown between arterial dilatation, clinical improvement, and reduced pharmacological activity.

Hunt, T M; Du Boulay, G H; Blaso, W P; Forster, D M; Boullin, D J



Endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm: a case report and literature review.  


We report a case of successful endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. An elderly female patient with subarachnoid hemorrhage (SAH) onset was admitted to the hospital. Computed tomography (CT) and digital subtraction angiography (DSA) confirmed the presence of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. Brain blood supply was provided by the bilateral vertebral artery through the basilar artery. We treated the aneurysm with the endovascular approach by embolizing the aneurysm with three coils. The patient recovered well after surgery and showed no recanalization of the aneurysm on a one-year follow-up DSA. We also reviewed six similar cases found with a PUBMED database search (1980-2010), including those with bilateral common carotid artery occlusion. In conclusion, by using the endovascular approach, bilateral carotid artery occlusion with concurrent basilar apex aneurysm was efficiently treated. PMID:21487570

Xu, Kan; Wang, Honglei; Luo, Qi; Li, Ye; Yu, Jinlu



Endovascular Treatment of Bilateral Carotid Artery Occlusion with Concurrent Basilar Apex Aneurysm: A Case Report and Literature Review  

PubMed Central

We report a case of successful endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. An elderly female patient with subarachnoid hemorrhage (SAH) onset was admitted to the hospital. Computed tomography (CT) and digital subtraction angiography (DSA) confirmed the presence of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. Brain blood supply was provided by the bilateral vertebral artery through the basilar artery. We treated the aneurysm with the endovascular approach by embolizing the aneurysm with three coils. The patient recovered well after surgery and showed no recanalization of the aneurysm on a one-year follow-up DSA. We also reviewed six similar cases found with a PUBMED database search (1980-2010), including those with bilateral common carotid artery occlusion. In conclusion, by using the endovascular approach, bilateral carotid artery occlusion with concurrent basilar apex aneurysm was efficiently treated.

Xu, Kan; Wang, Honglei; Luo, Qi; Li, Ye; Yu, Jinlu



A novel inhibitor of inflammatory cytokine production (CNI-1493) reduces rodent post-hemorrhagic vasospasm  

Microsoft Academic Search

Introduction  Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a devastating complication, yet despite multiple lines\\u000a of investigation an effective treatment remains lacking. Cytokine-mediated inflammation has been implicated as a causative\\u000a factor in the development of posthemorrhagic vasospasm. In previous experiments using the rat femoral artery model of vasospasm,\\u000a we demonstrated that elevated levels of the proinflammatory cytokine interleukin (IL)-6 are

George Bowman; Robert H. Bonneau; Vernon M. Chinchilli; Kevin J. Tracey; Kevin M. Cockroft



Outcomes of Early Endovascular Versus Surgical Treatment of Ruptured Cerebral Aneurysms A Prospective Randomized Study  

Microsoft Academic Search

Background and Purpose—This prospective study was conducted to compare the outcomes of surgical clipping and endovascular treatment in acute (,72 hours) aneurysmal subarachnoid hemorrhage (SAH). Methods—One hundred nine consecutive patients were randomly assigned to either surgical (n 557) or endovascular (n552) treatment. Clinical and neuropsychological outcome was assessed at 3 and 12 months after treatment; MRI of the brain was

Timo Koivisto; Ritva Vanninen; Heleena Hurskainen; Tapani Saari; Juha Hernesniemi; Matti Vapalahti



Aneurysm detection with computed tomographic angiography in a 1-month-old infant.  


We report an infant whose clinical condition deteriorated acutely at 1 month of age because of a subarachnoid hemorrhage with an intracerebellar hematoma. Computed tomographic angiography revealed an aneurysm of the left posterior inferior cerebellar artery. Because of the critical condition of the child and her very young age, the decision to perform surgery was based solely on the computed tomographic angiography findings. PMID:11068173

Jansen, F E; Vandertop, W P; Velthuis, B K



Magnetic resonance angiography in the selection of patients suitable for neurosurgical intervention of ruptured intracranial aneurysms  

Microsoft Academic Search

This study was aimed at establishing whether magnetic resonance angiography (MRA) can be applied to planning and performing surgery on ruptured intracranial aneurysms, especially in the early phase, without recourse to intra-arterial digital subtraction angiography (IA-DSA). From February 1998 to August 2001, in all patients presenting with a subarachnoid hemorrhage, MRA was performed first. A three-dimensional time-of-flight MRA protocol with

Henriëtte E. Westerlaan; A. M. van der Vliet; J. M. Hew; J. D. M. Metzemaekers; J. J. A. Mooij; M. Oudkerk



Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal-type posterior communicating artery--two case reports and review of the literature.  


Only a small number of aneurysms arising on the posterior communicating artery itself (true Pcom aneurysm) have been reported. We report two cases of ruptured true Pcom aneurysms with some characteristic features of true Pcom aneurysm. A 43 year old man suffering from subarachnoid hemorrhage (SAH) had an aneurysm arising on the fetal-type Pcom artery itself, and underwent surgery for clipping. Most of the aneurysm was buried in the temporal lobe, so retraction of the temporal lobe was mandatory. During the retraction, premature rupture was encountered. After tentative dome clipping and the control of bleeding, complete clipping was achieved. Another patient, a 71 year old woman presenting with consciousness disturbance due to SAH, had an aneurysm on the fetal-type Pcom artery itself, and underwent surgery for clipping. It has been generally considered that hemodynamic factor plays an important role in the formation, the growth, and the rupture of the cerebral aneurysm. This factor is especially significant in true Pcom aneurysm formation and rupture. According to the literature, a combination of fetal type Pcom and formation of the true Pcom aneurysm has been reported in most cases (81.8%). Most of the aneurysm can be buried in the temporal lobe, and the retraction of the temporal lobe during the dissection of the neck would be necessary, which causes premature rupture of the true Pcom aneurysm. In the surgery for a true Pcom aneurysm, we should be aware of possible premature rupture when temporal lobe retraction is necessary. PMID:22259835

Nakano, Yoshiteru; Saito, Takeshi; Yamamoto, Junkoh; Takahashi, Mayu; Akiba, Daisuke; Kitagawa, Takehiro; Miyaoka, Ryo; Ueta, Kunihiro; Kurokawa, Toru; Nishizawa, Shigeru



Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants.  


Aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of death in young and middle-aged individuals and causes tremendous morbidity in affected patients. Despite the identification of various risk factors, the series of events leading to the formation, growth, and rupture of intracranial aneurysms is poorly understood. Cerebral aneurysm rupture has been associated with sexual intercourse and other forms of physical exercise. In fact, multiple case series reported that coitus was the immediate preceding activity in 3.8-14.5% of patients suffering from aneurysmal SAH. This may be related to the large elevations in mean arterial blood pressure that occur in both males and females during sexual intercourse (130-175 and 125-160 mm Hg, respectively). While coitus and physical exercise share important physiological similarities, each may differentially affect the probability that a preformed aneurysm will rupture. In this literature review and synthesis, the authors analyze the physiological human response to sexual intercourse in an effort to delineate those factors that may precipitate aneurysmal rupture. The authors' analysis is based on the original data collected by Masters and Johnson. To the authors' knowledge, this is the first review to address the link between sexual intercourse and intracranial aneurysmal rupture. While actual measurements of the physiological variables relevant to SAH were not performed in this article, the authors make reasonable assumptions based on the available data to help elucidate the mechanism of sexually induced aneurysmal rupture. PMID:20540599

Reynolds, Matthew R; Willie, Jon T; Zipfel, Gregory J; Dacey, Ralph G



Nuclear factor-?B/Bcl-XL pathway is involved in the protective effect of hydrogen-rich saline on the brain following experimental subarachnoid hemorrhage in rabbits.  


Early brain injury (EBI), a significant contributor to poor outcome after subarachnoid hemorrhage (SAH), is intimately associated with neuronal apoptosis. Recently, the protective role of hydrogen (H2 ) in the brain has been widely studied, but the underlying mechanism remains elusive. Numerous studies have shown nuclear factor-?B (NF-?B) as a crucial survival pathway in neurons. Here we investigated the role of H2 in EBI following SAH, focusing on the NF-?B pathway. A double blood injection model was used to produce experimental SAH, and H2 -rich saline was injected intraperitoneally. NF-?B activity within the occipital cortex was measured. Immunofluorescence was performed to demonstrate the activation of NF-?B; Bcl-xL and cleaved caspase-3 were determined via Western blot. Gene expression of Bcl-xL was detected by real-time PCR, and TUNEL and Nissl staining were performed to illustrate brain injury in the occipital cortex. SAH induced a significant increase of cleaved caspase-3. Correspondingly, TUNEL staining demonstrated obvious neuronal apoptosis following SAH. In contrast, H2 treatment markedly increased NF-?B activity and the expression of Bcl-xL and decreased the level of cleaved caspase-3. Additionally, H2 treatment significantly reduced post-SAH neuronal apoptosis. The current study shows that H2 treatment alleviates EBI in the rabbits following SAH and that NF-?B/Bcl-xL pathway is involved in the protective role of H2 . © 2013 Wiley Periodicals, Inc. PMID:24105634

Zhuang, Zong; Sun, Xue-Jun; Zhang, Xing; Liu, Huan-Dong; You, Wan-Chun; Ma, Chi-Yuan; Zhu, Lin; Zhou, Meng-Liang; Shi, Ji-Xin



Safety and efficacy of fasudil monotherapy and fasudil-ozagrel combination therapy in patients with subarachnoid hemorrhage: sub-analysis of the post-marketing surveillance study.  


Sub-analysis of the fasudil post-marketing surveillance study compared the safety and efficacy of fasudil plus ozagrel to fasudil only. A total of 3690 patients received fasudil and 1138 received fasudil plus ozagrel between 1995 and 2000. The occurrence of adverse events, occurrence of low density areas associated with vasospasm on computed tomography, absence of symptomatic vasospasm, and poor clinical outcomes associated with vasospasm were compared between the fasudil and fasudil plus ozagrel groups. The pharmacokinetics of fasudil were assessed in 5 patients with subarachnoid hemorrhage. The drug interaction between fasudil and ozagrel was pharmacologically investigated in vitro and in vivo. The occurrence of adverse events and clinical outcomes were similar between the two groups. The occurrences of symptomatic vasospasm and low density areas were lower in the fasudil group than in the fasudil plus ozagrel group. The average trough value (8-hour value) of the fasudil active metabolite, hydroxyfasudil, was 50 nM. Fasudil showed no pharmacological interaction with ozagrel. The combination of fasudil plus ozagrel was well tolerated, but did not result in better efficacy than fasudil only. PMID:18574328

Suzuki, Yoshio; Shibuya, Masato; Satoh, Shin-ichi; Sugiyama, Hirotoshi; Seto, Minoru; Takakura, Kintomo



Computed tomographic diagnosis of intraventricular hemorrhage: etiology and prognosis  

SciTech Connect

Sixty-eight patients with intraventricular hemorrhage (IVH) diagnosed by computed tomography (CT) were reviewed retrospectively to determine the etiology and prognosis, relationship to delayed hydrocephalus, and effect on neurological outcome. The most common causes were a ruptured aneurysm, trauma, and hypertensive hemorrhage. Ruptured aneurysms of the anterior communicating artery can often be predicted from the nonenhanced CT scan. The total mortality rate was 50%; however, 21% of patients returned to normal or had only mild disability. Patients in whom no cause was identified had a better prognosis. Delayed hydrocephalus was related to the effects of subarachnoid hemorrahage rather than obstruction of the ventricular system by blood. IVH per se is seldon a major factor in the neurological outcome.

Graeb, D.A.; Robertson, W.D.; Lapointe, J.S.; Nugent, R.A.; Harrison, P.B.



Blood Brain-Barrier Disruption of Nonionic Iodinated Contrast Medium Following Coil Embolization of a Ruptured Intracerebral Aneurysm  

Microsoft Academic Search

Summary: Few reports of temporary disruption of the blood-brain barrier (BBB) following neurointerventional procedures, presumably caused by nonionic radiographic contrast medium (CM), exist in the literature. We de- scribed such a case in a 72-year-old man presenting with acute subarachnoid hemorrhage, who underwent coil em- bolization of a ruptured anterior communicating artery complex aneurysm. At the time of his follow-up

Yusuke Uchiyama; Toshi Abe; Masaru Hirohata; Norimitsu Tanaka; Kazuyuki Kojima; Hiroshi Nishimura; Alexander M. Norbash; Naofumi Hayabuchi


Correlation of Transcranial Color Doppler to N20 Somatosensory Evoked Potential Detects Ischemic Penumbra in Subarachnoid Hemorrhage  

PubMed Central

Background: Normal subjects present interhemispheric symmetry of middle cerebral artery (MCA) mean flow velocity and N20 cortical somatosensory evoked potential (SSEP). Subarachnoid haemorrhage (SAH) can modify this pattern, since high regional brain vascular resistances increase blood flow velocity, and impaired regional brain perfusion reduces N20 amplitude. The aim of the study is to investigate the variability of MCA resistances and N20 amplitude between hemispheres in SAH. Methods: Measurements of MCA blood flow velocity (vMCA) by transcranial color-Doppler and median nerve SSEP were bilaterally performed in sixteen patients. MCA vascular changes on the compromised hemisphere were calculated as a ratio of the reciprocal of mean flow velocity (1/vMCA) to contralateral value and correlated to the simultaneous variations of interhemispheric ratio of N20 amplitude, within each subject. Data were analysed with respect to neuroimaging of MCA supplied areas. Results: Both interhemispheric ratios of 1/vMCA and N20 amplitude were detected >0.65 (p <0,01) in patients without neuroimages of injury. Both ratios became <0.65 (p <0.01) when patients showed unilateral images of ischemic penumbra and returned >0.65 if penumbra disappeared. The two ratios no longer correlated after structural lesion developed, as N20 detected in the damaged side remained pathological (ratio <0.65), whereas 1/vMCA reverted to symmetric interhemispheric state (ratio >0.65), suggesting a luxury perfusion. Conclusion: Variations of interhemispheric ratios of MCA resistance and cortical N20 amplitude correlate closely in SAH and allow identification of the reversible ischemic penumbra threshold, when both ratios become <0.65. The correlation is lost when structural damage develops.

Di Pasquale, Piero; Zanatta, Paolo; Morghen, Ilaria; Bosco, Enrico; Forini, Elena



Psychosocial outcomes at three and nine months after good neurological recovery from aneurysmal subarachnoid haemorrhage: predictors and prognosis  

PubMed Central

Objectives: To investigate (1) the prevalence of various aspects of cognitive and psychosocial dysfunction, including post-traumatic stress symptoms, over nine months after subarachnoid haemorrhage (SAH); (2) whether SAH is preceded by increased life stress; (3) to what extent adverse outcomes may be predicted from preillness life stress, early neurological impairment, age, and sex; and (4) relations between emotional and functional outcomes. Methods: 52 patients with good neurological recovery after surgery for SAH were each matched for age, sex, and occupation with a healthy control participant. SAH patients were assessed three and nine months postdischarge on measures of cognitive functioning, mood, and social functioning. Objective stressors and subjective life change during the preceding year were rated retrospectively. Controls completed measures of mood and social functioning once only. Results: Compared with controls, SAH patients showed increased mood disturbance, subtle cognitive impairment, and abnormally low independence and participation on measures of social functioning. 60% showed clinically significant post-traumatic stress symptomatology (intrusive thoughts or avoidance of reminders) at three months and 30% at nine months. Independence in activities of daily living was greatly reduced in half to a third of the sample at both three and nine months. Productive employment was below the 10th percentile of the control group for 75% of patients at three months and for 56% at nine months; this outcome could not be predicted from selected demographic, premorbid, or clinical variables but dependence on others for organisational activities was predicted by impaired prose recall. Mood at nine months was strongly predicted by prior mental health problems, poor physical health, dysphasia, and impaired prose recall at three months. There was no evidence of an abnormally high level of stressful life events in the year before SAH, although patients rated their subjective level of stress in this period slightly more highly than did the control participants. Conclusions: These findings highlight the need for structured support and treatment after surgery for SAH to reduce persisting mood disturbance and increase independence and participation.

Powell, J; Kitchen, N; Heslin, J; Greenwood, R



Achieved serum magnesium concentrations and occurrence of delayed cerebral ischaemia and poor outcome in aneurysmal subarachnoid haemorrhage  

PubMed Central

Background Magnesium therapy probably reduces the frequency of delayed cerebral ischaemia (DCI) in subarachnoid haemorrhage (SAH) but uncertainty remains about the optimal serum magnesium concentration. We assessed the relationship between serum magnesium concentrations achieved with magnesium sulphate therapy 64?mmol/day and the occurrence of DCI and poor outcome in patients with SAH. Methods Differences in magnesium concentrations between patients with and without DCI and with and without poor outcome were calculated. Quartiles of last serum magnesium concentrations before the onset of DCI, or before the median day of DCI in patients without DCI, were related to the occurrence of DCI and poor outcome at 3?months using logistic regression. Results Compared with the lowest quartile of serum magnesium concentration (1.10–1.28?mmol/l), the risk of DCI was decreased in each of the higher three quartiles (adjusted odds ratio (OR) in each quartile 0.2; lower 95% CI 0.0 to 0.1; upper limit 0.8 to 0.9). The OR for poor outcome was 1.8 (95% CI 0.5 to 6.9) in the second quartile, 1.0 (95% CI 0.2 to 4.5) in the third quartile and 4.9 (95% CI 1.2 to 19.7) in the highest quartile. Discussion Magnesium sulphate 64?mmol/day results in a stable risk reduction of DCI over a broad range of achieved serum magnesium concentrations, and strict titration of the dosage therefore does not seem necessary. However, concentrations ?1.28?mmol/l could decrease the effect on DCI while concentrations ?1.62 might have a negative effect on clinical outcome.

Mees, Sanne M Dorhout; van den Bergh, Walter M; Algra, Ale; Rinkel, Gabriel J E



[Surgical treatment for asymptomatic non-ruptured intracranial aneurysms].  


The study was undertaken to analyze the outcomes of treatment in 37 patients with 44 non-ruptured aneurysms (NRA) at different sites. The paper presents a detailed classification of NRA, identifies individuals at risk for aneurysmal disease in whom an active search for aneurysms until they rupture is recommended to prevent aneurysmal subarachnoidal hemorrhages and their sequels. Total aneurysmal exclusion was achieved in 93.2% of the cases; the aneurysmal walls were consolidated with surgical gauze in 7.2%. There were no fatal cases. Postoperative progression of focal neurological symptoms was noted in 4 patients. In 3 patients, these symptoms were entirely reversible. All NRAs should be operated on irrespective of their size particularly in young and middle-aged patients since this is technically possible and there are no concomitant diseases that make surgery contraindicated. It is expedient to perform computed or magnetic resonance imaging in combination with angiography in risk-group patients in order to reveal or exclude aneurysm. PMID:15490631

Khe?reddin, A S; Filatov, Iu M; Eliava, Sh Sh; Zolotukhin, S P; Sazonov, I A; Belousova, O B; Torbotrias, N L


FOS protein expression and role of the vagus nerve in the rat medullary visceral zone in multiple organ dysfunction syndrome caused by subarachnoid hemorrhage  

PubMed Central

This study was designed to observe the role of FOS protein expression in the rat medullary visceral zone (MVZ) in multiple organ dysfunction syndrome (MODS) caused by subarachnoid hemorrhage (SAH), with and without severing the vagus nerve. We also investigated the regulatory and control mechanisms of the MVZ and the vagus nerve in MODS following SAH. A model of MODS following SAH was established by injecting arterial blood into the Willis’ circle. The vagus nerve was cut off and blocked. The FOS protein expression in the MVZ was detected by immunohistochemistry. The positive expression levels of FOS in the MVZ in the SAH and SAH + severed-down vagus nerve (SDV) groups were higher than those in the normal control, sham surgery and SDV groups (P<0.01). However, expression in the SAH+SDV group was lower than that in the SAH group (P<0.01). Inflammatory damage was observed in each visceral organ at every time-phased point in the SAH group and the SAH+SDV group. The most apparent damage was at 24–36 h, consistent with the peak of FOS protein expression; the SAH+SDV group presented a greater level of damage. The inflammatory changes in surrounding visceral organs following SAH correlated with FOS protein expression in the MVZ, which indicates that the MVZ participates in the functional control of surrounding visceral organs following SAH. Severing the subphrenic vagus nerve increases the incidence of MODS following SAH and enhances SAH-induced inflammatory damage to the surrounding visceral organs, which indicates that the vagus nerve plays a role in the protection of the surrounding visceral organs in MODS following SAH.




Activation of Nuclear Factor-?B in the Brain after Experimental Subarachnoid Hemorrhage and Its Potential Role in Delayed Brain Injury  

PubMed Central

It has been reported that inflammation is involved in brain injury after subarachnoid hemorrhage (SAH). Nuclear factor-?B (NF-?B) is a key transcriptional regulator of inflammatory genes. Here, we used pyrrolidine dithiocarbamate(PDTC), an inhibitor of NF-?B, through intracisternal injection to study the role of NF-?B in delayed brain injury after SAH. A total of 55 rabbits were randomly divided into five groups: the control group; the SAH groups including Day-3, 5, and 7 SAH groups (the rabbits in these groups were sacrificed at 3, 5, 7 days after SAH, respectively); and the PDTC group (n?=?11 for each group). Electrophoretic mobility shift assay (EMSA) was performed to detect NF-?B DNA-binding activity. The mRNA levels of tumor necrosis factor (TNF)-?, interleukin (IL)-1?, and intercellular adhesion molecule (ICAM)-1 were evaluated by RT-PCR analysis. Deoxyribonucleic acid fragmentation was detected by TUNEL and p65 immunoactivity was assessed by immunohistochemistry. Our results showed the activation of NF-?B after SAH, especially at day 3 and 5. The activated p65 was detected in neurons. NF-?B DNA-binding activity was suppressed by intracisternal administration of PDTC. Increased levels of the TNF-?, IL-1?, and ICAM-1 mRNA were found in the brain at day 5 after SAH, and which were suppressed in the PDTC group. The number of TUNEL-positive cells also decreased significantly in the PDTC group compared with that in the Day-5 SAH group. These results demonstrated that the activated NF-?B in neurons after SAH plays an important role in regulating the expressions of inflammatory genes in the brain, and ultimately contributes to delayed brain injury.

You, Wan-Chun; Wang, Chun-xi; Pan, Yun-xi; Zhang, Xin; Zhou, Xiao-ming; Zhang, Xiang-sheng; Shi, Ji-xin; Zhou, Meng-liang



Dopamine D2-Receptor-Mediated Increase in Vascular and Endothelial NOS Activity Ameliorates Cerebral Vasospasm After Subarachnoid Hemorrhage In Vitro  

PubMed Central

Introduction Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a serious complication resulting in delayed neurological deficit, increased morbidity, mortality, longer hospital stays, and rehabilitation time. It afflicts approximately 35 per 100,000 Americans per year, and there is currently no effective therapy. We present in vitro data suggesting that increasing intrinsic nitric oxide relaxation pathways in vascular smooth muscle via dopaminergic agonism ameliorates cerebral vasospasm after SAH. Methods Cerebrospinal fluid (CSF) from patients with cerebral vasospasm after SAH (CSFV) was used to induce vasospasm in porcine carotid artery in vitro. Dopamine was added to test its ability to reverse spasm, and specific dopamine receptor antagonists were used to determine which receptor mediated the protection. Immunohistochemical techniques confirmed the presence of dopamine receptor subtypes and the involvement of NOS in the mechanism of dopamine protection. Results Dopamine receptor 1, 2, and 3 subtypes are all present in porcine carotid artery. Dopamine significantly reversed spasm in vitro (67% relaxation), and this relaxation was prevented by Haloperidol, a D2R antagonist (10% relaxation, P < 0.05), but not by D1 or D3-receptor antagonism. Both eNOS and iNOS expression were increased significantly in response to CSFV alone, and this was significantly enhanced by addition of dopamine, and blocked by Haloperidol. Conclusion Cerebral vasospasm is significantly reversed in a functional measure of vasospasm in vitro by dopamine, via a D2R-mediated pathway. The increase in NOS protein seen in both the endothelium and vascular smooth muscle in response to CSFV is enhanced by dopamine, also in a D2R-dependent mechanism.

Caudell, Danielle N.; Cooper, Matthew; Clark, Joseph F.; Shutter, Lori A.



[Endovascular coiling of thrombosed basilar tip aneurysm using double stents in a y-configuration].  


Recent advances in endovascular techniques greatly improved the ability to treat complex cerebral aneurysms. However, patients with wide-necked cerebral aneurysms have posed a special challenge to conventional endovascular therapy. We report a novel method of embolizing wide-necked basilar apex aneurysms by employing a Y-configuration, double stent technique. A 40-year-old woman with a partially thrombosed basilar apex aneurysm transferred to our hospital after diagnosis of subarachnoid hemorrhage. Cerebral angiography revealed a wide-necked aneurysm which neck was incorporating the origins of both the posterior cerebral arteries. In treatment procedure, a microcatheter was inserted into the aneurysm followed by coiling of the upper half of the dome. Next, the first stent was deployed in the right P2 segment extending down to the mid basilar artery and the second stent was then deployed with half of the stent in the left P2 and the other half within the lumen of the previously placed stent. Finally, the microcatheter was withdrawn near the neck, and the rest of the aneurysmal dome was packed by additional coils. The result was favorable. Successful coil embolization of a wide-necked bifurcation aneurysm can be achieved by using the double stenting Y-configuration in this case. This result continues to provide highly encouraging support of this novel technique to treat a subset of complex, wide-necked aneurysms that until recently were considered poor candidates for endovascular therapies. PMID:23100390

Otani, Yoshihiro; Sugiu, Kenji; Tokunaga, Koji; Hishikawa, Tomohito; Itami, Hisakazu; Hiramatsu, Masafumi; Okuma, Yu; Date, Isao



Histopathologic characteristics of a saccular aneurysm arising in the non-branching segment of the distal middle cerebral artery.  


Currently, the characteristics of aneurysms arising in the distal middle cerebral artery (dMCA) are not well understood. Here, we report the case of a 56-year-old woman with a ruptured saccular aneurysm in the M2 segment of the middle cerebral artery (MCA). The patient presented with a disturbance of consciousness, and computed tomography revealed a subarachnoid hemorrhage that angiography disclosed as a result of a saccular-type aneurysmal dilatation in the M2 segment of the left MCA. We excluded infection, inflammation, trauma, and neoplasia as causes of the aneurysm. Pathologic examination confirmed a ruptured saccular aneurysm of the dMCA that was unrelated to a branching zone. The aneurysmal wall was composed primarily of alphaSMA-positive and calponin/desmin-negative spindle cells and lacked internal elastic lamina, which was completely disrupted at the neck of the aneurysm. There was a strong positive immunoreactivity for matrix metalloproteinases (MMPs) 1, 2, and 9 in the spindle cells of the aneurysmal wall. In contrast, tests for MMP-8 were negative. The parent artery showed thickening of both the intima and media, with preservation of the internal elastic lamina. Atherosclerosis was not detected in either the parent artery or aneurysm. These findings suggest that an overexpression of MMPs may contribute to the development of saccular aneurysms in regions of the arterial trunk unrelated to branching zones. PMID:19962251

Takemura, Yusuke; Hirata, Yoko; Sakata, Noriyuki; Nabeshima, Kazuki; Takeshita, Morishige; Inoue, Tooru



Cerebral Perfusion Pressure Thresholds for Brain Tissue Hypoxia and Metabolic Crisis after Poor-Grade Subarachnoid Hemorrhage  

PubMed Central

Background and Purpose To identify a minimally-acceptable CPP threshold above which the risk of brain tissue hypoxia (BTH) and oxidative metabolic crisis is reduced for patients with SAH. Methods We studied thirty poor-grade SAH patients who underwent brain multimodality monitoring (3042 hours). Physiological measures were averaged over 60 minutes for each collected microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio (LPR) >40 with a brain glucose concentration ?0.7 mmol/L. BTH was defined as PbtO2 <20 mm Hg. Outcome was assessed at 3 months with the modified Rankin Scale. Results Multivariable analyses adjusting for admission Hunt-Hess grade, intraventricular hemorrhage, systemic glucose, and end-tidal CO2 revealed that CPP ?70 mm Hg was significantly associated with an increased risk of BTH (OR=2.0; 95%-CI: 1.2–3.3, P=0.007) and metabolic crisis (OR=2.1; 95%-CI 1.2–3.7, P=0.007). Death-or-severe-disability at 3 months was significantly associated with metabolic crisis (OR 5.4; 95%-CI: 1.8–16, P=0.002) and BTH (OR 5.1; 95%-CI: 1.2–23, P=0.03) after adjusting for admission Hunt-Hess grade. Conclusions Metabolic crisis and BTH are associated with mortality and poor functional recovery after SAH. CPP levels below 70 mm Hg was associated with metabolic crisis and BTH and may increase the risk of secondary brain injury in poor-grade SAH patients.

Schmidt, J. Michael; Ko, Sang-Bae; Helbok, Raimund; Kurtz, Pedro; Stuart, R. Morgan; Presciutti, Mary; Fernandez, Luis; Lee, Kiwon; Badjatia, Neeraj; Connolly, E. Sander; Claassen, Jan; Mayer, Stephan A.



International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping Versus Endovascular Coiling in 2143 Patients With Ruptured Intracranial Aneurysms: A Randomised Comparison of Effects on Survival, Dependency, Seizures, Rebleeding, Subgroups, and Aneurysm Occlusion  

Microsoft Academic Search

Summary Background Two types of treatment are being used for patients with ruptured intracranial aneurysms: endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year

A. J. Molyneux; R. S. C. Kerr; L.-Y. Yu



Rate of Recanalization and Safety of Endovascular Embolization of Intracranial Saccular Aneurysms Framed with GDC 360 Coils  

PubMed Central

Summary Coil compaction and recanalization of cerebral aneurysms treated with coil embolization continue to be of great concern, especially in patients that presented with subarachnoid hemorrhage. The incidence of recanalization reported by previous studies ranges from 12 to 40 percent in experienced centers. We reviewed the incidence of recanalization requiring retreatment in patients treated with GDC 360 framing coils. A retrospective review of every patient who underwent coil embolization with GDC 360 coils for saccular aneurysms at our institution from December 2004 to March 2008 was performed. We studied the patients’ demographics, clinical presentation, aneurysm size and configuration, type of coils used to embolize the aneurysm, the percentage of coils that were GDC 360 in any given aneurysm, the need for remodeling techniques like stent and/or balloon for embolization, immediate complications, cases in which we were unable to frame with the GDC 360 coil, and rate of recanalization on follow-up. A total of 110 patients (33 men, 77 women) and 114 aneurysms were treated with GDC 360 coils. Ninety-eight aneurysms were framed with the GDC 360 coils. There were two patients in whom the initial GDC 360 coil intended for framing had to be pulled out and exchanged for another type of coil. There were five procedure related complications (4.4%). Four patients required intra-arterial abciximab due to thrombus formation. One patient that presented with a grade III subarachnoid hemorrhage had aneur-ysm rupture while the coil was being advanced. A total of 50 patients (15 men and 35 women) underwent follow-up femoral cerebral angio-grams at least six months after coiling (mean follow-up was 15 months). Forty-four of the patients with follow-up had the GDC 360 coil used as a framing coil. Three patients (6%) required retreatment due to recanalization. Every patient with recanalization requiring treatment had aneurysms of the anterior communicating complex that presented with subarachnoid hemorrhage. The rate of recanalization of cerebral aneur-ysms embolized with GDC 360 framing coils was lower in our case series compared to the existing literature reports. Patients with aneurysms of the anterior communicating artery were at increased incidence of recanalization in our patient cohort.

Ortiz, R.; Song, J.; Niimi, Y.; Berenstein, A.



[Usefulness of CT angiography for demonstrating cerebral aneurysms].  


We report the usefulness of computed cerebral angiotomography (CT angiography) for demonstrating cerebral aneurysm and the clinical significance of CT angiography for ruptured cerebral aneurysm. Our modified method of CT angiography was easy and less time-consuming. Fifteen seconds after starting a single bolus injection, 1 ml/kg/25 seconds via cubital vein, of contrast medium (60% urograffin), 5 serial 5 mm thick-CT slices were scanned in every 6.5 seconds including 2 seconds of interval, beginning from an axial level 20 mm above the orbitomeatal line and ending at a level 40 mm. A total of 103 patients were examined in this report, consisting of 70 unruptured asymptomatic, 8 unruptured symptomatic (oculomotor nerve palsy) and 25 subarachnoid hemorrhage (SAH). Seven unruptured aneurysms in 4 asymptomatic cases, 2 unruptured aneurysms in 2 symptomatic cases 27 aneurysms in 24 SAH cases were suspected by CT angiography. Of these 36 aneurysms suspected by CT angiography 32 aneurysms were confirmed by cerebral angiography. The detection rate of CT angiography in this report was 89%, higher than those of previous reports. Thirteen aneurysms were located at internal carotid-posterior communicating artery (ICPC) junction. 11 at anterior communicating artery (Acom), 7 at middle cerebral artery (MCA). CT angiography showed a false positive findings in 4 cases, which were all located at Acom. Four aneurysms were not detected in CT angiography, which were all located at MCA and were very small (2-3 mm) in diameter. There were no deteriorated cases during and after CT angiography. We suggest that CT angiography is a useful and safe method for predicting the location of not only unruptured but ruptured aneurysms. PMID:3374742

Okuno, T; Moriwaki, H; Miyamoto, K; Terada, T; Nishiguchi, T; Itakura, T; Hayashi, S; Komai, N



Regulation of enhanced cerebrovascular expression of proinflammatory mediators in experimental subarachnoid hemorrhage via the mitogen-activated protein kinase kinase/extracellular signal-regulated kinase pathway  

PubMed Central

Background Subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. It is suggested that the associated inflammation is mediated through activation of the mitogen-activated protein kinase (MAPK) pathway which plays a crucial role in the pathogenesis of delayed cerebral ischemia after SAH. The aim of this study was first to investigate the timecourse of altered expression of proinflammatory cytokines and matrix metalloproteinase in the cerebral arteries walls following SAH. Secondly, we investigated whether administration of a specific mitogen-activated protein kinase kinase (MEK)1/2 inhibitor, U0126, given at 6 h after SAH prevents activation of the MEK/extracellular signal-regulated kinase 1/2 pathway and the upregulation of cerebrovascular inflammatory mediators and improves neurological function. Methods SAH was induced in rats by injection of 250 ?l of autologous blood into basal cisterns. U0126 was given intracisternally using two treatment regimens: (A) treatments at 6, 12, 24 and 36 h after SAH and experiments terminated at 48 h after SAH, or (B) treatments at 6, 12, and 24 h after SAH and terminated at 72 h after SAH. Cerebral arteries were harvested and interleukin (IL)-6, IL-1?, tumor necrosis factor ? (TNF)?, matrix metalloproteinase (MMP)-9 and phosphorylated ERK1/2 (pERK1/2) levels investigated by immunohistochemistry. Early activation of pERK1/2 was measured by western blot. Functional neurological outcome after SAH was also analyzed. Results Expression levels of IL-1?, IL-6, MMP-9 and pERK1/2 proteins were elevated over time with an early increase at around 6 h and a late peak at 48 to 72 h post-SAH in cerebral arteries. Enhanced expression of TNF? in cerebral arteries started at 24 h and increased until 96 h. In addition, SAH induced sensorimotor and spontaneous behavior deficits in the animals. Treatment with U0126 starting at 6 h after SAH prevented activation of MEK-ERK1/2 signaling. Further, U0126 significantly decreased the upregulation of inflammation proteins at 48 and 72 h following SAH and improved neurological function. We found no differences between treatment regimens A and B. Conclusions These results show that SAH induces early activation of the MEK-ERK1/2 pathway in cerebral artery walls, which is associated with upregulation of proinflammatory cytokines and MMP-9. Inhibition of the MEK-ERK1/2 pathway by U0126 starting at 6 h post-SAH prevented upregulation of cytokines and MMP-9 in cerebral vessels, and improved neurological outcome.



Ruptured vertebral artery dissecting aneurysms treated with endovascular treatment.  


Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and a subsequent high rate of mortality. We retrospectively studied the treatment efficacy and outcomes of 26 patients with ruptured VA dissecting aneurysms treated with endovascular surgery. Twenty-six patients with ruptured VA dissecting aneurysms were enrolled. Fifteen patients presented with poor-grade SAH and eleven with good-grade SAH. All patients were treated with endovascular treatment. We reviewed modes of therapy, complications and clinical outcomes. Coil occlusion of the artery at the dissecting aneurysm was performed in 24 patients. Proximal parent artery occlusion was performed in 2 patients. Obliteration of the dissecting aneurysm on postoperative angiogram was found in all patients. No patient sustained permanent complications associated with endovascular treatment. Regarding clinical outcome, although five patients died due to severe SAH, 19 patients had a good recovery or moderate disability. Ruptured VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. PMID:20027810

Shibukawa, Masaaki; Sakamoto, Shigeyuki; Kiura, Yoshihiro; Matsushige, Toshinori; Kurisu, Kaoru



Microsurgical Relations between Internal Carotid Artery-Posterior Communicating Artery (ICA-PComA) Segment Aneurysms and Skull Base: An Anatomoclinical Study  

PubMed Central

Purpose?The study of the clinical, anatomic, imaging, and microsurgical characteristics of the aneurysms of the internal carotid-posterior communicating artery (ICA-PComA) segment and their relationships with the skull base structures. Methods?The anatomic relationships of PComA with neurovascular elements and skull base structures were studied in cadavers. The clinical, imaging, and microsurgical findings of 84 microsurgically treated ICA-PComA aneurysms compiled in a prospective database were reviewed. Results?The most important anatomic relations of the PComA and ICA-PComA aneurysms are with the oculomotor nerve around the oculomotor triangle that forms the roof of the cavernous sinus. Aneurysms of the ICA-PComA are classified according to the orientation of the aneurysmal sac in infratentorial, supratentorial, and tentorial. Infratentorial aneurysms frequently present with subarachnoid hemorrhage (SAH) and oculomotor nerve paralysis. They have relations with skull base structures that often make it necessary to totally or partially resect the anterior clinoid process (6.7%) or anterior petroclinoid dural fold (15%). Supratentorial aneurysms course with SAH and without oculomotor nerve involvement, but they often are associated with intracranial hematoma. Conclusion?ICA-PComA aneurysms have complex anatomic relations. The orientation of the aneurysmal fundus induces relevant differences in the anatomic relations, clinical presentation, and microsurgical approach to ICA-PComA aneurysms.

Gonzalez-Darder, Jose M.; Quilis-Quesada, Vicent; Talamantes-Escriba, Fernando; Botella-Macia, Laura; Verdu-Lopez, Francisco



Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature.  


The authors demonstrate the technical feasibility of using intravascular stents in conjunction with electrolytically detachable coils (Guglielmi detachable coils [GDCs]) for treatment of fusiform, broad-based, acutely ruptured intracranial aneurysms and review the literature on endovascular approaches to ruptured aneurysms and cerebral stent placement. A 77-year-old man presented with an acute subarachnoid hemorrhage of the posterior fossa. A fusiform aneurysm with a broad-based neck measuring 12 mm and involving the distal vertebral artery (VA) and proximal third of the basilar artery (BA) was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable. Six days later a repeated hemorrhage occurred. A 15-mm-long intravascular stent was placed across the base of the aneurysm in the BA and expanded to 4 mm to act as a bridging scaffold to create a neck. A microcatheter was then guided through the interstices of the stent into the body and dome of the aneurysm, and GDCs were deposited for occlusion. The arteriogram obtained after stent placement demonstrated occlusion of the main dome and body of the aneurysm. The coils were stably positioned and held in place by the stent across the distal VA and BA fusiform aneurysm. Excellent blood flow to the distal BA and posterior cerebral artery was maintained through the stent. There were no new brainstem ischemic events attributable to the procedure. No rebleeding from the aneurysm had occurred by the 10.5-month follow-up evaluation, and the patient has experienced significant neurological improvement. Certain types of intracranial fusiform aneurysms may now be treated by combining intravascular stent and GDC placement for aneurysm occlusion via an endovascular approach. This is the first known clinical application of this novel approach in a ruptured cerebral aneurysm. PMID:9384409

Higashida, R T; Smith, W; Gress, D; Urwin, R; Dowd, C F; Balousek, P A; Halbach, V V



Cigarette Smoke and Inflammation: Role in Cerebral Aneurysm Formation and Rupture  

PubMed Central

Smoking is an established risk factor for subarachnoid hemorrhage yet the underlying mechanisms are largely unknown. Recent data has implicated a role of inflammation in the development of cerebral aneurysms. Inflammation accompanying cigarette smoke exposure may thus be a critical pathway underlying the development, progression, and rupture of cerebral aneurysms. Various constituents of the inflammatory response appear to be involved including adhesion molecules, cytokines, reactive oxygen species, leukocytes, matrix metalloproteinases, and vascular smooth muscle cells. Characterization of the molecular basis of the inflammatory response accompanying cigarette smoke exposure will provide a rational approach for future targeted therapy. In this paper, we review the current body of knowledge implicating cigarette smoke-induced inflammation in cerebral aneurysm formation/rupture and attempt to highlight important avenues for future investigation.

Chalouhi, Nohra; Ali, Muhammad S.; Starke, Robert M.; Jabbour, Pascal M.; Tjoumakaris, Stavropoula I.; Gonzalez, L. Fernando; Rosenwasser, Robert H.; Koch, Walter J.; Dumont, Aaron S.



Ruptured vertebral artery dissecting aneurysm followed by spontaneous acute occlusion and early recanalization: case report.  


A 47-year-old man presented with a ruptured vertebral artery dissecting aneurysm manifesting as subarachnoid hemorrhage followed by acute occlusion and early recanalization of the affected artery. Cerebral angiography 2 hours after the onset of the symptom showed pearl-and-string sign in the right vertebral artery. Serial angiography showed that the affected artery was occluded at 12 hours but was recanalized on the 4th day. The dissecting aneurysm was resected with side-to-side anastomosis between the bilateral posterior inferior cerebellar arteries. Postoperative cerebral angiography demonstrated disappearance of the lesion and patency of the right posterior inferior cerebellar artery via the anastomosis. Histological examination of the lesion showed hematoma between the media and adventitia, disrupting the internal elastica and intima. Acute occlusion and early recanalization of the affected artery may occur in ruptured vertebral artery dissecting aneurysms. Serial neurological and neuroradiological examinations are essential to decide the timing and method of treatment. PMID:16127257

Endo, Hidehiko; Otawara, Yasunari; Ogasawara, Kuniaki; Ogawa, Akira; Nakamura, Shin-ichi



Simulation and virtual-reality visualization of blood hemodynamics: the virtual aneurysm  

NASA Astrophysics Data System (ADS)

Intracranial aneurysms are the primary cause of non- traumatic subarachnoid hemorrhage. Difficulties in identifying which aneurysms will grow and rupture arise because the physicians lack important anatomic and hemodynamic information. Through simulation, this data can be captured, but visualization of large simulated data sets becomes cumbersome and tedious, often resulting in visual clutter and ambiguity. TO address these visualization issues, we developed an automated algorithm that decomposes the patterns of 3D, unsteady blood flow into behavioral components to reduce the visual complexity while retaining the structure and information of the original data. Our structural approach analyzes sets of pathlines and groups them together based on spatial locality and shape similarity. Adaptive thresholding is used to refine each component grouping to obtain the largest and tightest cluster. These components can then be visualized individually or superimposed together to formulate a rich understanding of the flow patterns in the aneurysm.

Lee, Daren; Valentino, Daniel J.; Duckwiler, Gary R.; Karplus, Walter J.



Derivative spectrophotometric analysis of cerebrospinal fluid for the detection of a ruptured cerebral aneurysm  

NASA Astrophysics Data System (ADS)

A cerebral aneurysm is a weakened portion of an artery in the brain. When a cerebral aneurysm ruptures, a specific type of bleeding known as a subarachnoid hemorrhage (SAH) occurs. No test exists currently to screen people for the presence of an aneurysm. The diagnosis of a SAH is made after an aneurysm ruptures, and the literature indicates that nearly one-third of patients with a SAH are initially misdiagnosed and subjected to the risks associated with aneurysm re-rupture. For those individuals with a suspected SAH, a computerized tomography (CT) scan of the brain usually demonstrates evidence of the bleeding. However, in a considerable portion of people, the CT scan is unable to detect the blood that has escaped from the blood vessel. For circumstances when a SAH is suspected despite a normal CT scan, physicians make the diagnosis of SAH by performing a spinal tap. A spinal tap uses a needle to sample the cerebrospinal fluid (CSF) collected from the patient"s back; CSF is tainted with blood after the aneurysm ruptures. To distinguish between a common headache and a SAH, a fast and an effective solution is required. We describe the development of an effective detection system integrating hardware and a powerful software interface solution. Briefly, CSF from the patient is aspirated and excited with an appropriate wavelength of light. The software employs spectrophotometric analysis of the output spectra and lays the foundation for the development of portable and user-friendly equipment for detection of a ruptured cerebral aneurysm.

Bhadri, P. R.; Majumder, A.; Morgan, C. J.; Pyne, G. J.; Zuccarello, M.; Jauch, E.; Wagner, K. R.; Clark, J. F.; Caffery, J., Jr.; Beyette, Fred R., Jr.



Endoscopic Extracapsular Removal of Pituitary Adenoma: The Importance of Pretreatment of an Adjacent Unruptured Internal Carotid Artery Aneurysm  

PubMed Central

The presence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk of subarachnoid hemorrhage, during transsphenoidal surgery, particularly when the aneurysm lies near the operative field. A left supraclinoid internal carotid artery aneurysm and a clinically nonfunctioning pituitary adenoma coexisted in a 57-year-old woman. Initially, the aneurysm was treated by endovascular coil placement, and then the patient underwent pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach. Pseudocapsule-based extracapsular total resection was safely performed, because of the extirpated risk of rupture of the coil-treated aneurysm. Recently, transsphenoidal pseudocapsule-based extracapsular resection approach for pituitary adenomas provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate. Compared with conventional subcapsular removal, pseudocapsule-based extracapsular resection has more risks of aneurysmal rupture that is located adjacent to pituitary adenoma. Thus, in a patient having a cerebral aneurysm with the proximity to the operative field, the cerebral aneurysm should be first treated with endovascular coil placement or direct surgical procedure; subsequently, pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach should be performed.

Yamada, So; Yamada, Shoko M.; Hirohata, Toshio; Ishii, Yudo; Hoya, Katsumi; Murakami, Mineko; Matsuno, Akira



Visualisation of intracranial aneurysms by transcranial duplex sonography  

Microsoft Academic Search

We examined 72 patients with 89 angiographically confirmed intracranial aneurysms, using transcranial colour-coded duplex sonography (TCCD) to determine the location and size of the aneurysm. The patients were admitted for coil embolisation of their aneurysm following subarachnoid haemorrhage or because of a cranial nerve palsy. Using a 2\\/2.25 MHz transducer, 42 aneurysms (47 %) were seen satisfactorily through the temporal

C. Klötzsch; H. C. Nahser; B. Fischer; H. Henkes; D. Kühne; P. Berlit



Endovascular minimally invasive treatment of the intracranial aneurysms - first 124 cases  

PubMed Central

Introduction: Since May 2005, we have started to treat the intracranial aneurysms endovascular way as an alternative minimally invasive technique to the classic neurosurgery treatment. Objective: Studying the patients’ demographics, clinical presentation, aneurysm size and configuration, type of coils used for embolization, the percentage of compaction and recanalization (especially in patients who presented with subarachnoid hemorrhage), and immediate complications. Methods and Results: An all-inclusive retrospective review of every patient who underwent coils embolization (stent or balloon assisted included) of saccular aneurysms from May 2005 to September 2011 was performed. A total of 116 patients (46 men and 60 women) and 124 aneurysms were treated. A total of 96 patients (41 men and 55 women) underwent follow-up femoral cerebral angiograms (mean follow-up was 25 months and the longest was at 37 months). Five patients required intra-arterial abciximab due to thrombus formation. Four patients had aneurysm rupture while the coil was being advanced. Eleven patients were treated during vasospasm peak. Seven patients had recanalization at 12 months follow-up. Discussion: The average hospitalization period was of 4 days. There is a close relation between Hunt and Hess scale score before treatment and post interventional neurological status. Due to subarachnoid hemorrhage, the vasospasm remains a threat to the patient’s neurological status. The treatment of cerebral aneurysms with endosacular embolization by coils is a safe and durable option. The risk of recanalization or re-rupture in our cohort is small compared to series published elsewhere. Larger series of patients are needed to support our evidence.

Dima, S; Scheau, C; Stefanescu, F; Danaila, L



Anterior Choroidal Artery Aneurysm Surgery: Ischemic Complications and Clinical Outcomes Revisited  

PubMed Central

Objective Surgical results for anterior choroidal artery (AChA) aneurysms have previously been reported as unsatisfactory due to inadvertent occlusion of the AChA, while the low incidence of AChA aneurysms hampers the accumulation of surgical experience. The authors reviewed their related surgical experience to document the ischemic complications and surgical outcomes. Methods Identification of the AChA at its origin by rigorous visual scrutiny, careful microdissection, and meticulous clip placement to avoid the AChA origin are all crucial surgical maneuvers. A retrospective review of a surgical series of 62 consecutive cases of an AChA aneurysm between 2004 and 2012 was performed. Results All patients, except for five (8.1%) with a small residual neck, showed complete aneurysm obliteration in postoperative angiographic evaluations. There was no incidence of procedure-related permanent AChA syndrome or oculomotor nerve palsy, while three (4.8%) patients suffered from transient AChA syndrome. The clinical outcomes [the 3-month modified Rankin Scale (mRS)] of the patients were related to their preoperative World Federation of Neurologic Surgeons (WFNS) grade. As regards the 3-month mRS, significant differences were found between patients with an unruptured aneurysm (WFNS grade 0; n=20), good-grade subarachnoid hemorrhage (WFNS grade 1-3; n=30), and poor-grade subarachnoid hemorrhage (WFNS grade 4-5; n=4). Conclusion In surgical treatment of AChA aneurysms, a risk of AChA insufficiency can be minimized by taking every precaution to preserve the AChA patency and intraoperative monitoring. In addition, the surgical outcome is primarily determined by the preoperative clinical state.

Lee, Young-Sup



Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review  

Microsoft Academic Search

ABSTRACT: INTRODUCTION: Triple-H therapy and its separate components (hypervolemia, hemodilution, and hypertension) aim to increase cerebral perfusion in subarachnoid haemorrhage (SAH) patients with delayed cerebral ischemia. We systematically reviewed the literature on the effect of triple-H components on cerebral perfusion in SAH patients. METHODS: We searched medical databases to identify all articles until October 2009 (except case reports) on treatment

Jan W Dankbaar; Arjen JC Slooter; Gabriel JE Rinkel; Irene C van der Schaaf



Endovascular Treatment of Internal Carotid and Vertebral Artery Aneurysms Using a Novel Pericardium Covered Stent  

PubMed Central

Summary Intracranial aneurysm is a fairly common (often asymptomatic) condition. Subarachnoid hemorrhage associated with aneurysmal rupture is a potentially lethal event with a mortality rate as high as 50 percent and a high rate of disability among those who survive the initial hemorrhage, such that recently published guidelines support treatment of intracerebral aneurysms. The current treatment options include surgical clipping and endovascular treatment, but these are not without significant problems. Despite the trend toward endovascular treatment the rate of recurrence and complications is high. Current published evidence of the use of covered stent is limited to stents covered with polytetrafluoroethylene. It is now recognized that mammalian extracellular matrix represents an excellent scaffold material suitable for many therapeutic applications and glutaraldehyde treated pericardium has been widely used for many years due to its desirable features such as low immunogenicity and durability. This report describes the first published experience with the Aneugraft Pericardium Covered Stent (ITGI Medical, OR Akiva, Israel) in the treatment of internal carotid and vertebral artery aneurysms in three patients. In all three cases, the implantation of this novel device has resulted in successful closure of aneurysms.

Vulev, I.; Klepanec, A.; Bazik, R.; Balazs, T.; Illes, R.; Steno, J.



Diagnostic approach to cerebral aneurysms.  


Cerebral aneurysms are an important cause of morbidity and mortality due to their causal effect in non-traumatic subarachnoid hemorrhage. Neurosurgical progress in the 20th century helped to improve patient outcomes greatly. In recent years, techniques such as intravascular treatment by coiling and/or stenting have found an additional place in the management of the disease. With the development of less and less invasive surgical and endovascular techniques, there has also been a continuous development in imaging techniques that have led to our current situation where we dispose of CT and MR techniques that can help improve treatment planning greatly. CT is able to detect and together with its adjunct techniques CT angiography and CT perfusion, it can allow us to provide the physicians in charge with a detailed image of the aneurysm, the feeding vessels as well as the status of blood flow to the brain. Angiography has evolved by becoming the standard tool for guidance during decision making for whatever therapy is being envisioned be it endovascular procedures and or surgery and has even progressed more recently due to the development of so-called flat panel technology that now allows to acquire CT-like images during and directly after an intervention. Thus nowadays, the diagnostic and interventional techniques and procedures have become so much entwined as to be considered a whole. PMID:23158462

Pereira, Vitor Mendes; Bijlenga, Philippe; Marcos, Ana; Schaller, Karl; Lovblad, Karl-Olof



Influence of Plasma and Cerebrospinal Fluid Levels of Endothelin1 and No in Reducing Cerebral Vasospasm after Subarachnoid Hemorrhage During Treatment with Mild Hypothermia, in a Dog Model  

Microsoft Academic Search

Using vascular heat-exchange controller implemented mild hypothermia treatment, the authors established the cerebral vasospasm\\u000a model in which blood was injected twice into dog’s foramen magnum; and it was discussed the influence of the concentration\\u000a of endothelin-1 and NO in blood plasma and cerebrospinal fluid through continuing treatment of mild hypothermia at different\\u000a times in secondary brain vasospasm model after subarachnoid

Zhi-ping Wang; Hong-sheng Chen; Feng-Xiang Wang


Hereditary Hemorrhagic Telangiectasia - HHT  


... IR Treatments Abdominal aortic aneurysms Angiography Angioplasty and stent placement Cancer - bone Cancer - breast Cancer - kidney Cancer - ... Causes Life-threatening Malformations in Blood Vessels Throughout Body Hereditary Hemorrhagic Telangiectasia (HHT) is a genetic disorder ...


Prevalence and Risk Factors for Multiple Simultaneous Intracerebral Hemorrhages  

Microsoft Academic Search

Background: Multiple simultaneous intracerebral hemorrhages (MSICH) are rare. We aimed to describe the frequency and potential risk factors for MSICH. Methods: We reviewed 522 consecutive patients admitted to our institution with spontaneous ICH between August 1, 2006 and November 30, 2009. Patients with traumatic hemorrhages, predominantly subarachnoid or intraventricular hemorrhages, hemorrhagic transformation of ischemic infarcts, and hemorrhages due to cerebral

Andrew Stemer; Bichun Ouyang; Vivien H. Lee; Shyam Prabhakaran



Clipping of a vertebral artery aneurysm behind the hypoglossal nerve under the monitoring of lower cranial nerves.  


Under an operative view, an aneurysm of the vertebral artery is located behind the lower cranial nerves. To prevent neurological deficits we employed electrophysiological monitoring while clipping an aneurysm of the vertebral artery. A 64-year-old woman had suffered a sudden severe headache in the morning. Computed tomography (CT) revealed a subarachnoid hemorrhage (SAH) and CT angiography revealed an aneurysm at a branching point of the left vertebral artery. The condylar fossa approach was taken while recording electromyography (EMG) of the lower cranial nerves. The aneurysm was located just behind the hypoglossal nerve and could not be clipped without strong traction of the hypoglossal nerve. Therefore, the hypoglossal nerve was divided to separate the lower two bundles of the hypoglossal nerve from the other bundles, and the clip was applied to the aneurysm between the nerve bundles without any change of the tongue EMG. The patient went home 10 days after operation with no neurological deficit. In conclusion, we report a case of a ruptured aneurysm of a vertebral artery, which was clipped while monitoring the lower cranial nerves. Tongue EMG monitoring enabled us to clip the aneurysm without nerve injury and revealed that the hypoglossal nerve near the hypoglossal canal can be divided into several bands without neurological deficit. PMID:20197210

Ishikawa, Mami; Kusaka, Gen; Takashima, Kouichi; Kamochi, Haruna; Shinoda, Soji



Delayed aneurysm regrowth and recanalization after Guglielmi detachable coil treatment. Case report.  


Guglielmi detachable coil (GDC) treatment for complicated cerebral aneurysms is an attractive option that has become widely accepted in recent years. This technique is usually considered only if the patient harbors an aneurysm that is not a good candidate for surgical clipping. However, the definition of "surgical candidate" varies among institutions, and many patients worldwide are being treated with GDCs as primary therapy. Although most centers currently perform follow-up angiography at 6 months to 1 year, others do not routinely perform it after an initially good result. The authors present a case that indicates longer follow up may be necessary and illustrates some of the pitfalls of GDC treatment. This 56-year-old man presented to the emergency room with a Hunt and Hess Grade II subarachnoid hemorrhage and was found to have a wide-necked basilar apex aneurysm. Because of associated medical comorbidities, it was decided to treat the aneurysm with endovascular techniques. The patient did well on follow-up angiography at 1 year postprocedure. However, at approximately 2 years follow up, the aneurysm was demonstrated to have dramatically recanalized and regrown, requiring open surgical intervention. Endovascular coiling was insufficient to treat this aneurysm and complicated definitive surgical management because a large coil mass had been placed in the operative field. It can be inferred from this case that angiographic follow up of these types of lesions may be beneficial up to 2 years after GDC treatment. PMID:9647186

Mericle, R A; Wakhloo, A K; Lopes, D K; Lanzino, G; Guterman, L R; Hopkins, L N



Temporary semi-jailing technique for coil embolization of wide-neck aneurysm with small caliber parent artery following incomplete clipping.  


The authors describe the use of a self-expandable stent in a temporary deployment for treatment of a very wide-neck A1 segment of anterior cerebral artery (ACA) aneurysm following incomplete clipping. A 39-year-old hypertensive man presenting with seizure-like movement underwent computed tomography, which showed acute subarachnoid hemorrhage and an A1 segment of ACA aneurysm with superior and inferior projection. He underwent surgical clipping of the aneurysm, but superior and posterior portion of wide-neck aneurysm remained. We decided to treat the remnant aneurysm using an endovascular modality. After selection of the aneurysm, coil packing was performed assisted by the temporary semi-jailing technique. The Enterprise stent (Cordis Neurovascular, Miami, FL, USA) was deployed and recaptured repeatedly for angiography to ensure safety of the small caliber parent artery. Successful semi-deployment and recapture of the stent allowed subtotal coil occlusion of the aneurysm with good anatomic and clinical results. No complications were encountered. The stent could be recaptured up to the point where the proximal end of the stent marker was aligned with distal marker band of the microcatheter, approximately 70% of the stent length. The temporary semi-jailing technique is feasible for wide-neck aneurysm with small caliber parent artery. PMID:23826481

Byun, Jun Soo; Kim, Jae Kyun; Lee, Hwa Yeon; Hwang, Sung Nam



Temporary Semi-Jailing Technique for Coil Embolization of Wide-Neck Aneurysm with Small Caliber Parent Artery Following Incomplete Clipping  

PubMed Central

The authors describe the use of a self-expandable stent in a temporary deployment for treatment of a very wide-neck A1 segment of anterior cerebral artery (ACA) aneurysm following incomplete clipping. A 39-year-old hypertensive man presenting with seizure-like movement underwent computed tomography, which showed acute subarachnoid hemorrhage and an A1 segment of ACA aneurysm with superior and inferior projection. He underwent surgical clipping of the aneurysm, but superior and posterior portion of wide-neck aneurysm remained. We decided to treat the remnant aneurysm using an endovascular modality. After selection of the aneurysm, coil packing was performed assisted by the temporary semi-jailing technique. The Enterprise stent (Cordis Neurovascular, Miami, FL, USA) was deployed and recaptured repeatedly for angiography to ensure safety of the small caliber parent artery. Successful semi-deployment and recapture of the stent allowed subtotal coil occlusion of the aneurysm with good anatomic and clinical results. No complications were encountered. The stent could be recaptured up to the point where the proximal end of the stent marker was aligned with distal marker band of the microcatheter, approximately 70% of the stent length. The temporary semi-jailing technique is feasible for wide-neck aneurysm with small caliber parent artery.

Kim, Jae Kyun; Lee, Hwa Yeon; Hwang, Sung Nam



Endovascular and Microsurgical Treatment of Superior Cerebellar Artery Aneurysms  

PubMed Central

Objective Superior cerebellar artery (SCA) aneurysms are regarded as being as difficult to treat surgically as posterior circulation aneurysms. We describe here a series of 33 of these aneurysms treated with microsurgery or embolization. Methods Between June 1997 and August 2007, 33 patients (9 men, 24 women; age, 29 to 76 years) with SCA aneurysms underwent microsurgical (n = 12) or endovascular (n = 21) treatment. Twenty two patients presented with subarachnoid hemorrhage. Thirty aneurysms were located in the junction between the SCA and the basilar artery (BA), two in the proximal SCA (S1) and one in the distal SCA (S2-3). Results Of the 29 SCA aneurysms, located in the junction between the SCA and BA, which were available on conventional angiography, 20 were lateral-superior, six lateral-horizontal, two lateral inferior, and one posterior type. Of the 12 patients treated microsurgically, eight had clinically excellent or good outcomes. Causes of poor outcomes included initial poor clinical status (n = 2), infarction due to parent artery compromise (n = 1), and artery of Heubner injury due to surgery for a coexisting anterior communicating artery aneurysm (n = 1). Of the 21 patients treated endovascularly, 17 had clinical good or excellent outcomes. Causes of clinically poor outcomes included initial poor clinical status (n = 2) and infarction due to thrombosis of exposed coil mesh (n = 1). One patient underwent embolization resulted in death due to vasospasm. Three patients required additional embolization for coil compaction. Conclusion There was no morbidity related to perforator injury, regardless of the treatment modality. Embolization or microsurgery is an effective modality, with relatively low procedural morbidity and mortality rates.

Jin, Sung-Chul; Park, Eun Suk; Ahn, Jae Sung; Kwun, Byung Duk; Kim, Chang Jin; Choi, Choong-Gon



Immediate and follow-up results for 44 consecutive cases of small (<10 mm) internal carotid artery aneurysms treated with the pipeline embolization device  

PubMed Central

Background: The pipeline embolization device (PED) provides effective, durable and safe endovascular reconstruction of large and giant intracranial aneurysms. However, 80% of all cerebral aneurysms found in the general population are less than 10 mm in size. Treatment of small aneurysms (<10 mm) with flow diverters may be advantageous over endosaccular modalities that carry risks of procedural rupture during aneurysm access or coil placement. Methods: We retrospectively reviewed a prospective, single-center aneurysm database to identify all patients with small (<10 mm) internal carotid artery (ICA) aneu