Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who ...will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods.
The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH.
Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery ACoA), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH.
Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.
Proportions of patients with single and multiple aneurysms among patients suffering from subarachnoid hemorrhage (SAH) are not well established. We evaluated these proportions and the differences in ...outcome between SAH patients with a single aneurysm and those with multiple aneurysms in a defined population.
Between 1989 and 1998, 2037 patients (age, 20 to 89 years) with ruptured intracranial aneurysm were treated in 11 hospitals in Nagasaki Prefecture. Multiple aneurysms were found in 361 of these patients. Age- and sex-specific incidences of ruptured aneurysm per 100 000 people were calculated.
For both single and multiple aneurysms, the incidences were significantly higher in women than in men 60 to 69 and 70 to 79 years of age. In every age category except 80 to 89 years, the frequency of multiple aneurysms was higher in women than in men. The overall frequency of multiple aneurysms was 20.2% in women, which was significantly higher than the 12.4% in men (P<0.0001). In patients 70 to 89 years of age, outcome was significantly worse (in terms of surgical complications) in patients with multiple aneurysms (12.1%) than in patients with a single aneurysm (6.0%).
Among all patients with SAH, women >or =50 years of age outnumber other age and sex categories. Female sex itself is also associated with an increased rate of multiple aneurysms among SAH patients. Among the elderly > or =70 years of age, prognosis is less favorable for SAH patients with multiple aneurysms than for those with a single aneurysm.
Objective: Craniofacial injury with fracture may lead to pseudoaneurysm formation in the external carotid artery system, causing massive epistaxis. In this study, we report a patient with ...intermittent epistaxis related to a traumatic aneurysm following right blow-out fracture, and review the literature with respect to the pathogenesis and treatment of traumatic aneurysms.Case Presentation: The patient is a 91-year-old male. He had undergone conservative treatment for right blow-out fracture because he fell down while walking. Subsequently, he had received medication with an iron preparation to control intermittent massive epistaxis. Six months after the head injury, he consulted the Department of Otorhinolaryngology with persistent epistaxis. In the right nasal cavity, a pulsatile mass was detected, suggesting a vascular lesion. He was referred to our department. Neurologically, there were no abnormalities, but marked anemia was noted, and blood transfusion was performed. Head CT revealed a mass occupying the right maxillary sinus. The mass was partially enhanced on contrast-enhanced CT. Angiography showed a pseudoaneurysm, measuring 8 × 10 × 15 mm, originating from a branch of the right internal maxillary artery. Subsequently, transarterial embolization was performed. A microcatheter was inserted to reach the aneurysm, and it was embolized using a liquid embolic material. After surgery, there was no epistaxis, and an improvement of anemia was achieved.Conclusion: In epistaxis patients with a history of craniofacial injury, it is necessary to differentiate traumatic aneurysms. Endovascular treatment is effective for traumatic aneurysms, and should be selected as a first-choice treatment.
The authors report on a series of 46 patients harboring vestibular schwannomas (VSs) treated using linear accelerator (LINAC) radiosurgery and an analysis of serial magnetic resonance (MR) imaging ...data, specifically the changes in tumor volume.
Fifty-three consecutive patients underwent LINAC radiosurgery for VS between 1993 and 2002. Seven of these patients were lost to follow up. Three-dimensional (3D) spoiled gradient-echo (SPGR) MR imaging was performed at 3- to 4-month intervals after radiosurgery. Tumor volume was measured on Gd-enhanced MR images of each slice. The median duration of follow-up MR imaging studies was 56.5 months (range 12-120 months). Follow-up imaging studies were conducted for longer than 1 year in 42 of 53 patients. Tumor volume changes were categorized into four types: enlargement (eight lesions 19%), no change (two lesions 4.8%), transient enlargement followed by shrinkage (19 lesions 45.2%), and direct shrinkage (13 lesions 31%). Two cases (4.8%) with twice the initial tumor volume required repeated radiosurgery. All cases of transient enlargement had subsequent shrinkage within 2 years after radiosurgery. Nine (21.4%) of 42 patients demonstrated ventricular enlargement on MR images obtained after radiosurgery. Three patients (7.1%) required placement of a ventriculoperitoneal shunt because of symptomatic hydrocephalus, and another four cases (9.5%) spontaneously resolved.
Volume measurement on 3D-SPGR MR imaging was a suitable method to assess tumor changes. Volume changes beyond twofold or continuous enlargement for longer than 2 years after radiosurgery are key criteria in rating the effects of radiation. Some cases of hydrocephalus after radiosurgery resolved spontaneously and their rates of occurrence were similar to the typical incidence of hydrocephalus associated with VS.
The purpose of this study was to clarify the efficacy of single-voxel proton magnetic resonance spectroscopy (MRS) in differentiating high-grade glioma from metastasis. Thirty-one high-grade gliomas ...(11 anaplastic gliomas and 20 glioblastomas) and 25 metastases were studied. Proton MRS was performed using point-resolved spectroscopy with echo times (TEs) of both 136 and 30 ms. The peaks for lipid were evaluated at short TE, and those for N-acetyl-aspartate (NAA), creatine (Cr), and choline-containing compounds (Cho) were assessed at long TE. All the tumors exhibited a strong Cho peak at long TE. Twenty-one of 25 metastases showed no definite Cr peak. The remaining 4 metastases showed NAA and Cr peaks; however, the presence of NAA and relatively high NAA/Cr ratio (1.58+/-0.56) indicated normal brain contamination. All the gliomas, except for a single glioblastoma, showed a Cr peak with (n=16) or without (n=14) NAA. At short TE all metastases and glioblastomas showed definite lipid or lipid/lactate mixture, but anaplastic gliomas showed no definite lipid signal. Intratumoral Cr suggests glioma. Absence of Cr indicates metastasis. Definite lipid signal indicates cellular necrosis in glioblastoma and metastasis, and no lipid signal may exclude metastases.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract only Background and Purpose: Aneurysmal rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding ...might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysmal rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods. Methods: The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. We performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and the outcome after SAH. Results: Preoperative rebleeding occurred in 7.2% of patients. Patient age (P = 0.01), multiple aneurysms (P < 0.01), aneurysm size (P < 0.0001), and heart disease (P = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery ACoA), family history (P = 0.02), preoperative rebleeding (P < 0.01), and clipping/coiling (P < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR, 4.00; 95% CI, 1.82-8.80; P < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (P < 0.0001) and intraoperative rebleeding (P < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH. Conclusions: Aneurysmal rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.
Background
Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency ...room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH.
Methods
The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms.
Results
Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality.
Conclusions
Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient’s history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Spontaneous subarachnoid hemorrhage (SAH) occurs due to intracranial aneurysm rupture in most cases. Rheumatic disease may cause vessel wall inflammation, which can increase the risk of rupture. ...However, the characteristics of SAH with rheumatic disease are unknown. This study aimed to evaluate SAH features in patients with rheumatic disease. We retrospectively analyzed clinical data of 5066 patients from the Nagasaki SAH Registry Study who had been diagnosed with aneurysmal SAH between 2001 and 2018. We evaluated the SAH characteristics in patients with rheumatic disease using multivariable logistic regression analysis. In total, 102 patients (2.0%, 11 men and 91 women, median age 69.0 57.0–75.5) had rheumatic disease. In these patients, univariate logistic regression analysis showed that sex, hypertension, family history of SAH, smoking history, World Federation of Neurosurgical Societies grade on admission, aneurysm size, multiple aneurysms, treatment, and symptomatic spasms were associated with SAH. Multivariable logistic regression analysis showed that characteristics independently associated with SAH in rheumatic disease were female sex (odds ratio OR 3.38; 95% confidence interval CI 1.81–6.93,
P
< 0.001), hypertension (OR 0.60; 95% CI 0.40–0.90,
P
= 0.012), family history of SAH (OR 0.18; 95% CI 0.01–0.80,
P
= 0.020), small ruptured aneurysms (OR 1.50; 95% CI 1.02–2.24,
P
= 0.048), and multiple aneurysms (OR 1.69; 95% CI 1.09–2.58,
P
= 0.021) in comparison with SAH without rheumatic disease. In conclusion, SAH in patients with rheumatic disease was characterized by small multiple aneurysms, regardless of the low incidence of hypertension and family history of SAH.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In carotid arterial stenting (CAS), ischemic complications and cerebral hyperperfusion are recognized as devastating complications. To detect these complications in early stages, we assessed the ...feasibility for real-time measurement of regional oxygen saturation (rSO2) of the brain in 24 patients with symptomatic extracranial carotid artery stenosis in CAS. The rSO2 changes were easy to evaluate and significantly correlated with the ischemic neurological symptoms as well as postoperative hyperperfusion detected by single-photon emission computed tomography (SPECT). Moreover, the pattern of changes in rSO2 was significantly correlated with the asymmetry index and the cerebral vasoreactivity examined by preoperative SPECT. Therefore, simultaneous monitoring of rSO2 is feasible in detecting early hemodynamic complications in CAS.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
A 74-year-old woman presented with a microcystic meningioma which manifested as mental disturbance. A rapidly growing tumor in the left middle fossa had not been detected by examination 10 months ...before. The tumor was remarkably enhanced by contrast medium on both computed tomography and magnetic resonance imaging and was associated with massive perifocal edema. Cerebral angiography revealed that the tumor was mainly fed by the left middle meningeal artery, which was embolized preoperatively. The tumor was completely removed and no postoperative adjuvant therapy was administered. The histological diagnosis was microcystic meningioma with many mitotic figures and a MIB-1 labeling index of 12.8%. Four months later, the tumor recurred and invaded the paranasal sinus. Focal irradiation successfully controlled further regrowth. This case suggests that microcystic meningioma may have aggressive features, and close observation is necessary even after gross total removal.
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