摘要:

OBJECTIVE:Approximately 25% of patients with subarachnoid hemorrhage (SAH) have electrocardiographic (ECG) abnormalities consistent with myocardial ischemia or myocardial infarction (MI), and their cardiac prognosis remains unclear. The objective of this study was to determine the cardiac and all-cause mortality rate of a series of patients with SAH with ECG changes consistent with ischemia or MI.METHODS:Using an existing database of patients with SAH and predetermined ECG criteria for ischemia or MI, a study group of patients with abnormal ECG results within 3 days of presentation and before aneurysm surgery was identified. Database patients without abnormal ECG results served as a control group. Cardiac mortality, defined as death resulting from arrythmia, congestive heart failure, or cardiogenic shock, was assessed by chart review.RESULTS:Of 439 patients with SAH in the database, 58 met the criteria for the study group. Forty-one of these patients were treated neurosurgically. No deaths resulting from cardiac causes occurred, and 20 patients died as a result of noncardiac causes. In a multivariable analysis, age older than 65 years and Hunt and Hess grade of at least 3 were predictive of all-cause mortality. ECG abnormalities, however, were not a statistically significant predictor.CONCLUSION:In patients with SAH and ECG readings consistent with ischemia or MI, the risk of death resulting from cardiac causes is low, with or without aneurysm surgery. The ECG abnormalities are associated with more severe neurological injury but are not independently predictive of all-cause mortality.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVE:Little is known about the clinical behavior of cavernous malformations (CMs) associated with venous malformations (VMs) of the brain. The aim of this study is to compare the clinical profile of patients harboring CMs with and without associated VMs.METHODS:A retrospective analysis of 55 consecutive patients harboring CMs of the brain who presented to a single neurovascular team during a 4-year period was performed. Forty-two patients (76%) had CMs alone (CM group), and 13 patients (24%) had CMs associated with VMs (CM + VM group). Detailed clinical information regarding each patient was gathered. Statistical analysis was performed using Fisher's exact test for binary variables and Mann-WhitneyUtest for continuous variables.RESULTS:The lesion location was infratentorial for 19 of the 70 CMs (27%) in the CM group and for 14 of the 21 CMs (67%) in the CM + VM group (P= 0.001). Familial histories of CMs were documented for 7 of the 42 patients (17%) in the CM group and none of the 13 patients in the CM + VM group. There was a female-to-male gender bias of 1.6:1 in the CM group and 3.3:1 in the CM + VM group. Sixteen of the 42 patients (38%) in the CM group and 8 of the 13 patients (62%) in the CM + VM group presented with symptomatic hemorrhage. Seizure presentation was documented in 11 of the 42 patients (26%) in the CM group and in 1 of the 13 patients (8%) in the CM + VM group. Repeated symptomatic hemorrhage was diagnosed in 4 of the 42 patients (9.5%) in the CM group and in 3 of the 13 patients (23%) in the CM + VM group. There were no apparent differences in the mean age at presentation, lesion size, or multiplicity between the two groups.CONCLUSION:Patients with CMs associated with VMs are more likely to be female patients, have associated symptomatic hemorrhage, have lesions in the posterior fossa (statistically significant), suffer from repeated symptomatic hemorrhage, and are less likely to present with seizures or to have familial histories when compared with patients with CMs alone. The possible mechanisms for these apparent differences in clinical profile are discussed.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVE AND IMPORTANCE:The chronic delayed type of cerebral vasoconstriction that occurs after aneurysmal subarachnoid hemorrhage (SAH) is now the most important cause of mortality and neurological morbidity for patients who initially survive the rupture of cerebral aneurysms. Although intravascular volume expansion and cardiac performance enhancement have had a profound impact on the treatment of the chronic delayed type of cerebral vasoconstriction, this form of treatment is not tolerated by all patients and is unhelpful in some. A more specific and more reliable treatment for this condition has not been previously. Previous work in an animal model had demonstrated the efficacy of nitric oxide-donating compounds in reversing severe cerebral vasoconstriction when delivered to the adventitial side of the blood vessel. A clinical study was initiated after receiving approval from the United States Food and Drug Administration and the institutional review board.CLINICAL PRESENTATION:Three cases of prompt and substantial reversal of medically refractory vasospasm occurring after aneurysmal SAH in humans using an intrathecally administered nitric oxide donor and clinical, angiographic, and ultrasonographic documentation are presented. All patients developed severe vasospasm refractory to medical treatment 5 to 12 days after sustaining aneurysmal SAH. All patients manifested stupor of new onset (Glasgow Coma Scale score of 7) and new focal neurological deficit (hemiplegia). The condition was angiographically demonstrated in all cases.INTERVENTION:The patients were treated with intrathecally administered sodium nitroprusside, which caused the reversal of vasospasm, which was documented by angiography and transcranial Doppler ultrasonography up to 54 hours later and also by dramatic clinical improvement. Complications related to intracranial pressure elevation, changes in vital signs, and hemodynamic parameters were not observed during or after the procedures. Radiographic evidence of the reversal of vasospasm and brain ischemia was obtained. The clinical outcomes of the treated patients were excellent. All patients presented with hemiplegia and stupor that resolved or markedly improved (within several days, two patients; within 12 hours, one patient). All three patients were discharged and were living at home at the time of manuscript submission.CONCLUSION:These preliminary observations suggest that sodium nitroprusside delivered by an intrathecal route of administration may be a useful treatment for severe vasospasm complicating SAH in humans.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVE:Although the mainstays for treatment of metastatic brain disease have been surgery and/or external beam radiation therapy, an increasing number of patients are being referred for stereotactic radiosurgery as the primary intervention for their intracranial pathological abnormalities. The lack of efficacy and cognitive and behavioral consequences of whole brain irradiation have prompted clinicians to select patients for alternative therapies. This study analyzes the effectiveness of Leksell gamma unit therapy for metastatic melanoma to the brain.METHODS:We present our experience with 59 Leksell gamma unit treatment sessions in 45 consecutive patients who presented with metastatic melanoma to the brain. Five of these procedures were performed as salvage therapy for patients who needed second radiosurgical treatment for new lesions that were remote from the previous targets and were not included in the overall analyses.RESULTS:The population included 78% male patients. The mean patient age was 53 years (age range, 24-80 yr). The mean time from diagnosis of primary melanoma to discovery of brain metastasis was 43 months (median, 27.5 mo; range, 1-180 mo). At the time of diagnosis of brain disease, 35.5% of the patients (16 of 45 patients) had neurological symptoms, 77.7% (35 of 45 patients) had known visceral metastases, and 11.1% (5 of 45 patients) had seizure disorders. Eighty-six percent of the lesions (80 of 93 lesions) were cortical, 12% (11 of 93 lesions) were cerebellar, 1% (1 of 93 lesions) were pontine, and 1% (1 of 93 lesions) were thalamic. Fifty-seven percent of the sessions (31 of 54 sessions) were performed for a single lesion, 24.1% (13 of 54 sessions) for two lesions, 9.2% (5 of 54 sessions) for three lesions, 7.4% (4 of 54 sessions) for four lesions, and 1.8% (1 of 54 sessions) for five lesions. The mean treatment volume was 5.6 cc, with a mean prescription of 21.6 Gy to the 56.0% mean isodose line. The median survival time of the patients in our population, using Kaplan-Meier curves, was 43 months from the time of diagnosis of primary melanoma (range, 3-180 mo) and 8 months (range, 1-20 mo) from the time of gamma knife treatment. Complications included seizures within 24 hours of the procedure in four patients, with transient nausea and vomiting in three patients, transient worsening of preprocedure paresis responsive to steroids in three patients, and increased confusion in one patient. All 45 patients were located for follow-up (mean follow-up duration, 1 yr). After gamma knife treatment, 78% of the patients (35 of 45 patients) experienced either improved or stable neurological symptomatology before death or at the time of the latest follow-up examination. There were 26 deaths (58%). The cause of death was determined to be neurological in only 2 of 45 patients (7.7%). Follow-up magnetic resonance images revealed a 97% local tumor control rate of gamma knife-treated lesions, with 28% radiographic disappearance (9 of 32 cases). Six patients developed new lesions remote from radiosurgical targets and underwent second procedures.CONCLUSION:Although metastatic melanoma to the brain continues to have a foreboding prognosis for long-term survival, gamma knife radiosurgery seems to be a relatively safe, noninvasive, palliative therapy, halting or reversing neurological progression in 77.8% of treated patients (35 of 45 patients). The survival rate matches or exceeds those previously reported for surgery and other forms of radiotherapy. Only 7.7% of the patients in our study population who died as a result of metastatic melanoma (2 of 26 patients) died as a result of neurological disease. The routine use of therapeutic level antiseizure medication is emphasized, considering the findings of our review.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID