摘要:

OBJECTIVE:A small number of patients with aneurysmal subarachnoid hemorrhage have angiographic evidence of cerebral vasospasm within 48 hours of the onset of hemorrhage. The present study analyzes the prognostic value and determinants of this ultraearly angiographic finding.METHODS:We analyzed prospectively collected data from the placebo-treated group in a multicenter clinical trial conducted at 54 neurosurgical centers in North America. The presence and severity of ultraearly angiographic vasospasm (UEAV) was determined by a blinded review of the admission angiograms. Using logistic regression analysis, we identified independent determinants of UEAV from demographic, clinical, laboratory, and neuroimaging characteristics of the patients. The impact of UEAV on the risk of symptomatic vasospasm and 3-month outcome was analyzed after adjusting for potential confounding factors.RESULTS:Of 296 patients in the analysis, 37 (13%) had angiographic evidence of vasospasm at admission. An initial Glasgow Coma Scale score of less than 14 (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.1-6.0), and serum sodium greater than 138 mmol/L (OR, 3.4; 95% CI, 1.5-8.3) were associated with UEAV. UEAV was associated with increased risk of symptomatic vasospasm (OR, 2.5; 95% CI, 1.2-5.4) and poor outcome at 3 months (OR, 2.8; 95% CI, 1.2-6.3), after adjusting for other variables. This risk of symptomatic vasospasm was not influenced by early surgery (within 48 h of hemorrhage onset). Poor outcome was more likely to occur in patients with UEAV who did not undergo early surgery (P= 0.03).CONCLUSION:Our analysis suggests that patients with angiographic evidence of vasospasm at admission are at high risk for both symptomatic vasospasm and poor outcome. We also found that early surgery did not aggravate this risk.

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:

OBJECTIVES:To determine if a window of time could be defined during which angioplasty would be most effective in reversing neurological decline and ultimately improving outcome.METHODS:Of a group of 466 patients, 93 underwent endovascular management of clinical vasospasm that was medically refractory. Eighty-four of the 93 patients were available for follow-up for at least 6 months. All patients underwent mechanical angioplasty using compliant microballoon system and, if distal spasm was present, the administration of papaverine.RESULTS:Fifty-one patients underwent endovascular management within a 2-hour window, and 33 patients underwent treatment more than 2 hours after the development of their symptoms. Compared with the group treated more than 2 hours after neurological decline (P< 0.01; χ2= 8.02), the group that underwent endovascular management within a 2-hour window after the development of symptoms demonstrated sustained clinical improvement.CONCLUSION:When a patient develops symptomatic vasospasm and is unresponsive to traditional measures of critical care management, angioplasty may be effective in improving the patient's neurological status if this procedure is performed as early as possible. The results indicate that a 2-hour window may exist for restoration of blood flow to ultimately improve the patient's outcome.

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:A cellulose acetate polymer (CAP) solution was hypothesized to be useful for the embolization of arteriovenous malformations (AVMs). To investigate this possibility, we analyzed the clinical, radiological, and histological results of patients with AVMs embolized by using a CAP solution.METHODS:We reviewed the cases of 11 patients with AVMs treated by embolization before surgical resection. We used two types of CAP solutions, CAP-M and CAP-L, which are mixtures of 250 mg of solid CAP and 1800 or 2250 mg of bismuth trioxide dissolved in 5.5 or 7.0 ml of dimethyl sulfoxide, respectively. After the embolization procedure, percent reduction of the nidus volume was measured, and thereafter, the clinical course and computed tomographic scans and/or magnetic resonance imaging scans were evaluated. All patients underwent surgical resection 1 to 51 days after embolization. Resected specimens were stained for light microscopic examination.RESULTS:Thirty-nine feeding vessels were embolized. The reduction rate of the nidus volume ranged from 20% to nearly 100%. Transient and persistent ischemic deficits occurred in three patients and one patient, respectively, and there were no hemorrhagic complications. All AVMs but one were completely resected by surgery. The embolized AVMs were soft enough to be easily cut and retracted. The histological examinations disclosed no or mild inflammatory reactions within 2 weeks after embolization. The internal elastic lamina was preserved in every case. Recanalization through the cast of the CAP mass was not observed until 51 days after embolization.CONCLUSION:CAP solution is a safe and useful embolic agent for AVMs.

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:Basal ganglia and thalamic arteriovenous malformations (AVMs) show a poor natural history and have proven difficult to treat. We report the safety and efficacy of presurgical and preradiosurgical embolization of these deep central lesions and describe the contribution of embolization to multimodality treatment.METHODS:Thirty-eight patients with basal ganglia and/or thalamic AVMs underwent embolization in a total of 69 sessions. Seven of the 38 patients (18.4%) presented with hemorrhage, and 23 of 38 (60.5%) exhibited neurological deficits before therapy. Thirty patients (78.9%) underwent embolization with a liquid adhesive (cyanoacrylate), and five of these patients also underwent embolization with polyvinyl alcohol. Five patients (13.2%) were treated with polyvinyl alcohol or polyvinyl alcohol and silk. One patient (2.6%) underwent embolization alone, 19 (50.0%) underwent embolization followed by radiosurgery, 5 (13.2%) underwent embolization plus microsurgical resection, and 13 (34.2%) patients were treated using all three modalities.RESULTS:Three patients did not undergo embolization because of the morphological features of the AVMs and poor endovascular access. The patients who underwent embolization achieved AVM volume reductions of 10 to 100% (mean, 49.7%). Fifteen patients (39.5%) achieved complete obliteration of their AVMs, one with embolization alone, three with embolization followed by radiosurgery, five with embolization plus microsurgical resection, and six with a combination of all three modalities. At the time of the last follow-up imaging session, embolization combined with radiosurgery (19 patients) yielded a mean volume reduction of 81.1%, and all three modalities (13 patients) yielded a mean reduction of 84.6%. Four permanent neurological deficits from embolization (5.8% of procedures, 10.5% of patients). The embolization-related complication rate was higher in the earlier years (1984-1989) of this series.CONCLUSION:Endovascular embolization plays an important role in multimodality treatment of AVMs involving the basal ganglia and/or thalamus. Embolization can result in obliteration of a significant volume of the AVM and may allow complete obliteration of the AVM when combined with microsurgical resection and/or stereotactic radiosurgery.

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