摘要:

OBJECTIVE:Hunterian ligation of the internal carotid artery (ICA) is an accepted treatment for inoperable carotid aneurysms. Preliminary extracranial-intracranial (EC-IC) bypass surgery is required in some patients. The reported incidence of thromboembolic and ischemic complications remains significant for these patients, despite a variety of advocated management strategies. We present our treatment paradigm.METHODS:Between April 1992 and March 1997, nine patients with inoperable ICA aneurysms were treated using EC-IC bypass surgery and then permanent endovascular ICA occlusion. All of the patients except one had been selected for bypass surgery on the basis of failing results of the ICA test occlusion with hypotensive challenge. ICA occlusion was performed by endovascular means and was delayed after bypass surgery was performed by a mean of 6 days(range, 2-20 d). All patients were managed in the intensive care unit after ICA occlusion.RESULTS:Clinical improvement was noted in all patients (mean follow-up, 21 mo; range, 3-42 mo). There were no major complications. Aneurysmal thrombosis was confirmed in all patients. Although ICA occlusion was delayed after bypass surgery, only one bypass was noted to be occluded. The occluded bypass occurred in a patient who subsequently underwent successful ICA occlusion. This patient was thought to have been improperly selected for bypass surgery.CONCLUSION:Certain carotid aneurysms can be effectively managed with hunterian ICA ligation. After preliminary identification of patients with borderline cerebrovascular reserve as candidates for EC-IC bypass surgery, close attention to the following points may help enhance clinical outcome: 1) excellence in surgical technique for EC-IC bypass surgery, 2) occlusion of the parent vessel as close to the aneurysm neck as possible by endovascular means, and 3) judicious postoperative combination of anticoagulation, fluid, and pressure management.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:To study the safety and efficacy of endovascular treatment of acutely ruptured aneurysms with Guglielmi detachable coils.METHODS:From August 1992 until December 1995, 75 patients were referred for endovascular treatment of acutely ruptured aneurysms. There were 49 women and 26 men, with a mean age of 55 years. Patients were classified according to the Hunt and Hess grading system. There were 18 Grade I patients (24%), 13 Grade II patients (17%), 30 Grade III patients (40%), 11 Grade IV patients(15%), and 3 Grade V patients (4%). Fifty patients (66%) were treated within 48 hours, and 64 (85%) were treated within 1 week of hemorrhage. The most frequently treated aneurysms were located at the basilar bifurcation (32%), anterior communicating artery (16%), posterior communicating artery (15%), and ophthalmic segment of the carotid artery (11%). Most of the aneurysms were smaller than 15 mm (77%). Fifty-six percent of the aneurysms had small(4 mm) necks, and 44% had wide (> 4 mm) necks. Clinical follow-up was performed at 6 months, and results were classified according to the Glasgow Outcome Scale (GOS). Control angiograms were performed immediately, at 6 months, and yearly thereafter.RESULTS:Immediate angiographic results were considered to be satisfactory in 58 patients (77%) (complete obliteration, 40%; residual neck and dog ear, 37%). Technical failures occurred in 5 patients (7%), and 12 patients experienced some residual opacification of their aneurysms (16%). The procedure-related mortality and morbidity rate was 8%. At 6 months, the outcomes were as follows: GOS score of 1, 50 patients (66.7%); GOS score of 2, 4 patients (5.3%); GOS score of 3, 4 patients (5.3%); and GOS score of 5, 17 patients (22.7%). The main causes of death and disability at 6 months were the direct effect of the initial hemorrhage (9%), delayed ischemia (6.7%), subsequent bleeding (4%), intraprocedural rupture (4%), open surgical complications (3%), and unrelated deaths (4%). Six-month angiographic follow-up data were available for 50 patients (67%). The morphological results were considered to be satisfactory in 44 of these 50 patients (88%) (complete occlusion, 46%; residual neck or dog ear, 42%).CONCLUSION:Endovascular treatment of acutely ruptured aneurysms was attempted without clinically significant complication in 92% of the patients. The morphological results were unsatisfactory in 23% of the patients. Complete obliteration of the sac, with or without residual neck, is essential to prevent subsequent bleeding, which occurred in 5% of the patients. The overall outcome at 6 months was similar to that of surgical series, despite a selected group of patients with negative prognostic factors.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:Familial intracranial aneurysms are more common than has been appreciated, but systematic autopsy studies of affected individuals have not been reported. We reviewed the autopsy findings of a group of patients with familial aneurysms to elucidate the nature of the putative underlying arteriopathy.METHODS:Using a computerized diagnostic index, we identified all patients with intracranial aneurysms in whom postmorten examination had been performed at the Mayo Clinic between January 1, 1992, and December 31, 1994. The medical records, radiographic studies, and autopsy findings of these patients were reviewed.RESULTS:Among the 28 patients with intracranial aneurysms, 3 (11%) had one or more first-degree relatives with documented intracranial aneurysms. The mean age of the three patients (two women and one man) was 54 years. Microscopic examination of the vascular system revealed medial changes, consisting of degeneration of elastic fibers and increased ground substance, in the systemic arteries of 2 of the 3 patients with familial aneurysms but in none of the 25 patients with sporadic aneurysms. These nonspecific medial changes involved both common and extracranial internal carotid arteries in one patient and the entire aorta as well as intracranial and common carotid arteries in the other patient.CONCLUSION:These observations suggest that an underlying arteriopathy in patients with familial intracranial aneurysms involves the tunica media and commonly may affect systemic (extracranial) arteries.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:Evaluation of the accuracy of preoperative localization of language-related cortex by magnetic resonance imaging-guided positron emission tomography.METHODS:Patients with gliomas in the left dominant hemisphere were examined preoperatively with magnetic resonance imaging-guided positron emission tomography and intraoperatively by electrical stimulation of cortex.RESULTS:A verb generation task yielded more intense and better lateralized local increases of cerebral blood flow in the positron emission tomographic examination than did a naming task. Significant correspondence of preoperative and intraoperative findings was observed for the verb generation task. Cortical sites with aphasic disturbance during electrical stimulation had a significantly higher cerebral blood flow increase during preoperative activation than did sites without intraoperative language impairment. Areas with cerebral blood flow increases above an optimum threshold had 73% sensitivity and 81% specificity to predict aphasic disturbance during intraoperative stimulation.CONCLUSION:The data suggest that with further technical improvements, imaging of language function may become a preoperative diagnostic tool for patients with tumors close to language-related brain structures.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition.PATIENTS AND METHODS:From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data.RESULTS:Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died(mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died.CONCLUSION:Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:The goal of this study was to define clearly the role of management in patients with cyanotic heart disease and brain abscesses by evaluating retrospectively the factors influencing poor outcome in these patients.METHODS:This study included 62 patients with cyanotic heart disease and brain abscesses diagnosed in the computed tomography era. Basic characteristic parameters (number, size, location, computed tomographic classification and organism type of abscess, convulsion, type of cyanotic heart disease, age distribution, immunocompromised status, pretreatment neurological state, and intraventricular rupture of brain abscess [IVROBA]) and therapeutic parameters (type of antibiotics and duration of administration, steroid medication and therapeutic modalities, aspiration with or without cerebrospinal fluid drainage, total extirpation after aspiration, or primary extirpation and medical treatment) were evaluated as independent predictors of poor outcome (totally disabled state or death) by using univariate and multivariate logistic regression analysis. We also statistically estimated the possible causes of IVROBA and the multiplicity of brain abscess.RESULTS:Although there were no statistically significant correlations between patients with good and poor outcomes in regard to other basic characteristic and therapeutic parameters, patients with poor outcomes were older(P< 0.02), more frequently had IVROBA (P< 0.005), and had a higher frequency of neurological deterioration (P< 0.01) than those with good outcomes. Multiple logistic regression analysis predicted that poor outcome increased the relative risk of IVROBA by a factor of 18.9 (odds rate, 18.9; 95% confidence interval, 1.7-211.6;P< 0.02). More patients with multiple abscesses had positive immunocompromised states than those with single abscesses (P< 0.01). Deep-located abscesses also more frequently had IVROBA (P< 0.005) and abscesses located in the parieto-occipital region ruptured into the occipital horn of the lateral ventricle in a short period(P< 0.02).CONCLUSIONS:Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:To evaluate the treatment of serious and uncontrollable intracranial hypertension in patients with acquired immunodeficiency syndrome who developed cryptococcal meningitis.METHODS:All cases of cryptococcal meningitis with elevated pressure and acquired immunodeficiency syndrome were reviewed in detail and described.RESULTS:Cerebrospinal fluid shunting dramatically improved these critically ill patients and was much more successful than serial lumbar punctures or the use of high-dose dexamethasone.CONCLUSION:Patients with acquired immunodeficiency syndrome who develop cryptococcal meningitis and who suffer serious visual loss or ocular palsies with elevated pressures should be considered for cerebrospinal fluid shunting at an early stage.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

OBJECTIVE:Uncoupling of cerebral blood flow (CBF) and oxidative metabolism is observed after severe head injury in comatose patients; however, the mechanism(s) involved remain undefined. Adenosine can produce cerebral vasodilation and reduce neuronal activity and is a possible mediator of uncoupling. We hypothesized that cerebrospinal fluid (CSF) adenosine concentrations would be increased during uncoupling of CBF and oxidative metabolism, defined as a narrow arterio-jugular venous oxygen difference [D(a- v)O24 vol%] after head injury.METHODS:Adenosine concentrations were measured using fluorescent-based high-pressure liquid chromatography in 67 CSF samples obtained from 13 comatose (Glasgow Coma Scale score 7) adult patients who sustained a severe closed head injury. At the time each sample was obtained, CBF was measured by the xenon-133 method, and blood samples were obtained for determination of D(a - v)O2.RESULTS:CSF adenosine concentration was negatively associated with D(a - v)O2(P< 0.05, generalized multivariate linear regression model). In addition, CSF adenosine concentration was increased when D(a - v)O2was 4 versus >4 vol% (38.5 [3.2-306.3] versus 14.0 [2.7-795.5] nmol/L, respectively, median [range];P< 0.025) and in patients who died versus survivors (40.1 [6.9-306.3] versus 12.9 [2.7-795.5] nmol/L, respectively, median [range];P< 0.001).CONCLUSION:The association between increased CSF adenosine concentration and a reduction in global cross-brain extraction of oxygen supports a regulatory role for adenosine in the complex balance between CBF and oxidative and nonoxidative metabolism after severe head injury in humans.

ISSN:0148-396X    

出版商:OVID    

年代:1997

数据来源: OVID