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Acute management of poor condition subarachnoid hemorrhage patients.

Eleftherios A, Carvi y Nievas MN - Vasc Health Risk Manag (2007)

Bottom Line: We observed a reduced mortality (21%).The overall late outcome was favorable in 56% and unfavorable in 23%.Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Städtische Kliniken Frankfurt-Höchst, Frankfurt am Main, Germany.

ABSTRACT
Poor condition subarachnoid hemorrhage (SAH) patients present a high mortality and morbidity. In this study, we reviewed the acute interventional (surgical and endovascular) management of 109 SAH-poor condition patients, who were treated as early as logistically possible after confirming stable circulation parameters. Patients over the age of 70 years, without clinical response to painful stimulation were excluded. We recognized at least 3 different postinterventional therapeutic approaches: (1) Norm- or hypovolemic, normotensive hemodilution in 30 patients with space-occupying intracranial hematomas as well as in 31 cases with acute cerebro-spinal-fluid obstruction. (2) Normovolemic, hypertensive hemodilution after unilateral decompressive craniotomy in 23 surgical- and 2 endovascular-treated patients with focalized space occupying lesions and reduced cerebral perfusion. (3) Hypovolemic, normo-, or hypertensive hemodilution after bilateral decompressive craniotomy in 23 cases with massive brain-swelling. We observed a reduced mortality (21%). The overall late outcome was favorable in 56% and unfavorable in 23%. Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients.

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Related in: MedlinePlus

Upper sequence: SAH in a 48 year-old patient, H&H 4; (A) Preoperative CT-scan showing a right temporal mass occupying bleeding and secondary brain swelling; (B) Preoperative antero-posterior cerebral angiography of the right internal carotid artery demonstrating a multilobular giant aneurysm on the middle cerebral artery (white arrow) with vascular displacement; (C) Postoperative angiographic control showing a complete aneurysm occlusion and the borders of the decompressive craniotomy (black arrow); (D) Postoperative CT-scan demonstrating the clot-removal and the surgical decompression. Lower sequence: Fifty nine year-old woman with massive subdural and SAH and clinical herniation signs, H&H 5; A) Preoperative CT-scan demonstrating the right hemispheric subdural hemorrhage and the acute brain shift of the midline structures; (B) CT-angiography displaying the aneurysm (arrow) arising from the internal carotid artery; (C) Postoperative CT-scan demonstrating the brain reexpansion the surgical decompression.
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fig1: Upper sequence: SAH in a 48 year-old patient, H&H 4; (A) Preoperative CT-scan showing a right temporal mass occupying bleeding and secondary brain swelling; (B) Preoperative antero-posterior cerebral angiography of the right internal carotid artery demonstrating a multilobular giant aneurysm on the middle cerebral artery (white arrow) with vascular displacement; (C) Postoperative angiographic control showing a complete aneurysm occlusion and the borders of the decompressive craniotomy (black arrow); (D) Postoperative CT-scan demonstrating the clot-removal and the surgical decompression. Lower sequence: Fifty nine year-old woman with massive subdural and SAH and clinical herniation signs, H&H 5; A) Preoperative CT-scan demonstrating the right hemispheric subdural hemorrhage and the acute brain shift of the midline structures; (B) CT-angiography displaying the aneurysm (arrow) arising from the internal carotid artery; (C) Postoperative CT-scan demonstrating the brain reexpansion the surgical decompression.

Mentions: Ventriculostomy, angiography, and aneurysm clipping were performed in 22 cases and coiling in 9 patients with acute CSF obstruction. In patients with CSF obstruction and damaged cerebral autoregulation, only a postoperative normotensive hypovolemic hemodilution was administrated. Twenty four patients with initial CSF obstruction but without autoregulation disorders underwent a postoperative normotensive, normovolemic hemodilution. Patients with space occupying lesions due to vasospasms or developing massive cerebral infarction with concomitant edema (23 clipped and 2 coiled aneurysms), were treated with unilateral decompressive craniotomy and postoperative normovolemic hypertensive hemodilution. Patients with massive brain-swelling and computed tomography (CT)-scan absence of basal cisterns or ventricle as well as clinical herniation signs (23 cases), were managed with bilateral decompressive surgery. Aneurysm clipping had been previously performed in 20 and coiling in 3 of these cases. We observed a total reduced mortality (21%). The overall late outcome was favorable (GOS 4 to 5) in 56% and unfavorable in 23%. Space-occupying intracerebral and subdural hemorrhages were adequately removed and emergency aneurysm clipping performed with a reduced employment of brain retractors throughout an enlarged craniotomy (Figure 1). Decompressive surgery was performed not only in cases with space-occupying intracerebral and subdural hematomas and increased ICP but also in those patients where CPP was reduced due to the development of massive secondary local or generalized brain swelling. Postoperatively, all these patients experienced immediate decreases in ICP to levels at or below 20 mmHg (presentation mean ICP, 35.2 mmHg; postoperative mean ICP, 15.2 mmHg) and postoperative CPP improvements from at least 22.5 mmHg. Patient’s age and general clinical condition as well as aneurysm morphology and its location played an important role by cases where a primary endovascular aneurysm treatment was decided. Intraoperative technical difficulties were documented in 24 (25%) cases. The described problems were as follow: (1) restricted surgical access to the area of the aneurysm in 15 cases. Only 2 of these patients required an additional resection of brain parenchyma for clip application; (2) excessive brain retraction in 5 cases as documented on postoperative CT-scans; (3) use of temporary clip application in 4 cases (3 of them located on the AcoA). Ventriculostomy, and aneurysm clipping in cases with acute CSF obstruction, mostly had a favorable outcome, even in cases with combined IC mass occupying bleeding (Figure 2). However 4 of 9 endovascular-treated patients in this group had an unfavorable outcome and 3 died (Figure 3). Osmotic therapy, mechanical hyperventilation, and even short-acting barbiturates failed to prevent herniation and brain infarct in 45 cases. Unilateral or bilateral decompressive craniotomy (DC) showed additional benefits for all these patients reducing ICP and increasing CPP. Quantitative SPECT analysis of 16 regions of interest (ROIs) and PtiO2 monitoring in many of these patients revealed an increase of the cerebral perfusion after DC. Adequate cerebral perfusion pressure was obtained in such cases even with hypovolemic normotensive hemodilution. Hypodense CT-scan regions in the radiological controls from 17 patients were not associated to clinical relevant neurological deficits.


Acute management of poor condition subarachnoid hemorrhage patients.

Eleftherios A, Carvi y Nievas MN - Vasc Health Risk Manag (2007)

Upper sequence: SAH in a 48 year-old patient, H&H 4; (A) Preoperative CT-scan showing a right temporal mass occupying bleeding and secondary brain swelling; (B) Preoperative antero-posterior cerebral angiography of the right internal carotid artery demonstrating a multilobular giant aneurysm on the middle cerebral artery (white arrow) with vascular displacement; (C) Postoperative angiographic control showing a complete aneurysm occlusion and the borders of the decompressive craniotomy (black arrow); (D) Postoperative CT-scan demonstrating the clot-removal and the surgical decompression. Lower sequence: Fifty nine year-old woman with massive subdural and SAH and clinical herniation signs, H&H 5; A) Preoperative CT-scan demonstrating the right hemispheric subdural hemorrhage and the acute brain shift of the midline structures; (B) CT-angiography displaying the aneurysm (arrow) arising from the internal carotid artery; (C) Postoperative CT-scan demonstrating the brain reexpansion the surgical decompression.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2350130&req=5

fig1: Upper sequence: SAH in a 48 year-old patient, H&H 4; (A) Preoperative CT-scan showing a right temporal mass occupying bleeding and secondary brain swelling; (B) Preoperative antero-posterior cerebral angiography of the right internal carotid artery demonstrating a multilobular giant aneurysm on the middle cerebral artery (white arrow) with vascular displacement; (C) Postoperative angiographic control showing a complete aneurysm occlusion and the borders of the decompressive craniotomy (black arrow); (D) Postoperative CT-scan demonstrating the clot-removal and the surgical decompression. Lower sequence: Fifty nine year-old woman with massive subdural and SAH and clinical herniation signs, H&H 5; A) Preoperative CT-scan demonstrating the right hemispheric subdural hemorrhage and the acute brain shift of the midline structures; (B) CT-angiography displaying the aneurysm (arrow) arising from the internal carotid artery; (C) Postoperative CT-scan demonstrating the brain reexpansion the surgical decompression.
Mentions: Ventriculostomy, angiography, and aneurysm clipping were performed in 22 cases and coiling in 9 patients with acute CSF obstruction. In patients with CSF obstruction and damaged cerebral autoregulation, only a postoperative normotensive hypovolemic hemodilution was administrated. Twenty four patients with initial CSF obstruction but without autoregulation disorders underwent a postoperative normotensive, normovolemic hemodilution. Patients with space occupying lesions due to vasospasms or developing massive cerebral infarction with concomitant edema (23 clipped and 2 coiled aneurysms), were treated with unilateral decompressive craniotomy and postoperative normovolemic hypertensive hemodilution. Patients with massive brain-swelling and computed tomography (CT)-scan absence of basal cisterns or ventricle as well as clinical herniation signs (23 cases), were managed with bilateral decompressive surgery. Aneurysm clipping had been previously performed in 20 and coiling in 3 of these cases. We observed a total reduced mortality (21%). The overall late outcome was favorable (GOS 4 to 5) in 56% and unfavorable in 23%. Space-occupying intracerebral and subdural hemorrhages were adequately removed and emergency aneurysm clipping performed with a reduced employment of brain retractors throughout an enlarged craniotomy (Figure 1). Decompressive surgery was performed not only in cases with space-occupying intracerebral and subdural hematomas and increased ICP but also in those patients where CPP was reduced due to the development of massive secondary local or generalized brain swelling. Postoperatively, all these patients experienced immediate decreases in ICP to levels at or below 20 mmHg (presentation mean ICP, 35.2 mmHg; postoperative mean ICP, 15.2 mmHg) and postoperative CPP improvements from at least 22.5 mmHg. Patient’s age and general clinical condition as well as aneurysm morphology and its location played an important role by cases where a primary endovascular aneurysm treatment was decided. Intraoperative technical difficulties were documented in 24 (25%) cases. The described problems were as follow: (1) restricted surgical access to the area of the aneurysm in 15 cases. Only 2 of these patients required an additional resection of brain parenchyma for clip application; (2) excessive brain retraction in 5 cases as documented on postoperative CT-scans; (3) use of temporary clip application in 4 cases (3 of them located on the AcoA). Ventriculostomy, and aneurysm clipping in cases with acute CSF obstruction, mostly had a favorable outcome, even in cases with combined IC mass occupying bleeding (Figure 2). However 4 of 9 endovascular-treated patients in this group had an unfavorable outcome and 3 died (Figure 3). Osmotic therapy, mechanical hyperventilation, and even short-acting barbiturates failed to prevent herniation and brain infarct in 45 cases. Unilateral or bilateral decompressive craniotomy (DC) showed additional benefits for all these patients reducing ICP and increasing CPP. Quantitative SPECT analysis of 16 regions of interest (ROIs) and PtiO2 monitoring in many of these patients revealed an increase of the cerebral perfusion after DC. Adequate cerebral perfusion pressure was obtained in such cases even with hypovolemic normotensive hemodilution. Hypodense CT-scan regions in the radiological controls from 17 patients were not associated to clinical relevant neurological deficits.

Bottom Line: We observed a reduced mortality (21%).The overall late outcome was favorable in 56% and unfavorable in 23%.Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Städtische Kliniken Frankfurt-Höchst, Frankfurt am Main, Germany.

ABSTRACT
Poor condition subarachnoid hemorrhage (SAH) patients present a high mortality and morbidity. In this study, we reviewed the acute interventional (surgical and endovascular) management of 109 SAH-poor condition patients, who were treated as early as logistically possible after confirming stable circulation parameters. Patients over the age of 70 years, without clinical response to painful stimulation were excluded. We recognized at least 3 different postinterventional therapeutic approaches: (1) Norm- or hypovolemic, normotensive hemodilution in 30 patients with space-occupying intracranial hematomas as well as in 31 cases with acute cerebro-spinal-fluid obstruction. (2) Normovolemic, hypertensive hemodilution after unilateral decompressive craniotomy in 23 surgical- and 2 endovascular-treated patients with focalized space occupying lesions and reduced cerebral perfusion. (3) Hypovolemic, normo-, or hypertensive hemodilution after bilateral decompressive craniotomy in 23 cases with massive brain-swelling. We observed a reduced mortality (21%). The overall late outcome was favorable in 56% and unfavorable in 23%. Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients.

Show MeSH
Related in: MedlinePlus