Neuroendoscopic management of intraventricular hemorrhage.
(33/194)
BACKGROUND AND PURPOSE: We reviewed our 7-year experience in neuroendoscopic management of severe intraventricular hemorrhage (IVH) to evaluate its safety, efficiency, and efficacy. METHODS: Thirteen patients with spontaneous primary or secondary tetraventricular IVH underwent neuroendoscopy. In all procedures, we used a flexible instrument. CT scans obtained before and after surgery were compared for Graeb score and ventriculocranial ratio. Glasgow Outcome Scale was assessed at 12 months. RESULTS: In all patients, the procedure resulted in a substantial removal of ventricular blood. Graeb score was reduced by 65%, and ventriculocranial ratio was reduced by 30% (P<0.002). The procedure was carried out safely even in the presence of a vascular malformation, and no rebleeding or delayed hydrocephalus was observed in any case. Mortality at 12 months was 30.7%. Favorable outcome (Glasgow Outcome Scale, 3 to 5) was observed in 61.5% of cases. CONCLUSIONS: Neuroendoscopic management of severe IVH in this cohort of patients was safe, efficiently reduced the amount of ventricular blood and ventricular dilatation, and effectively produced an outcome profile that compares very favorably with other more conventional treatments. (+info)
Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction.
(34/194)
OBJECTIVE: To determine long term functional outcome and length of survival of patients undergoing decompressive craniectomy for space occupying infarction of the middle cerebral artery (MCA), and to identify risk factors associated with death and unfavourable outcomes METHODS: Databases of patients undergoing decompressive craniectomy for space occupying MCA infarction compiled at eight neurosurgical departments (1996-2001) were merged, and 188 patients were evaluated. Mortality was calculated by the Kaplan-Meier method. Clinical outcome was rated using the Glasgow outcome scale (GOS). The prognostic impact of patient related covariates on length of survival and the GOS was analysed multivariately. RESULTS: The unadjusted 3, 6, and 12 month mortality rates were 7.9%, 37.6%, and 43.8%, respectively (median follow up, 26 weeks). In the "best" multivariate model, age >50 years (p<0.02) and the involvement of two or more additional vascular territories (p<0.01) had an unfavourable impact on length of survival. The adjusted six month mortality was as low as 20.0% (no risk factor) and as high as 59.7% (two risk factors). A GOS score of 50 years (p<0.0003): 34.9% of the patients 3, as compared with 12.0% of the elderly subpopulation. The side of the infarct did not have prognostic relevance. CONCLUSIONS: Results of surgical treatment in patients <50 years of age undergoing decompressive craniectomy are encouraging. The effectiveness of decompressive craniectomy for patients >50 years remains questionable and should be analysed in the framework of a prospective randomised study. (+info)
CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage.
(35/194)
BACKGROUND AND PURPOSE: The overall mortality rate of primary pontine hemorrhage (PPH) in recent studies is 40-50%. The aim of the present study was to analyze the predictive value of clinical and neuroradiologic parameters concerning the outcome of patients with PPH. METHODS: We reviewed the clinical data of 29 consecutive patients (mean age, 59 +/- 13.5 years; 12 women, 17 men) with PPH. National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) scores were assessed on admission, and NIHSS, GCS, and Glasgow Outcome Scale (GOS) scores were assessed on discharge. The hemorrhage volume was calculated by using a previously published formula. Clinical manifestations, outcome, and volume and location of the bleeding were correlated. RESULTS: The mean GCS score on admission was 6.8 +/- 3.9 and increased to 9.0 +/- 3.9 on discharge. The NIHSS score improved from 29.1 +/- 12.5 to 12.1 +/- 7.3. Nine patients (31%) died as a result of PPH after 5 +/- 3 days. The mean GOS score was 3.0 +/- 1.5 (3.9 +/- 0.8 for patients who survived). Arterial hypertension was the most common risk factor (90%); other causes were anticoagulation therapy (7%) and amyloid angiopathy (3%). A high correlation was observed between a poor outcome (GOS score < 4) and hematoma volume greater than 4 mL (P =.006), ventral hemorrhage (P <.001), and necessity for mechanical ventilation (P <.001). Patients with dorsally located hematomas less than 4 mL in volume had a significantly better outcome. CONCLUSION: The prognosis of PPH is better than commonly expected. Most patients with moderate neurologic deficits on admission and dorsally located small hematomas are able to survive PPH with minor neurologic deficits. (+info)
Endovascular treatment of anterior choroidal artery aneurysms.
(36/194)
BACKGROUND AND PURPOSE: Ischemic stroke is the most common complication after surgical clipping of anterior choroidal artery (AChA) aneurysms, and the reported morbidity-mortality rates vary from 5% to 50%. We report the findings in a series of 18 consecutive patients who underwent endovascular treatment (EVT) for an AChA berry aneurysm. METHODS: In this retrospective study, the aneurysms were defined according to their size and position, the presence of a concomitant arteriovenous malformation (AVM), the mode of presentation. The patients were clinically assessed before and after the EVT, as well as at each angiographic follow-up. RESULTS: All were small-sized aneurysms, with greater diameters ranging from 2 to 8 mm (mean, 4 mm), arising from the supraclinoid internal carotid artery close to the origin of the AChA. Two were AVM-associated aneurysms. Fourteen patients (14/18 [78%]) presented with subarachnoid hemorrhage. All aneurysms were selectively embolized with coils. There was one (1/18 [5.5%]) treatment-related death due to aneurysm perforation. Another patient (1/18 [5.5%]) developed a transient controlateral hemiparesis. Fourteen patients (14/18 [78%]) were followed up clinically and angiographically for 3-32 months (mean, 14 months). None of them (re)hemorrhaged during this period. CONCLUSION: The EVT of AChA berry aneurysms is effective to protect from rebleeding. Our complication rate compares favorably with those of the surgical series. (+info)
Outcome of moderate and severe traumatic brain injury amongst the elderly in Singapore.
(37/194)
INTRODUCTION: In line with other established protocols, our unit has instituted a standardised protocol for the management of moderate and severe traumatic brain injury since 1996 in our neurointensive care unit. MATERIALS AND METHODS: We reviewed the outcomes, at 6 months' post-injury, in an elderly group aged > or = 64 years (73.86 +/- 8.0 years) and compared them to a younger group aged 20 to 40 years (29.2 +/- 5.7 years) in a cohort of 324 patients. Outcome was dichotomised as favourable (mild and moderate disability but independent; Glasgow Outcome Score [GOS] 4 and 5), unfavourable (severe disability and persistent vegetative state; GOS 2 and 3) and death (GOS 1). RESULTS: In the elderly group, the mortality (55.4%) was slightly more than double that of the younger group (20.9%); 21.5% had an unfavourable outcome (14.2% in the younger group) and only 23% had a favourable outcome (compared to 64.9% in the younger group). The final outcomes were significantly worse in all levels in the elderly group. This was in spite of data showing that the mechanism of injury was of a higher impact in the younger group, with a higher incidence of polytrauma and cervical spine injury. On admission, the mean Glasgow Coma Score (GCS) was 8.3 +/- 3.91 for the elderly group and 8.59 +/- 4.05 for the younger group (P = 0.763). Computed tomography scan showed that the elderly had a higher incidence of mass lesions (extradural haematoma and subdural haematoma) and traumatic subarachnoid haemorrhage. A subgroup (29.2%) of elderly patients had no surgical intervention based on poor clinical/neurological status, premorbid functional status and pre-existing medical conditions, with their family's consent. The GCS of < or = 8, on admission, was significant (P <0.001) in predicting mortality in the elderly. In the elderly group, the female gender had a higher mortality rate (70.4%) than the males (44.7%) (P = 0.19). CONCLUSION: Age must be considered an independent factor in outcome prediction in the elderly with moderate and severe traumatic brain injury. A more conservative approach in the management of an elderly patient with severe head injury may be reasonable given its dismal outcomes after careful dialogue with the relatives. (+info)
Cerebral perfusion pressure management of severe diffuse head injury: effect on brain compliance and intracranial pressure.
(38/194)
BACKGROUND: Cerebral perfusion pressure management (CPPM) is an accepted modality of treatment of severe diffuse head injury (SDHI). However, CPPM has the potential to cause transcapillary exudation in the presence of a disrupted blood brain barrier and can lead to further increase of intracranial pressure (ICP) and worsening of compliance. AIMS: This study attempts to evaluate the effect of both transient and prolonged changes in cerebral perfusion pressure (CPP) on ICP and cerebral compliance as measured by the Pressure Volume Index (PVI), and to correlate changes in PVI with outcome at 12 months using the Glasgow Outcome Score. SETTINGS AND DESIGN: Prospective study in a neurosurgical ICU. MATERIAL AND METHODS: Twenty-seven SDHI patients managed using standard protocol to maintain CPP above 70 mmHg. Mean arterial pressure (MAP), ICP and CPP were monitored every half-hour. Daily monitoring of the PVI and ICP was done before, and after the induced elevation of MAP using IV Dopamine infusion. The relationship between CPP, MAP, ICP, PVI and outcome was evaluated. STATISTICAL ANALYSIS USED: The paired and independent samples T-test, and the Pearson correlation coefficient. RESULTS: CPPM rarely leads to progressive rise in ICP. Maintaining CPP above 70mmHg does not influence ICP or PVI. Transient elevations in CPP above 70mmHg may produce a small rise in ICP. Trend of change in PVI influenced outcome despite similar ICP and CPP. CONCLUSION: Elevating the CPP above 70mmHg does not either reduce the ICP or worsen the compliance. Monitoring changes in compliance should form an integral part of CPPM. (+info)
Endovascular treatment of ruptured intracranial aneurysms in elderly people.
(39/194)
BACKGROUND AND PURPOSE: Endovascular detachable coil is being increasingly used for the treatment of cerebral aneurysms but little information is available about its feasibility and effectiveness in people. We assessed clinical outcomes in elderly patients with ruptured intracranial aneurysms treated with selective embolization. METHODS: Between 1996 and 2002, 68 patients aged 65-80 years (mean age, 71 years) were treated by selective embolization with coils. Among them, 34 had a Hunt and Hess (HH) grade of I or II; 15, an HH grade of III; and 19, an HH grade of IV or V. All patients except four were treated within 72 hours after initial bleeding; those four patients had an HH grade of IV or V and were treated at 3-6 weeks after their clinical recovery. Clinical outcomes were assessed by using the Modified Glasgow Outcome Scale. Mean duration of follow-up was 20 months (range, 6-36 months). RESULTS: Endovascular treatment resulted in 47 complete occlusions (69%), 15 neck remnants (22%), and six incomplete occlusions (9%). Procedural complications occurred in eight patients (12%). Outcomes were good or excellent in 40 patients (59%), including the four treated 3-6 weeks after initial bleeding. A fair or poor outcome was observed in 14 patients (20.5%), including two with an HH grade of I or II. Of 14 patients (20.5%) who died, 13 (93%) had an HH grade of IV or V. No rebleeding occurred during follow-up. CONCLUSION: Endosaccular coiling may be proposed in elderly people with ruptured intracranial aneurysms. However, in patients with HH grade IV or V lesions, morbidity and mortality rates remain high, and embolization should be considered only after their clinical recovery. (+info)
Endovascular management of poor-grade aneurysmal subarachnoid hemorrhage in the geriatric population.
(40/194)
BACKGROUND AND PURPOSE: The incidence of poor-grade (Hunt and Hess grade IV and V) subarachnoid hemorrhage (SAH) is higher in elderly patients (>70 years) than in younger groups. The aim of this retrospective study was to analyze the outcome of these poor grade elderly patients after endovascular treatment. METHODS: We retrospectively reviewed the clinical records of 27 patients older than 70 years who underwent endovascular treatment for aneurysmal SAH between January 1996 and July 2002. Thirteen patients with SAH and a poor Hunt and Hess grade at initial presentation had been treated by endovascular means. Their outcomes were assessed by the using the Glasgow Outcome Scale (GOS). RESULTS: Two patients (15%) had a good outcome according to the GOS. Three patients (23%) were moderately disabled, two (15%) were severely disabled at the time of discharge from the hospital, and six (47%) died. Five patients (38%) developed clinical vasospasm and underwent balloon angioplasty. Three procedure-related deaths occurred (23%). CONCLUSION: Endovascular treatment has modified the management of poor-grade SAH in elderly patients, most of whom are high-risk surgical candidates. Endovascular treatment can be administered early after the initial ictus, reducing the risk of rebleeding and providing an option to pursue aggressive triple-H therapy. Symptomatic vasospasm can also be treated by endovascular means in the initial setting. (+info)