RESUMEN
BACKGROUND AND PURPOSE: Cerebral vasospasm resistant to medical management frequently requires intra-arterial spasmolysis. Angiographic resolution of vasospasm does not provide physiologic data on the adequacy of reperfusion. We recorded pre- and postspasmolysis PbO(2) data in the endovascular suite to determine whether this physiologic parameter could be used to determine when successful reperfusion was established. MATERIALS AND METHODS: Eight patients with 10 Licox monitors and cerebral vasospasm underwent intra-arterial spasmolysis. Pre- and postspasmolytic PbO(2) was recorded for comparison. Other physiologic parameters, such as CPP, ICP, SaO(2), and Fio(2), were also recorded. RESULTS: Mean prespasmolysis PbO(2) recordings were 35.2 and 27.3 for the mild-to-moderate and moderate-to-severe vasospasm group, respectively. Mean postspasmolysis PbO(2) increased to 40.3 and 38.4, respectively, which was statistically significant (P < .05) for both groups. In 100% of instances in the moderate-to-severe group and 83% of instances in mild-to-moderate group, the mean PbO(2) increased after spasmolysis and correlated with improvement in angiographic vasospasm. Other physiologic parameters, such as CPP, ICP, SaO(2), and Fio(2), did not show any statistically significant difference before and after spasmolysis. CONCLUSIONS: PbO(2) monitoring provides the interventionalist with an objective physiologic parameter to determine adequate spasmolysis. Further investigation is needed to establish target PbO(2) rates indicative of adequate reperfusion, which can be used in the endovascular suite.
Asunto(s)
Encéfalo/metabolismo , Oxígeno/análisis , Perfusión/métodos , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/cirugía , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/cirugía , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oximetría/métodos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Hemorragia Subaracnoidea/metabolismo , Resultado del Tratamiento , Vasoespasmo Intracraneal/metabolismo , Adulto JovenRESUMEN
CE of brain aneurysms is safer with better outcomes than microsurgical clip ligation. However, the higher recurrence rate may nullify the acute benefits of coiling. Reported here are three patients who underwent surgery to treat their recurrent, previously coiled aneurysm. Intraoperatively, coils were seen extruding from the recurrent regions of each aneurysm and adherent to the surrounding neurovascular structures. These interesting findings question the premise that observation of a recurrent aneurysm is safe.
Asunto(s)
Embolización Terapéutica/efectos adversos , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/terapia , Platino (Metal) , Angiografía Cerebral , Embolización Terapéutica/instrumentación , Embolización Terapéutica/métodos , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Ligadura , Microcirugia , Procedimientos Neuroquirúrgicos , Recurrencia , Retratamiento , Instrumentos QuirúrgicosRESUMEN
A 51-year-old right-handed woman initially presented with generalized tonic-clonic seizures. MRI showed abnormal signal hyperintensity of the right temporal lobe that was thought to be consistent with ischemic stroke. Three years later, she developed an intensely enhancing centrally necrotic tumor in the right temporal-parietal lobes. A craniotomy was performed with gross total resection of the tumor followed by chemotherapy and radiation treatments. Histological examination demonstrated a gliosarcoma. A year later, she had a recurrence of the intra-axial gliosarcoma requiring a second craniotomy for tumor resection and placement of Gliadel wafers. Postoperatively, she developed plural effusions. A pulmonary workup revealed lung lesions that were biopsied and found to be gliosarcoma. After the second surgery, she underwent pleurodesis and one cycle of modified mesna, doxorubicin, ifosfamide, and dacarbazine (MAID) chemotherapy, but died 5 months later from progression of the lung metastases. There are fewer than 20 reported cases of extracranial metastases of gliosarcoma. This is the first report of gliosarcoma with prolonged survival (over 2 years) and death from non-CNS metastatic gliosarcoma.
Asunto(s)
Neoplasias Encefálicas/secundario , Encéfalo/patología , Gliosarcoma/secundario , Biopsia , Neoplasias Encefálicas/cirugía , Progresión de la Enfermedad , Resultado Fatal , Femenino , Gliosarcoma/cirugía , Humanos , Imagen por Resonancia Magnética , Persona de Mediana EdadRESUMEN
The acute management of primary intracerebral or aneurysmal subarachnoid hemorrhage requires a comprehensive approach involving stabilization of the patient, surgical intervention, and continued intensive care treatment of medical and neurologic complications. The are several causes of intracerebral hemorrhage (ICH), including hypertension, cerebral amyloid angiopathy, sympathomimetic drugs, and coagulopathies. More recently, use of thrombolytic agents in the treatment of acute ischemic stroke has increased the risk of ICH. Treatment of intracerebral hemorrhage is based on blood pressure control, and, in selected cases, surgical evacuation of clot. Patients with aneurysmal subarachnoid hemorrhage may experience rebleeding, symptomatic vasospasm, or hydrocephalus. Medical management in the intensive care unit with careful attention to fluid and electrolyte balance, nutrition, cardiopulmonary monitoring, and close observation for changes in the neurologic exam is vital. This review examines the diagnosis and intensive care management of patients with intracerebral or subarachnoid hemorrhage, and reviews some of the newer therapies for treatment of these disorders.