RESUMEN
PURPOSE: Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO's role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. METHODS: This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. RESULTS: TAO was associated with intraoperative rupture (IOR) (odds ratio - OR = 10.54; 95% confidence interval - 95%CI 4.72-23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11-4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). CONCLUSIONS: TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.
Asunto(s)
Aneurisma Roto , Arteriopatías Oclusivas , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/cirugía , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/cirugía , Estudios Prospectivos , Procedimientos Neuroquirúrgicos/efectos adversos , Aneurisma Roto/complicaciones , Aneurisma Roto/cirugía , Aneurisma Roto/epidemiología , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/cirugía , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Introducción: si bien varios estudios han abordado la comparación entre el tratamiento endovascular y el clipado quirúrgico de aneurismas rotos, no existe aún evidencia firme respecto a la utilización de una u otra técnica en términos de seguridad y mejor pronóstico. El objetivo de este trabajo es analizar las distintas modalidades de tratamiento de la hemorragia subaracnoidea (HSA) implementadas en Uruguay y su impacto sobre la curación del aneurisma y el pronóstico de los pacientes. Material y método: estudio prospectivo y multicéntrico que incluyó a todos los pacientes mayores de 18 años que fueron asistidos por HSA espontánea aneurismática en Uruguay entre el 1 de noviembre de 2019 y el 31 de octubre de 2020. Fueron relevadas las características clínico-epidemiológicas y comorbilidades al momento del diagnóstico, el tipo de tratamiento recibido y variables de evolución clínica durante los siguientes seis meses. Los datos fueron procesados a través del software estadístico Statistical Package for Social Sciences (SPSS) y el nivel de significación utilizado en los test fue de 5%. Debido al carácter multicéntrico y nacional del estudio, debió ser sometido a evaluación por todos los comités de ética de las instituciones de salud participantes. Resultados: se observó un total de 211 casos en el período evaluado. La media de edad fue de 57 años con predominancia del sexo femenino (75%). En el 74% de los casos fue indicado algún tipo de tratamiento específico (43% cirugía abierta y 31% terapia endovascular), mientras al resto de los pacientes no se les pudo tratar el aneurisma por su grave situación neurológica; 52 pacientes tuvieron complicaciones vinculadas al tratamiento recibido, observándose una mayor proporción de estas en el caso de la cirugía abierta respecto a la terapia endovascular (42% vs 21,5%; p=0,008). Conclusiones: se observó una mayor tasa de complicaciones en el tratamiento quirúrgico, sin impacto en la morbimortalidad. De los factores predictores independientes de mala evolución clínica encontrados, el único vinculado al tipo de tratamiento fue la presencia de isquemia extensa.
Introduction: While several studies have addressed the comparison between endovascular treatment and surgical clipping of ruptured aneurysms, there is still no definitive evidence regarding the use of one or the other in terms of safety and improved prognosis. The objective of this study is to analyze the various modalities of subarachnoid hemorrhage (SAH) treatment implemented in Uruguay and their impact on aneurysm resolution and patient prognosis. Method: This is a prospective, multicenter study that includes all patients over 18 years of age who were treated for spontaneous aneurysmal subarachnoid hemorrhage in Uruguay between November 1, 2019, and October 31, 2020. We collected and examined clinical-epidemiological characteristics and comorbidities at the time of diagnosis, the type of treatment received, and clinical outcome variables over the following 6 months. The data were analysed using the Statistical Package for Social Sciences (SPSS) software, and a significance level of 5% was applied in the tests. Due to the multicenter and national nature of the study, it had to be submitted for evaluation to all the Ethics Committees of the participating healthcare institutions. Results: A total of 211 cases were observed during the evaluated period. The mean age was 57 years with a predominance of females (75%). In 74% of the cases, some form of specific treatment was recommended (43% open surgery and 31% endovascular therapy), while the remaining patients could not undergo aneurysm treatment due to their severe neurological condition. 52 patients experienced complications related to the treatment received, with a higher proportion of these in the case of open surgery compared to endovascular therapy (42% vs. 21,5%; p=0,008). Conclusions: A higher rate of complications was observed in the surgical treatment, with no impact on morbidity and mortality. Among the independent predictors of poor clinical outcomes identified, the only one related to the type of treatment was the presence of extensive ischemia.
As campanhas de prevenção e promoção da saúde, bem como os avanços na medidas terapêuticas voltadas para pacientes neurocríticos conseguiram reduzir a incidência de pacientes com lesão cerebral aguda que evoluem para morte encefálica (ME). No entanto, na maioria dos países latino-americanos, os órgãos que podem ser perfundidos adequados para transplante (TX) vêm de doadores falecidos em ME. A doação em assistolia e em particular a doação em assistolia controlada (DAC), é uma opção aceita e válida para a obtenção de órgãos, o que contribuiria para a redução das listas de espera para transplantes. Durante o processo DAC, são aplicados conceitos com forte cunho bioético, que são fundamentais na o momento da tomada de decisão. Este artigo tem como objetivo analisar esses conceitos, com o objetivo de oferecer ferramentas válidas à equipe de saúde, para os processos em que há deliberação moral como ocorre na doação de órgãos em assistolia controlada considerada parte integrante dos cuidados de fim de vida.
Asunto(s)
Hemorragia Subaracnoidea/cirugía , Reparación Endovascular de Aneurismas , Estudios Prospectivos , Estudio MulticéntricoRESUMEN
Bibliometric analyses are a well-established strategy for understanding the dynamics of publications. Aneurysmal subarachnoid hemorrhage (aSAH) is a hot topic in neurology and neurosurgery research. To perform a bibliometric analysis of recent publications within aSAH. Articles addressing aSAH published between 2017 and 2021 were included and had their information extracted from Scopus. A total of 2177 articles were included. The mean number of citations was 6.18 (95%CI = 5.77-6.59). 2021 and 2020 were the most prolific years. World Neurosurgery (N = 389/2,177 articles; 17,87%) was the leading publisher, and American Journal of Neuroradiology had the highest number of citations per article (14.82) among journals with ≥ 10 publications. Primary research (N = 1624/2177) predominated, followed by case reports (N = 434/2,177). Among secondary studies, systematic reviews (N = 78/119) surpassed narrative reviews (N = 41/119). USA led the number of publications (N = 548/2,177 articles; 25.17%), followed by China (N = 358/2,177 articles; 16.44%). High-income countries had a higher number of publications (N = 1624/2177) and more citations per article (6.84) than middle-income countries (N = 553/2177 and 4.25, respectively). There were zero articles from low-income countries. European and North American institutions had the greatest research impact. There was an increase in the number of published articles in the last few years (2020 and 2021). Many studies had a low level of evidence, whereas interventional studies were uncommon.
Asunto(s)
Neurocirugia , Hemorragia Subaracnoidea , Estados Unidos , Humanos , Hemorragia Subaracnoidea/cirugía , Bibliometría , Publicaciones , Procedimientos NeuroquirúrgicosRESUMEN
INTRODUCTION: Life expectancy in individuals has increased in recent years. There is no consensus in the literature on the best treatment for a ruptured aneurysm in the elderly (> 60 years), but some places only have microsurgery as a therapeutic strategy. This work aims to develop a prognostic scale for ruptured intracranial aneurysms in the elderly. MATERIAL AND METHODS: Two thousand five hundred thirty patients with subarachnoid hemorrhage were retrospectively evaluated in the last ten years, and 550 of them were elderly. We developed a prognostic scale from the analysis of medical records, clinical and tomographic features that had statistical significance. Glasgow Coma Outcome (GOS) was the outcome of interest and p value < 0,05 was considered statistically significant. RESULTS: Five hundred fifty patients were evaluated, and the comorbidities that were independent variables for poor prognosis were smoking and arterial hypertension; clinical variables were Hunt-Hess, modified Rankin and Glasgow Coma Scale; tomographic was Fisher scale. Poor outcome was defined as GOS ≤ 3. Poor surgical outcomes were more remarkable in the high-risk factor categories, being 6.41 times higher among individuals who had 3 to 4 risk factors and 8.80 times higher among individuals with 5 to 6 risk factors. CONCLUSION: In some vascular neurosurgery services worldwide, microsurgery is the only therapeutic option. This scale aimed at the elderly patient individualizes the treatment and can predict the clinical outcome in ruptured intracranial aneurysms.
Asunto(s)
Aneurisma Roto , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Humanos , Anciano , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/complicaciones , Estudios Retrospectivos , Microcirugia/efectos adversos , Microcirugia/métodos , Resultado del Tratamiento , Hemorragia Subaracnoidea/cirugía , Hemorragia Subaracnoidea/etiología , Aneurisma Roto/cirugía , Aneurisma Roto/complicacionesRESUMEN
OBJECTIVES: We aimed to compare outcomes of patients with middle cerebral artery (MCA) aneurysms treated by either microsurgical clipping or endovascular therapy and provide a treatment algorithm based on available evidence. MATERIALS AND METHODS: We performed a retrospective analysis of 77 patients with 95 MCA aneurysms. Demographic, clinical, and aneurysm morphological variables were collected. Patients were divided into two groups depending on the received treatment. Clinical and radiological outcomes were collected at the end of a 1-year follow-up period and compared between both treatment groups. RESULTS: Mean age was 51.4 years. Fifty patients (65%) underwent microsurgical clipping and 27 (35%) were treated by endovascular therapy. Fifty-four patients (70%) presented with subarachnoid hemorrhage, while 23 (30%) were treated for unruptured aneurysms. Patients with subarachnoid hemorrhage were more frequently treated by microsurgical clipping than patients with unruptured aneurysms. Clinical outcomes, including functional status, were similar between treatment groups after 1-year follow-up even when adjusting for clinical presentation. Residual aneurysms were found less frequently in the microsurgical group (OR = 0.09; p < 0.001). CONCLUSIONS: In patients with MCA aneurysms, clinical outcomes at 1 year are similar between microsurgical clipping and endovascular therapy. However, microsurgery is associated with a lower risk of residual aneurysms.
OBJETIVO: Evaluar y comparar desenlaces de pacientes con aneurismas de arteria cerebral media (ACM) tratados mediante clipaje microquirúrgico o terapia endovascular, y proponer un algoritmo de tratamiento basado en evidencia. MATERIAL Y MÉTODOS: Estudio retrospectivo de 77 pacientes con 95 aneurismas de ACM. Se recabaron variables demográficas, clínicas y morfológicas de los aneurismas tratados. Se dividieron a los pacientes en dos grupos dependiendo del tratamiento recibido y se compararon los desenlaces clínicos y radiológicos al final del seguimiento a un año entre ambos grupos. RESULTADOS: La edad promedio fue 51.4 años. 50 pacientes (65%) fueron sometidos a clipaje microquirúrgico y 27 (35%) a terapia endovascular. 54 pacientes (70%) presentaron hemorragia subaracnoidea, quienes fueron tratados mediante microcirugía en mayor proporción que aquellos con aneurismas no rotos. Los desenlaces clínicos, incluyendo el estado funcional, fueron similares entre ambos grupos al año de seguimiento, aún tras ajustar el análisis por presentación clínica. El grupo de microcirugía presentó una menor proporción de aneurismas residuales (OR = 0.09; p < 0.001). CONCLUSIONES: En pacientes con aneurismas de ACM, los desenlaces clínicos a un año son similares entre clipaje microquirúrgico y terapia endovascular. Sin embargo, la microcirugía se asocia a un menor riesgo de aneurismas residuales.
Asunto(s)
Procedimientos Endovasculares , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Algoritmos , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Microcirugia , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/etiología , Hemorragia Subaracnoidea/cirugía , Resultado del TratamientoRESUMEN
Aneurysms are the most frequent issue for the posterior inferior cerebellar artery (PICA). PICA aneurysms account for 1.4% to 4.5% of all intracranial aneurysms.1-3 Although the majority of PICA aneurysms arise from their junction with the vertebral artery, they can be found in any of 5 segments.4,5 Although PICA is more prone to form nonsaccular aneurysms than other intracranial arteries, ruptured aneurysms are usually saccular.6 Nearly all PICA aneurysms are located intracranially, above the foramen magnum. Extracranial PICA aneurysms are rare, with few reports in literature.7 Microsurgical clipping remains a good treatment alternative for these aneurysms. Higher risk of rerupture has even been reported with embolization of the distal PICA aneurysm with parent artery preservation.8 Here we present the case of a 64-year-old male patient who presented right after a thunderclap headache, followed by a temporary loss of consciousness and disorientation. He was diagnosed with a modified Fisher 4 and Hunt and Hess 2 subarachnoid hemorrhage and found to have a partially thrombosed left PICA saccular aneurysm of the caudal loop just below the foramen magnum. The lesion was approached via a midline suboccipital craniotomy with C1 laminectomy. Microsurgical clipping of the aneurysm was performed without any complications (Video 1). Postoperatively, the patient was discharged without neurologic deficits. We present the first surgical video of the necessary steps in order to perform a microsurgical clipping of an extracranially located caudal loop PICA aneurysm through a midline suboccipital craniotomy with C1 laminectomy.
Asunto(s)
Aneurisma Roto , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Puntos Anatómicos de Referencia , Aneurisma Roto/complicaciones , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Cerebelo/irrigación sanguínea , Cerebelo/diagnóstico por imagen , Cerebelo/cirugía , Humanos , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Masculino , Persona de Mediana Edad , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/etiología , Hemorragia Subaracnoidea/cirugía , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/cirugíaRESUMEN
Ruptured intracranial aneurysms, as the leading cause of spontaneous subarachnoid hemorrhage (aSAH), represents an emergency with high morbi-mortality. The comprehension of the underlying pathology that involves inflammatory and immune responses, through the neutrophil-to-lymphocyte ratio (NLR), could help to predict complications such as delayed cerebral ischemia (DCI) or rebleeding and the functional outcome. Systematic review of English-based literature through PubMed and Biblioteca Vitural em Saúde (BVS) to find papers discussing the use of NLR in the aSAH setting. Area-under-curve (AUC) of receiver operating characteristics (ROC), cutoff value, sensitivity, and specificity were retrieved. From 53 articles included, 4 papers were evaluated after exclusion criteria. Rebleeding could be predicted with a NLR cutoff value of 9.88 (sensitivity 72.3%, specificity 63.3%). The mean cutoff value for DCI was 12.85, with sensitivity 66.3% and specificity 75.8%. Finally, a worse 3-month functional outcome could be predicted with a mean sensitivity of 73.3% and a mean specificity of 54%. NLR is a new issue in scientific community, especially neurosurgery. The current understanding points to a multifactorial process after aSAH that emerges as alterations on the NLR. As a measurement readily available and cost-effect after admission of the patient, its use signals that patients that need expedite surgical treatment or more aggressive treatment for vasospasm. As other medical subspecialties already use this ratio to predict outcomes, the literature reviewed by this paper constitute the earliest clues that higher NLR predicts re-bleeding, DCI, and functional outcome.
Asunto(s)
Isquemia Encefálica , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Humanos , Linfocitos , Neutrófilos , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/cirugíaRESUMEN
A persistência e a falha da involução das comunicações embrionárias entre a circulação cerebral anterior e posterior contribuem para anomalias vasculares em adultos. Esta variação é comumente detectada de forma incidental, causando sintomas muito raramente. Sua proximidade com os nervos oculomotor, troclear e abducente podem levar a paresia muscular ocular. Em alguns casos pode causar tinnitus pulsátil e ao espasmo de hemiface. Muitos casos de artéria trigeminal foram relatados como associados a aneurismas intracranianos.
The persistence and failure of the involution of embryonic communications between the anterior and posterior cerebral circulation contribute to vascular anomalies in adults. This variation is commonly detected incidentally, rarely causing symptoms. Its proximity to the oculomotor, trochlear, and abducent nerves can lead to ocular muscle paresis. Sometimes it can cause pulsatile tinnitus and hemiface spasm. Many cases of trigeminal artery have been reported to be associated with intracranial aneurysms.
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Humanos , Masculino , Adulto , Hemorragia Subaracnoidea/cirugía , Hemorragia Subaracnoidea/diagnóstico por imagen , Arterias Carótidas/anomalías , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Malformaciones Vasculares , Angiografía por Tomografía ComputarizadaRESUMEN
OBJECTIVE: The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA). METHODS: Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed. RESULTS: 16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage. CONCLUSION: When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.
Asunto(s)
Revascularización Cerebral/métodos , Craneotomía/métodos , Aneurisma Intracraneal/cirugía , Hemorragia Subaracnoidea/cirugía , Instrumentos Quirúrgicos , Enfermedad Aguda , Adulto , Anciano , Revascularización Cerebral/instrumentación , Chile/epidemiología , Craneotomía/instrumentación , Femenino , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/epidemiología , Masculino , Persona de Mediana Edad , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/epidemiología , Resultado del TratamientoRESUMEN
A 79-year-old patient was admitted to the emergency room with transitory monoparesis in the left hand and dysphasia. The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed a spontaneous right convexity subarachnoid hemorrhage (cSAH). Digital subtraction angiography (DSA) confirmed an asymptomatic occlusion of the right internal carotid artery (ICA) . Cases related to stenosis have already been described, but there is no similar report of a case related to occlusion, even though the pathophysiology of both entities is similar. Atraumatic SAH has been associated with intracranial and extracranial artery stenosis.
Asunto(s)
Humanos , Femenino , Anciano , Hemorragia Subaracnoidea/cirugía , Hemorragia Subaracnoidea/diagnóstico por imagen , Arteria Carótida Interna/anomalías , Estenosis Carotídea , Angiografía Cerebral/métodosRESUMEN
BACKGROUND AND PURPOSE: Because of the small number of yearly cases of ruptured cerebral aneurysms, endovascular treatment is not performed in Martinique. Therefore, patients from Martinique are sent 7000 km to Paris on commercial flights as soon as possible, where treatment is performed. Nontransportable patients are treated locally with either surgery or symptomatic care. The objective of our study was to assess patient outcomes and safety of this treatment strategy. METHODS: We retrospectively examined all cases of aneurysmal subarachnoid hemorrhage in Martinique diagnosed during 2004 to 2013. Medical case records were searched for the type and location of treatment, clinical status, and transfer duration. RESULTS: A total of 119 patients had an aneurysmal subarachnoid hemorrhage during the 10-year period. Of these, 91 were transferred to Paris, 12 were surgically treated locally, and 16 received symptomatic treatment. None of the transferred patients experienced any hemorrhagic recurrence, and none suffered a significant complication related to the air transportation. The median time between aneurysmal subarachnoid hemorrhage diagnosis and arrival at the referral center was 32 hours. The 30-day case fatality rate for treated cases was 14.6% (8.8% for those treated in Paris and 58.3% for those treated locally). CONCLUSIONS: Our treatment strategy for aneurysmal subarachnoid hemorrhage resulted in a 30-day case fatality rate similar to those observed elsewhere, despite an 8-hour flight and a median treatment delay of 32 hours. This strategy therefore seems to be safe and reliable for isolated regions with small populations.
Asunto(s)
Ambulancias Aéreas , Aneurisma Roto , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Anciano , Aneurisma Roto/diagnóstico , Aneurisma Roto/mortalidad , Aneurisma Roto/cirugía , Femenino , Francia/epidemiología , Humanos , Aneurisma Intracraneal/diagnóstico , Aneurisma Intracraneal/mortalidad , Aneurisma Intracraneal/cirugía , Masculino , Martinica/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/mortalidad , Hemorragia Subaracnoidea/cirugíaRESUMEN
Introduction Terson syndrome is described as an intraocular hemorrhage consequent to a spontaneous subarachnoid hemorrhage (SSAH). In the present article, we describe cases of patients who underwent neurosurgical treatment of ruptured cerebral aneurysmat our institution over a period of one year, and who were diagnosed with Terson syndrome. Methods The present study included patients with a diagnosis of SSAH by rupture of a cerebral aneurysm who underwent treatment in our neurosurgical service from December 2009 to December 2010. The patients were followed-up for a minimum of 20 months.We have also performed a literature review and compared the data with those available in the current literature. Results The present study included 34 patients, 18 (53%) of which underwent endovascular treatment, and 16 (47%) who underwent microsurgical clipping. In the sample, the mortality was 14.7% (5 patients), the same percentage of patients who were diagnosed with Terson Syndrome, which is an incidence of 14.7%. Regarding the ophthalmologic evaluation, all patients had vitreous hemorrhage detected by an ultrasound examination, which was unilateral in only two patients. Visual acuity improved in all patients, being incomplete in only one of them. Conclusion Terson syndrome is relatively common and is associated with higher mortality. With the existence of an effective treatment, it should be investigated in all patients with SSAH.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Hemorragia Vítrea/diagnóstico , Aneurisma Roto/cirugía , Hemorragia Subaracnoidea/cirugía , Síndrome , Vitrectomía , Brasil/epidemiología , Agudeza Visual , Aneurisma Roto/mortalidad , Procedimientos EndovascularesRESUMEN
Introduction Pericallosal artery (PA) aneurysms represent 2 to 9% of all intracranial aneurysms, and their management remains difficult. Objective The aim of the present study is to describe the case of an adult woman with subarachnoid hemorrhage and bilateral PA aneurysm in mirror position. Case Report A 46-year-old woman was referred to our institution 20 days after a sudden severe headache. She informed that she was treating her arterial hypertension irregularly, and consumed 20 cigarettes/day. The patient was neurologically intact at admission. A non-contrast computed tomography (CT) on the first day of the onset of the symptoms revealed hydrocephaly and subarachnoid hemorrhage (Fisher III). An angio-CT/digital subtraction arteriography showed bilateral PA aneurysms in mirror position. The patient was successfully treated with surgery via the right interhemispheric approach (because the surgeon is right-handed); the surgeon performed the proximal control with temporary clipping, and introduced an external ventricular drain at the end of the surgery. The patient was discharged on the fourth postoperative day without any additional neurological deficits or ventricular shunts. Conclusion Ruptured PA aneurysm is a surgically challenging aneurysm due to the many anatomical nuances and risk of rebleeding. However, the operativemanagement of ruptured bilateral PA aneurysms is feasible and effective.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Hemorragia Subaracnoidea/cirugía , Aneurisma Roto/cirugía , Arteria Cerebral Anterior/cirugía , Fumadores , Tomografía Computarizada por Rayos X , Aneurisma Roto/diagnóstico por imagen , Angiografía por Tomografía ComputarizadaRESUMEN
La hemorragia subarcnoidea por sangrado de aneurismas sigue siendo una enfermedad con una elevada mortalidad y morbilidad. Los avances en microcirugía y en terapia endovascular, no han logrado abatir los altos porcentajes de mala evolución. Por su parte, el tratamiento de los aneurismas no rotos se vuelve cada vez más rutinario, dados los buenos resultados. Un capítulo aparte es el tratamiento o no de aneurismas cerebrales con o sin hemorragia subaracnoidea en pacientes añosos (mayores de 70 años). Hay publicaciones al respecto. Los autores hacen una revisión retrospectiva de 179 pacientes mayores de 70 años portadores de aneurismas cerebrales, con o sin sangrado subaracnoideo. Todos fueron sometidos a cirugía. Se analizan los resultados, los que muestran que la morbimortalidad en este grupo etario no difiere sustancialmente de los que se dan en menores de 70 años.
Subarachnoid haemorrhage due to bleeding of cerebral aneurysms remains a disease with high mortality and morbidity. Advances in microsurgery and endovascular therapy have failed to reduce the high percentages of poor outcome. The treatment of unruptured aneurysms, on the other hand, becomes more and more routinary, given the good results. A separate chapter is the treatment or not of cerebral aneurysms with or without subarachnoid hemorrhage in elderly patients (older than 70 years). There are several publications about it. The authors make a retrospective review of 179 patients older than 70 years with cerebral aneurysms, with or without subarachnoid bleeding.All were submitted to surgery. We analyze the results, which show that morbidity and mortality in this age group do not differ substantially from those occurring under 70 years of age.
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Humanos , Anciano , Anciano de 80 o más Años , Aneurisma Intracraneal/cirugía , Hemorragia Subaracnoidea/cirugía , Estudios RetrospectivosRESUMEN
OBJECTIVE: Vitamin D deficiency has been associated with increased risk and adverse outcomes in many clinical settings including cardiovascular disease, stroke, and critically ill patients. Therefore we aimed to determine whether vitamin D deficiency had any effect in aneurysmal subarachnoid hemorrhage (aSAH) clinical outcomes. METHODS: A retrospective record review was conducted in a tertiary community hospital in Puerto Rico. Adult patients admitted to the neurosurgical intensive care unit with a diagnosis of aSAH from January 2013 to July 2014, who had a 25-hydroxyvitamin-D level drawn, were included. RESULTS: A total of 40 patients were admitted with a diagnosis of aSAH, and 33 met the inclusion criteria. Overall, 81% of patients were vitamin D deficient or insufficient. Subjects were grouped into those with vitamin D deficiency (n = 13) and those without (n = 20). Except for a larger prevalence of coronary artery disease, all other baseline parameters were similar. No significant difference in hospital mortality was observed (P = 0.676). The percentage of vasospasms, vasopressor use, hydrocephalus, and infections was also similar. An increase in length of neurosurgical intensive care unit stay and respiratory failure was observed in the vitamin D-deficient group, but it was not statistically significant. CONCLUSION: A high prevalence of vitamin D deficiency and insufficiency was found among patients admitted with a diagnosis of aSAH in this cohort. Despite this no difference in clinical outcomes was observed in patients when compared by vitamin D group. Further studies are needed to assess potential effects of vitamin D deficiency in this patient population including long term follow-up after discharge.
Asunto(s)
Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , Hemorragia Subaracnoidea/mortalidad , Hemorragia Subaracnoidea/cirugía , Deficiencia de Vitamina D/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Comorbilidad , Femenino , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Puerto Rico/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement. METHODS: This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil. RESULTS: The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%. CONCLUSIONS: Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.
Asunto(s)
Infecciones Relacionadas con Catéteres/epidemiología , Hemorragia Cerebral/cirugía , Ventriculitis Cerebral/epidemiología , Complicaciones Posoperatorias/epidemiología , Hemorragia Subaracnoidea/cirugía , Ventriculostomía , Adulto , Anciano , Brasil/epidemiología , Femenino , Humanos , Hemorragias Intracraneales/cirugía , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Prospectivos , Factores de TiempoAsunto(s)
Hemorragia Cerebral/diagnóstico por imagen , Aneurisma Intracraneal/diagnóstico por imagen , Neuroimagen/métodos , Hemorragia Subaracnoidea/diagnóstico por imagen , Angiografía de Substracción Digital , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/cirugía , Hemorragia Cerebral Intraventricular/diagnóstico por imagen , Hemorragia Cerebral Intraventricular/fisiopatología , Hemorragia Cerebral Intraventricular/cirugía , Niño , Craniectomía Descompresiva , Femenino , Humanos , Aneurisma Intracraneal/fisiopatología , Aneurisma Intracraneal/cirugía , Neurología/educación , Hemorragia Subaracnoidea/fisiopatología , Hemorragia Subaracnoidea/cirugía , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To assess the language and verbal fluency performance in aneurismal SAH pre- and post-surgery in patients caused by an aneurysm of the anterior communicating artery (AcomA), left middle cerebral artery (L-MCA) and left posterior comunicating artery (L-PcomA). METHODS: Assessment in 79 patients with SAH, on two occasions: pre- and post surgical treatment. They were divided into three groups by the aneurysms' location. RESULTS: Deterioration is detected in the performance of all patients during the post-surgical period; L-MCA aneurysm patients displayed a reduction in verbal naming and fluency; L-PcomA patients deteriorated in the written language and fluency tasks. CONCLUSION: After the surgical procedure the patients decreased in various language tasks and these differences in performance being directly related to the location of the aneurysm.
Asunto(s)
Aneurisma Roto/complicaciones , Aneurisma Intracraneal/complicaciones , Trastornos del Lenguaje/etiología , Hemorragia Subaracnoidea/complicaciones , Aneurisma Roto/clasificación , Aneurisma Roto/cirugía , Femenino , Humanos , Aneurisma Intracraneal/clasificación , Aneurisma Intracraneal/cirugía , Trastornos del Lenguaje/diagnóstico , Pruebas del Lenguaje , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Hemorragia Subaracnoidea/cirugíaRESUMEN
ABSTRACT Sub-arachnoid hemorrhage (SAH) promotes impairment of upper cortical functions. However, few information is available emphasizing changes in language after aneurismal SAH and aneurysm location influence. Objective To assess the language and verbal fluency performance in aneurismal SAH pre- and post-surgery in patients caused by an aneurysm of the anterior communicating artery (AcomA), left middle cerebral artery (L-MCA) and left posterior comunicating artery (L-PcomA). Methods Assessment in 79 patients with SAH, on two occasions: pre- and post surgical treatment. They were divided into three groups by the aneurysms’ location. Results Deterioration is detected in the performance of all patients during the post-surgical period; L-MCA aneurysm patients displayed a reduction in verbal naming and fluency; L-PcomA patients deteriorated in the written language and fluency tasks. Conclusion After the surgical procedure the patients decreased in various language tasks and these differences in performance being directly related to the location of the aneurysm.
RESUMO Hemorragia subaracnóidea (HSA) proporciona alterações nas altas funções cerebrais. Contudo, há poucos trabalhos enfatizando as alterações da linguagem na HSA aneurismática e a influência da localização do aneurisma. Objetivos Analisar e comparar os desempenhos da linguagem e fluência verbal na HSA nos períodos pré e pós-cirúrgicos nos pacientes com aneurismas da comunicante anterior (AcomA), cerebral média (ACME) e comunicante posterior esquerdas (AcomPE). Métodos A avaliação da linguagem de 79 pacientes com HSA aneurismática foi realizada em duas ocasiões: pré e pós cirurgia. Eles foram divididos em três grupos de acordo com a localização do aneurisma. Resultados Os grupos apresentaram deterioração na avaliação pós-operatória com diferentes características. O grupo da ACME demonstraram deterioração na fluência e nomeação, enquanto o da AcomPE pioraram nos testes de linguagem escrita e fluência. Conclusões Após o tratamento cirúrgico, os pacientes deterioraram em vários itens de linguagem com diferenças relacionadas à localização do aneurisma.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Hemorragia Subaracnoidea/complicaciones , Aneurisma Intracraneal/complicaciones , Aneurisma Roto/complicaciones , Trastornos del Lenguaje/etiología , Periodo Posoperatorio , Hemorragia Subaracnoidea/cirugía , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/clasificación , Estudios Prospectivos , Aneurisma Roto/cirugía , Aneurisma Roto/clasificación , Trastornos del Lenguaje/diagnóstico , Pruebas del LenguajeRESUMEN
We retrospectively evaluated the records of 49 grade 4 and 5 patients with 42 intracranial aneurysms treated within 72 h of subarachnoid hemorrhage (SAH). In total, 35 patients (71%) were grade 4, and 14 (29%) were grade 5. A total of 42 (85%) patients had one aneurysm, 6 (12%) had two aneurysms, and 1 (3%) had three aneurysms. Out of 49 patients, one technical (2%) and one clinical (2%) complication occurred at surgery. Twenty-one (43%) patients recovered well, including 7 with postoperative hematoma requiring an immediate evacuation of a clot. Fourteen (29%) patients had hydrocephalus and required a ventriculo-peritoneal shunt; 12 patients underwent tracheotomy postoperatively due to coma and pulmonary infection. We found that patients with Hunt and Hess grade 4 and 5 aneurysms can undergo successful neurosurgical clipping of the aneurysms after SAH. However, the morbidity and mortality rates remain high because of their poor clinical condition and a high incidence of vasospasm during treatment.