Evidence summary of blood pressure management strategies in patients with ruptured intracranial aneurysm bleeding / 中国实用护理杂志

Objective:To estimate and summarize the evidence for the blood pressure in patients with ruptured intracranial aneurysm bleeding, to provide valuable reference for clinical care and improve the prognosis of patients.Methods:BMJ Best Practice, UpToDate, Chinese Guideline Website, Cochrane Library, PubMed, American Stroke Association, Chinese National Knowledge Infrastructure, Wanfang Database and VIP Database were utilized for screening out evidences of blood pressure management strategies for patients with ruptured intracranial aneurysm bleeding from database establishment to December 8, 2020. The source of evidences included guidelines, evidence summarization, information brochure of optimal clinical practice, recommended practice, systematic review and original research. Upon the assessment of the included literature, the evidences meeting the enrollment criterion would be identified and extracted.Results:There were 9 articles involved in this research and 20 evidences possessing clinical applicability were extracted. The evidences involved in clinical assessment, regulation tenets, intervention protocol, and nursing to prevent complications in patients with ruptured intracranial aneurysm bleeding.Conclusions:To summarize, we suggested strongly to evaluate the individual differences in age, underlying diseases and pharmacological tolerance, and to effectivelly control blood pressure in patients with ruptured intracranial aneurysm bleeding through scientific nursing methods, which could improve the nursing qualification.

Risk assessment of chronic subdural hematoma after surgical clipping of intracranial aneurysms / 中国脑血管病杂志

Objective To compare the incidence of chronic subdural hematoma(CSDH) and its risk factors after surgical clipping unruptured intracranial aneurysms(UIA) and ruptured intracranial aneurysms (RIA). Methods From January 2006 to December 2015,410 consecutive patients with UIA and 464 patients with RIA treated with aneurysm clipping at the Department of Neurosurgery,Hanzhong Central Hospital were enrolled retrospectively. According to whether having postoperative CSDH or not(evaluating subdural effusion and its degree with head CT scan),the difference of the incidence of CSDH after aneurysm clipping in patients with UIA and RIA were compared,and logistic regression analysis was used to evaluate the risk factors for the occurrence of postoperative CSDH. Results (1) The incidence of CSDH after UIA clipping was higher than that of RIA(11.0% [45/410] vs. 3.0% [14/464]). There was significant difference (P<0.01). The rate of surgical treatment for CSDH because of the symptoms of nervous system injury in patients with UIA was higher than that in patients with RIA(35.6% [16/45] vs. 28.6% [4/14], P<0.05). (2) Multivariate logistic regression analysis showed that unruptured aneurysms (OR,2.59, 95% CI 2.19-3.06,P<0.01),subdural effusion ≥5 mm (OR,1.98,95% CI 1.94-2.03,P<0.01), and CT value≥40 HU (OR,2.87,95% CI 2.65-3.01,P<0.01) were the independent risk factors for postoperative CSDH in patients with intracranial aneurysm. Conclusions The incidence of CSDH was significantly higher than that of RIA after UIA clipping. UIA,subdural effusion ≥5 mm,and CT value ≥40 HU were the independent risk factors for CSDH of intracranial aneurysms.

Clinical Application of Detecting Serum PPAR-γ mRNA,MMP-9 mRNA in the Diagnosis of Ruptured Intracranial Aneurysm / 现代检验医学杂志

Objective To investigate the clinical application of detecting serum PPAR-γmRNA,MMP-9mRNA in the diagnosis of ruptured intracranial aneurysm.Methods The expression of serum PPAR-γmRNA,MMP-9mRNA were detected for 87 cases of patients with intracranial aneurysm,including ruptured group and non-ruptured group,respectively,with 57 cases and 30 cases of patients.The control group should be established to compare the changes of the above indicators.Results The expression of serum PPAR-γmRNA in the ruptured group,the non-ruptured and the controls group were 0.23±0.03,0.59±0.11 and 0.87±0.15,which of MMP-9mRNA were 0.93±0.17,0.63±0.13 and 0.25±0.05.Compared with those in the controls group,the expression of serum PPAR-γmRNA in the ruptured group significantly lowered (t=23.79,P＜0.01),which of MMP-9mRNA raised (t=25.63,P＜0.01).There were statistically significant differences.The expression of PPAR γmRNA in the ruptured group were lower than those in the unruptured group,which of MMP-9 mRNA were higher (t=15.32,16.27,P＜0.01).To establishing the receiver-operating characteristic curve (ROC curve) in evaluating the clinical significances of the two markers to use the rupture group and non-ruptured group as the dependent variable,the AUC of the expression of serum PPAR-ymRNA,MMP-9mRNA were 0.858 (95 ％ CI:0.775 ～ 0.940,P =0.000),0.842 (95 ％CI:0.756～0.929,P=0.000).As the dependent variable in the control group and unruptured group,the AUC of the expression of serum PPAR-γmRNA,MMP-9mRNA were 0.827 (95％CI:0.734～0.920,P=0.000);0.818 (95％CI:0.722 ～0.914,P=0.000).Conclusion Detection of serum PPAR-γ mRNA,MMP-9 mRNA can be applied in assessment of occurrence and progression for the intracranial aneurysm,and to provide evidences for the early detection of ruptured intracranial aneurysm.

Spontaneous Regression of Aneurysm Remnant after Incomplete Surgical Clipping in a Patient with Ruptured Cerebral Aneurysm

Cases of spontaneous regression of cerebral aneurysm remnant after incomplete surgical clipping have been rarely reported. This paper reports the regression of an aneurysm remnant after incomplete surgical clipping during postsurgical follow-up. A 50-year-old male presented with subarachnoid hemorrhage because of rupture of an anterior communicating artery aneurysm. An emergency clipping of the aneurysm was performed. A cerebral angiography, which was performed two weeks postoperatively, revealed an aneurysm remnant. The patient refused additional treatment and was discharged without apparent neurological deficit. One-year follow up cerebral angiography demonstrated a partially regressed aneurysm remnant.

Uso de simvastatina en la prevención de la isquemia cerebral en la hemorragia subaracnoídea aneurismática / Use of simvastatin in brain ischemia prevention in aneurysmal subarachnoid hemorrhage

Introducción: El vasoespasmo cerebral es una complicación temida y aun no resuelta en los pacientes que cursan con hemorragia subaracnoídea neurismática (HSA), y que significa una importante morbi-mortalidad en dichos pacientes. Material y métodos: Se revisaron los registros de 161 pacientes ingresados en el Hospital Carlos Van Buren de Valparaíso por HSA entre entre Mayo de 2007 y Agosto de 2009, comparando la aparición de complicaciones isquémicas y resultados funcionales, según fuesen o no tratados con Simvastatina (40 mg/día). Resultados: El grupo de pacientes tratados con Simvastatina presentó significativamente menos infartos cerebrales (9,30 por ciento vs. 24,58 por ciento, p=0,02) y menos mortalidad intrahospitalaria (1,24 por ciento vs. 11,80 por ciento, p=0,04). Conclusiones: Si bien el diseño del estudio impide atribuir las diferencias encontradas al uso de Simvastatina, dado el contexto del mismo, es muy probable que así sea. El uso de estatinas en la hemorragia subaracnoídea aneurismática, como profilaxis del vasoespasmo es aún un tema controversial y promisorio, que se encuentra en plena etapa de estudio y desarrollo.

Background: Vasospasm is a feared complication in patients who present with aneurysmal subarachnoid hemorrhage (SAH) and that means significant morbidity and mortality in these patients. Material and methods: We reviewed the records of 161 patients admitted to the Hospital Carlos Van Buren with SAH between May 2007 and August 2009, comparing the occurrence of ischemic complications and functional results as they were or not treated with simvastatin (40mg/day). Results: The patient group treated with simvastatin had significantly fewer strokes (p = 0.02) and fewer hospital mortality (p = 0.04). Conclusions: Although the study design precludes attributing the differences found when using simvastatin, given the context, it is likely to be so. The use of statins in aneurismal subarachnoid hemorrhage for vasospasm prophylaxis is still a controversial and promising topic, wich is under full development and study.

Risk factors of early rebleeding after endovascular embolization of ruptured intracranial aneurysms / 介入放射学杂志

Objective To discuss the clinical characteristics and risk factors related to the early rebleeding after endovascular embolization of ruptured intracranial aneurysms, to reduce its occurrence and to provide the theoretical basis for the clinical selection of therapeutic methods. Methods During the period of July 2002-Oct. 2007 in the Department of Neurosurgery of Changhai Hospital, patients with DSA-proved ruptured intracranial aneurysms were treated with pereutaneous endovascular embolization. The clinical data and imaging findings of the patients who had occurred early rebleeding after interventional therapy (study group) were retrospectively analyzed. The patients who had not occurred early rebleeding after interventional therapy during the same period were randomly selected and served as the control group. The number of patients in control group was 7.5 times of that in study group. The suspected risk factors were statistically analyzed by using univariate and multivariate methods, the results were compared between two groups. Results Of 881 patients with raptured intracranial aneurysms treated by endovascular interventional embolization, 17 (1.93%) occurred rebleeding in the early time, among them 12 (1.36%) died. The reality or falsity of the aneurysms, the ruptured times of the aneurysms before treatment, the obvious intracranial vascular spasms seen on DSA during the procedure and the degree of embolization were the four main independent risk factors related to the early rebleeding. The probability equation of the early rebleeding of ruptured intracranial aneurysms afterendovascular embolization was calculated.Conclusion Although the incidence of early rebleeding in patients after endovascular embolization of ruptured intracranial aneurysms is low, the outcome, if it occurs, is poor with high mortality. Preoperative prevention measures directed against the risk factors, embolizing the ruptured intracranial aneurysm as completely as possible and prompt postoperative cerebral angiography are all very important for reducing the incidence of the early rebleeding. And active and effective dealing with the rebleeding can definitely improve the prognosis.

Management of Poor-grade Patients with Ruptured Intracranial Aneurysm

To formulate treatment strategies for poor-grade patients after aneurysmal subarachnoid hemorrhage(SAH), medical records were analyzed for 166 patients who were in Hunt and Hess grade IV or V among 588 consecutive aneurysmal SAH patients admitted during the past 5 years. Causes for unfavorable outcome(poor or dead) in these 166 patients were carefully evaluated to improve the management outcome. Overall management results were favorable(good or fair) in 71(42.8%), and unfavorable in 95(78 dead, 17 poor). Direct clipping was performed in 90 patients, and the surgical results were favorable in 69(76.7%) and unfavorable in 21(23.3%). Surgery was not performed in 76 patients because of moribund state on arrival in 41, neurological deterioration due to rebleeding in 15, massive brain swelling in seven, serious medical illness in five, severe delayed ischemic deficit in one, and massive cerebral infarction following angiography in one, and refused surgery in six. Seven patients survived from non-surgery group(2 fair, 5 poor). Direct effects of aneurysm rupture(34.8%) and early rebleeding(34.8%) were the causes of unfavorable outcome in grade IV patients, while it was direct effect of aneurysm rupture(91.8%) in grade V patients. It is suggested that since rebleeding is the only preventable factor of unfavorable outcome, urgent management seems necessary to prevent rebleeding, especially for grade IV patients. Grade IV patients should be treated aggressively with direct clipping for non-complex aneurysms or for patients with hematoma, and with coil embolization for complex aneurysms without hematoma.

Patient Selection for Early Surgery in Ruptured Intracranial Aneurysm : Based on 10-year Experience with 1026 Patients

The purpose of this study was to set the guidelines for selection of patients to do early surgery in ruptured intracranial aneurysm. We assessed 706 patients with single rupture and without large hematoma, who underwent aneurysm surgery from 1985 to 1995. The male and female ratio was 1:1.5. Among the 706 patients, early surgery was performed in 214 cases. The results of early surgery were good in 193 cases(90.2%), fair in 13 cases(6.0%), poor in 1 case(0.5%) and dead in 7 cases(3.3%). The rate of dead outcome in the early surgery group was higher compared to other timing groups. The Fisher group 1, 2 and 3 reveale good outcome in early surgery group;92.6%, 96.3%, 88.8% respectively. The incidence of delayed ischemic deficits(DID) of early surgery group was same as other groups. However, in Fisher group 3, the incidence of DID was significantly low, 32.5%, in early surgery group. It is suggested that the criteria of selection of early surgery in patients with ruptured intracranial aneurysm would include as follows:1) patients with good clinical grade, 2) poor grade patients with marked irritability, acute hydrocephalus, and poorly controlled hypertension, 3) none-complex aneurysm requiring less brain retraction, dissection and brief temporary clipping, 4) age under 60 or over 60 with good physical status, and 5) Fisher group 3 requiring cisternal larvage and anticipated triple-H therapy.

Factors Affecting Development and Recovery of Symptomatic Vasoapasm in Patients with Ruptured Intracranial Aneurysm(s)

To determine the factors affecting development and recovery of symptomatic vasospasm, the author analyzed the results of patients with ruptured intracranial aneurysms treated by nimodipine and prophylactic "triple-H" therapy. From January 1991 to December 1995, 199 patients underwent surgery for ruptured intracerebral aneurysms. Combined hypervolemic hemodilution was initiated at the time of admission. Induced hypertension was added immediately after surgery(aneurysmal neck clipping). All patients received nimodipine intravenously or orally until the 14th day of SAH. Sixty patients underwent surgery on Day 0 through 2 after attackes of subarachnoid hemorrhage(Group A), 105 patients on Day 3 through 14(Group B), and 34 patients after Day 14(Group C). Of 199 patients, 76(38%) patients suffered from symptomatic vasospasm. Symptomatic vasospasm occurred in 34% of Group A patients, 33% of Group B patients, and 5% of Group C patients. Symtomatic vasospasm occurred more frequently in the older age group, the Fisher group 3, and Hunt & Hess grades 3, 4 and 5 groups. Of 76 patients who suffered from symptomatic vasospasm, 47(62%) patients recovered completely. The author analyzed the relationship between recovery rate and sex, age, Hunt & Hess grade and Fisher group among these 76 patients. Recovery rates between these groups were not significantly different. Based on this experience, the author believes that Hunt-Hess grade, Fisher group, and age are important factors affecting symptomatic vasospasm development.

Overall Management Outcome of Patients with Ruptured Intracranial Aneurysm During A 2-year Period

The purpose of this study was to assess the overall management outcome of patients with ruptured intracranial aneurysm during a 2-year period from 1991 to 1993. Among the 219 consecutive cases with ruptured intracranial aneurysm, 189 patients underwent surgery for ruptured aneurysm but 30 patients could not have surgery due to reasons such as being in a moribund state or refusal of surgery. Follow-up evaluation, performed at least 3 months after discharge, revealed 160 patients(73.0%) of good, 17(7.8%) of fair, 23(10.5%) of poor, and 19(8.7%) of dead outcome. Initial clinical condition on admission(Hunt and Hess Grade), amount and distribution of hemorrhage on brain computerized tomography(Fisher Grade), and presence of delayed ischemic deficits were closely related to the outcome. Patients with middle cerebral artery aneurysm showed a worse outcome than those with aneurysms at other locations. Patients admitted within 24 hours after rupture of the aneurysm or with early surgical treatment(within 3 days)also showed a worse outcome. The main causes of unfavorable outcome(poor or dead outcome)were initial hemorrhagic insult, delayed ischemic deficits, and rebleeding. In this study, favorable surgical outcome enabled a better overall outcome as compared to other reports. To improve overall management outcome, intensive management should be started from the very beginning of the patient's arrival. In addition, the elderly and patients with a poor grade should be managed aggressively and cautiously.

Clinical Significance of Intracranial Hematoma in Ruptured Aneurysms

The intracranial hematoma following cerebral aneurysmal rupture makes patient's clinical status and outcome worse by pressure effect on the brain structure. It's incidence has varied with authors between 5-30% of patients with ruptured cerebral aneurysms. Several authors emphasized the importance of early operation to obtain better results by early removal of hematoma and reducing intracranial pressure. The authors retrospectively evaluated seventy-six patients with intracranial hematomas in 370 patients with ruptured aneurysms from Jan. 1987 to Dec. 1992. The incidence of hematoma resulting from ruptured aneurysm was 20.5%. The most frequent site of aneurysm which was accompanied by intracranial hematoma was the middle cerebral artery, and the next was the anterior cerebral artery. The amount of hematoma and/or evidence of midline shift were the important factors in predicting the clinical outcome. The most favorable outcome was found in cases with intracerebral hematoma only, and the worst was in cases with intracerebral hematoma associated with intraventricular hemorrhage. Fifty out of 76 patients with intracranial hematomas were operated on. Their outcomes were more favorable than in the patients who were not operated on. Aggressive surgical intervention was especially effective in patients with poor Hunt & Hess grades(IV or V) .

Ruptured Intracranial Aneurysms in Patients with Polycystic Kidney Disease: Report of Two Cases

The authors present two cases of ruptured intercraial aneurysm s associated with nearly total destruction of kidney function due to polycystic kindney in one aged 35 years and the other aged 53 years. One patient had a aneurysm on anterior communicating artery and the other had three aneurysms located in cavenous and bifurcated portions of internal carotid artery, and anterior communicating artery. They were successfully treated by a direct surgical approach. We stress surgical management in a state of good consciousness regardless of poor kidney function, because the risk of early death by rebleeding is seemed to be higher than that by renal failure or others.

Clinical Analysis and Surgical Results of Early, Intermediate, Delayed Operation in 100 Consecutive Aneurysmal Patients

We retrospectively reviewed 100 consecutive patients who were ruptured intracranial aneurysm and were operated on in the department of neurosurgery of Wallace Memorial Baptist Hospital from August 1984 to August 1988. The patients who were operated upon within the first 3 days of their most recent subarachnoid hemorrhage formed the early group, the patients operated upon with 4-7 days formed the intermediate group, after 8 days were considered as the delayed group. Early operation was performed in 30 patients, intermediate operation in 20 patients, and delayed operation in 50 patients. On the base of their clinical outcome, the patients were allocated to one of 4 outcome categories(good, fair, poor, death) at the time of their hospital discharge. The 80% favorable outcome estimated from early operation and 85% from intermediate operation and 90% from delayed operation. The mortality was estimated 13% from early operation and 0% from intermediate operation and 8% from the delayed operation. Each 4 cases of early, intermediate and delayed operation was needed shunt operation for hydrocephalus. In operative result, after 1987 was better than before 1987. In hypertensive patients, there was a tendency to observe poor prognosis than normotensive patients, especially with vasospasm.

Clinical Analysis of Ruptured Intracranial Aneurysms

The author analyzed 177 consecutive cases of saccular, ruptured intracranial aneurysms admitted to the Department of Neurosurgery in Korea University Hospital during the period from August 1983 to July 1987. the results of analysis were summarized as follows. 1) Mean age of the patients was 50.4 years. 2) Incidence of clinical vasospasm was 27.2%(46/177) and of rebleeding was 10.7%(19/177). 3) Surgery was done for patients which accounts for 57.6% of all patients. Functional recovery was noted in 84 of the these surgically treated patients(84.6%). 4) The prognostic factors are age, hypertension, size of aneurysm, site of aneurysm, preoperative neurological state, vasospasm, hydrocephalus, rebleeding, timing of operation, multiplicity. 5) The mean size of aneurysms was 6.9mm. The direction of aneurysms was variable, but most of them pointed in the direction of blood flow in afferent arteries.

Clinical Analysis of Ruptured Intracranial Aneurysms

The author analyzed 177 consecutive cases of saccular, ruptured intracranial aneurysms admitted to the Department of Neurosurgery in Korea University Hospital during the period from August 1983 to July 1987. the results of analysis were summarized as follows. 1) Mean age of the patients was 50.4 years. 2) Incidence of clinical vasospasm was 27.2%(46/177) and of rebleeding was 10.7%(19/177). 3) Surgery was done for patients which accounts for 57.6% of all patients. Functional recovery was noted in 84 of the these surgically treated patients(84.6%). 4) The prognostic factors are age, hypertension, size of aneurysm, site of aneurysm, preoperative neurological state, vasospasm, hydrocephalus, rebleeding, timing of operation, multiplicity. 5) The mean size of aneurysms was 6.9mm. The direction of aneurysms was variable, but most of them pointed in the direction of blood flow in afferent arteries.