Transcranial dopplerosonography in subarachnoid hemorrhagen / Монголын Анагаах Ухаан

Background@#The incidence of acute SAH has been estimated at 2–22 cases per 100 000 persons per year. The most common cause of basal acute SAH is a ruptured cerebral aneurysm. Cerebral vasospasm in the first 2 weeks after aneurysmal subarachnoid hemorrhage is recognized as a major predictor of delayed cerebral ischemia. From 2014 through 2018, 5272 patients with a stroke (amongst them 20.4% were patients with aSAH) were hospitalized in the 3rd State Central Hospital of Mongolia.@*Objective@#To study the clinical features of the cerebral vasospasm and dopplerosonography parameters in the aSAH patients. @*Materials and Methods@#The methods, methodology and ethics of the research work were discussed at a Research meeting of Ethics Control Committee of the Mongolian National University of Medical Sciences held on December 22, 2017 (No2017 / 3-05), and the study was performed in accord with approval.</br> 60 patients with aSAH (hospitalized from 2017 to 2018 year) were enrolled in the case-control study. Informed consent were obtained from each participants. Clinical condition of participants was classified by Hunt-Hess scale (HHS). Cerebral vasospasm degree was graded by Lindegaard index.@*Results@#52.5% of the participants were men and 47.5% were women. Average age was 49.9±12. When clinical condition degree was compared to vasospasm grade it was revealed that amongst 1st degree of Hunt-Hess scale (HHS) group 11.1% of enrolled patients’ spasm was normal or had no spasm, while it was observed either 44.4% mild and moderate spasm. In the 2nd degree of HHS group: normal in 6.9%, mild in 3.4%, moderate in 86.2%, and severe spasm was in 3.4%. In the 3rd degree of HHS group, 11.1% had no spasm, moderate spasm was in 77.8%, and severe spasm was in 11.1%. In 4th degree of HHS group, 71.4% were with moderate spasm, 28.6% were with severe spasm (p = 0.001). </br> When the Hunt-Hess Scale was compared to the Sinus Rectus 1st degree of Hunt-Hess scale (HHS) group Sinus Rectus was normal for 22.2% patients, mild for 66.7% and severe for 11.1%. Though 4th and 5th degree of Hunt-Hess scale (HHS) groups’ Sinus Rectus mild for 7.1% normal, 50.0% mild and 42.9% severe (p=0.007). Thus whenever the clinical condition worsened the cerebral intracranial pressure was increasing.@*Conclusion@#aSAH patients clinical complication degree were directly associated with the cerebral vasospasm revealed by the transcranial dopplerosonography. Therefore, the evaluation of Hunt-Hess scale has an important significance in the prevention from clinical complications and in the selection of the appropriate treatment approaches for aSAH patients.

Research on the relationship between characteristics of aneurysm after aneurysmal subarachnoid hemorrhage and its clinical classification / 天津医药

Objective To explore the relationship between the size and location of the aneurysm after subarachnoid hemorrhage (aSAH) and its clinical classification. Methods A retrospective study was performed in patients with aSAH from January 1, 2008 to December 31, 2014. The relevant clinical data were collected including age, gender, aneurysm size, location, and Hunt-Hess (H-H) classification. The aneurysms were classified by size (A group d<5.00 mm, B group 5.00 mm≤d<10.00 mm, C group d≥10.00 mm), location and H-H classification according to the results of CT, digital subtrac?tion angiography (DSA), and magnetic resonance angiography (MRA). The relationship between size, position of aneurysm and H-H classification was observed and analyzed. Results There were 750 cases included in this study, with average age (56.14 ± 11.88), male 292 and female 458. The total number of aneurysms was 903, and the number of multiple aneurysms was 91 (12.13%). There was one case with multiple aneurysms that can be included in A, B and C groups. There were two cases with multiple aneurysms that can be included in A and B groups, two cases can be included in A and C groups, and three cases can be included in B and C groups. The number of aneurysms and the ratios of groups A, B and C were 20(3.9%), 12 (3.8%), 5 (7.5%), 70 (13.6%), 39 (12.2%), 10(14.9%), 2 (0.4%), 4 (1.3%), 2 (3.0%), 165 (32.0%), 94 (29.4%), 6 (9.0%), 130 (25.2%), 90 (28.1%), 6 (9.0%), 17 (3.3%), 11 (3.4%) and 2 (3.0%) for the location in the anterior cerebral artery, the middle cerebral artery, the posterior cerebral artery, the internal carotid artery, the anterior communicating artery, the posterior communicating artery, and the vertebral basilar artery, respectively. The number of aneurysms and the ratios of H-H classificationⅠ,Ⅱ,Ⅲ,ⅣandⅤin groups A, B and C were 48 (9.3%), 45 (14.1%), 12 (17.9%), 228 (44.2%), 150 (46.9%), 14 (20.9%), 68 (13.2%), 54 (16.9%), 30 (44.8%), 142 (27.5%), 43 (13.4%), 9 (13.4%), 30 (5.8%), 28 (8.8%) and 2 (3.0%). There was a negative correlation between the size of aneurysm and the H-H grade (rs=-0.075, P=0.024). Conclusion The anterior communicating artery and posterior communicating artery are high-risk areas for smaller aneurysms. The internal ca?rotid artery is high-risk areas for larger aneurysms. The size of aneurysm is negatively correlated with H-H classification.

Comparison of extent of postoperative hydrocephalus in patients between intervertional therapy with embolism and craniotomy occlusion in Hunt-HessⅢ-Ⅳ level aneurysm induced subarachnoid hemorrhage and their prognosis / 中华危重病急救医学

ObjectiveTo analyze and compare the difference and prognosis between vascular embolization and craniotomy occlusion in patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) with Hunt-Hess levelⅢ-Ⅳ, and acute postoperative hydrocephalus.Methods A retrospective study was conducted on 767 patients who had undergone vascular embolization (vascular embolization group,n = 403) or craniotomy occlusion operation (craniotomy occlusion operation group,n = 364), and the patients with postoperative acute hydrocephalus were screened. The clinical data of patients of both groups was analyzed. By judging short-term prognosis in patients with hydrocephalus with Glasgow outcome scale (GOS) score estimated at discharge, the advantages and disadvantages of two surgical procedures were compared.Results The number of cases with postoperative hydrocephalus in vascular embolization group was 56 (13.90%), while that in craniotomy occlusion group was 33 (9.07%). The difference between the two groups of incidence of hydrocephalus was statistically significant (χ2= 4.350,P = 0.037 ). In 767 patients with aSAH, the incidence of hydrocephalus among the patients after the hematoma removal operation was significantly lower than that of patients without hematoma removal [3.07% (11/358) vs. 19.07% (78/409),χ2 = 47.635,P = 0.000]. The incidence of hydrocephalus among the patients after ventricular drainage was significantly lower than that of patients without the drainage [2.77% (19/685) vs. 85.37% (70/82),χ2 = 487.032,P = 0.000]. In 403 cases of vascular embolization group, the incidence of hydrocephalus in the patients after the hematoma removal operation was lower than that of patients without it [8.06% (5/62) vs. 14.96% (51/341),χ2 = 2.082,P = 0.168]. The incidence of hydrocephalus in the patients after the ventricular drainage was lower than that of patients without drainage [2.59% (9/347) vs. 83.93% (47/56),χ2 = 266.599,P = 0.000]. In 364 cases of craniotomy occlusion operation group, the incidence of hydrocephalus in the patients after hematoma removal operation was significantly lower than that of patients did not receive [2.03% (6/296) vs. 39.71% (27/68),χ2 = 95.226,P = 0.000]. The incidence of hydrocephalus among the patients after the ventricular drainage was significantly lower than that of patients without drainage [2.96% (10/338) vs. 88.46% (23/26),χ2 = 203.852,P = 0.000]. The difference in incidence of hydrocephalus between the patients who had hematoma removal surgery between vascular embolization group and craniotomy occlusion operation group was statistically significant [8.06% (5/62) vs. 2.03% (6/296),χ2 = 4.411,P = 0.027], while no statistically difference was present in ventricular drainage patients [2.59% (9/347) vs. 2.96% (10/338),χ2 = 0.085,P = 0.819]. There were 23 patients (41.07%) with good outcome (GOS score 4-5), while 33 (58.93%) with poor outcome (GOS score 1-3) in 56 patients undergone vascular embolization operation. Good result (GOS score 4-5) was shown in 21 (63.64%) and 12 (36.36%) with poor outcome (GOS score 1-3) among 33 patients with hydrocephalus after craniotomy occlusion operation, and the difference was statistically significant (χ2 = 4.230,P = 0.039).Conclusions Hematoma is one of the main factor contributing to the differences in the incidence of postoperative hydrocephalus of Hunt-Hess gradeⅢ-Ⅳ patients either receiving vascular embolization or craniotomy occlusion operation. Lateral ventricle drainage may not be the factor that contributes to the difference in incidence of hydrocephalus formation between the vascular embolization and craniotomy occlusion operation groups in Hunt-Hess levelⅢ-Ⅳ patients. The short term prognosis in the craniotomy occlusion operation group is superior to that of endovascular intervention embolization group.

The role of lumbar drainage in symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage / 中华急诊医学杂志

Objective To investigate the risk factors of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage and evaluate the effect of lumbar drainage of cerebrospinal fluid on vasospasm.Methods In this retrospective controlled-cohort study, 175 patients with aneurysmal subarachnoid hemorrhage met our study criteria between January 2012 and December 2013.By multi-factor regression analysis, gender, age, Hunt-Hess grade, modified Fisher grade and lumbar drainage were analyzed.The outcomes were assessed by the presence or absence of symptomatic cerebral vasospasm and vasospasm-related infarction, and the mean days of hospital stay and score of Glasgow Outcome Scale at 1-month follow-up.Results Several factors affected the prognosis of subarachnoid hemorrhage.Lumbar drainage was a protective factor of symptomatic cerebral vasospasm (OR =0.243, 95％ CI: 0.119-0.497) and vasospasm-related infarction (OR =0.305, 95％ CI: 0.154-0.604).The patients with lumbar drainage had higher score of Glasgow Outcome Scale (P ＜ 0.05).But the patients with lumbar drainage had longer hospital stay (P ＜ 0.05).Conclusions Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage markedly reduced the risk of symptomatic cerebral vasospasm and improved outcome.

Outcome of Aneurysmal Subarachnoid Hemorrhage Patients with Hunt-Hess Grade III / 대한뇌혈관외과학회지

OBJECT: We designed this study to bring the outcome and the outcome predictors of Hunt-Hess grade III patients to light, and to be aid in determining treatment protocol of such a intermediate group. METHODS: All patients with non-traumatic subarachnoid hemorrhage who visited our hospital between January 1998 and December 2004, were reviewed. We selected 72 Hunt-Hess grade III aneurysmal subarachnoid hemorrhage patients for detailed review. 54 operations and 10 endovacular procedures were performed. The outcome of the patients were evaluated with Glasgow Outcome Scale (GOS). Through univariate and multivariate analysis, several clinical and operative factors were evaluated to determine the significance for the outcome. RESULT: Overall 58 patients were in good outcome group (GOS 4 or 5). overall 6-month mortality was 5.6%. Age, presence of intracerabral hemorrhage(ICH) on the initial computed tomography (CT) scan, and vasospasm were independently important in determining outcome. CONCLUSION: In the Hunt-Hess grade III aneurysmal SAH patient, age, presence of ICH on intial CT scan vasospasm have independent statistical significance to the outcome. More aggressive treatment of vasospasm can improve the outcome.

Hunt-Hess and Fisher Grades as Predicting Factors for Chronic Hydrocephalus in Surgically Treated Ruptured Aneurysm

OBJECTIVE: The popular grading systems in use, such as Hunt-Hess grade and Fisher scale score, are based primarily on the patient's clinical conditions or computerized tomography score after aneurysmal subarachnoid hemorrhage(SAH). The author investigated whether the need for ventriculoperitoneal(VP) shunt for chronic hydrocephalus and outcome can be predicted by Hunt-Hess grade and Fisher scale. METHODS: A series of 146 patients admitted to our hospital from August 1991 to July 1999, who presented with SAH and underwent craniotomy for aneurysm clipping were studied retrospectively. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after initial hemorrhage which required shunting. Patients were evaluated based on following factors: Hunt-Hess grade, Fisher scale, age, sex, hypertension, aneurysm location, and intervals from aneurysm rupture to operation. RESULTS: The overall mortality rate of the study group was 8.2%. Hunt-Hess grade(p=0.001) or Fisher scale (p=0.001) at all pretreatment times was significantly correlated with outcome. In addition, there was an increased risk of poor outcome in older age(650.05). Of 134 surviving patients, 16 patients(12%) underwent VP shunt placement secondary to chronic hydrocephalus. Hunt-Hess grade(p=0.001) is more predictive of chronic hydrocephalus than Fisher scale(p=0.146). Aneurysm location was significantly correlated with development of chronic hydrocephalus (p<0.05), without significant correlations in sex, age, hypertension. IVH, and ICH. CONCLUSION: This study suggests that there is a high clinical correlation between outcome and Hunt-Hess grades and Fisher scales on admission, but Hunt-Hess grade is more predictive for chronic hydrocephalus than Fisher scale. In addition, age(<65 yrs) is the significant factor for prediction of outcome. There was a trend of increasing risk for chronic hydrocephalus according to aneurymal location.

The Outcome of Urgent Surgery for Hunt-Hess Grade IV Patients with Ruptured Intracranial Aneurysm

OBJECTIVE: About 40% of patients who admit to the hospital after subarachnoid hemorrhage are poor clinical grade(Hunt-Hess grade IV, V). The majority of these patients have been excluded from early, aggressive treatment. The current study was undertaken to evaluate the outcome of urgent surgery for Hunt-Hess grade IV aneurysmal subarachnoid hemorrhage. MATERIALS AND METHODS: We reviewed hospital records and radiographic studies of 36 patients who were Hunt-Hess grade IV among 201 cases with ruptured intracranial aneurysm admitted between Sep. 1995 and Dec. 2000. Operated patients were treated with urgent angiography and surgery within 24 hours of presentation, except six patients, and medical records of these patients were reviewed for the clinical course and Glasgow outcome scale(GOS). RESULTS: Overall management results of the 36 patients were good recovery in 13(36.1%), moderate disability in 12 (33.3%), severe disability in 1(2.8%), vegetative state in 1(2.8%) and 9(25.0%) of surgically treated patients had died. CONCLUSION: Although with limited number of patients, we conclude that urgent surgery for Hunt-Hess grade IV patients results in a better neurologic outcome and urgent surgery combined with aggressive postoperative management can minimize mortality.

Management of Cerebral Aneurysms in Elderly Patientsc / 대한뇌혈관학회지

In many countries, the percentage of seninor citizens is expanding. Direct operation for ruptured aneurysm should be the choice of treatment in elderly patients of Hunt-Hess grade I through III, but should not be performed in cases of grade V. To evaluate the risk of early operation of elderly patients with ruptured cerebral aneurysm, conducted a retrospective analysis 464 elderly patients with ruptured aneurysms who were over aged 60 years between Jan 1980 to June 1999. Of these, 334 cases were performed early operation in which the direct intracranial operation was carried out within 3 days after last subarachnoid hemorrhage. The female: male ratio is 4.87: 1. The location of aneurysms are 144 anterior communicating artery aneurysms, 139 internal carotid artery aneurysms, 117 middle cerebral artery aneurysms, 35 multiple aneurysms, etc. Associated conditions are hypertension, diabetes mellitus, pulmonary problem, etc. Operation methods are 404 clippings, 53 coatings, 1 endovascular treatment, etc. Problems during operation are 29 broad aneurysms, 22 giant aneurysms, 21 tight brains, etc. In early operative group(within 3 days), 79% had favorable outcome, 11% unfavorable outcome and 10% died. The early operation is an effective and reliable method to reduce the occurrence of rebleeding, vasospasm, ischemic complication, medical complication and to shorten lengths of hospitalization.

Clinical Analysis of Surgically Treated 134 Cases of Anterior Communicating Artery Aneurysms

This study is a retrospective clinical analysis of 134 cases of anterior communicating artery aneurysms surgically treated in the Department of Neurosurgery, Chungnam National University Hospital from January 1990 to December 1996. The results of analysis were summarized as follows; 1) Peak age incidence was in the sixth decade and male to female ratio was 1: 1.2, showing female predominancy. 2) There was no statistically significant relationship between direction of aneurysm and Fisher's grade, and occurrence of hydrocephalus, and also between the direction, size and shape of aneurysm and preoperative Hunt-Hess grade. 3) There was statistically significant relationship between the shape of aneurysm and angiographic vasospasm; there was high incidence of vasospasm in lobulated and oval shape of aneurysm. But there was no statistically significant relationship between the direction, size of aneurysm and angiographic vasospasm. 4) The correlations between outcome and preoperative Hunt-Hess grade, and occurrence of angiographic vasospasm, and temporary clipping were statistically significant; the outcome was good in cases of no vasospasm, temporay clipping and better preoperative Hunt-Hess grade. 5) The direction, shape and size of aneurysm, existence or not of abnormality in circle of willis, timing of surgery and operative procedure had no statistically significant relationship with outcome. 6) Postoperative complications were vasospasm and infarction(18.7%), brain edema, hydrocephalus, in order of frequency, and the mortality rate was 3%.

Contributing Factors for Favorable Outcome in Spite of Initially Poor Graded Aneurysmal Subarachnoid Hemorrhage Patients(Hunt-Hess grade IV, V)

Aneurysmal subarachnoid hemorrhage carries a high rate of morbidity and mortality despite recent advance in the care of such patients. This is especially true in patients in poorer neurological condition(Hunt-Hess grade IV, V) after initial hemorrhage. Many factors are known to contribute to this poor outcome, but other factors might be contribute to the favorable outcome. This study underwent to examine in a prospective fashion to evaluate the influence of different clinical, radiological, and intra-operative factors upon eventual outcome to aid in determining the rationale for an aggressive management on individual cases. Total of 494 cases of SAH were surgically treated from Jan. 1984 to Sep. 1996. Among them, 92 cases(18.6%) were classified as Hunt-Hess grade IV, V. Favorable outcome was noted in 59 cases(64.1%), and poor outcome in 33 cases(35.9%). Statistically significant contributing factors for favorable outcome aare systolicBP24hr), and short operation time(<6hr).

Overview of Surgical Result of Multiple Intracranial Aneurysmal Patients

From January 1990 to January 1996, we analyzed outcome according to the distribution of aneurysms, the type of surgical treatment, the timing of operation, and the patient's pre-operative status in a total of 54 cases of multiple intracranial aneurysms. The frequency of multiple intracranial aneurysms was 13.4% and the sex ratio was 1:2 with female being predominant. The frequency of aneurismal location was MCA(35.0%), P-comm. Artery(25.0%) and A-comm. Artery(15.0%) in that order. The number of ruptured aneurysms was in the order to MCA aneurysms. A-comm aneurysms, and P-comm aneurysms. The size of ruptured aneurysms was 6-10mm in 34 cases(64.2%). The unilateral distribution of aneurysms was 31 cases(57.4%) and the bilateral was 28 cases(42.6%). Depending on how many times the patient had the operation, these were 29(57.4%) cases of complete single operation, 17 cases(31.5%) of complete two-stage operation, and 8 cases(14.8%) of partial operation. Surgical outcome was good(GOS< or =4) in 42 cases(77.8%), and six patients(11.1%) expired. Based on the results of the above study we have concluded that initial Hunt-Hess grade has a close relationship with the outcome, but the operation type, the timing of operation, the number and distribution of aneurysms do not significantly effect the outcome.