Cerebral blood flow in patients with a subarachnoid haemorrhage during treatment with tranexamic acid.

Many clinicians currently use antifibrinolytic therapy (AFT) routinely in the management of subarachnoid haemorrhage (SAH). Many others do not, either because they remain unconvinced that AFT reduces the risk of rebleeding, or that the medication itself causes serious complications and in particular cerebral ischaemia. Nineteen randomly selected patients were studied, 9 receiving tranexamic acid (9 g a day) and the remaining 10 placebo, with SAH confirmed by CT scanning and by lumbar puncture. There was no difference between the active and placebo group regarding the age, sex, clinical grade, CT scan and angiographic appearance. The intravenous Xe133 technique was used for serial determinations of hemispheral cerebral blood flow. The cerebral blood flow remained stable during the first week following subarachnoid haemorrhage, and then fell progressively, reaching its bottom level by the end of the second week. The cerebral blood flow levelled out during the third week at the end of which a sharp elevation, well above the first week's post-subarachnoid haemorrhage level, was noted. This rebound rise of cerebral blood flow was observed for both cerebral hemispheres. Cerebral flow was greatest in the contralateral (to side of ruptured aneurysm) brain hemisphere save for the peak observed during the first week post-subarachnoid haemorrhage. The difference between the ipsi- and contralateral hemispheres was most pronounced in patients receiving active treatment. Analysis of variance showed that cerebral blood flow was reduced by the active treatment and especially more so on the ipsilateral side with the ruptured aneurysm. The usefulness of AFT should therefore be reconsidered.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol consumption--a risk factor for hemorrhagic and non-hemorrhagic stroke.

PURPOSE: The risks of alcohol consumption and its association with stroke were studied in 621 patients with stroke and 573 control subjects using case-control methods. PATIENTS AND METHODS: Patients with stroke were subdivided into 193 with subarachnoid hemorrhage, 91 with intracerebral hemorrhage, and 337 with cerebral infarction. Data on recent alcohol consumption were obtained by questionnaire in patients with stroke and compared with data from an occupational screening survey in control subjects. RESULTS: Relative risks, adjusted for confounding variables, exhibited J-shaped associations with increasing levels of alcohol consumption classified into four categories--abstainer, 1 to 90 g, 100 to 390 g, and greater than or equal to 400 g weekly). The individual risks were 1, 0.7, 0.5, and 1.3 for subarachnoid hemorrhage; 1.0, 0.6, 0.5., and 2.5 for intracerebral hemorrhage, and 1.0, 0.6, 0.7, and 2.4 for cerebral infarction for men and women combined. CONCLUSIONS: The results suggest that low levels of alcohol consumption may have some protective effect upon the cerebral vasculature, whereas heavy consumption predisposes to both hemorrhagic and non-hemorrhagic stroke.

Seasonal variation of cerebrovascular diseases.

The seasonal variation in all admissions of all types of cerebrovascular disease within the West Midlands Region was examined between the years 1973-1980. There was a fluctuation for both sexes with a peak in winter, between the months of October and April; a trough was observed in late summer, in July and August. Multivariate analysis of the meteorological factors showed an association between hours of sunshine and intracerebral haemorrhage. The meterological variables were strongly correlated with each other making the selection of the most predictable variable to stroke difficult.

Spontaneous subarachnoid haemorrhage occurring in association with a platelet function disorder.

A case of spontaneous subarachnoid haemorrhage occurring in association with a disorder of platelet function is described and the features of the disorder of platelet function were consistent with a storage pool deficiency. There has been no previous report of subarachnoid haemorrhage with platelet dysfunction.

Fibrinolytic activity after subarachnoid haemorrhage and the effect of tranexamic acid.

Seventy-four patients with recent subarachnoid haemorrhage were randomly allocated to placebo or tranexamic acid treatment. Fibrinolytic activity in the blood and cerebrospinal fluid was assessed before treatment, one week later and two weeks later. The natural history of fibrinolysis following subarachnoid haemorrhage was obtained from analysis of the placebo group. Following subarachnoid haemorrhage, fibrin degradation products and plasminogen activity in the cerebrospinal fluid were elevated. Subsequently, fibrin degradation products in the cerebrospinal fluid fell progressively over the following 2 weeks. Changes in cerebrospinal fluid plasminogen activity correlated with those of blood plasminogen activity. Complications such as rebleeding, hydrocephalus or cerebral thrombosis could not be predicted from analysis of fibrinolytic activity. Tranexamic acid treatment resulted in a reduction in cerebrospinal fluid and blood plasminogen activity. The relevance of fibrinolysis in cerebrospinal fluid and blood to the management of subarachnoid haemorrhage is discussed.

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms. A double-blind placebo-controlled study.

One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances. More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage than a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p less than 0.04); the reverse was true for the placebo patient (p less than 0.05).

Cigarette smoking. A risk factor for hemorrhagic and nonhemorrhagic stroke.

Cigarette smoking habit was studied in 621 patients with stroke and in 573 control subjects using case control methods. There was an excess of smokers among the stroke group when compared with control subjects. Relative risks of cigarette smokers compared with nonsmokers, after adjustment for the possible confounding variables for subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction, were 4.5, 1.8, and 3.2 for men and 2.5, 1.3, and 2.3 for women, respectively. For all subtypes of stroke combined, the increased relative risk was related to the daily intake of cigarettes, the heaviest smokers having a higher relative risk than that for light smokers. The estimated increase in relative risk among smokers was 1.5 for each 10 cigarettes smoked daily in both men and women. We conclude that cigarette smoke may be an important preventable factor for both hemorrhagic and nonhemorrhagic stroke.

Reduced platelet function in subarachnoid hemorrhage.

The hypothesis that abnormalities of platelet function may relate to the occurrence or recurrence of subarachnoid hemorrhage (SAH) has been examined. Seventy patients with SAH and 65 control individuals were studied. The adenosine diphosphate (ADP) threshold for secondary platelet aggregation was significantly higher in the SAH group than in the controls. In tests using 4.0 micrograms/ml ADP, the percent platelet aggregation (at 2 minutes) and the maximum rate of platelet aggregation (over 20 seconds) were significantly lower in the SAH patients. There was no difference in total platelet count between the two groups. Platelet adhesiveness was lower in the SAH patients when compared to controls. Circulating microaggregates did not differ between the two groups. The results indicate that reduced platelet function does relate to SAH and may either contribute to aneurysmal rupture in cases of SAH or be a consequence of it.

Pituitary apoplexy.

Three patients with symptomatic haemorrhagic necrosis and infarction of the pituitary gland are described. They showed a range of clinical presentation, diagnostic pitfalls and diversity of treatment.

Oligoclonal immunoglobulin G in acute subarachnoid hemorrhage and stroke.

Oligoclonal Ig bands were found in serum and CSF of 13 of 83 patients (16%) with verified subarachnoid hemorrhage (SAH). Serum Ig bands were more common in patients with SAH than in those with cerebral ischemia. The reverse was true with oligoclonal Ig bands in CSF. These patterns suggest that there are two different mechanisms and sites of IgG synthesis: an inflammatory process after acute stage of vascular damage and a latent immunologic process--ie, polyclonal B-cell activation by injury to the brain.

Diurnal variation of and activity during the onset of stroke.

The diurnal variation in the onset of stroke was examined in 557 consecutive patients aged over 70 years. These included 194 patients with subarachnoid hemorrhage, 118 with intracerebral hemorrhage, and 245 with thromboembolic cerebral infarction. All three types of strokes exhibited a peak incidence between 1000 and 1200 hours. Intracerebral hemorrhages occurred less frequently between 0400 and 0600 hours, but there were no differences between the groups for the other time periods. There was no difference in the time of onset of stroke between normotensive and treated or untreated hypertensive patients. There were more untreated hypertensive patients in the intracerebral hemorrhage group than in the other stroke type groups. Subarachnoid hemorrhage occurred more frequently in the lavatory and during sexual and sporting activity. Intracerebral hemorrhage occurred more commonly during driving or the consumption of alcohol. Cerebral infarction occurred more frequently during sleep or was noticed on waking. No differences were found for the other activities examined. The relationship between diurnal variation in stroke and the known variation in blood pressure is discussed.

Comparative studies of the diagnostic value of cerebrospinal fluid spectrophotometry and computed tomographic scanning in subarachnoid hemorrhage.

Serial spectrophotometric scans of cerebrospinal fluid (CSF) and computed tomographic (CT) scans of 99 patients with a subarachnoid hemorrhage (SAH) were examined. The xanthochromic index (i.e., the sum of the absorption values at 416 nm (oxyhemoglobin) and 460 nm (bilirubin)) yielded an accurate diagnosis in 82%, as did the CT scan. When both spectrophotometric and CT scans were used, the accuracy of SAH diagnosis increased to 96%. The xanthochromic index was valuable in estimating the date of hemorrhage and also correlated well with the clinical outcome of these patients. Only 42% of the recurrent hemorrhages were diagnosed by CSF spectrophotometry; in this capacity, its role seems less clear. However, a positive diagnosis of recurrent hemorrhage by CT scan was made in 83%.

Determination of plasma tranexamic acid using cation-exchange high-performance liquid chromatography with fluorescence detection.

A procedure is described for the determination of plasma tranexamic acid concentrations using cation exchange high-performance liquid chromatography with fluorescence detection following post-column derivatisation with omicron-phthalaldehyde. The chromatographic conditions were optimised with respect to detector performance and the method applied to measuring the plasma tranexamic acid levels of patients in a double-blind trial.

Surgical management of intracerebral hematomas.

Traditional and recent developments in the management of spontaneous intracranial hematomas are reviewed. A comprehensive account of the epidemiological characteristics worldwide with an etiological analysis including prevention and prophylaxis introduce the size and clinical significance of this neurological problem. The usefulness and limitations of the available diagnostic methods are described. Most of the emphasis, however, is placed on the management and medicosurgical treatment of intracranial hematomas in correlation with their clinical presentation and localization.

The spoon test: a simple bedside test for assessing sudomotor autonomic failure.

The efficacy of a new dual simple bedside test--the spoon test--in demonstrating sudomotor skin derangements was assessed. The results were compared with those defined by the quinizarine sweat test. The advantages and disadvantages of these two above and other known similar tests are discussed.

Outcome from "rescue clipping" of ruptured intracranial aneurysms during induction anaesthesia and endotracheal intubation.

Eight patients with ruptured aneurysms during induction anaesthesia and endotracheal intubation underwent an emergency "rescue clipping" of their lesion. Three patients died. Of the five survivors three made a good final recovery, one patient was moderately disabled and one remained in coma. Conservative management of this crisis is doomed to failure but the comparatively good outcome of the operative cases supports emergency "rescue clipping".

Ophthalmological signs and prognosis in patients with a subarachnoid haemorrhage.

In cases of subarachnoid haemorrhage from various causes, ophthalmological signs can be a feature. In the clinical examination they can be of assistance in determining the site of the aneurysm or other responsible lesion, and they can also be of prognostic value. In a series of 48 cases the significance of these ocular signs is evaluated and discussed.

Rupture of intracranial vascular lesions during arteriography.

Four cases with ruptured intracranial vascular lesions during angiography and confirmed radiologically are presented to emphasise a dangerous complication of the procedure.