Does a routine operation for intracranial aneurysm incur brain damage?

A biochemical marker of brain cell damage, the BB-isozyme of the intracellular enzyme Creatine Kinase (CK), was used to evaluate any possible injury to the brain, caused by an operation for a ruptured intracranial aneurysm (SAH). CSF-CK BB was assessed before and at intervals after operation in a series of 60 patients, aged 29-71 (mean 51 years) operated on for intracranial aneurysms, all but one after SAH. The m/f ratio was 18/42. 35 of the 60 patients were operated on acutely, i.e. within 72 hours after the SAH. CK BB was determined as CKB-activity after immunological inactivation of CKM. Normally there should be almost no detectable enzyme activity in the CSF. The pre-operative CK BB-activity was 0.01+ -0.01 mikrokatal in the patients in Hunt & Hess grade I who were operated on > 7 days after their SAH, and 0.05+ -0.04 in those operated on acutely, probably still reflecting the effects of the SAH on the brain. The mean per-operative CK BB increase was 0.11+ -0.17 for patients who had an uneventful postoperative course, compared to 0.39+ -0.49 for those showing some degree of immediate postoperative deterioration. This difference is significant at the 1% level. 52 of the 60 patients showed a rise of CK BB after operation. The mean increase for those patients operated upon in a good state and without any complication or postoperative deterioration was 0.02+ -0.03 mikrokatal, which could therefore be considered as a "normal" or acceptable elevation.(ABSTRACT TRUNCATED AT 250 WORDS)

The protective effect of nimodipine, a calcium antagonist, and its influence on soman clearance in the anaesthetized rabbit.

The effect of pretreatment with a vasoactive compound, nimodipine, on soman intoxication in peripheral organs of rabbits was studied by measuring changes in the cholinesterase and acetylcholinesterase activity and by measuring clearance of soman in blood using gas chromatography/high resolution mass spectrometry. In animals receiving soman only, initial blood concentrations were approximately 100 ng mL-1 and were still detectable after 5 min. The clearance rate of soman in blood markedly increased following nimodipine pretreatment such that soman was below the detection limit (0.002-0.003 ng mL-1) in all samples. Soman injection caused a significant inhibition of the acetylcholinesterase activity in serum, and in brain. In rabbits pretreated with nimodipine, no significant inhibition of acetylcholinesterase activity occurred after soman injection. In view of the effects of nimodipine on soman clearance and on the acetylcholinesterase and cholinesterase inhibition during soman intoxication, we suggest that nimodipine has profound circulatory effects, which during soman intoxication, increase the vascular perfusion through the body and thereby increase the detoxifying capacity.

Surgery for chronic symptoms after whiplash injury. Follow-up of 20 cases.

20 patients operated on with discectomy and anterior cervical fusion because of chronic symptoms after whiplash injury were examined 4 years after surgery. The commonest indications for surgery were disabling headache and neck pain and radiographically verified disc protrusion. At follow-up, 11 patients had reduced headache and neck pain, while paresthesia and radicular pain were diminished in 9 patients. Based on Robinsson's criteria for the evaluation of surgical results, 2 patients had good, 9 had fair and 9 had poor results.

Causes of morbidity and mortality, with special reference to surgical complications, after early aneurysm operation: a prospective, one-year study from neurosurgical units in Sweden.

In the present prospective study, 6.93 of Sweden's 8.59 million inhabitants (81%) were covered by the five participating centres. All patients with verified aneurysmal SAH admitted between June 1, 1989 and May 31, 1990, were enrolled. Basically, all participating centres have the same management protocol for SAH victims, including ultra-early referral to a neurosurgical unit, followed by pan-angiography and surgery as early as logistically possible. In this presentation, 145 patients who preoperatively were in Hunt & Hess Grades I-III and who underwent surgery for a supratentorial aneurysm within 72 h after the bleed, are evaluated. Eighty-one % (117 patients) made a good recovery. The morbidity was 12% (17 patients) and the mortality 7% (11 patients). The most common cause of unfavorable outcome was surgical complications, which accounted for 8% of the total series (12 patients). A subanalysis of these cases did reveal a positive correlation to higher age and more severe SAH on CAT scan.

Overall outcome in aneurysmal subarachnoid hemorrhage. A prospective study from neurosurgical units in Sweden during a 1-year period.

The present prospective study, with participation of five of the six neurosurgical centers in Sweden, was conducted to evaluate the overall management results in patients with aneurysmal subarachnoid hemorrhage (SAH). The participating centers covered 6.93 million (81%) of Sweden's 8.59 million inhabitants. All patients with verified aneurysmal SAH admitted between June 1, 1989, and May 31, 1990, were included in this prospective study. A uniform management protocol was adopted involving ultra-early referral, earliest possible surgery, and aggressive anti-ischemic treatment. A total of 325 patients were admitted during the study period, 69% within 24 hours after hemorrhage. On admission, the patients were graded according to the scale of Hunt and Hess: 43 patients (13%) were classified in Grade I, 119 (37%) in Grade II, 53 (16%) in Grade III, 76 (23%) in Grade IV, and 34 (11%) in Grade V. Nimodipine was administered to 269 of the 325 patients: intravenously in 218, orally in 15, and intravenously followed by orally in 36. At follow-up examination 3 to 6 months after SAH, 183 patients (56%) were classified as having made a good neurological recovery, 73 patients (23%) suffered some morbidity, and 69 (21%) were dead. Surgery was performed in 276 (85%) of the patients; emergency surgery with evacuation of an associated intracerebral hematoma was carried out in 30 patients. Early surgery (within 72 hours after SAH) was performed in 170 individuals, intermediate surgery (between Days 4 and 6 post-SAH) in 29 patients, and late surgery (Day 7 or later after SAH) in 47 individuals. Of 145 patients with supratentorial aneurysms who were preoperatively in Hunt and Hess Grades I to III and who were treated within 72 hours, 81% made a good recovery; in 5.5% of patients, the unfavorable outcome was ascribed to delayed ischemia. It is concluded that, among patients with all clinical grades and aneurysmal locations, almost six of 10 SAH victims referred to a neurosurgical unit can be saved and can recover to a normal life.

Spinal epidural abscesses in adults: review and report of iatrogenic cases.

A retrospective review of the medical records of adults with diagnosed spinal epidural abscess (SEA) admitted to the Departments of Neurosurgery and Infectious Diseases at the University Hospital of Umeå, Sweden, during a 10-year-period (1978-1987) is presented. 10 patients were diagnosed as having SEA during the study period. An iatrogenic origin was suspected in 5. Spondylitis was the most common source of infection. Bacteriological aetiology was confirmed in 8 cases and Staphylococcus aureus was the most common aetiological agent. Trauma and degenerative diseases of the spine, were underlying conditions in 6 cases. Laminectomy was performed in 7 cases. 5/6 patients operated within 48 h after onset of neurological symptoms improved. The remaining case with therapy resistant tuberculous spondylitis died. One patient with surgery after 96 h became paretic. 2/3 conservatively treated patients had a successful outcome while the third patient had a permanent paraparesis due to missed diagnosis. Early diagnosis and early laminectomy are still the most important prognostic factors. Recommended initial antibiotic therapy is the combination of a cephalosporin with extended spectrum and metronidazole.

Aneurysmal subarachnoid haemorrhage: overall outcome and incidence of early recurrent haemorrhage despite a policy of acute stage operation.

A series of 480 patients who were alive upon admission following an aneurysmal subarachnoid haemorrhage (SAH) is reported. These patients represented 40% of the total Swedish incidence during a 3-year period. The three neurosurgical referral centres covering this population had a similar policy of early diagnosis and acute state surgery in all patients considered of having a potential to survive without permanent disabling cerebral malfunction. At 2-year follow up 45% showed a good neurological recovery, the morbidity was 25% and the mortality was 30%. Some more lives might have been saved with an improved ultra-early referral system since there were 21 initially good-to-fair risk patients (4% of the total SAH population) who rebled fatally before surgery and within 48 h. For comparison, in the Kingdom of Denmark, with a general policy of delayed operation, out of 1076 patients who were alive upon admission, 27.5% made a good recovery, while the morbidity was 27%, and the mortality was 45.5%.

On the composition and characteristics of microvessels isolated from the rabbit and bovine brain.

Brain capillaries (microvessels) were isolated from the rabbit and bovine brain. Extensive morphological examinations were performed at the light and electron microscopical levels. The relative contribution of endothelium (52%), basal membrane (32%) and pericytes (16%) to the composition of the microvessel was assessed. The ability of the endothelium from bovine brains to maintain a membrane potential, i.e. to accumulate the lipophilic cation [3H]TPMP, was shown. The transmitter catabolizing enzymes MAO and AchE were shown to be, and COMT and GABA-T not to be associated with the microvessel fraction isolated from rabbits.

Soman intoxication and the blood-brain barrier.

Brain capillaries (microvessels) were isolated from rabbit brain. Morphological characterization revealed relatively pure fractions of microvessels consisting of the capillary endothelium, the basal membrane, and the pericyte. These fractions of brain capillaries show acetylcholinesterase (AChE) and monoamine oxidase (MAO) activity, but lack catechol-O-methyltransferase and GABA transaminase activity. Isolated brain capillaries together with samples of the brain parenchyma and serum were used to study the role of AChE present in the brain capillary wall in soman intoxication. The results showed this AChE to be less sensitive to soman inhibition than AChE of brain parenchyma. Serum and brain AChE recovered to some extent in soman-intoxicated rabbits given HI-6, whereas AChE present in the microvessel was even further inhibited. It is suggested that soman-induced vasospasm in rabbit brain may explain both the inaccessibility of capillary AChE to soman and also the unfavorable effect of HI-6 on this enzyme.

Fibrinolytic activity of cerebral tissue after experimental subarachnoid haemorrhage: inhibitory effect of tranexamic acid (AMCA).

The influence of tranexamic acid (AMCA) on the fibrinolytic activity induced by plasminogen activators (PA) of the cerebral leptomeninges, arteries and choroid plexus after artificial subarachnoid haemorrhage (SAH) was studied in 90 rabbits. SAH was induced by injection of 1-2 ml autologous blood into the suboccipital cistern. Half of the rabbits were given AMCA, 200 mg per kg body weight, in daily single i.v. injections. The rabbits were sacrificed after 3-5, 8-10 and 14-15 days respectively. Part of the leptomeninges, basilar artery and choroid plexus were removed for assaying PA by the histochemical fibrin slide and fibrin plate methods, using thiocyanate for extraction of plasminogen activator from the tissues. Quantitative assays for the fibrin plate method showed high PA in the arterial and meningeal tissues from the untreated animals 3-5 days after SAH. The PA had decreased to normal levels 8-10 days after SAH but increased again 14-15 days after SAH. A lower PA in the choroid plexus followed the same pattern. The concentration of the primary plasmin inhibitor in plasma had decreased to half of the normal value 8 days after SAH when compared to the concentration in pooled plasma from normal rabbits. In AMCA treated animals the meningeal PA, assayed by both methods, was decreased 3-5 days after SAH while no or an insignificant decrease in PA was seen 8-10 and 14-15 days after SAH. The PA of the arterial vessel wall and choroid plexus in the AMCA treated animals, assayed by the histochemical method, was moderately decreased 3-5 days after SAH, while no significant differences between untreated and AMCA treated animals were seen after 8-10 or 14-15 days when the tissues were assayed by either method. These findings indicate that AMCA suppresses PA primarily in the leptomeninges during the first few days after SAH and presumably before the meningeal fibrosis has developed.