Assessment of the haemostatic system in patients surgically treated for ruptured cerebral aneurysm.

BACKGROUND AND PURPOSE: The aim of the study was to evaluate selected markers of thrombin generation and subsequent fibrinolysis in patients with aneurysmal subarachnoid haemorrhage (SAH) and to assess the relationship between thrombin generation/fibrinolysis and clinical course and outcome. MATERIAL AND METHODS: This prospective study included 72 patients after aneurysmal SAH who underwent surgery within 72 hours after onset of symptoms. The results were compared with 84 control patients without SAH. Selected markers of thrombin generation (thrombin-antithrombin complexes, TAT), fibrinolysis (D-dimer) and fibrinogen level were examined in blood just after admission and on day 7 after surgery. The relationship between levels of those markers and selected clinical and radiological data, and outcome at 3-6 months after surgery, were assessed. RESULTS: On admission, patients with SAH had higher levels of TAT (p<0.001), D-dimer (p=0.048), and fibrinogen than the control group (p<0.001). Also, patients with severe bleeding demonstrated higher TAT (p<0.001) and D-dimer (p=0.04) levels. The admission level of TAT (higher than 24 g/l; odds ratio = 10.8) and the elevated blood fibrinogen level (odds ratio = 1.2) showed a strong correlation with mortality. Furthermore, a level of TAT higher than 24 g/l (odds ratio = 9.98) and the level of fibrinogen (odds ratio = 1.3) strongly correlated with poor outcome. There was no significant correlation between markers of coagulation on the 7th day after surgery for SAH and the outcome. CONCLUSIONS: Activation of blood coagulation as well as the fibrinolytic system occurred early in the course of SAH. Such activation was associated with poor clinical status of patients on admission, greater amount of subarachnoid blood, and poor clinical outcome. Thus, blood levels of TAT and fibrinogen are independent factors associated with mortality and morbidity after aneurysmal SAH.

[Diagnosis and operative treatment cavernous angiomas of the central nervous system]. / Diagnostyka i leczenie operacyjne naczyniaków jamistych osrodkowego ukladu nerwowego.

UNLABELLED: Among all detected cerebral angiomas the frequency of cavernous angiomas (CAs) is 5-13%. The aim of this study is to present the diagnostic methods of CA of the central nervous system (CNS), indications for surgery and assessment of its outcome. Between 1993-2000, eleven cases of CAs were operated on at the Department of Neurosurgery, Medical College, Jagiellonian University in Krakow. In 6--seizures were observed, in 4--headache (supratentorial CAs), increasing neurological deficits in 4 (location in vertebral channel and cerebellum), hemorrhage--1 case (CA in pons combined with supratentorial lesion). Surgery was carried out by means of craniotomy, and via laminectomy in the cases of spinal channel tumours. Early and late outcome were assessed in following cathegories: very good, good, fair, bad (significant deterioration). The shortest late observation was 5 years. Direct very good surgical outcome was attained in 4 cases (36%), good in 4. (36%), fair in 2. (18%), bad in 1 case. In late observation, 7 patients were very good (64%), and 3 good (27%). In one case the neurological improvement was poor, later observed--late outcome was fair. In 6 cases they suffered from frequent epileptic seizures before surgery; they were seizure free in the late assessment. CONCLUSIONS: (1) direct surgical outcome in CA of the CNS is good and very good in the majority of cases; (2) in late observation, further neurological improvement allows to attain over 90% good and very good outcomes; (3) the high antiepileptic effectiveness after surgery of CA is observed.

[Surgery of the ruptured distal anterior cerebral artery aneurysms]. / Leczenie operacyjne chorych z peknietymi tetniakami dalszego odcinka tetnicy mózgu przedniej.

INTRODUCTION: Distal anterior cerebral artery aneurysms (DACAA) are the particular group of the aneurysms of anterior circle of Willis. The characteristic factors are: different location on the distal anterior cerebral artery, specific surgical approach and rare occurrence. AIM: Retrospective analysis of the outcome and attempt to find risk factors in DACAA surgical treatment were goals of this report. MATERIAL AND METHOD: The authors report a series of 49 cases with DACAA who were operated on in the Department of Neurosurgery, Jagiellonian University in Kraków, in the period of 16 years. There were 29 women (59.2%) and 20 men (40.8%) with a mean age of 49 years. Multiple aneurysm were in 12 cases (24.5%), in which ruptured DACAA were always the cause of the haemorrhage. We investigated age, sex, Hunt and Hess grade, arterial hypertension, timing of operation, coexistence of intracerebral haematoma (ICH), intraventricular haemorrhage (IVH), cerebral ischaemia, hydrocephalus, multiple aneurysms, intraoperative aneurysmal rupture, use of temporary parent vessel clipping, significant brain oedema during surgery, anatomical variability of anterior cerebral artery as a potential risk factors. RESULTS: There were 29 patients (59.2%) in good and very good clinical state and 11 (22.4%) in poor clinical state on discharge. Nine (18.4%) patients died. Statistically significant factors such as age (p<0.035), arterial hypertension (p<0.0035), Hunt and Hess grade (p<0.0073), IVH (p<0.0054), cerebral ischaemia (p<0.036) affected the direct outcome of patients. CONCLUSIONS: There are typical risk factors in surgically treated DACAA: age, arterial hypertension, clinical status, intraventricular haemorrhage, cerebral ischemia. Most of treated cases remain in good and very good condition. Haemorrhagic and ischaemic complications were most frequent causes of operating losses in DACAA patients.

[Cerebral vasospasm after subarachnoid hemorrhage. Current possibilities of prevention and treatment]. / Skurcz naczyn mózgowych po krwotoku podpajeczynówkowym. Obecne mozliwosci zapobiegania i leczenia.

Cerebral vasospasm is a complication diagnosed in angiography among about 2/3 of patients after subarachnoid haemorrhage with ruptured cerebral aneurysm. In half of the cases it appears in disturbances of consciousness, neurological deficits and vegetative disturbances. It's final result can be ischemic stroke. Among patients with symptomatic cerebral vasospasm around 1/3 fully recover in 1/3 of cases persistent neurological deficit remains and 1/3 of the patients die. Authors basing on literature and taking into consideration their own experience, reviewed and estimated current methods of prevention and treatment of cerebral vasospasm. Discussed mainly were methods which had been used in every day clinical practice, however some of them still remain controversial. The accepted model of treatment suggests as follows: 1. The exclusion of the aneurysm which was the cause of haemorrhage from the circulation and clot removal from the subarachnoid space; 2. Nimodipine administration; 3. Undertaking hemodynamic treatment; 4. Aminosteroid administration; 5. Performance of angioplasty in the case of lack of reaction to previous types of treatment of cerebral vasospasm.