Fate of Patients with Chronic Cerebrovascular Steno-occlusive Disease According to Change of Cerebral Perfusion, Cerebrovascular Reserved, and Incidence of Recurrent Ischemic Stroke.

OBJECTIVE: The objective is to demonstrate change of cerebral perfusion and cerebrovascular reserve (CVR) in treating patients with cerebrovascular steno-occlusive disease stratified by change of cerebral perfusion and CVR. METHODS: Retrospective review patients with radiographic proven major cerebrovascular steno-occlusive disease whom underwent cerebral perfusion imaging with vasoactive stimuli stress test in Siriraj Hospital and Bangkok General Hospital during 2010-2018. Medical records were also reviewed. Radiographic findings, cerebral perfusion parameters and signal change during the stress test were reviewed and used to categorize into three groups. RESULTS: There were 40 patients sent to radiology department for the evaluation of CVR. One patient had airway problem during the procedure and was excluded. Remaining 39 patients were included in this study (32 males and 7 females, mean age of 54.55 years). In 42 sites involved, 28 (66%) were internal carotid artery, 14 (33%) were middle cerebral arteries. Laterality is left side in 20 cases, right side in 14 cases, and bilateral in 5 cases. Poor CVR response (increased cerebral blood flow <10%) was found in 9 patients (2 severe stenoses and 7 total occlusions). The mean follow-up time was 28.9 months. Eight cases (20.5%) underwent surgical treatment; surgical bypasses and endovascular interventions. Only one patient had subsequential ischemic symptom at immediate postoperative vascular bypass surgery. The remaining patients had no report of progressive or recurrent neurological deficit symptom. CONCLUSION: Poor CVR response is more often found in higher degree of steno-occlusion. Even inconclusive predicting incidence of recurrent ischemic stroke, CVR that reflects the capacity of neuro-autoregulation.

Degree of midline shift from CT scan predicted outcome in patients with head injuries.

OBJECTIVE: To evaluate the relationship between the degree of midline shift by Computed Tomography (CT) finding and Glasglow Coma Score (GCS) as a predictive of clinical outcome in patients after head injury. METHOD AND METHOD: The present study was performed by retrospectively reviewing 216 consecutive cases of traumatic head injury admitted to the trauma center in Siriraj Hospital from 1999 until 2004. All patients were evaluated for level of consciousness by a neurosurgeon determining by GCS and underwent CT brain for evaluation of intracranial hemorrhage and midline shift. The final clinical outcome was also divided into two groups; good outcome for the patients who recovered well with moderate disability and the poor outcome for the patients who suffered severe disability, vegetative status and death. Then, the authors compared midline shift vs. GCS and midline shift vs. clinical outcomes. RESULTS: Total of 216 cases, the three most common types of head injury were motorcycle accident, fall or assault and car accident. 96 of 216 patients had midline shifting, 53 of 96 patients had CT scan of midline shifting less than 10 mm whereas 37 of 96 patients had a CT scan of greater than 10 mm of midline shifting. 63.3% with midline shifting up to 10 mm had severe head injury and up to 81% with brain shifting greater than 10 mm had severe head injury. The clinical outcome also showed that poor clinical outcomes correlated to midline shifting greater than 10 mm. CONCLUSION: The increased degree of midline shift in patients with head injuries by CT scan was related to the severity of head injury (GCS = 3-12) and was significantly related to poor final clinical outcome.