Alain Reverdin

Therapeutic decision and management of aneurysmal subarachnoid haemorrhage based on computed tomographic angiography.

The purpose of this study was to evaluate the potential of high quality computed tomographic angiography (CTA) to replace digital subtraction angiography (DSA) in cases of ruptured saccular aneurysms and perform early surgical clipping or coiling on the basis of CTA alone. In a prospective study, 100 patients with aneurysmal subarachnoid haemorrhage (SAH) diagnosed by computed tomography underwent CTA. CTA revealed a total of 118 aneurysms including all ruptured aneurysms. A decision of direct surgical clipping, endovascular coiling or therapeutic abstention was made in 89 cases (89%) on the basis of CTA alone. Sixty-one direct surgical procedures were performed after CTA. Twenty-six cases underwent DSA for immediate endovascular treatment of the ruptured aneurysm. In 11 cases (11%), a DSA was performed prior to the therapeutic decision because of unclear aneurysm. Four cases were not treated because of initial poor clinical grade. The surgical findings were compared with CTA data and were considered accurate in all but one case. All patients underwent postoperative DSA within 10 days after SAH. The sensitivity and the specificity of CTA for the detection of all aneurysms, as compared with postoperative DSA, were 95.1 and 100%, respectively. A total of six unruptured aneurysms were missed initially, but were visible retrospectively on CTA in all but one case and were found in patients with multiple aneurysms in whom the ruptured aneurysm was detected by CTA. Current quality CTA allows reliable pretreatment planning for the majority of cases of aneurysmal subarachnoid haemorrhage and diminishes the pretreatment evaluation time critically. Complementary pretreatment DSA is required in situations where CTA characteristics of the ruptured aneurysm is unsatisfactory.

Does Treatment Modality of Intracranial Ruptured Aneurysms Influence the Incidence of Cerebral Vasospasm and Clinical Outcome

Background: Cerebral vasospasm is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). This study is designed to determine whether the incidence of symptomatic vasospasm and the overall clinical outcome differ between patients treated with surgical clipping compared with endovascular obliteration of aneurysms. Methods: In this prospective study, 98 patients with aneurysmal SAH were treated. Seventy-two patients underwent surgery and clipping and 26 had coil embolization. The incidence of symptomatic vasospasm, permanent neurologic deficit due to vasospasm and clinical outcome were analyzed. Patients with better clinical and radiological grades (World Federation of Neurological Surgeons grades I–III and Fisher grades I–III) were analyzed separately. Results: Symptomatic vasospasm occurred in 22% of the patients; 25% in the surgical group and 15% in the endovascular group. Nine percent of the patients in the surgical group and 7% in the endovascular group suffered ischemic infarction with permanent neurological deficit. These differences did not reach statistical significance (p = 0.42). For patients with better clinical and radiological grades, no significant difference was found for the rate of symptomatic vasospasm; 23% in the surgical and 12% in the endovascular group (p = 0.49). The overall clinical outcome was comparable in both groups, with no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less (15% in the surgical and 16% in the endovascular group; p = 0.87). The same results for outcome were obtained for the subgroup of patients with better clinical grades on admission. Conclusion: Symptomatic vasospasm and ischemic infarction rate seem comparable in both groups, even for patients with better clinical and radiological admission grades. There is no significant difference in the overall clinical outcome at the long-term follow-up between both groups.

Early surgery for brainstem cavernomas

SummaryBackground. The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome.Method. We retrospectively reviewed 22 patients harboring a BSC, who underwent 23 procedures.Findings. Surgery was carried out during the early stage after the last haemorrhage, with a mean delay of 21.6 days (range 4–90 days). Sixteen procedures were performed after a first bleeding event while seven after multiple bleedings. Complete resection was achieved in 19 patients (86.4%). Early after surgery, 12 patients (52.2%) improved neurologically, 5 (21.7%) were stable and 6 (26.1%) worsened. New postoperative deficits were noted after 9 procedures (39.1%). Statistically significant factors for postoperative aggravation were: late surgery (P = 0.046) and multiple bleedings (P = 0.043). No patient operated on within the first 19 days after bleeding did worsen (n = 11), as opposed to 6 out of 12 who did when operated on later. After a mean follow-up of 44.9 months, 20 patients (90.9%) were improved, 1 patient (4.6%) was worse and 1 patient was lost to follow-up (4.6%), after reoperation for rebleeding of a previously completely resected cavernoma. Late morbidity was reduced to 8.6%. The mean Glasgow Outcome Scale (GOS) at the end of the follow-up period was 4.24, compared to a mean preoperative GOS of 3.22 (P<0.001). Complete neurological recovery of motor deficits, sensory disturbances, cranial nerves (CNs), internuclear ophtalmoplegia and cerebellar dysfunction were respectively 41.7%, 38.5%, 52.6%, 60.0% and 58.3%. Among the most affected CNs: CN 3, CN 5 and CN 7 were more prone to completely recover, respectively in 60.0%, 70.0% and 69.2%.Conclusions. Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome. Early surgery and single bleeding were associated with better surgical results.

Cervical Sympathetic Block to Reverse Delayed Ischemic Neurological Deficits After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose— The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Methods— Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure. Results— No complications occurred in this short series. The procedure appeared to be simple and safe. Horner’s signs appeared within 12±0.1 minutes and lasted for an average of 6.3±4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment. Conclusions— Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.

Cardiovascular and endocrine effects of clonidine premedication in neurosurgical patients

The present study was conducted to examine the haemodynamic and endocrine effects of clonidine, given as sole preanaesthetic medication, in neurosurgical patients. Nineteen patients of ASA physical status I and II, subjected to craniotomy, randomly received po premedication of either clonidine (300 μg, n=9) or placebo (n=10). Blood pressure and heart rate were monitored continuously, while arterial blood samples were collected at specific times, from induction of anaesthesia to recovery, for the measurement of plasma concentrations of epinephrine, norepinephrine, cortisol, aldosterone, and glucose. Clonidine treatment led to a decrease in mean arterial blood pressure (MABP), heart rate (HR), and plasma cortisol and aldosterone concentrations throughout the study, compared with placebo (P<0.05). Clonidine, however, did not prevent increases in MABP (16±5 mmHg, mean ±SE, P<0.05) and HR (18±4 bpm, P<0.05) during induction of anaesthesia, which was comparable to the placebo group. Plasma catecholamine concentrations did not differ between the two groups. Plasma glucose concentrations increased in both groups at the end of the study (P<0.05), but were lower in clonidine-treated patients (P<0.05). Though statistically significant, the observed inhibitory haemodynamic and endocrine effects of clonidine seem to be of minor clinical importance. As the action of clonidine on cerebral blood flow regulation is not well known, we see no advantage in the preanaesthetic administration of clonidine to neurosurgical patients with normal cardiovascular status.RésuméCette étude fut conduite afin d’examiner les affets hémodynamiques et endocriniens de la clonidine administrée comme seule prémédication chez les patients neurochirurgicaux. Dixneuf patients ASA classe I et II, devant subir une craniotomie, furent randomisés afin de recevoir une prémédication orale soit de clonidine (300 μg, n=9)_ou un placebo (n=10). La pression artérielle et la fréquence cardiaque furent surveillées continuellement alors que des échantillons sanguins furent prélevés à des temps précis à partir de l’induction de l’anesthésie jusqu’au réveil pour la mesure des concentrations plasmatiques d’épinéphrine, norépinéphrine, cortisol, aldostérone et glucose. Le traitement à la clonidine a amené une diminution dans la pression artérielle moyenne (PAM), la fréquence cardiaque (FR), et les concentrations plasmatiques de cortisol et d’aldostérone à travers l’étude comparativement au placebo (P<0.05). La clonidine, cependant, n’a pas empêché l’augmentation de la PAM (16±5 mmHg, moyenne ±SE, P<0.05) et FR (18±4 bpm, P<0.05) lors de l’induction de l’anesthésie fut comparable au groupe placebo. Les concentrations plasmatiques de catécholamines n’étaient pas différentes entre les deux groupes. Les concentrations plasmatiques de glucose ont augmenté dans les deux groupes à la fin de l’étude (P<0.05) mais étaient moindres chez les patients traités à la clonidine (P<0.05). Même si statistiquement significatifs, les effets hémodynamiques et endocriniens de la clonidine semblent avoir une importance clinique mineure. Etant donné que l’action de la clonidine sur la régulation du flux sanguin cérébral n’est pas connue, on ne voit aucun avantage dans l’administration pré-anesthésique de la clonidine chez les patients neurochirurgicaux avec un état cardiovasculaire normal.

Cefuroxime Prophylaxis Is Effective in Noninstrumented Spine Surgery : A Double-Blind, Placebo-Controlled Study

Study Design. Double-blind, placebo-controlled randomized clinical trial. Objective. To assess the efficacy of 1 preoperative 1.5 g dose of cefuroxime in preventing surgical site infection after surgery for herniated disc. Summary of Background Data. Antibiotic prophylaxis was only tested in nonconclusive trials in this setting. Methods. The study was conducted in 2 university hospitals in Switzerland. Patients were assessed for occurrence of surgical site infection (defined by the criteria of the Centers for Diseases Control and Prevention), other infections, or adverse events up to 6 months after surgery. Outcome measures were compared in a univariate, per-protocol analysis. Results. Baseline characteristics were similar in patients allocated to cefuroxime (n = 613) or placebo (n = 624). Eight (1.3%) patients in the cefuroxime group and 18 patients (2.8%) in the placebo group developed a surgical site infection (P = 0.073). A diagnosis of spondylodiscitis or epidural abscess was made in 9 patients in the placebo group, but none in the cefuroxime group (P < 0.01), which corresponded to a number necessary to treat of 69 patients to prevent one of these infections. There were no significant adverse events attributed to either cefuroxime or placebo. Conclusion. A single, preoperative dose of cefuroxime significantly reduces the risk of organ-space infection, most notably spondylodiscitis, after surgery for herniated disc.

Jugular venous desaturation due to epidural hematoma after craniotomy

T he indication for jugular venous bulb catheterization to monitor cerebral oxygen extraction is well established for patients with severe head injuries (l-3). The use of jugular venous catheters is safe, with a low incidence of complications such as venous thrombosis or increased intracranial pressure (4,5). For elective craniotomy the indication is less well established, although its usefulness, and the significance of changes, is now being documented (6). We report a case where jugular venous bulb oxygen saturation (Svjo,) decreased in conjunction with development of a significant acute epidural hemorrhage in the immediate postoperative period.