Angelika Sorteberg

Blood blister–like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome

OBJECT The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) trunk. METHODS The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up. RESULTS A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9-67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001). CONCLUSIONS Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.

Cognitive outcome after aneurysmal subarachnoid hemorrhage : Time course of recovery and relationship to clinical, radiological, and management parameters

OBJECTIVEAlthough many patients show a satisfactory physical outcome after aneurysmal subarachnoid hemorrhage (SAH), disabling cognitive dysfunction may still be present. This study focuses on the time course of cognitive recovery during the first year after aneurysmal SAH, and relates the neuropsychological test results to clinical, radiological, and management parameters. METHODSThirty-two patients were followed prospectively with neuropsychological examinations at 3, 6, and 12 months after SAH. Test results were compared with clinical entry variables, management variables, and pre- and postoperative radiological findings. RESULTSThe time course of cognitive recovery after aneurysmal SAH is heterogeneous, with motor and psychomotor functions recovering within the first 6 months, whereas verbal memory did not improve significantly until at least 6 months after the ictus. Clinical and radiological parameters reflecting the impact of the bleed were related to memory function, intelligence, and aphasia. The site of aneurysm and mode of treatment could not be linked to neuropsychological outcome. The time length of volume-controlled mechanical ventilation as a reflector of the aggregated consequences of being subjected to an aneurysm rupture correlated with both motor and psychomotor functioning and memory performance, predominantly 6 to 12 months after SAH, but was not linked to intelligence or aphasia. CONCLUSIONThe various cognitive functions have different time courses of recovery, with verbal memory requiring the longest time. Parameters reflecting the impact of the bleed and patient management can be linked to neuropsychological outcome.

ANGIOGRAPHIC BALLOON TEST OCCLUSION AND THERAPEUTIC SACRIFICE OF MAJOR ARTERIES TO THE BRAIN. Commentary

OBJECTIVETreatment of certain cerebral aneurysms, caroticocavernous fistulae, and tumors of the neck or cranial base may involve therapeutic arterial sacrifice, which requires preoperative knowledge of the feasibility of permanent occlusion of the internal carotid artery (ICA) or vertebral artery or arteries. METHODSRetrospective study of transcranial Doppler ultrasonography-monitored angiographic balloon test occlusion and therapeutic sacrifice of the ICA or vertebral artery. RESULTSWe performed transcranial Doppler-guided balloon test occlusion in 136 patients at a procedural risk equivalent to that of conventional neuroangiography, and with correct prediction of the hemodynamic result of therapeutic arterial sacrifice in all instances. Patients with an immediate drop in ipsilateral middle cerebral artery (MCA) velocity to 65% or more of baseline values upon ICA balloon occlusion tolerated ICA sacrifice well, whereas hemodynamic infarction is likely in those with a corresponding drop in MCA velocity to 54% or less. When ICA balloon occlusion caused a drop in MCA velocity to between 55 and 64% of baseline, the pulsatility of the MCA signal had to be analyzed. Patients who tolerated bilateral vertebral artery closure had reversal of flow and an increase in velocity in the P1 section of the posterior cerebral artery. In 212 patient-years of observation after therapeutic arterial sacrifice, no de novo aneurysms formed. CONCLUSIONAngiographic balloon test occlusion with transcranial Doppler monitoring can be performed ultra-swiftly at a risk equal to conventional neuroangiography and with correct prediction of the hemodynamic outcome of arterial sacrifice. Elective therapeutic arterial occlusion is a safe and efficient treatment of large cerebral aneurysms and caroticocavernous fistulae.

Cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

OBJECTIVEThe objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients). METHODSPatients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires. RESULTSThirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function. CONCLUSIONA high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.

Infections related to intrathecal baclofen therapy in children and adults: frequency and risk factors

OBJECT The purpose of this study was to determine the frequency of infection and to identify risk factors for infection in connection with the implantation of an intrathecal baclofen (ITB) pump. METHODS This retrospective study included all pediatric and adult patients who received ITB at Rikshospitalet during the years 1999-2005. A database was created that included the following variables: patient age, sex, weight, diagnosis, surgical procedure performed, presence of a percutaneous endoscopic gastrostomy (PEG) tube, urinary as well as fecal incontinence, anesthetists classification of patient status (American Society of Anesthesiologists grade), timing of antibiotics administration, surgeon, assisting nurse, and surgical procedure time. Moreover, the mode of intrathecal screening trial (transcutaneous vs subcutaneous catheter insertion) and any complications were registered. The authors differentiated between deep and superficial infection, and they registered the causative agent. RESULTS A total of 163 patients received ITB; of these, 91 were pediatric patients (median age 10 years), and 72 were adults (median age 44 years). A total of 408 surgical procedures were performed. No infections occurred in direct relation to the screening trials. When a pump was implanted subsequent to a screening trial with transcutaneous catheter insertion, the rate of infection was 9% in the pediatric patients. The corresponding infection rate for pumps implanted after a screening trial with a subcutaneous distal catheter (Albright method) was 12%. This difference was not significant. There was a significantly higher incidence of deep infections following pump implantation in the pediatric group (p = 0.028) than in the adult group. The presence of a PEG tube increased the incidence of infection (p = 0.008) and may be one of the main reasons for a higher frequency of infections in children. When the patient suffered urinary and/or fecal incontinence, there was a higher chance of infection (p = 0.021). The surgical time was significantly longer in the pediatric group than in adults; however, the length of the surgical procedure had no impact on the occurrence of infection. The most common causative agent was Staphylococcus aureus; this microbe was responsible for 69% of deep infections. Also, 69% of deep infections occurred within 1 month after surgery. CONCLUSIONS The rate of infection is significantly higher in children undergoing ITB pump implantation than it is in adults. Screening trials applying the Albright method fail to reduce the frequency of infection subsequent to pump implantation. The presence of a PEG tube has the greatest significance as a predictor of infection.

The ELANA technique: constructing a high flow bypass using a non-occlusive anastomosis on the ICA and a conventional anastomosis on the SCA in the treatment of a fusiform giant basilar trunk aneurysm.

SummaryA patient with a partially thrombosed fusiform giant basilar trunk aneurysm presented with devastating headache and symptoms of progressive brain stem compression. Having an aneurysm inaccessible for endovascular treatment, and after failing a vertebral artery balloon occlusion test, he was offered bypass surgery in order to exclude the aneurysm from the cerebral circulation and relieve his symptoms. A connection between the intracranial internal carotid artery and the superior cerebellar artery was created whereupon the basilar artery was ligated just distally to the aneurysm. The proximal anastomosis on the internal carotid artery was made using the excimer laser-assisted non-occlusive anastomosis (ELANA) technique, while a conventional end-to-side anastomosis was used for the distal anastomosis on the superior cerebellar artery. Intra-operative flowmetry showed a flow through the bypass of 40 ml/min after ligation of the basilar artery. An angiogram 24 hours later showed normal filling of the bypass and the vessels supplied by it, but also disclosed a subtotal occlusion of the proximal ipsilateral middle cerebral artery with delayed filling distally. The patient, who had a known thrombogenic coagulopathy, died the following day. Autopsy showed no signs of ischemia in the territories supplied by the bypass, but a thrombus in the proximal middle cerebral artery and massive acute hemorrhagic infarction with swelling in its territory and uncal herniation. Multiple fresh thrombi were found in the lungs. The ELANA anastomosis showed re-endothelialisation without thrombus formation on the inside.

A randomized and blinded single-center trial comparing the effect of intracranial pressure and intracranial pressure wave amplitude-guided intensive care management on early clinical state and 12-month outcome in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND In patients with aneurysmal subarachnoid hemorrhage (SAH), preliminary results indicate that the amplitude of the single intracranial pressure (ICP) wave is a better predictor of the early clinical state and 6-month outcome than the mean ICP. OBJECTIVE To perform a randomized and blinded single-center trial comparing the effect of mean ICP vs mean ICP wave amplitude (MWA)-guided intensive care management on early clinical state and outcome in patients with aneurysmal SAH. METHODS Patients were randomized to 2 different types of ICP management: maintenance of mean ICP less than 20 mm Hg and MWA less than 5 mm Hg. Early clinical state was assessed daily using the Glasgow Coma Scale. The primary efficacy variable was 12-month outcome in terms of the Rankin Stroke Score. RESULTS Ninety-seven patients were included in the study. There were no significant differences in treatment between the 2 groups apart from a larger volume of cerebrospinal fluid drained during week 1 in the MWA group. There was a tendency toward higher Glasgow Coma Scale scores in the MWA group during weeks 1 (P = .08) and 2 (P = .07). Outcome in terms of Rankin Stroke Score at 12 months was significantly better in the MWA group (P < .05). CONCLUSION This randomized and blinded trial disclosed a significant better primary efficacy variable (Rankin Stroke Score after 12 months) in the MWA patient group. We suggest that proactive intensive care management with MWA-tailored cerebrospinal fluid drainage during the first week improves aneurysmal SAH outcome. ABBREVIATIONS CCP: cerebral perfusion pressure EVD: external ventricular drain ICP: intracranial pressure MWA: mean intracranial pressure wave amplitude SAH: subarachnoid hemorrhage

Surgical repair of unruptured and ruptured middle cerebral artery aneurysms: impact on cognitive functioning and health-related quality of life.

OBJECTIVETo assess the impact of surgical treatment of unruptured and ruptured middle cerebral artery (MCA) aneurysms on cognitive functioning and health-related quality of life (HRQOL). METHODSThis was a prospective study enrolling 15 patients with unruptured MCA aneurysms and 22 patients with ruptured MCA aneurysms in good clinical condition postictally. Patients with unruptured aneurysms underwent preoperative neuropsychological testing and answered 2 HRQOL questionnaires. All patients were investigated 3 and 12 months postoperatively with a comprehensive neuropsychological test battery, clinical investigation, and interview. The modified Rankin Scale score, Glasgow Outcome Scale score, employment status, and 2 HRQOL questionnaires were also used for assessment. RESULTSPreoperative cognitive deficits were aggravated 3 months after surgery for the unruptured MCA aneurysm group, but after 12 months these patients performed at their preoperative level. Subjects who underwent clipping for ruptured MCA aneurysms had reduced verbal memory; otherwise, they had close to normal cognitive function 12 months postoperatively. There was no difference between the 2 groups in Rankin Scale score or Glasgow Outcome Scale score. High preoperative levels of anxiety and depression markedly decreased after repair of an unruptured aneurysm; however, in both groups, HRQOL was reduced on the same measures even 12 months after surgery. Patients treated for unruptured MCA aneurysms regained their preoperative employment status, whereas only 60% of those who had bled from their aneurysm had returned to full-time work after 12 months. CONCLUSIONSurgical treatment of unruptured MCA aneurysms does not cause new cognitive deficits, but it reduces some aspects of HRQOL in a similar manner as in patients who undergo clipping for ruptured MCA aneurysms.

Cerebral haemodynamics in internal carotid artery trial occlusion.

SummaryThe purpose of this study was to analyse the cerebral haemodynamic changes brought about by trial occlusion of the internal carotid artery (ICA). Sixteen patients with surgically inaccessible cerebral aneurysms, carotid cavernous fistulas or neck neoplasms were monitored with transcranial Doppler ultrasonography (TCD) during 90–120 s angiographie ICA balloon occlusion or ICA closure with a Selverstone clamp. The blood velocity (V) was registered continuously in both middle cerebral arteries (MCA) while the pulsatility index (PIMCA) and haemodynamic tension (Uhemmca) were calculated.ICA closure led to an instantaneous drop in the ipsilateral Vmca, PImca and Uhemmca. The Vmca thereafter increased gradually until reaching a stable level. The subjects were grouped into those with initial drops in Vmca to ≥ 60% of pre-occlusion value (group 1) and those that fell to < 60% (group 2), respectively. In group 1 autoregulatory mechanisms made the PImca decline further, while the Uhemmca remained unaltered during ICA closure. In group 2, however, the PImca did not change further, while the Uhemmca increased slightly. The cerebral haemodynamic features during ICA test occlusion were thus essentially different in the two groups. On re-opening the ICA, there was an overshoot in Vmca and Uhemmca. Contralaterally, the Vmca was increased during ICA occlusion.Seven of the patients later had their ICA closed permanently. While none of five group 1 patients developed haemodynamic complications, two group 2 individuals experienced haemodynamic stroke. Assuming ICA sacrifice is feasable when test occlusion results in an ipsilateral initial reduction in Vmca to ≥ 60% of preocclusion value, the corresponding limit for the Uhemmca is ≥ 40%. In the pre-operative evaluation of the haemodynamic risk related to ICA loss, TCD emerges as a reliable method. It also seems to allow for the reduction of test occlusion time to 90–120 s.

Cognitive functioning and health related quality of life after rupture of an aneurysm on the anterior communicating artery versus middle cerebral artery.

The neuropsychological outcome and Health Related Quality of Life (HRQOL) after SAH have been largely believed to be unrelated to the location of the ruptured aneurysm. This notion needs verification due to the contemporary availability of more sensitive neuropsychological test batteries and more recent clinical observations of deviant behaviour after SAH. To this end, we compared patients with ruptured aneurysms on respectively the anterior communicating artery (ACoA) (n = 24) or middle cerebral artery (MCA) (n = 22). All patients underwent an extensive neuropsychological examination, clinical interview and answered questionnaires 12 months after SAH. We found mild to moderate discrepancies from population norm in test scores on a number of areas of cognitive functioning in both patient groups, with a consistent, but statistically non-significant trend towards better functioning in MCA patients despite of the fact that patients with ruptured MCA aneurysms were initially in a poorer clinical condition and more often had intracranial haematomas. We observed slight reductions in executive functions, on the first conditions on the Delis-Kaplan Executive Functioning System (D-KEFS) tests, and some measures of memory functions in the ACoA patients. ACoA patients seemed to have problems with initiation of problem solving behaviour. None of the patient groups scored for apathy and depression. Some measures of HRQOL were equally reduced as compared to the population norm in both groups. ACoA patients remained longer on sick-leave compared to MCA patients.