Eishi Sato

Transcranial Doppler monitoring in severe brain damage: relationships between intracranial haemodynamics, brain dysfunction and outcome.

Transcranial Doppler (TCD) monitoring in the middle cerebral (MCA) and common carotid arteries (CCA) was studied in 105 comatose patients with severe brain damage. TCD-measured velocity waveforms in the MCA were evaluated in relation to loss of cerebral function as assessed by EEG and compressed spectral arrays, loss of brain stem function as measured by somatosensory and auditory evoked potentials, loss of all brain function and the clinical outcome. The velocity waveforms exhibited six patterns: continuous forward flow (FF); diastolic no flow (NF); diastolic reverse flow with (RF) or without (DRF) diastolic FF; brief systolic FF (SFF); and undetectable (U). In the 58 fatal cases, the appearance of RF/DRF or SFF in the MCA more often preceded loss of brain stem function than loss of cerebral function. A U pattern in the MCA, which was confirmed by loss of FF in the CCA, was correlated with loss of brain stem function. Only one of the 47 survivors showed DRF in the MCA. No patients in whom SFF or U was observed in the MCA survived. Therefore the presence of these patterns is reliably predictive of brain death. Intracranial diastolic reverse flow (DRF), however, indicates imminent loss of brain function and the need for prompt resuscitative measures.

A therapy against vasospasm after subarachnoidal haemorrhage: clinical experience of balloon angioplasty

Vasospasm is a phenomenon often present in human cases after subarachnoidal haemorrhage. Its aetiology and pathophysiology are unknown. As a result, cases of vasospasm do not respond to any known pharmacological therapy. We present in this paper, a practical application of intravascular surgery for vasospasm. In this procedure the requirement for a portable digital subtraction unit, transcranial Doppler sonography, and being able to determine quickly the neurological state of the patient are very important points. The use of monitoring equipment is especially indispensable during the carrying out of percutaneous transluminal angioplasty (PTA), which should be performed as soon as possible after the occurrence of vasospasm. The case of a 54-year-old male patient suffering from a ruptured anterior cerebral artery aneurysm was studied. Neck clipping was performed on the second day. On the fifth day the neurological state was stupor, and transcranial Doppler sonography (TCD) revealed a flow velocity of over 100 cm s-1. PTA was performed on the sixth day. The bilateral middle cerebral artery was dilated and the flow velocity slowed to within the normal range. The neurological state improved to clouding of consciousness after PTA. On the eighteenth day, the patients consciousness and bilateral carotid angiograms revealed the vessels to be dilated still. It was concluded that PTA therapy, and the use of a portable digital subtraction unit and TCD sonography, for vasospasm caused by subarachnoidal haemorrhage is useful and effective.

A combined surgical and endovascular treatment for a case with five vertebro-basilar aneurysms and bilateral internal carotid artery occlusions

BACKGROUND Whereas multiple aneurysms may be found in 20% of patients in whom one aneurysm is discovered, the identification of five vertebrobasilar aneurysms is distinctly rare. We described such a case treated by surgical and endovascular method. CASE DESCRIPTION A case of multiple aneurysms treated with combined surgical clipping and intravascular surgery is described. Five separate posterior circulation aneurysms and bilateral internal carotid artery occlusion were identified in one patient. Three of the aneurysms were treated surgically. Access to the fourth aneurysm was deemed difficult because of its location and because of the previously placed surgical clips; this aneurysm was treated by endovascular approaches that provided optimum therapy in this unusual multiple aneurysms case. CONCLUSIONS We have described an unusual case of multiple posterior circulation aneurysms in the setting of bilateral internal carotid occlusions, treated by a combination of surgical and endovascular therapies. We will be able to provide safer treatment for such difficult cases in the future.

Outcomes of chronic subdural hematoma with preexisting comorbidities causing disturbed consciousness

OBJECTIVE Chronic subdural hematoma (CSDH) is widely treated by drainage through a bur hole opening. However, whether and how preexisting comorbidities causing disturbance of consciousness affect patient outcomes remains unclear. METHODS The authors analyzed 188 consecutive patients with CSDH who were surgically treated at the Neurosurgery Institute of the Kyorin University School of Medicine between 2010 and 2012 and followed them for more than 90 days. The mean patient age was 77.0 years (range 33-101 years) and 56 were women. Patient outcomes including modified Rankin Scale (mRS) score, postoperative morbidity and mortality, and recurrence 90 days after initial surgery were analyzed according to preexisting comorbidities causing disturbance of consciousness. The comorbidities observed in 46 patients (24%) included dementia (30 patients), history of ischemic stroke (10 patients), psychiatric disorders (3 patients), and others (3 patients). RESULTS Background characteristics of patients with comorbidities showed older patient age (p < 0.001), lower preoperative Glasgow Coma Scale score (p < 0.001), and higher preoperative mRS score (p < 0.001). The mean mRS score 90 days after the neurosurgical procedure was 1.2 in all 188 patients, which was significantly higher in those with comorbidities (p < 0.001). By 1-way ANOVA with repeated measures, interaction existed between the presence of comorbidities and mRS score, and improvement of mRS score was observed in smaller proportions of patients with comorbidities (p = 0.002). By multivariate logistic regression analysis, the presence of comorbidities, patient age, reoperation for recurrence, and preoperative mRS score were significantly related to poor outcomes, defined as mRS score of 3 or more at 90 days after surgery. Postoperative morbidity (p < 0.01) and mortality (p < 0.01) were significantly higher in those with comorbidities, whereas the rate of recurrence of CSDH was not significantly different. CONCLUSIONS The preexistence of comorbidities causing disturbance of consciousness affected severity and outcomes 90 days after surgical treatment of CSDH, and comorbidities were also correlated with aging.

Risk of clot formation with ionic and nonionic contrast media in cerebral angiography

RATIONALE AND OBJECTIVES The introduction of low-osmolality contrast media has improved patient tolerance to angiographic procedures. However, nonionic contrast media may be associated with an increase in the risk of clot formation. The objective of this study was to test whether there is more clotting with nonionic agents than with ionic agents. METHODS Ninety-eight patients undergoing transfemoral cerebral angiography were randomly assigned to receive ionic (ioxaglate) (n = 62) or nonionic (iopamidol or iohexol) (n = 36) contrast material. Incidence of clot formation was examined by observation of catheters. RESULTS Clot formation was found in 4.8% of patients in the ionic contrast material group and 22.2% of patients in the nonionic contrast material group (P < .05). CONCLUSION Nonionic contrast media resulted in a statistically significantly higher incidence of clot formation than ionic media during cerebral catheter angiography. These results suggest that ionic contrast media are preferable in patients with risk of thrombosis.

Continuous Monitoring of Transcranial Doppler, Jugular Venous Oxygen Saturation, and Quantitative EEG in Severe Head Injury

To prevent neuronal brain damage caused by circulatory and metabolic disturbances following severe head injury, we have introduced a continuous monitoring system of transcranial Doppler (TCD), jugular bulb venous oxygen saturation (Sj02), and quantitative EEG (qEEG). The clinical significance was evaluated in terms of autoregulation (decreased cerebral perfusion pressure, CPP), C02 reactivity (hyperventilation), vasospasm and delayed focal ischemic lesions (CT), hyperemia and diffuse brain swelling (CT), and patients’ outcome at one month after injury. The TCD, qEEG, and Sj02 (8 cases) of 46 comatose patients (ages 7–75, mean 46; 38 with focal and 8 with diffuse injuries) were monitored in acute phase for 2–14 days (mean, 6).

Does Reducing the Duration from Symptom Onset to Recanalization Improve the Results of Intracranial Mechanical Thrombectomy in the Elderly

Endovascular recanalization for acute major cerebral artery occlusion is effective within a short time after symptom onset. However, its efficacy in the elderly remains unknown. We assessed the efficacy of our comprehensive stroke center’s reduction of this time in 28 consecutive patients for elderly patients (defined as patients aged ≥75 years) with acute major cerebral artery occlusion treated with intravenous injection of tissue plasminogen activator, followed by thrombus retrieval by endovascular therapy. The patients were divided into groups according to whether they were treated before implementation of the time reduction measure (from January 2012 to May 2014) or after (from June 2014 to May 2015). The onset-to-door, onset-to-needle, onset-to-recanalization (O2R), door-to-image (D2I), door-to-needle (D2N), door-to-puncture (D2P), door-to-recanalization (D2R), and puncture-to-recanalization time intervals were compared between the two groups. There were 14 patients (including 8 elderly patients ≥80 years) before and 14 patients (including 10 elderly patients ≥80 years) after the time reduction measure. The mean duration of each of the following time intervals was significantly reduced after the time reduction measure (P < 0.05). To reduce the O2R time, the D2P time is the first time interval that can be reduced. At our center, conferences were regularly held to raise awareness among staff and make specific changes in the workflow, and overall time reduction was achieved. Similar results were obtained in elderly patients.

Multimodal Evaluation of Cerebral Oxygen Metabolism Disturbances in Patients with Severe Head Injury: Special Reference to Cerebrovascular CO2 Reactivity

In the management of severe head injury patients, hyperventilation (HV) routinely has been used for reduction of intracranial pressure (ICP) or improvement of cerebral acidosis that might otherwise increase the risk of ischemic brain damage [1, 2]. Cerebrovascular CO2 reactivity induced by HV, which has a direct relationship with reduction of cerebral blood flow (CBF) and ICP [3], also has been suggested to have a close relationship with the prognosis of patients with severe head injuries [4, 5]. This study was aimed at evaluating disturbances in cerebral oxygen metabolism and cerebral hemodynamics, and related factors, on the basis of CO2 reactivity induced by HV in comatose patients with severe head injuries. To this end, we have introduced and analyzed a computerized multimodal system for continuously monitoring jugular bulb venous oxygen saturation (SjO2), arterial oxygen saturation measured by pulse oximeter (SpO2), transcranial Doppier (TCD), end-tidal CO2 partial pressure (PetCO2), ICP, cerebral perfusion pressure (CPP), and Fourier-transformed quantitative electroencephalogram (qEEG) [6].