Hiroshi Yatsushige

Surgical Outcome following Decompressive Craniectomy for Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Patients with Associated Massive Intracerebral or Sylvian Hematomas

Background: Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH. Methods: 110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records. Results: Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died. Conclusion: Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients.

Clinical and radiological findings and surgical management of ruptured aneurysms at the non-branching sites of the internal carotid artery

Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical strategies will be required for a further improvement of the clinical outcome.

Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy.

OBJECTIVE This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Hemorrhagic encephalitis associated with Epstein-Barr virus infection

Epstein-Barr virus (EBV) encephalitis is a rare neurological complication, usually only reported in pediatric patients. We present a 20-year-old, previously healthy male who developed hemorrhagic encephalitis caused by EBV. He was admitted to our hospital with a 1-week history of fever, diarrhea, headache, and confusion. Brain T2-weighted MRI showed a focal area of increased signal in the right temporal lobe. Brain MRI and CT scans on day 2 revealed progression of the lesion, with partial hemorrhagic change, acute brain swelling, and severe midline shift. The patient underwent external decompression and external ventricular drainage. EBV DNA was identified in brain biopsy specimens by polymerase chain reaction. The postoperative course was uneventful. To our knowledge, this is the second report of hemorrhagic EBV encephalitis in an adult.

Prognosis for Severe Traumatic Brain Injury Patients Treated with Bilateral Decompressive Craniectomy

PURPOSE Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy. METHODS Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale. RESULTS Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis. CONCLUSION Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.

Decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage.

Hemispheric hypertensive intracerebral hemorrhage (ICH) has a high mortality rate. Decompressive craniectomy (DC) has generally been used for the treatment of severe traumatic brain injury, aneurysmal subarachnoid hemorrhage, and hemispheric cerebral infarction. However, the effect of DC on hemispheric hypertensive ICH is not well understood. To investigate the effects of DC for treating hemispheric hypertensive ICH, we retrospectively reviewed the clinical and radiological findings of 21 patients who underwent DC for hemispheric hypertensive ICH. Eleven of the patients were male and 10 were female, with an age range of 22-75 years (mean, 56.6 years). Their preoperative Glasgow Coma Scale scores ranged from 3 to 13 (mean, 6.9). The hematoma volumes ranged from 33.4 to 98.1 mL (mean, 74.2 mL), and the hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. Intraventricular extensions were observed in 11 patients. With regard to the complications after DC, postoperative hydrocephalus developed in ten patients, and meningitis was observed in three patients. Six patients had favorable outcomes and 15 had poor outcomes. The mortality rate was 10 %. A statistical analysis showed that the GCS score at admission was significantly higher in the favorable outcome group than that in the poor outcome group (P = 0.029). Our results suggest that DC with hematoma evacuation might be a useful surgical procedure for selected patients with large hemispheric hypertensive ICH.

Simultaneous multiple hypertensive intracranial hemorrhages.

We retrospectively reviewed the clinical and radiological findings, management, and factors correlated with outcomes in 20 patients with simultaneous multiple hypertensive intracranial hemorrhages (ICH). The mean admission Glasgow Coma Scale score was 7.8. The most common hematoma location was the putamen, while putamen-brainstem hematomas were the most common combination. The mean hematoma volume was 27.5 mL. Eight patients had favorable outcomes and 12 had poor outcomes. Statistical analysis identified that the GCS score on admission, hematoma distribution (unilateral supratentorial hematomas were the most favorable), and total hematoma volume were prognostic factors. This study provides important information on the clinicoradiological findings and prognosis in patients with simultaneous multiple hypertensive ICH.

Development of chronic encapsulated intracerebral hematoma after radiosurgery for a cerebral arteriovenous malformation.

BackgroundWe report a rare case of chronic encapsulated intracerebral hematoma (CEIH) after radiosurgery for a cerebral arteriovenous malformation (AVM).MethodsSeven years after radiosurgery, magnetic resonance imaging revealed a high-intensity mass in the right basal ganglia with a peripheral low signal ring and fluid level on both T1- and T2-weighted images, which was compatible with CEIH.ResultsStereotactic evacuation and placement of an Ommaya reservoir were performed.ConclusionThe concentration of vascular endothelial growth factor was high in the hematoma, suggesting that CEIH may be similar to chronic subdural hematoma.

Prognostic factors in patients with primary brainstem hemorrhage.

OBJECTIVE Primary brainstem hemorrhage (PBH) frequently causes severe disturbances of consciousness, papillary abnormalities, as well as respiratory and motor disturbances. The prognosis has been reported to be highly dependent on the clinical severity at presentation and the presence of certain radiological markers. However, the number of PBH patients enrolled in previous reports tended to be small, and precise statistical analyses were also lacking. The aim of this study was to analyze the impact of clinical or radiologic parameters on the outcome of patients with PBH. METHODS We retrospectively reviewed 212 consecutive patients with PBH and analyzed the impact of the clinical or radiological parameters on the outcome of patients with PBH. RESULTS Of the 212 patients, 134 (63.2%) were male and 78 (36.8%) were female, with an age range of 17-97 years (mean, 60.3 years). The median admission GCS score was 4. The outcomes included a good recovery in 13 patients (6.1%), moderate disability in 27 (12.7%), severe disability in 27 (12.7%), a vegetative state in 23 (10.8%), and death in 122 (57.5%). A multivariate analysis demonstrated bilateral hematoma extension, a GCS score ≤8, the presence of hydrocephalus, gender, and the hematoma volume to all be significantly associated with the 3-month mortality, while the GCS score ≤8, the presence of a pupillary abnormality, and the hematoma volume were found to be associated with the 3-month poor outcome. CONCLUSION The identification of these factors is therefore considered to be useful for managing patients with PBH.

Progressive subdural hematomas after epidural blood patch for spontaneous intracranial hypotension

To the Editor: Spontaneous intracranial hypotension (SIH) is an increasingly recognized disorder of cerebrospinal fluid (CSF) volume depletion presenting with a postural headache and CSF pressure \60 mm H2O. The headache typically resolves with bed rest and hydration, although an epidural blood patch (EBP) or epidural saline infusion may provide alternative and effective treatments. Subdural hematomas (SDHs) are frequently associated with SIH, although progressive SDH after EBP for SIH is extremely rare. Herein, we present a rare case of progressive SDH after EBP for SIH. A 48-year-old woman presented with a severe headache. On admission, the headache was clearly a postural feature, being aggravated when she was erect and relieved when she was supine. Physical and neurological examinations were normal. Initial CSF pressure was 60 mm H2O. A brain computed tomography (CT) scan (Fig. 1a) and coronal fluid attenuation inversion recovery (FLAIR) image (Fig. 1b) showed thin, bilateral SDHs. T1-weighted magnetic resonance image (MRI) with gadolinium enhancement revealed diffuse pachymeningeal thickening (Fig. 1c), consistent with SIH. She was diagnosed with SIH and treated with hydration and rest. Four days after admission, EBP was performed with 10 ml autologous blood injected at the T3–T4 interspace. The following day, although the postural features had disappeared, the headache persisted, and the patient lost consciousness (Glasgow Coma Scale score, 13) 6 days after EBP (10 days after admission). A CT scan demonstrated increased bilateral SDHs (Fig. 1d). Bilateral burrhole irrigations were performed and the patient’s consciousness immediately improved. She was discharged with no neurological deficits. A CT scan 1 month after presentation showed disappearance of the hematomas (Fig. 1e). Follow-up T1-weighted MRI with gadolinium enhancement at 5 months showed disappearance of the SIH signs (Fig. 1f). Progressive SDH after EBP for SIH is extremely rare, with only two reported cases [1, 2]. Fujimaki et al. [1] reported a patient with thin SDH associated with SIH who underwent burrhole irrigation because of SDH progression 5 days after EBP, and Mikawa and Ebina [2] reported a patient with thin SDH associated with SIH who underwent burrhole irrigation because of oculomotor palsy 18 h after EBP. Interestingly, all three cases (including our patient) complained of a persistent nonpostural headache [1, 2] after disappearance of the postural headache. This observation suggests that persistent nonpostural headache after EBP might be predictive of progressive SDH and that an early CT scan should be performed. The mechanism responsible for progressive SDH after EBP is unclear. Many reports have suggested that SDH associated with SIH can resolve after CSF leaks are secured; this could be explained by the theory suggesting that SDH with SIH is caused by rupture of the bridging veins as the brain is pulled away from the dura by a decrease in CSF volume. Sato et al. [3], however, suggested that even after CSF leaks were secured, persistent fragility and dilatation of small dural vessels could result in vascular rupture leading to progressive SDH. The present case supports this hypothesis as one possible mechanism of progressive SDH after EBP. S. Takeuchi (&) Y. Takasato H. Masaoka T. Hayakawa N. Otani Y. Yoshino H. Yatsushige T. Sugawara Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo 190-0014, Japan e-mail: s.takeuchi@room.ocn.ne.jp