J. Campollo

Prognostic Factors on Hospital Admission after Spontaneous Subarachnoid Haemorrhage

Summary Background and Objective. Factors related to prognosis after subarachnoid haemorrhage (SAH) have been mainly extracted from surgical series, and only few authors have considered these factors in total management or population series. Though the level of consciousness is a major determinant of outcome after subarachnoid haemorrhage, there is not a consensus about which classification should be used to define it. The objective of this study was twofold. Firstly to find which factors recorded on hospital admission relate to outcome determining their relative importance in a non-selected series of patients suffering from aneurysmal SAH admitted to our centre, and secondly to assess the validity of the WFNS clinical scale for predicting the final result. Methods. A series of 294 patients consecutively admitted to Hospital 12 de Octubre Madrid between January 1990 and June 2000 with the diagnosis of aneurysmal SAH were retrospectively reviewed. All factors possibly related to prognosis were recorded on hospital admission. Outcome was measured by means of the Glasgow Outcome Scale measured one month after hospital discharge. Relationship between factors and outcome was evaluated by univariate and logistic regression multivariate analysis. Results. Although several factors appeared related to prognosis in the univariate analysis, only the age, the level of consciousness defined by the WFNS scale and the presence of global brain hypodensity on the initial CT scan had a significant prognostic influence in the logistic regression model. Global brain hypodensity was strongly related to mortality. Since a number of factors associated with poor outcome in the univariate analysis are related to age, their influence could be explained by the difficulty of recovery of the ageing brain. The WFNS grading scale failed to predict significant differences in outcome between some of its grades. Conclusions. Age and clinical grade on admission are the most important factors influencing the final outcome of patients suffering aneurysmal SAH. A reappraisal of the WFNS grading scale should be considered as no significant differences in outcome were found between some of its grades.

A comparison of different grading scales for predicting outcome after subarachnoid haemorrhage.

SummaryBackground. Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale.Method. A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by χ2 statistics. ROC curves were plotted for the different scales and their areas compared.Findings. Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH.Interpretation. Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.

Cerebral aneurysm rupture after r-TPA thrombolysis for acute myocardial infarction.

BACKGROUND Intracranial hemorrhage is the most dreaded risk of thrombolytic therapy for acute myocardial infarction because of the high mortality and disability rates associated with this complication. Brain structural lesions may predispose a patient to bleeding. To date, aneurysm rupture has not been described as a complication of such therapy. CASE DESCRIPTION A 66-year-old hypertensive woman was admitted because of chest pain. Myocardial infarction was diagnosed and fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA) was initiated. Eight hours after admission she became unconscious. Brain computed tomography scan showed subarachnoid hemorrhage, and a cerebral arteriography showed an anterior communicating artery aneurysm. Because of her poor clinical condition treatment was postponed. Death occurred 7 days later because of multiorgan failure. CONCLUSIONS Cerebral aneurysms should be considered as a possible contributing factor to intracranial bleeding after thrombolytic therapy.

Idiopathic subarachnoid hemorrhage and venous drainage: are they related?

OBJECTIVE In the past, several possible explanations for idiopathic subarachnoid hemorrhage (ISAH) have been proposed; however, neuroimaging studies have never provided conclusive data about the structural cause of the bleeding. The aim of this study is to determine whether there are anatomic differences in the deep cerebral venous drainage in patients with ISAH compared with those with aneurysmal subarachnoid hemorrhage (ASAH) and those without intracranial hemorrhage. METHODS We reviewed the venous phase of carotid digital angiograms of 100 consecutive patients who had a final diagnosis of ISAH. We also analyzed the angiograms of a control group of 112 patients with ASAH and the angiograms of a nonhemorrhagic group of 25 patients having incidental aneurysms. The anatomic variants of the basal vein of Rosenthal (BVR) on both sides were classified into the following types: Type A (normal continuous), in which the BVR is continuous with the deep middle cerebral veins and drains mainly into the vein of Galen; Type B (normal discontinuous), in which there is discontinuous venous drainage, anterior to the uncal vein and posterior to the vein of Galen; and Type C (primitive), which drains mainly to veins other than the vein of Galen. We calculated the proportions to analyze the differences in the type of venous drainage between patients with ISAH, patients with ASAH, and patients without hemorrhage. χ2 statistics were used to search for differences. RESULTS Types A and C venous drainage were present in 23.8 and 32.3%, respectively, of patients with ISAH compared with 58.7 and 15.4%, respectively, in the ASAH group and 57.5 and 5%, respectively, in the nonhemorrhagic group (P < 0.001). A primitive variant was present in at least 1 hemisphere in 38 patients with ISAH (41.8% of the cases) compared with 24 patients with ASAH (21.4%) and 2 patients (8%) in the nonhemorrhagic group (P < 0.001). CONCLUSION In patients with ISAH, deep cerebral venous drainage more commonly drains directly into dural sinuses instead of via the vein of Galen compared with patients with ASAH and patients without intracranial hemorrhage. The way in which this venous configuration might influence bleeding remains unknown.

Dural arteriovenous fistula presenting as brainstem ischaemia

SummaryDural arteriovenous fistulas presenting with ascending myelopathy are characterised by the presence of an abnormal retrograde drainage through spinal veins. The authors present a case of cranial dural arteriovenous fistula causing brainstem dysfunction secondary to venous hypertension, treated by surgical interruption of the pial venous drainage which resulted in complete clinical and radiological resolution of the brainstem lesion.

Global Cerebral Edema After Subarachnoid Hemorrhage

Background and Purpose— Cerebral edema visualized by CT is often seen after subarachnoid hemorrhage (SAH). Inflammatory or circulatory mechanisms have been postulated to explain this radiographic observation after SAH. We sought to determine the frequency, causes, and impact on outcome of early and delayed global cerebral edema after SAH. Methods— We evaluated the presence of global edema on admission and follow-up CT scans in 374 SAH patients admitted within 5 days of onset to our Neurological Intensive Care Unit between July 1996 and February 2001. Using multivariate analysis, we identified predictors of global cerebral edema and evaluated the impact of global edema on outcome 3 months after onset with the modified Rankin Scale. Results— Global edema was present on admission CT scans in 8% (n=29) and developed secondarily in 12% (n=44) of the patients. Global edema on admission was predicted by loss of consciousness at ictus and increasing Hunt-Hess grade. Delayed global edema was predicted by aneurysm ...

Venous angioma associated with atypical ophthalmoplegic migraine.

Background.—Ophthalmoplegic migraine is a rare syndrome in which episodic headaches are associated with ophthalmoplegia. Several recent reports emphasize the possibility, especially in atypical cases, of a heterogeneous type of ophthalmoplegic migraine.

Embolización de MAVs intracraneales coadyuvante de cirugía o radiocirugía

Resumen Objetivos La embolizacion de malformaciones arteriovenosas (MAVs) se ha mostrado como una tecnica efectiva coadyuvante del tratamiento quirurgico o radioquirurgico. El objetivo de este trabajo es analizar la tecnica, efectividad y complicaciones de la embolizacion terapeutica en una serie de pacientes con MAV intracraneal que posteriormente fueron sometidos a cirugia convencional o radioterapia estereotaxica. Material y metodos Se consideran 17 pacientes consecutivos tratados con embolizacion por via endovascular extraidos de una serie de 212 portadores de MAV intracraneal admitidos entre 1975 y 1999. La embolizacion se llevo a cabo utilizando NBCA (hystoacril) o PVA (polivinil-alcohol) como material embolizante. Se realizaron estudios angiograficos pre y postembolizacion para determinar el grado de reduccion del tamano del nidus. Asimismo, se comparo la dificultad del tratamiento quirurgico postembolizacion frente a casos similares operados sin embolizacion previa. Resultados se embolizaron una media de 1,4 pediculos vasculares por sesion en 27 sesiones, con una media de 2,2 pediculos vasculares por paciente. El porcentaje de disminucion del tamano del nidus oscilo entre el 20 y el 100% (media 74%). La embolizacion facilito el tratamiento microquirurgico o radioquirurgico posterior. Dos enfermos presentaron un deficit neurologico menor (11,7%) y un enfermo un deficit neurologico severo tras la embolizacion. La mayor parte de los casos presento una buena evolucion final. Conclusiones La embolizacion de las MAVs intracraneales es un procedimiento terapeutico coadyuvante que facilita el posterior tratamiento quirurgico o radioquirurgico de estas lesiones.

Regresión espontánea de las malformaciones arteriovenosas cerebrales: presentación de un caso y revisión de la literatura

Resumen La regresion espontanea de las malformaciones arteriovenosas cerebrales (MAVs) es poco frecuente. Este hecho parece ser mas comun en aquellas MAVs de pequeno tamano, cuyo modo de presentacion clinica preferente es con hemorragia cerebral, con una unica arteria aferente, y una sola vena de drenaje. No se conocen con exactitud cuales son los factores responsables de la desaparicion de las MAVs. La trombosis secundaria al sangrado es el factor mas comunmente asociado a este hecho. Otros posibles factores implicados son la gliosis secundaria a microsangrados repetidos o la oclusion de las arterias aferentes por pequenos embolos. Se presentan las caracteristicas clinico radiologicas de un caso de regresion espontanea de MAV y se revisa la literatura al respecto

Hemorragia subaracnoidea secundaria a aneurismas disecantes de la arteria vertebral. Descripción de 2 casos y revisión de la literatura

Resumen Introduccion y objetivos Hasta la fecha esta es una enfermedad de evolucion desconocida, debido a su rareza. En este trabajo se revisa el estado actual del manejo diagnostico y terapeutico de esta entidad y se resalta el resultado obtenido con la embolizacion con “coil” GDC. Metodos Se describen dos casos de aneurisma disecante de la arteria vertebral intracraneal que debutaron con hemorragia subaracnoidea. Uno de ellos debuto inicialmente con una isquemia y posteriormente como una HSA; el segundo debuto como una HSA grave, y fue tratado con embolizacion con “coil” GDC obteniendose una buena evolucion clinica. Conclusiones La hemorragia subaracnoidea secundaria a rotura de un aneurisma disecante de la arteria vertebral es una patologia poco conocida que tiene unas peculiaridades propias que deben ser tenidas en cuenta. La incidencia de resangrado inicial es muy elevada (hasta el 60%), por lo que es fundamental su diagnostico y tratamiento precoz. Clasicamente el tratamiento preferido ha sido la oclusion vertebral proximal a la diseccion; sin embargo, la reciente introduccion de la embolizacion con “coil” GDC ha supuesto una gran ayuda en la oclusion de la diseccion, con escasa morbilidad y buen resultado final.