Mizuo Kagawa

Management of intracranial hemorrhage associated with anticoagulant therapy

BACKGROUND Intracranial hemorrhage may be a particularly devastating complication of anticoagulant therapy. Very few accounts have reported data on the duration of anticoagulant discontinuation following intracranial hemorrhage or the intensity of anticoagulation during treatment for it, although we must adequately manage such a complication. METHODS We analyzed the management of warfarin-related intracranial hemorrhages in 27 patients with cardiac diseases. We evaluated the degree of anticoagulation using the thrombotest. Anticoagulants were stopped as soon as the diagnosis of intracranial hemorrhage was established by computed tomographic scan. RESULTS Mechanical valve prosthesis patients, who required intensive long-term anticoagulant therapy, constituted the majority of our series (74.1%). Intraoperative hemostasis was brought under control despite low thrombotest values (13%-68%) at the time of surgery except for the acute subdural hematoma (SDH) patients with cerebral contusion. Early resumption of anticoagulant therapy (within 3 days) did not cause intracranial rebleeding in any operative patient. All the chronic SDH patients and some of the subcortical hematoma patients had a good outcome. All three patients with acute SDH and contusion, however, had a fatal outcome because of intracranial rebleeding within a short period of time or ineffective intraoperative hemostasis. CONCLUSIONS The patients with anticoagulant-related intracranial hemorrhage may undergo surgery with thrombotest values approximately between 20% and 60%, and anticoagulants can be resumed after an interval of 3 days. Aggressive surgery should particularly be performed in patients with anticoagulation-related chronic SDH or subcortical hemorrhage, as in the cases of anticoagulant-unrelated intracranial hemorrhage.

The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis of 108 patients.

The effects of continuous drainage of cerebrospinal fluid (CSF) on vasospasm and hydrocephalus were analyzed retrospectively in 108 patients with subarachnoid hemorrhage (SAH) who were operated on for ruptured aneurysms within 48 hours of their onset. Ninety-two of these patients underwent a procedu

Current treatment of brain abscess in patients with congenital cyanotic heart disease.

OBJECTIVE The goal of this study was to define clearly the role of management in patients with cyanotic heart disease and brain abscesses by evaluating retrospectively the factors influencing poor outcome in these patients. METHODS This study included 62 patients with cyanotic heart disease and brain abscesses diagnosed in the computed tomography era. Basic characteristic parameters (number, size, location, computed tomographic classification and organism type of abscess, convulsion, type of cyanotic heart disease, age distribution, immunocompromised status, pretreatment neurological state, and intraventricular rupture of brain abscess [IVROBA]) and therapeutic parameters (type of antibiotics and duration of administration, steroid medication and therapeutic modalities, aspiration with or without cerebrospinal fluid drainage, total extirpation after aspiration, or primary extirpation and medical treatment) were evaluated as independent predictors of poor outcome (totally disabled state or death) by using univariate and multivariate logistic regression analysis. We also statistically estimated the possible causes of IVROBA and the multiplicity of brain abscess. RESULTS Although there were no statistically significant correlations between patients with good and poor outcomes in regard to other basic characteristic and therapeutic parameters, patients with poor outcomes were older (P < 0.02), more frequently had IVROBA (P < 0.005), and had a higher frequency of neurological deterioration (P < 0.01) than those with good outcomes. Multiple logistic regression analysis predicted that poor outcome increased the relative risk of IVROBA by a factor of 18.9 (odds rate, 18.9; 95% confidence interval, 1.7-211.6; P < 0.02). More patients with multiple abscesses had positive immunocompromised states than those with single abscesses (P < 0.01). Deep-located abscesses also more frequently had IVROBA (P < 0.005) and abscesses located in the parieto-occipital region ruptured into the occipital horn of the lateral ventricle in a short period (P < 0.02). CONCLUSIONS Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.

Aspergillotic aneurysm formation of cerebral artery following neurosurgical operation

A rare case of intracranial aspergillotic aneurysm following neurosurgical operation for facial spasm is presented. Severe meningitis had persisted several days prior to the subarachnoid hemorrhage which occurred on 70th postoperative day. Angiography demonstrated a fusiform aneurysm at the peduncular segment of the superior cerebellar artery on the other side of operation. As the repeated cultures of CSF were negative, the pathogenetic factor causing aneurysm formation could not be identified before second operation of aneurysmal resection. Pathological study of the specimen revealed the arterial wall being deeply invaded by aspergillotic hyphae.

Ischemic stroke in infancy, childhood, and adolescence

The authors studied 34 patients with juvenile ischemic cerebrovascular disease over a 15-year period. Of the 34 patients, 23 had intracranial occlusions attributed to cerebral thrombosis or embolism and 11 had occlusions resulting from moyamoya disease. Clinicopathological features were evaluated in the 23 cases with ischemic stroke, but not those with moyamoya disease. The cause of the arterial occlusion remained undetermined in 11 patients and was found to be an embolism based on congenital heart disease in 8, on trauma in 3, and on infection in 1. Cerebral angiography was performed in 21 patients. Of these, 17 had stenoses or occlusions corresponding to their symptoms. CT scans were performed in 10 patients; the lesion in question showed no stenosis or occlusion with cerebral angiography. With regard to prognosis, patients with unknown etiology had good outcomes compared with those with congenital heart disease. With respect to “acute infantile hemiplegia”, 10 patients had convulsive seizures and 4 had a history of an earlier infection. Angiography and CT scans in patients with congenital heart disease demonstrated arterial occlusive sites in the middle cerebral artery region. Three patients had abscesses after their ischemic lesions.

Natural history of arteriovenous malformations: analysis of non-radically treated patients

The natural history of cerebral arteriovenous malformations (AVMs) was studied in 115 patients with untreated or incompletely obliterated AVM. Sixty-six patients had histories of hemorrhage, 20 had seizures, 18 had progressive ischemic neurologic deficits and 8 had headache. Three patients had no symptoms attributable to the AVM. Twenty-seven (23%) AVMs rebled or newly bled and the cumulative bleeding or rebleeding rate was 72.5% (4.2% per year). The cumulative bleeding rate of the neurologic deficit group, however, was significantly lower than the cumulative rebleeding rate of the hemorrhagic group (P < 0.05) and that of the seizure group (P < 0.05). No significant differences were found in regard to the initial clinical manifestations. The cumulative survival rate was 84% and the average mortality rate was 1.4% per year. Fifty patients (43%) were below 90 in Karnofskys Index at the end of the follow-up period and the average morbidity rate was 6.0% per year.

Forme fruste of von Recklinghausen's disease : unilateral association of an orbital neurofibroma, a trigeminal neurinoma, and an acoustic neurinoma. Case report

A patient who presented with a tumor of the left ambient cistern, a left cerebellopontine angle tumor, and a left orbital tumor causing left hearing loss and left exophthalmos without café au lait spots or cutaneous neurofibromas is described. There was no family history of von Recklinghausens disease. A cerebellopontine angle tumor removed by a suboccipital craniectomy was an acoustic neurinoma. An ambient cistern tumor was approached through a subtemporal route. A tumor arising from the trigeminal nerve was also a neurinoma. An orbital neurofibroma was excised by a frontal craniotomy with removal of the orbital roof. This rare unilateral association of neurinomas and a neurofibroma on the left side was thought to be a forme fruste of von Recklinghausens disease, and it could be considered a presentation of a mosaic of von Recklinghausens disease.

HLA-type of cerebral vasospasm patients after aneurysmal subarachnoid hemorrhage

We studied human lymphocyte antigen (HLA) types in a group of 45 patients who had aneurysmal subarachnoid hemorrhage (SAH). A significantly increased frequency of HLA antigen A31 and a significantly decreased frequency of HLA antigen B40 were found. In patients with delayed ischemic neurological deficit (DIND) following aneurysmal SAH and HLA typing, HLA-Bw60 antigen showed significant increases; in patients who did not develop HLA-Aw33 and-Cw4 antigens showed significant. Among the patients with Fishers Group 3 on CT, in particular, these antigens significantly increased when compared with controls from the same geographic area. These results suggest that HLA-Bw60 antigen plays a role as a predisposing factor of DIND resulting from vasospasm following aneurysmal SAH, and that HLA-Aw33 and-Cw4 exert protective influence against DIND.

Acetylcholine determination of cerebrospinal fluid in aneurysmal subarachnoid hemorrhage

Acetylcholine (ACh) concentrations were determined serially in cerebrospinal fluid (CSF) obtained from 23 patients with aneurysmal subarachnoid hemorrhage (SAH) by high-performance liquid chromatography (HPLC) with electrochemical detection (ED). The values of CSF ACh were significantly low in the initial stage of SAH, and increased subsequently but they did not return to control values within 3 weeks. In addition, serial measurements of CSF butyrylcholinesterase (BChE) activity in 12 SAH patients showed that the activity was elevated significantly in the initial stage of SAH and returned to control levels within a week. This discrepancy in the recovery period between the ACh levels and the BChE activity in CSF indicated that significantly lower CSF ACh levels after SAH could not be attributed to plasma BChE contamination of CSF. These results suggested central cholinergic dysfunction after SAH, especially in the initial stage.

Complications of Embolization with Detachable Balloon for Cerebral Aneurysms

Between 1987 and 1991, 14 patients with cerebral aneurysm were treated by endovascular detachable balloon embolization technique. A detachable latex balloon was directly guided into the aneurysm, inflated with silicone or contrast material and detached. The patients ranged in age from 28 to 69 years (mean age, 48) and consisted of 9 males and 5 females. Five aneurysms distributed in the anterior circulation and 9 in the posterior circulation. Six of the aneurysms were small (<10mm), 7 large (10< <25mm), and 1 giant (25mm<). Nine patients presented with subarachnoid hemorrhage, 4 with mass effect and 1 without symptom. In 3 patients the parent arteries as well as the aneurysm were occluded. In 11 patients direct balloon embolizations were achieved with preservation of the parent arteries. Complications associated directly with balloon embolization therapy included 3 ruptures of the aneurysms that occured as a result of incomplete occlusion in 2 and slight overinflation of balloon in 1. One aneurysm ruptured at 4 months and 2 within 1 day after treatment. Two patients died of subarachnoid hemorrhage and 1 developed carotid-cavernous sinus fisutula that was treated by detachable balloon technique with good outcome. After balloon embolization therapy, 2 patients developed stroke due to narrowing of parent arteries. One patient had Webers syndrome and another had hemiparesis.