Takao Kitahara

Diagnostic significance of serum neuron-specific enolase and myelin basic protein assay in patients with acute head injury

BACKGROUND Neuron-specific enolase (NSE) and myelin basic protein (MBP) in the peripheral venous blood (PVB) have been reported to be sensitive markers for judging the prognosis of patients with head injury. However, to our knowledge, the levels of NSE and MBP in the internal jugular venous blood (IJVB) have never been studied. METHODS In 25 patients with acute head injury, blood samples were taken from the internal jugular vein and the peripheral vein at the same time before any medical or surgical procedure was performed. The levels of NSE and MBP in the both venous blood samples were measured. The time interval between injury and sampling was 1.5-8.0 hours (mean 4.3 hours). The levels of NSE and MBP in the IJVB were compared to those in the PVB. The relationship between the clinical outcome and the serum levels of those was evaluated. RESULTS The levels of NSE and MBP in the IJVB were almost equal to those in the PVB. The levels of NSE and MBP were significantly higher in the patients who died than in those who survived. In the survivors, the levels of NSE and MBP in the IJVB were 17.6 +/- 11.4 ng/ml and 1.4 +/- 1.5 ng/ml, whereas in the patients who died, both levels were elevated to 51.3 +/- 27.3 ng/ml (p < 0.005) and to 11.3 +/- 9.5 ng/ml (p < 0.01), respectively. CONCLUSIONS The assay of serum NSE and MBP levels provides a reliable laboratory indicator of the degree of brain damage and allows early prediction of the prognosis in patients with acute head injury.

Association of head trauma with cervical spine injury, spinal cord injury, or both

BACKGROUND Links between cervical spine and/or spinal cord injuries and head trauma have not been reported in detail. METHODS 188 patients with cervical spine and/or spinal cord injury were divided into two groups, i.e., with upper cervical and mid-lower cervical injury, and compared for head injury. RESULTS Associated head trauma was investigated in 188 patients with cervical spine and/or spinal cord injuries; 35% had moderate or severe injuries. Brain damage was more frequently observed in patients with upper cervical injury than in those with mid to lower cervical injury. Those patients with upper cervical injury appeared to have an elevated risk of suffering skull base fractures, traumatic subarachnoid hemorrhage, and contusional hemotoma. CONCLUSIONS Approximately one third of patients with cervical spine and/or spinal cord injuries had moderate or severe head injuries. Brain damage was more frequently associated with upper cervical injury. Those patients with upper cervical injury are at greater risk of suffering from skull base fractures and severe intracranial hematomas than those with mid to lower cervical injury.

Management of Unruptured Intracranial Aneurysm in Japan A Markovian Decision Analysis with Utility Measurements Based on the Glasgow Outcome Scale

The purpose of this study was to analyze the management of individual patients with unruptured intracranial aneurysms (UN-ANs) using a decision-analytic approach. Tran sition probabilities among Glasgow Outcome Scale (GOS) categories were estimated from the published literature and data from patients who had been treated at Kitasato University Hospital. Utilities were obtained from 140 health providers based principally on the GOS. Baseline analysis for a healthy 40-year-old man with an anterior UN-AN less than 10 mm in diameter showed that the quality-adjusted life expectancies for preventive operation and follow-up were 15.34 and 14.66 years, respectively. For a follow-up strategy to be preferred, the annual rupture rate had to be as low as 0.9%. These results were sustained through extensive sensitivity analysis. The results sup port preventive operation for UN-ANs, and identify problems that can be clarified with a well-designed stratified clinical trial. Key words: decision analysis; Markov model; unruptured intracranial aneurysms; Glasgow Outcome Scale; utility; preventive oper ations. (Med Decis Making 1998;18:357-364)

Rerupture of cerebral aneurysms during angiography – a retrospective study of 13 patients with subarachnoid hemorrhage

SummaryObjective, background. Cerebral angiography, performed within 24 hr of aneurysmal rupture, carries an increased risk of rebleeding. We have investigated the rerupture rate during angiography procedures under deep general anesthesia and the factors that contribute to rebleeding.Methods. We divided 69 patients who had experienced aneurysmal rerupture into 2 groups. Group I (n = 13) suffered rebleeding during cerebral angiography and group II (n = 56) who rebled at a different time. We assessed the effects on rebleeding of the (1) time between the first insult and angiography, (2) WFNS clinical grade on admission, (3) blood pressure during angiography, (4) age and sex, (5) Fisher classification on admission, (6) aneurysmal site, and (7) Glasgow outcome score (GOS).Results. Factors that had a statistically relevant effect on rebleeding during cerebral angiography (Group I) were the performance of angiography within 3 hr of the initial insult, the admission grade, and the aneurysmal site. Especially, the rerupture events during cerebral angiography were concentrated within 3 hr of the initial insult; the rate was 23.9% when angiograms were obtained within 3 hr of onset. Group I patients manifested a worse clinical grade and middle cerebral artery (MCA) aneurysms were prevalent in this group. However, there was no significant difference between the 2 groups with respect to blood pressure, age, sex, Fisher classification, and GOS.Conclusions. Cerebral angiography at ultra-early timing (within 3 hr of the insult) carries a high risk of aneurysmal rerupture, even if the procedure is performed under deep anesthesia and normotensive blood pressure. Cerebral angiography during that period should be avoided.

The Mechanism of ICP Reducing Effect of Mannitol

The effect of mannitol to decrease raised ICP is well documented and mannitol is now widely used in clinical practice. However, the exact mechanism involved in the lowering of ICP still remains controversial, especially under the condition of vasogenic edema. The objective of this study is to reexamine and delineate the mechanism of the ICP reducing effect of mannitol, using the mathematical method to estimate the CSF dynamics and intracranial compliance (Marmarou 1975), the quantitative vasogenic edema model (Marmarou 1980), and specific gravimetric technique to measure the brain water content, without disturbing the semiclosed condition of the cranial cavity in cats.

Correlation between intravascular pressure and risk of hemorrhage due to arteriovenous malformations

The correlation between intraoperative pressure levels measured in the feeding arteries and in the draining veins, and the risk of hemorrhage from arteriovenous malformations (AVMs) is discussed. Feeding artery pressure (FAP) was significantly higher in AVMs with hemorrhage (57 +/- 11 mmHg) than in AVMs without hemorrhage (38 +/- 4), and draining vein pressure (DVP) in the former (24 +/- 5) was significantly higher than that in the latter (13 +/- 5). FAP and DVP were inversely related to the number of draining veins and size of the AVMs. The present study suggests that a high FAP and a high DVP may contribute to the development of hemorrhage from AVMs, and supports previous reports that small AVMs and AVMs with only one draining vein are susceptible to hemorrhage.

Outcomes analysis of ruptured distal anterior cerebral artery aneurysms treated by endosaccular embolization and surgical clipping.

Although endovascular surgery is now widely used to treat intracranial aneurysms, no comparative studies of clipping versus endovascular surgery to address distal ACA aneurysms at the same institution are available. We compared the results of these treatment modalities to address distal ACA aneurysms at our institution. We treated 68 patients with ruptured distal ACA aneurysms (endovascular surgery, n=13; clipping surgery, n=55). We performed a retrospective comparison of the treatment outcomes. To study the efficacy of endovascular surgery we classified all our cases into three types: type A were small-necked aneurysms, type B were wide-necked aneurysms on the parent artery, and type C were aneurysms in which the A3 portion of the ACA arose from the aneurysmal dome near the neck. Intraoperative hemorrhage occurred in 7.7% of aneurysms treated by endovascular surgery and in 34.5% treated by clipping surgery. In 7.7% of the endovascularly-treated aneurysms we noted coil migration during embolization surgery; venous infarction due to cortical vein injury occurred in 7.3% of clipped aneurysms. Of the endovascularly-treated aneurysms, 7.7% manifested post-embolization hemorrhage; 23.1% manifested coil compaction. In clipping surgery, postoperative rerupture occurred in 1.8% of the aneurysms; one patient presented with postoperative acute epidural hematoma. Clip dislocation was noted in 1.8% of aneurysms. Angiography was indicative of post-treatment vasospasm in 7.7% of aneurysms treated endovascularly and in 50.9% of the clipped aneurysms. The clinical outcome showed no significant difference between endovascular surgery and clipping surgery.

Reanalysis of unruptured intracranial aneurysm management: effect of a new international study on the threshold probabilities.

Objective. This report updates previous clinical decision analysis for patients with unruptured intracranial aneurysm (UN-AN) based on newly published data and discusses the role of reanalysis in individual decision making. Methods. The authors employed probabilities for the natural history of UN-AN and results of preventive surgery based on the report by the International Study of Unruptured Intracranial Aneurysms. Probabilistic sensitivity analysis with Monte Carlo simulation and traditional n-way sensitivity analyses were used to assess the uncertainty of clinical decisions. Results. The baseline decision in favor of preventive surgery is reversed by new data from the international study. Probabilistic sensitivity analyses revealed several populations showing heterogeneity in terms of strategy selection. One- and two-way sensitivity analyses detected two important factors for decision making: annual rupture rate and utility for knowingly living with UN-AN. Conclusions. Annual UN-AN rupture rate and the utility for knowingly living with UN-AN are key factors when deciding on a therapeutic strategy. Also, updating published decision analyses can improve clinical decision making by integrating clinical judgment and newly available clinical data.

Impact of Platelet Transfusion on Survival of Patients with Intracerebral Hemorrhage after Administration of Anti-Platelet Agents at a Tertiary Emergency Center

This study examined the impact of platelet transfusion (PLT) on the survival of intracerebral hemorrhage (ICH) patients who had been administered anti-platelet agents (APA). This retrospective cohort analysis investigated 432 patients (259 men, 60%) who were newly diagnosed with ICH between January 2006 and June 2011 at the tertiary emergency center of Kitasato University Hospital. Median age on arrival was 67.0 years (range, 40–95 years). ICH was subcortical in 72 patients (16.7%), supratentorial in 233 (53.9%), and infratentorial in 133 (30.8%). PLT was performed in 16 patients (3.7%). Within 90 days after admission to the center, 178 patients (41.2%) had died due to ICH. Before the onset of ICH, 66 patients had been prescribed APA because of atherosclerotic diseases. Multivariate regression analysis indicated APA administration was an independent risk factor for death within 7 days (odds ratio, 5.12; P = 0.006) and within 90 days (hazard ratio, 1.87; P = 0.006) after arrival. Regarding the effect of a PLT in ICH patients with APA, no patient with PLT died. PLT had a survival benefit on patients with ICH, according to our analysis. Further prospective analysis is necessary to confirm the effects of PLT on survival in ICH with APA.

Three-dimensional digital subtraction angiography vs two-dimensional digital subtraction angiography for detection of ruptured intracranial aneurysms: A study of 86 aneurysms

AIMS Three-dimensional reconstruction of intracranial vessels is of interest for evaluation of aneurysms. This study determined diagnostic difference of three-dimensional digital subtraction angiography (3D-DSA, volume-rendering image) versus 2D-DSA for evaluating ruptured intracranial aneurysms, particularly focusing on the size of aneurysms as depicted in both images. SETTINGS AND DESIGN Sixty-nine patients underwent 3D-DSA and 2D-DSA. The relative size of an aneurysm, which is the ratio of the maximal diameter of an aneurysm to the diameter of a major vessel, was compared between imaging techniques. In addition, relative sizes of smaller aneurysms (< 5 mm) were compared with those of larger aneurysms (>10 mm). STATISTICAL ANALYSIS USED For comparison of aneurysm size and location of aneurysm, statistical analysis was performed with the Yates chi square test; statistical significance was set with a P value of less than 0.05. RESULTS Sixty-three (73.3%) of the 86 total aneurysms were bigger when measured with 3D-DSA versus 2D-DSA. When measured with 3D-DSA, 28 (84.8%) of the 33 smaller aneurysms were bigger, and 50% of the larger aneurysms were bigger versus measurements of 2D-DSA images (P < 0.05). In ACA and ICA territories, which tended to have smaller mean aneurysmal size, relative size of the aneurysm was bigger when measured with 3D-DSA (81.5% and 81.0%, respectively). In MCA, where the mean aneurysmal size was the largest, relative size of aneurysms was bigger when measured with 3D-DSA in 15 cases (53.6%, P < 0.05). In the posterior circulation, aneurysm size was similar between 3D-DSA and 2D-DSA measurements. CONCLUSIONS 3D-DSA, especially volume-rendering images, tends to depict ruptured intracranial aneurysms bigger than 2D-DSA. This is particularly true with cerebral aneurysms that are < 5 mm in size and are located in the anterior circulation, especially ICA and ACA territories.