Takashi Usami

Prevention of Vasospasm by Early Operation with Removal of Subarachnoid Blood

Sixty-four patients who were operated on within 4 days after acute subarachnoid hemorrhage are included in this study. All patients underwent preoperative computed tomographic (CT) scanning, and the amount and distribution of subarachnoid blood clot were noted. Operation was carried out by the frontobasal lateral approach, and the subarachnoid clot was removed by microsurgical suction-irrigation after clipping of the aneurysm. Immediate postoperative CT scanning was performed to evaluate the completeness of the subarachnoid blood clot removal. The presence or absence of postoperative vasospasm was determined with angiography performed between the 7th and 10th postoperative days. All patients were, of course, also evaluated for evidence of neurological deterioration. Approximately two-thirds of the patients in this series showed high density subarachnoid blood clot on the preoperative CT scan. The postoperative CT scans showed that it was possible to remove the majority of the blood clot except that located in the frontal interhemispheric fissure, the posterior part of the insular cistern on the approached side, and all of the insular cistern on the contralateral side. There was no spasm or only mild spasm in any site where the blood clot had been successfully removed. Delayed neurological deficits occurred only in those cases in which subarachnoid blood clot remained in the cisterns. These results suggest that it is possible to prevent intracranial arterial spasm and associated neurological deterioration by early operation and removal of clotted blood from the subarachnoid space.

Relationship between contrast enhancement on computed tomography and cerebral vasospasm in patients with subarachnoid hemorrhage.

To elucidate the relationship between abnormal enhancement of the cisterns on computed tomography and cerebral vasospasm, we performed a systematic and prospective study in 60 patients with ruptured cerebral aneurysms. There is a significant relationship between the findings of contrast-enhanced computed tomography (CECT) within Day 3 of rupture and cerebral vasospasm. Among 37 patients undergoing CECT between Day 0 and Day 3, 17 (46%) showed prominent increases in density in the region around the circle of Willis and its branches. In 13 of 17 cases (76%), severe vasospasm with motor paralysis occurred. In the remaining 4 cases (24%) with only slight or no cerebral vasospasm, the hematoma in the subarachnoid space was removed surgically by Day 3. In 19 of 20 cases without remarkable CECT, no severe cerebral vasospasm with motor paralysis occurred. There is no significant relationship between the CECT findings after Day 3 and cerebral vasospasm. The results indicate that the prominent increase in density in the region of the circle of Willis and its branches often observed on CECT within Day 3 of subarachnoid hemorrhage is useful for prediction of the occurrence of cerebral vasospasm and also provide information on the pathogenesis of cerebral vasospasm.

Size of Hematoma and Time Course of Intracranial Pressure in Patients with Hypertensive Intracerebral Hemorrhage

It is generally believed that the hematoma of hypertensive intracerebral hemorrhage (ICH) and the surrounding cerebral edema play a role in producing increased intracranial pressure (ICP), a major factor accounting for a poor prognosis. As pointed out by Pappo et al. (3), however, ICP is not always correlated with the clinical condition. In the present study, we monitored the ventricular fluid pressure (VFP) continuously in 22 patients with putaminal hemorrhage. Our purpose was to investigate the dynamic pressure variations in relation to the size of hematoma and to the clinical condition of the patients.