Thomas A. Duff

Early treatment of ruptured aneurysms with Guglielmi detachable coils: effect on subsequent bleeding.

The major causes of mortality and morbidity in patients surviving the rupture of a saccular aneurysm are subsequent bleeding and vasospasm. The purpose of this study was to evaluate the influence of early treatment of ruptured aneurysms with Guglielmi detachable coils on the incidence of subsequent bleeding. Thirteen patients were treated within 72 hours of initial aneurysm rupture with Guglielmi detachable coils. Excluding three patients who died 2, 4, and 12 weeks after initial hemorrhage, all others have been followed up for intervals between 6 and 36 months (mean, 16 mo). None of these have had either clinical or radiographic evidence of subsequent bleeding. Assuming that there is a 30% incidence of subsequent bleeding in conservatively (nonsurgically) treated patients, the 0% subsequent bleed rate observed in this subgroup was significant at a P value of 0.01. Only one procedure-related complication occurred in this series, and 9 of 13 (69%) aneurysms were 100% occluded at the time of initial treatment. All aneurysms were at least 90% occluded at the end of initial treatment. In addition to reducing the risk of subsequent bleeding, early treatment facilitated the institution of an aggressive approach for management of both vasospasm and increased intracranial pressure. Patient outcome, as measured by the Glasgow Outcome Scale, was good in 9 of 13 (69%), poor in 1 of 13 (8%), and death in 3 of 13 (23%) patients. The results of this study suggest that early Guglielmi detachable coil treatment of ruptured aneurysms may be effective in reducing the incidence of subsequent bleeding and can be performed with a low incidence of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Early Treatment of Ruptured Aneurysms with Guglielmi Detachable Coils

ABSTRACTTHE MAJOR CAUSES of mortality and morbidity in patients surviving the rupture of a saccular aneurysm are subsequent bleeding and vasospasm. The purpose of this study was to evaluate the influence of early treatment of ruptured aneurysms with Guglielmi detachable coils on the incidence of sub

Erythrocytes are essential for development of cerebral vasculopathy resulting from subarachnoid hemorrhage in cats.

In an effort to determine which blood elements play a critical role in the development of cerebral vasospasm, adult cats were subjected to prepontine injection of either autogenous whole blood or erythrocyte-free blood containing latex beads as a substitute morphologic marker. Seven or 10 days later the cats were anesthetized and perfused with fixative, and the basilar arteries were prepared for light and electron microscopy. Successful clot deposition was confirmed by the presence of numerous erythrocytes or latex beads within the adventitia of vessels. In agreement with previous studies, instillation of whole blood produced luminal narrowing associated with profound ultrastructural changes in all layers of the vascular wall. No significant alterations, however, occurred in arteries bathed in erythrocyte-free blood. These findings suggest first, that erythrocytes are essential for the development of the vasculopathy associated with chronic cerebral vasospasm, and second, that the role, if any, of other blood elements is not autonomous.

Metrizamide--CSF contrast medium. Analysis of clinical application in 215 patients.

Two-hundred-fifteen patients were evaluated with metrizamide, a new water-soluble contrast agent for use in the subarachnoid spaces. Side effects were reported in 67% of these; 39% were moderate or severe. Cervical injections monitored by fluoroscopy provide the most precise positioning of the medium. The benefits of metrizamide use outweigh its risk.

Topography of scalp recorded potentials evoked by stimulation of the digits

The amplitude of the primary positive deflection, P24, was measured in each wave form recorded from a 36-channel scalp electrode array placed over sensorimotor cortex. Electrical stimulation of contralateral little, middle, index finger, or thumb produced wave forms possessing common features, but the location of peak P24 amplitude depended upon the digit stimulated. With thumb stimulation peak P24 amplitude was located approximately two-thirds the distance from midline to sylvian fissure, while stimulation of the other digits resulted in more medially located topographic peaks. These shifts correlate with previous descriptions of body-part representation in somatosensory cortex and suggest that at least certain wave form deflections recorded from the scalp provide accurate localization of their underlying neural generators.

Treatment of increased intracranial pressure: a comparison of different hyperosmotic agents and the use of thiopental.

Long term intracranial pressure (ICP) monitoring was carried out in over 200 patients with various intracranial abnormalities; a fiberoptic epidural intracranial pressure monitor was used. Ninety of these patients had significantly elevated ICP or exhibited pressure waves requiring therapy. Initial therapy consisted of hyperventilation with a respirator and administration of hyperosmotic agents. Comparison studies utilizing 30% urea, 20% mannitol, and furosemide intravenously and 30% urea and 10% glycerol orally were randomly done. In 45 patients two or more of these agents were used at different times in the same patient for comparison of effectiveness. When equimolar amounts of intravenous urea and mannitol were used, similar effects on increased ICP were obtained. There was no significant reduction of increased ICP with the use of furosemide alone. No rebound effect was observed with either mannitol or urea. Orally, urea was more effective than glycerol in equimolar amounts. Again no rebound was observed. In 14 patients who required doses of hyperosmotic agents more frequently than every 4 hours, continuous infusion of thiopental was used in conjunction with the hyperosmotic agents to control pressure. This regimen resulted in good ICP control in 12 patients. A rational protocol for the medical management of increased ICP utilizing hyperosmotic agents and, in refractory cases, hyperosmotic agents plus thiopental has resulted in effective control of ICP in 96% of our patients throughout their course without the need to resort to decompressive surgery. (Neurosurgery, 5: 570--575, 1979).

Nonsurgical Management of Spontaneous Intracerebral Hematoma

This report describes our experience with the use of osmotic diuretics, governed by continuous monitoring of intracranial pressure (ICP), as the primary treatment for 12 consecutive patients suffering from an acute, supratentorial intracerebral hematoma. In all cases the hematoma, as shown by computed tomographic scan, had a long axis of greater than 4.0 cm. ICP and cerebral perfusion pressure were successfully maintained within the assigned limits in all patients, and in none was surgical evacuation required. There was one death during the 6-month follow-up period. With appropriate weighting to differences in admission status, statistical comparison of the patient outcome in the present series with that reported by McKissock et al. suggests that ICP monitoring can improve the outcome of conservatively (and perhaps surgically) treated patients.

Does cerebral vasospasm result from denervation supersensitivity

This study examined the role of denervation supersensitivity in the development of cerebral vasospasm. Adrenergic denervation of cat basilar artery was accomplished by resection of the superior cervical ganglia or by injection of 6-hydroxydopamine into the cisterna magna. In vivo dose-response characteristics were determined for normal and for denervated arteries, and no significant differences were found between topical applications of serotonin, norepinephrine, epinephrine, fresh blood, or incubated blood. In addition, analysis of cat blood incubated in vitro revealed that the levels of serotonin, norepinephrine, and epinephrine diminished over time, whereas levels of hemoglobin and methemoglobin increased up to Day 14. The results of this study indicate that adrenergic denervation is not the cause of cerebral vasospasm and that, whatever the mechanism, hemoglobin is far more likely to play a role than are the other agents.

Bilirubin levels in subarachnoid clot and effects on canine arterial smooth muscle cells.

Background and Purpose Previous studies have suggested that bilirubin is a potential contributor to cerebral vasospasm. The purpose of this investigation was to determine whether bilirubin accrues in subarachnoid clot, whether its vasoconstrictive effect could involve a direct action on arterial smooth muscle cells, and, if so, whether bilirubin affects their Ca2+ uptake. Methods Subarachnoid clots were analyzed for bilirubin using high-performance liquid chromatography. The length and 45Ca2+ uptake of vascular smooth muscle cells enzymatically dissociated from canine carotid arteries were measured before and after exposure to bilirubin solution. Additional experiments were conducted on cultured smooth muscle cells from canine basilar artery and on ATP-depleted cardiac myocytes. Results Mean±SE bilirubin concentration in experimental clot was 263±35.7 μmol/L. Vascular smooth muscle cells exposed to bilirubin showed progressive shortening (P<.01) and an increased uptake of 45Ca2+ (P<.001). Contraction was prevented by Ca2+-free media but not by verapamil. Experiments with heart myocytes showed that bilirubin caused an increased uptake of 45Ca2+ but not of [14C] sucrose. Conclusions The results indicate that bilirubin accrues in subarachnoid clot, that it exerts a direct constrictive effecton arterial smooth muscle cells, and that this effect is associated with an increased uptake of Ca2+. Studies on heart myocytes suggest that the Ca2+ uptake induced by bilirubin could be dueto a selective increase in membrane permeability to Ca2+.

Midline craniectomy for sagittal suture synostosis: Comparative efficacy of two barriers to calvarial reclosure

This report quantitatively compares long-term head remolding achieved by two methods for retarding bone reunion after midline craniectomy for sagittal suture synostosis. In one group of six children the adjacent bone edges were overlayed with 1.0-cm-wide U-channel silicone strips, and in the other group, composed of seven patients, a considerably larger extent of the adjacent cranium was covered with silicone sheets. Mean percent change in the cephalic indices of the former group 18 months postoperatively was 9.1% +/- S.D. = 6.7, and of the latter group 23.7% +/- S.D. = 6.0 (p congruent to 0.01). These results indicate that the use of large silicone sheets lead to a significantly greater normalization of cranial proportions.