Toshiaki Tazawa

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.

Value of computed tomography in the prediction of cerebral vasospasm after aneurysm rupture.

The relationship between high density (HD) on computed tomographic (CT) scans (which indicates a collection of blood in the subarachnoid space) and cerebral vasospasm was studied in 177 patients with ruptured aneurysm. The development of cerebral vasospasm was confirmed at the high rate of 84.6% in 26 cases where HD was demonstrated on the CT scan within 4 days after subarachnoid hemorrhage (SAH). In 8 cases where HD was not found on the CT scan obtained within 4 days after SAH, no cerebral vasospasm was seen. However, no relationship was found between HD and the occurrence of cerebral vasospasm in cases in which CT was performed after the 5th day of disease. It is suggested that CT performed within 4 days after SAH may give important information for predicting cerebral vasospasm.

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.

Intraoperative use of real time ultrasonography applied to aneurysm surgery.

The intraoperative application of real time ultrasonography during 13 neurosurgical operations for intracranial aneurysms is reported. In 2 cases, the aneurysms themselves could be detected clearly by real time ultrasonic imaging. In the case of a large aneurysm, information about the nature of the aneurysmal wall was obtained. Other lesions coexisting with the aneurysm (namely, intracerebral hematoma, massive subarachnoid hemorrhage, and hydrocephalus) could be recognized clearly. Real time intraoperative ultrasonography is considered to be useful in aneurysm surgery.

Piperacillin-induced encephalopathy

Dear Sir, Piperacillin (PIPC) is a new semisynthetic ampicillin derivative which is effective against Gram-negative bacteria including Pseudomonas. It has a lower CNS toxicity compared with benzylpenicillin. We have recently experienced a case of PIPC-induced encephalopathy. A 82-year-old woman was admitted to our hospital because of fever and anorexia. On admission physical examination showed systolic cardiac murmur over apex. Laboratory examinations showed normocytic normochromic anemia, hypoalbuminemia and hypergammaglobulinemia. White blood cell count was 5000/mm3 and CRP was 3.8 mg/dl (N < 0.2 mg/dl). Serum electrolytes, liver enzymes, blood urea nitrogen, creatinine and urinalysis were normal. Initially PIPC 2 g/day was administered for possible infection. Fever resolved on the third hospital day. PIPC therapy was continued for ten days and discontinued on the twelfth hospital day. During this period no side effects were observed. Fever developed again on nineteenth hospital day. Blood cultures were performed twice. They showed o-streptococcus was positive. The diagnosis of subacute bacterial endocarditis was made judging from the findings of anemia, hypoalbuminemia, hypergammaglobulinemia and cardiac murmur. PIPC 6 g/day was administered. Five days later she became confused, disoriented and developed hallucinations. These symptoms continued for five days. PIPC was discontinued for possible side effects of PIPC. The symptoms resolved 24 h after withdrawal. Thereafter cephamezin 4 g/day was

Cerebral Venous Thrombosis: Findings from Computer Tomography and Fluorescein Angiography

Four cases of cerebrovenous thrombosis showed a high density focus in simulating subcortical arterial haemorrhage in the computer-tomographic (CT) scan. The diagnosis was made by angiography and fluorescein microangiography (FCA) performed at operation. Frontal cortical veins, with or without the anterior part of the superior sagittal sinus, were involved in 3 cases and the vein of Labbe was occluded in one case. In the CT scan, marginal irregularity and cortical involvement of the haemorrhage with a wide perifocal low density area were the specific findings which suggested venous haemorrhage. Contrast medium enhancement was minimal in the acute stage. Marked subarachnoid haemorrhage was noted at operation. With FCA, the site of occluded veins, collateral flow and fluorescein extravasation were visualized. A pathological specimen taken from a high density focus demonstrated haemorrhagic infarction. All patients had a good recovery during in-patient treatment, but two had recurrent attacks after discharge.

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.

Long-Term Follow-up Study of STA-MCA Anastomosis and EMS in Moyamoya Disease

The condition of 62 children with moyamoya disease was followed after cerebral revascularization. The mean follow-up period was 87 months. For revascularization, 42 cases were treated with superficial temporal artery—middle cerebral artery (STA-MCA) anastomosis and encephalomyosynangiosis (EMS) on both sides, nine with only EMS on both sides, and the remaining 11 with STA-MCA anastomosis on one side and with EMS on the other side. Clinical improvement was obtained in 61 among 62 cases. Complete remission without any neurological deficits was obtained in 27 cases. Speech disturbance worsened in the remaining one. Though postoperative improvement in the motor and speech function was satisfactory in most of the cases, these surgical procedures could not restore the visual field defect caused by completed stroke. Minor deficits in the intellectual function persisted in 14 cases.

Clinicopathological study on pulmonary thrombosis or thromboembolism in cerebrovascular diseases

肺血栓あるいは塞栓症は稀な疾患とされているが, 脳血管障害剖検274例中20例7.3%に認められ, また肺梗塞を証明した症例に限ると13例4.7%となる.発症頻度はいずれも脳出血, クモ膜下出血, 脳梗塞の順に高い.なお臨床上肺梗塞と思われる症状を呈した症例は3例に過ぎず, 臨床検査では胸部X線写真で無気肺, 葉間肋膜炎各1例, 肺炎2例を認めた.血液所見としては白血球増多症が大部分に認められ, GOTが正常でLDHの上昇をみた症例が40%を数えた.病理所見としては, 全身多発性血栓の部分症 (7例) として, また単独に肺動脈血栓あるいは塞栓を認めたもの (13例) があり, 後者の大部分は血栓由来の塞栓症 (肺血栓塞栓症) と考えられた.肺梗塞を認めなかった7症例のうち, 太い血管における閉塞症を示した脳塞栓症1例を除き, 他の6例は肺の小動脈に多発した新鮮な血栓あるいは塞栓症であった.