X. L. Zhu

Spontaneous Intracranial Hemorrhage: Which Patients Need Diagnostic Cerebral Angiography?: A Prospective Study of 206 Cases and Review of the Literature

BACKGROUND AND PURPOSE In spontaneous intracerebral hemorrhage (ICH), the site, age of the patients, and preexisting hypertension are important factors in determining the possibility of finding an underlying vascular abnormality by cerebral angiography. To what extent these three factors affect the indication for angiography remains controversial. A prospective study was carried out to correlate the angiographic findings with these three factors. METHODS Two hundred six consecutive spontaneous ICH cases with an age range from 5 to 79 years (median, 45) were investigated with CT and cerebral angiography over a 3-year period (April 1993 through March 1996). Exclusion criteria were (1) poor surgical risk or severely neurologically disabled patients, (2) refusal of angiography, (3) patients in whom severe coagulopathy accounted for the hemorrhage, (4) bleeding into tumor, or (5) subarachnoid hemorrhage-predominant cases. RESULTS Angiographic yield (the frequency of positive angiography in a defined patient group) was significantly higher in patients (1) at or below the median age of 45 than those above (53/105, 50%, versus 18/101, 18%; P < .001) and (2) without preexisting hypertension than those with (64/145, 44%, versus 5/58, 9%; P < .001). The correlation of age and preexisting hypertension to angiographic yield was independent (logistic regression coefficients -0.056 and -1.59 and SE 0.12 and 0.515, respectively, both P < .001). In patients of the younger age group without preexisting hypertension, angiographic yield was 48% in putaminal, thalamic, or posterior fossa ICH and 65% in lobar ICH. In the older hypertensive patients, the yields were 0% and 10%, respectively. However, in patients with isolated intraventricular hemorrhage, most were normotensive and the yield was high in both age groups (67% versus 63%). CONCLUSION Diagnostic cerebral angiography should be considered for all spontaneous ICH patients except those over 45 years old with preexisting hypertension in thalamic, putaminal, or posterior fossa hemorrhage.

The role of computed tomographic angiography in the diagnosis of intracranial aneurysms and emergent aneurysm clipping.

Conventional cerebral angiography has always been regarded as the gold standard for intracranial aneurysm detection. However, conventional angiography has the disadvantages of being invasive and time consuming. We present here 30 patients who underwent computed tomographic angiography (CTA) with three-dimensional reconstruction for the detection of intracranial aneurysms. All of these patients had subarachnoid hemorrhage or suspected intracranial aneurysms. CTA was performed in all patients with the use of a General Electric Hispeed Advantage helical scanner. Iohexol, 135 ml, was used as the contrast agent. Twenty-five patients also underwent conventional angiography for comparison. The five patients who underwent CTA only did not have conventional angiography because of poor clinical condition, and four of them subsequently died. Five patients had subarachnoid hemorrhage, but the results of both CTA and conventional angiography were negative for aneurysms. One patient had an incidental finding of a 3-mm left posterior communicating artery aneurysm on CTA, which was confirmed by conventional angiography. In the remaining 19 patients, 19 saccular aneurysms and 1 fusiform aneurysm were detected by CTA. Locations and sizes were confirmed by conventional angiography in all except two. The first exception was a patient who had a 2.5-mm anterior communicating artery aneurysm detected by CTA but not by conventional angiography. Surgical exploration confirmed the CTA diagnosis. The other exception was a patient in whom a 2-mm right posterior communicating artery aneurysm was detected by CTA but in whom conventional angiography showed a 2-mm left posterior communicating artery aneurysm. Unfortunately, there was no surgical confirmation in this case because the family of the patient refused surgery. Our results have demonstrated that CTA is a quick, reliable, and relatively simple diagnostic tool for intracranial aneurysms. In an emergent situation, such as a deteriorating patient with a hematoma, it is superior to either empiric exploration or infusion computed tomographic scans because it delineates the orientation and configuration of the aneurysm and its associated vascular anatomy.

Predicting one year clinical outcome in traumatic brain injury (TBI) at the beginning of rehabilitation

Predicting long-term clinical outcome for patients with traumatic brain injury (TBI) at the beginning of rehabilitation provides essential information for counseling of the family and priority-setting for the limited resources in intensive rehabilitation. The objective of this study is to work out the probability of the one-year outcome at the beginning of rehabilitation. Sixty-eight patients with moderate-to-severe TBI and known one-year outcome were employed for outcome prediction using the logistic regression model. A large number of prospectively collected data at admission (age, Glasgow Coma Scale [GCS] Score, papillary response), during intensive care unit (ICU) management (duration of coma, intracranial pressure [ICP] and its progress) and at the beginning of rehabilitation (baseline Functional Independence Measure [FIM], Neuro-behavioral Cognitive Status Examination [NCSE] and Functional Movement Assessment [FMA]) were available for preliminary screening by univariate analysis. Six prognostic factors (age, GCS, duration of coma, baseline FIM, NCSC and FMA) were utilized for the final logistic regression model. Age, GCS and baseline FIM at the beginning of rehabilitation have been found to be independent predictors for one-year outcome. The accuracy of prediction for a good Glasgow Outcome Score is 68% and an outcome for disability (either moderate or severe) is 83%. Validation of this model using a new set of data is required.

Computed Tomographic Angiography and Venography for Young or Nonhypertensive Patients With Acute Spontaneous Intracerebral Hemorrhage

Background and Purpose— We compared the effectiveness of using computed tomographic angiography and venography (CTAV) with digital subtraction angiography (DSA) in young or nonhypertensive patients with acute spontaneous intracerebral hemorrhage. Methods— We prospectively recruited 109 young (age between 18 and 45 years) or nonhypertensive patients with acute spontaneous intracerebral hemorrhage for this comparative study. All patients had CTAV using multidetector CT with 64 detectors. They were then scheduled to have catheter angiography the next day. Radiological data were collected for blinded analysis. Results— DSA-positive pathologies causing hemorrhage were identified in 37 (33%) patients, which included cerebral arteriovenous malformation in 22 cases. The positive and negative predictive values of CTAV for DSA-positive pathologies causing hemorrhage were 97.3% (95% CI, 88.3%–99.9%) and 100% (95% CI, 95.9%–100%), respectively. Conclusions— CTAV was able to detect DSA-positive pathologies causing acute spontaneous intracerebral hemorrhage in young (age between 18 and 45 years) or nonhypertensive patients with high positive and negative predictive values.

Beneficial effect of cerebrolysin on moderate and severe head injury patients: result of a cohort study.

Cerebrolysin is used as a neurotrophic agent for the treatment of ischemic stroke and Alzheimers Disease. Exploratory studies in patients with post-acute traumatic brain injury have shown that this treatment might help improve recovery. Aim of this study was to investigate whether addition of Cerebrolysin to the initial treatment regimen of moderate and severe head injury patients would improve their outcome. At 6 months, 67% of the patients (Cerebrolysin group) attained good outcome (GOS 3-5). The study group was compared with the historical cohort of patients from the hospital trauma data bank, with age, sex and admitting GCS matching. More patients tended to a good outcome in the Cerebrolysin group (P = 0.065). No significant side-effect requiring cessation of Cerebrolysin was noted. It can be concluded that the use of Cerebrolysin as part of the initial management of moderate and severe head injury is safe and well tolerated. The results suggest that Cerebrolysin is beneficial in regard to the outcome in these patients, especially in elderly patients.

Neurological outcome in patients with traumatic brain injury and its relationship with computed tomography patterns of traumatic subarachnoid hemorrhage

OBJECT Traumatic subarachnoid hemorrhage (SAH) is a poor prognostic factor for traumatic brain injury. The authors aimed to further investigate neurological outcome among head injury patients by examining the prognostic values of CT patterns of traumatic SAH, in particular, the thickness and distribution. METHODS The study was conducted using a database in a regional trauma center in Hong Kong. Data had been prospectively collected in consecutive trauma patients between January 2006 and December 2008. Patients included in the study had significant head injury (as defined by a head Abbreviated Injury Scale [AIS] score of 2 or more) with traumatic SAH according to admission CT. RESULTS Over the 36-month period, 661 patients with significant head injury were admitted to the Prince of Wales Hospital in Hong Kong. Two hundred fourteen patients (32%) had traumatic SAH on admission CT. The mortality rate was significantly greater and a 6-month unfavorable outcome was significantly more frequent in patients with traumatic SAH. Multivariate analysis showed that the maximum thickness (mm) of traumatic SAH was independently associated with neurological outcome (OR 0.8, 95% CI 0.7-0.9) and death (OR 1.3, 95% CI 1.2-1.5) but not with the extent or location of hemorrhage. CONCLUSIONS Maximum thickness of traumatic SAH was a strong independent prognostic factor for death and clinical outcome. Anatomical distribution per se did not affect clinical outcome.

Single burr hole rigid endoscopic third ventriculostomy and endoscopic tumor biopsy: What is the safe displacement range for the foramen of Monro?

OBJECTIVE To investigate the safe displacement range of the foramen of Monro (FM) during single burr hole rigid endoscopic third ventriculostomy (ETV) and endoscopic tumor biopsy (ETB). METHODS Eleven patients who received ETV/ETB for third ventricular and pineal region tumor were reviewed. The burr-hole location, the size, and the virtual displacement of FM were measured using neuronavigation software. RESULTS Hydrocephalus was resolved, and no subsequent cerebrospinal fluid (CSF) shunting was required in all cases. Histological diagnosis was established in 11 patients. Ten cases received instrumental cognitive and memory assessment postoperatively. The results were within the normal range for eight cases. The mean burr-hole location was 1.7 cm anterior to coronal suture and 3 cm from the midline. The mean diameters of FM measured on the axial, coronal, sagittal, and views were 5.7, 7.8, and 5.6 mm, respectively. The mean virtual displacements of the FM were 1.9±2.0 mm (range=0-4.8) for ETV and 2.4±2.1 mm (range=0-5.5) for ETB. The maximum displacements were 4.8 mm anteriorly for ETV and 5.5 mm posteriorly for ETB. CONCLUSION Single burr hole rigid ETV/ETB is likely to be safe within maximum FM displacements of 4.8 mm anterior for ETV and 5.5 mm posterior for ETB. Preoperative trajectory planning using neuronavigation software is recommended.

Radiation-induced spinal glioblastoma multiforme

Radiation-induced intracranial tumour has been welldocumented since 1950, of which the largest groupwas meningioma, followed by gliomas and sarcomas[1]. On the other hand, glioblastoma multiforme(GBM) of the brain is the most frequent primarybrain tumor in adults. GBM of the spinal cord is arare disease when compared with that of the brain. Itonly accounts for 1

Incidence and Mortality of Spontaneous Subarachnoid Hemorrhage in Hong Kong from 2002 to 2010: A Hong Kong Hospital Authority Clinical Management System Database Analysis

BACKGROUND Ninety-five percent of the Hong Kong population is Chinese, and no previous epidemiological study has focused on spontaneous subarachnoid hemorrhage (SAH) in Hong Kong. These data would have significant public health implications and can guide future resource allocations and service development in Hong Kong. The aim of this study was to investigate the local incidences of spontaneous SAH and 1-year mortality rates in Hong Kong, with the respective time trends in recent years. METHODS Data from the Clinical Management System database of the Hong Kong Hospital Authority were used to examine the incidence of SAH and 1-year mortality rates among the Hong Kong population for the 2002-2010 period. Age-standardized incidence rates were calculated by the direct method using the standard population given in World Health Organization World Standard Population 2000-2025. RESULTS Crude SAH incidences increased from 5.5 per 100,000 person-years in 2002 to 7.5 in 2010. Standardized SAH incidences increased from 4.1 per 100,000 person-years in 2002 to 5.6 in 2010. Crude 1-year mortality rates decreased from 43% in 2002 to 19% in 2010, and the standardized 1-year mortality rate decreased from 38% in 2002 to 19% in 2010. CONCLUSION The Hong Kong SAH incidence was 7.5 per 100,000 person-years in 2010, and an increasing trend over time was noted. The 1-year mortality rates decreased from 43% in 2002 to 19% in 2010, in accordance with the worldwide trend.

Evolution of intracranial aneurysm treatment: From Hunterian ligation to the flow diverter

Background:  Intracranial aneurysm rupture has the highest levels of mortality and morbidity among all stroke types. To answer the question of how and why different well‐established and novel treatment techniques were developed, it is crucial to understand the historic hurdles and breakthroughs in intracranial aneurysm treatment over the years.