The authors present a unique case of a patient with communicating hydrocephalus and repeated ventriculoperitoneal shunt obstructions resulting from mucin-secreting enterogenous cell deposits at the cervicomedullary junction. Pathological examinations revealed that these cellular deposits lacked characteristic cystic architecture and the patient had no history of previous cyst with dissemination. Because of the repeated shunt obstructions and inability to surgically resect the lesion in its entirety, the authors elected radiation therapy to the cervicomedullary junction, encompassing the radiological abnormality. As of this writing, the patient has remained at neurological baseline and has not required further shunt revisions for obstruction.
Sohum Desai, Jonathan A. Friedman, Joseph Hlavin, Rudy P. Briner, L. Gerard Toussaint III, J. Bradley White, and Alexander Van Amerogen
L. Gerard Toussaint III, Jonathan A. Friedman, Eelco F. M. Wijdicks, David G. Piepgras, Mark A. Pichelmann, Jon I. McIver, Robyn L. McClelland, Douglas A. Nichols, Fredric B. Meyer, and John L. D. Atkinson
Object. Previous studies have indicated an increased incidence of death in patients with subarachnoid hemorrhage (SAH) who are currently receiving anticoagulation therapy. The significance of previous aspirin use in patients with SAH is unknown. The authors analyzed the effects of prior aspirin use on clinical course and outcomes following aneurysmal SAH.
Methods. The medical records of 305 patients with angiogram-confirmed aneurysmal SAH who consecutively presented to our institution between 1990 and 1997 within 7 days of ictus were analyzed. Twenty-nine (9.5%) of these patients had a history of regular aspirin use before onset of the SAH. The Glasgow Outcome Scale (GOS) was used to measure patient outcome at the longest available follow up.
Aspirin users were older on average than nonusers (59 years of age compared with 53 years; p = 0.018). The mean admission Hunt and Hess grades of patients with and without aspirin use were similar (2 compared with 2.3; p = 0.51). Two trends, which did not reach statistical significance, were observed. 1) The rebleeding rate in aspirin users was 14.3%, compared with a 4.7% rebleeding rate in nonusers (p = 0.06). 2) Permanent disability from vasospasm was less common among aspirin users (23% compared with 50%; p = 0.069). Outcomes did not differ between aspirin users and nonusers (mean GOS Score 3.83 compared with GOS Score 3.86, respectively; p = 0.82).
Conclusions. Despite trends indicating increased rebleeding rates and a lower incidence of permanent disability due to delayed ischemic neurological deficits, there was no significant effect of previous aspirin use on overall outcome following aneurysmal SAH. Based on these preliminary data, the presence of an intracranial aneurysm is not a strict contraindication to aspirin use.
Alejandro A. Rabinstein, Mark A. Pichelmann, Jonathan A. Friedman, David G. Piepgras, Douglas A. Nichols, Jon I. McIver, L. Gerard Toussaint III, Robyn L. McClelland, Jimmy R. Fulgham, Fredric B. Meyer, John L. D. Atkinson, and Eelco F. M. Wijdicks
Object. The authors studied patients with aneurysmal subarachnoid hemorrhage (SAH) to determine whether the incidence of symptomatic vasospasm or overall clinical outcomes differed between patients treated with craniotomy and clip application and those treated by endovascular coil occlusion.
Methods. The authors reviewed 415 consecutive patients with aneurysmal SAH who had been treated with either craniotomy and clip application or endovascular coil occlusion at a single institution between 1990 and 2000. Three hundred thirty-nine patients underwent surgical clip application procedures, whereas 76 patients underwent endovascular coil occlusion.
Symptomatic vasospasm occurred in 39% of patients treated with clip application, 30% of patients treated with endovascular coil occlusion, and 37% of patients overall. Compared with patients treated with clip application, patients treated with endovascular coil occlusion were more likely to suffer acute hydrocephalus (50 compared with 34%, p = 0.008) and were more likely to harbor aneurysms in the posterior circulation (53 compared with 20%, p < 0.001). Logistic regression models controlling for patient age, admission World Federation of Neurosurgical Societies (WFNS) grade, acute hydrocephalus, aneurysm location, and day of treatment revealed that, among patients with an admission WFNS grade of I to III, endovascular coil occlusion carried a lower risk of symptomatic vasospasm (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14—0.8) and death or permanent neurological deficit due to vasospasm (OR 0.28, 95% CI 0.08–1) compared with craniotomy and clip application. Similar models revealed no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less at the longest follow-up review (median 6 months) between treatment groups (OR 0.58, 95% CI 0.28–1.21).
Conclusions. Patients with better clinical grades (WFNS Grades I–III) at hospital admission were less likely to suffer symptomatic vasospasm when treated by endovascular coil occlusion, compared with craniotomy and clip application. Nevertheless, there was no significant difference in overall outcome at the longest follow-up examination between the two treatment groups.
Jon I. McIver, Jonathan A. Friedman, Eelco F. M. Wijdicks, David G. Piepgras, Mark A. Pichelmann, L. Gerard Toussaint III, Robyn L. McClelland, Douglas A. Nichols, and John L. D. Atkinson
Object. Despite the widespread use of ventriculostomy in the treatment of acute hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), there is no consensus regarding the risk of rebleeding associated with ventriculostomy before aneurysm repair. This present study was conducted to assess the risk of rebleeding after preoperative ventriculostomy in patients with aneurysmal SAH.
Methods. The authors reviewed the records of all patients with acute SAH who were treated at a single institution between 1990 and 1997. Thus, the records of 304 consecutive patients in whom an aneurysmal SAH source was documented on angiographic studies and who had presented to the authors' institution within 7 days of ictus were analyzed. Rebleeding was confirmed by evidence of recurrent hemorrhage on computerized tomography scans in all cases.
Forty-five patients underwent ventriculostomy for acute hydrocephalus after aneurysmal SAH at least 24 hours before aneurysm repair. Ventriculostomy was performed within 24 hours of SAH in 38 patients, within 24 to 48 hours in three patients, and more than 48 hours after SAH in four patients. The mean time interval between SAH and surgery in patients who did not undergo ventriculostomy was no different from the mean interval between ventriculostomy and surgery in patients who underwent preoperative ventriculostomy (3.6 compared with 3.8 days, p = 0.81). Fourteen (5.4%) of the 259 patients who did not undergo ventriculostomy suffered preoperative aneurysm rebleeding, whereas two (4.4%) of the 45 patients who underwent preoperative ventriculostomy had aneurysm rebleeding.
Conclusions. No evidence was found that preoperative ventriculostomy performed after aneurysmal SAH is associated with an increased risk of aneurysm rebleeding when early aneurysm surgery is performed.
Jonathan A. Friedman, Stephan J. Goerss, Fredric B. Meyer, David G. Piepgras, Mark A. Pichelmann, Jon I. McIver, L. Gerard Toussaint III, Robyn L. McClelland, Douglas A. Nichols, John L. D. Atkinson, and Eelco F. M. Wijdicks
Object. Predicting which patients with aneurysmal subarachnoid hemorrhage (SAH) will develop delayed ischemic neurological deficit (DIND) due to vasospasm remains subjective and unreliable. The authors analyzed the utility of a novel software-based technique to quantify hemorrhage volume in patients with Fisher Grade 3 aneurysmal SAH.
Methods. Patients with aneurysmal SAH in whom a computerized tomography (CT) scan was performed within 72 hours of ictus and demonstrated Fisher Grade 3 SAH were analyzed. Severe DIND was defined as new onset complete focal deficit or coma. Moderate DIND was defined as new onset partial focal deficit or impaired consciousness without coma. Fifteen consecutive patients with severe DIND, 13 consecutive patients with moderate DIND, and 12 consecutive patients without DIND were analyzed. Software-based volumetric quantification was performed on digitized admission CT scans by a single examiner blinded to clinical information.
There was no significant difference in age, sex, admission Hunt and Hess grade, or time to admission CT scan among the three groups (none, moderate, or severe DIND). Patients with severe DIND had a significantly higher cisternal volume of hemorrhage (median 30.5 cm3) than patients with moderate DIND (median 12.4 cm3) and patients without DIND (median 10.3 cm3; p < 0.001). Intraparenchymal hemorrhage and intraventricular hemorrhage were not associated with DIND. All 13 patients with cisternal volumes greater than 20 cm3 developed DIND, compared with 15 of 27 patients with volumes less than 20 cm3 (p = 0.004).
Conclusions. The authors developed a simple and potentially widely applicable method to quantify SAH on CT scans. A greater volume of cisternal hemorrhage on an admission CT scan in patients with Fisher Grade 3 aneurysmal SAH is highly associated with DIND. A threshold of cisternal hemorrhage volume (> 20 cm3) may exist above which patients are very likely to develop DIND. Prospective application of software-based volumetric quantification of cisternal SAH may predict which patients will develop DIND.