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Masami Shimoda, Shinri Oda, Ryuichi Tsugane, and Osamu Sato

✓ This investigation has revealed the frequency of various intracranial complications that may result from hypervolemic therapy for a delayed ischemic deficit following subarachnoid hemorrhage (SAH). Among 323 patients with SAH, 112 patients developed a delayed ischemic deficit, 94 of whom underwent hypervolemic therapy. Infarction due to vasospasm was found ultimately in 43 of these 94 patients. Twenty-six patients (28%) developed an intracranial complication during hypervolemic therapy: cerebral edema was aggravated in 18, and a hemorrhagic infarction developed in eight. In 13 of 18 patients with aggravation of edema, delayed ischemic deficit developed within 6 days after the SAH; at that time, a massive new infarction was found in four and edema in 10 patients. After hypervolemic therapy, the 18 patients with aggravation of edema deteriorated rapidly, and 14 of them died. In every case in which hemorrhagic infarction followed hypervolemic therapy, a new infarct was found on computerized tomography (CT) when the delayed ischemic deficit became apparent. Hemorrhagic infarction developed as the delayed ischemic deficit resolved, with one exception. In patients who sustained no complication from hypervolemia, the incidence of both massive new infarction and edema at the time when the delayed ischemic deficit was manifested was only 1%. In 44 of 68 patients who sustained no complication from hypervolemia, the delayed ischemic deficit was manifested on or after the 7th day following the SAH. This study suggests that hypervolemic therapy is contraindicated in a patient who is found to have a massive abnormality on CT at the time when a delayed ischemic deficit is manifested, especially when it occurs within 6 days after the SAH. To avoid hemorrhagic infarction, it is important to discontinue hypervolemic therapy as soon as the delayed ischemic deficit resolves.

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Masami Shimoda, Shinri Oda, Yoshiaki Mamata, Ryuichi Tsugane, and Osamu Sato

The authors retrospectively analyzed surgical outcomes in patients with an intracerebral hemorrhage (ICH) due to a ruptured middle cerebral artery aneurysm. A total of 47 patients with ICH who underwent early aneurysm surgery and hematoma evacuation within 24 hours following onset were studied. The types of ICH were classified into three groups by computerized tomography findings: 1) temporal ICH; 2) intrasylvian hematoma; and 3) ICH with diffuse subarachnoid hemorrhage (SAH). Overall, 25 patients (54%) had a favorable outcome and 18 (38%) died. Prognostic factors that predicted a favorable outcome included age less than 60 years, temporal ICH, World Federation of Neurological Surgeons Grade II or III, absence of a surgical complication, and a hematoma volume of less than 25 ml. In the patients with temporal ICH, eight of nine patients had a good recovery, and no patient developed a surgical complication or a delayed ischemic deficit. The most important predictive factor for a favorable outcome in patients with an intrasylvian hematoma was that they underwent early surgery (within 6 hours after symptom onset). In patients with a temporal ICH or intrasylvian hematoma, the initial neurological examination did not accurately predict outcome. By contrast, in the patients with ICH and diffuse SAH, those who developed an ICH with a volume of 25 ml or greater had a poor prognosis. These results suggest that aggressive surgical treatment should be initiated in patients with a temporal ICH or an intrasylvian hematoma, regardless of neurological findings on admission. In patients with an ICH and diffuse SAH, careful review of surgical indications is required.

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EDITOR'S PERSPECTIVE ON ARTICLE 3

Surgical indications in patients with an intracerebral hemorrhage due to a ruptured middle cerebral artery aneurysm

Masami Shimoda, Shinri Oda, Yoshiaki Mamata, Ryuichi Tsugane, and Osamu Sato

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Masami Shimoda, Shinri Oda, Yoshiaki Mamata, Ryuichi Tsugane, and Osamu Sato

✓ In this retrospective study, the authors analyzed surgical outcomes in patients who suffered an intracerebral hemorrhage (ICH) as a result of a ruptured middle cerebral artery aneurysm. They studied 47 patients who underwent early aneurysm surgery and hematoma evacuation within 24 hours after onset of ICH. The types of ICH were classified into three groups according to their appearance on computerized tomography scanning: 1) temporal ICH; 2) intrasylvian hematoma; and 3) ICH with diffuse subarachnoid hemorrhage (SAH). Overall, 25 patients (53%) achieved a favorable outcome and 18 (38%) died. Factors that could be used to predict a favorable outcome included age less than 60 years, temporal ICH, World Federation of Neurological Surgeons Grade II or III, absence of a surgical complication, and a hematoma volume less than 25 ml. In the patients with temporal ICH, eight of nine patients achieved a good recovery and no patient developed a surgical complication or delayed ischemic deficit. The significant prognostic factor in patients with an intrasylvian hematoma was surgery within 6 hours after onset of symptoms. In patients with temporal ICH or intrasylvian hematoma, the results of the initial neurological examination did not accurately predict outcome. On the other hand, in patients with ICH and diffuse SAH, those patients who developed an ICH with a volume greater than 25 ml had a poor prognosis. These results indicate that aggressive surgical treatment should be performed in patients with a temporal ICH or an intrasylvian hematoma, regardless of the neurological findings on admission; in patients with ICH and diffuse SAH, a careful review of surgical indications is required.

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Masami Shimoda, Shinri Oda, Masayoshi Shibata, Jiro Tominaga, Mamoru Kittaka, and Ryuichi Tsugane

Object. The goal of this study was to evaluate the results of early surgical evacuation of “packed” intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH).

Methods. The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view.

Conclusions. Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.

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Shizuo Oi, Masami Shimoda, Masayoshi Shibata, Yumie Honda, Kouji Togo, Masaki Shinoda, Ryuichi Tsugane, and Osamu Sato

Object. Long-standing overt ventriculomegaly in adults (LOVA) is a unique form of hydrocephalus that develops during childhood and manifests symptoms during adulthood. The aim of the present study was to analyze the specific pathophysiological characteristics of LOVA.

Methods. The specific diagnostic criteria for LOVA include severe ventriculomegaly in adults that is associated with macrocephalus measuring more than two standard deviations in head circumference and/or neuroradiological evidence of a significantly expanded or destroyed sella turcica. Twenty patients who fulfilled these criteria, 14 males and six females, were retrospectively studied. These patients' ages at diagnosis ranged from 15 to 61 years (mean 39.4 years). All had symptoms and/or signs indicating that hydrocephalus first occurred at birth or during infancy in the absence of any known underlying disease. The authors performed a pathophysiological study that included specific variations of magnetic resonance (MR) imaging, such as fluid-attenuated inversion recovery and cardiac-gated cine-mode imaging; intracranial pressure (ICP) monitoring; three-dimensional computerized tomography (CT) scanning; and other techniques.

Hydrocephalus was caused by aqueductal stenosis in all patients. Severe ventriculomegaly involving the lateral and third ventricles was associated with a marked expansion or destruction of the sella turcica in 17 cases. Cardiac-gated cine-MR imaging did not reveal any significant movements of cerebrospinal fluid in the aqueduct. Three-dimensional CT ventriculography confirmed that the expanded third ventricle protruded into the sella and, sometimes, extended a diverticulum. Fourteen patients revealed symptoms and signs that indicated increased ICP with prominent pressure waves. Dementia or mental retardation was seen in 11 patients, gait disturbance in 12, and urinary incontinence in eight; all three of these symptoms were observed in seven patients. Thirteen patients experienced visual disturbance. Nine patients underwent ventriculoperitoneal shunt implantation as the initial treatment, leading to postoperative subdural hematoma in all seven cases in which a differential pressure valve was used. Nine patients, three of whom were initially treated by shunt placement, underwent a neuroendoscopic procedure, mainly for third ventriculostomy. Postoperatively, ICP returned to normal, and marked to-and-fro pulsatile movements at the site of ventriculostomy were recognized on cine-MR imaging in patients treated endoscopically. However, the ventriculomegaly was little improved. Consequently, all patients eventually demonstrated improvement in response to either a shunt equipped with a pressure-programmable valve or an endoscopic procedure; however, depression appeared in six patients, who required psychiatric consultation or medication.

Conclusions. Such remarkably decreased intracranial compliance but relatively high ICP dynamics are the pathophysiological characteristics of LOVA. The therapeutic regimen should be determined based on the individual's specific pathophysiological makeup.

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Shinri Oda, Masami Shimoda, Akihiro Hirayama, Masaaki Imai, Fuminari Komatsu, Hideaki Shigematsu, Jun Nishiyama, Kazuko Hotta, and Mitsunori Matsumae

OBJECTIVE

This study attempted to determine whether a previous minor leak correlated with the occurrence of symptomatic delayed cerebral ischemia (sDCI).

METHODS

The authors retrospectively evaluated sDCI-related clinical features and findings from MRI, including T1-weighted imaging (T1WI)–FLAIR mismatch at the time of admission, in 151 patients admitted with subarachnoid hemorrhage (SAH) within 48 hours of ictus.

RESULTS

The overall incidence of sDCI was 23% (35 of 151 patients). In all subjects, multivariate analysis revealed that World Federation of Neurosurgical Societies Grades II–V, age 70 years or older, presence of rebleeding after admission, a previous minor leak before the major SAH attack as diagnosed by T1WI-FLAIR mismatch, acute infarction on diffusion-weighted imaging, and CT SAH score were significantly associated with occurrence of sDCI. In patients with no previous minor leak before major SAH as diagnosed by T1WI-FLAIR mismatch, the incidence of sDCI was only 7% (7 of 97 patients).

CONCLUSIONS

A previous minor leak before major SAH as diagnosed by T1WI-FLAIR mismatch represents an important sDCI-related factor. When the analysis was restricted to patients with true acute SAH without a previous minor leak diagnosed by T1WI-FLAIR mismatch, the incidence of sDCI was extremely low.