✓ A series is presented of 43 patients with multiple aneurysms and subarachnoid hemorrhage in whom a second operation was necessary in order to clip all the aneurysms. There was one surgical death due to coronary thrombosis and infarction which occurred 3 weeks after surgery, for a surgical mortality rate of 2.3%. One patient developed a permanent neurological deficit (hemiparesis and dysphasia). Thus, the surgical risks are smaller than the natural risk of bleeding and death from hemorrhage. Patients with any other serious illness increasing the surgical risk should not be subjected to an operation for an unruptured aneurysm; a second operation is indicated in all low-risk patients with multiple aneurysms or with incidentally identified aneurysms.
✓ A 22-month-old girl had a large noncommunicating cyst of the septum pellucidum which blocked the foramen of Monro and caused increased intracranial pressure and hydrocephalus. She recovered completely after the cyst wall was removed.
✓ The author presents a follow-up review of 61 patients with subarachnoid hemorrhage (SAH) and at least two intracranial artery aneurysms, in whom only the ruptured aneurysm had been clipped. During a 10-year follow-up period, seven patients bled from a previously unruptured aneurysm; four of the hemorrhages were fatal. Three additional patients suffered fatal bleeding more than 10 years after the first SAH. The surgical mortality rate when operating on a ruptured aneurysm at this clinic was 4.2% in 1979. Considering that the mortality rate after rebleeding during an average follow-up period of 16 years was 11.5%, operation for unruptured aneurysms seems to have a slight edge over conservative treatment.
Juha Öhman and Olli Heiskanen
✓ A total of 216 patients with a ruptured aneurysm of the anterior part of the circle of Willis were enrolled into this prospective randomized study of timing of the operation after aneurysmal subarachnoid hemorrhage (SAH). Only patients in clinical Grades I to III (according to the classification of Hunt and Hess) who were admitted and randomly assigned to a treatment group within 72 hours after the SAH were included in the trial. The patients were randomly assigned to one of three operation groups: acute surgery (AS: 0 to 3 days after the SAH; day of SAH = Day 0), intermediate surgery (IS: 4 to 7 days after the SAH), or late surgery (LS: 8 days to an indefinite time after the SAH). Three patients (4.3%) in the IS group and six patients (8.6%) in the LS group died before surgery was undertaken. At 3 months post-SAH, 65 patients (91.5%) from the AS group were classified as independent compared to 55 (78.6%) from the IS group and 56 (80.0%) from the LS group. The management mortality rate in the AS group was 5.6% compared to 12.9% in the LS group.
Of the 216 patients enrolled in the timing study, 159 were randomly assigned to an independent double-blind placebo-controlled trial of nimodipine in Grade I to III patients. A total of 79 patients received nimodipine and 80 placebo. When the nimodipine group and the no-nimodipine group (the 80 placebo-treated patients plus the 52 patients who were not entered into the nimodipine trial) were analyzed separately, a significant difference was seen in the outcome of the no-nimodipine group (dependent AS vs. dependent IS, p = 0.01). Nimodipine treatment was associated with a significant reduction of delayed ischemic deterioration (all operation groups combined, nimodipine vs. no nimodipine p = 0.01; LS with nimodipine vs. LS with no nimodipine, p = 0.03).
Juha Öhman and Olli Heiskanen
✓ The effect of intravenous nimodipine on the incidence of mortality and delayed ischemic neurological deficits of patients after aneurysmal subarachnoid hemorrhage (SAH) and surgery was studied in a prospective double-blind placebo-controlled trial. Upon admission, all of the patients were in Grades I to III according to the classification of Hunt and Hess. Of the 213 patients enrolled in the study, 58 underwent early surgery (within 72 hours after the bleed: Days 0 to 3), 69 were operated on subacutely (between Days 4 and 7), and 74 had late surgery (on Day 8 or later). Eleven patients died before surgery was undertaken and one was not scheduled for operation. Administration of the drug was started immediately after the radiological diagnosis of a ruptured aneurysm had been made. The dose of nimodipine or matching placebo was 0.5 µg/kg/min via continuous intravenous infusion for 7 to 10 days after the SAH and, if the patient was operated on late, for 2 to 3 days after the operation as well. After intravenous treatment, oral administration of nimodipine or placebo was continued for up to 21 days after SAH in a dose of 60 mg every 4 hours. Nimodipine treatment was associated with a significant decrease in mortality rate (p = 0.03) in the early and subacute surgery groups. In the total series the number of deaths due to delayed ischemic deterioration was significantly lower in the nimodipine group than in the placebo group (p = 0.01).
Olli Heiskanen and Irja Marttila
Influence of patient's age on symptoms, signs, and thickness of hematoma
Rainer Fogelholm, Olli Heiskanen and Olli Waltimo
✓The relationship of age to clinical and pathological findings was analyzed in 109 adult patients operated on because of chronic subdural hematoma. A well-formed membrane on the inner and outer surface of the hematoma was used as the criterion for chronicity of the hematoma. Younger patients had more evidence of increased intracranial pressure; older patients had more evidence of mental deterioration and pyramidal tract lesions. The interval from trauma to operation was shorter in the young patients. The thickness of the hematoma as measured from angiograms increased with the age of the patient. The cause of this difference is discussed.
Juha Öhman, Antti Servo and Olli Heiskanen
✓ A prospective series of 30 patients with a single, angiographically verified aneurysmal subarachnoid hemorrhage (SAH) was studied for the effect of intrathecal thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) on outcome, angiographic vasospasm, and computerized tomography (CT) findings after surgery. The patients included fulfilled the following criteria: operation was performed by Day 3 after the hemorrhage, CT showed only blood in the basal cisterns, and the patient had a single aneurysm or multiple aneurysms that could be treated surgically at the same operation. The patients were divided into groups of 10, with patients receiving 3, 10, or 13 mg of rt-PA in a single intracisternal injection at the end of the operation. There were no differences between the treatment groups in overall outcome. One patient from the 3-mg rt-PA group developed a postoperative intracerebral hemorrhage, and one patient from the 10-mg rt-PA group had a postoperative epidural hematoma. There was one death in the 13-mg rt-PA group that was caused by inclusion of a segment of pericallosal artery in the clip. In all treatment groups a reduction was observed in the amount of blood seen on the postoperative CT scans compared to the preoperative CT scans. The reduction in SAH grade between the 10-mg and 13-mg rt-PA groups was significant (p < 0.05). The difference in the severity of angiographic vasospasm between the 3-mg and 13-mg rt-PA groups was also significant (p < 0.05).
Juha Öhman, Antti Servo and Olli Heiskanen
✓ A total of 213 patients with verified aneurysmal subarachnoid hemorrhage (SAH) of Grades I to III (Hunt and Hess classification) were enrolled in a double-blind placebo-controlled trial to determine the effect of intravenous nimodipine on delayed ischemic deterioration and computerized tomography (CT)-visualized infarcts after SAH and surgery. The administration of the drug or matching placebo was started immediately after the radiological diagnosis of a ruptured aneurysm had been made. Of the 213 patients enrolled in the study, 58 were operated on early (within 72 hours after the bleed: Days 0 to 3), 69 were operated on subacutely (between Days 4 and 7), and 74 had late surgery (on Day 8 or later). Eleven patients died before surgery was undertaken and one was not operated on. A follow-up examination with CT scanning, performed 1 to 3 years after the SAH (mean 1.4 years), revealed no significant differences in the overall outcome between the groups. However, nimodipine treatment was associated with a significantly lower incidence of deaths caused by delayed cerebral ischemia (p = 0.01) and significantly lower occurrence of cerebral infarcts visualized by CT scanning in the whole population (p = 0.05), especially in patients without an associated intracerebral hemorrhage on admission CT scan (p = 0.03).