Surgically treated cerebral aneurysms in south Trinidad: twenty years experience 1986-2005.

INTRODUCTION: For many years the treatment of cerebral aneurysms was surgical - clipping or wrapping. In recent years however, interventional radiology is available with techniques of coiling and stenting. The current treatment of any aneurysm is based on a combination of interventional and surgical techniques and in many cases the final treatment is interventional. It may be useful to document surgically treated aneurysms at San Fernando General Hospital serving a population area of half million in south Trinidad in the twenty years 1986-2005 before the advent of interventional radiology in Trinidad which became available in late 2005

Outcome of stroke in patients with sickle cell disease

Cerebral vasculopathy is a major cause of morbidity in sickle cell disease (SCD). We report the first UK population-based study of stroke in SCD. Of 669 SCD patients (HbSS 429, HbSC 193, HbS-thalassaemia 48, HbSO 1) followed at the King's College hospital between 1970 and 1995, 21 (3.1 percent) developed stroke. A further ten patients were referred. 29 had HbSS and 2, HbSC. 3 (10 percent) suffered subarachnoid haemorrhage, the remaining 28 strokes were ischaemic. Median age at initial stroke was 6 years (19 mo- 31 yr) with 24 (80 percent) patients aged >10. Precipitating factors included parvovirus associated aplastic crisis in 2/25 98 percent) evaluable patients and bacterial meningitis in 2 (8 percent). 9 (36 percent) patients experienced transient neurological disturbance prodromally. 27 (87 percent) presented with paresis, 5 (16 percent) cranial nerve defects. 11 (35 percent) dysphasia and 3 (10 percent) seizures. No patient died during the acute episode. Patients with stroke had significantly lower Hb and higher WCC at age 1 compared to matched controls. Exchanged transfusion was performed with 26 patients following which 15 (58 percent) recovered neurologically. 19 patients subsequently entered a transfusion programme to maintain HbS <30 percent. Transfusion was stopped in 10 patients. Of these, 6 (60 percent) had recurrent stroke at a median of 4.5 months. A similar recurrence rate (50 percent) was observed among patients who did not receive regular transfusion whilst no patient maintained on monthly transfusions suffered further stroke. Recurrence was more common in patients suffering initial stroke at an early age and in whom no trigger was identified. Median follow-up after initial stroke is 8 years. 14 (45 percent) patients have no residual neurological deficit, 6 (19 percent) are severely disabled, 13 (42 percent) have learning disabilities and 7 (23 percent) epilepsy. There were two deaths in both patients with recurrent stroke. 1 patient with moyamoya-type disease has undergone extracranial-intracranial bypass and 1 allogeneic-BMT. In conclusion, whilst transfusion is effective in prevention of further stroke, cessation is associated with a high rate of recurrence which frequently results in severe physical and/or neuropsychological disability. The 6.5 percent mortality following stroke supports the rationale for early consideration of allogeneic-BMT in these patients. (AU)

A comparison of early versus delayed surgery for ruptured intracranial aneurysms - abstract

The timing of surgical clipping for ruptured intracranial aneurysms has been a subject of debate for many years. Initial attempts at early surgery (within 24-72 hours) had disastrous results and led to the standard practice of delaying surgery for 7-10 days. The use of antifibrinolytic agents during this waiting period was shown to decrease the incidence of rebleeding but also seemed to cause increased frequency of ischaemic deficits and hydrocephalus. With the refinement of microneurosurgical techniques, early surgery for intracranial aneurysms underwent a rebirth in many centres over the last few years. This paper presents the experiences with aneurysm surgery at the Neurosurgical Unit Halifax, Nova Scotia over the four-year period 1984-1987. Ruptured aneurysms lead to subarachnoid haemorrhage in over 50 percent of the cases, arteriovenous malformations comprised 10 percent, and subarachnoid haemorrhage with normal angiography 25 percent of the total cases. During the period under review 25 patients presented with ruptured vertebrobasilar aneurysms and 211 patients presented with ruptured supratentorial aneurysms. The latter group form the basis for comparing results of early vs. delayed clipping for ruptured aneurysms. Despite the fact that the series comprised a consecutive, unmatched group of patients without any attempt at randomization, there were striking similarities in the mean ages, sex distribution and distribution of aneurysms at the various sites in the two groups being compared. Sixty-nine patients presented in good clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades I and II). Twenty-nine patients (mean age 44.5 years) underwent early surgery and 40 (mean age 45 years) had delayed surgery. Despite the higher rebleed rate in the delayed group (12.5 percent vs. 0 percent) there was no statistically significant difference in the eventual outcome between the two groups (mortality rate and the quality of survival). Eighty-five of the patients had excellent outcomes. However, the length of hospital stay was significantly shorter in the patients operated on early (17 days vs. 30 days). Symptomatic vasospasm (40 percent) and hydrocephalus (10 percent) occurred with similar frequencies in both groups. Fifty-two patients presented in poor clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades III and IV). Twenty-three patients (mean age 49.5 years) had early surgery and 29 patients (mean age 53 years) had delayed surgery. The mortality rate (approximately 25 percent) was similar in both groups. Rebleeding was the culprit in the delayed group (24 percent) whereas the surgical mortality was 26 percent in the early group. There was an equally high incidence of symptomatic vasospasm and hydrocephalus in both groups. The quality of survival was better in the early group but achieved statistical significance only in the number of patients making "excellent" recoveries (43 percent vs. 17 percent). The numbers of patients however were small. Aggressive treatment of acute hydrocephalus by ventricular drainage played a large part in improving the clinical status prior to surgery in the early group. As with previous studies (including a large co-operative series), we have been unable to show a really convincing advantage of early aneurysm surgery over delayed surgery if mortality rate and quality of survival are used as the basis of comparison. Clearly, a large scale randomized trial would have to be launched to answer this question conclusively. To answer the criticisms of ardent proponents of delayed surgery, however, we have confirmed that early surgery provides at least as good results. We have not found early surgery technically more difficult. It allows removal of large collections of subarachnoid blood and aggressive treatment of cerebral vasospasm and hydrocephalus and at the same time prevents rebleeding from the aneurysm. We feel early surgery will become more frequently used as newer methods of preventing cerebral vasospasm are discovered. The implications of our experiences to the situations that obtain in the Caribbean will be discussed (AU)

Cerebro-vascular complications of sickle cell disease in Jamaica - abstract

Homozygous sickle cell disease is an uncommon but important cause of hemiparesis and subarachnoid haemorrhage. A 24-year review showed that 42 cases of hemiparesis and 9 cases of subarachnoid haemorrhage had been seen at the University Hospital of the West Indies. All living patients (32) were examined in 1984 for residual defects. Twenty-two males and 20 females, with a median age of 7 years (range 8 months to 36 years) had had a stroke. Most (69 percent) were under 10 years of age at the time of the first stroke. No haematological or clinical predictor for stroke was identified, although transient ischaemic episodes prior to the onset of a complete stroke were seen in one 13-year-old. Recurrence clustered within the first 30 months with 10 of the 17 cases occurring in the first year. Contralateral occurrences were commonest (14) and resulted in death in 13. Subarachnoid haemorrhage was seen in 5 males and 4 females, aged 6 to 57 years (median 19 years), and 3 patients died. At re-evaluation of 32 patients, 8 had complete recovery, 20 residual hemiplegia and 4 quadriplegia. It is concluded that cerebro-vascular accident, though uncommon in sickle cell disease, affects a young age group and is associated with devastating consequences (AU)

Some clinical aspects of subarachnoid haemorrhage

Two hundred and forty-six cases of "subarachnoid haemorrhage" admitted to a general hospital over a five year period (1952-56) are presented, of which 190 were treated "medically" and 56 "surgically". The results are compared. If patients dying within the first 24 hours of admission to hospital are excluded, the comparison between those treated medically and surgically is quite favourable towards "conservatism", confuting the generally quoted figures which usually have a decided bias towards surgery and are too often derived from selected groups. Patients with persisting symptoms and signs, or with a secondary rise in pulse rate and recurrence of signs and symptoms should be promptly investigated by angiography and sent to surgery. Non-ganglion blocking hypotensive drugs should be considered in the hypertensive subject. A plea is made for a more rational approach to the problem, particularly in centres where they are admitted to the wards of a general hospital. (AU)

Some aspects of acute oedema of the lungs

A case is described of subarachnoid haemorrhage in a boy of fourteen years followed at once by fatal oedema of the lungs. The prevalent theory as to the cause of pulmonary oedema i.e. ventricular imbalance was propounded by Welchin 1878. Sufficient clinical and experimental observations have now been made to suggest that there are cases of pulmonary oedema of strictly neurologic origin, i.e. without any cardiac pathology. A part of the syndrome of cerebral haemorrhage is congestion of the lungs which may go on to oedema. It is suggested that the cough and other signs and symptoms of 'chestiness' (which are so frequently observed in patients who have had a 'stroke' and which rarely last more than the first few days of the illness) are central in origin (AU)