An examination of aneurysm rerupture rates with epsilon aminocaproic acid.

BACKGROUND: Epsilon aminocaproic acid (EACA) has been used in the past to prevent cerebral aneurysm rerupture. Recent studies have indicated that short-term treatment with EACA can lower rebleeding rates without significantly increasing ischemic or thrombotic complications or permanent shunt rates. The goal of this study is to determine the efficacy of EACA in the prevention of aneurysm rerupture at a high volume subarachnoid hemorrhage center. METHODS: We conducted a retrospective study of 355 consecutive subarachnoid hemorrhage patients over a 2-year period under our current protocol for EACA use. Patients were divided by presentation time to our institution and whether the patient received EACA. The primary endpoints of the study were rebleeding rates, ischemic complications, thrombotic complications, vasospasm, shunt rates, and outcomes. RESULTS: Rerupture rates were reduced by half in the entire pool of patients on EACA after controlling for Hunt and Hess Scores and Fisher Scores. In patients who received early aneurysm treatment, this effect persisted but was non-statistically significant due to the small numbers of reruptures. In addition, there was no evidence to suggest that EACA increased ischemic or thrombotic complications, vasospasm, or VPS rates. In patients presenting earlier than 24 h to our institution, there was a non-significant trend toward worse outcomes after EACA use. This trend was reversed in patients arriving after 24 h. CONCLUSION: There is evidence to suggest that EACA is protective from aneurysm rerupture without significant ischemic or thrombotic complications when used for less than 72 h. However, if the aneurysm is treated, this effect is modest indicating that early aneurysm treatment remains the gold standard for rerupture prevention.

Minimally invasive retrieval of a bullet from the L5-S1 neural foramina after transperitoneal gunshot wound.

BACKGROUND CONTEXT: In victims of gunshot wounds with retained bullet fragments in the central nervous system, delayed neurological deficit may result from copper-induced neurotoxicity. The mainstay of therapy involves surgical exploration and retrieval of fragments. PURPOSE: A patient who presented with delayed neurological deficit after a transperitoneal gunshot wound is presented. STUDY DESIGN: Technical report. METHODS: A 25-year-old male, who was the victim of a transperitoneal gunshot wound with a copper-jacketed bullet, presented several weeks after recovering from his abdominal injury. The patient presented with a worsening radiculopathy in the L5 distribution and progressive dorsiflexion weakness. Subsequent imaging demonstrated a bullet lodged lateral to the L5-S1 neural foramina. RESULTS: A minimally invasive approach with the use of a tubular retractor was used to retrieve the retained bullet. The lateral location of the bullet, the proximity of the nerve root to the bullet, and the limited visualization of the operative field from a minimally invasive approach, placed the nerve root at increased risk. Intraoperative myelography and electrophysiological monitoring were used to locate the nerve root in relation to the bullet and guide the extraction of the bullet. Postoperatively, the patient had complete resolution of his preoperative symptoms. CONCLUSIONS: In cases where proximity to neural structures and limited visualization of bony landmarks may increase the risk of injury when extracting a foreign body, intraoperative myelography and electrophysiological monitoring are valuable adjuncts to further elucidate the surgical anatomy for a minimally invasive approach.