Update on acute endovascular and surgical stroke treatment.

Emergency stroke care has become a natural part of the emerging discipline of neurocritical care and demands close cooperation between the neurologist and neurointerventionists, neurosurgeons, and anesthesiologists. Endovascular treatment (EVT), including intra-arterial thrombolysis, mechanical thrombectomy and angioplasty/stenting, is under rapid development. Although EVT has yet to be shown in randomized controlled trials to improve clinical outcome compared to intravenous thrombolysis, it is far better in achieving recanalization of occluded large cerebral vessels, which is crucial for rescuing the penumbra. Moreover, decompressive craniectomy is now a well-established treatment option for malignant middle cerebral artery infarction and cerebellar stroke. Using a case-based approach, this article reviews recent achievements in advanced treatment options for patients with acute ischemic stroke.

Trends in monitoring patients with aneurysmal subarachnoid haemorrhage.

After aneurysmal subarachnoid haemorrhage (SAH), the clinical outcome depends upon the primary haemorrhage and a number of secondary insults in the acute post-haemorrhagic period. Some secondary insults are potentially preventable but prevention requires prompt recognition of cerebral or systemic complications. Currently, several neuro-monitoring techniques are available; this review describes the most frequently used techniques and discusses indications for their use, and their value in diagnosis and prognosis. None of the techniques, when considered in isolation, has proved sufficient after SAH. Furthermore, the use of multi-modality monitoring is hampered by a lack of clinical studies that identify combinations of specific techniques in terms of clinical information and reliability. However, ischaemia at the tissue level can be detected by intracerebral microdialysis technique. Used together with the conventional monitoring systems, for example intracranial pressure measurements, transcranial Doppler ultrasound and modern neuro-imaging, direct assessment of biochemical markers by intracerebral microdialysis is promising in the advancement of neurointensive care of patients with SAH. A successfully implemented monitoring system provides answers but it also raises valuable new questions challenging our current understanding of the brain injury after SAH.

A controlled study of microsurgical versus standard lumbar discectomy.

The purpose of the study was to evaluate whether a microsurgical discectomy (MS), compared with a standard lumbar discectomy (SD), could reduce the stay at the hospital or the postoperative morbidity. The study was prospective and of 79 patients with "virgin' lumbar radiculopathy from only one nerve root, 39 were randomized to MS and 40 to SD. All patients had positive myelography or CT findings. The fascia incision was 31 and 70 mm (p < 0.0001), respectively, but the skin incision was of the same length in both groups to blind the study. For the MS and SD group of patients, the median operation time was 48 and 35 min (p < 0.0001), and the stay at the hospital was 5.2 and 4.6 days, respectively. The two groups were not different in sex, age, localization or type of herniated discs. Use of analgesic medicine and the presence of pain in the back or legs pre- and postoperative was the same. We conclude that in a controlled and prospective study, reducing the fascia incision and the muscular dissection from a median of 70-31 mm, does not shorten the length of a stay at a hospital and it has no influence on postoperative morbidity.

[Is there a connection between size and risk of bleeding in unruptured intracranial aneurysms?]. / Er der sammenhaeng mellem størrelse og blødningsrisiko for urumperede intrakraniale aneurysmer?

Of 1076 patients with intracranial ruptured aneurysms (RA), 948 had the RA verified by angiography, and of 908 RA with a maximum diameter less than 25 mm, 162 RA were < 5 mm, 474 were between 5-10 mm and 272 were between 11-24 mm. The average diameter of the RA according to the day of angiography after rupture did not differ significantly within the first 10 days. In these circumstances, using the indirect method for estimation of the risk of aneurysm rupture according to the size, we also recommend that unruptured aneurysms with a size 10 mm or less should be seriously considered for operative closure of the aneurysm.

[Prognosis after ruptured intracranial aneurysm in men and women]. / Prognosen efter rumperet intrakranialt aneurysme hos maend og kvinder.

Of 1076 patients with aneurysmal subarachnoid haemorrhage, 674 were females and 402 males. No significant differences between females and males were seen as regards age, clinical condition on admission, pre-existing arterial hypertension and number of rebleeds. Angiographically demonstrated vasospasm was seen with a significantly higher incidence in females, which may possibly explain a significantly poorer outcome in females compared to males, despite a much higher rate in females of internal carotid artery aneurysms which have a significantly better prognosis compared with aneurysms at other sites.

Patients with ruptured intracranial saccular aneurysms: clinical features and outcome according to the size.

In the prospective consecutive Danish Aneurysm Study 192 patients (19%) had a ruptured intracranial aneurysm (RA) with a maximum diameter < 5 mm (small). In 524 (51%) and 306 patients (30%) the size was 5-10 mm (medium) and 11-24 mm (large), respectively. More patients with large RA (35%) were unconscious more than 1 h after the bleeding and had more CT-visualized haematomas (49%) compared with the patients with small RA (28 and 34%) and medium RA (27 and 37%). After 2 years, more patients with small RA and medium RA had resumed their previous occupation (49 and 49%), regained a normal daily functional capacity (55%, 55%) and normal mental outcome (29 and 32%) compared with the patients with large RA (34, 44 and 23%). The mortality was 47, 39 and 51% for patients with small, medium and large RA, respectively. With also a very serious prognosis after rupture of aneurysms of 10 mm or less and even less than 5 mm we also recommend surgical treatment of unruptured aneurysms of these sizes.

The prognostic significance of intracerebral haematoma as shown on CT scanning after aneurysmal subarachnoid haemorrhage.

In a prospective study of 1076 consecutive patients with aneurysmal subarachnoid haemorrhage (SAH), CT was carried out in 815 patients. CT visible intracerebral haematoma (ICH) was found in 42.6% of the 815 patients. There were no differences in age, pre-existing hypertension or sex between patients with or without ICH. Patients with ICH were in poorer clinical condition on admission, and had a poorer mental outcome and a higher mortality at the 2-year follow-up examination compared with patients without ICH. Of the 491 operated patients, there were in every group according to the clinical condition on admission fewer patients with a normal mental outcome and more fatal cases if an ICH was present after aneurysm rupture. This indicates that the acute brain dysfunction from SAH complicated by ICH is more likely to be followed by permanent cerebral damage compared to the corresponding acute cerebral dysfunction from SAH without ICH.

Importance of cerebral pan-angiography for detection of multiple aneurysms in patients with aneurysmal subarachnoid haemorrhage.

In the Danish Aneurysm Study 948 patients had a ruptured intracranial aneurysm (RA) revealed by cerebral angiography. Unilateral carotid angiography (UCA) with or without vertebral angiography (VA) demonstrated the RA in 206 patients, and 16 (7.8%) unruptured aneurysms (UA) were disclosed by UCA and 1 UA by VA. In 740 patients with at least bilateral carotid angiography (BCA) 164 UA (22.2%) were disclosed by BCA and 10 by VA. I.e. the number of UA demonstrated in patients with RA is not only doubled by BCA compared to ipsilateral UCA, but tripled demonstrating that an additional UA is more likely situated on the opposite side of the RA. Pan-angiography (or at least BCA) is therefore recommended in patients with RA.

Does a safe size-limit exist for unruptured intracranial aneurysms?

Of 1076 patients with intracranial ruptured aneurysms (RA) included in the Danish Aneurysm Study, 948 had the RA verified by angiography. Of these cases 908 RA had a maximum diameter less than 25 mm. 162 RA were < 5 mm, 474 and 272 were between 5-10 mm and 11-24 mm, respectively. The average diameter of the RA according to the day of angiography after the aneurysm rupture did not differ significantly within the first 10 days. In these circumstances, using this indirect method for estimation of aneurysm rupture according to the size, we also recommend that unruptured aneurysms with a size 10 mm or less should be seriously considered for operation.

Clinical features and outcome in females and males with ruptured intracranial saccular aneurysms.

Of 1076 patients with aneurysmal subarachnoid haemorrhage 674 were females and 402 males. No significant differences between females and males were seen as regards age, clinical condition on admission, pre-existing arterial hypertension and number of rebleeds. Angiographically demonstrated vasospasm was seen with a significantly higher incidence in females (p < 0.05) which may possibly explain a significantly poorer outcome in females compared with males (p < 0.05), despite the much higher rate in females of internal carotid artery aneurysms which have a significantly better prognosis compared with aneurysms at other sites.

Central nervous system reactions to cervical myelography.

In a double blind prospective study of side effects to cervical myelography 38 patients were evaluated with neurologic examination, electroencephalography (EEG), brainstem evoked response (BER), somatosensory evoked responses (SSER), and continuous reaction times prior to and at 6 h and 24 h after myelography with either metrizamide or iohexol. A difference in the incidence of side effects (for example headache, dizziness, nausea, and neck pain) to the two different contrast media indicated that the inconveniences related to myelography were not only due to the spinal puncture. A contrast medium effect on the central nervous system varying from one agent to another was present. A high frequency of EEG deteriorations among patients with adverse clinical reactions and on only discrete affection upon BER indicated the reaction to be located to the cerebral cortex. Weakened tendon reflexes and reduced strength in the upper extremities were probably caused by blockade in the motor roots as SSER were normal indicating no affection of the sensory pathways. This hypothesis is in agreement with the fact that the patients were in the prone position in the first phase of the investigation causing the highest concentration of contrast medium around the motor roots and the anterior part of the spinal cord. Difference in metabolic effect may explain differences in side effects of metrizamide and iohexol.

Importance of the recognition of a warning leak as a sign of a ruptured intracranial aneurysm.

In the Danish Aneurysm Study 1076 patients (pts.) were admitted with an aneurysmal subarachnoid hemorrhage in the 5-year period 1978-83. A warning leak (WL), defined as a sudden episode of headache, vomiting, nuchal pain, dizziness or drowsiness, was identified in 166 pts. (15.4%). In 99 of these the episode was evaluated by a physician but misdiagnosed. A 2-year follow-up examination of the 99 pts. showed that 30 pts. had a normal mental outcome and 43 pts. were dead. If these patients were correctly diagnosed after the WL, when they were in Hunt grade 1-2, the outcome-figures would probably have been significantly better. A theoretical transfer of the outcome-probabilities for pts. in Hunt grade 1-2 to the above mentioned 99 pts. would result in 66 pts. with a normal mental outcome and 25 dead pts. This shows the importance of recognition of a WL episode.

The influence of unruptured intracranial aneurysms on life expectancy in relation to their size at the time of detection and to age.

A theoretical evaluation of the lifetime probabilities of different outcomes in patients with unruptured intracranial aneurysms (UA) has been made using a life table method. The calculations were performed for aneurysm presenting ages from 20 to 70 years of age for men and women assuming an annual risk of aneurysm rupture of 1%, 2% and 3% and a rate of mortality after rupture of 50%. At 10, 20, 30, 40, 50 and 60 years after the diagnosis of an UA the probability of survival without bleeding is reduced below the expected probability of survival according to the life tables by the following percentages (assuming an annual risk of bleeding of 2%): 19%, 34%, 46%, 56%, 64% and 72%, respectively. A survey of the lifetime probabilities of four different outcomes for patients with an UA indicates a substantial reduction in life expectancy after the diagnosis of an UA. In most ages the surgical risks are more than balanced by the risks associated with an untreated unruptured aneurysm.

Antifibrinolytic therapy in patients with aneurysmal subarachnoid haemorrhage.

In a prospective consecutive non-randomised study including 1076 patients with ruptured intracranial aneurysms 205 patients received epsilon aminocraproic acid (EACA) and 871 did not. No significant differences between the two groups concerning clinical condition on admission, sex, age, localisation and size of the aneurysms were seen. No cases of rebleeding (RB) were observed within the first 4 days in the EACA treated patients, but within the first 48 hours, which is the optimal period recommended for operation of patients in good clinical condition, this difference of the rates of RB between EACA treated and not treated patients is not significant. A significantly lower rate of RB was observed in the EACA group within the first 2 weeks, but no significant differences in morbidity and mortality were found at the 2-year follow-up examination.

The impact of rebleeding on the life time probabilities of different outcomes in patients with ruptured intracranial aneurysms. A theoretical evaluation.

In order to strengthen patient-information a theoretical evaluation of the impact of rebleeding on the life time probabilities of different outcomes in patients with an aneurysmal subarachnoid haemorrhage (SAH) has been made using a life table method. The calculations were performed for SAH-presenting ages from 20 to 70 years assuming a rate of rebleeding of 50% in the first 6 months after the initial bleeding with a mortality rate of 70%, and the following years an annual rate of rebleeding of 3%, and with a mortality rate of 60%. A survey of the life time probabilities of the 4 different outcomes after an aneurysmal SAH shows the great life time reducing effect of rebleedings in all SAH-presenting ages.

Unruptured intracranial aneurysms: an assessment of the annual risk of rupture based on epidemiological and clinical data.

From autopsy and neuroradiological studies a maximum prevalence of unruptured intracranial aneurysms (UA) of 0.5% in the general population is revealed. Studies concerning the incidence of aneurysmal subarachnoid haemorrhage (SAH) revealed 10 cases per 100,000 inhabitants per year. From these epidemiological parameters a minimum annual risk of 2% of rupture of an UA is calculated. It is in accordance with clinical studies, which also demonstrated an annual risk of UA rupture of at least 2%. No critical size of the UA predisposing to rupture has been found. Operation on diagnosed UA is recommended because of the serious prognosis after aneurysmal SAH (morbidity 20%-25% and mortality 50%-60%) and because the morbidity (4%) and the mortality (0%) after operative treatment of UA are very low.

Seasonal variation of aneurysmal subarachnoid haemorrhage.

In a prospective consecutive series of 1,076 patients with aneurysmal subarachnoid haemorrhage (SAH) admitted to the 6 Danish neurosurgical departments in the 5-year period April 1, 1978 to March 31, 1983 a significantly higher seasonal incidence of SAH was seen during spring and autumn compared to summer and winter. No significant seasonal differences in monthly mortality or between females and males were registered. Contrary to several other studies concerning cerebral apoplexy excluding SAH no explanation to the seasonal variation was obtained from differences in weather conditions. A correlation between seasonal variation of aneurysm rupture and physical activity is possible.