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Z Geburtshilfe Neonatol. 2002 Apr;206(2):51-6.
[Dopplersonographic findings in neonates with significant persistent ductus arteriosus]
[Article in German]
Robel-Tillig E, Knupfer M, Pulzer F, Vogtmann C.
Poliklinik und Klinik fur Kinder und Jugendliche der Universitat Leipzig, Germany.
BACKGROUND: The aim of the study was the description and review of a diagnostic management for treatment of patent ductus arteriosus in preterm neonates. Indomethacin, widely used to effect nonoperative closure of patent ductus arteriosus, has been implicated in vasoactive side effects and requires an accurate diagnosis. PATIENTS AND METHODS: Firstly, the hemodynamic significance of the ductus arteriosus was assessed by clinical signs, such as tachycardia, disturbed microcirculation and a high difference of central and peripheral temperature. The patent ductus arteriosus was confirmed by echocardiography. The left ventricular systolic time intervals and the cerebral perfusion were obtained by pulsed doppler recordings. 48 preterm infants below 1500 g were investigated within the first 12 hours of life and during the first week. RESULTS: In 32 preterm neonates (67 %) a patent ductus arteriosus without hemodynamic significance and in 9 neonates a patent ductus arteriosus with hemodynamic changes was detected. In 9 neonates there were no signs of patent ductus arteriosus. Neonates with typical clinical signs of patent ductus arteriosus exhibited significantly diminished preejection time, prolonged ejection time and a decreased quotient of preejection and ejection time. We found pathologically changed parameters of anterior cerebral artery in neonates with clinical signs of patent ductus arteriosus. To judge the efficiency of the diagnostic management the groups of neonates were compared concerning the evidence of complications. Neonates with ductus arteriosus but without therapy did not reveal more pulmonary problems as well as intracerebral hemorrhages, renal or intestinal disturbances than the group of neonates with treated ductus arteriosus. CONCLUSIONS: Summarizing, we suggest that the described criteria are to be taken into account before treatment of ductus arteriosus in preterm neonates. In this way a wide clinical and echocardiographical investigation will be performed in risk neonates and a useless therapy can be avoided.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12015635&dopt=Abstract hemorrhage
Neurosurgery. 2002 Jun;50(6):1190-7; discussion 1197-8.
Long-term results after stereotactic radiosurgery for patients with cavernous malformations.
Hasegawa T, McInerney J, Kondziolka D, Lee JY, Flickinger JC, Lunsford LD.
Department of Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
OBJECTIVE: Stereotactic radiosurgery has been used for patients with high-risk cavernous malformations of the brain. We performed radiosurgery for patients with symptomatic, imaging-confirmed hemorrhages for which resection was believed to be associated with high risk. This study examines the long-term hemorrhage rate after radiosurgery. METHODS: We reviewed data obtained before and after gamma knife radiosurgery on 82 patients treated between 1987 and 2000. Most patients had multiple hemorrhages from brainstem or diencephalic cavernous malformations. Follow-up data were examined to identify hemorrhages, and an overall hemorrhage rate was calculated. RESULTS: Observation before treatment averaged 4.33 years (range, 0.17-18 yr) for a total of 354 patient-years. During this period, 202 hemorrhages were observed, for an annual hemorrhage rate of 33.9%, excluding the first hemorrhage. Temporal clustering of hemorrhages was not significant. After radiosurgery, patient follow-up averaged 5 years (range, 0.42-12.08 yr), for a total of 401 patient-years. During this period, 19 hemorrhages were identified, 17 in the first 2 years posttreatment and 2 after 2 years. The annual hemorrhage rate was 12.3% per year for the first 2 years after radiosurgery, followed by 0.76% per year from Years 2 to 12. Eleven patients had new neurological symptoms without hemorrhage after radiosurgery (13.4%). The symptoms were minor in six of these patients and temporary in five. CONCLUSION: Radiosurgery confers a reduction in the risk of hemorrhage for high-risk cavernous malformations. Risk reduction, although in evidence during initial follow-up, is most pronounced after 2 years. Given the difficulty of identifying high-risk patients, treatment after one major hemorrhage should be considered in selected younger patients. Such a strategy warrants further investigation.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12015835&dopt=Abstract hemorrhage
Neurosurgery. 2002 Jun;50(6):1199-205; discussion 205-6.
Endovascular treatment for poorest-grade subarachnoid hemorrhage in the acute stage: has the outcome been improved?
Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Mayanagi K, Ichikizaki K.
Department of Neurosurgery, National Tokyo Medical Center, Tokyo, Japan. GInamasol.com
OBJECTIVE: Patients with poor-grade subarachnoid hemorrhage (SAH) have been considered good candidates for endovascular treatment. The results of treatment of Grade V SAH, the poorest grade, however, have not been fully elucidated. METHODS: The clinical characteristics and outcome parameters of 22 World Federation of Neurosurgical Societies Grade V SAH patients treated endovascularly in the acute stage between 1998 and 2000 are summarized and compared with those of 18 Grade V SAH patients treated conservatively between 1995 and 1997. RESULTS: Among the 22 patients treated endovascularly, 8 patients (36.4%) survived. The rate was significantly higher than that of the 18 patients treated conservatively (5.6%), only one of whom survived. The favorable outcome rate, however, was not significantly different between the two groups (4.5% versus 6.0%). Subdivision of both treatment groups according to Glasgow Coma Scale (GCS) score showed that the improved survival among those treated endovascularly was attributable to the improved survival in those with a preprocedural GCS score of 6 but not of 4 or 5. CONCLUSION: Endovascular treatment of the 22 World Federation of Neurosurgical Societies Grade V SAH patients improved their survival rate but not their favorable outcome rate in comparison with conservative treatment. Further accumulation of clinical data is essential to determine whether endovascular treatment can improve the functional outcome of those with GCS scores of 6 and whether there is no role for endovascular treatment in those with GCS scores of 4 or 5.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12015836&dopt=Abstract hemorrhage
Neurosurgery. 2002 Jun;50(6):1207-11; discussion 1211-2.
Risk of hemorrhage from unsecured, unruptured aneurysms during and after hypertensive hypervolemic therapy.
Hoh BL, Carter BS, Ogilvy CS.
Neurosurgical Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
OBJECTIVE: Hypertensive hypervolemic therapy for vasospasm is widely practiced. It is not clear, however, whether the use of hypertension and hypervolemia as a treatment for vasospasm risks hemorrhage from an unsecured, unruptured aneurysm. METHODS: From 1991 to 2000, the neurovascular unit at the Massachusetts General Hospital treated 1908 aneurysms, of which 966 were ruptured. Forty patients with ruptured aneurysms had unsecured, unruptured aneurysms and underwent hypertensive hypervolemic therapy for vasospasm. Hypertension was induced by intravenously administered phenylephrine, norepinephrine, and/or dopamine, and hypervolemia was achieved by intravenously administered crystalloid and colloid solutions. The 24-hour mean arterial systolic blood pressure (SBP) and the 24-hour mean central venous pressure were calculated on the basis of hourly measurements during hypertensive hypervolemic treatment. RESULTS: The 40 study patients harbored 124 aneurysms, of which 51 aneurysms were treated (clipping, 37; coiling, 14) by the time hypertensive hypervolemic therapy began, leaving 73 unsecured aneurysms at risk. The mean size of the unsecured aneurysms was 4.45 mm. Nineteen patients were treated with mild hypertension (SBP, 140-180 mmHg), 12 patients were treated with moderate hypertension (SBP, 180-200 mmHg), and 9 patients were treated with severe hypertension (SBP, >200 mmHg). The 24-hour mean SBP readings were 166.81 +/- 8.19, 187.57 +/- 5.79, and 204.01 +/- 3.75 mmHg for the mild, moderate, and severe hypertension groups, respectively. The mean central venous pressure was 10.43 +/- 3.89 mmHg. The mean course of hypertensive hypervolemic therapy was 7.25 days, and therapy began on mean post-subarachnoid hemorrhage Day 6.73. Twenty-eight aneurysms were eventually treated in later procedures (clipping, 25; coiling, 3). The mean interval to treatment was 6.93 months. In a treatment and follow-up period of 121.75 aneurysm-years of risk, there was no instance of hemorrhage. CONCLUSION: Hypertension and hypervolemia do not seem to increase the risk of hemorrhage from unsecured, unruptured aneurysms in the acute setting or in their short-term natural history.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12015837&dopt=Abstract hemorrhage
Neurosurgery. 2002 Jun;50(6):1213-21; discussion 1221-2.
Adverse cerebral events detected after subarachnoid hemorrhage using brain oxygen and microdialysis probes.
Kett-White R, Hutchinson PJ, Al-Rawi PG, Gupta AK, Pickard JD, Kirkpatrick PJ.
Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, England. p.hutchich.net
OBJECTIVE: A prospective observational study was conducted to investigate whether episodes of ischemia are detected by continuous cerebral monitoring and whether such episodes are related to clinical outcome. METHODS: Forty patients (35 after subarachnoid hemorrhage and 5 after complex aneurysm surgery) were monitored for a total of 174 days (mean, 4 d; range, 1-12 d). Brain tissue partial pressures of oxygen and carbon dioxide, pH, and temperature were measured continuously using Neurotrend sensors (Codman, Bracknell, England). Bedside analysis of extracellular chemistry was performed hourly using microdialysis. Glasgow Outcome Scale score was assessed at 3 to 6 months. RESULTS: Patients with poor World Federation of Neurosurgical Societies grades (4 and 5) or an unfavorable outcome (severe disability or death) had, on average, higher lactate and lactate/pyruvate ratio but lower glucose/lactate ratio (P < or = 0.05). Brain tissue partial pressure of oxygen decreased to below 1.1 kPa in 78% of the patients for 18% (95% confidence interval, 12-24%) of time monitored. There were 197 episodes in which brain tissue partial pressures of oxygen decreased to below 1.1 kPa for at least 30 minutes. Unfavorable outcome was associated with more of these episodes (8.8 episodes; 95% confidence interval, 4.4-13.2 episodes) than favorable outcome (2.2 episodes; 95% confidence interval, 1.1-3.3 episodes), as well as an episode of glutamate levels of more than 10 micromol/L or lactate/pyruvate ratio more than 40 (P < 0.05, chi(2) test). CONCLUSION: Intraparenchymal oximetry and microdialysis can detect but fail to predict the development of delayed cerebral ischemia. There were associations between episodes of low brain oxygen, abnormal microdialysis, and unfavorable outcome, but these associations were weak.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12015838&dopt=Abstract hemorrhage
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