1/47. Use of intra-aortic balloon pump counterpulsation for refractory symptomatic vasospasm.Delayed neurologic deficits secondary to vasospasm remain a vexing problem. Current treatments include: hypertensive hypervolemic hemodilution (Triple-H) therapy, angioplasty, and intra-arterial papaverine administration. Significant morbidity and mortality still result from vasospasm despite these therapies. We present two patients with symptomatic vasospasm who received intra-aortic balloon pump counterpulsation (IABP) to improve cerebral blood flow when they were unable to tolerate Triple-H therapy. One patient (L.T.) developed vasospasm after resection of a meningioma that encased the carotid and middle cerebral artery. The other patient (D.F.) suffered a subarachnoid hemorrhage (Fisher Grade III, Hunt/Hess Grade III) from a basilar tip aneurysm. Postoperatively, both patients developed vasospasm. Treatment with Triple-H therapy, angioplasty, and papaverine yielded modest results. When they experienced cardiac ischemia, Triple-H therapy was stopped, but their neurologic condition deteriorated markedly. Because of this, IABP was started. Both patients had an immediate improvement in cardiac function. IABP was able to reverse some of the neurologic deficits, and was weaned off after several days of support. Both patients had a substantial improvement in function, and are now capable of caring for themselves. We conclude that IABP may play an important role for improving cerebral blood flow in patients with vasospasm. It may be particularly useful in those patients with limited cardiac reserve.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
2/47. Complications associated with intraarterial administration of papaverine for vasospasm following subarachnoid hemorrhage--two case reports.Complications associated with intraarterial papaverine infusion occurred in two patients treated for vasospasm due to subarachnoid hemorrhage (SAH). A 42-year-old male with an anterior communicating artery aneurysm underwent craniotomy and aneurysm clipping. Five days after the SAH occurred, angiography demonstrated moderate vasospasm in spite of hypervolemic-hypertensive therapy. During papaverine infusion into the carotid artery, he suffered loss of consciousness due to a seizure for a few minutes. A 61-year-old female with a right internal carotid-posterior communicating artery aneurysm underwent clipping. Six days after the SAH occurred, angiography demonstrated severe vasospasm in spite of hypervolemic-hypertensive therapy. Angiography performed immediately after papaverine infusion into the carotid artery revealed exacerbation of the vasospasm. Finally she suffered cerebral infarction and died. Complications of intraarterial papaverine infusion are potentially dangerous. We recommend trial administration of papaverine with angiography and neurological examination before full dose infusion to avoid complications.- - - - - - - - - - ranking = 5keywords = administration (Clic here for more details about this article) |
3/47. Acute hemorrhagic complication of diagnostic lumbar puncture.OBJECTIVE: To present a case of an epidural hematoma after lumbar puncture in a pediatric patient without known risk factors for such a complication and to review the literature regarding this complication. DESIGN: Case report, review of the literature, and discussion. DATA SOURCES: A review of medline (1966-1998) for keywords "lumbar puncture" and "hemorrhage" or "hematoma" was conducted, and each bibliography was reviewed for other sources extending to 1911. Articles describing a case of spinal hematoma after a lumbar puncture for any procedure were included. RESULTS: A 5-year-old boy underwent a lumbar puncture for evaluation of lethargy and fever, and subsequently developed marked back pain and severe pain on flexion of his legs. magnetic resonance imaging revealed an epidural blood collection. The patient's symptoms resolved over the next few days in association with steroid administration. Multiple reports of epidural and subdural hematomas were found on literature review, most occurring in the setting of coagulation abnormalities. These reports involve lumbar puncture in anesthetic, interventional, and diagnostic settings. CONCLUSION: Lumbar puncture is a frequently employed procedure. Known complications include epidural, subdural, and subarachnoid hemorrhage, usually in the setting of abnormal coagulation. The case presented is unusual in that the patient is a child and lacks any known risk factors for a hemorrhagic complication. Such a complication appears to be rare; only five of the 64 cases discovered in the literature review occurred following this diagnostic procedure in patients without known risk factors.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
4/47. Intra-arterial papaverine-induced seizures: case report and review of the literature.BACKGROUND: Microcatheter-guided intra-arterial (IA) papaverine infusion in conjunction with balloon angioplasty is an available therapy for patients with symptomatic vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hypertensive, hypervolemic therapy. However, side effects and complications have been reported in association with its use. CASE DESCRIPTION: We report on a patient who developed symptomatic vasospasm after subarachnoid hemorrhage due to rupture of a left terminal internal carotid artery (ICA) saccular aneurysm. Seven days after the hemorrhage and 4 days after surgical clipping, the patient developed aphasia and right hemiparesis due to vasospasm, which was refractory to maximal medical treatment with volume and blood pressure elevation. cerebral angiography identified severe narrowing of distal ICA and proximal middle cerebral artery segments bilaterally. These findings partially resolved after balloon angioplasty. However, after 300 mg of IA papaverine, the patient developed generalized convulsions. This occurred despite therapeutic serum levels of phenytoin. Twenty-four hours later, after brief neurologic improvement, recurrent neurologic deficits prompted repeat papaverine administration. seizures again occurred after the administration of 240 mg of IA papaverine and prevented administration of the full dose. The patient did not develop further seizures and her neurologic deficits continue to resolve. CONCLUSIONS: IA papaverine-induced seizures are infrequently reported. This potential complication should be considered when papaverine administration is entertained in the treatment of anterior circulation refractory symptomatic vasospasm after SAH.- - - - - - - - - - ranking = 4keywords = administration (Clic here for more details about this article) |
5/47. Hypodipsic hypernatremia and diabetes insipidus following anterior communicating artery aneurysm clipping: diagnostic and therapeutic challenges in the amnestic rehabilitation patient.Hypodipsic hypernatremia (HH) represents a pathological increase in serum sodium due to a lack of thirst and defect in hypothalamic osmoreceptors. While 15% of patients with HH have a vascular aetiology, few cases have been described. Moreover, the presence of such abnormalities in the amnestic patient can have particularly threatening implications, as HH tends to recur unless the patient complies with a regimen of water intake. This study reports the case of a 46-year-old male admitted for rehabilitation of functional deficits following subarachnoid haemorrhage (SAH), with clipping of an anterior communicating artery (ACoA) aneurysm. Clinical examination was remarkable for profound short-term memory loss and inability to retain new information. Blood chemistry on admission showed a serum sodium level of 160 mEq/L, increasing to 167 mEq/L the following day. The patient denied thirst, and showed no clinical signs of dehydration. Neuroendocrine evaluation revealed diabetes insipidus (DI) and HH. Treatment initially included DDAVP and intravenous hydration, later supplemented with chlorpropramide. Stabilization of serum sodium and osmolality did not ensue until the treatment regimen included hydrochlorothiazide and supervision of enforced fluid intake. Endocrine abnormalities may be encountered among patients with vascular lesions adjacent to the hypothalamus. rehabilitation interventions include establishing a structured medication regimen with fluid administration in the amnestic patient with hypothalamic dysfunction.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
6/47. Reversal of radiographically impending stroke with multiple intraarterial papaverine infusions in severe diffuse cerebral vasospasm induced by subarachnoid hemorrhage.BACKGROUND: Selective intraarterial infusion of papaverine is used in the treatment of symptomatic cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage (SAH). Delays in instituting therapy for vasospasm can lead to irreversible cerebral infarction and a devastating outcome. Endovascular papaverine treatment of vasospasm in the presence of low-attenuation lesions on computed tomography (CT) is controversial, because of the fear of reperfusion hemorrhage in completed infarcts. METHOD: Two patients with aneurysmal SAH who subsequently developed severe diffuse vasospasm were identified. In both patients, large areas of low-attenuation change suggesting impending cerebral infarction were seen on CT scans. The patients received multiple infusions of intraarterial papaverine in an effort to treat vasospasm refractory to medical management. FINDINGS: After multiple intermittent administrations of papaverine, which initially appeared to increase the low-attenuation changes, there was dramatic reversal of the radiographic findings. There was also improvement in circulation time, transcranial Doppler velocities, and clinical outcome. INTERPRETATION: These findings suggest that in some patients, intraarterial infusions of papaverine initiated in the earliest stages of ischemia may exacerbate the radiographic appearance of low-attenuation changes, but may ultimately reverse the evolution of cerebral infarction.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
7/47. Fatal hemorrhage after radiochemotherapy for leptomeningeal dissemination of glioma: report of two cases.BACKGROUND: Dissemination of malignant gliomas is often observed, but the treatment of choice for leptomeningeal dissemination has not been established. CASE DESCRIPTIONS: A 55-year-old man suffered fatal hemorrhage 1 day after whole brain irradiation (2 Gy) along with intravenous administration of 150 mg of nitrosourea (ACNU) for leptomeningeal dissemination of glioblastoma. A 14-year-old boy suffered hemorrhage after intrathecal administration of 10 mg of methotrexate for recurrence of leptomeningeal dissemination of anaplastic astrocytoma 4 months after local brain irradiation and ACNU administration, and died 19 days later. CONCLUSION: Massive fatal hemorrhage is an unusual but possible acute complication after radiochemotherapy for leptomeningeal dissemination of gliomas.- - - - - - - - - - ranking = 3keywords = administration (Clic here for more details about this article) |
8/47. Use of intraventricular tissue plasminogen activator and Guglielmi detachable coiling for the acute treatment of casted ventricles from cerebral aneurysm hemorrhage: two technical case reports.OBJECTIVE AND IMPORTANCE: We report two cases of massive intraventricular hemorrhage resulting from subarachnoid hemorrhage. Both patients had experienced a ruptured cerebral aneurysm and were initially moribund. The patients were treated with Guglielmi detachable coiling and then administration of intraventricular tissue plasminogen activator (tPA). Rapid clot resolution was demonstrated radiographically in both. Both patients survived and had a meaningful functional neurological recovery. These are the first reported cases of the acute use of intraventricular tPA after Guglielmi detachable coiling treatment for ruptured cerebral aneurysm. CLINICAL PRESENTATION: A 59-year-old woman and a 44-year-old man presented with high-grade subarachnoid hemorrhage. Both had had extensive casting of their ventricular systems with blood. INTERVENTION: The patients were treated with Guglielmi detachable coiling thrombosis of the aneurysm and then intraventricular administration of tPA for dissolution of blood clots. Both patients survived; one is able to carry out activities of daily living with moderate assistance, and the other is able to communicate with his family. CONCLUSION: This is a novel method to manage patients with high-grade aneurysms with massive intraventricular blood clots. The tPA reduced the mass effect of the blood clot, possibly helping to improve the neurological grade; in addition, the administration of tPA helped keep the external ventricular drains functional, enabling treatment of the acute hydrocephalus. The safety of administering tPA after endovascular thrombosis was demonstrated in these two patients. Further investigation is required to determine the applicability of this approach on a broader scale.- - - - - - - - - - ranking = 3keywords = administration (Clic here for more details about this article) |
9/47. Intravenous magnesium sulfate administration in a patient with refractory vasospasm following subarachnoid hemorrhage.OBJECTIVE: magnesium sulfate is being investigated for the prevention or treatment of vasospasm following subarachnoid hemorrhage. PATIENT: A 45-year-old woman suffered subarachnoid hemorrhage and developed after 8 days symptomatic vasospasm in the left middle cerebral artery (MCA) while she was receiving nimodipine prophylactically. methods AND RESULTS: Transcranial Doppler monitoring was performed. Cerebral autoregulation was abolished in the left MCA. Despite this finding the administration of a bolus dose of MgSO(4), followed by a continuous infusion in order to achieve serum magnesium levels in the range of 4-4.5 mg/dl (1.65-1.85 mmol/l), resulted in a marked decrease (12.2%) of the left MCA mean blood flow velocity, without clinically relevant change in systemic blood pressure (3%). This effect was maintained for at least 4 h. It did not prevent the development of ischemic lesions.- - - - - - - - - - ranking = 5keywords = administration (Clic here for more details about this article) |
10/47. Spinal subdural hematoma: a sequela of a ruptured intracranial aneurysm?BACKGROUND: A case of spinal subdural hematoma (SSDH) following subarachnoid hemorrhage (SAH) because of a ruptured internal carotid aneurysm is described. Such a case has never been reported. CASE DESCRIPTION: A 52-year-old woman underwent a craniotomy for a ruptured internal carotid aneurysm. A computed tomography scan showed that SAH existed predominantly in the posterior fossa and subdural hematoma beneath the cerebellar tentorium. Intrathecal administration of urokinase, IV administration of fasudil hydrochloride, and continuous cerebrospinal fluid (CSF) evacuation via cisternal drainage were performed as prophylactic treatments for vasospasm. On the sixth postoperative day, the patient complained of severe lower back and buttock pain. magnetic resonance imaging showed a subdural hematoma in the lumbosacral region. Although the mass effect was extensive, the patient showed no neurologic symptoms other than the sciatica. She was treated conservatively. The hematoma dissolved gradually and had diminished completely 15 weeks later. Her pain gradually subsided, and she was discharged 7 weeks later without any neurologic deficit. CONCLUSION: Although the exact mechanism of SSDH in this case is unclear, we speculate that this SSDH was a hematoma that migrated from the intracranial subdural space. Low CSF pressure because of continuous drainage and intrathecal thrombolytic therapy may have played an important role in the migration of the hematoma through the spinal canal. It is important to recognize the SSDH as a possible complication of the SAH accompanied with intracranial subdural hematoma.- - - - - - - - - - ranking = 2keywords = administration (Clic here for more details about this article) |
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