Relationship between leukocytosis and ischemic complications following aneurysmal subarachnoid hemorrhage.

The prognostic significance of admission leukocytosis with respect to ischemic complications of subarachnoid hemorrhage was retrospectively investigated in a series of patients with recently ruptured intracranial aneurysms. The present study concerned 47 consecutive cases admitted within 72 hours following the last hemorrhage, in the years 1982-1984. There was no difference in the admission WBC counts between patients who subsequently deteriorated due to ischemic complications and those who did not. However, the cell count rose significantly at the time of the clinical manifestations of ischemia, possibly as a result of structural damage of brain tissue and/or increased sympathetic and adrenocortical activity. The possible contribution of leukocytes to the pathogenesis of ischemic damage following subarachnoid hemorrhage--perhaps through the release of leukotrienes--will require further investigation

The role of antifibrinolytic therapy in the preoperative management of recently ruptured intracranial aneurysms

In a retrospective study of the use of antifibrinolytic therapy in a series of patients with recently ruptured intracranial aneurysms, 131 patients were selected based on the following criteria: commencement of therapy within 3 days of the last subarachnoid hemorrhage (SAH); continuation of therapy for at least 6 days; and apparently uncomplicated surgery. Two main modalities of antifibrinolytic therapy were used: Group A, tranexamic acid (AMCA) 3 gm daily plus aprotinin k.i.u. (kallikrein inactivating units) daily (82 cases); Group B, AMCA 6 gm daily (41 cases). The remaining 8 patients were treated with ε-aminocaproic acid alone or in combination with aprotinin and were not considered to constitute a large enough group for statistical comparison. The rest of the preoperative treatment consisted of bed rest; mild sedation; antihypertensives, if the blood pressure exceeded 160 mm Hg; and osmotic diuretics as needed. The mean interval between last SAH and operation was about 13 days in both groups. The rates of rebleeding and thromboembolism were similar in the two groups but the rates of ischemic complications and post-SAH hydrocephalus were higher in Group B. The difference in the rate of severe cerebral ischemic complications was statistically significant (11 of 82 in Group A versus 12 of 41 in Group B, p < 0.02), and in the main they were present preoperatively. The rates of rebleeding (approximately 10%) and of death from rebleeding (approximately 5%) are lower than in other published series on the natural history of this condition. In cases in which antifibrinolytics are indicated, present evidence indicates that low-dose AMCA plus aprotinin seems to be a rational combination for lowering the rebleeding, ischemic complication, and post-SAH hydrocephalus rates

Benign extramedullary tumors of the foramen magnum

This paper analyzes the clinical, diagnostic and surgical data of 18 benign extramedullary tumors at the foramen magnum extending into the posterior fossa and the spinal canal. These cases represent 30% of 60 foramen magnum tumors operated on between 1952 and 1978, among 4187 brain tumors and 587 tumors of the spinal cord. Foramen magnum meningiomas constitute 11 of this series (1.2% of 873 meningiomas, 113 of which were spinal). The considerable difficulty in early diagnosis is emphasized. However, in the present series, myelography showed positive findings in all cases, and angiography in most of them. CT scan, performed in 1 case, demonstrated the lesion. Surgical mortality was 11% (2 deaths). On both patients who died after the operation, multiple surgical procedures have been performed because of erroneous diagnoses made in another unit. At the time of operation neurological symptoms were very advanced, and large tumors were located anteriorly. The review of the remaining patients showed a regression of preoperative symptoms with good to excellent results in all. No recurrences were recorded

The surgical treatment of choroid plexus papillomas - The results of 27 years experience

This paper reports the results of 27 choroid plexus papillomas surgically treated, out of 28 cases observed in the authors insitute during the period 1952-1978. These were divided into two groups: a) those operated on before 1969; b) those operated on in 1969 and the following years, when microsurgical facilities were routinely employed. As a rule, neither ventricular shunting nor radiation therapy were used preoperatively. A total removal was attempted in all cases, and performed in all but three. The second group (1969-1978) showed better results as regards the number of totally removed tumours (92% against 87%), surgical deaths (16% against 31%), and long-term good results (67% against 44%). Considering both groups together, long-term good results were achieved in 15 patients (55%), followed up from 2 to 27 years. Radical operation is the treatment of choice for choroid plexus papilloma. As indicated by the author's experience, this produces satisfactory long-term results, whilst surgical mortality can be held within acceptable limits, provided that modern techniques are used properly. The value of radiation therapy, which in any event should be restricted to malignant cases, remains questionable

The management of arteriovenous malformations of the corpus callosum.

A series of 15 arteriovenous malformations (AVMs) of the corpus callosum--9% of 170 intracranial AVMs admitted to the School of Medicine of the University of Rome during a 30-yr period--was studied. In all cases the lesion concerned mainly the corpus callosum, although in some it also involved the surrounding structures, such as septum pellucidum, tela choroidea, and the mesial hemisphere. These malformations are divided into three groups, namely, those involving mainly the genu, the truncus, or the splenium of the corpus callosum. The last predominated in the present series. Each type has a peculiar angiographic appearance. In general these lesions are fed by branches from the anterior cerebral and/or posterior cerebral arteries, although in some cases minor contributions from the middle cerebral artery may also be present. Vascularization is often bilateral. Venous drainage occurs through the inferior and/or superior sagittal sinuses and/or the Galen system. As to clinical presentation, Subarachnoid Hemorrhage (SAH) is the usual presenting symptom and tends to recur frequently. Neurological localizing symptoms are infrequent, as are seizures; psychological symptoms are an exception. Of the 4 cases managed conservatively, only one had no further episodes of bleeding and remained free of complaints. On the other hand, surgical results of the 11 operated patients were satisfactory, in the sense that no mortality and low morbidity were recorded. Accordingly, surgical treatment of AVMs of the corpus callosum is recommended as a rule

Choroid plexus papillomas in infancy and childhood

The present study deals with 15 cases of choroid plexus papilloma, out of approximately 500 cases of brain tumors observed in children up to 16 years old. Several features are considered, including clinical symptoms and signs—mostly related to increased intracranial pressure—radiological diagnosis, pathology and surgical treatment, and results. Surgery may be radical in most cases, with the exception of histologically malignant papillomas. The management results are usually satisfactory. An adequate choice of surgical approach is mandatory and surgical technique should be meticulous, also in order to avoid the risk of intraoperative tumoral seeding

Low-dose tranexamic acid combined with aprotinin in the pre-operative management of ruptured intracranial aneurysms.

Among our patients with ruptured intracranial aneurysms 149 were managed pre-operatively with a combination of tranexamic acid (AMCA), 3 gm daily, and aprotinin at an average of 400000 KIU (Kallikrein inactivating units) daily. Antifibrinolytics were started within three days of the last haemorrhage, and continued for at least six days. The first 91 cases, managed in the years 1971 to 1980, have been evaluated retrospectively. The remaining 58 patients were managedin the period 1981-1985 and carefully watched for possible complications of treatment. No significant differences were noted in the results of patients managed either before or after 1981. The rate of recurrent SAH (10%) was lower than the natural history of aneurysmal SAH. Satisfactory inhibition of fibrinolysis was documented in the CSF collected at the time of operation in 15 patients. This, as well as our previous suggestions that the combination of low-dose AMCA and aprotinin might carry a lesser risk of causing ischaemic complications and hydrocephalus than the conventional antifibrinolytic treatment, might stimulate future studies on fibrinolysis in SA

Low-dose tranexamic acid combined with aprotinin in the pre-operative management of ruptured intracranial aneurysms.

Among our patients with ruptured intracranial aneurysms 149 were managed pre-operatively with a combination of tranexamic acid (AMCA), 3 gm daily, and aprotinin at an average of 400000 KIU (Kallikrein inactivating units) daily. Antifibrinolytics were started within three days of the last haemorrhage, and continued for at least six days. The first 91 cases, managed in the years 1971 to 1980, have been evaluated retrospectively. The remaining 58 patients were managedin the period 1981-1985 and carefully watched for possible complications of treatment. No significant differences were noted in the results of patients managed either before or after 1981. The rate of recurrent SAH (10%) was lower than the natural history of aneurysmal SAH. Satisfactory inhibition of fibrinolysis was documented in the CSF collected at the time of operation in 15 patients. This, as well as our previous suggestions that the combination of low-dose AMCA and aprotinin might carry a lesser risk of causing ischaemic complications and hydrocephalus than the conventional antifibrinolytic treatment, might stimulate future studies on fibrinolysis in SA