The association of tranexamic acid and nimodipine in the pre-operative treatment of ruptured intracranial aneurysms.

In the scope of a late intervention policy on ruptured intracranial aneurysms, on D.+12 on an average, we first used tranexamic acid, at moderate doses: 3 g orally or 1.5 g intravenously per day. We, subsequently, added nimodipine, usually 240 mg orally per day or 2 mg intravenously per hour. The medical treatment consisted of amply sufficient hydration, and in systematic and regular administration of analgesics and sedatives. Hypotension was absolutely avoided; if necessary, an antihypertensive treatment was prescribed very cautiously. Phenytoin was regularly given. In the present study, we try to answer the following questions: (1) Can we confirm that the preventive action of tranexamic acid remains as effective, when doses, markedly lower than usually recommended, are used? (2) Does nimodipine prevent the increase of pre-operative ischaemic complications, which should be expected when tranexamic acid is administered? Amongst 101 patients with SAH of proven aneurysmal origin, 84 were treated with tranexamic acid and nimodipine. In 25 patients, an aneurysm was not visualised; 21 received this treatment. For several reasons, only a retrospective study was possible, to evaluate the results of our antifibrinolytic and calcium-blocking therapies, on rebleeding and pre-operative delayed ischaemia. We compared, therefore, similar cases from the literature, with our own cases, taking into consideration the clinical grades, the days of admission and of intervention, the moment of rebleeding and of delayed pre-operative ischaemia, etc. The following impressions emerge: (1) same effectiveness of moderate doses of tranexamic acid; (2) no increase of pre-operative delayed ischaemic complications, in comparison with patients not receiving antifibrinolytics but nimodipine; (3) important role of a devastating initial bleed and of operative complications; (4) difficulty of avoiding rebleeding at D.0, whatever the therapeutic measures, medical and/or surgical

Clinical and MRI long term evolution of intracavernous and carotid ophtalmic artery aneurysms, treated by common carotid ligation.

In four large, 15-25 mm, internal carotid artery aneurysms (3 intracavernous and 1 carotid ophthalmic), treatment by common carotid ligation was preferred. Pre- and postoperative MRI were obtained, at a delay between 5 to 9 years. Recovery of the ocular and visual symptomatology was a function of the role played by mechanical and/or ischaemic factors. No early or late consequences, ascribable to the common carotid ligation, were observed. Aneurysmal thrombosis occurred in the first postoperative week, but retraction of the thrombosed aneurysms was only obvious and maximal after several months. For this reason, rapid clinical recovery could be due, in the first instance, to the loss of aneurysmal pulsatility. Complete disappearance of the aneurysm was observed in two cases. In the other two, a small remnant of the initial lesion, without any unfavourable consequences, was revealed, respectively 6 and 9 years after the intervention, by current, modern-days, MRA

Pathogenetic Factors in Chronic Subdural-hematoma and Causes of Recurrence After Drainage

The radiological aspect, pathology, treatment and results of 132 subdural haematomas observed in 100 patients, are discussed. The majority of these cases were characterized by a nonhomogenous CT scan picture, resulting from repeated bleeding in a previous subdural haematoma evolving to chronicity, or in a pre-existent subdural hygroma. Taking aspirin may have constituted a predisposing factor in 16% of our patients, whilst coagulation disturbances, including anticoagulant treatment, were observed in another 6%; ethylism was present in 11%. A traumatic origin was ascertained in 80% of the patients. The treatment consisted of burr hole evacuation and drainage in 91.5% of the haematomas, corresponding to 99% of the patients; it was eventually repeated once or twice in some cases. In 6% of the patients, a subduro-peritoneal drainage had to be placed ultimately and in 2%, a membranectomy had to be performed because the haematoma had become nearly completely fibrous. The necessity for repeated evacuation and eventual subduro-peritoneal drainage seems to depend mainly on a slow brain re-expansion in some elderly people, who are actually more frequently referred. Two patients died; one was deeply comatose and another in poor general condition. Morbidity in the 96 remaining patients, 2 being lost to follow-up, was 11%: 5% related to the haematoma or to the causal trauma, and 6% from other concomitant neurological disease. The functional result was satisfactory in 85%

Intraneural Ganglionic Cyst of the Common Peroneal Nerve - Case-report and Review of the Literature

The authors report a case of compression of the peroneal nerve by an intraneural ganglionic cyst. The chief complaint is generally a lateral upper leg pain occasionally associated with foot drop and swelling of the upper tibiofibular joint. In our case, the disease was revealed by a tentative intraarticular injection of betamethasone. Early microsurgical treatment remains the only way to avoid permanent motor sequellae

Vasospasm after subarachnoid hemorrhage: diagnosis with MR angiography.

BACKGROUND AND PURPOSE: The possibility of treating intracranial vasospasm has increased the significance of its diagnosis and follow-up; however, so far, no ideal method is available. The goal of this study was to assess the accuracy of MR angiography versus intraarterial angiography (IA-DSA) in detecting vasospasm. METHODS: The study included 42 patients with acute spontaneous subarachnoid hemorrhage (SAH). Serial MR angiograms (minimum, two per patient within 10 days after the event; total, 149) were obtained prospectively using a 3D time-of-flight technique covering the circle of Willis at 0.5 T. Forty-seven MR angiograms could be compared with intraarterial angiograms obtained within 24 hours of MR angiography. Vascular narrowing on both studies was rated consensually by two pairs of neuroradiologists using a scale from 0 (no narrowing) to 3 (severe narrowing). Categories 0 and 1 were considered an absence of vasospasm and categories 2 and 3 a presence of vasospasm. RESULTS: Agreement between MR angiography and IA-DSA (assessed with weighted kappa statistics) was substantial for the middle and anterior cerebral arteries (MCA and ACA) but moderate for the internal carotid artery (ICA). The sensitivity, specificity, accuracy, and positive and negative predictive values of MR angiography for detecting patients with vasospasm were 92%, 98%, 96%, 92%, and 98%, respectively. Considering each vessel separately, specificity was high for all locations (95-99%) and sensitivity was excellent for the ACA (100%) but poorer for the ICA (25%) and MCA (56%). CONCLUSION: MR angiography at 0.5 T is capable of identifying vasospasm after acute SAH but is less sensitive than IA-DSA for depicting vasospasm in the ICA and MCA