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CEREBROVASCULAR DISEASES
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the end of the following 6 months, 8 of every 100 patients had died of the original hemorrhage and 59 had had a recurrence (with 40 deaths), making a total of 48 deaths and 52 survivors In regard to recurrence of bleeding, it was found that of 50 patients seen on the rst day of the illness, 5 rebled in the rst week (all fatal), 8 in the second week (5 fatal), 6 in the third and fourth weeks (4 fatal), and 2 in the next 4 weeks (2 fatal), making a total of 21 recurrences (16 fatal) in 8 weeks The most comprehensive long-term analysis of the natural history of the disease is contained in the report of the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage (Sahs et al) This study was based on long-term observations of 568 patients who sustained an aneurysmal bleed between 1958 and 1965 and were managed only by a conservative medical program A follow-up search in 1981 and 1982 disclosed that 378, or twothirds of the patients, had died; 40 percent of the deaths had occurred within 6 months of the original hemorrhage For the patients who survived the original hemorrhage for 6 months, the chances of survival during the next two decades were signi cantly worse than those of a matched normal population Rebleeding occurred at a rate of 22 percent per year during the rst decade and 086 percent per year during the second Rebleeding episodes were fatal in 78 percent of cases These statistics, however, also re ect the outcome prior to the modern era of microsurgery and neurologic intensive care management One would expect these gures to have improved in recent years, but the change has not been striking In a prospective clinical trial conducted by the International Cooperative Study in 1990 and based on observations of 3521 patients (surgery performed in 83 percent), it was found, at the 6-month evaluation, that 26 percent of the patients had died and 58 percent had made a good recovery (Kassell et al) Vasospasm and rebleeding were the leading causes of morbidity and mortality in those who survived the initial bleed In respect to rebleeding, all series indicate that the risk is greatest in the rst day but extends for weeks The observations of Aoyagi and Hayakawa are similar to those of other series; they found that rebleeding occurred within 2 weeks in 20 percent of patients, with a peak incidence in the 24 h after the initial episode Treatment This is in uenced by the neurologic and general medical state of the patient as well as by the location and morphology of the aneurysm Ideally, all patients should have the aneurysmal sac obliterated, but the mortality is high if the patient is stuporous or comatose (grade IV or V, see below) Before deciding on a course of action, it has been useful to assess the patient with reference to the widely employed scale introduced by Botterell and re ned by Hunt and Hess, as follows: Grade I Asymptomatic or with slight headache and stiff neck Grade II Moderate to severe headache and nuchal rigidity but no focal or lateralizing neurologic signs Grade III Drowsiness, confusion, and mild focal de cit Grade IV Persistent stupor or semicoma, early decerebrate rigidity and vegetative disturbances Grade V Deep coma and decerebrate rigidity The general medical management in the acute stage includes the following, all or in part: bed rest, uid administration to maintain above-normal circulating blood volume and central venous pressure, use of elastic stockings and stool softeners; administration of beta blockers, calcium channel blockers, intravenous nitroprus-
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side, or other medication to reduce greatly elevated blood pressure and then maintain systolic blood pressure at 150 mmHg or less; and pain-relieving medication for headache (this alone will often reduce the hypertension) The prevention of systemic venous thrombosis is critical, usually accomplished by the use of cyclically in ated whole-leg compression boots The use of anticonvulsants is controversial; many neurosurgeons administer them early, with a view of preventing a seizure-induced risk of rebleeding We have generally avoided them unless a seizure has occurred Calcium channel blockers are being used extensively to reduce the incidence of stroke from vasospasm Nimodipine 60 mg, administered orally every 4 h, is currently favored Although calcium channel blockers do not alter the incidence of angiographically demonstrated vasospasm, they have reduced the number of strokes in each of ve randomized studies, beginning with the one conducted by Allen and colleagues Several groups have been using angioplasty techniques to dilate vasospastic vessels and reporting symptomatic improvement, but there are as yet insuf cient controlled data to judge the merits and safety of this procedure The most notable advances have been in the techniques for the obliteration of aneurysms, particularly the operating microscope and endovascular approaches, and in the management of circulatory volume In the majority of patients intravascular volume is depleted in the days after subarachnoid hemorrhage This, in turn, greatly increases the chances of ischemic infarction from vasospasm, though it does not alter its incidence or severity In part, this volume contraction can be attributed to bed rest, but sodium loss, probably resulting from the release of atrial natriuretic factor (ANF), a potent oligopeptide stimulator of sodium loss in renal tubules, may also be a factor Hyponatremia develops in the rst week after hemorrhage, but it is unclear whether this also results from the natriuretic effects of ANF or is an effect of antidiuretic hormone, causing water retention The work of Diringer and coworkers suggests that both mechanisms are operative, but we would emphasize that it is the volume depletion, not hyponatremia per se, that is of the greatest clinical consequence Both the risk of rerupture of the aneurysm and some of the secondary problems that arise because of the massive amount of blood in the subarachnoid space can be obviated by early obliteration of the aneurysm Because of the changes in water balance and the risk of delayed stroke from vasospasm, there has been an emphasis on early volume expansion and sodium repletion by the intravenous infusion of crystalloids As Solomon and Fink have pointed out, this can be accomplished with relative safety and without fear of aneurysmal rupture if blood pressure is allowed to rise only minimally And, or course, uid replacement and a modest elevation of blood pressure become completely safe if the aneurysm has been surgically occluded Thus the current approach is to operate early, within 36 h if possible, on all patients in grades I and II and then to increase intravascular volume and maintain normal or above-normal blood pressures This eliminates the risk of rebleeding, with its high mortality, and helps prevent the second cause of morbidity, stroke from vasospasm The timing of surgery or endovascular treatment for grade III patients is still controversial, but if their medical condition allows, they too probably bene t from the same early and aggressive approach In grade IV patients, the outcome is generally dismal, no matter what course is taken, but we have usually counseled against early operation; some neurosurgeons disagree The insertion of ventricular drains into both frontal horns has occasionally raised a patient with severe hydrocephalus to a better grade and facilitated early operation In the
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