Articles: subarachnoid-hemorrhage.
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Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. ⋯ We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Angiographic treatment of asymptomatic cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage remains controversial. We sought to investigate its relationship with the development of delayed cerebral ischemia. ⋯ Cerebral angiography has a low rate of detecting moderate-severe CVS in asymptomatic patients. Moreover, there was no statistically significant difference in the rate of delayed cerebral ischemia between asymptomatic patients treated versus those not treated for CVS. There was significant association between the severity of CVS and the intensive care unit and hospital length of stay. More studies are needed to evaluate the utility of treating asymptomatic CVS in high-grade aneurysmal subarachnoid hemorrhage.
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We report a 74-year-old male patient who presented with left hemiplegia and disturbance of consciousness. Computed tomography revealed diffuse subarachnoid hemorrhage, which was prominent in the right Sylvian and basal cisterns. Digital subtraction angiography revealed absence of the C2 segment of the right internal carotid artery (ICA) and a significantly developed circuminfundibular anastomosis. ⋯ It is formed by the superior hypophyseal arteries, prechiasmal arteries, and infundibular arteries bilaterally. Agenesis of the contralateral ICA often leads to development of ICA-ICA anastomoses. In this case, the anastomosis developed due to agenesis of the C2 segment of the right ICA and occlusion of the bilateral VAs.
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Case Reports
Modified Orbitozygomatic Craniotomy for Clipping of a Ruptured Thrombotic A1-A2 Aneurysm.
Ruptured thrombotic aneurysms pose a dual challenge of subarachnoid hemorrhage and local mass effect on neurovascular structures causing cranial nerve palsies or other neurologic symptoms. Although many thrombotic aneurysms can be treated with endovascular techniques, the benefit of surgical treatment of these aneurysms is the fact that clipping can be followed by removal of the clot and decompression of the contents of the aneurysm sac, thereby relieving local mass effect. In Video 1 we present the case of a young man with a ruptured thrombotic anterior cerebral artery (first segment of anterior cerebral artery-second segment of anterior cerebral artery) aneurysm who presented with bilateral vision loss. ⋯ The patient remained blind in the right eye after the operation, likely due to the initial subarachnoid hemorrhage being directed into the optic nerve. He did, however, have improvement of vision in his left eye. Microsurgical clipping of thrombotic aneurysms allows for exclusion of the aneurysm from the circulation, thereby protecting the patient from repeated hemorrhage, and simultaneous decompression of the local mass effect caused by the rapid increase in the size of the aneurysm due to the clot burden.
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J Neurosurg Anesthesiol · Oct 2022
Randomized Controlled TrialGoal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial.
Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients. ⋯ Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.