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105 Patients With Subarachnoid Hemorrhage (SAH): A Retrospective Study
Mira? Aysen ünsal ?AKMAK,Nihal ISIK,Ilknur CANTURK,Ramazan SARI
Journal of Neurological Sciences , 2008,
Abstract: Objective: Subarachnoid hemorrhage (SAH) may arise due to trauma or spontaneously, and is a medical emergency which can lead to death or severe disability even if recognized and treated in an early stage. In this study 105 SAH patients,consulted and diagnosed by neurology and neurosurgery clinics in our hospital between January 2005 and January 2008,evaluated to determine etiopathologic and clinical manifestations.Materials and Methods: Clinical records,neuro-imaging and CSF reports of patients were reviewed.Cranial CT scanning performed in all patients at administration.For further evaluation cerebral anjiography used in 98 patients (%93.3) and lumbar puncture in 3 patients.Results: We detected intracranial aneurysms as the most common pathology (86.6 %),trauma and arteriavenous malformations consecutively. SAH severity was assessed according to Yasargil SAH Grading scale. We found out middle cerebral artery aneurysm in 31 patients (34%),anterior communican artery aneurysm in 23 patients ( 25.2 %),internal carotis artery aneurysm in 8 patients (8.8 %),posterior communican artery aneurysm in 7 patients (7.69%),anterior cerebral artery aneurysm in 5 patients ( 5.4 %), basillary artery aneurysm in 3 patients (3.29 %), anterior coroidal artery aneurysm in 1 patient(1.09 %).Conclusions: Our study confirms earlier studies reporting the most common cause of SAH is intracranial aneurysms (86.6 %).The diagnosis of SAH usually depends on a high index of clinical suspicion combined with radiographic confirmation via CT scan without contrast.After the diagnosis of SAH, further imaging should be performed to characterize the source of the hemorrhage.This effort can include standard angiography, CT angiography, and lumbar puncture.period in female migraine patients. The examination of serum sex hormones levels can be useful to determine the etiopathogenesis and treatment in female migraine patients.
Monitoring in Neurointensive Care – The Challenge to Detect Delayed Cerebral Ischemia in High-Grade Aneurysmal SAH  [PDF]
Asita S. Sarrafzadeh,Philippe Bijlenga,Karl Schaller
Frontiers in Neurology , 2014, DOI: 10.3389/fneur.2014.00134
Abstract: Delayed cerebral ischemia (DCI) is a feared and significant medical complication following aneurysmal subarachnoid hemorrhage (aSAH). It occurs in about 30% of patients surviving the initial hemorrhage, mostly between days 4 and 10 after aSAH. Clinical deterioration attributable to DCI is a diagnosis of exclusion and especially difficult to diagnose in patients who are comatose or sedated. The latter are typically patients with a high grade on the World Federation of Neurosurgical Societies scale (WFNS grade 4–5), who represent approximately 40–70% of the patient population with ruptured aneurysms. In this group of patients, the incidence of DCI is often underestimated and higher when compared to low WFNS grade patients. To overcome difficulties in diagnosing DCI, which is especially relevant in sedated and comatose patients, the article reports the most recent recommendation for definition of DCI and discusses their advantages and problematic issues in neurocritical care practice. Finally, appropriate neuromonitoring techniques and their clinical impact in high-grade SAH patients are summarized.
Poor-grade subarachnoid hemorrhage: Is surgical clipping worthwhile?  [cached]
Gupta Sunil,Ghanta Rajesh,Chhabra Rajesh,Mohindra Sandeep
Neurology India , 2011,
Abstract: Background : Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center. Material and Methods : In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead. Results : Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome. Conclusions : With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term follow-up, the surviving patients showed significant improvement from the status at discharge.
Predicting Outcome of Poor Grade Patients of Subarachnoid Haemorrhage Due to Anterior Communicating Artery Aneurysm  [PDF]
Abrar WANI,Sanjay BEHARI,Vivek VAID,Awdesh JAISWAL
Journal of Neurological Sciences , 2007,
Abstract: Background: This study deals with analyzing our protocol in managing patients of poor grade aneurysmal subarachnoid haemorrhage (aSAH) and in determining the factors that influenced outcome. The aim of our study is to find the outcome following aneurysmal subarachnoid haemorrhage in poor grade patients due to anterior communicating artery aneurysm and to find out if outcome could be predicted on basis of presentation.Material and Methods: This is a retrospective study of 71 patients of aSAH due to anterior communicating artery aneurysm who were in Hunt and Hess grade IV and V. The efficacy of aggressive management on outcome and the potential factors influencing outcome were analyzed. The outcome was assessed on basis of Glasgow outcome scale (GOS) as favorable (GOS 3 to 5) or unfavorable group (GOS of 2 or 1)Statistical method: Initially all the factors that were presumed to affect the outcome were analyzed for statistical significance using cross-tab and chi-square analysis. At 95%, confidence interval p values were calculated and p≤ 0.05 was considered significant. Than a discriminant, analysis was done to assess the efficacy of various factors in predicting outcome.Results: We could predict the outcome correctly as poor in 62.7% of patients and good in 75% of patients. The overall predictability of outcome could be done correctly in 66.2% cases. In grade IV patients, we found favorable outcome in 20 patients (40 %) while in grade V it was not observed in any of the patient. Five factors were statistically significant (p<0.05) in predicting outcome, these were - Glasgow coma score, angiographic vasospasm, age, intraventricular haemorrhage and hydrocephalus.Conclusion: In patients with grade IV SAH outcome seems to be favorable with aggressive management and early surgery seems justified and is recommended. Early surgery did not lead to increased mortality. In grade V patients outcome is poor and it is not clear whether early or late surgery is best for these patients .The significant factors determining outcome are age, GCS and H&H grade, vasospasm, IVH and hydrocephalus. By initial presentation, one cannot predict outcome with reasonable accuracy so aggressive management is advocated in all patients of grade IV SAH and one cannot withhold treatment on basis of initial presentation alone. In cases of grade, V SAH we could not find good outcome in any patient, hence the aggressiveness of treatment in these patients is debatable.
Cerebral microdialysis for detection of bacterial meningitis in aneurysmal subarachnoid hemorrhage patients: a cohort study
Florian Schlenk, Katja Frieler, Alexandra Nagel, Peter Vajkoczy, Asita S Sarrafzadeh
Critical Care , 2009, DOI: 10.1186/cc7689
Abstract: Retrospectively, 167 patients with SAH in an ongoing investigation on cerebral metabolism monitored by MD were analysed for the presence of BM and related MD changes. Diagnosis of BM was based on microbiological CSF culture or clinical symptoms responding to antibiotic treatment, combined with an increased CSF cell count and/or fever. Levels of MD parameters before and after diagnosis of BM were analysed and compared with the spontaneous course in controls.BM developed in 20 patients, of which 12 underwent MD monitoring at the time of diagnosis. A control group was formed using 147 patients with SAH not developing meningitis. On the day BM was diagnosed, cerebral glucose was lower compared with the value three days before (p = 0.012), and the extent of decrease was significantly higher than in controls (p = 0.044). A decrease in cerebral glucose by 1 mmol/L combined with the presence of fever ≥ 38°C indicated BM with a sensitivity of 69% and a specificity of 80%. CSF chemistry failed to indicate BM, but the cell count increased during the days before diagnosis (p < 0.05).A decrease in MD glucose combined with the presence of fever detected BM with acceptable sensitivity and specificity, while CSF chemistry failed to indicate BM. In patients with SAH where CSF cell count is not available or helpful, MD might serve as an adjunct criterion for early diagnosis of BM.Bacterial meningitis (BM) is a severe and cost-intensive complication in patients with aneurysmal subarachnoid haemorrhage (SAH) and requires immediate treatment. Although appropriate therapy with potent antibiotics is available, BM continues to be associated with a prolonged stay in the intensive care unit (ICU) and high morbidity [1]. External drainage of cerebrospinal fluid (CSF), frequently applied especially in patients with high-grade SAH, may raise the risk of infections of the central nervous system (CNS). The diagnosis is difficult in patients with SAH because the clinical signs of meningits are oft
Is continuous insulin treatment safe in aneurysmal subarachnoid hemorrhage?  [cached]
Florian Schlenk,Asita S Sarrafzadeh
Vascular Health and Risk Management , 2008,
Abstract: Florian Schlenk, Asita S SarrafzadehClinic of Neurosurgery, Charité Campus Virchow Medical Center, Berlin, GermanyObjectives: To investigate the long-term effect of continuous insulin infusion for glucose control on cerebral metabolism in aneurysmal subarachnoid hemorrhage (SAH) patients. Methods: Prospective, nonrandomized study of 31 SAH patients in the ICU (52 ± 10 years, WFNS Grade 2.9 ± 1.6). A microdialysis catheter was inserted into the vascular territory of the aneurysm. Metabolic changes during 4 days after onset of insulin infusion were analyzed. Blood glucose levels >140 mg/dL after clinical stabilization were treated with intravenous insulin.Results: 24 patients were treated with intravenous insulin. Though no insulin-induced hypoglycemia occurred, cerebral glucose decreased on days 1–4 after insulin onset without reaching critical levels. Glycerol, a marker of membrane degradation, showed a reversible increase on day 1 while the lactate/pyruvate ratio remained stable and glutamate even decreased indicating absence of severe cerebral crisis following insulin infusion and excluding ischemia as a cause for cerebral glucose depletion.Conclusions: Concerning cerebral metabolism, long-term continuous insulin infusion appears to be safe as long as cerebral glucose levels do not fall below the physiological range. In view of the high incidence of hyperglycemia and need for insulin treatment, future studies on the effect of insulin on cerebral metabolism in SAH patients are desirable.Keywords: glucose, hyperglycemia, insulin, subarachnoid hemorrhage, microdialysis
Perceptions of stakeholders on causes of poor performance in Grade 12 in a province in South Africa
M.W. Legotlo, M.P. Maaga, M.G. Sebego
South African Journal of Education , 2002,
Abstract: Although a great deal of debate surrounds poor performance in Grade 12 National Examinations, very little research has addressed the factors influencing student performance. This paper gives an overview of causes of poor student performance in Grade 12. Stakeholders' perceptions on causes of poor student performance were gathered through interviews. The study revealed that major causes of poor student performance included lack of resources, lack of discipline and poor morale, problems concerning the implementation of policies, and inadequate parental involvement. (South African Journal of Education: 2002 22(2): 113-118)
Expression of the global regulator SATB1 is an independent factor of poor prognosis in high grade epithelial ovarian cancer  [cached]
Nodin Bj?rn,Hedner Charlotta,Uhlén Mathias,Jirstr?m Karin
Journal of Ovarian Research , 2012, DOI: 10.1186/1757-2215-5-24
Abstract: Background The global gene regulator Special AT-rich sequence-binding protein1 (SATB1) has been reported to reprogramme tumour cells into a more malignant phenotype and associate with poor clinical outcome in several cancer forms. In this study, we investigated the molecular correlates and prognostic impact of SATB1 expression in human epithelial ovarian cancer (EOC). Findings Immunohistochemical expression of SATB1 was examined in tissue microarrays with tumours from 151 incident EOC cases from two prospective, population-based cohorts. Benign-appearing fallopian tube epithelium from 32 cases was also analyzed. A multiplier of nuclear fraction and staining intensity of SATB1 was calculated. While barely expressed in tubal epithelium, nuclear SATB1 expression was denoted in 35/151 (23.2%) EOC cases. Spearman′s Rho test revealed an inverse correlation between SATB1 expression and histological grade (R = -0.22, p = 0.006) and a positive correlation with expression of dachshund 2 protein (R = 0.28, p = 0.001), phosphorylated Chek1 (R = 0.26, p = 0.002) and minichromosome maintenance protein 3 (R = 0.17, p = 0.042). Univariable Cox regression analysis revealed that SATB1 expression, while not prognostic in the full cohort, was associated with a reduced ovarian cancer-specific survival and 5-year overall survival in high grade tumours (n = 105) (HR = 2.14 and HR = 1.96, respectively). This association remained significant in multivariable analysis, adjusted for age and clinical stage (HR = 2.20 and HR = 2.06, respectively). Conclusions These results demonstrate that SATB1 expression is an independent factor of poor prognosis in high grade EOC and correlates in vivo with cellular processes involved in the maintenance of DNA integrity. The functional basis for these observations merits further investigation.
An Observational Study of the First Experience with Bevacizumab for the Treatment of Patients with Recurrent High-Grade Glioma in Two Belgian University Hospitals  [PDF]
M. Huylebrouck,S. Lv,J. Duerinck,A. Van Binst,I. Salmon,J. De Greve,O. De Witte,S. Luce,A. Michotte,J. D'Haens,B. Neyns
Journal of Oncology , 2012, DOI: 10.1155/2012/801306
Abstract: Background. Bevacizumab (BEV), a humanized immunoglobulin G1 monoclonal antibody that inhibits VEGF has demonstrated activity against recurrent high-grade gliomas (HGG) in phase II clinical trials. Patients and Methods. Data were collected from patients with recurrent HGG who initiated treatment with BEV outside a clinical trial protocol at two Belgian university hospitals. Results. 19 patients (11 M/8 F) were administered a total of 138 cycles of BEV (median 4, range 1–31). Tumor response assessment by MRI was available for 15 patients; 2 complete responses and 3 partial responses for an objective response rate of 26% for the intent to treat population were observed on gadolinium-enhanced T1-weighted images; significant regressions on T2/FLAIR were documented in 10 out of 15 patients (67%). A reduced uptake on PET was documented in 3 out of 4 evaluable patients. The six-month progression-free survival was 21% (95% CI 2.7–39.5). Two patients had an ongoing tumor response and remained free from progression after 12 months of BEV treatment. Conclusions. The activity and tolerability of BEV were comparable to results from previous prospective phase II trials. Reduced uptake on PET suggests a metabolic response in addition to an antiangiogenic effect in some cases with favorable clinical outcome. 1. Introduction Gliomas are the most frequent primary tumors of the central nervous system (CNS) and represent approximately 2% of all malignant diseases. Their annual incidence is about 11.5 new cases per 100.000 persons per year [1, 2]. The WHO classification of tumors of the central nervous system distinguishes the subtypes of glioma according to morphology and grade [3]. High-grade gliomas (HGG, WHO-grade 3 and 4 glioma) are malignant tumors with a poor survival outcome. In a pivotal phase III trial, where patients diagnosed with glioblastoma (GB, WHO-grade IV glioma) who were treated with postoperative radiation therapy (RT) and concomitant temozolomide (TMZ) followed by six cycles of adjuvant TMZ, the median survival was 14,6 months, while the overall survival (OS) was 27.2% at 2 years, 16.0% at 3 years, 12.1% at 4 years, and 9.8% at 5 years [4]. The prognosis of patients with WHO-grade III glioma is superior to that of GB patients but much more heterogeneous and correlated with the histopathological and molecular-genetic subtype [5, 6]. Following initial resection and postoperative RT, anaplastic gliomas recur after a median of 2-3 years. Most often, recurrent grade III glioma will have transformed into a more aggressive tumor at recurrence (a so-called
Diagnosis of High-Grade Osteosarcoma by Radiology and Cytology: A Retrospective Study of 52 Cases  [PDF]
Veli S derlund,Lambert Skoog,Krishnan K. Unni,Franco Bertoni,Otte Brosj ,Andris Kreicbergs
Sarcoma , 2004, DOI: 10.1080/13577140410001679239
Abstract: The diagnostic value of combined radiology and fine needle aspiration cytology (FNAC) was retrospectively assessed in a consecutive series of 52 patients with high-grade osteosarcoma. The series was divided into typical and atypical osteosarcomas according to radiological features and site. Thirty-two of 33 radiologically typical osteosarcoma cases were correctly diagnosed by cytology; one lesion was diagnosed as sarcoma NOS. Nineteen osteosarcoma cases were radiographically atypical. Six of these were diagnosed as osteosarcoma and another six as sarcoma NOS. In three cases another type of sarcoma was suggested. One case was falsely classified as benign. FNAC of three cases were non-diagnostic. Overall, the diagnostic difficulties pertained to the radiologically atypical cases. Notably, four of these also posed considerable difficulties in the histopathological assessment prompting external consultation. Our study suggests that open biopsy can be obviated in high-grade osteosarcomas exhibiting typical radiological features, i.e., in two-thirds.
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