Neurosurgery
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To clarify the efficacy and limitations of the intra-arterial local infusion of a high-dose fibrinolytic agent for acute embolic stroke, we analyzed the results of 44 patients and compared them with those of 51 patients treated with intracarotid (18 patients) or intravenous (33 patients) infusion therapy. Ten megaunits of recombinant tissue plasminogen activator or 24 x 10(4) IU of urokinase were administered through a microcatheter placed into or proximal to an embolus for 20 minutes. When arterial recanalization was not achieved, a second or third infusion was performed. ⋯ The incidence of hemorrhagic infarction was 28%. The outcome in this group and the intravenous infusion group (18 x 10(4) IU of urokinase a day for 1 wk) was poor compared with that in the local infusion group showing complete recanalization. This preliminary study appears to suggest that intra-arterial local fibrinolytic therapy could be a new strategy for acute embolic stroke.
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Clinical Trial
Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator.
We have tested a treatment protocol for intracerebral hemorrhage (ICH), consisting of stereotactic insertion of a catheter into the clot, hematoma lysis by the injection of a fibrinolytic agent, recombinant tissue-plasminogen activator (rt-PA), and closed system drainage of the liquefied clot. Fourteen patients underwent computed tomographically guided stereotactic hematoma puncture and silicone tube insertion within 72 hours of intracerebral hemorrhage. The majority (nine patients) suffered from ganglionic ICH, and the size of the hematoma ranged between 3 x 3 x 4 cm and 7 x 7 x 4 cm (mean, 5.2 x 4 x 3.6 cm). ⋯ The number of rt-PA injections was four in one patient, three in eight patients, two in four patients, and one in one patient, and the total dose of rt-PA required ranged from 5 to 16 mg (mean, 9.9 mg). After rt-PA injection, the tubing was clamped for 2 hours and then opened to drain spontaneously through a closed system against 0 cm of pressure. At follow-up 6.6 months (mean) after treatment (ranging from 3 to 13 months) and according to the Glasgow outcome score, one patient was Grade V, four were Grade IV, five were Grade III, two were Grade II, and two had died.(ABSTRACT TRUNCATED AT 250 WORDS)
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The general availability of cerebral computed tomographic and magnetic resonance imaging scans makes the observation of symptomatic intracranial meningiomas in very elderly patients (aged 80 yr or more) relatively frequent. A few authors have reported on patients who have undergone surgery for intracranial meningiomas in their 9th decade of life, without providing indications regarding the surgical criteria and the prognostic factors. ⋯ Patients with severe systemic disease and definite functional limitations (American Society of Anesthesiology Class III) had a major postoperative morbidity (P = 0.020) and mortality (P = 0.005), especially if they scored low (< 70) on the preoperative Karnofsky Rating Scale (P = 0.010). The risk of postoperative morbidity was higher when the maximum diameter of the tumor was > 5 cm (P = 0.031).
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Direct carotid-cavernous fistulas are high-flow shunts with a direct connection between the internal carotid artery and the cavernous sinus. The goals of treatment are to eliminate the fistula and preserve carotid artery patency. The authors reviewed the outcome of 98 patients with 100 consecutive direct carotid-cavernous fistulas initially treated by transarterial embolization with detachable balloons (1979-1992) at the University of Cincinnati Medical Center to evaluate the merits of this technique and to provide a standard for comparison with future treatment alternatives. ⋯ One death occurred related to cerebral infarction from a balloon that shifted. Transient ischemia occurred in three patients. On the basis of these results, we conclude that transarterial embolization with detachable balloons provides a high rate of fistula obliteration with low morbidity and is the best initial procedure to treat direct carotid-cavernous fistulas.