Management of Patients Presenting with Acute Subdural Hematoma due to Ruptured Intracranial Aneurysm

Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establish reliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm rupture results in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determining initial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and the mixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinical and radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmal subarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past 20 years are discussed and summarized in a proposed treatment flowchart.

Intravascular ultrasound-guided creation of re-entry sites to improve intermittent claudication in patients with aortic dissection

PURPOSE: To report percutaneous fenestration of aortic dissection flaps to relieve distal ischemia using a novel intravascular ultrasound (IVUS)-guided fenestration device. CASE REPORTS: Two men (47 and 62 years of age) with aortic dissection and intermittent claudication had percutaneous ultrasound-guided fenestration performed under local anesthesia. Using an ipsilateral transfemoral approach, the intimal flap was punctured under real-time IVUS guidance using a needle-catheter combination through which a guidewire was placed across the dissection flap into the false lumen. The fenestration was achieved using balloon catheters of increasing diameter introduced over the guidewire. Stenting of the re-entry was performed in 1 patient to equalize pressure across the dissection membrane in both lumens. The procedures were performed successfully and without complications. In both patients, ankle-brachial indexes improved from 0.76 to 1.07 and from 0.8 to 1.1, respectively. Both patients were without claudication at the 3- and 6-month follow-up examination. CONCLUSION: Percutaneous intravascular ultrasound-guided fenestration and stenting at the level of the iliac artery in aortic dissection patients with claudication is a technically feasible and safe procedure and relieves symptoms.

Repeated laser-assisted high-flow bypass for recurrent giant intracranial aneurysm

The treatment of intracranial aneurysms is changing as endovascular obliteration possibilities and long-term results are being published in regard to outcome. However, not all aneurysms are amenable to direct endovascular or surgical treatment. In such situations, a high flow bypass for flow preservation can be considered as indirect treatment alternative, enabling a trapping of the aneurysm or occlusion of the feeding artery. We present the case history of a 57 year-old patient suffering of a recurrent giant intracranial carotid aneurysm. The aneurysm could be excluded using a new cerebral high-flow bypass technique for which no temporary occlusion of any intracranial vessels is required. This technique reduces the risks of perioperative neurological complications.

Impact of left ventricular hypertrophy late after aortic valve replacement for aortic stenosis on cardiovascular morbidity and mortality

AIMS: The goal of this study was to assess the prevalence of left ventricular (LV) hypertrophy in patients with aortic stenosis late (>6 months) after aortic valve replacement and its impact on cardiac-related morbidity and mortality. METHODS AND RESULTS: In a single tertiary centre, echocardiographic data of LV muscle mass were collected. Detailed information of medical history and angiographic data were gathered. Ninety-nine of 213 patients (46%) had LV hypertrophy late (mean 5.8 +/- 5.4 years) after aortic valve replacement. LV hypertrophy was associated with impaired exercise capacity, higher New York Heart Association dyspnoea class, a tendency for more frequent chest pain expressed as higher Canadian Cardiovascular Society class, and more rehospitalizations. 24% of patients with normal LV mass vs. 39% of patients with LV hypertrophy reported cardiac-related morbidity (p = 0.04). In a multivariate logistic regression model, LV hypertrophy was an independent predictor of cardiac-related morbidity (odds ratio 2.31, 95% CI 1.08 to 5.41), after correction for gender, baseline ejection fraction, and coronary artery disease and its risk factors. Thirty seven deaths occurred during a total of 1959 patient years of follow-up (mean follow-up 9.6 years). Age at aortic valve replacement (hazard ratio 1.85, 95% CI 1.39 to 2.47, for every 5 years increase in age), coexisting coronary artery disease at the time of surgery (hazard ratio 3.36, 95% CI 1.31 to 8.62), and smoking (hazard ratio 4.82, 95% CI 1.72 to 13.45) were independent predictors of overall mortality late after surgery, but not LV hypertrophy. CONCLUSIONS: In patients with aortic valve replacement for isolated aortic stenosis, LV hypertrophy late after surgery is associated with increased morbidity.

Sodium pump reduction correlates with aortic clamp time in pediatric heart surgery

Myocardial depression after cardiac surgery is modulated by cardiopulmonary bypass (CPB) and the underlying heart disease. The sodium pump is a key component for myocardial function. We hypothesized that the change in sodium pump expression during CPB correlates with intraoperative and postoperative laboratory and clinical parameters in neonates and children with various congenital heart defects. Sodium pump isoforms alpha1 (ATP1A1) and alpha3 (ATP1A3) mRNA expression in right atrial myocardium, excised before and after CPB, was quantified. Groups were assigned according to presence (VO group, n = 8) or absence (NO group, n = 8) of right atrial volume overload. CPB and aortic clamp time correlated with postoperative troponin-I values and ICU stay. ATP1A1 (P = 0.008) and ATP1A3 (P = 0.038) mRNA expression were significantly reduced during CPB. Longer aortic clamp times were associated with lower postoperative ATP1A1 (P = 0.045) and ATP1A3 (P = 0.002) mRNA expression. Low postoperative ATP1A1 (P = 0.043) and ATP1A3 (P = 0.002) expressions were associated with high troponin-I values. These results were restricted to the VO group. No correlation of sodium pump mRNA expression was found with the duration of ICU stay or ventilation. The postoperative troponin-I and clinical parameters correlated with the length of CPB, regardless of volume overload. In contrast, only dilated right atrium seemed to be susceptible to CPB in terms of sodium pump expression, showing a reduction during the operation and a correlation of sodium pump with postoperative troponin-I values.

Aortic rupture in high-speed skiing crashes

BACKGROUND: New equipment and techniques in winter sports, such as carving skis and snowboards, have brought up new trauma patterns into the spectrum of leisure trauma. The injuries resemble high-energy trauma known from road crashes. The aim of the present study was to assess the incidence of acute traumatic descending aortic rupture in recreational skiing-crashes. MATERIAL: Between January 1995 and December 2004, 22 patients were admitted to our hospital for aortic rupture. Four patients had skiing crashes (18.2%). Mean age was 31 years, all patients were male. In two cases, aortic rupture was associated with fractures of the upper and lower extremities. One patient additionally had a cerebral contusion with an initial Glasgow Coma Scale score of 13. In two patients, isolated aortic rupture was diagnosed. RESULTS: Two patients were treated by graft interposition, and one by endograft. One patient arrived under mechanical resuscitation without blood pressure. He died at admission. He had been observed for 5 hours in another hospital, complaining of severe intrascapular back pain, before transport to our trauma unit for unknown bleeding. In the other three cases, treatment was successful. CONCLUSION: Rescue services and paramedics should be aware of this new type of injury. Acute aortic rupture has to be considered as possible injury in high velocity skiing crashes.

Is there a place for D-dimers in acute type A aortic dissection?

Plasma concentrations of D-dimer may prove a valuable addition in the diagnostic work-up of acute type A aortic dissection, but not as means of predicting mortality.

Comparison of Doppler-derived aortic velocities obtained from various transducer sites in healthy dogs and cats

In normal dogs and dogs with subaortic stenosis, it is known that the subcostal transducer site provides higher left ventricular ejection velocities than does the left apical site. We hypothesized that aortic flow velocities could also be obtained from the right parasternal long-axis view, optimized for the placement of the Doppler cursor as parallel as possible into the aortic root. In 15 healthy dogs and 13 healthy cats, high-pulsed repetition frequency Doppler flow velocity measurements in the proximal aorta were performed using two-dimensional echocardiographic guidance. The mean [ +/- standard error of the mean (SEM)] peak aortic flow velocities in healthy dogs were as follows: subcostal site 1.46 +/- 0.05 m/s; apical site 1.12 +/- 0.06 m/s; right parasternal long-axis site 1.09 +/- 0.05 m/s. In healthy cats, the following peak aortic flow velocities were observed: apical site 0.87 +/- 0.03m/s; right parasternal long-axis site 0.87 +/- 0.03 m/s. Aortic flow velocities obtained from the subcostal site were significantly higher in healthy dogs than those obtained from the left apical and right parasternal long-axis site (P< 0.001). There was no statistical difference between the peak aortic flow velocities obtained from right parasternal long-axis and left apical transducer position in all groups. We conclude therefore that right parasternal long-axis and left apical-derived aortic flow velocities are similar and may be used interchangeably in healthy dogs and cats.

MRI follow-up of TNF-dependent differential progression of atherosclerotic wall-thickening in mouse aortic arch from early to advanced stages

OBJECTIVES: An optimized, longitudinal in vivo magnetic resonance vessel wall-imaging protocol was evaluated regarding its capability of detecting differences in the time-dependent atherosclerotic lesion progression in the aortic arch between ApoE(-/-) and double-deficient ApoE(-/-)/TNF(-/-) mice at comparatively early plaque development stages. MATERIALS AND METHODS: Seven ApoE(-/-) and seven ApoE(-/-)/TNF(-/-) female mice underwent MRI at 11.75 teslas at four stages up to 26 weeks of age. A double-gated spin-echo MRI sequence was used with careful perpendicular slice positioning to visualize the vessel wall of the ascending aortic arch. RESULTS: Wall-thickness progression measured with MRI was significant at 11 weeks of age in ApoE(-/-) mice, but only at 26 weeks in ApoE(-/-)/TNF(-/-) mice. A significant correlation was found between MRI wall-thickness and lesion area determined on histology. CONCLUSION: MRI was shown to be sensitive enough to reveal subtle genetically-induced differences in lesion progression at ages earlier than 25 weeks.

Aortic root replacement does not affect outcome and quality of life

BACKGROUND: Different studies have analyzed the potential impact of the underlying pathologic process and the use of deep hypothermic circulatory arrest on outcome and quality of life after surgery on the thoracic aorta. The aim of this study is to analyze the impact of different surgical procedures on outcome and quality of life. METHODS: Between June 2001 and December 2003, 244 patients underwent surgery for various diseases of the ascending aorta with or without involvement of the aortic valve or root. They were divided according to the operative procedure: 76 patients (31.2%) underwent isolated replacement of the ascending aorta, 42 patients (17.2%) received separate aortic valve replacement and supracoronary replacement of the ascending aorta, 86 patients (35.2%) received a mechanical composite graft, and 40 patients (16.4%) received a biologic composite graft. All in-hospital data were assessed, and a follow-up was performed in all survivors after 26.6 +/- 8.8 months, focusing on outcome and quality of life (SF-36). RESULTS: Overall in-hospital mortality was 6.1%, and late mortality was 5.7%, with no significant difference between groups. Independent of the surgical technique and the extent of surgery, there was no difference in quality of life between the surgical collective and an age-matched and sex-matched standard population. CONCLUSIONS: Operations of the ascending aorta and aortic valve are very safe, with low in-hospital mortality and favorable midterm outcome regarding late mortality and morbidity. Quality of life after operations of the ascending aorta and aortic valve is equal to a standard population and is not affected by the surgical procedure. Liberal use of aortic root replacement is therefore justified to radically treat the diseased aortic segment.