SummaryAmong l0 patients with primary malignant melanoma of the CNS, the turnout was localized to the brain in 7 cases (group I) and to the spinal cord in the remaining 3 cases (group II). A mean age of about 50 years and a male preponderance were found. In group I there were various neurological symptoms, and cerebral ar~eriography disclosed either vaseular or non-vascular lesions. Diagnosis was made at light microscopic examination of material obtained at operation or autopsy. The tumour was either diffuse or localized and involved both the leptomeninges and cerebral parenchyma. After operation the patients survived for between 2 weeks and 7 months. In group II there were compression symptoms and pathological gas myelography. At operation tumours were found that involved the leptomeninges and medulla. Light microscopic examination showed malignant melanoma. The postoperative survival was longer (12 months-2 years and 9 months) than in group I.
In 4 patients with subarachnoid haemorrhage after ruptured intracranial aneurysm, tranexamic acid (AMCA) was used to prevent the recurrence of the bleeding. 1000 mg of AMCA was given intravenously 6 times a day for 8 days. The fibrinolytic activity of blood and spinal fluid was measured simultaneously with the etermination of AMCA levels before and after the beginning of treatment. The fibrin plate method showed no fibrinolytic activity in plasma or in CSF. Local fibriolysis was demonstrated by the presence of fibrin degradation products in spinal fluid. After repeated administration, AMCA crossed the blood‐brain barrier and effectively inhibited the local fibrinolysis within the spinal fluid. The findings in this study suggest that in patients with subarachnoid haemorrhage AMCA should be aministrated intravenously in a dosage of 15–20 mg/kg body weight 6 times a day as soon as possible after the bleeding. But treatment with the antifibrinolytic drug does not change the indication for surgical therapy.
For some time we have been interested in the use of antifibrinolytic substances in neurosurgery. In 1967 we described the use of epsilon -aminocaproic acid (EACA) in two cases of arteriovenous malformations operated on in 1965 and considered it to be of definite value during the surgical procedures. In 1965 Mullan, reporting on some cases of intracranial saccular aneurysms, described the value of EACA in prolonging the duration of thrombosis in an electrically thrombosed aneurysm. In April 1967 at the European Neurosurgical Congress in Madrid we reported our principles for using EACA in the management of ruptured saccular aneurysms.It is well known that immediately after rupture a clot forms at the site of rupture in the aneurysm wall. This can be very well observed in operations in the acute stage. Early recurrent bleedings, which we all know have a very high mortality rate, usually take place around the second week after the initial bleeding. These are probably due to dissolution of the clot or changes in haemodynamic factors which cause the clot to give way. It is also a well-known fact that complicating vasospasm might occur in connection with early operations and the operative procedure can not be excluded as a factor contributing to this. If the risk of early recurrent bleeding could be eliminated or diminished by giving EACA the operative procedure could be postponed to a later time when the operative risk is considerably less.These considerations do not alter our opinion that in certain circumstances very early surgery may be indicated even on the same day as the initial bleeding. Angiography has to be performed as early as possible in these cases and before EACA has been given.14 cases of ruptured aneurysm at different locations have been given antifibrinolytic substance and all have been operated upon. Three patients were treated with EACA, 4-5 g 4 times daily and 11 cases received Cyklokapron, 10 mgm per kilo body weight 3-4 times daily intravenously. 11 cases were treated 1-7 days before operation, 1 case 11 days preoperatively and 2 cases 14 and 16 days preoperatively. For different reasons a strict program could not be followed in all cases. In 7 cases the antifibrinolytic treatment was started immediately in the first week after bleeding, in 5 cases within two weeks and in the remaining 2 cases in the third week. In none of our cases did recurrent bleeding occur during treatment. 2 cases died after operation. In one, recurrent bleeding occurred after inadequate surgery where the aneurysm could not be eliminated by a ligature and a big basal part had to be wrapped with plastic adhesive. The second case is of greater interest. The patient died 18 days after operation. The postoperative course was uneventful for 10 days and then slow deterioration and death occurred without any signs of increased intracranial pressure. At post-mortem bilateral thrombosis of the anterior cerebral arteries was demonstrated.It is quite clear that many problems arise in these cases, in which an accurate evaluation of earl...
The fibrinolytic activity of peripheral blood and cerebrospinal fluid was estimated by the fibrin plate method and by assays for fibrin degradation products in 11 patients with proven aneurysmal subarach‐noid haemorrhage. Five of the patients were treated conservatively; the remaining 6, surgically. An increase in the fibrinolytic activity of the cerebrospinal fluid, as judged from the appearance of fibrin degradation products, occurred in all the patients on the third day after the initial haemorrhage. This fibrinolytic activity tended to decrease the first three weeks after the onset of the haemorrhage in 7 patients. In the remaining 4 it was still elevated at the end of the third week. In one of these patients haemorrhage recurred. Demonstration of high concentrations of fibrin degradation products in cerebrospinal fluid after surgery on the brain suggests the release of tissue activators from the damaged brain during the operation. Premature dissolution of the haemostatic plug at the site of the ruptured intra‐cranial aneurysm might therefore be responsible for the rebleeding. Hence the use of anti‐fibrinolytic drugs may be useful in the management of patients with subarachnoid haemorrhage.
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