The likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1 and was substantially higher among those in group 2. The risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients in group 1 with unruptured intracranial aneurysms smaller than 10 mm in diameter.

More than 90% of patients reached the neurosurgical center within 12 hours of their first hospital admission after SAH; 70% of all aneurysms were clipped or coils were inserted within 24 hours of the first hospital admission. Given the protocol, only one rebleed occurred later than 24 hours after the first hospital admission. Despite this strong emphasis on early intervention, however, a cluster of 27 very early rebleeds still occurred in the control group within hours of randomization into the study, and 13 of these patients died. In the tranexamic acid group, six patients rebled and two died. A reduction in the rebleeding rate from 10.8 to 2.4% and an 80% reduction in the mortality rate from early rebleeding with tranexamic acid treatment can therefore be inferred. Favorable outcome according to the GOS increased from 70.5 to 74.8%. According to TCD measurements and clinical findings, there were no indications of increased risk of either ischemic clinical manifestations or vasospasm that could be linked to tranexamic acid treatment. Neurosurgical guidelines for aneurysm rupture should extend also into the preneurosurgical phase to guarantee protection from ultraearly rebleeds. Currently available antifibrinolytic drugs can provide such protection, and at low cost. The number of potentially saved lives exceeds those lost to vasospasm.

Primary ICH remains a stroke subtype associated with a high mortality rate and for which the level of consciousness on admission is the strongest predictor of fatal outcome both at 30 days and during the 1st year after bleeding. A preictal history of heart disease increased the 30-day mortality rate.

Bedside intracerebral microdialysis monitoring of patients with subarachnoid hemorrhage and signs of delayed ischemia revealed dramatic changes in extracellular concentrations of glucose, lactate, and glycerol that could be directly correlated to the clinical status of the patients. These findings emphasize the potential of microdialysis in neurosurgical intensive care patients.

The mortality rate has recently been reduced to only a small percentage of patients selected for early aneurysm surgery. Despite recovery without neurological deficits, however, a diffuse encephalopathy may remain, with emotional and psychological sequelae that will interfere with rehabilitation and social reintegration. The present study evaluates quality of life, degree of cognitive dysfunction, and adjustment of patients with a satisfactory neurological recovery after aneurysm operation in the acute stage following a major subarachnoid hemorrhage (SAH). Of 118 patients with a good neurological recovery, 40 patients were randomly sampled for a cross-sectional study and subjected to a questionnaire relating to their symptoms, a clinical interview, and a comprehensive neuropsychological investigation. The time interval between SAH and assessment varied between 14 months and 7 years, averaging 3 1/2 years. By means of standardized psychometric testing of intellectual capacity, memory functions, visuo-spatial abilities, perceptual speed and accuracy, and concept formation, degrees of cognitive impairment ranging from slight to severe dysfunction were identified. The results suggest that these disturbances may be permanent. The degree of impairment appeared to correlate with the patients' age. Interview data revealed substantial post-hemorrhagic maladjustment with respect to vitality, social management, self-assertion, emotional control, temperament, mood, and cognitive abilities. These findings were considerably at variance with the symptoms reported. It is stressed that, in the absence of gross neurological deficits, vital information on post-hemorrhage adjustment and impairment may easily be overlooked due to psychological defensive measures. It remains an open question whether post-SAH encephalopathy is enhanced by surgery performed in the acute stage.

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.

Fatigue after aneurysmal subarachnoid hemorrhage evaluated by pituitary function and 3D-CBF.

Our purpose was to evaluate treatment safety as well as complications frequency and management in endovascular coiling of intracerebral aneurysms using MR diffusion and perfusion imaging. In this prospective study, 77 MR examinations were performed in conjunction with 43 procedures in 40 patients, 14 patients presented with ruptured and 26 with unruptured aneurysms. Mean time interval between treatment and post-procedure MRI was 29 and 25 h for the ruptured and unruptured aneurysm group, respectively. Peri-procedural complications, including five major events and five minor transient events, occurred in 10/43 procedures (23%), necessitating thrombolytic therapy in two patients and angioplasty in one, all three within the unruptured aneurysm group. Fifty-one new lesions were found on post-treatment DWI and 47 of them were regarded as of ischemic origin. Most lesions were small (<3 mm), ipsilateral to the treated aneurysm and asymptomatic (37/40 patients). Sixty-seven percent of the lesions were found in the ruptured and 33% in the unruptured aneurysm group. The ischemic lesions did occur more frequently in patients treated for aneurysm of large neck size and according to the remodelling technique. The overall morbidity and mortality rates were 14.6 and 7.3% whereas morbidity and mortality rates related to the technique were only 2.6 and 0%, respectively. Silent embolism seems to be more common than clinically evident and partially related to patient presentation, heparinazation and treatment strategy. The capability to depict early complications and analyse their potential causes by using MR with DWI has been of great importance in our modification and improvement of therapeutic protocols, evaluations and strategies.