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くも膜下出血

著者: 藤中俊之 国立病院機構大阪医療センター 脳神経外科

監修: 内山真一郎 国際医療福祉大学臨床医学研究センター

著者校正/監修レビュー済:2018/02/28
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. くも膜下出血とは、くも膜と軟膜の間(くも膜下腔)に出血が生じ、脳脊髄液中に血液が混入した状態である。
  1. くも膜下出血を来す危険因子としては多量の飲酒習慣(1週間に150g以上のアルコール摂取)、喫煙習慣、最近の感染症、高血圧保有、脳動脈瘤保有やくも膜下出血の家族歴などが挙げられる。
  1. なお、未破裂動脈瘤に関しては、別項の「」を参照にしてほしい
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
藤中俊之 : 未申告[2021年]
監修:内山真一郎 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報  
  1. くも膜下出血とは、くも膜と軟膜の間に出血が生じ、脳脊髄液中に血液が混入した状態である。
  1. わが国でのくも膜下出血の年間発症率は人口10万人あたり約20人(10~23人)で女性に多い傾向を認める(男女比1:2)。
  1. 日本国内での脳血管障害に占めるくも膜下出血の割合はやや増加傾向にある。年齢調整死亡率でも、男性が横ばい傾向を示しているのに比べ、女性は倍増しており近年の女性の生活形態の変化による影響が考えられている。
  1. くも膜下出血を来す危険因子としては喫煙習慣、高血圧保有、多量の飲酒(1週間に150g以上のアルコール摂取)や最近の感染症が挙げられる。なかでも多量の飲酒は、単独ではくも膜下出血の最も危険な因子とされている。また、7mm以下の比較的小さな脳動脈瘤を保有する患者群において、高血圧保有、比較的若年(50歳未満)、後方循環の動脈瘤、が破裂の危険因子であるとの報告もある。
  1. 家族性脳動脈瘤(2親等以内)は4~10に認めるとされている。家族性脳動脈瘤にはくも膜下出血を発症する平均年齢が非家族性のものより約5歳若い、多発性脳動脈瘤が多い、同胞例では同一部位あるいは鏡像部位に動脈瘤を認めることが多く同年代で発症することが多いなどの特徴がある。
病歴・診察のポイント  
  1. くも膜下出血は多くの場合「突然起こった今までに経験したことのない激しい頭痛」で発症する。脳血管障害が疑われる患者のうち、突然の頭痛に加えて、比較的若く4060歳代)、局所神経症状を欠く場合にはくも膜下出血が強く疑われる。
  1. 典型例では臨床症状と頭部CT検査で診断が確定するが、軽症である場合や重篤な出血を来す前のごく少量の出血(警告症状)では頭痛が一過性であったり、めまいや悪心・嘔吐、意識消失が主症状であることもある。警告症状を正しく診断した場合と見逃した場合では予後に大きな差がみられるため注意が必要である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

著者: P B Gorelick, D B Hier, L R Caplan, P Langenberg
雑誌名: Neurology. 1986 Nov;36(11):1445-50.
Abstract/Text Headache features were compared in 51 patients with acute subarachnoid hemorrhage (SAH), 61 with intraparenchymal hemorrhage (IPH), and 160 with ischemic stroke (IS). SAH patients had more sentinel headaches, more onset headaches, and more bilateral and severe onset headaches than patients with IPH or IS. Vomiting with onset headache was more common in SAH and IPH. In stepwise logistic regression analysis, onset headache and vomiting were direct predictors of SAH, but were inversely related to IS. Sentinel headache was not a predictor of underlying stroke mechanism. The data suggest that some headache features are more frequently associated with particular stroke subtypes and that onset headache and vomiting may be important indicators of stroke mechanism.

PMID 3762963  Neurology. 1986 Nov;36(11):1445-50.
著者: A Polmear
雑誌名: Cephalalgia. 2003 Dec;23(10):935-41.
Abstract/Text The aim of this systematic review was to determine the incidence of sentinel headache reported by patients with aneurysmal subarachnoid haemorrhage, and whether they are likely to be due to recall bias or to misdiagnosis of a previous haemorrhage. Nine studies of good quality, which reported the number of patients with aneurysmal subarachnoid haemorrhage with a history of sentinel headache, gave rates of 10% to 43%. Two case-control studies, in which the frequency of a history of sentinel headache in patients with aneurysmal subarachnoid haemorrhage was compared with that in controls with non-aneurysmal subarachnoid haemorrhage or with stroke, gave an incidence of 5% (95% confidence interval 0.5, 16) in controls, suggesting that only a small number of apparent sentinel headaches are due to recall bias. Sentinel headaches appear to be a real entity. Their true incidence may vary from near zero to about 40% according to the rate of misdiagnosis in the community under consideration.

PMID 14984225  Cephalalgia. 2003 Dec;23(10):935-41.
著者: P B Fontanarosa
雑誌名: Ann Emerg Med. 1989 Nov;18(11):1199-205.
Abstract/Text The medical records of 109 patients who presented to the emergency department during a five-year period with proven nontraumatic, spontaneous subarachnoid hemorrhage (SAH) were retrospectively reviewed. The clinical presentation, diagnostic modalities used, and accuracy of diagnosis by emergency physicians were analyzed. The most common historical features were headache (81 patients, or 74%), nausea or vomiting (85 patients, or 77%), and loss of consciousness (58 patients, or 53%). Nonexertional activities preceding SAH were more frequent than exertional events (57% vs 21%). Neurologic findings were present in 70 patients (64%) and consisted primarily of altered levels of consciousness. Thirty-eight patients (35%) had nuchal rigidity. Ninety-six emergency cranial computed tomography scans were performed, of which 91 were diagnostic for SAH (sensitivity, 95%). Lumbar puncture was performed on two patients with normal computed tomography scans and revealed bloody spinal fluid. The overall diagnostic accuracy by emergency physicians was 85%. The correct diagnosis was delayed in 16 patients (15%), the majority of whom had headaches and normal neurologic examinations. Atypical symptoms, the warning leak syndrome, and the need for prompt diagnosis and therapy are reviewed.

PMID 2683901  Ann Emerg Med. 1989 Nov;18(11):1199-205.
著者: Jeffrey J Perry, Ian G Stiell, Marco L A Sivilotti, Michael J Bullard, Corinne M Hohl, Jane Sutherland, Marcel Émond, Andrew Worster, Jacques S Lee, Duncan Mackey, Merril Pauls, Howard Lesiuk, Cheryl Symington, George A Wells
雑誌名: JAMA. 2013 Sep 25;310(12):1248-55. doi: 10.1001/jama.2013.278018.
Abstract/Text IMPORTANCE: Three clinical decision rules were previously derived to identify patients with headache requiring investigations to rule out subarachnoid hemorrhage.
OBJECTIVE: To assess the accuracy, reliability, acceptability, and potential refinement (ie, to improve sensitivity or specificity) of these rules in a new cohort of patients with headache.
DESIGN, SETTING, AND PATIENTS: Multicenter cohort study conducted at 10 university-affiliated Canadian tertiary care emergency departments from April 2006 to July 2010. Enrolled patients were 2131 adults with a headache peaking within 1 hour and no neurologic deficits. Physicians completed data forms after assessing eligible patients prior to investigations.
MAIN OUTCOMES AND MEASURES: Subarachnoid hemorrhage, defined as (1) subarachnoid blood on computed tomography scan; (2) xanthochromia in cerebrospinal fluid; or (3) red blood cells in the final tube of cerebrospinal fluid, with positive angiography findings.
RESULTS: Of the 2131 enrolled patients, 132 (6.2%) had subarachnoid hemorrhage. The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for subarachnoid hemorrhage. Adding "thunderclap headache" (ie, instantly peaking pain) and "limited neck flexion on examination" resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity.
CONCLUSIONS AND RELEVANCE: Among patients presenting to the emergency department with acute nontraumatic headache that reached maximal intensity within 1 hour and who had normal neurologic examination findings, the Ottawa SAH Rule was highly sensitive for identifying subarachnoid hemorrhage. These findings apply only to patients with these specific clinical characteristics and require additional evaluation in implementation studies before the rule is applied in routine clinical care.

PMID 24065011  JAMA. 2013 Sep 25;310(12):1248-55. doi: 10.1001/jama.20・・・
著者: J A Edlow, L R Caplan
雑誌名: N Engl J Med. 2000 Jan 6;342(1):29-36. doi: 10.1056/NEJM200001063420106.
Abstract/Text
PMID 10620647  N Engl J Med. 2000 Jan 6;342(1):29-36. doi: 10.1056/NEJ・・・
著者: Robert G Kowalski, Jan Claassen, Kurt T Kreiter, Joseph E Bates, Noeleen D Ostapkovich, E Sander Connolly, Stephan A Mayer
雑誌名: JAMA. 2004 Feb 18;291(7):866-9. doi: 10.1001/jama.291.7.866.
Abstract/Text CONTEXT: Mortality and morbidity can be reduced if aneurysmal subarachnoid hemorrhage (SAH) is treated urgently.
OBJECTIVE: To determine the association of initial misdiagnosis and outcome after SAH.
DESIGN, SETTING, AND PARTICIPANTS: Inception cohort of 482 SAH patients admitted to a tertiary care urban hospital between August 1996 and August 2001.
MAIN OUTCOME MEASURES: Misdiagnosis was defined as failure to correctly diagnose SAH at a patient's initial contact with a medical professional. Functional outcome was assessed at 3 and 12 months with the modified Rankin Scale; quality of life (QOL), with the Sickness Impact Profile.
RESULTS: Fifty-six patients (12%) were initially misdiagnosed, including 42 of 221 (19%) of those with normal mental status at first contact. Migraine or tension headache (36%) was the most common incorrect diagnosis, and failure to obtain a computed tomography (CT) scan was the most common diagnostic error (73%). Neurologic complications occurred in 22 patients (39%) before they were correctly diagnosed, including 12 patients (21%) who experienced rebleeding. Normal mental status, small SAH volume, and right-sided aneurysm location were independently associated with misdiagnosis. Among patients with normal mental status at first contact, misdiagnosis was associated with worse QOL at 3 months and an increased risk of death or severe disability at 12 months.
CONCLUSIONS: In this study, misdiagnosis of SAH occurred in 12% of patients and was associated with a smaller hemorrhage and normal mental status. Among individuals who initially present in good condition, misdiagnosis is associated with increased mortality and morbidity. A low threshold for CT scanning of patients with mild symptoms that are suggestive of SAH may reduce the frequency of misdiagnosis.

PMID 14970066  JAMA. 2004 Feb 18;291(7):866-9. doi: 10.1001/jama.291.7・・・
著者: F H Linn, E F Wijdicks, Y van der Graaf, F A Weerdesteyn-van Vliet, A I Bartelds, J van Gijn
雑誌名: Lancet. 1994 Aug 27;344(8922):590-3.
Abstract/Text Retrospective surveys of patients with subarachnoid haemorrhage suggest that minor episodes with sudden headache (warning leaks) may precede rupture of an aneurysm, and that early recognition and surgery might lead to improved outcome. We studied 148 patients with sudden and severe headache (possible sentinel headache) seen by 252 general practitioners in a 5-year period in the Netherlands. Subarachnoid haemorrhage was the cause in 37 patients (25%) (proven aneurysm in 21, negative angiogram in 6, no angiogram done in 6, sudden headache followed by death in 4). 103 patients had headache as the only symptom, 12 of whom proved to have subarachnoid haemorrhage (6 with a ruptured aneurysm). Previous bouts of sudden headache had occurred in only 2. Other serious neurological conditions were diagnosed in 18. In the remaining 93, no underlying cause of headache was found; follow-up over 1 year showed no subsequent subarachnoid haemorrhage or sudden death. In this cohort, acute, severe headache in general practice indicated a serious neurological disorder in 37% (95% CI 29-45%), and subarachnoid haemorrhage in 25% (18-32%). 12% (5-18%) of those with headache as the only symptom. The notion of warning leaks as a less serious variant of subarachnoid haemorrhage is not supported by this study. Early recognition of subarachnoid haemorrhage is important but will probably have only limited impact on the outcome in the general population.

PMID 7914965  Lancet. 1994 Aug 27;344(8922):590-3.
著者: A-M Landtblom, S Fridriksson, J Boivie, J Hillman, G Johansson, I Johansson
雑誌名: Cephalalgia. 2002 Jun;22(5):354-60.
Abstract/Text Sudden onset headache is a common condition that sometimes indicates a life-threatening subarachnoid haemorrhage (SAH) but is mostly harmless. We have performed a prospective study of 137 consecutive patients with this kind of headache (thunderclap headache=TCH). The examination included a CT scan, CSF examination and follow-up of patients with no SAH during the period between 2 days and 12 months after the headache attack. The incidence was 43 per 100 000 inhabitants >18 years of age per year; 11.3% of the patients with TCH had SAH. Findings in other patients indicated cerebral infarction (five), intracerebral haematoma (three), aseptic meningitis (four), cerebral oedema (one) and sinus thrombosis (one). Thus no specific finding indicating the underlying cause of the TCH attack was found in the majority of the patients. A slightly increased prevalence of migraine was found in the non-SAH patients (28%). The attacks occurred in 11 cases (8%) during sexual activity and two of these had an SAH. Nausea, neck stiffness, occipital location and impaired consciousness were significantly more frequent with SAH but did not occur in all cases. Location in the temporal region and pressing headache quality were the only features that were more common in non-SAH patients. Recurrent attacks of TCH occurred in 24% of the non-SAH patients. No SAH occurred later in this group, nor in any of the other patients. It was concluded that attacks caused by a SAH cannot be distinguished from non-SAH attacks on clinical grounds. It is important that patients with their first TCH attack are investigated with CT and CSF examination to exclude SAH, meningitis or cerebral infarction. The results from this and previous studies indicate that it is not necessary to perform angiography in patients with a TCH attack, provided that no symptoms or signs indicate a possible brain lesion and a CT scan and CSF examination have not indicated SAH.

PMID 12110111  Cephalalgia. 2002 Jun;22(5):354-60.
著者: J van Gijn, K J van Dongen
雑誌名: Neuroradiology. 1982;23(3):153-6.
Abstract/Text We performed serial CT scans in a prospective series of 100 patients with a ruptured aneurysm who were first scanned within 2 days of the haemorrhage. In all patients the early CT scan showed evidence of extravasated blood. In 96 patients the source of bleeding was clearly at the base of the brain, and 32 of these had a haematoma. We estimated from the results of 139 repeat scans that the probability of recognizing an aneurysmal haemorrhage on CT is 85% after 5 days, 50% after 1 week, 30% after 2 weeks (mostly patients with haematomas), and almost nil after 3 weeks.

PMID 7088285  Neuroradiology. 1982;23(3):153-6.
著者: A Ferbert, I Hubo, R Biniek
雑誌名: J Neurol Sci. 1992 Jan;107(1):14-8.
Abstract/Text We investigated 91 patients with non-traumatic subarachnoid hemorrhage (SAH) in whom no aneurysm was found on initial angiography. In 31 of these patients CT did not show subarachnoid blood. A typical feature was a localized blood clot in the prepontine or interpeduncular cistern. Follow-up was obtained 6 months to 11.8 years after SAH by personal re-examination (n = 49) or questionnaire sent to patients or their doctors. 79 patients were free of neurological signs, 3 had a mild and one a severe neurological deficit. Five patients had died from SAH. Those patients who died or had complications often had blood in the frontal basal interhemispheric fissure. None of the 3 therapeutic regimens applied proved to be superior. We conclude that prognosis is good, but an unidentified aneurysm must be considered and repeat angiogram is warranted if blood is found in the anterior part of the basal cisterns. When the hemorrhage is in the prepontine cistern, repeat angiogram is not necessary.

PMID 1578229  J Neurol Sci. 1992 Jan;107(1):14-8.
著者: H Iwanaga, S Wakai, C Ochiai, J Narita, S Inoh, M Nagai
雑誌名: Neurosurgery. 1990 Jul;27(1):45-51.
Abstract/Text The authors reviewed the computed tomographic (CT) scans of patients with subarachnoid hemorrhage whose initial angiograms were negative, to investigate the validity of CT scans in predicting the presence of an angiographically missed aneurysm in such patients. During the past 14 years, additional angiograms have been obtained for 38 of the 45 patients with subarachnoid hemorrhage whose initial angiograms disclosed no aneurysm. Aneurysms were found in 8 patients; 7 on the anterior communicating artery and 1 at the junction of the internal carotid and posterior communicating arteries. CT scans were taken within 4 days after subarachnoid hemorrhage in 31 patients. Analysis of these scans showed that the second angiogram revealed 1) an aneurysm in 21% of the patients with a thin layer of subarachnoid blood and in 63% of those with a thick layer; 2) no aneurysm in the patients without subarachnoid blood; and 3) an aneurysm of the anterior communicating artery in 70% of the patients who showed a considerable amount of blood in the basal frontal interhemispheric fissure. These results suggest that if CT scans show thin or thick subarachnoid blood, angiographic study should be repeated early in the course. If a considerable amount of blood is shown in the basal frontal interhemispheric fissure, it is highly probable that an aneurysm is hidden on the anterior communicating artery, even if the angiogram is negative for an aneurysm.

PMID 2377280  Neurosurgery. 1990 Jul;27(1):45-51.
著者: H Urbach, J Zentner, L Solymosi
雑誌名: Neuroradiology. 1998 Jan;40(1):6-10.
Abstract/Text This study was designed to assess the necessity for a second angiogram study in patients in whom initial angiography after primary subarachnoid haemorrhage (SAH) was negative. During a 12-year period, 122 of 694 patients (17.5%) had negative initial angiograms. CT, available for 98 patients, showed a preponderance of subarachnoid blood in the perimesencephalic cisterns in 50 of 73 patients (68.5%) in whom blood was visible on CT. Angiography, repeated in 67 patients, revealed an aneurysm in 4 (6%): 2 had an aneurysm of the anterior communicating artery, 1 of the posterior inferior cerebellar artery, and 1 of the P2 segment of the posterior cerebral artery. CT showed subarachnoid blood in the interpeduncular and ambient cisterns in this last case, and a preponderance of subarachnoid blood outside the perimesencephalic cisterns in the remaining 3 patients.

PMID 9493179  Neuroradiology. 1998 Jan;40(1):6-10.
著者: S B Tatter, R M Crowell, C S Ogilvy
雑誌名: Neurosurgery. 1995 Jul;37(1):48-55.
Abstract/Text The source of bleeding remains obscure in most cases of subarachnoid hemorrhage (SAH) with a negative angiogram. From January 1, 1989, to July 1, 1993, 40 patients were admitted to the Massachusetts General Hospital with angiogram-negative SAH; 9 of these patients underwent surgical exploration. In seven of these explorations, an arterial source of the hemorrhage was discovered. These arterial sources included three anterior communicating artery complex lesions, two middle cerebral artery lesions, one internal carotid artery aneurysm arising at the origin of the posterior communicating artery, and one vertebral/posterior inferior cerebellar artery aneurysm. Three of these seven lesions had small aneurysmal sacs, but the other four were microaneurysms too small to accept a surgical clip. No source of hemorrhage could be found during surgery on one patient with a perimesencephalic pattern of blood. Two of the four patients with a microaneurysmal source of hemorrhage had two episodes of SAH. We propose that microaneurysms are the source of a significant percentage of nonperimesencephalic angiogram-negative SAH and suggest that these lesions may represent a forme fruste of saccular aneurysms. These findings lead us to propose a protocol for the management of angiogram-negative SAH based on the distribution of blood as seen on the patient's first computed tomogram.

PMID 8587690  Neurosurgery. 1995 Jul;37(1):48-55.
著者: G B Bradac, M Bergui, M F Ferrio, M Fontanella, G Stura
雑誌名: Neuroradiology. 1997 Nov;39(11):772-6.
Abstract/Text Of 440 patients with spontaneous subarachnoid haemorrhage in whom an aneurysm was suspected, 60 had a negative angiogram. A second angiogram performed 1-4 weeks later revealed an aneurysm in 5 of 40 cases. Of these patients, 3 had a second haemorrhage. In all cases, diffuse bleeding, with involvement of the anteroinferior interhemispheric fissure, was present on CT. There were three aneurysms of the anterior communicating artery and two of the carotid siphon. The reasons for the false-negative angiograms and the usefulness of repeated angiography are discussed.

PMID 9406201  Neuroradiology. 1997 Nov;39(11):772-6.
著者: R W Baumgartner, H P Mattle, K Kothbauer, G Schroth
雑誌名: Stroke. 1994 Dec;25(12):2429-34.
Abstract/Text BACKGROUND AND PURPOSE: Diagnosis and successful therapy before rupture of cerebral aneurysms would be most desirable in view of the high mortality and morbidity rates of aneurysmal subarachnoid hemorrhage. Using transcranial color-coded duplex sonography, we studied radiologically proven cerebral aneurysms to define ultrasonographic criteria and sensitivity for their diagnosis and detection.
METHODS: Twenty-nine consecutive patients with 30 radiologically proven cerebral aneurysms were prospectively examined using transcranial color-coded duplex sonography. The sonographer was aware of cerebral computed tomographic and magnetic resonance imaging findings but was blinded to the results of cerebral angiography.
RESULTS: Ultrasonographic findings for aneurysms studied were as follows: (1) Scanning planes that transsected approximately mid-aneurysm showed a round or oval mass that was divided by a "separation zone" into red and blue areas. (2) The "separation zone" was characterized by dark or no colors. (3) Peripheral scanning planes showed monochromatic images. (4) No turbulence was found. (5) No spontaneous fluctuations were detected. Twenty-three of 27 (85%) nonthrombosed aneurysms with a diameter of 6 to 25 mm were identified. The walls and three thrombosed and four nonthrombosed aneurysms (mean diameter, 5 mm) were missed.
CONCLUSIONS: Transcranial color-coded duplex sonography can provide the diagnosis of nonthrombosed aneurysm using the above-cited criteria because of its capacity to reveal flow phenomena. It is not the method of choice in the search for aneurysms because small and thrombosed aneurysms are missed. Careful visual inspection of the intracranial arteries to permit incidental detection of cerebral aneurysms should be part of every transcranial color-coded duplex examination.

PMID 7974585  Stroke. 1994 Dec;25(12):2429-34.
著者: J M Wardlaw, J C Cannon
雑誌名: J Neurosurg. 1996 Mar;84(3):459-61. doi: 10.3171/jns.1996.84.3.0459.
Abstract/Text "Color Doppler energy" (or "power Doppler"), a new color Doppler ultrasound technique that is independent of flow direction and very sensitive to movement, was assessed for its use in the identification of intracranial aneurysms in patients with recent subarachnoid hemorrhage immediately prior to using cerebral angiography. Features that identified aneurysms using this technique included the appearance of abnormal color where no normal artery was expected, abnormal bulging of an artery, and greater "expansibility" of the aneurysm in comparison to an adjacent normal vessel. In this exploratory study, 30 of 33 aneurysms were correctly identified in 35 patients with a good bone window. Color Doppler energy is considerably more sensitive to intracranial blood flow than conventional color Doppler imaging. Color Doppler energy is a useful research tool; if these preliminary results are verified in larger series, in addition to examination for vasospasm, the technique could be used for identification and follow up of aneurysms.

PMID 8609558  J Neurosurg. 1996 Mar;84(3):459-61. doi: 10.3171/jns.19・・・
著者: C Klötzsch, H C Nahser, B Fischer, H Henkes, D Kühne, P Berlit
雑誌名: Neuroradiology. 1996 Aug;38(6):555-9.
Abstract/Text We examined 72 patients with 89 angiographically confirmed intracranial aneurysms, using transcranial colour-coded duplex sonography (TCCD) to determine the location and size of the aneurysm. The patients were admitted for coil embolisation of their aneurysm following subarachnoid haemorrhage or because of a cranial nerve palsy. Using a 2/2.25 MHz transducer, 42 aneurysms (47%) were seen satisfactorily through the temporal bone window or foramen magnum. In 24 cases (27%) image quality was insufficient as a result of a poor bone window, of the aneurysm having a diameter of less than 6 mm or of its being in an unfavorable location. In 23 other cases (26%) it was not possible to detect the aneurysm. Thrombosed structures could be demonstrated using TCCD in 8 of 12 giant intracavernous or basilar artery aneurysms, and in 15 of 19 aneurysms treated by platinum coil embolisation. TCCD offers a noninvasive method for monitoring progressive intra-aneurysmal thrombosis following coil embolisation and for follow-up of patients with untreatable fusiform aneurysms, should this be required. Detection of small aneurysms is limited by spatial resolution and insonation angles.

PMID 8880718  Neuroradiology. 1996 Aug;38(6):555-9.
著者: A C van Bruggen, D W Dippel, J D Habbema, J J Mooij
雑誌名: Acta Neurochir (Wien). 1996;138(10):1148-56.
Abstract/Text We present a further evaluation of an improved recording method for the acoustic detection of intracranial aneurysms (ADA). A sensor was applied to the patient's eyes. Two measures were derived to summarize the power spectral density function of the sound frequencies that were obtained from each patient: the power median (PM), the median of the power spectral density function, and the mean difference error (MDE), a measure of the difference between the normalized, logarithmically transformed spectra of the patient and a template, the normal spectrum. The capability of these two measures (alone or combined) to discriminate between patients with and without an intracranial aneurysm was tested in a series of 89 patients harbouring a total of 109 aneurysms and 73 controls, using multiple logistic regression analysis. When PM and MDE were combined, the accuracy of the predictions amounted to 79%. Individualized threshold values of the likelihood ratio of harbouring an aneurysm, for ordering four-vessel angiography are suggested, depending on the prior probability of harbouring an aneurysm, the risks of unnecessary angiography and the risk of living with an undetected aneurysm. Our decision analysis suggests that using these recommendations, employing acoustic detection results in a small gain in quality adjusted life expectancy (0.01 life year) for patients aged between 40 and 60, compared to no diagnostic testing, and 0.02 life year compared to angiography, which cannot be recommended. For patients with a three times increased prior risk of harbouring an intracranial aneurysm, the benefit of ADA compared to angiography increases to 0.05 life year. We conclude that acoustic detection has the potential of becoming a useful tool in the non-invasive diagnosis of occult, asymptomatic intracranial aneurysms.

PMID 8955432  Acta Neurochir (Wien). 1996;138(10):1148-56.
著者: G J Rinkel, E F Wijdicks, D Hasan, G E Kienstra, C L Franke, L M Hageman, M Vermeulen, J van Gijn
雑誌名: Lancet. 1991 Oct 19;338(8773):964-8.
Abstract/Text 15% of patients with spontaneous subarachnoid haemorrhage have normal cerebral angiograms; they fare better than patients with demonstrated aneurysms, though rebleeding and cerebral ischaemia can still occur. In patients with a normal angiogram and accumulation of blood in the cisterns around the midbrain--"perimesencephalic nonaneurysmal haemorrhage"--outcome is excellent. To test the hypothesis that rebleeding and disability in angiogram-negative subarachnoid haemorrhage might be limited to those with other patterns of haemorrhage on initial computed tomography (CT), complications and long-term outcome were studied in 113 patients with angiogram-negative subarachnoid haemorrhage, admitted between January, 1983, and July, 1990. All patients were investigated with third-generation CT scans within 72 h of the event, and with cerebral angiography. The mean follow-up period was 45 (range 6-96) months. None of 77 patients with a perimesencephalic pattern of haemorrhage on CT died or was left disabled as a result of the haemorrhage (0% [95% confidence interval 0-5%]). Among the other 36 patients, who had a blood distribution on CT indistinguishable from that in proven aneurysmal bleeds, 4 had rebleeds and 9 died or were left disabled as result of the haemorrhage (25% [14-43%]). Thus, two distinct subsets of patients with angiogram-negative subarachnoid haemorrhage should be recognised. Patients with a perimesencephalic pattern of haemorrhage have an excellent prognosis. Rebleeding, cerebral ischaemia, and residual disability occur exclusively in patients with aneurysmal patterns of haemorrhage on initial CT. Repeated angiography in search of an occult aneurysm is justified only in the patients with aneurysmal patterns.

PMID 1681340  Lancet. 1991 Oct 19;338(8773):964-8.
著者: J van Gijn, K J van Dongen, M Vermeulen, A Hijdra
雑誌名: Neurology. 1985 Apr;35(4):493-7.
Abstract/Text We studied 28 patients with subarachnoid hemorrhage and normal angiograms. On early CT (within 5 days) in 13 cases, blood was seen mainly or only in the cisterns around the midbrain. This pattern of hemorrhage was found in only 1 of 92 patients with a ruptured aneurysm. None of the unexplained perimesencephalic hemorrhages was associated with intracerebral hematoma or intraventricular hemorrhage. The clinical features also differed from those of aneurysmal hemorrhage; loss of consciousness was rare, and after 3 months, all 13 patients had returned to normal life. The cause of this benign disorder remains elusive, but a venous or capillary source seems likely.

PMID 3982634  Neurology. 1985 Apr;35(4):493-7.
著者: P Canhão, J M Ferro, A N Pinto, T P Melo, J G Campos
雑誌名: Acta Neurochir (Wien). 1995;132(1-3):14-9.
Abstract/Text BACKGROUND: van Gijn and co-workers identified "Perimesencephalic haemorrhage" (PM) as distinct, benign, non-aneurysmal subarachnoid haemorrhage. However, there is only one retrospective series of this entity outside the Netherlands.
PURPOSE: to confirm (or not) the benign nature of perimesencephalic subarachnoid haemorrhage by evaluating its clinical course and long-term follow-up in a consecutive series of patients admitted to a University Hospital.
METHODS: Patients with subarachnoid haemorrhage and negative cerebral angiography admitted between January 1985 and April 1992 were classified according to the distribution of blood on a CT scan performed within 72 hours after onset, in perimesencephalic and non-perimesencephalic haemorrhages. Demographic and clinical data (collected consecutively), complications and long-term follow-up (obtained by chart review and follow-up by mail) were compared in the two groups.
RESULTS: Seventy one cases, 36 perimesencephalic and 35 nonperimesencephalic were included. Sex and age distribution were similar in the two groups. A normal examination on admission was the rule in the perimesencephalic group. Only one patient with perimesencephalic haemorrhage had a complication--transient neurological signs during angiography--and there were no deaths or morbidity during follow-up. In the non-perimesencephalic group three patients rebleed, four developed hydrocephalus and two had delayed cerebral ischaemia. Mean duration of follow-up was 27.6 months for the perimesencephalic and 30.8 months for the non-perimesencephalic group. After discharge there was a fatal rebleed in the latter group. Fifteen percent of the subjects (11% of the perimesencephalic group and 20% of the non-perimesencephalic group) retired from work during the follow-up period. Headaches and depression were found in similar percentages (22-25%) in both groups.
CONCLUSIONS: This study confirms that perimesencephalic haemorrhage is a distinct entity within the larger group of subarachnoid haemorrhage with negative angiograms, with a good short term and long-term prognosis, and no need for repeated angiographic investigation.

PMID 7754850  Acta Neurochir (Wien). 1995;132(1-3):14-9.
著者: G J Rinkel, E F Wijdicks, M Vermeulen, L M Ramos, H L Tanghe, D Hasan, L C Meiners, J van Gijn
雑誌名: AJNR Am J Neuroradiol. 1991 Sep-Oct;12(5):829-34.
Abstract/Text We describe a characteristic distribution of cisternal blood in 52 patients with nonaneurysmal subarachnoid hemorrhage proved by a normal angiogram. On CT, the center of the bleeding was located immediately anterior to the brainstem in all patients, which was confirmed in four patients who were studied with MR imaging. Extension to the ambient cisterns or to the basal parts of the sylvian fissures was common, but the lateral sylvian or anterior interhemispheric fissures were never completely filled with blood. Rupture into the ventricular system did not occur. MR demonstrated downward extension of the blood anterior to the brainstem as far as the medulla, but failed to detect the source of hemorrhage. Our aim was to determine whether this so-called nonaneurysmal perimesencephalic hemorrhage could be distinguished from aneurysmal subarachnoid hemorrhage on early CT scans. Two neuroradiologists were shown a consecutive series of 221 CT scans of patients with subarachnoid hemorrhage who subsequently underwent angiography. Only one patient with a basilar artery aneurysm on angiography was incorrectly labeled by both observers as having a nonaneurysmal perimesencephalic pattern of hemorrhage. The high predictive value of the perimesencephalic pattern of hemorrhage for a normal angiogram (0.95 and 0.94, respectively, for the two observers) and the excellent interobserver agreement (kappa 0.87) demonstrate that nonaneurysmal perimesencephalic hemorrhage can be distinguished on CT in the majority of patients. Recognition of this pattern of hemorrhage is important as patients with this subset of subarachnoid hemorrhage have an excellent prognosis.

PMID 1950905  AJNR Am J Neuroradiol. 1991 Sep-Oct;12(5):829-34.
著者: J van Gijn, G J Rinkel
雑誌名: Brain. 2001 Feb;124(Pt 2):249-78.
Abstract/Text The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

PMID 11157554  Brain. 2001 Feb;124(Pt 2):249-78.
著者: B Taylor, P Harries, R Bullock
雑誌名: Br J Neurosurg. 1991;5(6):591-600.
Abstract/Text Two-hundred and ninety-five patients with angiographically demonstrated intracranial aneurysms presented to the Institute of Neurological Sciences, Glasgow over a 3-year period (1986-88). We have reviewed this group to assess the effect of changing patterns of management upon outcome. The overall mortality rate was 9.4%, and the surgical mortality rate was 4% in this selected series. Factors significantly associated with a poor outcome were: WFNS grades III-V on admission, presence of a haematoma on the first CT scan, delayed ischaemic deficit, and development of a post-operative haematoma. Seventy-six per cent of the patients who developed a delayed ischaemic deficit (nearly a third of those with recent subarachnoid haemorrhage) made a good recovery, in contrast to previous studies, and over two-thirds of those accepted in grades IV and V (28 patients) made a good recovery after surgery. Active management of patients in grades IV and V, and those with delayed ischaemia, together with prophylactic Nimodipine therapy and selective early surgery, offers the best prospect for further improvement in outcome after aneurysmal subarachnoid haemorrhage.

PMID 1772605  Br J Neurosurg. 1991;5(6):591-600.
著者: G Neil-Dwyer, D Lang, P Smith, F Iannotti
雑誌名: Acta Neurochir (Wien). 1998;140(10):1019-27.
Abstract/Text In 102 consecutive prospectively identified patients with subarachnoid haemorrhage (SAH) we have analysed the severity of the initial haemorrhage and the direct and indirect effects of adverse factors on outcome. The data we recorded included delay in diagnosis, risk groups, Doppler measurements, angiographic findings, surgical events and outcome at 1 year. By using a temporal graphical chain model, the associations between all variables and possible causal pathways were statistically determined. The severity of the initial haemorrhage, as determined by means of a clinical assessment and CT scanning, allowed low-, medium- and high-risk patient groups and a statistically predictable outcome to be identified. The overall management mortality was 13.7% at 1 year; 70.6% had a favourable outcome and 15.7% were severely disabled. Outcome was directly associated with risk group (p = 0.0038) and rebleeding (p = 0.0000). Delayed diagnosis led to a poorer outcome (p = 0.014)--an indirect association probably due to rebleeding. Adverse surgical events led to a significantly poorer outcome in high-risk patients. No significant relationship was found either between age and risk group (p = 0.7784) or between age and outcome (p = 0.6418). Preoperative clinical (WFNS) grade was unreliable in predicting outcome. It is the particular risk group, determined by the initial SAH, that indicates the individual patient's outcome. Management strategies can reduce preventable adverse events such diagnostic delay and rebleeding. Future studies should stratify patients according to risk group, delay in diagnosis and rebleeding in order to enable a clearer comparison to be made of treatment methods.

PMID 9856245  Acta Neurochir (Wien). 1998;140(10):1019-27.
著者: M R Mayberg, H H Batjer, R Dacey, M Diringer, E C Haley, R C Heros, L L Sternau, J Torner, H P Adams, W Feinberg
雑誌名: Stroke. 1994 Nov;25(11):2315-28.
Abstract/Text
PMID 7974568  Stroke. 1994 Nov;25(11):2315-28.
著者: Andrew J Molyneux, Richard S C Kerr, Jacqueline Birks, Najib Ramzi, Julia Yarnold, Mary Sneade, Joan Rischmiller, ISAT Collaborators
雑誌名: Lancet Neurol. 2009 May;8(5):427-33. doi: 10.1016/S1474-4422(09)70080-8. Epub 2009 Mar 28.
Abstract/Text BACKGROUND: Our aim was to assess the long-term risks of death, disability, and rebleeding in patients randomly assigned to clipping or endovascular coiling after rupture of an intracranial aneurysm in the follow-up of the International Subarachnoid Aneurysm Trial (ISAT).
METHODS: 2143 patients with ruptured intracranial aneurysms were enrolled between 1994 and 2002 at 43 neurosurgical centres and randomly assigned to clipping or coiling. Clinical outcomes at 1 year have been previously reported. All UK and some non-UK centres continued long-term follow-up of 2004 patients enrolled in the original cohort. Annual follow-up has been done for a minimum of 6 years and a maximum of 14 years (mean follow-up 9 years). All deaths and rebleeding events were recorded. Analysis of rebleeding was by allocation and by treatment received. ISAT is registered, number ISRCTN49866681.
FINDINGS: 24 rebleeds had occurred more than 1 year after treatment. Of these, 13 were from the treated aneurysm (ten in the coiling group and three in the clipping group; log rank p=0.06 by intention-to-treat analysis). There were 8447 person-years of follow-up in the coiling group and 8177 person-years of follow-up in the clipping group. Four rebleeds occurred from a pre-existing aneurysm and six from new aneurysms. At 5 years, 11% (112 of 1046) of the patients in the endovascular group and 14% (144 of 1041) of the patients in the neurosurgical group had died (log-rank p=0.03). The risk of death at 5 years was significantly lower in the coiling group than in the clipping group (relative risk 0.77, 95% CI 0.61-0.98; p=0.03), but the proportion of survivors at 5 years who were independent did not differ between the two groups: endovascular 83% (626 of 755) and neurosurgical 82% (584 of 713). The standardised mortality rate, conditional on survival at 1 year, was increased for patients treated for ruptured aneurysms compared with the general population (1.57, 95% CI 1.32-1.82; p<0.0001).
INTERPRETATION: There was an increased risk of recurrent bleeding from a coiled aneurysm compared with a clipped aneurysm, but the risks were small. The risk of death at 5 years was significantly lower in the coiled group than it was in the clipped group. The standardised mortality rate for patients treated for ruptured aneurysms was increased compared with the general population.
FUNDING: UK Medical Research Council.

PMID 19329361  Lancet Neurol. 2009 May;8(5):427-33. doi: 10.1016/S1474・・・
著者: Marieke J H Wermer, Paut Greebe, Ale Algra, Gabriël J E Rinkel
雑誌名: Stroke. 2005 Nov;36(11):2394-9. doi: 10.1161/01.STR.0000185686.28035.d2. Epub 2005 Oct 6.
Abstract/Text BACKGROUND AND PURPOSE: Because intracranial aneurysms develop during life, patients with subarachnoid hemorrhage (SAH) and successfully occluded aneurysms are at risk for a recurrence. We studied the incidence of and risk factors for recurrent SAH in patients who regained independence after SAH and in whom all aneurysms were occluded by means of clipping.
METHODS: From a cohort of patients with SAH admitted between 1985 and 2001, we included those patients who were discharged home or to a rehabilitation facility. We interviewed these patients about new episodes of SAH. We retrieved all medical records and radiographs in case of reported recurrences. If patients had died, we retrieved the cause of death. We analyzed the incidence of and risk factors for recurrent SAH by Kaplan-Meier curves and Cox regression analysis.
RESULTS: Of 752 patients with 6016 follow-up years (mean follow up 8.0 years), 18 had a recurrence. In the first 10 years after the initial SAH, the cumulative incidence of recurrent SAH was 3.2% (95% confidence interval [CI], 1.5% to 4.9%) and the incidence rate 286 of 100,000 patient-years (95% CI, 160 to 472 per 100,000). Risk factors were smoking (hazard ratio [HR], 6.5; 95% CI, 1.7 to 24.0), age (HR, 0.5 per 10 years; 95% CI, 0.3 to 0.8) and multiple aneurysms at the time of the initial SAH (HR, 5.5; 95% CI, 2.2 to 14.1).
CONCLUSIONS: After SAH, the incidence of a recurrence within the first 10 years is 22 (12 to 38) times higher than expected in populations with comparable age and sex. Whether this increased risk justifies screening for recurrent aneurysms in patients with a history of SAH requires further study.

PMID 16210556  Stroke. 2005 Nov;36(11):2394-9. doi: 10.1161/01.STR.000・・・
著者: CARAT Investigators
雑誌名: Stroke. 2006 Jun;37(6):1437-42. doi: 10.1161/01.STR.0000221331.01830.ce. Epub 2006 Apr 20.
Abstract/Text BACKGROUND AND PURPOSE: Although results of the randomized International Subarachnoid Aneurysm Trial suggested that coil embolization was superior to surgical clipping 1 year after treatment, a paucity of data on long-term outcomes has been a major concern.
METHODS: In an ambidirectional cohort study, 9 institutions with expertise in intracranial aneurysm treatment identified all ruptured saccular aneurysms treated 1996 to 1998. After an initial medical record review, all patients meeting entry criteria were contacted by postal questionnaire or telephone. Possible reruptures were adjudicated independently by a neurologist, a neurosurgeon, and a neurointerventional radiologist. Rates of delayed (>1 year) and early rerupture and retreatment were evaluated using Kaplan-Meier survival analysis and the log-rank test.
RESULTS: A total of 1010 patients (711 surgically clipped, 299 treated with coil embolization) were included. Patients treated with coil embolization were older, more likely to have smaller aneurysms arising from the posterior circulation, and less likely to have middle cerebral artery aneurysms. Rerupture of the index aneurysm after 1 year occurred in 1 patient treated with coil embolization during 904 person-years of follow-up (annual rate 0.11%) and in no patients treated with surgical clipping during 2666 person-years (P=0.11). Aneurysm retreatment after 1 year was more frequent in patients treated with coil embolization (P<0.0001), but major complications were rare during retreatment.
CONCLUSIONS: Rerupture of aneurysms treated by either coil embolization or surgical clipping is rare after the first year. Late retreatment is more common after coil embolization than after clipping but complication rates are low. Thus, late events are unlikely to overwhelm differences between procedures at 1-year follow-up.

PMID 16627789  Stroke. 2006 Jun;37(6):1437-42. doi: 10.1161/01.STR.000・・・
著者: Gabriel J E Rinkel, Ale Algra
雑誌名: Lancet Neurol. 2011 Apr;10(4):349-56. doi: 10.1016/S1474-4422(11)70017-5.
Abstract/Text More and more patients survive aneurysmal subarachnoid haemorrhage (aSAH), with case fatality decreasing by 17% in absolute terms over the past three decades and incidence remaining relatively stable at nine per 100,000 patient-years. The mean age at which aSAH occurs is reasonably young at 55 years, and people of this age in the general population have a good life expectancy. However, there are few data for life expectancy after aSAH, and the risks of late recurrent aSAH and other vascular diseases are unclear. The course of associated long-term physical and cognitive deficits after aSAH is not well established, leading to questions about potential outcomes to quality of life and working capacity, as well as best clinical practices.

Copyright © 2011 Elsevier Ltd. All rights reserved.
PMID 21435599  Lancet Neurol. 2011 Apr;10(4):349-56. doi: 10.1016/S147・・・
著者: K Tsutsumi, K Ueki, M Usui, S Kwak, T Kirino
雑誌名: Stroke. 1998 Dec;29(12):2511-3.
Abstract/Text BACKGROUND AND PURPOSE: The neck clipping of cerebral aneurysms is a well-established treatment for subarachnoid hemorrhage (SAH) caused by aneurysmal rupture. However, it is still unclear how great a risk of recurrence patients with a successfully treated aneurysm carry over a long-term period.
METHODS: Of 425 patients with SAH surgically treated in Aizu Chuou Hospital from 1976 to 1994, 220 cases meeting the following criteria were studied: (1) all aneurysms detected by 3- or 4-vessel cerebral angiography were clipped, (2) complete obliteration of aneurysm(s) was confirmed by postoperative angiography, and (3) the patient survived >3 years. All patients were traced until January 1998 for recurrent SAH or death. The mean follow-up period was 9.9 (range, 3 to 21) years.
RESULTS: Six patients (2.7%) had recurrent SAH, each with an interval ranging from 3 to 17 years (mean, 11 years) since the original treatment. In addition, 2 patients were found to have regrowth of the originally operated aneurysms. The cumulative recurrence rate of SAH, calculated using the Kaplan-Meier method, was 2.2% at 10 years and 9. 0% at 20 years after the original treatment.
CONCLUSIONS: The recurrence rate was considerably higher than the previously reported risk of SAH in the normal population, and the rate increased with time. These data indicate that patients with ruptured cerebral aneurysms still carry higher risks for SAH in a long-term period, even after complete obliteration of the aneurysm, and that periodic examination to detect recurrent aneurysms may be indicated for such patients.

PMID 9836760  Stroke. 1998 Dec;29(12):2511-3.
著者: David S Rosen, R Loch Macdonald
雑誌名: Neurocrit Care. 2005;2(2):110-8. doi: 10.1385/NCC:2:2:110.
Abstract/Text Numerous systems are reported for grading the clinical condition of patients following subarachnoid hemorrhage (SAH). The literature was reviewed for articles pertaining to the grading of such patients, including publications on the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Score (GCS), and World Federation of Neurological Surgeons Scale. This article reviews the advantages and limitations of these scales as well as more recent proposals for other grading systems based on these scales with or without addition of other factors known to be prognostic for outcome after SAH. There remain substantial deficits in the literature regarding grading of patients with SAH. Most grading scales were derived retrospectively, and the intra- and interobserver variability has seldom been assessed. Inclusion of additional factors increases the complexity of the scale, possibly making it less likely to be adopted for routine usage and increasing (only marginally in some cases) the ability to predict prognosis. Until further data are available, it is recommended that publications on patients with SAH report at least the admission GCS as well as factors commonly known to influence prognosis, such as age, pre-existing hypertension, the amount of blood present on admission computed tomography, time of admission after SAH, aneurysm location and size, presence of intracerebral or intraventricular hemorrhage, and blood pressure at admission.

PMID 16159052  Neurocrit Care. 2005;2(2):110-8. doi: 10.1385/NCC:2:2:1・・・
著者: C Aulmann, W I Steudl, U Feldmann
雑誌名: Zentralbl Neurochir. 1998;59(3):171-80.
Abstract/Text The course of 185 patients operated for a ruptured intracranial aneurysm at the University of Saarland between 1991 and 1993 has been followed up. The main emphasis of the investigation was placed on the scrutiny of the coma scales on admission (Hunt & Hess-Scale, Glasgow Coma Scale and WFNS-Scale [= World Federation of Neurological Surgeons]) with regard to the outcome. Outcome was defined as the patients' state six months after aneurysm rupture according to the Glasgow Outcome Scale. The sensitivities, specifities and predictive values of almost all scale grades were poor. The Hunt&Hess-Scale was the one with the best correlation. By half the patients with the worst scale grades on admission had a good outcome. A gradation of the outcome with regard to the middle admission grades has not been identified. These observations have been demonstrated by using ROC (Receiver Operating Characteristic)-curves. The admission scales are not suitable to give a definite prognosis and do not justify any decision neither pro nor contra an operation. A lot of parameters besides the neurological findings have an effect on the prognosis. Additionally, unexpected complications may occur in the pre- and postoperative phase. The score values determined at the day of operation have shown a more precise prognosis than the values determined immediately after hospitalization. Therefore the evaluation of the most relevant phase could improve the prognostic value of the scales.

PMID 9816668  Zentralbl Neurochir. 1998;59(3):171-80.
著者: J M Findlay
雑誌名: Can J Neurol Sci. 1997 May;24(2):161-70.
Abstract/Text Published medical evidence pertaining to the management of aneurysmal subarachnoid hemorrhage (SAH) was critically reviewed in order to prepare practice guidelines for this condition. SAH should be considered as a possible cause of all sudden and/or unusual headaches, and every attempt should be made to recognize mild SAHs, as they are still frequently misdiagnosed. The first test for SAH is computed tomography (CT), followed by lumbar puncture when the CT is negative for intracranial bleeding (the case in only several per cent of patients within 24 hours of aneurysm bleeding). Urgent cerebral angiography is necessary to detect the underlying cerebral aneurysm. The advantage of rapid diagnosis of SAH followed by early aneurysm repair is minimizing the risk of catastrophic aneurysm rebleeding. Early surgery for aneurysm repair is often possible and is recommended, unless the aneurysm location or size renders it technically difficult to expose in clot-laden subarachnoid cisterns beneath an acutely swollen brain. Aneurysm ablation is optimally accomplished with open microsurgery and clipping of the aneurysm neck, although other options include proximal parent artery occlusion, "trapping" of the aneurysmal segment of the artery, and embolization of thrombogenic materials (e.g., platinum "microcoils") directly into the aneurysm dome using endovascular techniques. Neurological outcome following SAH is also optimized through the prevention of secondary SAH complications, and further management specific for ruptured cerebral aneurysms can include anticonvulsants, neuroprotectants, and various agents and techniques to prevent or reverse delayed-onset cerebral vasospasm. All patients with aneurysmal SAH should be treated with the calcium antagonist nimodipine, and in certain circumstances patients should receive anticonvulsants. Induced arterial hypertension, hypervolemia and in some instances percutaneous balloon angioplasty are recommended to reverse vasospasm causing symptomatic cerebral ischemia prior to cerebral infarction.

PMID 9164696  Can J Neurol Sci. 1997 May;24(2):161-70.
著者: E Sander Connolly, Alejandro A Rabinstein, J Ricardo Carhuapoma, Colin P Derdeyn, Jacques Dion, Randall T Higashida, Brian L Hoh, Catherine J Kirkness, Andrew M Naidech, Christopher S Ogilvy, Aman B Patel, B Gregory Thompson, Paul Vespa, American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology
雑誌名: Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3.
Abstract/Text PURPOSE: The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).
METHODS: A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.
RESULTS: Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.
CONCLUSIONS: aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

PMID 22556195  Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e・・・
著者: Masoud Hatefi, Shirzad Azhary, Hussein Naebaghaee, Hasan Reza Mohamadi, Molouk Jaafarpour
雑誌名: J Clin Diagn Res. 2015 Jul;9(7):PC15-8. doi: 10.7860/JCDR/2015/13603.6264. Epub 2015 Jul 1.
Abstract/Text BACKGROUND AND AIMS: SAH (Sub Arachnoid Haemorrhage) is a life threatening that is associated with complications such as vasospasm and shunt-dependent hydrocephalus. The purpose of this study was to assess the effect of FLT (Fenestration of Lamina Terminalis) on the incidence of vasospasm and shunt-dependent hydrocephalus in ACoA (Anterior Communicating Artery) aneurismal in SAH.
MATERIALS AND METHODS: The data of 50 ruptured ACoA aneurism patients were selected during the year 2001-2009 admitted to Imam Hussein hospital, Tehran, IR. In a randomized double-blind trial patients assigned in two group {with fenestration (FLT, n=25), without fenestration (No FLT, n=25)}. All patients underwent craniotomy by a single neurosurgeon. Patient's age, sex, Hunt-Hess grade, Fisher grade, vasospasm, presence of hydrocephalus and incidences of shunt-dependent hydrocephalus were compared between groups.
RESULTS: There were no significant differences among groups in relation to demographic characteristics, neurological scale scores (Hunt-Hess grade) and the severity of the SAH (Fisher grade) (p>0.05). The rate of hydrocephalus on admission, were 24% and 16% in FLT and no FLT group respectively (p>0.05). The shunt placement postoperatively in FLT and no FLT group were 16% and 12% respectively (p>0.05). The clinical vasospasm was 20% and 24% in FLT and no FLT group respectively (p>0.05).
CONCLUSION: Despite FLT can be a safe method there were not significant differences of FLT on the incidence of vasospasm and shunt-dependent hydrocephalus. A systematic evaluation with multisurgeon, multicentre and with greater sample size to disclose reality is suggested.

PMID 26393164  J Clin Diagn Res. 2015 Jul;9(7):PC15-8. doi: 10.7860/JC・・・
著者: Jukka Huttunen, Mitja I Kurki, Mikael von Und Zu Fraunberg, Timo Koivisto, Antti Ronkainen, Jaakko Rinne, Juha E Jääskeläinen, Reetta Kälviäinen, Arto Immonen
雑誌名: Neurology. 2015 Jun 2;84(22):2229-37. doi: 10.1212/WNL.0000000000001643. Epub 2015 May 6.
Abstract/Text OBJECTIVE: The aim was to elucidate the incidence and risk factors of epilepsy after subarachnoid hemorrhage (SAH) from saccular intracranial aneurysm (sIA) in a population-based cohort.
METHODS: The Kuopio sIA Database (www.uef.fi/ns) includes all unruptured and ruptured sIA cases admitted to the Kuopio University Hospital from its defined catchment population in Eastern Finland. The use of prescribed medicines, including reimbursable antiepileptic drugs, has been entered from the Finnish national registries. The cumulative incidence and independent risk factors of epilepsy and death were analyzed in 876 patients with sIA-SAH admitted from 1995 to 2007. The competing risks analysis was used to correctly estimate the probability of epilepsy, because epilepsy and death after sIA-SAH may share risk factors.
RESULTS: The follow-up ended at death (n = 200) or December 31, 2008; median follow-up time was 76 months. Epilepsy was diagnosed in 113 patients in a median of 8 months after sIA-SAH. Cumulative incidence of epilepsy after sIA-SAH was 8% at 1 year and 12% at 5 years. Thirty-three percent of patients with intracerebral hemorrhage (ICH) >15 cm(3) developed epilepsy. In the 876 patients with sIA-SAH, the independent risk factors for epilepsy were ICH >15 cm(3), Hunt and Hess grade III-V, and acute seizures.
CONCLUSIONS: Cumulative incidence of epilepsy is 12% at 5 years. Epilepsy and 12-month mortality after sIA-SAH share poor Hunt and Hess grading as an independent risk factor. Epilepsy in the 2-week survivors of sIA-SAH is predicted by signs of primary injury in the brain tissue, most notably ICH.

© 2015 American Academy of Neurology.
PMID 25948726  Neurology. 2015 Jun 2;84(22):2229-37. doi: 10.1212/WNL.・・・
著者: Nancy McLaughlin, Michel W Bojanowski, François Girard, André Denault
雑誌名: Can J Neurol Sci. 2005 May;32(2):178-85.
Abstract/Text BACKGROUND: Pulmonary edema (PE) can occur in the early or late period following subarachnoid hemorrhage (SAH). The incidence of each type of PE is unknown and the association with ventricular dysfunction, both systolic and diastolic, has not been described.
METHODS: Retrospective chart review of 178 consecutive patients with SAH surgically treated over a three-year period. Patients with pulmonary edema diagnosed by a radiologist were included. Early onset SAH was defined as occurring within 12 hours. Cardiac function at the time of the PE was analyzed using hemodynamic and echocardiographic criteria of systolic and diastolic dysfunction. Pulmonary edema was observed in 42 patients (28.8%) and was more often delayed (89.4%). Evidence of cardiac involvement during PE varied between 40 to 100%.
RESULTS AND CONCLUSIONS: Pulmonary edema occurs in 28.8% of patients after SAH, and is most commonly delayed. Cardiac dysfunction, both systolic and diastolic, is commonly observed during SAH and could contribute to the genesis of PE after SAH.

PMID 16018152  Can J Neurol Sci. 2005 May;32(2):178-85.
著者: Vivien H Lee, Heidi M Connolly, Jimmy R Fulgham, Edward M Manno, Robert D Brown, Eelco F M Wijdicks
雑誌名: J Neurosurg. 2006 Aug;105(2):264-70. doi: 10.3171/jns.2006.105.2.264.
Abstract/Text OBJECT: Neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage (SAH) is associated with a wide spectrum of reversible left ventricular wall motion abnormalities and includes a subset of patients with a pattern of apical akinesia and concomitant sparing of basal segments called "tako-tsubo cardiomyopathy".
METHODS: After obtaining institutional review board approval, the authors retrospectively identified among all patients admitted to the Mayo Clinic's Neurological Intensive Care Unit between January 1990 and January 2005 those with aneurysmal SAH who had met the echocardiographic criteria for tako-tsubo cardiomyopathy. Among 24 patients with SAH-induced reversible cardiac dysfunction, the authors identified eight with SAH-induced tako-tsubo cardiomyopathy. All eight patients were women with a mean age of 55.5 years (range 38.6-71.1). Seven patients presented with a poor-grade SAH, reflected by a Hunt and Hess grade of III or IV. Four patients underwent aneurysm clip application, and four underwent endovascular coil occlusion. The initial mean ejection fraction (EF) was 38% (range 25-55%), and the mean EF at recovery was 55% (range 40-68%). Cerebral vasospasm developed in six patients, but cerebral infarction developed in only three patients.
CONCLUSIONS: The authors describe the largest cohort with aneurysmal SAH-induced tako-tsubo cardiomyopathy. In the SAH population, tako-tsubo cardiomyopathy predominates in postmenopausal women and is often associated with pulmonary edema, prolonged intubation, and cerebral vasospasm. Additional studies are warranted to understand the complex mechanism involved in tako-tsubo cardiomyopathy and its intriguing relationship to neurogenic stunned myocardium.

PMID 17219832  J Neurosurg. 2006 Aug;105(2):264-70. doi: 10.3171/jns.2・・・
著者: Andrew M Naidech, Nazli Janjua, Kurt T Kreiter, Noeleen D Ostapkovich, Brian-Fred Fitzsimmons, Augusto Parra, Christopher Commichau, E Sander Connolly, Stephan A Mayer
雑誌名: Arch Neurol. 2005 Mar;62(3):410-6. doi: 10.1001/archneur.62.3.410.
Abstract/Text BACKGROUND: Aneurysm rebleeding has historically been an important cause of mortality after subarachnoid hemorrhage (SAH).
OBJECTIVE: To describe the frequency and impact of rebleeding in the modern era of aneurysm care, which emphasizes early surgical or endovascular treatment.
DESIGN: Inception cohort.
SETTING: Tertiary care medical center.
PATIENTS: A total of 574 patients enrolled in the Columbia University SAH Outcomes Project between August 1996 and June 2002. Early aneurysm repair was performed whenever feasible.
MAIN OUTCOME MEASURES: Rebleeding was defined by prespecified clinical and radiographic criteria, excluding prehospital, intraprocedural, and postrepair events. Functional outcome was assessed at 3 months with the modified Rankin Scale. Multiple logistic regression was used to identify predictors of rebleeding, poor functional outcome, and mortality.
RESULTS: Rebleeding occurred in 40 (6.9%) of the 574 patients; most cases (73%) occurred within 3 days of ictus. Hunt-Hess grade on admission (odds ratio [OR], 1.92 per grade; 95% confidence interval [CI], 1.33-2.75; P<.001) and maximal aneurysm diameter (OR, 1.07/mm; 95% CI, 1.01-1.13; P = .005) were independent predictors of rebleeding. After controlling for Hunt-Hess grade and aneurysm size, rebleeding was associated with a markedly reduced chance of survival with functional independence (modified Rankin Scale score, CONCLUSIONS: Despite an aggressive management strategy, rebleeding still occurred in 6.9% of patients and was associated with a dismal outcome. Poor Hunt-Hess grade and larger aneurysm size are related to rebleeding. Pharmacologic therapy to reduce the risk of rebleeding before aneurysm repair, particularly in patients with poor grade neurologic status and large aneurysms, deserves renewed attention.

PMID 15767506  Arch Neurol. 2005 Mar;62(3):410-6. doi: 10.1001/archneu・・・
著者: Jürgen Beck, Andreas Raabe, Andrea Szelenyi, Joachim Berkefeld, Rüdiger Gerlach, Matthias Setzer, Volker Seifert
雑誌名: Stroke. 2006 Nov;37(11):2733-7. doi: 10.1161/01.STR.0000244762.51326.e7. Epub 2006 Sep 28.
Abstract/Text BACKGROUND AND PURPOSE: The clinical significance of sentinel headaches in patients with subarachnoid hemorrhage (SAH) is still unknown. We investigated whether patients with a sentinel headache (SH) have a higher rate of rebleeding after SAH.
METHODS: An SH was defined as a sudden, severe, unknown headache lasting >1 hour with or without accompanying symptoms, not leading to a diagnosis of SAH in the 4 weeks before the index SAH. Age, sex, smoking status, clinical grade, computed tomography (CT) findings, angiographic findings, placement of an external ventricular drain, and time to aneurysm obliteration were prospectively recorded. All rebleeding events were confirmed by CT. Outcome was assessed at 6 months according to the modified Rankin Scale.
RESULTS: Of 237 consecutive patients with SAH, 41 (17.3%) had an SH. Rebleeding occurred in 23 (9.7%) of all patients. Patients with an SH had a 10-fold increased odds of rebleeding compared with patients without SH. Aneurysm size and the total number of aneurysms were also significantly associated with rebleeding. There were no differences in age, sex, smoking, CT or angiographic findings, external ventricular drain placement, or time to aneurysm obliteration between groups. Patients with rebeeding had a significantly worse outcome. Logistic regression revealed the presence of an SH as an independent risk factor for rebleeding.
CONCLUSIONS: In our study, patients with SAH who had an SH constituted a special group of patients with a 10-fold odds for early rebleeding. The presence of an SH may select candidates for ultraearly aneurysm obliteration or drug treatment.

PMID 17008633  Stroke. 2006 Nov;37(11):2733-7. doi: 10.1161/01.STR.000・・・
著者: Andrew Molyneux, Richard Kerr, Irene Stratton, Peter Sandercock, Mike Clarke, Julia Shrimpton, Rury Holman, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group
雑誌名: Lancet. 2002 Oct 26;360(9342):1267-74.
Abstract/Text BACKGROUND: Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomised, multicentre trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments.
METHODS: We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n=1070) or endovascular treatment by detachable platinum coils (n=1073). Clinical outcomes were assessed at 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale score of 3-6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol.
FINDINGS: 190 of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) allocated neurosurgical treatment (p=0.0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively.
INTERPRETATION: In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.

PMID 12414200  Lancet. 2002 Oct 26;360(9342):1267-74.
著者: Andrew J Molyneux, Richard S C Kerr, Ly-Mee Yu, Mike Clarke, Mary Sneade, Julia A Yarnold, Peter Sandercock, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group
雑誌名: Lancet. 2005 Sep 3-9;366(9488):809-17. doi: 10.1016/S0140-6736(05)67214-5.
Abstract/Text BACKGROUND: Two types of treatment are being used for patients with ruptured intracranial aneurysms: endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment.
METHODS: 2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or endovascular coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3-6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment.
FINDINGS: We report the 1-year outcomes for 1063 of 1073 patients allocated to endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23.5%) of 1063 patients allocated to endovascular treatment were dead or dependent at 1 year, compared with 326 (30.9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7.4% (95% CI 3.6-11.2, p=0.0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0.03). The risk of epilepsy was substantially lower in patients allocated to endovascular treatment, but the risk of late rebleeding was higher.
INTERPRETATION: In patients with ruptured intracranial aneurysms suitable for both treatments, endovascular coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after endovascular coiling than after neurosurgical clipping.

PMID 16139655  Lancet. 2005 Sep 3-9;366(9488):809-17. doi: 10.1016/S01・・・
著者: P C Whitfield, H Moss, D O'Hare, P Smielewski, J D Pickard, P J Kirkpatrick
雑誌名: J Neurol Neurosurg Psychiatry. 1996 Mar;60(3):301-6.
Abstract/Text OBJECTIVE: To audit the outcome in patients with subarachnoid haemorrhage (SAH) after a change in management strategy.
METHODS: A retrospective analysis of patients with aneurysmal subarachnoid haemorrhage over a 20 month period (phase 1) was followed by a prospective analysis of patients presenting during the next 20 months (phase 2) in which a protocol driven management regime of immediate intravenous fluid resuscitation and earlier surgery was pursued. Patients in this phase were grouped into those receiving early (within four days of subarachnoid haemorrhage) and late (after four days of subarachnoid haemorrhage) surgery. In phase 1, 75 out of a total of 92 patients underwent surgery on (median) day 12. From phase 2, 109 patients out of a total of 129 underwent surgery on (median) day 4, 58 of which had their surgery within 4 days of the subarachnoid haemorrhage. Patients in each phase/group were well matched for demographic features, site of aneurysm, and severity of subarachnoid haemorrhage.
RESULTS: The surgical morbidity and mortality were no different in the two phases (P < 0.92; chi2 test). The management outcomes in the two phases of the study were also no different (P < 0.52). However, there was a significant reduction in the rebleed rate in patients undergoing surgery within four days of the subarachnoid haemorrhage in phase 2 (P < 0.0001) with an associated trend towards reduced incidence of postoperative ischaemia (P = 0.06) and mortality (P = 0.11). Operating earlier in phase 2 of the trial resulted in a lower total hospital inpatient stay of 15.8 (95% CI 13.1-18.5) days for survivors compared with 25.7 (95% CI 21.6-29.8) days in the late group (P < 0.00001; t test).
CONCLUSIONS: surgical morbidity and mortality seemed independent of the timing of aneurysm surgery. Early surgery within four days was associated with a highly significant reduction in rebleed rate, and in the duration of total hospital inpatient stay.

PMID 8609508  J Neurol Neurosurg Psychiatry. 1996 Mar;60(3):301-6.
著者: E C Haley, N F Kassell, J C Torner
雑誌名: Stroke. 1992 Feb;23(2):205-14.
Abstract/Text BACKGROUND AND PURPOSE: The timing of aneurysm surgery after subarachnoid hemorrhage is a major neurosurgical controversy addressed by the International Cooperative Study on the Timing of Aneurysm Surgery (1980-1983). The present report examines the results of this trial in the subgroup of patients admitted to North American centers.
METHODS: The method of study was a large, multicenter, prospective, epidemiological survey. Neurosurgeons were required to indicate prospectively the interval to planned aneurysm surgery at the time of patient admission. Outcome at 6 months was determined by a blinded evaluator, and overall management results were analyzed by the planned surgical interval.
RESULTS: Seven hundred seventy-two (21.9% of the total study population) patients admitted from days 0 to 3 after subarachnoid hemorrhage were accrued in North American centers. Overall outcome in patients planned for surgery in days 0-3 was equivalent in terms of mortality (after adjustment for prognostic variables) to patients planned for days 11-32, but the early patients had significantly improved rates of good recovery (70.9% versus 61.7%, p less than 0.01). Patients planned for surgery during the days 7-10 interval had nearly twice the mortality of patients in the other intervals.
CONCLUSIONS: In contrast to the results from the overall trial, which found no difference between early and delayed surgery, results were best in North American centers when surgery was planned between days 0 and 3 after subarachnoid hemorrhage. These findings argue strongly for early diagnosis and referral for surgical intervention of North American patients suspected of having a ruptured cerebral aneurysm.

PMID 1561649  Stroke. 1992 Feb;23(2):205-14.
著者: T Inagawa
雑誌名: Surg Neurol. 1990 Apr;33(4):239-46.
Abstract/Text The effect of early operation on cerebral vasospasm was studied in 150 patients with aneurysmal subarachnoid hemorrhages who fulfilled all of the following criteria: admission by day 2 after subarachnoid hemorrhage, no rebleeding, clinical grades I to IV on admission, subarachnoid hemorrhage alone on computed tomography scan, not operated on between days 4 and 20, and availability of bilateral carotid angiograms done by day 2 and redone between days 7 and 9. The patients were divided into two groups: those operated on by day 3 (group 1: 116 patients) and those operated on after day 20 or not operated on (group 2: 34 patients). Severity of both subarachnoid hemorrhage on computed tomography scan and angiographic vasospasm were graded into 0-IV. Angiographic vasospasm was observed in 95% of group 1 and in 88% of group 2 patients. A significant difference could not be found between groups 1 and 2 in the angiographic vasospasm grades. The incidence of symptomatic vasospasm in group 1 was 18%, which was significantly lower than the 44% in group 2. In group 1 patients with subarachnoid hemorrhage grades II to III, the incidences of symptomatic vasospasm and low density area on computed tomography scan were 13% and 10%, respectively. Both of these rates were significantly lower than those in group 2, which were 50% and 36%, respectively. However, in patients with subarachnoid hemorrhage grade IV, no differences could be found between groups 1 and 2. There was a close correlation between the angiographic vasospasm grades and the incidence of symptomatic vasospasm in group 1. However, in group 1, no correlation could be observed between the site of ruptured aneurysms or the timing of operations and vasospasm. Although there is still a limit to the effect of early operation on cerebral vasospasm in patients with subarachnoid hemorrhage grade IV, symptomatic vasospasm after subarachnoid hemorrhage may be ameliorated by early operation in patients with subarachnoid hemorrhage grades II to III.

PMID 2326728  Surg Neurol. 1990 Apr;33(4):239-46.
著者: N F Kassell, J C Torner, J A Jane, E C Haley, H P Adams
雑誌名: J Neurosurg. 1990 Jul;73(1):37-47. doi: 10.3171/jns.1990.73.1.0037.
Abstract/Text A prospective, observational clinical trial was conducted by the International Cooperative Study on the Timing of Aneurysm Surgery to determine the best time in relation to the hemorrhage for surgical treatment of ruptured intracranial aneurysms. Sixty-eight centers contributed 3521 patients in a 2 1/2-year period beginning in December, 1980. Analysis by a prespecified "planned" surgery interval demonstrated that there was no difference in early (0 to 3 days after the bleed) or late surgery (11 to 14 days). Outcome was worse if surgery was performed in the 7 to 10-day post-bleed interval. Surgical results were better for patients operated on after 10 days. Patients alert on admission fared best; however, alert patients had a mortality rate of 10% to 12% when undergoing surgery prior to Day 11 compared with 3% to 5% when surgery was performed after Day 10. Patients drowsy on admission had a 21% to 25% mortality rate when operated on up to Day 11 and 7% to 10% with surgery thereafter. Overall, early surgery was neither more hazardous nor beneficial than delayed surgery. The postoperative risk following early surgery is equivalent to the risk of rebleeding and vasospasm in patients waiting for delayed surgery.

PMID 2191091  J Neurosurg. 1990 Jul;73(1):37-47. doi: 10.3171/jns.199・・・
著者: M Miyaoka, K Sato, S Ishii
雑誌名: J Neurosurg. 1993 Sep;79(3):373-8. doi: 10.3171/jns.1993.79.3.0373.
Abstract/Text Between 1980 and 1987, 1622 patients with angiographically verified ruptured cerebral aneurysms were admitted within 7 days after subarachnoid hemorrhage. A retrospective analysis evaluated both the timing of surgery in operative patients and the status of nonsurgical patients. The patients' clinical grade according to the Hunt and Hess classification was assessed at admission, and a comparative analysis of outcome was carried out for each grade in relation to time of surgery: those operated on from Day 0 to 3 and those undergoing surgery on Day 4 or later. Among nonsurgical cases, fatal rebleeding occurred in 105 cases and fatal vasospasm in 69 cases. These nonsurgical cases were divided into one of two groups, either an early- or a late-management group, and the outcome of each group was analyzed by clinical grade. The mortality rates in the early-surgery groups were higher than in the late-surgery groups, especially in Grade V, in which the rate was significantly different. However, with the 174 nonsurgical patients included in these management results, marked differences in mortality rates disappeared except in Grade V, which failed to show statistical significance. A higher rate of good recovery among Grade III patients receiving early surgery shifted significantly in the early-management group. The results suggest that the timing of surgery in clinical Grade I or II patients is not a major factor; however, early surgery appears to be beneficial in Grade III and IV patients. The incidence of rebleeding in the early- and late-management groups was 2.7% and 9.5%, respectively.

PMID 8360733  J Neurosurg. 1993 Sep;79(3):373-8. doi: 10.3171/jns.199・・・
著者: R A Solomon, S T Onesti, L Klebanoff
雑誌名: J Neurosurg. 1991 Jul;75(1):56-61. doi: 10.3171/jns.1991.75.1.0056.
Abstract/Text A consecutive series of 145 patients with acute aneurysmal subarachnoid hemorrhage (SAH) were operated on within 7 days of SAH and were prospectively evaluated over a 4-year period to determine if the timing of aneurysm surgery influenced the development of delayed cerebral ischemia. All patients were managed with a standardized policy of urgent surgical clipping and treatment with aggressive prophylactic postoperative volume expansion. Patients with delayed ischemic symptoms were additionally treated with induced hypertension. Forty-nine patients underwent surgery on Day 0 or 1 (Group 1) post-SAH, 60 patients on Day 2 or 3 (Group 2), and 36 patients on Days 4 through 7 (Group 3). Postoperative delayed cerebral ischemia developed in 16% of (Group 1) patients, in 22% of Group 2 patients, and in 28% of Group 3 patients. Cerebral infarction resulting from delayed cerebral ischemia developed in only 4% of Group 1 patients, 10% of Group 2 patients, and 11% of Group 3 patients. A bad clinical outcome as a result of delayed cerebral ischemia occurred in one Group 1 patient (2%), two Group 2 patients (3%), and one Group 3 patient (3%). Preoperative grade was not significantly correlated with the incidence or severity of delayed cerebral ischemia at any time interval except that patients in modified Hunt and Hess Grade I or II who underwent surgery on Day 0 or 1 after SAH had no strokes or bad outcomes from delayed cerebral ischemia. This study demonstrates that there is no rationale for delaying aneurysm surgery based on the time interval between SAH and patient evaluation.

PMID 2045919  J Neurosurg. 1991 Jul;75(1):56-61. doi: 10.3171/jns.199・・・
著者: J Vajda, E Pasztor, E Orosz, I Nyary, J Juhasz, M Horvath, S Czirjak, J Futo
雑誌名: Int Surg. 1990 Apr-Jun;75(2):123-6.
Abstract/Text Preliminary experience with 150 consecutive cases of ruptured cerebral aneurysms operated on within 48 hours is reported. The rationale of this emergency procedure is to prevent early rerupture and also to prevent neurological ischaemic consequences of the subarachnoid haemorrhage likely to develop in the first week after a rupture. The acceptable outcome of the surgically treated cases (87% excellent and good outcome) has been favourably matched to those of a group of equal number of consecutive cases seen in suitable condition for surgery within 48 hours by medical personnel but that remained unoperated for various reasons. The incidence of delayed neurological ischaemia as the definite cause of death is lower in the group operated on in the acute stage than those with delayed surgery, although the overall incidence of clinical vasospasm does not seem significantly lower than in the delayed surgery group.

PMID 2379991  Int Surg. 1990 Apr-Jun;75(2):123-6.
著者: H R Winn, D W Newell, M R Mayberg, M S Grady, R G Dacey, J Eskridge
雑誌名: Clin Neurosurg. 1990;36:289-98.
Abstract/Text
PMID 2403886  Clin Neurosurg. 1990;36:289-98.
著者: L F Zhou, D J Jiang
雑誌名: Chin Med J (Engl). 1994 Jan;107(1):41-6.
Abstract/Text From 1978 to 1988, 14 giant intracranial aneurysms (more than 2.4 cm in diameter) and one large aneurysm (1.5 cm in diameter) were treated by extracranial/intracranial (EC/IC) bypass or cerebral artery reconstruction. Of the aneurysms, 10 were located at the intracavernous carotid artery (CCA). One of the 10 aneurysms was posttraumatic and located at both the carotid-ophthalmic artery segment and the bifurcation of the internal carotid artery (ICA). Three were seen at the middle cerebral artery (MCA) trunk. The aneurysms were demonstrated by angiography and CT scanning. They were treated with trapping of the aneurysm and superficial temporal artery (STA)/middle cerebral artery (STA-MCA) bypass with/without a graft (6 cases), cervical ICA ligation and STA-MCA bypass with/without a graft (6) aneurysm excision with an end-to-end anastomosis of the MCA and a STA-MCA bypass with a graft (1), proximal MCA occlusion and STA-MCA bypass with a graft (1), and aneurysm neck clipping following a STA-MCA bypass with a graft (1). The patients showed marked improvement after operation except one whose neurological deficit was aggravated temporarily. Postoperative angiography revealed that the anastomoses were patent in all cases. No surgical mortality or any delayed ischemic complications were noted after follow-up for 5.6 years. We believe that cerebral artery reconstruction or EC/IC bypass is still effective in the treatment of large and giant intracranial aneurysms.

PMID 8187571  Chin Med J (Engl). 1994 Jan;107(1):41-6.
著者: R D Page, P L Richardson
雑誌名: Br J Neurosurg. 1990;4(3):199-204.
Abstract/Text Patients with intracerebral haematomas (ICH) secondary to aneurysmal bleeds usually have a poor prognosis or die if treated conservatively. Younger patients with rupture of a middle cerebral artery (MCA) aneurysm and temporal haematomas have the potential to return to useful life. They should be assessed separately from other subarachnoid haemorrhage (SAH) patients and considered for emergency surgery. Seven such cases are presented, five made an acceptable recovery. The experience of other units as represented in the literature is considered.

PMID 2397045  Br J Neurosurg. 1990;4(3):199-204.
著者: M Wojtacha, P Bazowski, M Mandera, I Krawczyk, A Rudnik
雑誌名: Childs Nerv Syst. 2001 Jan;17(1-2):37-41.
Abstract/Text OBJECTS: The aim of this work was to ascertain any clinical and anatomical factors allowing differentiation between aneurysms of childhood and those occurring in adults by comparing both groups.
METHODS: Results obtained in a total of 17 children and adolescents aged up to 18 who had been operated on for cerebral aneurysm in our department from 1989 to 1997 (3% of all patients treated for subarachnoid haemorrhage resulting from ruptured cerebral aneurysm in this period) were compared with those in the adult group operated on in our department. In contrast to the situation in adults, there was a male predominance in our population. In children we found only 1 case of middle cerebral aneurysm and 1 case of multiple aneurysms. We also found a high rate of rebleeding in the paediatric group.
CONCLUSIONS: We suggest that the very good outcome (100% very good results in patients operated on early) obtained and the high risk of rebleeding in children with cerebral aneurysm allow the recommendation of early surgery in children with ruptured cerebral aneurysms.

PMID 11219621  Childs Nerv Syst. 2001 Jan;17(1-2):37-41.
著者: D J Nieuwkamp, K de Gans, A Algra, K W Albrecht, S Boomstra, P J A M Brouwers, R J M Groen, J D M Metzemaekers, P C G Nijssen, Y B W E M Roos, C A F Tulleken, W P Vandertop, J van Gijn, P E Vos, G J E Rinkel
雑誌名: Acta Neurochir (Wien). 2005 Aug;147(8):815-21. doi: 10.1007/s00701-005-0536-0. Epub 2005 Jun 16.
Abstract/Text BACKGROUND: There is still lack of evidence on the optimal timing of surgery in patients with aneurysmal subarachnoid haemorrhage. Only one randomised clinical trial has been done, which showed no difference between early and late surgery. Other studies were observational in nature and most had methodological drawbacks that preclude clinically meaningful conclusions. We performed a retrospective observational study on the timing of aneurysm surgery in The Netherlands over a two-year period.
METHOD: In eight hospitals we identified 1,500 patients with an aneurysmal subarachnoid haemorrhage. They were subjected to predefined inclusion criteria. We included all patients who were admitted and were conscious at any one time between admission and the end of the third day after the haemorrhage. We categorised the clinical condition on admission according the World Federation of Neurological Surgeons (WFNS) grading scale. Early aneurysm surgery was defined as operation performed within three days after onset of subarachnoid haemorrhage; intermediate surgery as performed on days four to seven, and late surgery as performed after day seven. Outcome was classified as the proportion of patients with poor outcome (death or dependent) two to four months after onset of subarachnoid haemorrhage. We calculated crude odds ratios with late surgery as reference. We distinguished between management results (reconstructed intention to treat analysis) and surgical results (on treatment analysis). The results were adjusted for the major prognosticators for outcome after subarachnoid haemorrhage.
FINDINGS: We included 411 patients. There were 276 patients in the early surgery group, 36 in the intermediate surgery group and 99 in the late surgery group. On admission 78% were in good neurological condition (WFNS I-III). MANAGEMENT RESULTS: Overall, 93 patients (34%) operated on early had a poor outcome, 13 (36%) of those with intermediate surgery and 37 (37%) in the late surgery group had a poor outcome. For patients in good clinical condition on admission and planned for early surgery the adjusted odds ratio (OR) was 1.3 (95% CI 0.5 to 3.0). The adjusted OR for patients admitted in poor neurologicalcondition (WFNS IV-V) and planned for early surgery was 0.1 (95% CI 0.0 to 0.6). SURGICAL RESULTS: For patients in good clinical condition on admission who underwent early operation the adjusted OR was 1.1 (95% CI 0.4 to 3.2); it was 0.2 (95% CI 0.0 to 0.9) for patients admitted in poor clinical condition.
CONCLUSIONS: In this observational study we found no significant difference in outcome between early and late operation for patients in good clinical condition on admission. For patients in poor clinical condition on admission outcome was significantly better after early surgery. The optimal timing of surgery is not yet settled. Ideally, evidence on this issue should come from a randomised clinical trial. However, such a trial or even a prospective study are unlikely to be ever performed because of the rapid development of endovascular coiling.

PMID 15944811  Acta Neurochir (Wien). 2005 Aug;147(8):815-21. doi: 10.・・・
著者: T H Schwartz, R A Solomon
雑誌名: Neurosurgery. 1996 Sep;39(3):433-40; discussion 440.
Abstract/Text OBJECTIVE: A critical review of the literature on the incidence, presentation, diagnosis, and prognosis of perimesencephalic nonaneurysmal subarachnoid hemorrhage.
METHODS: Review of the relevant literature.
CONCLUSION: The importance of early computed tomography (< 3 d), anatomy of the perimesencephalic and neighboring cisterns, and adequate four-vessel angiography are discussed. Treatment strategies, including the avoidance of repeated angiographic studies and surgical exploration, are presented.

PMID 8875472  Neurosurgery. 1996 Sep;39(3):433-40; discussion 440.
著者: Jin Young Jung, Yong Bae Kim, Jae Whan Lee, Seung Kon Huh, Kyu Chang Lee
雑誌名: J Clin Neurosci. 2006 Dec;13(10):1011-7. doi: 10.1016/j.jocn.2005.09.007. Epub 2006 Aug 23.
Abstract/Text The need for repeat angiography in patients with subarachnoid haemorrhage (SAH) who initially present with a negative angiogram is still debated. The aim of this study was to provide a management protocol for 'angiogram-negative SAH'. From January 1986 to June 2004, 143 patients with SAH were admitted to our institution with negative initial angiograms. We classified the 143 patients into three groups: group I, with no SAH on CT scan, but confirmed by cerebrospinal fluid analysis; group II, with a perimesencephalic pattern of SAH; and group III, with a non-perimesencephalic pattern of SAH. Out of the 143 patients, 103 underwent repeat angiography, and 18 were found to have ruptured aneurysms that were not detected on the initial angiogram (false negative rate: 17.5% overall, 0% in group I, 1.5% in group II, and 45.9% in group III). Repeat angiography should be performed, particularly in patients who have a non-perimesencephalic SAH pattern, for detection of initially unrecognised ruptured aneurysms.

PMID 16931020  J Clin Neurosci. 2006 Dec;13(10):1011-7. doi: 10.1016/j・・・
著者: Matthew L Flaherty, Mary Haverbusch, Brett Kissela, Dawn Kleindorfer, Alexander Schneider, Padmini Sekar, Charles J Moomaw, Laura Sauerbeck, Joseph P Broderick, Daniel Woo
雑誌名: J Stroke Cerebrovasc Dis. 2005 Nov-Dec;14(6):267-71. doi: 10.1016/j.jstrokecerebrovasdis.2005.07.004.
Abstract/Text BACKGROUND: Nonaneurysmal perimesencephalic subarachnoid hemorrhage (PMSAH) appears to have an etiology and natural history distinct from aneurysm rupture. Referral-based studies suggest that 15% of SAH patients have no discernable cause of bleeding, but the incidence of PMSAH is unknown. We describe the first population-based study of PMSAH and place it in the context of all non-traumatic SAH, with presentation of incidence rates, patient demographics, and clinical outcomes.
METHODS: All patients age >/= 18 hospitalized with first-ever, non-traumatic SAH in the Greater Cincinnati area were identified from 5/98-7/01 and 8/02-4/04. PMSAH was defined as hemorrhage restricted to the cisterns surrounding the brainstem and suprasellar cistern and a negative cerebral angiogram. Incidence rates were age, race, and sex adjusted to the 2000 US population.
RESULTS: There were 431 SAHs identified. Cases in Asian-Americans (2) were excluded, leaving 429 SAHs for analysis. Of these patients, 77 did not have angiograms. Among remaining cases, 285 had aneurysm rupture, 43 had nonaneurysmal hemorrhage not of the PMSAH pattern, and 24 had PMSAH. The overall annual incidence rates for SAH and PMSAH were 8.7 (95% CI 7.9-9.5) and 0.5 (95% CI 0.3-0.7) per 100,000 persons age >/= 18. Patients with PMSAH were younger (p = 0.018) and less likely to be female (p = 0.020) or hypertensive (p = 0.005) than other SAH patients. There was one death among PMSAH patients during 14 months mean follow-up.
CONCLUSIONS: PMSAH represents approximately 5% of all SAH. Its risk factors and outcome differ from other forms of SAH.

PMID 16518463  J Stroke Cerebrovasc Dis. 2005 Nov-Dec;14(6):267-71. do・・・
著者: E W Lang, A Khodair, H Barth, R G Hempelmann, N W C Dorsch, H M Mehdorn
雑誌名: J Clin Neurosci. 2003 Jan;10(1):74-8.
Abstract/Text It is unclear whether the configuration of the basilar artery (BA) in patients with subarachnoid hemorrhage (SAH) of unknown origin is comparable to that in normal subjects or whether there are differences which may help to identify the origin. We studied the BA configuration in 57 patients with SAH of unknown origin (10%), who were identified in a prospectively collected series of 549 SAH patients consecutively admitted to our service over a 9-year period. There were 30 patients (53%) with non-perimesencephalic SAH and 27 with perimesencephalic SAH (47%). According to a standardized algorithm we determined, on straight anteroposterior digital subtraction angiography (DSA), the width of the proximal BA segment at the origin of the anterior inferior cerebellar artery and the width of the most distal BA segment between the superior cerebellar arteries and the posterior cerebral arteries. Based on these measurements we calculated the distal-proximal BA ratios and compared them to the ratios obtained in a control group of 31 patients who had DSA for reasons other than aneurysmal SAH. The mean ratio in patients with non-perimesencephalic SAH of unknown origin was 1.150 (range: 1.080-1.230). In patients with perimesencephalic SAH of unknown origin it was 1.156 (range: 1.120-1.250). In the control group the mean ratio was 1.163 (range: 1.125-1.200). There are no variations in the configurations of the BA which could possibly explain the cause of this type of SAH or clarify the origin of hemorrhage.

PMID 12464527  J Clin Neurosci. 2003 Jan;10(1):74-8.
著者: Ferdinand K Hui, Luis M Tumialán, Tomoko Tanaka, C Michael Cawley, Y Jonathan Zhang
雑誌名: Neurocrit Care. 2009;11(1):64-70. doi: 10.1007/s12028-009-9203-2. Epub 2009 Mar 10.
Abstract/Text OBJECTIVE: To identify prognostic factors for vasospasm, hydrocephalus, and clinical outcomes in patients with angiographically negative, non-traumatic, diffuse subarachnoid hemorrhage (d-SAH).
METHODS: Retrospective review of patients who experienced angiographically negative SAH at our institution over the past 6 years was undertaken. The patients were stratified based on grade at presentation, severity, and pattern of SAH on initial non-enhanced, computed tomography (CT) of the head into perimesencephalic and diffuse subtypes. The patients were further differentiated based on the development of vasospasm, hydrocephalus and required treatments, and clinical outcomes. Patients were excluded if a causative lesion was discovered subsequently.
RESULTS: Ninety-four patients with angiographically negative SAH were identified. A total of 31 patients were considered to have the perimesencephalic (p-SAH) subtype, while 63 patients fit criteria for the diffuse (d-SAH) subtype. Compared to the p-SAH subtype, those patients with d-SAH subtype had significantly higher risk for complications related to SAH with an increased incidence of hydrocephalus (50.8% vs. 9.6%), requirement for external ventricular drainage (41% vs. 9.6%), and for the hydrocephalus requiring eventual permanent cerebrospinal fluid diversion (20.6% vs. 0%). Patients with d-SAH were also at an increased risk for symptomatic vasospasm (28.6% vs. 9.6%). Ultimately, only 76% of d-SAH patients achieved complete recovery and independent living, compared to 96.7% of p-SAH patients.
CONCLUSION: The angiographically negative d-SAH pattern is associated with worse presentations and outcome. These patients are at increased risk for vasospasm and hydrocephalus requiring aggressive treatment and should therefore be cared for with a higher level of surveillance.

PMID 19277905  Neurocrit Care. 2009;11(1):64-70. doi: 10.1007/s12028-0・・・
著者: G Marquardt, T Niebauer, U Schick, R Lorenz
雑誌名: J Neurol Neurosurg Psychiatry. 2000 Jul;69(1):127-30.
Abstract/Text OBJECTIVES: To evaluate the long term sequelae of perimesencephalic subarachnoid haemorrhage (PMSAH).
METHODS: Twenty one consecutive patients were studied. All patients were examined by CT, angiography, MRI, multimodal evoked potentials, and transcranial Doppler sonography. All relevant clinical data during hospital stay and outcome at discharge were obtained by reviewing the charts. Long term follow up was evaluated by reviewing the outpatient files and dedicated outpatient review. Patients were specifically questioned about their perceived recovery, residual complaints, and present occupational status.
RESULTS: Apart from the initial CT confirming the diagnosis of PMSAH all other examinations disclosed no abnormalities. None of the patients developed any complications during hospital stay, and all patients were discharged in good clinical condition and without neurological deficits. At long term follow up 62% of the patients had residual complaints consisting of headaches, irritability, depression, forgetfulness, weariness, and diminished endurance. Apart from four patients who had already retired before the PMSAH, only seven of the remaining 17 patients (41%) returned to their previous occupation, whereas nine patients (53%) retired from work and one man became unemployed. One patient had a recurrence of PMSAH 31 months after the first event.
CONCLUSION: PMSAH can have considerable long term psychosocial sequelae, and may also recur. Prognosis may not be as good as previously reported.

PMID 10864620  J Neurol Neurosurg Psychiatry. 2000 Jul;69(1):127-30.
著者: Faruk Ildan, Metin Tuna, Tahsin Erman, Alp Iskender Göçer, Erdal Cetinalp
雑誌名: Surg Neurol. 2002 Mar;57(3):160-5; discussion 165-6.
Abstract/Text BACKGROUND: Perimesencephalic nonaneurysmal hemorrhage is a benign form of subarachnoid hemorrhage with a low risk of rebleeding. The authors conducted a retrospective study to investigate the prognosis, possible prognostic factors, and long-term natural history in perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH).
METHODS: This report contains a retrospective analysis of 29 patients with PNSH who were followed from 1 month to 8 years with an average follow-up period of 5.4 years. We evaluated computed tomography (CT) scan features; clinical grade; loss of consciousness during hemorrhage; ventricular ratio; angiographic spasm; complications such as ischemic complications, early rebleeding, late rebleeding, epilepsy, hydrocephalus, and fixed ischemic deficit; and outcome.
RESULTS: There were 7 men and 22 women, and the ages ranged from 22 to 69 years (mean 49.5 years). In the group with PNSH 93% of the patients were in grade I-II, as compared to 70.8% of patients with non-PNSH according to the Hunt and Hess system. Loss of consciousness during hemorrhage was detected in 9 patients (31%). We observed acute hydrocephalus in 4 patients (13.7%). The first cerebral four-vessel angiograms disclosed vasospasm in 3 patients (10.3%). Patients with PNSH have the best outcome according to the activities of daily living (ADL) grading system when compared with other groups of patients with negative angiogram (aneurysmal pattern and invisible blood).
CONCLUSION: This study provides evidence that patients with PNSH have an uncomplicated course and a particularly favorable outcome.

PMID 12009538  Surg Neurol. 2002 Mar;57(3):160-5; discussion 165-6.
著者: Paut Greebe, Gabriël J E Rinkel
雑誌名: Stroke. 2007 Apr;38(4):1222-4. doi: 10.1161/01.STR.0000260093.49693.7a. Epub 2007 Mar 1.
Abstract/Text BACKGROUND AND PURPOSE: Patients with a perimesencephalic nonaneurysmal subarachnoid hemorrhage are not at risk for rebleeding in the initial years after the hemorrhage. Nevertheless, uncertainty remains on the long-term prognosis after perimesencephalic hemorrhage, and former patients are often considered high-risk cases for health insurance or are denied life insurance. We performed a very long-term follow-up study of a large consecutive series of such patients and compared mortality in this cohort with that in the general population.
METHODS: All patients with a perimesencephalic hemorrhage (defined by pattern of hemorrhage on computed tomography within 72 hours after onset and absence of aneurysm) admitted between 1983 and 2005 to our service were followed-up by telephone. For patients who had died, we retrieved age and cause of death. We compared the age- and sex-specific mortality of this cohort with that of the general population by means of standardized mortality ratios with corresponding 95% confidence intervals.
RESULTS: The cohort consisted of 160 patients, with a total number of patient-years of 1213. No new episodes of subarachnoid hemorrhage had occurred. During follow-up 11 patients had died; the expected number of deaths based on mortality rates in the general population (adjusted for age and gender) was 18.1. The standardized mortality ratio was 0.61 (95% confidence interval, 0.34 to 1.1).
CONCLUSIONS: Patients with perimesencephalic hemorrhage have a normal life expectancy and are not at risk for rebleeding. No restrictions should be imposed on these patients by physicians or health or life insurance companies.

PMID 17332451  Stroke. 2007 Apr;38(4):1222-4. doi: 10.1161/01.STR.0000・・・
著者: G J Rinkel, E F Wijdicks, M Vermeulen, L M Hageman, J T Tans, J van Gijn
雑誌名: Neurology. 1990 Jul;40(7):1130-2.
Abstract/Text We interviewed 37 patients with perimesencephalic hemorrhage, 18 months to 7 years after the bleed. None rebled or had persisting neurologic deficits. These findings are remarkably good compared with recent series of patients with subarachnoid hemorrhage and normal angiogram. When blood is confined to the mesencephalic cisterns in patients with normal angiogram, repeat angiography may not be indicated.

PMID 2356015  Neurology. 1990 Jul;40(7):1130-2.

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