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Purpose: There is an an increasing awareness of the importance of health and lifestyle for stroke diseases like spontaneous subarachnoid hemorrhage (SAH). However, the importance of pre-existing medical conditions for clinical course and mortality after SAH has not been studied. The aim of the present study was to identify pre-existing conditions contributing to mortality after SAH. Methods: Data were extracted from a Swedish national prospective study on patients with SAH. Variables were defined for age, sex, body mass index (BMI), clinical condition at admission, and for 10 pre-existing medical conditions. Models predicting mortality in three time intervals with all possible subsets of these variables were generated, compared and selected using Akaike’s information criterion. Results: 1155 patients with ruptured aneurysms were included. The mortality within 1 week was 7.6%, 1 month 14.3%, and 1 year 18.7%. The most common pre-existing medical conditions were smoking (57.6%) and hypertension (38.7%). The model’s best predicting mortality within 1 week and from 1 week to 1 month included only the level of consciousness at admission and age, and these two variables were present in all the models among the top 200 in Akaike score for each time period. The most predictive model for mortality between 1 month and 1 year added previous stroke, diabetes, psychiatric disease, and BMI as predictors. Conclusion: Mortality within the first month was best predicted simply by initial level of consciousness and age, while mortality within from 1 month to 1 year was significantly influenced by pre-existing medical conditions.

Conditions involving intracranial vascular anomalies are increasingly diagnosed, not least incidentally, with the increasing availability of neuroradiological investigations. Acute deterioration and development of symptoms due to a vascular condition could require neurosurgical intervention depending on the nature of the condition and status of the patient. On the other hand, asymptomatic patients with incidental findings require careful consideration and risk assessment when deciding on whether or not to treat the condition, and if so, how. In this review article we provide a summary of some of the most common neurosurgical vascular conditions and outline management considerations in both the acute and elective setting.

Background Adverse events (AEs) or complications may arise secondary to the treatment of aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to identify AEs associated with microsurgical occlusion of ruptured aneurysms, as well as to analyse their risk factors and impact on functional outcome. Methods Patients with aneurysmal SAH admitted to the neurosurgical centres in Sweden were prospectively registered during a 3.5-year period (2014–2018). AEs were categorised as intraoperative or postoperative. A range of variables from patient history and SAH characteristics were explored as potential risk factors for an AE. Functional outcome was assessed approximately 1 year after the bleeding using the extended Glasgow Outcome Scale. Results In total, 1037 patients were treated for ruptured aneurysms, of which, 322 patients were treated with microsurgery. There were 105 surgical AEs in 97 patients (30%); 94 were intraoperative AEs in 79 patients (25%). Aneurysm rerupture occurred in 43 patients (13%), temporary occlusion of the parent artery >5 min in 26 patients (8%) and adjacent vessel injury in 25 patients (8%). High Fisher grade and brain oedema on CT were related to increased risk of AEs. At follow-up, 38% of patients had unfavourable outcome. Patients suffering AEs were more likely to have unfavourable outcome (OR 2.3, 95% CI 1.10 to 4.69). Conclusion Intraoperative AEs occurred in 25% of patients treated with microsurgery for ruptured intracerebral aneurysm in this nationwide survey. Although most operated patients had favourable outcome, AEs were associated with increased risk of unfavourable outcome.

Conditions involving intracranial vascular anomalies are increasingly diagnosed, not least incidentally, with the increasing availability of neuroradiological investigations. Acute deterioration and development of symptoms due to a vascular condition could require neurosurgical intervention depending on the nature of the condition and status of the patient. On the other hand, asymptomatic patients with incidental findings require careful consideration and risk assessment when deciding on whether or not to treat the condition, and if so, how. In this review article we provide a summary of some of the most common neurosurgical vascular conditions and outline management considerations in both the acute and elective setting., Vaskulära sjukdomstillstånd som kan bli aktuella för neurokirurgisk åtgärd inkluderar cerebrala kavernösa missbildningar (CCM), arteriovenösa missbildningar (AVM), intrakraniella aneurysm, spontana intracerebrala hematom (ICH), durala arteriovenösa fistlar (AV-fistlar) och arteriell intrakraniell stenos (så kallad moyamoya-­sjuka). Denna artikel behandlar de vanligaste av dessa. När patienten insjuknar akut med en blödning vid något av ovan nämnda tillstånd krävs ofta skyndsam handläggning, ibland tillsammans med åtgärder med anledning av bakomliggande patologi. Vid elektiv handläggning föreligger ofta ytterligare svårigheter för riskvärdering och beslut om åtgärd mot det bakomliggande tillståndet. Allt fler vaskulära tillstånd upptäcks incidentellt i takt med att radiologisk avbildning av hjärnan blir vanligare. Behandlingsrisk måste då vägas mot den kumulativa risken av att lämna tillståndet obehandlat, vilket ofta är ett komplext ställningstagande. I samråd med patienten görs bästa möjliga bedömning av den samlade riskbilden, vilket vägs samman med patientens önskemål och förhållningssätt. I praktiken handlar det om att patient och läkare tillsammans måste komma fram till om man vill ta risken för morbiditet och mortalitet här och nu eller om man föredrar att leva med den ofta låga, men långsiktiga risken för blödningskomplikation. När man bestämt sig för behandling uppstår därtill frågor om vilken modalitet man bör välja. Under de senaste decennierna har mindre invasiva behandlingsmöjligheter utvecklats, såsom endovaskulär behandling och stereotaktisk strålbehandling, vilket har lett till att traditionell öppen neuro­kirurgisk åtgärd används alltmer sällan vid vissa av dessa tillstånd.

Udgivelsesdato: 2009-Jan, OBJECT: The calcium antagonist nimodipine has been shown to reduce the incidence of ischemic complications following aneurysmal subarachnoid hemorrhage (SAH). Although most randomized studies have been focused on the effect of the peroral administration of nimodipine, intravenous infusion is an alternative and the preferred mode of treatment in many centers. It is unknown whether the route of administration is of any importance for the clinical efficacy of the drug. METHODS: One hundred six patients with acute aneurysmal SAH were randomized to receive either peroral or intravenous nimodipine treatment. The patients were monitored for at least 10 days after bleeding in terms of delayed ischemic neurological deficits (DINDs) and with daily measurements of blood flow velocities in the middle cerebral arteries by using transcranial Doppler ultrasonography. Three months after SAH, clinical outcome and new cerebral infarctions according to MR imaging studies were recorded. RESULTS: Baseline characteristics (age, sex distribution, clinical status on admission, radiological findings, and aneurysm treatment) did not differ between the treatment groups. There was no significant difference in the incidence of DINDs (28 vs 30% in the peroral and intravenous groups, respectively) or middle cerebral artery blood flow velocities (> 120 cm/second, 50 vs 45%, respectively). Clinical outcome according to the Glasgow Outcome Scale was the same in both groups, and there was no difference in the number of patients with new infarctions on MR imaging. CONCLUSIONS: The results suggest that there is no clinically relevant difference in efficacy between peroral and intravenous administration of nimodipine in preventing DINDs or cerebral vasospasm following SAH.