Systematic review of antifibrinolytic treatment in aneurysmal subarachnoid haemorrhage.
Explore the source record for details and available documents.
Antifibrinolytic Agents↗
Biomedical subjects
A Algra
Publications and source records attributed to A Algra.
Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms.
PURPOSE: To establish normal reference values for the presence of the anatomic variants of the circle of Willis and average diameters for its component vessels by using three-dimensional time-of-flight magnetic resonance (MR) angiography and to determine whether age- or sex-related differences exist in the circle's anatomy. MATERIALS AND METHODS: One hundred fifty volunteers were grouped according to age: those aged 20-25 years (n = 50) and those aged 60-88 years (n = 100). All subjects underwent three-dimensional time-of-flight MR angiography of the arterial circle at 1.5 T. The anatomic variants of the anterior and posterior parts of the circle were determined separately, the completeness of the entire circle was assessed, and the diameters of all component vessels were measured. RESULTS: On MR angiograms, 111 (74%) subjects demonstrated a complete anterior part of the circle, 78 (52%) demonstrated a complete posterior part of the circle, and 63 (42%) demonstrated an entirely complete circle of Willis (complete anterior and posterior parts of the circle combined). The presence of an entirely complete circle of Willis was slightly higher in younger persons and in women. Most vessel diameters were smaller in women, except for the diameter of the posterior communicating artery. Statistically significant differences were found in vessel diameters between the younger and the older age groups. CONCLUSION: The authors determined normal reference values for morphologic variants and diameter measurements of the circle of Willis specific to three dimensional time-of-flight MR angiography.
Adult↗
Prevalence and risk of rupture of intracranial aneurysms: a systematic review.
BACKGROUND AND PURPOSE: The estimates on the prevalence and the risk of rupture of intracranial saccular aneurysms vary widely between studies. We conducted a systematic review on prevalence and risk of rupture of intracranial aneurysms and classified the data according to study design, study population, and aneurysm characteristics. METHODS: We searched for studies published between 1955 and 1996 by means of a MEDLINE search and a cumulative review of the reference lists of all relevant publications. Two authors independently assessed eligibility of all studies and extracted data on study design and on numbers and characteristics of patients and aneurysms. RESULTS: For data on prevalence we found 23 studies, totalling 56,304 patients; 6685 (12%) of these patients were from 15 angiography studies. Prevalence was 0.4% (95% confidence interval, 0.4% to 0.5%) in retrospective autopsy studies, 3.6% (3.1 to 4.1) for prospective autopsy studies, 3.7% (3.0 to 4.4) in retrospective angiography studies, and 6.0% (5.3 to 6.8) in prospective angiography studies. For adults without specific risk factors, the prevalence was 2.3% (1.7 to 3.1); it tended to increase with age. The prevalence was higher in patients with autosomal dominant polycystic kidney disease (relative risk [RR], 4.4 [2.7 to 7.2]), a familial predisposition (RR, 4.0 [2.7 to 6.0]), or atherosclerosis (RR, 2.3 [1.7 to 3.1]). Only 8% (5 to 11) of the aneurysms were >10 mm. For the risk of rupture, we found nine studies, totalling 3907 patient-years. The overall risk per year was 1.9% (1.5 to 2.4); for aneurysms = 10 mm, the annual risk was 0.7% (0.5 to 1.0). The risk was higher in women (RR, 2.1[1.1 to 3.9]) and for aneurysms that were symptomatic (RR, 8.3 [4.0 to 17]), >10 mm (RR, 5.5 [3.3 to 9.4]), or in the posterior circulation (RR, 4.1 [1.5 to 11]). CONCLUSIONS: Data on prevalence and risk of rupture vary considerably according to study design, study population, and aneurysm characteristics. If all available evidence with inherent overestimation and underestimation is taken together, for adults without risk factors for subarachnoid hemorrhage, aneurysms are found in approximately 2%. The vast majority of these aneurysms are small (=10 mm) and have an annual risk of rupture of approximately 0.7%.
Adult↗
Quality of life in patients and partners after aneurysmal subarachnoid hemorrhage.
BACKGROUND AND PURPOSE: Outcome after subarachnoid hemorrhage (SAH) is often graded as "poor," "fair," or "good." Such categories are usually based on physicians' assessments of physical abilities of patients rather than on how patients themselves perceive their physical, psychological, and social well-being. We assessed functional outcome and quality of life (QoL) in patients with SAH and their partners. METHODS: In a consecutive series of 64 patients and 51 partners studied 4 months after the SAH, we assessed functional outcome by means of the Rankin Scale, and QoL by means of the SF-36, the Sickness Impact Profile (SIP), and a visual analogue scale. Additionally, we asked two "simple questions" about dependency and recovery. All questionnaires were completed in an interview setting. The scores on the QoL instruments from patients and partners were stratified according to the Rankin grades of the patients and were compared with data from a Dutch reference population. RESULTS: Only patients who had no symptoms at all (Rankin grade 0) had no reduction in QoL compared with the reference population; some of these patients even indicated an improvement in QoL from before the SAH according to the visual analogue scale. Patients who had symptoms but were independent (Rankin grades 1 to 3) and therefore usually designated as having "good outcome" often had reductions in QoL, on both the physical and psychosocial subscores of the SIP and SF-36. The QoL of partners was considerably reduced in several psychosocial domains. CONCLUSIONS: SAH has a considerable impact on the QoL of patients and their partners. Only patients without residual symptoms (Rankin grade 0) have a good outcome in terms of physical performance and QoL.
Aneurysm, Ruptured↗
Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis.
BACKGROUND AND PURPOSE: Greater availability and improvement of neuroradiological techniques have resulted in more frequent detection of unruptured aneurysms. Because prognosis of subarachnoid hemorrhage is still poor, preventive surgery is increasingly considered as a therapeutic option. Elective surgery requires reliable data on its risks. Therefore, we performed a meta-analysis on the mortality and morbidity of surgery for unruptured intracranial aneurysms. METHODS: Through Medline and additional searches by hand, we retrieved studies on clipping of unruptured (additional, symptomatic, or incidental) aneurysms published from 1966 through June 1996. Two authors independently extracted data. We used weighted linear regression for data analysis. RESULTS: We included 61 studies that involved 2460 patients (57% female; mean age, 50 years) and at least 2568 unruptured aneurysms (27% >25 mm, 30% located in the posterior circulation). Mortality was 2.6% (95% confidence interval [CI], 2.0% to 3.3%). Permanent morbidity occurred in 10.9% (95% CI, 9.6% to 12.2%) of patients. Postoperative mortality was significantly lower in more recent years for nongiant aneurysms and aneurysms with an anterior location; the last 2 characteristics were also associated with a significantly lower morbidity. CONCLUSIONS: In studies published between 1966 and 1996 on clipping of unruptured aneurysms, mortality was 2.6% and morbidity was 10.9%. In calculating the pros and cons of preventive surgery, these proportions should be taken into account.
Adolescent↗
Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage: a systematic review.
BACKGROUND AND PURPOSE: It has been reported that nimodipine reduces the frequency of secondary ischemia and improves outcome after aneurysmal SAH, but definitive evidence concerning all available calcium antagonists is lacking. METHODS: Systematic overview of randomized trials that were completed by January 1996 compared calcium antagonists with control and started treatment within 10 days after onset of subarachnoid hemorrhage (SAH) was performed. All calcium antagonists studied thus far (nimodipine, nicardipine, and AT877) were included. RESULTS: We analyzed 10 trials totaling 2756 patients. The relative risk (RR) reduction of poor outcome (death or dependency) was 16% (95% CI, 6 to 27%) and that of case fatality was 10% (95% CI, -6 to 25%). To prevent one poor outcome, 19 (12 to 59) patients need to be treated. Calcium antagonists give a 33% (95%, CI 25 to 41) RR reduction in the frequency of ischemic neurologic deficit and a 20% (95% CI, 11 to 28) RR reduction in the frequency of CT-scan documented cerebral infarction. Eight (6 to 11) patients need to be treated to prevent one ischemic neurologic deficit. In the analyses for nimodipine only, treatment was associated with a 24% RR reduction of poor outcome (95% CI, 12 to 38). To prevent one poor outcome, 13 (8 to 30) patients need to be treated with nimodipine. The RR reduction of angiographically detected cerebral vasospasm was statistically significant for AT877 (38%; 95% CI, 17 to 54%) and nicardipine (21%; 95% CI, 6 to 34%) but not for nimodipine (9%; 95% CI, -2 to 19%). CONCLUSION: Calcium antagonists reduce the proportion of ischemic neurologic deficits and nimodipine improves overall outcome within 3 months of aneurysmal SAH; evidence for a reduction of poor outcome from all causes by nicardipine and AT877 is inconclusive. The intermediate factors by which nimodipine exerts its beneficial effect remain uncertain.
1-(5-Isoquinolinesulfonyl)-2-Methylpiperazine↗
Transient monocular blindness and antiphospholipid antibodies in systemic lupus erythematosus.
BACKGROUND AND OBJECTIVE: Among patients with systemic lupus erythematosus (SLE), the presence of antiphospholipid antibodies (APA), notably the lupus anticoagulant, and anticardiolipin antibodies (aCL) characterizes a subset of patients with a thrombotic tendency. During the regular follow-up care of patients with SLE, we noticed that many described transient visual disturbances. Because a hypercoagulable state may cause transient monocular blindness (TMB), we determined the frequency of TMB and studied its relation to the presence of APA in patients with SLE. METHODS: We asked 175 unselected patients with SLE whether they had transient visual disturbances and reviewed their medical charts. All patients were examined with specific attention to the presence of livedo reticularis. Blood was examined for APA. RESULTS: Visual disturbances were recorded for 136 (78%) patients. According to predefined criteria, the symptoms were diagnosed as TMB for 10 (6%) patients and as visual disturbances associated with migraine for 18 (10%) patients. Five of the 10 patients with TMB had attacks in either eye. The 175 patients with SLE accrued a maximum total of 6,349 patient years in their lifetime. From this, the incidence of TMB can be calculated to be at least 158 per 100,000 per year. Lupus anticoagulant was detected in 3 of 10 patients with TMB and 41 of 165 patients without TMB (odds ratio, 1.3; 95% CI, 0.2 to 6.0). aCLs were found in 5 of 10 patients with TMB and 91 of 165 patients without TMB (odds ratio, 0.8; 95% CI, 0.2 to 3.7). CONCLUSIONS: The frequency of TMB among patients with SLE is at least 158 per 100,000 compared with the normal population (14 per 100,000 per year). However, among patients with SLE, no significant relation could be shown between TMB and the presence of APA or livedo reticularis.
Acute Disease↗
Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke.
Explore the source record for details and available documents.
Aspirin↗
Familial intracranial aneurysms.
Explore the source record for details and available documents.
Finland↗
Oligoastrocytomas: a clinicopathological study of 52 cases.
Oligoastrocytomas form a poorly defined subgroup of glial tumors, and few clinical series have been reported. We performed a retrospective study to elucidate the histopathological features of these tumors and to relate the clinical signs and symptoms and proliferative potential to survival. Oligoastrocytomas were defined as glial tumors with at least 10% neoplastic astrocytes and 10% neoplastic oligodendrocytes; tumors were graded with the St. Anne-Mayo criteria for astrocytomas and oligodendrogliomas. Proliferative potential was estimated with antibodies against proliferating cell nuclear antigen (PCNA). Median survival of 52 patients (median age, 42 years) was 75 weeks (range 2-703 weeks). Actuarial 1-, 2-, 3-, and 5-year survival rates were 67%, 43%, 40%, and 29%, respectively. For 15 patients with grade 3 and 33 with grade 4 lesions (St. Anne-Mayo astrocytoma classification), median survival was 217 and 55 weeks, respectively. For 19 patients with grade 2 and 33 with grade 3 lesions (St. Anne-Mayo oligodendroglioma classification), median survival was 305 and 55 weeks, respectively. Interobserver agreement between three experienced neuropathologists on identification of astrocytes, oligodendrocytes, and unclassifiable cells was low, indicating considerable subjectivity in the histopathological diagnosis. Median PCNA labeling indices correlated with tumor grade, but individual values varied so widely within grades that they had no predictive value for survival. In a multivariate analysis, symptoms of increased intracranial pressure and microvascular proliferation were independently associated with poor prognosis. The biological behavior of subgroups appeared to be distinctly less aggressive than that of 'pure' astrocytomas of similar grade. Better histopathological definition of oligoastrocytomas and improved assessment of percentages of constituent cell types may allow more accurate prognosis.
Adolescent↗
Family history of subarachnoid haemorrhage: supplemental value of scrutinizing all relatives.
OBJECTIVE AND METHODS: To assess the validity of the family history obtained at the bedside of patients with recent subarachnoid haemorrhage by subsequently contacting all first and second degree relatives, with verification from medical record data. RESULTS: In a prospectively collected series of 163 patients with recent subarachnoid haemorrhage the history or cause of death could be ascertained in 1259 (98%) of the first degree relatives and in 3038 (85%) of the second degree relatives. For first degree relatives only, the sensitivity of the family history at the bedside was 0.75 (95% confidence interval (95% CI) 0.35-0.97) and the positive predictive value was 0.55 (95% CI 0.23-0.83); for first and second degree relatives together the sensitivity was 0.58 (95% CI 0.28-0.85) and the positive predictive value was 0.64 (95% CI 0.31-0.89). CONCLUSION: The accuracy of the family history taken at the bedside is modest; a more thorough collection of data is crucial if the decision is taken to screen relatives based on the family history.
Cause of Death↗
Outcome of aneurysmal subarachnoid hemorrhage in patients on anticoagulant treatment.
BACKGROUND AND PURPOSE: Intracranial hemorrhage is an important complication of treatment with anticoagulants. We studied outcome of aneurysmal subarachnoid hemorrhage (SAH) occurring in patients on anticoagulant drugs because this may influence management of patients needing anticoagulant treatment but with increased risk of aneurysmal hemorrhage. METHODS: From the prospective database of patients admitted with SAH to the Utrecht University Hospital, we compared 3-month outcome in patients with or without anticoagulant drugs by means of stratified analyses to adjust relative risks for biological and clinical differences between the two groups. RESULTS: Death or dependency after SAH occurred in 14 of 15 patients on anticoagulant treatment and in 62 of 126 patients not being treated with anticoagulants (relative risk, 1.9; 95% confidence interval, 1.5 to 2.4). The patients on treatment with anticoagulants were more often comatose on admission; the frequencies of rebleeding, secondary ischemia, and hydrocephalus were not higher in patients on anticoagulants. In the stratified analysis the worse outcome in the group on anticoagulant drugs was not essentially influenced by differences in sex, age, cardiovascular history, site of aneurysm, amount of cisternal blood, or extension of hemorrhage into the ventricles. CONCLUSIONS: The outcome of aneurysmal SAH in patients or anticoagulant drugs is extremely poor. The explanation for the worse prognosis in patients on anticoagulants lies in a worse clinical condition from the outset. The poor outcome urges a reconsideration of the balance of risks for anticoagulant treatment in patients with an unoperated intracranial aneurysm or with a family history of SAH and may lead to withholding treatment with anticoagulant drugs or to a preventive operation.
Activities of Daily Living↗
Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review.
BACKGROUND: During the last three decades, new management strategies have been developed for patients with aneurysmal subarachnoid hemorrhage. To assess whether the case-fatality rate has improved after the introduction of new management strategies, we studied outcome in all population-based studies from 1960 onward. SUMMARY OF REVIEW: To identify population-based studies that reported on case-fatality rate in subarachnoid hemorrhage, we performed a MEDLINE search and checked all reference lists of the studies found. Two authors (J.W.H. and G.J.E.R.) independently assessed all studies for eligibility, using predefined criteria for case finding and diagnosis, and extracted data on case-fatality rates. We used weighted linear regression analysis to quantify change in case-fatality rate over time. We found 21 studies, describing 25 study periods between 1960 and 1992. Case-fatality rates varied between 32% and 67%, with the exception of one recent study. The case-fatality rate decreased by 0.5% per year (95% confidence interval, -0.1 to 1.2); the decline was steeper after adjustment for age and sex (0.9% per year; 95% confidence interval, -0.7 to 2.6; data from 12 studies). CONCLUSIONS: The case-fatality rate after subarachnoid hemorrhage has decreased during the last three decades. A plausible explanation for this decrease is the improved management of patients with subarachnoid hemorrhage.
Australia↗
Reproducibility of in vivo carotid intima-media thickness measurements: a review.
BACKGROUND: The early phase of atherosclerosis can be studied by two-dimensional B-mode ultrasonography. Measurements of the combined thickness of the carotid intima and media arc currently used as intermediate outcome in clinical trials. Comparison of results between studies is difficult because of the different methods of image acquisition and analysis used. We review these methods and the reported reproducibility of intima-media thickness (IMT) measurements. SUMMARY OF REVIEW: Articles were collected using the MEDLINE literature search system and the references in the selected articles. Literature concerning human in vivo IMT measurements published in the English language in the period 1991 through 1995 was reviewed. A description of the methods of measuring IMT to determine intraobserver and/or interobserver variability was a prerequisite for inclusion. Twenty-three studies were included. Best reproducibility was found when measuring the mean IMT in the common carotid artery in more than one direction. CONCLUSIONS: We conclude that a consensus concerning the assessment of IMT is urgently needed. Variability of IMT measurements is lowest when determining the mean thickness in the common carotid artery in different directions.
Carotid Arteries↗
Circadian fluctuations in onset of subarachnoid hemorrhage. New data on aneurysmal and perimesencephalic hemorrhage and a systematic review.
BACKGROUND AND PURPOSE: Several studies have found a morning peak in onset of stroke. A similar peak has been suggested for subarachnoid hemorrhage (SAH), which seems in contradiction with the physical activities associated with aneurysmal rupture. Most studies included only a few patients with SAH. We analyzed time of onset of aneurysmal SAH in our patients and in data pooled from previous studies. We also studied time of onset in patients with perimesencephalic hemorrhage, which is believed to have a nonaneurysmal venous origin. METHODS: Of all 468 patients registered from 1989 through 1995, 385 fulfilled the criteria for aneurysmal SAH and 37 the criteria for perimesencephalic hemorrhage. Time of onset was categorized in 2-hour and 6-hour intervals. We did a Medline search to find previous studies on time of onset of SAH and pooled the data in 2-hour, 3-hour, and 6-hour intervals. Analysis of all intervals was performed by calculating rate ratios with 95% confidence intervals by means of Poisson methods. RESULTS: The risk of aneurysmal rupture was lower at night (from 12 PM to 6 AM) in our series and in the pooled-data series. Risk remained high throughout the day and evening, we found the same fluctuation in onset but without a nadir around noon. CONCLUSIONS: The risk of aneurysmal SAH is low during the night and at noon and high during working hours. This circadian fluctuation parallels that of blood pressure and suggests that an increase in blood pressure is a risk factor for aneurysmal rupture.
Blood Pressure↗
Carotid intima-media thickness in hyperlipidemic type I and type II diabetic patients.
OBJECTIVE: Ultrasonographic measurements of the combined thickness of the carotid intima and media can be used to examine early vessel wall changes in atherosclerosis. Premature atherosclerosis is common in diabetes, especially when other risk factors are present. Intima-media thickness was quantified in hyperlipidemic type I and type II diabetic patients, and relationships between various risk factors and intima-media thickness were investigated. RESEARCH DESIGN AND METHODS: Thirty-one patients with type I diabetes and 56 with type II diabetes were examined, with an LDL cholesterol of > 2.6 mmol/l and/or triglycerides of > 1.7 mmol/l and/or HDL cholesterol of < 0.9 mmol/l for men or < 1.1 mmol/l for women. Intima-media thickness was measured on-line, over a length of 1 cm in the common carotid artery. Later, the mean and the maximum of six measurements was calculated (left and right side, both in three directions). RESULTS: Mean intima-media thickness was 0.63 +/- 0.18 (+/-SD) mm for type I diabetes and 0.80 +/- 0.31 mm for type II diabetes. Adjusted for age, the difference was 0.06 mm, with a 95% CI of -0.08 to 0.20 mm. In multivariate regression analysis, age over 50 years and higher HbA1c were independently associated with an increase in mean intima-media thickness in type I diabetes. In type II diabetes, none of the variables reached a significance level of < or = 0.10. Results for maximum intima-media thickness were essentially the same. CONCLUSIONS: In general, intima-media thickness is larger in type II diabetes than in type I diabetes. The effect of age is absent in type II diabetes, whereas in type I diabetes, age and blood glucose control have an important effect on intima-media thickness.
Adult↗
Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis.
BACKGROUND: Early classification of patients presenting with peritonitis and intra-abdominal sepsis by means of objective scoring systems is desirable to select patients for 'aggressive' surgery and to compare results of different treatment regimens. However, none of the existing scoring systems has fulfilled all expectations. METHODS: Evaluation of the value of various scoring systems (Acute Physiology And Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score, Sepsis Severity Score, Multiple Organ Failure, Mannheim Peritonitis Index (MPI), Ranson and Imrie) was performed in 50 patients. Additionally, scoring systems were combined to obtain a 'combined score' for the prediction of peritonitis-related in-hospital death. Hazard ratios were calculated in a univariate and multivariate analysis. RESULTS: In the univariate analysis all scoring systems, except Ranson and Imrie, predicted the primary outcome. In the multivariate analysis, only the APACHE II score (hazard ratio 6.7) and the MPI (hazard ratio 9.8) contributed independently to the prediction of outcome. All patients with an APACHE II score of 20 or more and a MPI of 27 or more died in hospital. CONCLUSION: Combination of the APACHE II and the MPI provides the best scoring system fitting clinical goals.
APACHE↗
Cost-effectiveness of implantable defibrillator as first-choice therapy versus electrophysiologically guided, tiered strategy in postinfarct sudden death survivors. A randomized study.
BACKGROUND: Rising costs of health care, partly as a result of costly therapeutic innovations, are of concern to both the medical profession and healthcare authorities. The implantable cardioverter-defibrillator (ICD) is still not remunerated by Dutch healthcare insurers. The aim of this study was to evaluate the cost-effectiveness of early implantation of the ICD in postinfarct sudden death survivors. METHODS AND RESULTS: Sixty consecutive postinfarct survivors of cardiac arrest caused by ventricular tachycardia or fibrillation were randomly assigned either ICD as first choice (n = 29) or a tiered therapy starting with antiarrhythmic drugs and guided by electrophysiological (EP) testing (n = 31). Median follow-up was 729 days (range, 3 to 1675 days). Fifteen patients died, 4 in the early ICD group and 11 in the EP-guided strategy group (P = .07). For quantitative assessment, the cost-effectiveness ratio was calculated for both groups and expressed as median total costs per patient per day alive. Because effectiveness aspects other than mortality are not incorporated in this ratio, other factors related to quality of life were used as qualitative measures of cost-effectiveness. The cost-effectiveness ratios were $63 and $94 for the early ICD and EP-guided strategy groups, respectively, per patient per day alive. This amounts to a net cost-effectiveness of $11,315 per patient per year alive saved by early ICD implantation. Costs in the early ICD group were higher only during the first 3 months of follow-up, but as a result of the high proportion of therapy changes, including arrhythmia surgery and late ICD implantation, costs in the EP-guided strategy group became higher after that. Patients discharged with antiarrhythmic drugs as sole therapy had the lowest total costs. This subset, however, showed extremely high mortality, resulting in a poor cost-effectiveness ratio ($196 per day). Invasive therapies and hospitalization were the major contributors to costs. If quality-of-life measures are taken into account, the cost-effectiveness of early ICD implantation was even more favorable. Recurrent cardiac arrest and cardiac transplantation occurred in the EP-guided strategy group only, whereas exercise tolerance, total hospitalization duration, number of invasive procedures, and antiarrhythmic therapy changes were significantly in favor of early ICD implantation. CONCLUSIONS: In terms of cost-effectiveness, early ICD implantation is superior to the EP-guided therapeutic strategy in postinfarct sudden death survivors.
Anti-Arrhythmia Agents↗