Biomedical subjects
Publications and source records attributed to A Andreoli.
The concept of crisis is defined from the point of view of the actual practice and is compared with the concepts of illness, of acute states and emergency psychiatry. The crisis intervention means of the psychiatric sector in Geneva are described as well as their place in the general organisation of the psychiatric care.
In patients with cerebral transient ischemic attacks or stroke myocardial infarction is the leading long-term cause of death. Despite the importance of coronary artery disease, patients with cerebrovascular insufficiency are seldom evaluated for the detection of ischemic heart disease and usually the cardiological evaluation is limited to the patients with angina or previous myocardial infarction. In order to identify asymptomatic coronary artery disease 74 consecutive patients with cerebral ischemia, and without symptoms or electrocardiographic signs of ischemic heart disease, underwent a maximal exercise treadmill test according to the Bruce protocol. An exercise Thallium myocardial scintigraphy was performed in patients with positive exercise test. A control group of 74 asymptomatic subjects underwent the same study protocol. The study population (Group I) included 57 men and 17 women; the age ranged from 22 to 72 years (mean age 54 years). An adequate exercise test was obtained in 67 patients. Exercise test was positive (ST-segment depression greater than or equal to 1.5 mm) in 19 cases (28%). The end points were exhaustion in 15 patients, ST-segment depression greater than 3 mm in 2 and systolic blood pressure greater than 240 mmHg in 2. The exercise Thallium myocardial scintigraphy was normal in 2 and abnormal in 17: reversible perfusion defects were detected in 12 cases and fixed defects in 5. In the control group (Group II), comparable for age and sex, exercise test was positive in 4 cases (5%; p less than 0.01 percentage of positive exercise tests in Group I vs Group II); the exercise myocardial scintigraphy was normal in 1 and abnormal in 3 subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
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The results obtained in 304 consecutive patients with spontaneous subarachnoid hemorrhage are described, the majority of whom (86%) were admitted while in acute condition. Only 46% of the patients in this series were in good condition at admission. The initial management was standardized for all patients, but the protocol of "delayed surgery" was applied to patients with subarachnoid hemorrhage from aneurysmal rupture. Two hundred and twenty-two patients (73%) had intracranial aneurysms. Of these, 20 (9%) were moribund and died shortly after admission; nine (4%) underwent emergency surgery due to the coexistence of a life-threatening cerebral hematoma; seven (3%) were operated upon within 3 days of admission; 78 (35%) died after rebleeding or after steady deterioration of the patient's condition due to vasospasm while awaiting surgery. Of the remaining 108 patients ready for delayed surgery, 12 (11%) (operation refused, elderly patients in poor general condition, spontaneous thrombosis of the aneurysm) were treated conservatively, and 96 (89%), who were in various clinical conditions, were actually operated on. Of these 96 patients, 79 (82%) exhibited excellent or good results, 5 (5%) were disabled, and 12 (12%) died. In the authors' experience, the overall management of intracranial aneurysms in unselected patients according to the protocol of delayed surgery results in significant loss of patients awaiting surgery, and good surgical results in the survivors.
Two sisters harbouring an intracranial aneurysm are described. Rather than merely adding new cases to the records of familial aneurysms, this communication reports clinical and radiological findings supporting the hypothesis of inheritance: same anatomical location with involvement of the anterior communicating artery (ACoA), which is uncommon when dealing with familial aneurysms, and similar morphology of the lesions; identical haemodynamic pattern; similar timing of haemorrhage, occurring in both cases during the sixth decade.
The reduction of an intracranial arteriovenous malformation (AVM) by conventional radiation therapy is described in a patient who refused surgery. The 2-year follow-up angiogram documented nearly complete obliteration of the nidus of the AVM, accompanied by progressive narrowing of the arteries supplying the lesion. The scanty literature dealing with this form of treatment is summarized.
Circulating antibody levels to the phenolic glycolipid from Mycobacterium leprae and soluble M. leprae antigens were monitored before, during and following ENL episodes in 12 patients. It was observed that during ENL reaction, there was a fall in circulating antibody levels to the phenolic glycolipid but not to the soluble antigens from M. leprae. When the patients had recovered from their ENL reactions, the anti-glycolipid antibody levels usually increased again to levels similar to those observed before the ENL reaction.
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Many cardiac disorders can cause acute cerebrovascular insufficiency. The spectrum of potentially embolic cardiac conditions is wide; early recognition may determine a definite change in the management and prognosis of patients. In recent years the relevance of echocardiography in the screening of patients with cerebral ischemia has been emphasized. In order to identify potentially embolic cardiac conditions, 180 consecutive non selected patients with cerebrovascular insufficiency, underwent a clinical cardiological evaluation and an echocardiogram. The study population included 132 men and 48 women; the mean age was 51.7 years (range 19 to 72 years). A technically adequate echocardiogram was obtained in 153 patients. In 131 patients echocardiography was negative; cardiac lesions were detected in 22 patients (14.4%): mitral stenosis in 2, calcified aortic stenosis in 1, valvular endocarditis vegetations in 3, dilatative cardiomyopathy in 2, hypertrophic cardiomyopathy in 4, mitral valve prolapse in 4, regional left ventricular diskynesia in 5, mitral anulus calcification in 1. Patients were divided into 3 groups according to the results of cerebral angiography: 68 patients with normal angiography (Group I), 54 patients with atheromasic lesions on cerebral angiography (Group II), 31 patients in whom cerebral angiography was not performed (Group III). A higher incidence of cardiac diseases was found in the patients of Group I. The lack of lesions on cerebral angiography and the presence of embolic high-risk cardiac conditions strengthened a causal relationship of the cardiac disorder with cerebrovascular insufficiency in 10 of the 23 patients. In the mean follow-up period of 18 months of these 10 patients who underwent cardiac surgery or anticoagulation, no further attacks of cerebrovascular insufficiency were observed.(ABSTRACT TRUNCATED AT 250 WORDS)
Seventy patients who had developed occlusion of the middle cerebral artery confirmed by angiography between 1970 and 1980 were followed up after an average of six years. Fourteen patients had died in the acute stage of the initial stroke. In the remaining 56 patients actuarial analysis showed that the observed incidence of survival for five years was 81.8% compared with an incidence of 94.1% in a matched normal population. Six patients sustained new strokes, four of which were ipsilateral to the middle cerebral artery occlusion. The observed cumulative incidence of subsequent strokes was 2% a year for the first five years of follow up. Twelve patients developed epileptic seizures.
Angiography is indispensable for the selection of appropriate candidates for extra-intracranial arterial bypass (E.I.A.B.). It allows the visualization of ICA and/or MCA occlusion or inaccessible stenosis which are considered indications for E.I.A.B. Complete angiographic study also gives information about other vascular lesions and the morphology of ECA and its branches as well as collateral circulation. Moreover angiography evaluates the result of bypass. The methods of the preoperative and postoperative angiography are described.
A technically adequate four-vessel cerebral angiogram was normal on the first day after a typical episode of subarachnoid hemorrhage. The study was repeated 40 days later showing a large aneurysm of the basilar bifurcation. Hypothetically, the first attempt to visualize the aneurysm was negative due to early transitory thrombosis of the aneurysmal sac. In some cases of subarachnoid hemorrhage it is beneficial to repeat previously normal angiographic studies.
Failure of unilateral carotid angiography to opacify a saccular aneurysm of the anterior communicating artery was observed; this occurred despite excellent visualization of the parent artery with spontaneous cross-filling and adequate demonstration of the intracranial carotid system bilaterally. In the absence of thrombosis of the aneurysm (which was discounted by contralateral carotid angiograms), vasospasm, and hypoplasia of the afferent arteries, a hemodynamic mechanism involving velocity of blood flow and intravascular turbulence is considered.
A giant fusiform aneurysm of the right middle cerebral artery was treated with extracranial-intracranial arterial bypass followed by controlled occlusion of the proximal parent artery using a Drake tourniquet. Thrombosis of the aneurysm is documented, with the distal extremity of the lesion being smoothly contrasted in a retrograde fashion by the hypertrophied bypass. The low risk as well as effectiveness of this combined approach to inaccessible intracranial aneurysms is confirmed.
The long-term follow-up of 100 consecutive patients who suffered from a reversible ischaemic attack (RIA) in the carotid territory and were submitted to extra-intracranial arterial bypass (EIAB) surgery in seven Italian Neurosurgical Centres is reported. The preoperative angiographic and clinical features, and the surgical complications are reported. The follow-up ranged from two to seven years with a mean of thirty-five months. In this period in the territory served by the bypass only two completed strokes and six RIAs occurred. Four patients died, only one for cerebral ischaemic problems. The results of the present series have been compared with those of the literature: they appeared consistent with other surgical series and clearly better than those of medical treated patients. The EIAB can then be considered a good therapeutic choice for the treatment of RIAs in carotid territory.
The purpose of this paper is to estimate the real value of the Extra-Intracranial Arterial Bypass (EIAB) in preventing or reducing further and more catastrophic ischaemic events in patients suffering from an Internal Carotid Artery (ICA) occlusion. 257 patients, suffering from ICA occlusion, are considered retrospectively: 122 of them submitted to EIAB and 135 medically treated or untreated. In both groups, homogeneous by sex, age, neurological grading distribution and length of follow-up, the following parameters were considered: the incidence of ischaemic recurrences during the follow-up period; the characters of the recurrences with particular reference to the fatal stroke; the rate of ischaemic events per year. The comparison between the outcome in surgically treated patients and in "untreated" ones indicates that the EIAB can be effective in preventing or reducing the ischaemic recurrences and the frequency of fatal stroke in TIA-, RIND, or stroke-patients suffering from ICA occlusion.