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Letter to the Editor: Role of Subconcussion and Repetitive

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Letter to the Editor: Role of Subconcussion and Repetitive Neurosurgical forum Letters to the editor Aneurysm rupture RESPONSE: In their article, Suzuki and colleagues stated that active bleeding was observed with increasing TO THE EDITOR: We read with interest the article by enhancement in 25.5% of patients (13 of 51).1 All patients Tsuang and colleagues2 (Tsuang FY, Su IC, Chen JY, et al: with extravasation had Claassen Grade 3 or 4 and World Hyperacute cerebral aneurysm rerupture during CT an- Federation of Neurosurgical Societies (WFNS) Grade III, giography. Clinical article. J Neurosurg 116:1244–1250, IV, or V. The other group without extravasation included June 2012), in which they described 21 subarachnoid patients in all grades. In our series of patients with acute hemorrhage (SAH) patients with active contrast extrava- extravasation on CTA, those who presented with a good sation from a ruptured aneurysm during initial cerebral neurological status initially, mainly those with WFNS CT angiography (CTA). They divided these patients with Grade I or II, had the chance for a favorable outcome “reruptured” aneurysms into two subgroups: those with a if timely and successful decompressive surgery and ap- good initial neurological status who showed rapid neuro- propriate aneurysm obliteration were done. Those who logical deterioration, and those with a poor neurological showed a poor neurological status at presentation died no status. The former may still have a favorable outcome if matter what kind of treatment they received. they undergo timely and successful decompressive sur- In our article, the group with favorable outcomes gery and appropriate aneurysm obliteration; there is no that had presented with a good neurological status ex- effective treatment for the latter. perienced rebleeding from the aneurysm during CTA, We recently surveyed a series of patients with SAH and thus further neurological deterioration was reason- who underwent CT perfusion (CTP) with 18-phase dynam- able. Patients who had an initial poor neurological sta- ic enhancement, confirmed the presence of extravasated tus showed extravasation during CTA, indicating that contrast medium in the source image, and reported that ac- primary active bleeding of the aneurysms had not been tive bleeding from an aneurysm was observed with increas- stopped yet or that those aneurysms bled again, but this ing enhancement in 25.5% (13 of 51 cases).1 All CTP results could not be clarified. Their neurological status remained in patients with extravasation were obtained within 2 hours poor throughout the clinical course. of its onset. Moreover, the incidence of active bleeding in The time from ictus to the CT suite also matters. If that patients scanned within 2 hours was 42.3% (11 of 26 cases). period is relatively long and if neurological status deterio- We believe that bleeding from a ruptured aneurysm rates abruptly during the examination, rebleeding is more is arrested immediately when the intracranial pressure is likely. There must be another small group of patients whose increased to the level of the systolic blood pressure.1 We primary bleeding was not stopped and whose bleeding was could observe rerupture from an aneurysm by the extrav- so minimal that we could detect the primary bleeding on asation of contrast material from the aneurysm on intra- CTA with intra-examination neurological deterioration. arterial angiography in patients with marked changes in If the extent of extravasation is great and the time vital and neurological signs. We have encountered many from ictus to CTA examination is long, then rebleeding is patients with extravasation of contrast material during more likely; if the time from ictus to examination is short, CTA and CTP without marked neurological deterioration, then extravasation might indicate either primary bleeding which may reflect the inclusion of patients with continuous or rebleeding. At that time, the best indicator for differ- bleeding, as seen with other systematic injuries. It is time entiation is whether the clinical neurological status dete- to recognize that extravasation from an aneurysm on CTA riorates. Our article emphasized that timely intervention and CTP does not always mean rerupture and that bleeding might offer better outcomes for any patients with acute from an aneurysm is not arrested immediately. extravasation, except those who present with a poor neu- YASUHIRO KUROI, M.D. rological status initially. KAZUFUMI SUZUKI, M.D. FON-YIH TSUANG, M.D. HIDETOSHI KASUYA, M.D. CHUNG-WEI LEE, M.D. Tokyo Women’s Medical University Medical Center East KUO-CHUAN WANG, M.D. Tokyo Women’s Medical University National Taiwan University Hospital Tokyo, Japan Taipei City, Taiwan Disclosure Reference The authors report no conflict of interest. 1. Suzuki K, Tanaka N, Morita S, Machida H, Ueno E, Kasuya H: References Active bleeding in acute subarachnoid hemorrhage observed by multiphase dynamic-enhanced CT. AJNR Am J Neurora­ 1. Suzuki K, Tanaka N, Morita S, Machida H, Ueno E, Kasuya H: diol 33:1374–1379, 2012 Active bleeding in acute subarachnoid hemorrhage observed by multiphase dynamic-enhanced CT. AJNR Am J Neurora­ diol 33:1374–1379, 2012 2. Tsuang FY, Su IC, Chen JY, Lee JE, Lai DM, Tu YK, et al: Hy- Please include this information when citing this paper: published peracute cerebral aneurysm rerupture during CT angiography. online December 6, 2013; DOI: 10.3171/2012.11.JNS121816. Clinical article. J Neurosurg 116:1244–1250, 2012 ©AANS, 2014 778 J Neurosurg / Volume 120 / March 2014 Unauthenticated | Downloaded 09/24/21 09:17 AM UTC Neurosurgical forum Intracranial pressure monitoring and monitor ICP or not. In order to address known parameters traumatic brain injury that independently affect 2-week mortality, we adjusted for Glasgow Coma Scale score, hypotension, age, pupil examination findings, and CT parameters. After this ad- TO THE EDITOR: We are interested in the clinical re- search of Farahvar et al.1 (Farahvar A, Gerber LM, Chiu justment, patients treated without ICP monitoring had a YL, et al: Increased mortality in patients with severe trau- significantly higher mortality than those treated with ICP matic brain injury treated without intracranial pressure monitoring. Patients who had a do not resuscitate order or monitoring. Clinical article. J Neurosurg 117:729–734, lacked brainstem reflexes were not included in the analy- Oc to ber 2012). sis. Severe traumatic brain injury (TBI) often leads to a JAMSHID GHAJAR, M.D., PH.D. Brain Trauma Foundation high mortality rate. Therefore, intensive monitoring of New York, NY intracranial pressure (ICP) or imaging studies is crucial to save the patient’s life. Farahvar et al.1 used a massive, prospectively enrolled database to identify the effect of Please include this information when citing this paper: published ICP monitoring on the 2-week mortality of patients with online December 20, 2013; DOI: 10.3171/2012.11.JNS121675. severe TBI. They found that several parameters, including ©AANS, 2014 age, initial Glasgow Coma Scale score, low blood pres- sure, and CT findings, were correlated with the 2-week The lucid interval and the role of Benjamin mortality. Moreover, patients of all ages who underwent ICP monitoring had decreased mortality at 2 weeks (p = Bell 0.02) compared with those who did not have ICP monitor- 2 TO THE EDITOR: Ganz is to be congratulated on his ing. detailed description of our evolving understanding of the Since this is not a randomized controlled trial, it lucid interval following skull trauma in which he kindly would be unavoidable not to have some potential inter- acknowledges my careful reading over of the text (Ganz fering factors, such as family decision on whether or not JC: The lucid interval associated with epidural bleeding: to resuscitate the patient, comorbidities, associated major 2 evolving understanding. Historical vignette. J Neurosurg trauma, and the extent of primary underlying brain injury, 118:739–745, April 2013). However, this was not as care- that contribute to mortality. ful as it should have been, as I must take issue with the Despite these minor limitations, the authors’ study statement that in Benjamin Bell’s A System of Surgery has called on neurosurgeons to pay more attention to per- “there is absolutely no mention of a symptom-free lucid forming ICP monitoring to improve the outcome in pa- interval between injury and deterioration.” Nor is it true tients with severe TBI. Further large-scale randomized to say that “There is nothing in his A System of Surgery to controlled trials for consideration of ICP monitoring in show he understood the time element separating concus- patients with severe TBI are warranted to reduce the mor- sion and compression.” tality rate. Bell describes the lucid interval on more than one oc- YU-LI PENG casion in chapter 4 of his A System of Surgery,1 expressing NIEN-TZU LIU the concept on page 171 in section 5, when he writes “In DING-YUAN PENG every case, indeed, of injuries done to the head, in which YU-TSE HSIEH the symptoms do not commence till several days after the DUENG-YUAN HUENG, M.D., PH.D. Tri-Service General Hospital accident, as it is clear that the cause of the disorder has not National Defense Medical Center originally affected the brain or its membranes, for if it did Taipei, Taiwan so its effects would be immediate, it is probable that it op- erates almost solely by forming some effusion externally between the pericranium and the skull.” Disclosure Bell appreciated the dangers of posttraumatic cere- The authors report no conflict of interest. bral compression, for when describing on page 117 “cases of extravasation,” he goes on to say, “A patient, in such circumstances, we suppose to be in great hazard, from the References brain being compressed in one part or another: unless this 1. Farahvar A, Gerber LM, Chiu YL, Carney N, Härtl R, Ghajar compression be removed by an operation, he must in all J: Increased mortality in patients with severe traumatic brain probability die.” injury treated without intracranial pressure monitoring.
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