acetylcellulose and Aneurysm--Ruptured

Six aneurysms in five patients with acute aneurysmal subarachnoid hemorrhages were treated with direct thrombosis using cellulose acetate polymer within 4 hours of rupture. The aneurysms involved the internal carotid and posterior communicating arteries (two patients), the anterior choroidal artery (one patient), the bifurcation of the basilar artery (one patient), and the middle cerebral artery (two patients). Four patients underwent aggressive volume expansion after direct thrombosis with cellulose acetate polymer. The aneurysms remained thrombosed until operations on the necks were performed 2 to 7 weeks after the subarachnoid hemorrhages. Three patients were given intrathecal tissue plasminogen activator. One patient, who remained at neurological Grade V, was not treated surgically and died from cardiac failure. Five aneurysms in the remaining four patients were successfully clipped. These preliminary data suggest that immediate aneurysmal thrombosis, then aggressive preoperative prophylactic volume expansion and/or administration of intrathecal tissue plasminogen activator, can help prevent new bleeding and reduce delayed cerebral ischemia in patients after aneurysmal subarachnoid hemorrhages.

Topics: Aged; Aneurysm, Ruptured; Cellulose; Cerebral Angiography; Combined Modality Therapy; Embolization, Therapeutic; Female; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Polymers; Preoperative Care; Subarachnoid Hemorrhage; Tomography, X-Ray Computed

Twelve patients with Hunt and Hess neurological Grades III to V underwent thrombosis of aneurysms using cellulose acetate polymer within 23 hours of aneurysm rupture. On computerized tomography (CT), nine of these patients had difuse or localized thick subarachnoid blood clots, two had diffuse thin clots and one had intraventricular clots. Immediately after thrombosis, all patients were administered tissue plasminogen activator (TPA) through spinal or ventricular catheters. The pressure of the lumbar cerebrospinal fluid was maintained at 100 to 150 mm H2O. The TPA was given as multiple injections of 2 mg on Day 0 and 1 to 2 mg on the following 1 to 2 days. In two patients the second injection of TPA was not given because of severe brain damage resulting from the initial subarachnoid hemorrhage. Ten patients showed complete clearance of the cisternal clot on CT within 72 hours after thrombosis. Seven partially thrombosed aneurysms and five multiple aneurysms were clipped during delayed surgery. Only one patient experienced mild vasospasm as shown on the follow-up angiogram. Eight patients improved clinically and had a good recovery, two had severe disability, and two died. Urgent thrombosis of a ruptured aneurysm followed by immediate postthrombotic administration of TPA may be a safe and reasonable means of preventing vasospasm and improving patient outcome.

Topics: Aged; Aged, 80 and over; Aneurysm, Ruptured; Cellulose; Cerebral Angiography; Drainage; Female; Follow-Up Studies; Humans; Hydrocephalus; Intracranial Aneurysm; Ischemic Attack, Transient; Male; Microsurgery; Middle Aged; Recurrence; Subarachnoid Hemorrhage; Thrombolytic Therapy; Tissue Plasminogen Activator; Tomography, X-Ray Computed; Treatment Outcome

Cellulose acetate polymer solution is a liquid thrombotic material that hardens into the shape of an aneurysm into which it is injected. Therapy using this solution is a rapid technique that helps prevent the rupture of aneurysms, especially those that extravasate contrast material during angiography in the acute stage of subarachnoid hemorrhage. Using this polymer solution and an endovascular technique, we treated two patients who had aneurysms of the basilar and anterior communicating arteries with extravasation of contrast material during angiography a few hours after the initial subarachnoid hemorrhage. In one patient with an aneurysm of the anterior communicating artery, the aneurysm's wall was perforated with the catheter during neurointerventional procedures. In both patients, postoperative angiograms demonstrated obliteration of the aneurysmal dome, including the site of extravasation or perforation. The parent artery and surrounding perforating branches were preserved. Although we do not advocate aggressive therapy for patients who bleed during angiography, we pursued this therapy in these two patients because of the opportunity to introduce cellulose acetate polymer in an attempt to preserve the patients' lives. Unfortunately, both patients died. Histopathological studies performed at the time of autopsy demonstrated that the luminal surface of cellulose acetate polymer was covered with thrombus by 6 days after cellulose acetate polymer thrombosis. By 10 days, the thrombus had a prominent fibrin network, a concentrated plasma component, and few fibrocytes adhering to its luminal surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Aneurysm, Ruptured; Angiography, Digital Subtraction; Basilar Artery; Cellulose; Cerebral Angiography; Cerebral Arteries; Embolization, Therapeutic; Emergencies; Extravasation of Diagnostic and Therapeutic Materials; Fatal Outcome; Female; Humans; Intracranial Aneurysm; Male; Polymers; Subarachnoid Hemorrhage