ABSTRACT BACKGROUND This study assessed the impact of treatment modality of aneurysmal subarachnoid hemorrhage (aSAH) on the rate of vasospasm (VSP), mortality, and hospital length of stay (LOS) of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We analyzed patients with aSAH admitted between 1999 and 2005 undergoing either endovascular coiling (EC) or surgical clipping (SC) within 72 hours of onset. Clinical VSP was defined as neurological deficits unexplained by another etiology. Radiological VSP was defined based on transcranial Doppler (TCD) ultrasound, digital subtraction angiography (DSA), and CT criteria. Bivariate and logistic regression analysis was used to determine VSP predictors. RESULTS Of 216 patients included, 98 (45%) underwent EC and 118 (55%) underwent SC. Clinical VSP was found in 26% of EC and 40% of SC patients ( P < .03). TCD VSP, angiographic VSP, and CT infarctions were all significantly higher in the SC group. Mortality was similar in both groups however the LOS was longer in the SC patients ( P = .03). Multivariate analysis showed that SC doubled the risk of clinical VSP ( P < .03) and tripled the risk of composite VSP ( P < .0006). CONCLUSIONS Our study reveals that EC has a lower rate of VSP, shorter LOS, and comparable mortality to SC in aSAH.

Introduction: Pulmonary edema is a serious condition following brain injury of diverse etiologies.In a well characterized animal model of large ischemic stroke, we tested the hypotheses that there are increases in lung water and determined the effects of osmotherapy with hypertonic saline (HS) and mannitol on lung water, as well as on cerebral edema.Methods: Halothane-anesthetized adult male Wistar rats (300-450 g, n=103) were subjected to permanent middle cerebral artery occlusion (MCAO) by the intraluminal occlusion technique.At 6 hr post-MCAO, rats were treated in a blinded randomized fashion with no IV fluids (n=24), an IV infusion (0.3 mL/hr) of 0.9 % saline (NS; n=21), 20% mannitol (2 g/Kg) (n=20), 5% HS (n=20), or 7.5% HS (n=18).Serum osmolality as well as cerebral hemispheric and lung water content were determined by comparing wet-to-dry weights at 48 hr post-MCAO.Sham-operated rats served as controls (n=20).Results: Lung water content increased significantly in rats subjected to MCAO and treated with no IV fluids (76.7 ± 0.7%; 317 ± 7 mOsm/L) (mean ± SD) and NS (76.8 ± 1.2%; 311 ± 10 mOsm/L), as compared to controls (74.5 ± 0.9%; 302 ± 4 mOsm/L).Treatment with mannitol (74.4 ± 1.2%; 352 ± 15 mOsm/L), 5% HS (75.6 ± 1.3%; 339 ± 16 mOsm/L) and 7.5% HS (74.9 ± 0.7%; 360 ± 23 mOsm/L) significantly attenuated lung water content.Water content increased both in the ipsilateral (I) and contralateral (C) hemispheres treated with NS (I: 85.1 ± 1.7%; C: 80.7 ± 0.7%), as compared to controls (I: 79.6 ± 0.9%; C: 79.5 ± 0.9%), as well as in rats that received no fluids (I: 84.6 ± 1.8%; C: 80.4 ± 0.9%).Treatment with 5% HS (I: 83.8 ± 1.0%; C: 79.7 ± 0.6%) and 7.5% HS (I: 82.3 ± 1.3%; C: 78.6 ± 0.7%) attenuated increases in brain water to a greater extent than mannitol (I: 83.6 ± 1.6%; C: 79.1 ± 1.0%).Discussion: In a well characterized animal model of large ischemic stroke, total lung water increases, which is likely neurogenic in origin.Attenuation of stroke-associated increases in lung and brain water content with HS may have therapeutic implication in the treatment of cerebral and pulmonary edema following ischemic stroke.

In acute stroke, chemical neuroprotection is an important strategy aimed at limiting the biochemical cascade of events induced by cerebral ischemia which lead to secondary neuronal damage. Among multiple pharmaceutical interventions tried magnesium (Mg++), which is a physiological voltage-dependent N-metyl-D-aspartate (NMDA) antagonist, has demonstrated promising results. As opposed to other antiglutamate agents, Mg++ has limited adverse effects, is widely available, easy to administer, and has good penetrability in the central nervous system (CNS). Mg++ is involved in the pathogenesis of an expanding array of clinical conditions via vascular and cellular effects. Experimental stroke models and pilot clinical studies have provided encouraging data regarding the neuroprotective role of Mg++ in acute ischemic stroke. Observations from subarachnoid hemorrhage (SAH) animal models have suggested that Mg++ might have a neuroprotective effect directed against the ischemic injury which accompanies cerebral vasospasm. Large randomized, double blind clinical studies assessing Mg++ efficacy in stroke are already in progress. Magnesium sulfate is also under active investigation as a neuroprotective agent in SAH. Keywords: neuroprotection, excitotoxicity, nmda, magnesium, stroke, sah

The cerebellar examination evolved from observations of experimental lesions made by neurophysiologists and clinical descriptions of patients with trauma to the cerebellum. At the beginning of the 19th century, neurophysiologists such as Luigi Rolando, Marie-Jean-Pierre Flourens, and John Call Dalton, Jr. ablated portions of the cerebellum of a variety of animals and observed staggering gait, clumsiness, and falling from side to side without loss of strength. They concluded that the cerebellum coordinated voluntary movements. In 1899, Joseph Francois Félix Babinski observed that patients with cerebellar lesions could not execute complex movements without breaking down into their elemental movements and described the defect as dysmetria. In 1902, Babinski coined the term dysdiodochokinesis to describe the inability to perform rapid execution of movements requiring alternate contractions of agonist and antagonist muscles. Gordon Holmes in 1904 described the phenomena of rebound, noting that if a limb ipsilateral to a cerebellar lesion is suddenly released from tension, the appendage will flail. In 1917, Gordon Holmes reported hypotonia and dysmetria in men wounded by gunshot wounds to their cerebellum. These observations were rapidly included in descriptions of the cerebellar examination in popular contemporaneous textbooks of neurology. Modern observations have demonstrated that the cerebellum influences such cognitive functions such as planning, verbal fluency, abstract reasoning, prosody, and use of correct grammar.