Background and Purpose-Optimal monitoring of cardiac output and intravascular volume is of paramount importance for good fluid management of patients with subarachnoid hemorrhage (SAH). The aim of this study was to demonstrate the feasibility of advanced hemodynamic monitoring with transpulmonary thermodilution and to provide descriptive data early after SAH. Methods-Forty-six patients with SAH treated within 24 hours of the ictus were investigated. Specific targets for cardiac index (Ն3.0 L ⅐ min Ϫ1 ⅐ m Ϫ2 ), global end-diastolic volume index (700 to 900 mL/m 2 ), and extravascular lung water index (Յ14 mL/kg) were established by the single-indicator transpulmonary thermodilution technique, and a fluid management protocol emphasizing supplemental colloid administration was used to attain these targets. Plasma hormones related to stress and fluid regulation were also measured. Results-A higher cardiac index (mean value of 5.3 L ⅐ min Ϫ1 ⅐ m Ϫ2 ) and a lower global end-diastolic volume index (555 mL/m 2 ) were observed on initial measurement, for which elevations of plasma adrenaline, noradrenaline, and cortisol were also detected. Cardiac index was progressively decreased (3.5 L ⅐ min Ϫ1 ⅐ m Ϫ2 ) and global end-diastolic volume index was normalized by fluid administration aimed at normovolemia. The extent of the initial hemodynamic and hormonal profile was greater in patients with a poor clinical status (PϽ0.05). The extravascular lung water index was mildly elevated but within the target range throughout the study period. No patients developed pulmonary edema or congestive heart failure. Conclusions-The impact of sympathetic hyperactivity after SAH predisposes patients to a hyperdynamic and hypovolemic state, especially in those whose clinical status is poor. Bedside monitoring with the transpulmonary thermodilution system may be a powerful tool for the systemic management of such patients. (Stroke.

The features or mechanisms of dyshidrosis have not been suYciently clarified. Neither has the diVerence between hyperhidrosis and hypohidrosis. To clarify the features and mechanisms of dyshidrosis (hyperhidrosis and hypohidrosis) in syringomyelia, the clinical features focusing on hidrosis of 30 patients with syringomyelia and Chiari malformation located from a syringomyelia database were prospectively analysed. The patients were classified into three groups: eight patients (26.7%) had segmental hypohidrosis, 10 (33.3%) had segmental hyperhidrosis, and 12 (40.0%) had normohidrosis. We found that the Karnofsky functional status for the hyperhydrosis and normohidrosis groups were significantly higher than for the hypohidrosis group (p=0.0012), with no significant diVerences between the hyperhidrosis and normohidrosis groups. The duration from the onset of syringomyelia to the current dyshidrosis was significantly longer in the hypohidrosis group than in the hyperhidrosis group (p=0.0027). A significant correlation was identified between the duration from the onset of syringomyelia to the time at study and the performance score (r=−0.599, p=0.0003). The results substantiate previous hypotheses that in its early stage syringomyelia causes segmental hyperactivity of the sympathetic preganglionic neurons, and hyperactivity of these gradually subsides as tissue damage progresses. Focal hyperhidrosis may be regarded as a hallmark of a relatively intact spinal cord, as well as normohidrosis. (J Neurol Neurosurg Psychiatry 1999;67:106-108)

• Abstract • Objective: Endovascular thrombectomy may be a topic treatment in this year, because new evidences and increase in the number of cases will be expected. Elderly patients or arteriosclerosis patients often exhibited difficult access to the occlusive vessel, and it may lead to poor result. The direct common carotid artery puncture is an alternative method in cases of difficult access. Case presentation: A 90-year-old male presented with sudden-onset of the left hemiparesis. Magnetic resonance imaging revealed early ischemic changes in the right deep white matter, and magnetic resonance angiography showed a right middle cerebral artery occlusion. After recombinant tissue plasminogen activator (rt-PA) therapy, his symptom showed no improvement, and endovascular therapy was performed. Right innominate angiography showed that the access to right common carotid artery was difficult, because of anatomical problem. Therefore, a direct common carotid artery puncture was performed and recanalization was achieved using stent retriever. Conclusion: Direct common carotid artery puncture may be technically acceptable in a case of anatomical difficulty to internal carotid artery.• Key words • direct carotid artery puncture, endovascular thrombectomy, stroke, cerebral vessel occlusion 5 7 1-1

A 76-year-old man presented with subarachnoid hemorrhage. Selective angiography revealed a dural arteriovenous fistula (DAVF) at the right anterior clinoid process, draining into the superficial middle cerebral vein in a retrograde fashion. Two internal carotid artery aneurysms were also demonstrated at the origin of the posterior communicating artery and the anterior choroidal artery on the same side. The patient underwent craniotomy, and all lesions were treated simultaneously. Rupture of the anterior choroidal artery aneurysm was confirmed. DAVF draining directly into the superficial middle cerebral vein is extremely rare. The precise location of the shunt, the anatomical features, and venous drainage must be evaluated to consider treatment.

We describe a very rare case of subarachnoid hemorrhage (SAH) due to a right internal carotid-posterior communicating artery (IC-PC) aneurysm simultaneously associated with a left temporal intracerebral hemorrhage (ICH).