[Cerebral perfusion computerized tomography in vasospasm after subarachnoid hemorrhage: diagnostic value of MTT]. / Die zerebrale Perfusions-Computertomografie beim Vasospasmus nach Subarachnoidalblutung: Diagnostischer Wert der MTT.

PURPOSE: Analysis of the value of the perfusion parameter mean transit time (MTT) for the diagnosis of cerebral vasospasm after Subarachnoid Hemorrhage (SAH). Comparison with other perfusion parameters. An MTT threshold indicating the necessity of conventional angiography will be defined. MATERIALS AND METHODS: We analyzed the CT Perfusion (CTP) of 20 patients suffering from SAH (Fisher grading 3 and 4). In each patient a baseline examination was performed the day after treatment of the ruptured aneurysm. Follow-up was indicated for the occurrence of clinical symptoms, pathologic Doppler values or the first day after endovascular therapy. The cortical mean transit time (MTT), T (max,) cerebral blood flow (CBF) and cerebral blood volume (CBV) were calculated. A vasospasm score resulting from the Doppler values and clinical neurological symptoms was compared to MTT in the follow-up. The outcome after discharge from the intensive care unit was compared to the maximum MTT. RESULTS: 18 patients were able to be evaluated. We found parallelism between the time course of MTT and clinical symptoms in 14 of 18 patients. In 4 of 18 patients no relationship between MTT and clinical symptoms was found. There is a good correlation between the clinical outcome at the time of discharge and the MTT. Clinical symptoms occurred if the MTT was between 3.2 and 4.0 s. An MTT above 4.0 s resulted in a bad clinical outcome. 9 of 18 patients showed angiographic criteria for endovascular treatment. All those patients showed an MTT of more than 3.2 s at the time of angiography. CONCLUSION: The analysis of the cortical perfusion parameter MTT is suitable for revealing clinically relevant global and regional vasospasm. A risk potential prediction is possible. An MTT of 3.2 s indicates a conventional angiography (DSA). This should be verified using a larger number of patients.

[Computerized analysis of brain perfusion parameter images]. / Automatisierte Analyse von Parameterbildern der Hirnperfusion.

PURPOSE: The development of a computerized method which allows a direct quantitative comparison of perfusion parameters. The display should allow a clear direct comparison of brain perfusion parameters in different vascular territories and over the course of time. The analysis is intended to be the basis for further evaluation of cerebral vasospasm after subarachnoid hemorrhage (SAH). The method should permit early diagnosis of cerebral vasospasm. MATERIALS AND METHODS: The Angiotux 2D-ECCET software was developed with a close cooperation between computer scientists and clinicians. Starting from parameter images of brain perfusion, the cortex was marked, segmented and assigned to definite vascular territories. The underlying values were averages for each segment and were displayed in a graph. If a follow-up was available, the mean values of the perfusion parameters were displayed in relation to time. The method was developed under consideration of CT perfusion values but is applicable for other methods of perfusion imaging. RESULTS: Computerized analysis of brain perfusion parameter images allows an immediate comparison of these parameters and follow-up of mean values in a clear and concise manner. Values are related to definite vascular territories. The tabular output facilitates further statistic evaluations. The computerized analysis is precisely reproducible, i. e., repetitions result in exactly the same output. CONCLUSION: Computerized analysis of brain perfusion parameters with Angiotux 2D-ECCET is objective and ensures reproducible results. It may become the basis and a requirement for the analysis of minimal changes in brain perfusion prior to irreversible damage from posthemorrhagic vasospasm.

[From the concept of guilt to the value-free notification of errors in medicine. Risks, errors and patient safety]. / Von der Schuldfrage zur Fehlerkultur in der Medizin. Risiken, Fehler und Patientensicherheit.

The number of liability cases but also the size of individual claims due to alleged treatment errors are increasing steadily. Spectacular sentences, especially in the USA, encourage this trend. Wherever human beings work, errors happen. The health care system is particularly susceptible and shows a high potential for errors. Therefore risk management has to be given top priority in hospitals. Preparing the introduction of critical incident reporting (CIR) as the means to notify errors is time-consuming and calls for a change in attitude because in many places the necessary base of trust has to be created first. CIR is not made to find the guilty and punish them but to uncover the origins of errors in order to eliminate them. The Department of Anesthesiology of the University Hospital of Basel has developed an electronic error notification system, which, in collaboration with the Swiss Medical Association, allows each specialist society to participate electronically in a CIR system (CIRS) in order to create the largest database possible and thereby to allow statements concerning the extent and type of error sources in medicine. After a pilot project in 2000-2004, the Swiss Society of Gynecology and Obstetrics is now progressively introducing the 'CIRS Medical' of the Swiss Medical Association. In our country, such programs are vulnerable to judicial intervention due to the lack of explicit legal guarantees of protection. High-quality data registration and skillful counseling are all the more important. Hospital directors and managers are called upon to examine those incidents which are based on errors inherent in the system.

Adnexal torsion during pregnancy -- management and literature overview.

We present a patient in the 30th week of gestation with adnexal torsion, which was treated by laparotomy with oophorectomy. After 2 days, we had to perform a cesarean section because of bowel obstruction. We discuss the diagnosis and treatment of adnexal torsion in pregnancy and compare laparoscopic management with laparotomy. By reviewing the literature, we evaluate the conservative therapy by detorsion employing Doppler sonography.