Transiently increased basilar artery flow velocity following severe head injury: a time course transcranial Doppler study.

BACKGROUND AND PURPOSE: Transcranial Doppler ultrasonography has been used to study changes in cerebral hemodynamics following head injury. However, most studies evaluated the anterior circulation and little information exists on transcranial Doppler of the vertebrobasilar arteries after head injury. METHODS: Thirty-two patients with a Glasgow Coma Scale (GCS) score between 4-8 and 11 patients with a GCS score between 9-14 were studied using transcranial Doppler ultrasonography for the first 10 days after injury. Daily variations in the mean blood flow velocities of all major cerebral arteries were recorded. RESULTS: In patients with GCS score between 4-8, the mean blood flow velocities in the middle cerebral and basilar arteries gradually increased beginning on day 2 postinjury and peaked on the 4th-5th day after injury. Those changes were more prominent, and appeared earlier, in the basilar artery. The ratio between the mean flow velocities of the middle cerebral artery and the basilar artery during the first 4 days was significantly lower than in normal controls, indicating a particular increase of flow velocity in the basilar artery. Nineteen out of 32 patients (60%) with severe head injury showed mean blood flow velocity increased over 75 cm/sec in the basilar artery. Mean blood flow velocity >90 cm/sec in the basilar artery, compatible with vasospasm, was observed in 12 of 32 patients (37%). Spasm in the middle cerebral artery was observed in 12 (37%) of patients; 10 of them also had evidence of basilar artery spasm. On the whole, 14 of 32 (43%) patients had evidence of spasm either in the middle cerebral or basilar arteries or in both. In 5 of 11 patients (50%) with moderate head injury (GCS score 9-14), blood flow velocity in the basilar artery greater than 75 cm/sec was observed, but in only two of them it reached the values over 90 cm/sec. Vasospasm in the middle cerebral artery was noted in one patient. CONCLUSIONS: A significant number of patients develop increased flow velocities compatible with vasospasm in the basilar artery after severe head injury. This phenomenon may represent an additional factor that contributes to the poor outcome of severely head-injured patients.

Application of transcranial doppler ultrasonography for the diagnosis of brain death.

OBJECTIVE: To determine the clinical validity of transcranial Doppler ultrasonographic (TCD) signs of total cerebral circulatory arrest for confirmation of brain death and to define the test protocol. DESIGN: Study of a diagnostic test. SETTING: General and neurosurgery intensive care units. PATIENTS: 137 patients in a coma (Glasgow Coma Score 3-5), caused by various pathological conditions, observed from January 1992 to July 1998. 84 patients met the clinical criteria of brain death; 43 patients out of 137 received sedative drug therapy and 31 of these developed brain death. RESULTS: Total cerebral circulatory arrest was demonstrated by TCD in 81 patients. All of them proved to be brain dead according to subsequent clinical examination In 29 of 31 patients who had received sedative drug therapy TCD examination showed total cerebral circulatory arrest 12-48 h before the formal confirmation of the diagnosis. In 1 out of 84 clinically brain dead patients a false negative result was obtained. In 2 of 84 cases, no clear signals from intracranial vessels were obtainable. Fifty-three patients who did not meet the clinical criteria for brain death showed no TCD signs of total cerebral circulatory arrest. The specificity of the TCD test for confirmation of brain death was 100 % and the sensitivity 96.5 %. CONCLUSIONS: In agreement with previously published data, we conclude that TCD ultrasonography is a highly specific and sensitive confirmatory test and should be included as an additional test in the protocol for the assessment of brain death.

Transcranial Doppler in vertebrobasilar vasospasm after subarachnoid hemorrhage.

OBJECTIVE: The primary objective of this study was to assess the incidence of vertebrobasilar vasospasm after subarachnoid hemorrhage (SAH) by means of transcranial Doppler ultrasonography and to evaluate the clinical significance of this phenomenon. The secondary objective was to analyze the different factors influencing the development, the severity, and the duration of vertebrobasilar vasospasm. METHODS: Fifty-seven patients with traumatic SAH and 44 patients with spontaneous SAH were evaluated and monitored by means of transcranial Doppler ultrasonography. Vasospasm of the anterior and middle cerebral arteries was defined by mean flow velocities (FVs) exceeding 120 cm per second and at least three times the FV of the internal carotid artery. Vasospasm of the basilar and vertebral arteries was defined by a mean FV exceeding 60 cm per second. RESULTS: Vasospasm of the anterior or middle cerebral arteries was found in 27 patients and was associated with vertebrobasilar spasm in 20 patients. FVs in anterior circulation vessels were neither related to the cause of the SAH nor did they correlate with the outcome. Forty-six patients (45.5%) had FVs exceeding 60 cm per second and 25 (24.8%) had FVs exceeding 85 cm per second. In 10 of these patients, direct or computed tomographic angiography showed arterial narrowing involving the vertebrobasilar system, whereas in 21 more patients, computed tomography disclosed a cerebral infarction involving the vertebrobasilar vascular territory. Vertebral artery FVs in this group were twice that of the ipsilateral carotid artery. Vertebrobasilar vasospasm was significantly more frequent after head injury, although it was not related to the type of intracranial lesion or the Glasgow Coma Scale score at admission. It did correlate, however, with outcome (P < 0.0001) and with the intensity of SAH (P < 0.0001). Delayed neurological deterioration occurred in 14 patients and was significantly more frequent in patients with basilar artery FVs above 85 cm per second (P < 0.001). Prognosis, however, could not be reliably predicted by FVs in the basilar artery, even when an FV of 110 cm per second was chosen for prediction criterion. CONCLUSION: These results suggest that vertebrobasilar vasospasm is more common than previously thought, especially in association with head injury, with which it may significantly contribute to brain stem ischemic lesions and therefore justify specific therapeutic measures.

[Myocardial hypoplasia of the right heart ventricle (Uhl's anomaly)]. / Gipplaziia miokarda pravogo zheludochka serdtsa (anomaliia ulia).

Uhl's anomaly (right ventricular myocardial hypoplasia), a rarely occurring congenital anomaly of the heart, is described in a newborn who lived 69 hours. In this case, the above anomaly was accompanied by an open oval window and atresia of the pulmonary artery, which led to the baby's short-term lifespan.

[Brain stem auditory evoked potentials in the early period after a brain concussion]. / Slukhovye stvolovye vyzvannye potentsialy v rannie sroki posle sotriaseniia golovnogo mozga.

Acoustic truncal evoked potentials (ATEP) were studied in 24 patients in the first 48 hours after concussion of the brain. The absolute peak latency of components 1, 3, and 5, the interpeak intervals 1-3, 3-5, and 1-5, and the interaural difference were determined. The results were compared with those of examination of a control group of 24 healthy individuals. Individual and group appraisal failed to reveal any significant differences from normal values in none of the studied parameters in patients with brain concussion. The informativeness of the method in mild craniocerebral trauma is discussed.

[Teratoblastoma of the lung in a child]. / Teratoblastoma legkogo u rebenka.

A rare case of teratoblastoma located in the lungs is described. Pleural fluid was examined; its principal morphologic component was vascular tissue, which permitted a tentative diagnosis of a vascular tumor (possibly perithelioma); the presence of connective tissue and oxyphilic interstitial substance elements necessitated a differential diagnosis to rule out chemodectoma. The final diagnosis of teratoblastoma was made in pathohistologic examination.