[Findings from 10 years of CIRS-AINS : An analysis of usepatterns and insights into new challenges]. / Erkenntnisse aus 10 Jahren CIRS­AINS : Eine Analyse von Nutzerverhalten und Ausblick auf neue Herausforderungen.

BACKGROUND: Critical incident reporting systems (CIRS) serve to sensitize organizations and individuals to unknown events relevant to patient safety and therefore help in developing safer systems; however, the use and impact of these systems in healthcare has recently been questioned for a variety of reasons, among them unclear and imprecise reporting criteria. Some authors claim that fundamental aspects of successful CIRS have been misunderstood, misapplied or entirely missed during the adaptation to the healthcare context. The aim of this study was the analysis of all reports accumulated over 10 years in the German system CIRSmedical Anesthesiology (CIRS-AINS) as a basis for improved reporting guidelines, user training and generation of further hypotheses. METHODS: In a retrospective analysis all reports from CIRS-AINS entered between April 2010 and June 2019 were analyzed for structure and content. RESULTS: A total of 6013 reports were filed consisting of 3492 incidents (58.1%), 1734 near misses (28.8%) and 787 others (13.1%). Those other reports contained 21 interpersonal conflicts (0.4%), 102 general complaints (1.7%), 89 stress or workload complaints (1.5%) and 575 reports that did not contain any critical incident or safety-related content (9.6%). Since 2015 these other reports have increased 2.8-fold from 7.4% to 20.8%. Of the reports 20.1% contained information about technical problems and 27.7% about certified medical devices. Medication was mentioned in 10.7% of reports, 47.8% of inpatient incidents concerned the perioperative setting, 24.6% were reported from intensive care units (ICU) and postanesthesia care units (PACU). Of the cases 198 (3.3%) explicitly mentioned communication issues, 346 cases (5.8%) concerned incomplete or inadequate documentation involving orders, blood products or laboratory tests. Of the reports 36.1% were analyzed and commented on by the CIRS team of the German Society of Anesthesiologists (BDA). CONCLUSION: The analysis provides insights into reporting practices and can influence both reporting guidelines as well as user training. Report format, content and context are of utmost importance for further analysis: A distinction has to be made between reports that contain locally rational information and cannot be understood without further context and reports that may help inform about patient safety activities on a national level. Especially in light of the limited resources for incident analysis, the content should be critically reflected upon by the user when submitting a report to support a wise allocation of available capacities. In this respect, the increase of non-CIRS reports has to be considered in the future implementation of nationwide IRS. Also, it has to be questioned whether adequate alternative means of communication for these non-CIRS reports exist. The majority of reports were made by physicians, which is in contrast to international experiences with increased engagement of nursing staff and underlines the need for increased interprofessional collaboration with incident reporting and analysis activities in Germany. Reports containing workload complaints, while constituting important signals on a local level, usually fail to address the idea of learning from others inherent to the philosophy of national IRS.

Identification and stability of a new bichalcone in Achyrocline satureioides spray dried powder.

A new chemical structure, the 4,2',4",2'''-tetrahydroxy-6',6'''-dimethoxy-4'-O-4'''- bichalcone, named achyrobichalcone was isolated and identified from an Achyrocline satureioides spray-dried powder (SDP80). The thermal and photo stability of this new compound as well as that of the main polyphenols present in the spray dried powder, quercetin, luteolin, 3-O-metylquercetin and the corresponding kinetics of degradation are reported. In the long-term testing (30 +/- 2 degrees C/75 +/- 5% RH, 12 months), the total polyphenols contained in SDP80 demonstrated to be stable, remaining higher than 90% after a 12 month exposure. The photo stability testing revealed that all polyphenols were stable for 48 h when SDP80 was conditioned in amber or transparent flasks and exposed to UV-C radiation (light express LE UV, 254 nm, 30W). In contrast, when unprotected, the polyphenols demonstrated to be sensitive to both, thermal stress testing (80 +/- 2 degrees C), for 14 days and to UV-C radiation. Luteolin showed to be the most stable against UVC light and 3-O-methylquercetin against temperature. The achyrobichalcone demonstrated to be the more unstable against both, temperature and light. The kinetics of polyphenol thermal degradation (80 +/- 2 degrees C, 49 days) and photodegradation (UV-C radiation, 96 h) followed, 2nd and 1st order reaction, respectively.

Thermal and photo stability of phenolic constituents of an Achyrocline satureioides spray-dried powder.

Thermal and the photo stabilities of an Achyrocline satureioides powder (SDP40) were evaluated in particular concerning the total polyphenol content as well as the main identified constituents quercetin, luteolin, 3-O-methylquercetin and caffeic acid. SDP40 presented good stability for nine months under normal storage conditions of 25 degrees C temperature and 60% relative humidity (RH). In accelerated term testing, 50 degrees C temperature and 90% RH and also in stress testing, 80 degrees C, caffeic acid and a non-identified constituent P3 were the most instable constituents. Luteolin and 3-O-methylquercetin were the most stable constituents. Quercetin presented an unusual behavior, improving its concentration after 1 month at 50 degrees C or 2 days at 80 degrees C exposition, followed by a decrease in its concentration. The hypothesis that this observation is related to the simultaneous decreasing of a non-identified peak P3 or to the hydrolysis of a non-identified precursor as a quercetin heteroside is being investigated. The SDP40 presented good stability against UV-C light when conditioned in amber or transparent containers, but it suffered degradation when stored in open-dishes. In summary, the total polyphenol content remains within acceptable limits of 10% under normal storage conditions for nine months. However, the LC polyphenol analysis demonstrated that the behavior of individual constituents has still to be enlightened.

Monitoring of cerebral oxygen metabolism in the jugular bulb: reliability of unilateral measurements in severe head injury.

To investigate the reliability of unilateral jugular venous monitoring and to determine the appropriate side, we performed bilateral jugular venous monitoring in 22 head-injured patients. Fiberoptic catheters were placed in both jugular bulbs. Arterial and bilateral jugular venous blood samples were obtained simultaneously for in vitro determination of jugular venous oxygen saturation (SJO2), arterial minus jugular venous lactate content difference (AJDL), and modified lactate-oxygen index (mLOI). Ischemia was assumed if one of the following pathologic values occurred at least unilaterally: SJO2 <54%, AJDL <-0.37 mmol/L, mLOI >0.08. The sensitivity of calculated unilateral monitoring in detecting ischemia was evaluated by comparing the incidence detected unilaterally with that disclosed bilaterally. The mean and maximum bilateral SJO2 differences varied between 1.4% and 21.0%, and 8.1% and 44.3%, respectively. The bias and limits of agreement (mean differences +/- 2 SD) between paired samples were 0.4% +/- 12.8%. There was no significant variation in bilateral SJO2 differences with time. Decreasing cerebral perfusion pressure (r = -0.559, P < 0.001) and arterial PCO2 (r = -0.342, P < 0.001) were associated with increasing bilateral SJO2 differences. Regarding AJDL, the maximum bilateral differences varied between 0.04 mmol/L and 1.52 mmol/L. The bias and limits of agreement were -0.01 +/- 0.18 mmol/L. At best, 87% of ischemic events were disclosed by monitoring on the side of predominant lesion or, in diffuse injuries, on the side of the larger jugular foramen (computed tomographic [CT] approach). We conclude that in severe head injury, even calculated unilateral jugular venous monitoring has an unpredictable risk for misleading or missing data. Therefore, the reliability of unilateral jugular venous monitoring appears suspicious. For diagnosing ischemia the CT approach is recommended.

Role of the renin-angiotensin system in the development of congestive heart failure in the dog as assessed by chronic converting-enzyme blockade.

Hormonal factors may be important in the regulation of peripheral vascular resistance (PVR) in congestive heart failure (CHF). The role of the renin-angiotensin system in the development of CHF was studied in 16 unanesthetized dogs. CHF was induced by rapid right ventricular pacing, with and without chronic converting-enzyme inhibition (CEI) by captopril. The hemodynamic changes and the activity of renin, aldosterone, norepinephrine and vasopressin were studied. The control dogs showed a greater decrease in cardiac output and a greater increase of mean pulmonary artery pressure than the captopril-treated group. In the group with CEI, only a small, transient increase in PVR was observed during the development of CHF; in the control group, there was an increase of 94% of basal values. The control group showed a continual increase of renin, aldosterone and norepinephrine. Four control dogs showed an inappropriately high secretion of arginine vasopressin. The increase of sympathetic nervous activity was only insignificantly attenuated by angiotensin II inhibition and was without a considerable influence on PVR except for an early transient increase in vascular tone. In our animal model, the renin-angiotensin system plays an important role in the regulation of PVR in CHF. In this kind of CHF the sympathetic nervous system appears to be of minor importance for the long-term regulation of PVR. Plasma arginine vasopressin levels were increased in control dogs; this increase may contribute to the increased vascular tone.

Transcranial Doppler sonography in a patient with Ehlers-Danlos syndrome: case report.

OBJECTIVE AND IMPORTANCE: Ehlers-Danlos syndrome is of special interest because of the risk of formation of intracranial aneurysms. The reason is increased elasticity of the vessel wall, which can influence the waveform of the transcranial doppler signal. CLINICAL PRESENTATION: A patient with Ehlers-Danlos syndrome Type IV and an aneurysm of the left middle cerebral artery was studied with transcranial doppler sonography. Compared with a reference group of 29 volunteers, there was no difference in blood flow velocity in the middle cerebral and anterior cerebral arteries on both sides. The pulsatility index, however, was lower compared to the pulsatility index of the reference group (right middle cerebral artery, 0.69 versus 0.89; left middle cerebral artery, 0.58 versus 0.87; right anterior cerebral artery, 0.66 versus 0.94; left anterior cerebral artery, 0.68 versus 0.88). There was no difference in blood pressure during examination between the described patient and the reference group. CONCLUSION: Under the concept of an increased elasticity of the vessel wall, a decreased flow resistance can be expected, which is represented by a decreased pulsatility of the blood flow waveform. It might be possible that in patients with Ehlers-Danlos syndrome, intracranial arteries that show a very low pulsatility index run a high risk to develop an aneurysm.

Prognostic factors of posterior cervical disc surgery: a prospective, consecutive study of 54 patients.

OBJECTIVE: To our knowledge, there is no prospective study to date about the prognostic factors of dorsal foraminotomy. The aim of this prospective study was to provide further information in this field. METHODS: From January 1994 to January 1995, we performed a prospective, consecutive study of 54 patients, each of whose lateral herniated cervical disc was operated on via a dorsal foraminotomy. We analyzed the general data, the case history, the neurological examination at admission, and all data from imaging examinations and therapy. Most of the patients (93%) were followed up at 1 year, postoperatively. The patients were divided into one group with good results and another group with bad results, according to their ratings on a pain scale. The groups were analyzed in relation to the patients' initial condition. RESULTS: At follow-up, 94% of the patients had completely recovered or their condition had improved. CONCLUSION: A long duration of preoperative complaints and a long-standing neurological deficit seem to be important prognostic factors for a bad outcome after dorsal foraminotomy.

Moderate hypothermia in patients with severe head injury: cerebral and extracerebral effects.

Cerebral and extracerebral effects of moderate hypothermia (core temperature 32.5 degrees C-33.0 degrees C) were prospectively studied in 10 patients with severe closed head injury (Glasgow Coma Scale score < 7) in the intensive care unit of a university hospital. Hypothermia was induced by cooling the patient's body surface with water-circulating blankets. Before cooling, a conventional intracranial pressure (ICP) reduction therapy was applied, which remained unchanged throughout the study. Cerebral blood flow (CBF), cerebral metabolic rates for oxygen (CMRO2) and lactate (CMRL), and ICP were simultaneously measured prior to inducing hypothermia, after obtaining hypothermia, after 24 hours of hypothermia, and after rewarming. With respect to extracerebral effects, supplemental investigations were conducted 24 and 72 hours after rewarming. The median delay between injury and induction of hypothermia was 16 hours. Hypothermia reduced CMRO2 by 45% (p < 0.01), whereas CBF did not change significantly. Before cooling, six patients had elevated CMRL indicating cerebral ischemia. Cooling normalized CMRL in all patients (p < 0.01). The intracranial hypertension present prior to cooling declined markedly during hypothermia (p < 0.01) without significant rebound effects after rewarming. Cardiac index decreased by 18% after hypothermia was reached (p < 0.05), recovered at 24 hours of hypothermia, and surpassed baseline values after rewarming. Platelet counts dropped continuously up to 24 hours after rewarming (p < 0.01). Plasma coagulation tests did not show significant worsening. Creatinine clearance decreased during cooling (p < 0.01) and recovered by 24 hours after rewarming. Twenty-four hours after cooling had begun, eight patients had elevated serum lipase activity (p < 0.01) and four of them acquired pancreatitis. Rewarming normalized both pancreatic alterations. Seven patients made a good recovery; one survived severely disabled; and two patients died. Moderate hypothermia is effective in preventing secondary brain damage while reducing cerebral ischemia. However, there are potentially hazardous side effects that require additional monitoring.

Dynamic changes of cerebral oxygenation measured by brain tissue oxygen pressure and near infrared spectroscopy.

The aim of this study was to find out whether a correlation exists between changes in brain tissue oxygen pressure (ti-pO2) and hemoglobin oxygenation (HbO2) measured by near-infrared spectroscopy. We studied 10 patients with severe head injury. A ti-pO2 monitoring device was introduced in the frontal white matter as soon as possible after administration. Additionally a NIRS sensor was placed at the forehead. All data were recorded simultaneously. Changes of the ti-pO2 curve were defined as events with the following criteria: > 10% change from the baseline value, > 3 min duration, clearly not an artifact. 137 events were found with a mean change of ti-pO2 of 8.3 +/- 10.2 mmHg. In 77.4% we observed a corresponding change of the HbO2. In 7 patients we found a good correlation (r > 0.7) between change ti-pO2 and change HbO2. In 3 patients the correlation was poor. The reason for poor correlation might be poor signal quality of the NIRS sensor or inhomogenous distribution of ischemic areas in the whole brain. We conclude that under the condition of a stable NIRS signal and a diffuse brain lesion, changes of ti-pO2 are well reflected by NIRS.

Is there a clinical correlate to the histologic evidence of inflammation in herniated lumbar disc tissue?

STUDY DESIGN: The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histologic results were compared with prospectively obtained clinical data. OBJECTIVES: To assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. SUMMARY OF BACKGROUND DATA: It is postulated that in addition to nerve root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. However, the clinical relevance of the histologically described inflammatory infiltrates is not defined clearly. METHODS: Disc specimens from 44 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Before surgery, severity of pain was classified in each patient according to a visual analog scale, and general clinical data were recorded prospectively. RESULTS: Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical analysis, no statistically significant correlation between the histologic evidence of macrophage infiltrates and the pain grading scale or the clinical data was noted. CONCLUSIONS: There is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimens and the obtained clinical data.

Variability of outcome after lumbar disc surgery.

STUDY DESIGN: A prospective, consecutive study of patients' outcome at three subsequent follow-up times after lumbar disc surgery. OBJECTIVES: To evaluate how consistent outcome remained in a group of patients after lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Despite similar results concerning the overall outcome, results in most studies show different prognostic factors for lumbar disc surgery at different follow-up times. A reason for this observation could be that patients shift to a different outcome group during the observation period. METHODS: Before surgery and at the three follow-ups (3, 12, and 28 months after surgery) the Low Back Outcome Score was calculated. Groups with favorable and unfavorable outcome were determined after each follow-up according to the scores. RESULTS: Ninety-eight patients were studied. Forty percent showed an unstable outcome at different follow-up times. For each follow-up, three prognostic factors were determined. No prognostic factor showed significance at all follow-up examinations. CONCLUSIONS: Patients whose outcome after lumbar disc surgery does not remain stable present a major problem in the calculation of prognostic factors.

Validation of a LC method for the analysis of phenolic compounds from aqueous extract of Phyllanthus niruri aerial parts.

A reversed-phase high-performance liquid chromatographic separation and quantitative method using a phosphoric acid-acetonitrile gradient was developed to analyze phenolic compounds present in aqueous extract from the aerial parts of Phyllanthus niruri. The chromatographic method was validated for linearity, precision and accuracy for both reference substance (gallic acid) and for three well resolved peaks from P. niruri aqueous extract. Both calibration curves were linear with correlation coefficients higher than 0.999. The reproducibility for the three peaks ranged from 2.3% to 4.6% and the accuracy for gallic acid in the aqueous extract was 103%. The method allowed the complete resolution of three peaks, one of them was identified by diode array detection as gallic acid. The analysis of the botanic morphological elements of the aerial parts from P. niruri showed that the leaves have a higher amount of phenolic compounds than the branches.

Clinical signs in patients with brachialgia and sciatica: a comparative study.

BACKGROUND: The aim of the study was to compare the clinical signs of patients with cervical and lumbar root affections. METHODS: From January 1994 to January 1995, we performed a prospective study on 395 patients. The study comprised 93 patients with a cervical and 302 patients with a lumbar root affection. 338 patients underwent surgery. General data, case histories, and neurological findings were analyzed. RESULTS: The patients with brachialgia had a nonradicular pain radiation in 67%, the patients with sciatica only in 35%. All other data showed no significant differences. The investigation also shows that a radicular pain radiation is significantly correlated with an unequivocal radicular deficit. In particular, the patients with a cervical radicular pain radiation had a highly significant incidence of a radicular neurological deficit. CONCLUSIONS: We could demonstrate in this prospective study that only about one third of the patients with a cervical root affection showed an unequivocal radicular pain radiation. This contradicts the traditional medical textbook concept of a cervical root compression syndrome. This difference in respect of the clinical signs of lumbar and cervical root compressions might be explained by the anatomical variations of cervical root anastomoses. To determine the affected cervical root level, further investigation of the myotomes is recommended.

Brain ischemia detected by tissue-PO2 measurement and the lactate-oxygen index in head injury.

The aim of the study was to find out whether there is a correlation between the tissue-pO2 (ti-pO2) measurement and the lactate-oxygen index (mLOI). Both methods are to be considered as methods to detect brain ischemia. We studied 7 patients after severe head injury (GCS < 8) with a jugular bulb catheter and a tissue pO2 probe. Possible ischemia was defined with ti-pO2 below 10 mm Hg and mLOI above 0.08. 67 pairs of ti-pO2 and corresponding mLOI were found. In 5 cases out of the 7 cases with a ti-pO2 below 10 we found a pathological mLOI above 0.08. In 11 cases with pathological mLOI values, however, we found only 6 cases of decreased ti-pO2. The absolute values did not correlate. The sensitivity to predict normal values is above 85% with both methods. The specifity to predict ischemia is low (< 72%). The reason is the fact, that ti-pO2 is a local method in contrast to the mLOI values. In cases of diffuse brain injury without major contusions there should be a correlation between ti-pO2 and the mLOI.

Jugular bulb monitoring of cerebral oxygen metabolism in severe head injury: accuracy of unilateral measurements.

To investigate the accuracy of unilateral jugularvenous monitoring, we performed bilateral jugularvenous monitoring in 22 comatose head injured patients. Fiberoptic catheters were placed upstream in both internal jugular veins and advanced into the jugular bulbs. Arterial and bilateral jugularvenous blood samples were obtained simultaneously for in vitro determination of jugularvenous oxygen saturation (SJO2), arterial minus jugularvenous lactate content difference (AJDL) and modified lactate-oxygen-index (mLOI). Ischemia was assumed, if one of the following pathologies occurred at least unilaterally: SJO2 < 55%, AJDL < -0.37 mmol/L, mLOI > 0.08. The mean and maximum bilateral SJO2 differences varied between 1.4% to 21.0%, and 8.1% to 44.3% respectively. The bias and limits of agreement (mean differences +/- 2SD) between paired samples were -0.4% +/- 12.8%. Regarding AJDL bias and limits of agreement were -0.01 mmol/L +/- 0.18 mmol/L. At best 87% of defined ischemic events could be evaluated by monitoring at the side of predominant lesion or, in diffuse injuries, at the side of the larger jugular foramen in CT scan (CT approach). We conclude, due to the wide limits of agreement in bilateral SJO2 and AJDL the reliability of unilateral jugularvenous monitoring in patients with intracranial pathology is questionable. For diagnosing ischemia the CT approach has the highest sensitivity and is therefore recommended.

Microwave ablation of porcine kidneys in vivo: effect of two different ablation modes ("temperature control" and "power control") on procedural outcome.

PURPOSE: This study was designed to analyze the effect of two different ablation modes ("temperature control" and "power control") of a microwave system on procedural outcome in porcine kidneys in vivo. METHODS: A commercially available microwave system (Avecure Microwave Generator; MedWaves, San Diego, CA) was used. The system offers the possibility to ablate with two different ablation modes: temperature control and power control. Thirty-two microwave ablations were performed in 16 kidneys of 8 pigs. In each animal, one kidney was ablated twice by applying temperature control (ablation duration set point at 60 s, ablation temperature set point at 96°C, automatic power set point; group I). The other kidney was ablated twice by applying power control (ablation duration set point at 60 s, ablation temperature set point at 96°C, ablation power set point at 24 W; group II). Procedural outcome was analyzed: (1) technical success (e.g., system failures, duration of the ablation cycle), and (2) ablation geometry (e.g., long axis diameter, short axis diameter, and circularity). RESULTS: System failures occurred in 0% in group I and 13% in group II. Duration of the ablation cycle was 60±0 s in group I and 102±21 s in group II. Long axis diameter was 20.3±4.6 mm in group I and 19.8±3.5 mm in group II (not significant (NS)). Short axis diameter was 10.3±2 mm in group I and 10.5±2.4 mm in group II (NS). Circularity was 0.5±0.1 in group I and 0.5±0.1 in group II (NS). CONCLUSIONS: Microwave ablations performed with temperature control showed fewer system failures and were finished faster. Both ablation modes demonstrated no significant differences with respect to ablation geometry.

Dual-energy CT-cholangiography in potential donors for living-related liver transplantation: improved biliary visualization by intravenous morphine co-medication.

PURPOSE: To prospectively evaluate whether intravenous morphine co-medication improves bile duct visualization of dual-energy CT-cholangiography. MATERIALS AND METHODS: Forty potential donors for living-related liver transplantation underwent CT-cholangiography with infusion of a hepatobiliary contrast agent over 40 min. Twenty minutes after the beginning of the contrast agent infusion, either normal saline (n=20 patients; control group [CG]) or morphine sulfate (n=20 patients; morphine group [MG]) was injected. Forty-five minutes after initiation of the contrast agent, a dual-energy CT acquisition of the liver was performed. Applying dual-energy post-processing, pure iodine images were generated. Primary study goals were determination of bile duct diameters and visualization scores (on a scale of 0 to 3: 0--not visualized; 3--excellent visualization). RESULTS: Bile duct visualization scores for second-order and third-order branch ducts were significantly higher in the MG compared to the CG (2.9±0.1 versus 2.6±0.2 [P<0.001] and 2.7±0.3 versus 2.1±0.6 [P<0.01], respectively). Bile duct diameters for the common duct and main ducts were significantly higher in the MG compared to the CG (5.9±1.3 mm versus 4.9±1.3 mm [P<0.05] and 3.7±1.3 mm versus 2.6±0.5 mm [P<0.01], respectively). CONCLUSION: Intravenous morphine co-medication significantly improved biliary visualization on dual-energy CT-cholangiography in potential donors for living-related liver transplantation.

Super-micro-bland particle embolization combined with RF-ablation: angiographic, macroscopic and microscopic features in porcine kidneys.

PURPOSE: To describe angiographic, macroscopic and microscopic features of super-micro-bland particle embolization in combination with RF-ablation in kidneys. Thereby, a special focus was given on the impact of the sequence of the different procedural steps. MATERIALS AND METHODS: In ten pigs, super-micro-bland particle embolization combined with RF-ablation was carried out. Super-micro-bland embolization was performed with spherical particles of very small size and tight calibration (40 ± 10 µm). In the left kidneys, RF-ablations were performed before embolization (I). In the right kidneys, RF-ablations were performed after embolization (II). The animals were killed three hours after the procedures. Angiographic (e.g. vessel architecture), macroscopic (e.g. long and short axes of the RF-ablations) and microscopic (e.g. particle distribution) study goals were defined. RESULTS: Angiography detected almost no vessels in the center of the RF-ablations in I. In II, angiography could not define the RF-ablations. Macroscopy detected significantly larger long and short axes of the RF-ablations in II compared to I (52.2 ± 3.2 mm vs. 45.3 ± 6.9 mm [P<0.05] and 25.1 ± 3.5mm vs. 20.0 ± 1.9 mm [P<0.01], respectively). Microscopy detected irregular particle distribution at the rim of the RF-ablations in I. In II, microscopy detected homogeneous particle distribution at the rim of the RF-ablations. Microscopy detected no particles in the center of the RF-ablations in I and II. CONCLUSION: The sequence of the different procedural steps of super-micro-bland particle embolization combined with RF-ablation impacts angiographic, macroscopic and microscopic features in kidneys in the acute setting.

Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961.

Twenty patients with an epidural haematoma of the posterior fossa (EPIPF) among a total number of 359 patients with an epidural haematoma are reported (5.6%). Nine patients obtained a good outcome, four patients had a moderate disability and seven patients died (mortality 35%). Mortality of the acute cases was 50%, of the subacute cases 20%. In general, the clinical features were uncertain. Sixteen cases showed an occipital skull fracture or diastasis of the lambdoid suture respectively. A total number of 127 cases with EPIPF from the literature since 1961 was studied. The mortality in the CT-diagnosed group ran to 21.7% and to 25.9% in the group without CT. None of the patients showing a subacute course died when the diagnosis was made by CT, in the group without CT, however, four patients out of 11 subacute cases died. Head injured patients with an occipital trauma should therefore undergo CT scanning to detect a surgically significant lesion before clinical deterioration occurs.

Cerebral blood flow and cerebrovascular reserve 5 years after EC-IC bypass.

CBF-studies using the Xenon-133-inhalation technique were performed in 18 patients with a unilateral carotid artery occlusion, 5.4 years after a STA-MCA procedure. For comparison we used the CBF data of 29 patients with the same diseases who had had conservative treatment for a variable period of time. CBF was measured during rest and after the intravenous administration of 1 g acetazolamide. During rest we found a significant interhemispheric difference in both groups. After activation with acetazolamide this difference disappeared in the bypass group, but not in the conservatively treated patients. Our data show that the bypass procedure obviously affects the vascular reserve capacity in a positive way over a long period of time. One criteria for success of STA-MCA procedures might be the cerebral reserve capacity tested with CBF-studies under activation.