[Pain management in subarachnoid haemorrhage: a survey of French analgesic practices]. / Prise en charge des céphalées secondaires aux hémorragies sous-arachnoïdiennes dans les centres de neurochirurgie français.

OBJECTIVE: Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres. STUDY DESIGN: Nationwide survey. METHODS: A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management. RESULTS: Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS. CONCLUSION: The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.

Altered capillary permeability in neurogenic pulmonary oedema.

Two cases of fatal neurogenic pulmonary oedema are depicted. The hemodynamic study failed to document any hypertensive crisis or pulmonary hypertension. By contrast, the low values of pulmonary capillary wedge pressures and the high protein concentration in tracheal fluid suggest a pulmonary capillary wall lesion.

Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils.

BACKGROUND AND PURPOSE: We describe four cases of aneurysmal rupture during embolization with Guglielmi electrodetachable coils (GDCs) in an attempt to identify those aneurysms whose rupture during embolization represents a life-threatening risk; our emphasis is on emergency management, in particular, ventriculostomy. METHODS: Medical records were reviewed retrospectively for 91 aneurysms treated with GDCs 0 to 21 days after subarachnoid hemorrhage. Rupture was ascertained by the presence of extravascular effusion of contrast medium. RESULTS: Of the perforated aneurysms, two involved the anterior communicating artery, one the posterior inferior communicating artery, and one the basilar artery. Only two patients, whose aneurysms were located in the posterior fossa, had major complications (arterial hyperpressure, mydriasis, angiographically documented circulatory arrest or slowing). One of these patients died and the other improved after emergency ventriculostomy. CONCLUSION: Aneurysmal perforation during embolization may be accompanied by severe intracranial hypertension, which causes either a decrease or arrest of cerebral perfusion, the duration of which determines clinical outcome. Emergency ventriculostomy (which should be performed in the angiographic suite) is an effective means to reduce intracranial pressure. Recognition of aneurysms associated with a high risk of mortality by rupture in the course of embolization (recently ruptured small aneurysms, posterior fossa aneurysms, associated ventricular dilatation, massive cisternal hemorrhage) and use of proper logistics should ensure the effective management of this devastating complication.

A technique for stereotactic aspiration of deep intracerebral hematomas under computed tomographic control using a new device.

A new device, modified from the Nucleotome (Surgical Dynamics, Alameda, CA), was used for stereotactic aspiration of deep brain hematomas. Real-time monitoring by computed tomography allows a very safe procedure, and the risk of aspirating the surrounding brain is avoided. The technique was applied in 13 cases of deep brain hematomas. The intraoperative computed tomographic scan demonstrated that the mass effect was always immediately improved. Aspiration was stopped when the midline shift disappeared or was dramatically reduced. For most of the cases, a total aspiration of the hematoma was not needed (mean value of the aspiration rate of 71, 5%). No rebleeding and no complication related to the technique was observed. This technique was easily performed in emergency conditions.

Endoscopic management of colloid cysts.

OBJECTIVE: Several surgical approaches have been proposed for the treatment of colloid cysts, which still remains controversial. The most recent technique used is endoscopy. By its nature, endoscopy cannot offer complete removal, as compared to microsurgical techniques, but can do more than puncture. To evaluate the usefulness of endoscopy for colloid cyst surgery, a series of 15 patients who were operated on for colloid cysts under endoscopic control since 1994 was reviewed. METHODS: The presenting symptoms of our patients (10 men and 5 women) were intermittent headache (10 patients), nausea (3 patients), short-term memory loss (4 patients), coma (2 patients), gait disturbance (3 patients), blurred vision (2 patients), and mental status changes (3 patients). The sizes of the cysts ranged from 4 to 50 mm (median, 22.93 mm). Depending on the radiological appearance, the procedure was performed via a right (10 patients) or left (5 patients) precoronal burr hole. A rigid neuroendoscope was used. Initial stereotactic placement of the neuroendoscope was used in two patients who had moderate hydrocephalus. In the other patients, hand-guided endoscopy was performed using an articulated arm. The cysts were perforated with a needle. The opening was enlarged with microscissors. The cyst material was aspirated, and the remaining capsule was coagulated. RESULTS: The average follow-up was 15.26 months (range, 1-28 mo). Total aspiration of the cysts was achieved in 12 patients, as revealed by normal postoperative magnetic resonance imaging. Control magnetic resonance imaging revealed residual cysts in three patients. One patient presented with an asymptomatic recurrence at 1 year. Resolution of the symptoms was obtained in all patients except for two of the four patients with preoperative memory deficit (improvement without complete recovery). There was no mortality or morbidity. CONCLUSION: These results show that endoscopy is a safe and promising percutaneous technique for the treatment of colloid cysts of the third ventricle. Longer follow-up is, however, still required.

Changes in cerebral blood flow during PaCO2 variations in patients with severe closed head injury: comparison between the Fick and transcranial Doppler methods.

OBJECT: The aim of this study was to reassess whether middle cerebral artery blood flow velocity (MCAv) variations measured by transcranial Doppler ultrasonography during acute PaCO2 manipulation adequately reflect cerebral blood flow (CBF) changes in patients with severe closed head injury. METHODS: The study was performed by comparing MCAv variations to changes in CBF as assessed by measurements of the difference in the arteriovenous content in oxygen (AVDO2). The authors initiated 35 CO2 challenges in 12 patients with severe closed head injury during the acute stage. By simultaneous recording of systemic and cerebral hemodynamic parameters, 105 AVDO2 measurements were obtained. Patients were stratified into two groups, "high" and "low," with respect to whether their resting values of MCAv were greater than 100 cm/second during moderate hyperventilation. Four patients displayed an elevated MCAv, which was related to vasospasm in three cases and to hyperemia in one case. The PaCO2 and intracranial pressure levels were not different between the two groups. The slope of the regression line between 1 divided by the change in (delta)AVDO2 and deltaMCAv was not different from identity in the low group (1/deltaAVDO2 = 1.08 x deltaMCAv - 0.07, r = 0.93, p < 0.001) and significantly differed (p < 0.05) from the slope of the high group (1/deltaAVDO2 = 1.46 x deltaMCAv - 0.4, r = 0.83, p < 0.001). CONCLUSIONS: In patients with severe closed head injury, MCAv variations adequately reflect CBF changes as assessed by AVDO2 measurements in the absence of a baseline increase in MCAv. These observations indicate that both moderate variations in PaCO2 and variations in cerebral perfusion pressure do not act noticeably on the diameter of the MCA. The divergence from the expected relationship in the high group seems to be due to the heterogeneity of CO2-induced changes in cerebrovascular resistance between differing arterial territories.

Ruptured fusiform aneurysm of the superior third of the basilar artery associated with the absence of the midbasilar artery. Case report.

A case involving the absence of the midthird portion of the basilar artery (BA) associated with a ruptured fusiform aneurysm of the superior third of the basilar artery discovered after a subarachnoid hemorrhage is reported. Surgical clipping was precluded by the anatomical conditions. The aneurysm was treated by occlusion (surgical clipping and balloon occlusion) of both posterior communicating arteries to decrease the hemodynamic stress on the aneurysm wall. The pericerebellar arterial network was allowed to supply the distal BA and its collateral vessels indirectly. This treatment proved to be efficient; angiography and magnetic resonance imaging demonstrated shrinkage of the aneurysm cavity. The absence of the midthird of the BA is usually associated with a persisting trigeminal artery (nonexistent in this case) or disclosed in cases of acute BA occlusion in dramatic clinical conditions. A similar anatomical feature has been described only once before. There may be a segmental maldevelopment of the longitudinal neural arteries during embryogenesis or a defect in fusion of these paired structures during the development of the BA itself.

[96 cases of spontaneous medical cerebral hemorrhage. Diagnostic and therapeutic experience]. / Quatre-vingt-seize cas d'hémorragie cérébrale médicale spontanée. Expérience diagnostique et thérapeutique.

Prognosis in a homogeneous series of 96 cases of non-traumatic cerebral hemorrhage admitted to a neurosurgical department within 6 to 24 hours of onset was assessed by studying possible correlations between clinical condition (grade I: conscious; grade II: somnolent; grade III: comatose; grade IV: comatose with signs of brain stem involvement) and computed tomography findings (site, extension, size of hemorrhage; degree of edema and of mass effect; presence of hydrocephalus or ventricular hemorrhage). It was possible to distinguish effects due to destruction and/or compression of functional cerebral regions for a given clinical picture, and to apply these data to determine types of therapy and surveillance according to 3 time-periods. During the first 48 hours there was almost perfect agreement between the severity of the clinical picture and the degree of cerebral destruction (62,6 p. 100 of grade IV, 27,7 p. cent of grade III died). Only patients in grade III with temporal hemorrhage directly menacing the brain stem were operated upon. From the 3rd to the 7th day surveillance was based on clinical findings and computed tomography, repeated in principle on the 3rd and 7th days. Patients operated upon during this period were those in whom clinical signs and/or effects due to mass effect as seen on the CTscan were becoming worse. The third period, lasting from the 8th to the 21st day, was that during which the vital prognosis was generally no longer affected, and indications for surgery were functional in nature. The prognostic value of measurements of intracranial pressure is discussed.

[Pathophysiology and principles of treatment of vasospasm]. / Physiopathologie et principes de traitement du vasospasme.

The exact mechanism of vasospasm is still unknown. The etiology of cerebral vasospasm is subarachnoid blood clot. Vasospasm is a multifactorial process. Oxyhemoglobin is released by erythrocyte lysis and exert several effects on the endothelium that could lead to vasoconstriction. The production of free radical and superoxide anion radical secondary to hemoglobin degradation stimulates the release of vasoconstricting products. Arterial vasoconstriction secondary to smooth muscle contraction could be related to increase in protein kinase C. Narrowing of cerebral vessels produces cerebral ischemia by hemodynamic mechanisms. Direct hypothalamic insults may be associated. Clot removal and clot lysis have been proposed to prevent vasospasm. Pharmacological treatments are targeted to the vasospasm itself (nicardipine, AT 877) or the prevention of delayed ischemic events (nimodipine, tirilazad). General measures such as the "triple H therapy" (hemodilution, hypertension, hypervolemia) are widely used in the prevention and/or treatment of cerebral vasospasm.

Anatomy-computerized tomography correlations in transtentorial brain herniation.

The diagnosis of transtentorial brain herniation has long relied on encephalography, then arteriography. Computerized tomography (CT) is a safer method which permits a more precise and earlier visualization of temporal and central herniations and herniation of the culmen cerebelli, which are the three varieties of transtentorial herniation. In an attempt to evaluate the reliability of CT images of herniation, the authors have conducted a study of anatomy-CT correlations, using autopsy specimens of brains with these three types of transtentorial herniation. Temporal herniation was well studied, irrespective of the CT reference plane. Direct visualization of temporal uncus herniation and filling of the homolateral perimesencephalic cistern was regularly obtained. Central herniation was better visualized when the occipito-temporal plane was used as reference. The disappearance of perimesencephalic cisterns on CT sections through the widest part of the tentorial incisura is the best element of diagnosis. Herniation of the culmen is easily studied on the conventional orbito-meatal plane. Provided CT scans are performed with the technique they recommend, the authors consider that this examination is reliable for the diagnosis of transtentorial herniation. Some variations in the anatomy of the incisura may explain why the clinical consequences of herniation are varied. CT perfectly shows the configuration of this notch and therefore may be helpful in predicting the prognosis.

[Cerebral-vein thrombosis: retrospective study of twenty seven cases]. / Thrombophlébite cérébrale: étude rétrospective de vingt-sept cas.

PURPOSE: Among the locations of venous thrombosis, even if rare, cerebral-vein thrombosis is a severe event with a high mortality rate. No aetiology is found in 20 to 30% of the cases. In recent years, inherited coagulation disorders have been described, as risk factors for venous thrombosis. We report the results of a retrospective study of 27 patients who suffered cerebral-vein thrombosis, in which coagulation abnormalities have been searched for. METHOD: The patients were referred to the haemostasis laboratory of the Henri Mondor hospital between august 1982 and June 1988, after a cerebral-vein thrombosis. The predisposing factors, personal and family history of thromboembolism, clinical presentation, thrombosis location, evolution under treatment and long-term outcome, have been noted. Deficiencies in antithrombine, protein C, protein S, the Factor V Leiden and the G20210A prothrombin-gene mutation, the presence of lupus anticoagulant, of anticardiolipin antibodies as well as a hyperhomocysteinaemia have been searched, either at the initial presentation, or a posteriori. RESULTS: Fourty-one percent of patients had a coagulation abnormality. The prevalence of the different abnormalities was: inherited deficiency in AT 7.4%, in PC 8%, in PS 12.5%, factor V Leiden mutation 12%, G20210A prothrombin-gene mutation 12%. Two patients had combined defects: AT and PC deficiency in one, F V Leiden and F II G20210A mutations in one. e of the patient had lupus anticoagulant. Three patients had a significant rate of anticardiolipin antibodies. Five patients out of eight displayed a moderate hyperhomocysteinaemia. Nothing (past history, age, predisposing factors) distinguished those patients bearing a coagulation disorder from the others. The venous thromboembolic relapse rate of 15 % (4/27 patients). Three of them had an inherited thrombophilic abnormality. CONCLUSION: We recommend an investigation of the haemostasis after every cerebral venous thrombosis.

[Correlations between anatomy and computerized tomography findings in transtentorial cerebral herniation]. / Corrélations anatomo-scanographiques dans les engagements cérébraux transtentoriels.

The diagnosis of transtentorial brain herniation has long relied on encephalography, then arteriography. Computerized tomography (CT) is a safer method which permits a more precise and earlier visualization of temporal and central herniations and herniation of the culmen cerebelli, which are the three varieties of transtentorial herniation. In an attempt to evaluate the reliability of CT images of herniation, the authors have conducted a study of anatomy-CT correlations, using autopsy specimens of brains with these three types of transtentorial herniation. Temporal herniation was well studied, irrespective of the CT reference plane. Direct visualization of temporal uncus herniation and filling of the homolateral perimesencephalic cistern was regularly obtained. Central herniation was better visualized when the occipito-temporal was used as reference. The disappearance of perimesencephalic cisterns on CT sections through the widest part of the tentorial incisura is the best element of diagnosis. Herniation of the culmen is easily studied on the conventional orbito-meatal plane. Provided CT scans are performed with the technique they recommend, the authors consider that this examination is reliable for the diagnosis of transtentorial herniation. Some variations in the anatomy of the incisura may explain why the clinical consequences of herniation are varied. CT perfectly shows the configuration of this notch and therefore may be helpful in predicting the prognosis.

[Indications for monitoring intracranial pressure]. / Indications du monitorage de la pression intracrânienne.

A main indication for intracranial pressure monitoring is severe head trauma, where it acts as a diagnostic, prognostic and therapeutic guide. Others indications for intracranial pressure monitoring are patients with CSF circulation disturbances, whatever the cause, and various pathologies inducing intracranial hypertension, such as encephalopathies. Intracranial pressure monitoring must be associated with the measurement of mean arterial pressure, arterial and jugular venous oxygen saturation and blood flow velocity in major intracranial arteries with transcranial Doppler sonography.

[Pharmacological treatment of vasospasm in subarachnoid hemorrhage]. / Traitement pharmacologique du vasospasme de l'hémorragie sous-arachnoïdienne.

Pharmacological treatment of vasospasm in subarachnoid haemorrhage (SAH) is founded on prevention and treatment of arterial narrowing and delayed ischaemic deficits. Safety and efficacy of different agents have been studied and trials classified according to the level of evidence proposed by the "Stroke Council" of the American Heart Association. Early intracisternal fibrinolysis can prevent vasospasm (level III to V of evidence, grade C). Pharmacological treatment is based on few drugs. Nimodipine reduces poor outcome related to vasospasm, but does not affect angiographic vessel caliber (level of evidence I and II, grade A). Its use is strongly recommended. Nicardipine decreases symptomatic and angiographic vasospasm, but does not affect outcome (level of evidence I to V, grade B). Tirilazad associated with nimodipine prevents delayed ischaemic deficits due to vasospasm and improves outcome in male patients. Intra-arterial infusion of papaverine associated with transluminal angioplasty can improve symptomatic vasospasm, resistant to conventional therapy (level of evidence IV to V, grade C). Pharmacological treatment of vasospasm associated with specific management founded on pathophysiology of SAH has improved patients outcome.

[Anesthesia for thalamic stimulations: value of flumazenil]. / Anesthésie pour stimulations thalamiques: intérêt du flumazénil.

Five cases are reported of peroperative awakening in order to obtain patient cooperation during stereotaxic procedures. General anaesthesia was induced with 0.25 mg.kg-1 midazolam, 1.5 to 2 micrograms.kg-1 fentanyl, and 0.1 mg.kg-1 vecuronium. Maintenance was obtained with isoflurane, nitrous oxide, and small doses of fentanyl. Isoflurane inhalation was discontinued 30 to 40 min before the time of awakening required by surgery. Once expiratory isoflurane concentration reached a level less than or equal to 0.1%, nitrous oxide administration was stopped, and 0.5 mg flumazenil administered. After surgical checking, on the fully awake patient of the efficiency of thalamic stimulation and the lack of any motor deficit, anaesthesia was deepened again, with either isoflurane or a non benzodiazepine intravenous agent. All five patients recovered rapidly and calmly.

[Cranial traumatology. Recent statistical data]. / Traumatologie crânienne. Données statistiques récentes.

The authors describe a one-year prospective study carried out in Créteil from October, 1983 to October, 1984 in 155 selected patients admitted for at least 24 hours with traumatic head injury. Patients with gunshot wounds of the head were excluded from the study. 30% of the patients were infants, 60% were adults aged between 15 and 60, and 5% were over 60; 48% were not comatose (initial Glasgow symptomatic score [GSC] greater than or equal to 8) and 36% were free of any neurological symptom. Prognosis was related to the initial neurological status, to the patient's age and to underlying diseases, such as alcoholism. 10 out of 11 patients with an initial GSC of 4 or less died, against 12 out of 144 with a GSC above 5. At the first CT scan, 10% were found to have an extradural haematoma, but the examination was normal in 20% of patients with neurological symptoms and/or coma; 22% of the CT scans were abnormal without any clinical symptom, as was the case, in particular, with 4 extradural haematomas. Surgery was performed in 24% of all patients and in 17.4% of infants, whereas the percentage reached 30% in alcoholic patients, due to the frequency of intracerebral haematomas in this population. In 16% of the 155 cases, barbiturates were used to treat uncontrolled intracranial pressure higher than 20 mmHg. 15% of the 155 patients deteriorated; a second operation was necessary in 9 cases. The final outcome on discharge was: 112/155 patients with good recovery or moderate disability, 22 with severe disability, 5 with persistent vegetative state and 21 deaths.

[Treatment of severe head injuries by external ventricular drainage and barbiturate therapy. Mortality and morbidity in 57 cases (author's transl)]. / Traumatismes cranio-cérébraux avec signes précoces de souffrance axiale. Traitement par drainage ventriculaire externe et barbituriques. Mortalité et morbidité d'une série de 57 cas.

After severe head injury the majority of deaths, during the early period, is due to acute intracranial hypertension. We report a series of 57 severe head injuries with early signs of brainstem involvement. CT Scan performed within 6 hours after injury and repeated at 48 hours showed hemispheric lesions and edema, without shift of the middle line. Treatment consisted of controlled ventilation, water and sodium restriction and barbiturates. A ventricular catheter was inserted in 52 patients allowing intracranial pressure (I.C.P.) monitoring, and permanent subtraction of cerebrospinal fluid (C.S.F.). This treatment allowed the control of a normal I.C.P. in 80% of the patients. In 6 patients a secondary surgical treatment was performed. In this series the mortality rate was 31,5% the good results and moderate disability 54,3%, the severe disability and vegetatives states 14,2%.

[Functional prognosis in skull injuries with signs of axial damage. Value of the quality of the arousal phase (series of 80 cases)]. / Le pronostic fonctionnel du traumatisme crânien avec signes de souffrance axiale. Valeur de la qualité de la phase d'éveil (série de 80 cas).

In a series of 80 diffuse brain injuries with early clinical signs of brainstem dysfunction without shift of the midline on the first CT SCAN investigation; the authors have studied the time course of recovery. Among several neurological parameters, they have choosen two steps: first one the spontaneous opening of the eyes, which marks a restoration of vigilance, second one the capacity to execute simple commands which marks the end of unconsciousness). The duration of the period of recovery (delta) (between the eyes opening and the obays commands) was variable from 0 to 173 days. But it was a good statistic correlation (p less than 0,001) between the length of this period and the functional outcome at one year.

Trace elements and metals in farmed sea bass and gilthead bream from Tenerife Island, Spain.

The aim of this study was to determine the levels of metals (Ca, K, Na, Mg) and trace metals (Ni, Fe, Cu, Mn, Zn, Pb, Cd) in two fish species (gilthead bream [Sparus aurata] and sea bass [Dicentrarchus labrax]) collected from fish farms located along the coast of Tenerife Island. Ca, K, Na, Mg, Fe, Cu, Zn, and Mn were measured by flame atomic absorption spectrometry, whereas Pb, Cd, and Ni were determined using graphite furnace atomic absorption spectrometry. Mean Fe, Cu, Mn, and Zn contents were 3.09, 0.59, 0.18, and 8.11 mg/kg (wet weight) in S. aurata and 3.20, 0.76, 0.24, and 10.11 mg/kg (wet weight) in D. labrax, respectively. In D. labrax, Ca, K, Na, and Mg levels were 1,955, 2,787, 699.7, and 279.2 mg/kg (wet weight), respectively; in S. aurata, they were 934.7, 3,515, 532.8, and 262.8 mg/kg (wet weight), respectively. The Pb level in S. aurata was 7.28 ± 3.64 µg/kg (wet weight) and, in D. labrax, 4.42 ± 1.56 µg/kg (wet weight). Mean Cd concentrations were 3.33 ± 3.93 and 1.36 ± 1.53 µg/kg (wet weight) for D. labrax and S. aurata, respectively. All Pb and Cd levels measured were well below the accepted European Commission limits, 300 and 50 µg/kg for lead and cadmium, respectively.