Pulmonary function and radiographic abnormalities related to neurological outcome after aneurysmal subarachnoid hemorrhage.

OBJECT: This observational study is based on a consecutive series of 207 patients with aneurysmal subarachnoid hemorrhage who were treated within 7 days of their most recent bleed. The purpose of the study was to evaluate the effect of respiratory failure on neurological outcome. METHODS: Pulmonary function was assessed by determination of parameters describing pulmonary oxygen transport and exchange, by using composite scores for quantification of lung injury (lung injury score [LIS]) and mechanical ventilator settings (PIF score). Pulmonary function was related to the Hunt and Hess (H & H) grade assigned to the patient at hospital admission (p < 0.001). The pattern and time course of lung injury differed significantly between patients with H & H Grade I or II, Grade III, and Grade IV or V. Hunt and Hess grade, Fisher computerized tomography grade, intracranial pressure, cerebral perfusion pressure, LIS, ratio of PaO2 to the fraction of inspired oxygen (FiO2), and the ratio of the alveolar-minus-arterial oxygen tension difference (AaDO2) to FiO2 were related to neurological outcome (p < 0.001). The LIS on the day of maximum lung injury remained an independent predictor of outcome (p = 0.01) in a stepwise logistic regression analysis. The probability of poor neurological outcome significantly increased with both decreasing cerebral perfusion pressure and increasing severity of lung injury. CONCLUSIONS: The overall mortality rate was 22.2% (46 of 207 patients). Subarachnoid hemorrhage and its neurological sequelae accounted for the principal mortality in this series. Medical (nonneurological and nontreatment-related) complications accounted for 37% of all deaths. Systemic inflammatory response syndrome with associated multiple organ dysfunction syndrome was the leading cause of death from medical complications. The authors conclude that respiratory failure is related to neurological outcome, although it is not commonly the primary cause of death from medical complications.

Spiral CT angiography with digital subtraction of extra- and intracranial vessels.

OBJECTIVE: A new imaging modality is presented in which a digital subtraction algorithm is applied to spiral CT angiography of extra- and intracranial vessels. MATERIALS AND METHODS: Spiral CT angiography was carried out in 26 patients. When this was done for stereotactic purpose before radiosurgery, a Leksell stereotactic frame was used; in the other cases an atraumatic fixation system was applied. Spiral CT data were acquired twice--before and after contrast agent administration. Then, computerized subtraction of the density values of plain CT from the topographically corresponding enhanced CT was performed. Maximum intensity projection was used to visualize the vessels. RESULTS: This method provided significant effacement of nonvascular structures and a considerably improved visualization of extracranial as well as intracranial vessels could be achieved. In some conditions, e.g., to exclude a suspected thrombotic occlusion of the basilar artery, conventional angiography could even be omitted. CONCLUSION: Adequate visualization of extra- and intracranial vessels is possible with spiral CT angiography and digital subtraction. An important scope of this modality could be its contribution to radiosurgical planning and the follow-up after radiotherapy. In some conditions, CT subtraction angiography may possibly supersede conventional subtraction angiography.

[Ischemic stroke: new therapeutic possibilities]. / Der Schlaganfall: Neue Therapiemöglichkeiten.

Recent randomized placebo-controlled studies have introduced new concepts in the therapy of acute ischemic stroke, such as thrombolysis either with intraarterial or intravenous administration, lowering of the level of fibrinogen or administration of aspirin. High dosis of heparin may be useful only in certain groups of patients. Stroke units proved to be effective in the acute care of stroke patients. Further advances are achieved by the introduction of new anti-platelet drugs in secondary stroke prevention and by precise definitions of the criteria for carotid surgery.

[Complications of radical operation of uterine cancer. Closure of the peritoneal defects--yes or no?]. / Komplikationen nach Radikaloperation der Uteruskarzinome. Verschluss der Peritonealdefekte--ja oder nein?

The case reports of 70 patients (including 12 cases of endometrial carcinoma operated by the same method) were evaluated for postoperative complications such as pathological changes in the iv-pyelograms, incidence of haemorrhage or haematomas at the operation site, and for the frequency of lymphatic cysts. In addition, the amount of secretion and the duration of drainage were recorded. In 26 patients, the wounds of the parietal peritoneum were sutured, in 44 women, the pelvic peritoneum was left open after primary occlusion of the vaginal vault. If the two groups are compared with respect to the incidence of complications, the results are: pathologic postoperative ivP: 3.4:1; haemorrhage or haematomas: 5:1; lymphatic cysts: 1.6:1. The duration of drainage was almost the same in both groups (1.1:1), but the amount of liquid drained was less in the peritonealised group (0.5:1). These data and the fact, that the overall morbidity in the "open peritoneum" group was significantly lower, leads us to recommend strongly that leaving the pelvic peritoneum open provides evident advantages compared with the traditional procedure. In addition, a marked reduction of the operation time is achieved. Negative consequences, such as postoperative ileus, did not occur.

Delayed visual deterioration after surgery for pituitary adenoma.

Despite its description in the literature there remains uncertainty about the incidence, the pathophysiological basis and the best management of a delayed visual deterioration in the presence of an empty sella after surgery for pituitary adenomas. Out of a series of 501 patients with pituitary adenomas operated on at our institution between 1984 and 1996, four patients (0.8%) developed a worsening of their visual function 3 to 37 months after surgery in the absence of tumour recurrence. None of the patients had received radiotherapy. Magnetic resonance imaging (MRI) ruled out compression by tumour and showed herniation of suprasellar structures into an empty sella. In three cases re-operation by a subfrontal approach with freeing of the optic structures from tethering scar tissue led to an improvement of visual deficits. In one case a spontaneous recovery was initiated by a minor head injury. Although apparently a rare event, our cases provide evidence for the occurrence of a potentially reversible delayed deterioration of visual function after surgery for pituitary adenomas. Based on our operative findings and our outcome we recommend re-operation by a transcranial approach in patients in whom repeated ophthalmological testing does not show spontaneous improvement within a short period of time.

Magnetic resonance angiography and selective angiography following extra-intracranial bypass operations.

Magnetic resonance angiography (MRA) was compared with conventional angiography in 14 patients following extra-intracranial arterial anastomosis. In 13 patients the bypass was shown by MRA and confirmed by conventional angiography. In five of these, the anastomosed vessels, in particular the superficial temporal artery, was of the same calibre or smaller than the same vessels on the contralateral, healthy side. In one patient no anastomosis could be shown by MRA, and occlusion of the bypass was confirmed by conventional angiography. Absence of dilatation of the anastomotic vessels may indicate insufficient bypass function due to stenosis or an incorrect indication for surgery.

Tumour blood flow and partition coefficients: correlation with grade of cerebral gliomas using xenon-enhanced computed tomography.

It is possible to underestimate the grade of nonenhancing cerebral tumours on conventional contrast-enhanced MRI or CT. Differentiation of high- and low-grade gliomas by measurement of the brain-blood partition coefficient lambda (T lambda) with Xe-enhanced CT (XeCT) has been reported. We assessed the practical applications of XeCT in suspected low-grade astrocytomas. We examined 15 patients with tumours which showed no contrast enhancement on conventional MRI and CT, using XeCT. Tumour blood flow (TBF) and T lambda were calculated. Fourteen patients underwent surgery, one patient had a biopsy. We recognized three histological groups. While T lambda differed significantly between them, TBF did not. Group 1 contained grade II-III astrocytomas and T lambda was 0.77; group 2 contained grade I-II astrocytomas with T lambda 1.14, and group 3 four oligodendrogliomas in which a T lambda of 1.50 was found.

Cavernous malformations: from frame-based to frameless stereotactic localization.

An exact surgical approach to cavernous malformations, in particular those located in areas of critical brain function, is important for their microsurgical resection without putting too much strain on the patient. During a two-year period, 29 cavernoma resections were performed. Stereotactic guidance was performed in 16 cases (55.2%). Nine cavernomas located in the supratentorial region were resected using the stereotactic operating microscope "MKM", which represents 21.6% of a total of 51 MKM-navigated operations; in one further case system referencing failed. The experience gathered with this frameless stereotactic system is compared to a retrospective analysis of 5 frame-based stereotactic cavernoma localizations. Frameless stereotactic localization has been shown to be sufficiently accurate but more advantageous than frame-based techniques in terms of utility, ease of integration, and detailed image-guided anatomical information. Software improvements have resulted in a high stability of the frameless stereotactic system.

[Acute symptom transverse laminectomy for a benign osteoclastoma of thethoracic spine--case report and review of the literature]. / Akute Querschnittsymptomatik durch benignes Osteoklastom der Brustwirbelsäule--Falldarstellung und Literaturübersicht.

Benign osteoclastomas of the spine above the sacrum are uncommon lesions. Acute paraparesis as the presenting sign of disease is unusual and rarely described in the literature. We report on the case of a 41 yrs old male who underwent acute T3-5 laminectomy for spinal cord decompression from a T4 expansive mass lesion with locally destructive growth. Although a malignant lesion was suspected, definitive histologic examination disclosed a benign osteoclastoma. Therefore, elective trans-thoracic total vertebrectomy T4 with ventral stabilization was performed to allow for marginal total resection of the tumor and reconstruction of the spine. Twenty-four months after the procedure the patient has made a good neurologic recovery with no evidence of tumor recurrence.