RESUMEN
BACKGROUND AND PURPOSE: Increased CSF stroke volume through the cerebral aqueduct has been proposed as a possible indicator of positive surgical outcome in patients with idiopathic normal pressure hydrocephalus; however, consensus is lacking. In this prospective study, we aimed to compare CSF flow parameters in patients with idiopathic normal pressure hydrocephalus with those in healthy controls and change after shunt surgery and to investigate whether any parameter could predict surgical outcome. MATERIALS AND METHODS: Twenty-one patients with idiopathic normal pressure hydrocephalus and 21 age- and sex-matched healthy controls were prospectively included and examined clinically and with MR imaging of the brain. Eighteen patients were treated with shunt implantation and were re-examined clinically and with MR imaging the day before the operation and 3 months postoperatively. All MR imaging scans included a phase-contrast sequence. RESULTS: The median aqueductal CSF stroke volume was significantly larger in patients compared with healthy controls (103.5 µL; interquartile range, 69.8-142.8 µL) compared with 62.5 µL (interquartile range, 58.3-73.8 µL; P < .01) and was significantly reduced 3 months after shunt surgery from 94.8 µL (interquartile range, 81-241 µL) to 88 µL (interquartile range, 51.8-173.3 µL; P < .05). Net flow in the caudocranial direction (retrograde) was present in 11/21 patients and in 10/21 controls. Peak flow and net flow did not differ between patients and controls. There were no correlations between any CSF flow parameters and surgical outcomes. CONCLUSIONS: Aqueductal CSF stroke volume was increased in patients with idiopathic normal pressure hydrocephalus and decreased after shunt surgery, whereas retrograde aqueductal net flow did not seem to be specific for patients with idiopathic normal pressure hydrocephalus. On the basis of the results, the usefulness of CSF flow parameters to predict outcome after shunt surgery seem to be limited.
Asunto(s)
Acueducto del Mesencéfalo/fisiopatología , Hidrocéfalo Normotenso/líquido cefalorraquídeo , Hidrocéfalo Normotenso/cirugía , Anciano , Derivaciones del Líquido Cefalorraquídeo , Femenino , Humanos , Hidrocéfalo Normotenso/fisiopatología , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND AND PURPOSE: MR imaging is used in the diagnostic evaluation of patients with idiopathic normal pressure hydrocephalus. The aim of this study was to describe the prevalence of several imaging features and their prognostic use in the selection of shunt candidates with idiopathic normal pressure hydrocephalus. MATERIALS AND METHODS: Preoperative MR imaging scans of the brain were retrospectively evaluated in 108 patients with idiopathic normal pressure hydrocephalus who had undergone a standardized, clinical evaluation before and 12 months after shunt surgery. The MR imaging features investigated were the Evans index, callosal angle, narrow sulci at the high convexity, dilation of the Sylvian fissure, diameters of the third ventricle and temporal horns, disproportionately enlarged subarachnoid space hydrocephalus, flow void through the aqueduct, focal bulging of the roof of the lateral ventricles, deep white matter hyperintensities, periventricular hyperintensities, and focal widening of sulci and aqueductal stenosis. RESULTS: In logistic regression models, with shunt outcome as a dependent variable, the ORs for the independent variables, callosal angle, disproportionately enlarged subarachnoid space hydrocephalus, and temporal horns, were significant (P < .05), both in univariate analyses and when adjusted for age, sex, and previous stroke. CONCLUSIONS: A small callosal angle, wide temporal horns, and occurrence of disproportionately enlarged subarachnoid space hydrocephalus are common in patients with idiopathic normal pressure hydrocephalus and were significant predictors of a positive shunt outcome. These noninvasive and easily assessed radiologic markers could aid in the selection of candidates for shunt surgery.
Asunto(s)
Derivaciones del Líquido Cefalorraquídeo , Hidrocéfalo Normotenso/diagnóstico , Hidrocéfalo Normotenso/cirugía , Anciano , Anciano de 80 o más Años , Acueducto del Mesencéfalo/anomalías , Acueducto del Mesencéfalo/patología , Dilatación Patológica , Femenino , Enfermedades Genéticas Ligadas al Cromosoma X , Humanos , Hidrocefalia , Hidrocéfalo Normotenso/patología , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Selección de Paciente , Pronóstico , Espacio Subaracnoideo/patologíaRESUMEN
OBJECTIVES: The cerebrospinal fluid (CSF) infusion test is frequently used when selecting hydrocephalus patients for shunt surgery. Very little has been reported regarding adverse events. We present a prospective feasibility study. METHODS: Standardized devices for measuring CSF dynamics were built and 562 patients investigated: Needles were placed by lumbar puncture (LP). An automatic CSF infusion protocol was performed. Course of events during the investigation as well as adverse events were registered. RESULTS: Preoperative evaluation of normal-pressure hydrocephalus was the most common indication (63%), followed by evaluation of shunt function (23%) and intracranial pressure recordings (14%). The LP was successfully performed in all but nine cases with 24 patients (4.3%) reporting major discomfort. Ringer infusion was performed in 474 investigations, and a valid measurement of the outflow resistance was received in 439 (93%). During the infusion phase, 17 (4%) patients reported severe headache. Infusion volume was significantly higher in patients having subjective symptoms during the infusion phase compared with those without adverse events. During 269 preoperative CSF tap tests, six (2%) patients had severe headache. Post-investigational headache was reported by 83 (15%) patients at the 24-h follow-up. No serious adverse events were observed. CONCLUSION: Infusion testing was safe and without serious adverse events with a high rate of successful procedures. The investigation was associated with expected mild to moderate discomfort.
Asunto(s)
Presión del Líquido Cefalorraquídeo/fisiología , Derivaciones del Líquido Cefalorraquídeo/instrumentación , Hidrocefalia/diagnóstico , Hidrocefalia/cirugía , Bombas de Infusión/tendencias , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Derivaciones del Líquido Cefalorraquídeo/normas , Pruebas Diagnósticas de Rutina/instrumentación , Pruebas Diagnósticas de Rutina/métodos , Estudios de Factibilidad , Humanos , Hidrocefalia/fisiopatología , Bombas de Infusión/normas , Manometría/métodos , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The cerebrospinal fluid tap test (TT) is a diagnostic tool used to select patients with idiopathic normal pressure hydrocephalus (iNPH) for shunt surgery. The procedure and the evaluation of the TT vary between centres. We aimed to describe the evaluation time after the TT, to assess the variability between repeated measurements, the interrater agreement of the gait tests chosen and finally to investigate whether pain affects the gait performance post-TT. METHODS: Forty patients (21 men and 19 women) under evaluation for iNPH underwent a TT. Standardized gait analyses were performed before and 2, 4, 6, 8 and 24 h after the TT and repeated twice on every occasion. Independent of each other, two investigators evaluated the quality of gait. At each assessment time, the patients graded headache and back pain on a visual analogue scale. RESULTS: Twenty-seven patients (15 men and 12 women) responded to TT. Improvements in gait speed and number of steps were significant at every assessment time post-TT. The variability between two measurements was low (Intra class correlation coefficient=0.97), and the inter-rater agreement was good with a κ=0.74. Pain correlated negatively with improvement in gait speed (r=-0.40, P<0.05). CONCLUSIONS: We suggest that the TT can be evaluated at any time within the first 24 h and should be repeated if the patient does not initially improve. Gait analysis appears reliable between two evaluators. Further, it is indicated that post-lumbar puncture pain negatively affects the gait and should be minimized.
Asunto(s)
Marcha , Hidrocéfalo Normotenso/líquido cefalorraquídeo , Hidrocéfalo Normotenso/diagnóstico , Examen Neurológico , Dolor/líquido cefalorraquídeo , Punción Espinal/métodos , Anciano , Anciano de 80 o más Años , Derivaciones del Líquido Cefalorraquídeo , Femenino , Humanos , Hidrocéfalo Normotenso/cirugía , Masculino , Persona de Mediana Edad , Dolor/cirugía , Valor Predictivo de las Pruebas , Reproducibilidad de los ResultadosRESUMEN
Subarachnoid hemorrhage (SAH) is not an unusual disease in an elderly population. The clinical outcome has improved over time. It has been suggested that elderly SAH patients would benefit from endovascular aneurysm treatment. The aim of this study was to evaluate technical results and clinical outcome in a series of elderly SAH-patients treated with endovascular coil embolization. Sixty-two patients (> or = 65 years) presenting with aneurysmal SAH underwent early endovascular coil embolization at Uppsala University Hospital between September 1996 and December 2000. In all 62 cases included in the study, endovascular coil embolization was considered the first line of treatment. Admission variables, specific information on technical success, degree of occlusion and procedural complications, and outcome figures were recorded. Clinical grade on admission was Hunt and Hess (H&H) I-II in 39%, H&H III in 27% and H&H IV-V in 34% of the patients. The proportion of posterior circulation aneurysms was 24%. Coil embolization was successfully completed in 94%. The degree of occlusion of the treated aneurysm was complete occlusion in 56%, neck remnant in 21%, residual filling in 11%, other remnant in 5% and not treated in 6%. The rate of procedural complications was 11%. Outcome after 6 months was favorable in 41%, severe disability in 36% and poor in 22%. Favorable outcome was achieved in 57% of the H&H I-II patients, 47% of the H&H III patients and 17% of the H&H IV-V patients. Endovascular aneurysm treatment can be performed in elderly patients with SAH with a high level of technical success, acceptable aneurysm occlusion results, an acceptable rate of procedural complications and fair outcome results.
Asunto(s)
Aneurisma Roto/terapia , Angioplastia , Embolización Terapéutica , Complicaciones Intraoperatorias , Hemorragia Subaracnoidea/terapia , Factores de Edad , Anciano , Anciano de 80 o más Años , Aneurisma Roto/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Masculino , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Intracerebral microdialysis (MD) was applied in patients with severe subarachnoid haemorrhage treated in a neurosurgical intensive care unit in order to explore their cerebral energy metabolism. METHOD: Brain MD fluid levels of glucose, lactate and pyruvate were measured for 3 to 12 days in 20 patients and 2,635 hourly samples were analysed. The MD data were related to computerized tomography and clinical outcome, assessed by the Glasgow Outcome Scale. FINDINGS: The study showed that most patients who made a good recovery had a specific curve pattern when plotting the studied metabolites over time, characterised by a distinct decrease in MD-glucose and a parallel increase in both MD-lactate and pyruvate. Patients who had an unfavourable outcome lacked this distinct curve pattern and exhibited more irregular changes, including increased levels of both MD-glucose and lactate and low MD-pyruvate levels. INTERPRETATION: This exploratory study suggests that accumulation of interstitial lactate and pyruvate, together with decreasing levels of glucose is a favourable prognostic pattern presumably reflecting increased glucose metabolism. Such hyperglycolysis may be elicited in patients with recovery potential to cope with an extreme metabolic demand set in motion by a brain insult to restore brain cell homeostasis and integrity.
Asunto(s)
Encéfalo/fisiopatología , Metabolismo Energético/fisiología , Glucólisis/fisiología , Aneurisma Intracraneal/fisiopatología , Hemorragia Subaracnoidea/fisiopatología , Adolescente , Adulto , Anciano , Glucemia/metabolismo , Embolización Terapéutica , Femenino , Escala de Consecuencias de Glasgow , Humanos , Aneurisma Intracraneal/mortalidad , Aneurisma Intracraneal/terapia , Ácido Láctico/metabolismo , Masculino , Microdiálisis , Microcirugia , Persona de Mediana Edad , Pronóstico , Ácido Pirúvico/metabolismo , Hemorragia Subaracnoidea/mortalidad , Hemorragia Subaracnoidea/terapia , Tasa de SupervivenciaRESUMEN
BACKGROUND AND PURPOSE: The elderly constitute a significant and increasing proportion of the population. The aim of this investigation was to study time trends in clinical management and outcome in elderly patients with subarachnoid hemorrhage. METHODS: Two hundred eighty-one patients >/=65 years of age with aneurysmal subarachnoid hemorrhage who were accepted for treatment at the Uppsala University Hospital neurosurgery clinic during 1981 to 1998 were included. Hunt and Hess grades on admission, specific management components, and clinical outcomes were recorded. Three periods were compared: A, 1981 to 1986 (before neurointensive care); B, 1987 to 1992; and C, 1993 to 1998. RESULTS: The volume of elderly patients (>/=65 years of age) increased with time, especially patients >/=70 years of age. Furthermore the proportion of patients with more severe clinical conditions increased. A greater proportion of patients had a favorable outcome (A, 45%; B, 61%; C, 58%) despite older ages and more severe neurological and clinical conditions. In period C, Hunt and Hess I to II patients had a favorable outcome in 85% of cases compared with 64% in period A. This was achieved without any increase in the number of severely disabled patients. CONCLUSIONS: Elderly patients with subarachnoid hemorrhage can be treated successfully, and results are still improving. The introduction of neurointensive care may have contributed to the improved outcome without increasing the proportion of severely disabled patients. A defeatist attitude toward elderly patients with this otherwise devastating disease is not justified.
Asunto(s)
Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Hemorragia Subaracnoidea/terapia , Distribución por Edad , Anciano , Anciano de 80 o más Años , Actitud del Personal de Salud , Angiografía Cerebral , Cuidados Críticos , Manejo de la Enfermedad , Femenino , Estudios de Seguimiento , Escala de Consecuencias de Glasgow , Hospitales Universitarios , Humanos , Modelos Logísticos , Masculino , Pruebas Neuropsicológicas/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/tendencias , Respiración Artificial/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/mortalidad , Suecia/epidemiología , Tomografía Computarizada por Rayos X , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Ventriculostomía/estadística & datos numéricosRESUMEN
OBJECT: When evaluating the results of intracerebral microdialysis, the in vivo performance of the microdialysis probe must be considered, because this determines the fraction of the interstitial concentration obtained in the microdialysis samples. The in vivo performance is dependent on several factors, for example, the interstitial compartment's diffusion characteristics, which may vary during the course of the acute brain injury process. In the present study the authors investigated the method of controlling the in vivo performance by using urea, which is evenly distributed in all body fluid compartments, as an endogenous reference compound and by comparing the urea levels in three compartments: the brain (CNS), abdominal subcutaneous tissue (SC), and blood serum (BS). METHODS: Sixty-nine patients with traumatic brain injury or cerebrovascular disease were included in the study. In 63 of these patients a CNS probe was used, an SC probe was used in 40, and both were used in 34. Urea was measured by enzymatic methods, at bedside for the microdialysis samples and in routine clinical laboratory studies for the BS samples, with the probe calibrated to give identical results. The correlation coefficient for CNS/SC urea was 0.88 (2414 samples), for CNS/BS urea it was 0.89 (180 samples), and for SC/BS urea it was 0.98 (112 samples). CONCLUSIONS: Urea levels in the CNS, SC, and BS were highly correlated, which supports the assumption that urea is evenly distributed. The CNS/SC urea ratio can therefore be used for monitoring the CNS probe's in vivo performance. Fluctuations in other substances measured with microdialysis are probably caused by biological changes in the brain, as long as the CNS/SC urea ratio remains constant.
Asunto(s)
Química Encefálica , Lesiones Encefálicas/diagnóstico , Cuidados Críticos/métodos , Microdiálisis/métodos , Microdiálisis/normas , Urea/análisis , Tejido Adiposo/química , Adulto , Anciano , Arteriopatías Oclusivas/diagnóstico , Compartimentos de Líquidos Corporales , Isquemia Encefálica/diagnóstico , Hemorragia Cerebral Traumática/diagnóstico , Femenino , Humanos , Técnicas In Vitro , Modelos Lineales , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Monitoreo Fisiológico/normas , Sistemas de Atención de Punto , Estándares de Referencia , Urea/sangreRESUMEN
OBJECT: Based on the concept that unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the disease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelines, diagnostic and monitoring methods, and pharmacological and surgical treatment in a neurointensive care setting. The impact of such changes on the outcome of aneurysmal SAH over a longer period of time has not previously been studied in detail. This was the present undertaking. METHODS: The authors analyzed all patients with SAH admitted to the neurosurgery department between 1981 and 1992. This period was divided in two parts, Period A (1981-1986) and Period B (1987-1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patients with SAH (mean age 52 years, 59% females) were admitted; an aneurysm presumably causing the SAH was found in 874 (72%). The 30-day mortality rate decreased from 29% during the first 2 years (1981-1982) to 9% during the last 2 years (1991-1992) (Period A 22%; Period B 10%; p<0.0001) and the 6-month mortality rate decreased from 34 to 15% (Period A 26%; Period B 16%; p<0.001). At follow-up review conducted 2 to 9 years (mean 5.2 years) after SAH occurred, patients were evaluated according to the Glasgow Outcome Scale. Subarachnoid hemorrhage-related poor outcome (vegetative or dead) was reduced (Period A 30%; Period B 18%; p<0.001). There was an increase both in patients with favorable outcome (good recovery and moderate disability) (Period A 61 %; Period B 66%) and in those with severe disability (Period A 9%; Period B 16%; p<0.01). CONCLUSIONS: This study provides evidence that the prognosis for patients with aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical outcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinical outcomes of patients with Hunt and Hess Grades III to V SAH were less conspicuous, although reduced incidences of mortality were seen in some subgroups; however, few survivors subsequently appeared to attain a favorable outcome.
Asunto(s)
Aneurisma Intracraneal/complicaciones , Hemorragia Subaracnoidea/terapia , Adolescente , Adulto , Anciano , Isquemia Encefálica/etiología , Causas de Muerte , Hemorragia Cerebral/etiología , Hemorragia Cerebral/terapia , Cuidados Críticos , Personas con Discapacidad , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estado Vegetativo Persistente/etiología , Pronóstico , Derivación y Consulta , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/tratamiento farmacológico , Hemorragia Subaracnoidea/etiología , Hemorragia Subaracnoidea/cirugía , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
In 15 patients without acute brain injury the concentrations of Neuron-specific Enolase (NSE), S-100 Protein (S-100), Creatine Kinase (CK), and Creatine Kinase BB isoenzyme (CK-BB) in ventricular cerebrospinal fluid (CSF) were measured immediately after lateral ventricle cannulation for diagnostic or treatment purposes. From patients who were treated with a shunt another CSF sample was obtained one week after shunt implantation by puncture of the antechamber of the valve. The CSF concentrations of NSE, S-100, CK and CK-BB after cannulation were found to be of the same order as found in patients with severe head injury, stroke or subarachnoid haemorrhage. One week after shunt implantation the concentrations of S-100, CK and CK-BB had returned to normal levels in almost all patients, while the NSE concentrations remained elevated. These findings indicate that the sampling procedure may result in contamination of CSF with NSE, S-100, CK and CK-BB and they should be taken into account in the prognostic evaluation of enzyme concentrations after brain injury.
Asunto(s)
Daño Encefálico Crónico/diagnóstico , Lesiones Encefálicas/cirugía , Derivaciones del Líquido Cefalorraquídeo , Creatina Quinasa/líquido cefalorraquídeo , Fosfopiruvato Hidratasa/líquido cefalorraquídeo , Complicaciones Posoperatorias/diagnóstico , Proteínas S100/líquido cefalorraquídeo , Daño Encefálico Crónico/enzimología , Lesiones Encefálicas/enzimología , Humanos , Hidrocéfalo Normotenso/enzimología , Hidrocéfalo Normotenso/cirugía , Isoenzimas , Peritoneo , Complicaciones Posoperatorias/enzimología , Seudotumor Cerebral/enzimología , Seudotumor Cerebral/cirugía , Resultado del TratamientoRESUMEN
Thirty patients with spasmodic torticollis were injected with Botulinum A toxin into sternomastoid and posterior neck muscles. Neurophysiological investigation showed neuromuscular transmission in the sternomastoid muscle to be impaired already within the first day after injection of 50 U toxin. Signs of denervation were discernible after seven days, and of reinnervation after two weeks. As assessed by 'blind' ratings of videotapes, 78 per cent of the patients improved, as compared with the figure of 87 per cent based on clinical evaluation. When injections were repeated every third month, there was a tendency for symptomatic effects to increase with time. Side effects were mild and transient. Thus local injections of botulinum toxin would seem to be the treatment of choice in this form of dystonia.