Neurogenic Pulmonary Edema in Aneurysmal Subarachnoid Hemorrhage.

Neurogenic pulmonary edema (NPE) is observed in cerebral injuries and has an impact on treatment results, being a predictor of fatal prognosis. In this study we retrospectively reviewed medical records of 250 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) for the frequency and treatment results of NPE. The following factors were taken under consideration: clinical status, aneurysm location, presence of NPE, intracranial pressure (ICP), and mortality. All patients had plain- and angio-computer tomography performed. NPE developed most frequently in case of the aneurysm located in the anterior communicating artery. The patients with grades I-III of SAH, according to the World Federation of Neurosurgeons staging, were immediately operated on, while those with poor grades IV and V had only an ICP sensor's implantation procedure performed. A hundred and eighty five patients (74.4 %) were admitted with grades I to III and 32 patients (12.8 %) were with grade IV and V each. NPE was not observed in SAH patients with grade I to III, but it developed in nine patients with grade IV and 11 patients with grade V. Of the 20 patients with NPE, 19 died. Of the 44 poor grade patients (grades IV-V) without NPE, 20 died. All poor grade patients had elevated ICP in a range of 24-56 mmHg. The patients with NPE had a greater ICP than those without NPE. Gender and age had no influence on the occurrence of NPE. We conclude that the development of neurogenic pulmonary edema in SAH patients with poor grades is a fatal prognostic as it about doubles the death rate to almost hundred percent.

Treatment of chronic subdural hematoma by burr holes and closed-system drainage.

This article highlights the treatment of choice of chronic subdural hematoma. The importance, effectiveness, and low complication rate of minimally invasive procedure by burr holes and closed-system drainage is discussed.

Head-injured adult patients with GCS of 3 on admission--who have a chance to survive?

The authors analysed a series of 111 adult patients admitted to the Department of Neurosurgery, Medical University of Lódz directly after trauma with initial GCS of 3 points. 74% of them had intracranial haematoma, mainly subdural, and were treated surgically within the first 3 hours after trauma. 8 patients had no abnormalities on CT scans. 99 (89%) patients died 2 to 30 days after injury, 8 (7%) survived in a vegetative state, and only in 4 (4%) was a satisfactory result noted, but 2 of them had a stable neurological deficit. 3 of these 4 patients had epidural haematomas and 1 had not abnormalities on repeated CT examinations. We conclude, that among patients with GCS of 3 on admission, only those without major CT abnormalities or with epidural haematoma have a chance of survival. Cases with cerebral lesions on the initial CT examination have an invariably bad prognosis. They could be taken into account as a potential organ donor from the very moment of admission, but only after cerebral circulatory arrest occurred and brain death has been proved according to internationally accepted standards.

[Cerebral cysticercosis. Case report]. / Wagrzyca mózgu. Opis przypadku.

The authors present a case of a long course of disseminated cerebral cysticercosis. Diagnosis of cysticercosis was confirmed by serial magnetic resonance examinations.

Middle cerebral artery aneurysm developing apparently de novo.

The author reports a patient with a fatal subarachnoid and intracerebral hemorrhage from a middle cerebral artery aneurysm, which apparently developed de novo. 18 years before, the patient was operated for an anterior communicating artery aneurysm and, during this procedure, an anterior cerebral artery was ligated. Hemodynamic disturbances due to anterior artery occlusion are suggested as the cause of new aneurysm formation.

Acute subdural haematoma in adults: an analysis of outcome in comatose patients.

The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of Lódz with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18-30 year old had lower mortality-25%, while patients above 50 revealed 75% mortality. Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery-those with quickly developing haematomas and intracranial hypertension-had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma. Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.

[Usefulness of intracranial pressure measurement by Camino V420 system: preliminary report]. / Ocena przydatnosci aparatu Camino V420 do pomiaru cisnienia wewnatrzczaszkowego (ICP)--doniesienie wstepne.

The authors discuss the basis of ICP measurements with Camino V420 system and present the introductory experience of Department of Neurosurgery, Medical Academy of Lódz with it's clinical use. Continuous ICP measurements, lasting from 24h to 15 days were performed in 16 patients. In 13 of them ICP measurements were done in order to establish the dynamics of hydrocephalus and indications for shunt surgery. The other 3 suffered from intracranial hypertension, caused by trauma (1 patient) or spontaneous intracranial haemorrhage (2 patients). Camino system proved to be easy in handling, highly reliable, and infallible, even for successive days.

[Parkinsonism caused by bilateral subdural haematomas]. / Zespól parkinsonowski spowodowany przez obustronne przewlekle krwiaki podoponowe.

The authors present a case of 75-year old man with bilateral chronic subdural haematomas presenting as parkinsonism. Surgical removal haematomas was followed by complete recovery of the patient.

Cerebral and cerebellar glial tumors in the same individual.

We report histologically different gliomas occurring simultaneously in both the cerebrum and cerebellum in a 53-year-old woman. One tumor was a cerebellar astrocytoma, and the second was a temporal glioblastoma multiforme. Two months after the removal of both tumors, the third lesion, located in the basal ganglia, was found on a computed tomographic examination, but it was not verified histologically. We recommend a biopsy of one tumor when a diagnosis of multiple brain tumors is established based on a computed tomographic examination, in order to avoid the misdiagnosis of multicentric gliomas as brain metastases.

[Usefulness of computerized myelotomography in the diagnosis of discopathy of the cervical spine]. / Ocena przydatnosci mielotomografii komputerowej w rozpoznawaniu dyskopatii szyjnego odcinka kregoslupa.

The authors compared the results of preoperative computer-assisted myelography (CAM) with surgical findings in 45 patients with suspected cervical disc disease. In 98% CAM gave full and proper diagnosis confirmed by surgery. Only in one patient, the preoperative diagnosis was extraspinal tumour, and surgery revealed prolapsed nucleus pulposus lying freely on the anterior wall of the dural sac. In authors's opinion, CAM is sufficient for planning of surgical treatment in cervical disc disease, and other radiological studies, myelography or nuclear magnetic resonance tomography are usually not necessary.

[Cranioplasty of extensive defects of the cranial vault bones using a "Codubix" prosthesis]. / Kranioplastyka olbrzymich ubytków kosci pokrywy czaszki proteza "Codubix".

In the years 1980-1987 in the Neurosurgery Department, Medical Academy in Lódz in 21 patients aged 12 to 59 years covering of cranial vault bone defects over 100 cm2 of area was done using of cranioplasty polypropylene-polyester knitted fabric Codubix. The size of the implanted prostheses was from 100 to 430 cm2. The time from bone defect occurrence to cranioplasty was from 4 weeks to 18 years. Cranial defects resulted from treatment of trauma complications in 10 cases, treatment of intracranial tumours in 7, aneurysms in 2 and intracranial infections in 2 cases. The follow-up after cranioplasty was from 3 to 10 years. In 18 cases (85.7%) good and very good therapeutic results were obtained. Three patients required removal of prosthesis because of purulent complication, in 2 of these cases high risk of infection was present before the operation. Codubix prosthesis was particularly useful for filling giant of cranial bones.

[Clinical course and the results of the treatment of unilateral chronic subdural hematoma]. / Przebieg kliniczny i wyniki leczenia operacyjnego jednostronnych przewleklych krwiaków podtwardówkowych.

The authors analysed the clinical and surgical results in 131 patients treated for unilateral chronic subdural haematoma. 71% of patients had a history of head trauma, 34% were addicted to alcohol. In 18% of cases the clinical course mimicked cerebral stroke. All patients were treated by burr holes and closed-system drainage lasting for 24-48 hours. There were 4 deaths, 3 from ischaemic stroke, and 1 from subdural empyema. 19 patients revealed postoperative complications--intracranial hypotension, cerebral oedema, and haematoma recurrence being the commonest. Follow-up revealed that 83% of patients were healthy, 10% had stable neurological deficit, and 7% presented epileptic fits.

Acute head injuries in the elderly. An analysis of 136 consecutive patients.

136 patients older than 70 years, admitted to our neurosurgical ward directly after head trauma, were analysed. 40% of them were admitted with low GCS, below 9 points, and showed a mortality of 85%. 45 patients had intracranial mass lesions--the commonest was subdural haematoma, with a low incidence of epidural haematomas. In patients admitted with GCS above 12, mortality was 20%, mainly due to pneumonia. Satisfactory results were achieved in 30% of trauma victims. From patients with intracranial space occupying lesions and GCS below 9 points on admission practically all died, despite aggressive surgical treatment and intensive care. Thus, especially in departments with limited resources, therapy can be limited, or even no therapy may be introduced in this group. Surgical treatment can be limited only to patients who are conscious on admission. In patients with non-surgical lesions, low GCS--below 9 points--leads to mortality of 80%, and in this group we propose aggressive intensive care for 24 hours and the limitation of further "maximal" therapy only to those, who significantly improve within this period of time. If the patient has a non-surgical lesion and is conscious after trauma, aggressive treatment of extracranial complication is the most important, because brain injury can usually be well tolerated by these patients. If pneumonia or heart complications do not occur this group of old patients often have a good prognosis.

Effect of mannitol on intracranial pressure in focal cerebral ischemia. An experimental study in a rat.

The authors studied the effects of mannitol on intracranial pressure (ICP) in experimental focal ischemia in a rat. Stroke was produced by occlusion of middle cerebral artery (MCA). The study revealed that mannitol decreases ICP in ischemic stroke much less then in healthy animals and also a significant rebound effect was seen, especially in the 5th and 7th day after MCA occlusion. The authors suggest a very limited use of mannitol in clinical treatment of elevated ICP after cerebral ischemic stroke.

Clinical pattern of chronic subdural haematoma.

To assess the clinical manifestation of chronic subdural haematoma (CSH) the authors retrospectively analysed the files of 131 adult patients treated in the Department of Neurosurgery Medical Academy of Lódz. In 14 patients the illness had a sudden onset, suggesting cerebral stroke. 50% of patients had symptoms of raised ICP, there were no differences between young and older patients. In patients older than 40 years focal neurological deficits were more frequent, and in 13% of them focal signs were homolateral to CSH. In 9 patients the lesion produced symptoms of transtentorial herniation within a very short period. The authors think that despite the great progress in neuroradiology and neurosurgery, the condition may still be overlooked if the clinical picture does not suggest an intracranial space-occupying growth.

[Aphasia without alexia after surgical treatment of aneurysm of the right middle cerebral artery--incomplete lateralization of verbal functions?]. / Afazja bez aleksji po operacji tetniaka prawej tetnicy srodkowej mózgu--niepelna lateralizacja funkcji werbalnych?

The authors present a case of aphatic disorders after surgical treatment of the right middle cerebral artery aneurysm. A prominent dissociation of verbal function was noticed.

Interstitial and cerebrospinal fluid levels of energy-related metabolites after middle cerebral artery occlusion in rats.

This investigation was designed to study the dynamics of energy-related metabolites (i.e., lactate, pyruvate, inosine, and hypoxanthine) in the extracellular fluid (ECF) of the striatum and in cisternal cerebrospinal fluid (CSF) during the first 6 h after middle cerebral artery occlusion (MCAO) using microdialysis. Ischemia induced a dramatic increase in the ECF levels of lactate, inosine, and hypoxanthine, while pyruvate did not change significantly. The major part of these changes occurred during the first 10 min after MCAO. Inosine tended to normalize towards the end, while lactate and hypoxanthine remained elevated throughout the experiment. There was no increase of the energy-related metabolites in CSF during the experiment. It was concluded that lactate, inosine, and hypoxanthine appear to be useful ECF markers of the compromised energy state of the brain during ischemia. Because the metabolites did not appear in CSF during the first 6 h after MCAO, such measurements seem not to be useful for early detection of a disturbance in energy metabolism.

Intracranial pressure changes following middle cerebral artery occlusion in rats.

Prolonged recording of intracranial pressure (ICP) was performed on rats subjected to middle cerebral artery (MCA) occlusion. ICP was repeatedly recorded before and after occlusion of the vessel via a narrow catheter placed in the cisterna magna. MCA occlusion was followed by an increase in ICP, and a pressure peak occurred after 12-24 h in all animals. Subsequently, essentially two patterns of ICP changes were observed. These seemed to be related to the severity of neurological deficits and extension of the infarct area. In the most severely affected animals, raised ICP was noted throughout the 1st week after MCA occlusion; in rats with reversible neurological deficits, ICP returned to normal values after the first peak at 12-24 h. The present investigation shows that prolonged ICP recording is feasible in MCA-occluded rats. The MCA occlusion model in rats is well characterized. Thus, ICP registration can be used in conjunction with other methods for evaluating treatment against increased ICP.

Chronic subdural haematoma treated by burr holes and closed system drainage: personal experience in 131 patients.

One-hundred and thirty-one patients with chronic subdural haematoma were treated by burr holes and closed system drainage. Four patients died, and in 19 patients postoperative complications were noted: intracranial hypotension in eight, cerebral oedema in four, haematoma recurrence in three, bronchopneumonia in three, and intracerebral haematoma in one. The high risk groups were those in grade III and IV on admission, and the elderly. Follow-up revealed that more than 80% of patients recovered completely, 10% still had neurological or mental deficits and 7% suffered epileptic seizures.

Cranioplasty of an extremely large cranial defect caused by transitional meningioma with a knitted polypropylen-polyester prothesis "Codubix".

The authors report a case of transitional cell meningioma of the convexity which destroyed a large portion of the calvarium and invaded subcutaneous tissue. The tumour was totally removed and a large cranial defect/430 cm2 in size/was filled with a polypropylenopolyester knitted prothesis "Codubix" with an excellent result. The problems of chronioplastic closure of such an unusually large skull defect and the advantages of the use of the material "Codubix" are discussed.