Analysis of risk factors influencing the development of severe dizziness in patients with vestibular schwannomas in the immediate postoperative phase.

OBJECTIVE: Dizziness, a common postoperative symptom in patients with vestibular schwannomas (VSs) has a negative effect on the course of recovery, particularly in patients with severe symptoms. Reports on incidence and possible risk factors contributing to these symptoms are inconsistent and sometimes even contradictory. In order to establish a profile of patients at risk of severe symptoms in the immediate postoperative phase we retrospectively analyzed data of patients with unilateral VSs focusing on the incidence of severe dizziness and nausea during the immediate postoperative period and up to 1 year after surgery. METHODS: In a retrospective study data of 104 consecutive patients with VSs were analyzed. All patients underwent microsurgical tumor resection via a lateral-suboccipital approach. Factors that were assumed to affect the development of severe dizziness, such as age, gender, tumor size, tumor side, and cranial nerve function, were analyzed by means of univariate and multivariate logistic regression analyses. A three step grading system was used to describe symptoms of patients included in this study: 0=no symptoms of dizziness, 1=slight dizziness including light-headedness or feeling of disequilibrium and 2=severe dizziness with nausea including imbalance or insecurity when walking, requiring antiemetic treatment. RESULTS: Data of 92 patients, 41 men and 51 women, were available for analyses. Mean age of treated patients was 53 years (range 17-81). There was no predilection of side (52.2% right/47.8% left). Before surgery 39 patients (42.4%) were symptom free (grade 0), 13 patients (14.1%) had slight symptoms (grade 1) and 40 patients (43.5%) suffered from severe symptoms (grade 2). Immediately after surgery two patients (2.2%) where symptom free (grade 0), 19 patients (20.7%) had slight symptoms (grade 1) and 71 patients (77.2%) suffered from severe symptoms (grade 2). All patients with grade 2 symptoms required antiemetic treatment ranging between 1 and 10 days (mean 4 days). Logistic regression analyses showed young age, large tumor size (T3/T4), female gender, and severe preoperative symptoms to be main factors increasing the odds for patients to develop severe symptoms postoperatively. CONCLUSION: Patients at risk to develop severe symptoms should receive antiemetic treatment even before surgery. If in doubt about the actual risk for a specific patient with a large tumor (T3 or T4) available data suggests that patients will benefit if antiemetic treatment is started early, even before surgery.

Cognitive decline as an important sign for an operable cause of dementia: chronic subdural haematoma.

BACKGROUND: Cognitive decline, slow psychomotor regression and confusion, especially in the elderly, often result in medical consultation. Frequently, these rather unspecific symptoms are interpreted as signs of beginning dementia. When mental regression is joined by tremor or motor deficits, neurodegenerative disease is commonly considered and the need for neuroimaging is underestimated. Chronic subdural haematoma (CSH) is known to be the most frequent type of intracranial bleeding, appearing mostly in the elderly after minor trauma with unspecific symptoms. The aim of this retrospective study was the identification of the leading clinical symptoms in patients with the diagnosis CSH who had been treated surgically in our Neurosurgical Department. PATIENTS AND METHOD: 356 patients with symptomatic CSH (225 male, 131 female; mean age 68.3 years), who were admitted to our Neurosurgical Department between 1992 and 2003, were included in the study. We reviewed the charts documenting preoperative clinical status, radiological signs, history of trauma, operative complications, postoperative clinical status, days of hospitalisation as well as gender and age. RESULTS: The primary surgical procedure performed in 343 patients (96.4%) was burr-hole trepanation. The leading preoperative symptoms were mnestic deficits (cognitive decline, confusion) in 192 patients (55.8%), followed by headache in 150 patients (45.5%) and motor deficit in 144 patients (41.1%). Furthermore, we found a statistically significant correlation (p<0.005) between the thickness of the left-sided haematoma and the symptoms aphasia and psychosyndrome. CONCLUSION: The leading clinical symptoms identified in our cohort were mnestic deficits, headache and motor deficit, signs that mostly appear at the beginning of demential diseases. Thus, CSH should be taken into account as an important differential diagnosis for demential and neurodegenerative diseases and neuroimaging should be demanded. Once a CSH is detected this way, the patient should be transferred to a neurosurgical department where an easy standard procedure may potentially lead to early recovery.

A study of possible correlation between subarachnoid haemorrhage related vasospasm and the post-bleed blood platelet count chart in a Caucasian population.

INTRODUCTION: There has been controversy about the aetiology and pathophysiology of subarachnoid haemorrhage (SAH) related vasospasm. Several pathogenic factors like endothelin and adhesion molecules have been discussed. A recently published study concerning an exclusively Asian population suggested a relationship between SAH related vasospasm and the blood platelet count. The aim of our study was to examine this relationship in a European population. METHOD: We carefully reviewed 88 patients with aneurysmal SAH (54 females, 34 males; mean age 52.5 years, range from 22 to 78 years) treated in our centre with regard to the occurrence of vasospasm and the blood platelet count in a ten day interval after initial SAH. Symptomatic vasospasm was defined as a focal neurological deficit or deterioration in the level of consciousness with or without confirmation of infarction on a CT scan. Thirty-seven patients (42%) developed clinically relevant vasospasm. RESULTS: There was no statistically significant correlation between the blood platelet count chart (maximum and minimum values) and vasospasm or clinical outcome; we also found no gender or age-related influence on the above mentioned relationships. CONCLUSIONS: In our opinion there appears to be a difference between Caucasian and Asian populations regarding the influence of platelets in the pathophysiology of SAH and vasospasm.

Cerebrospinal fluid and neutrophil respiratory burst after subarachnoid hemorrhage.

OBJECTIVES: To investigate the effect of cerebrospinal fluid (CSF) from patients with subarachnoid hemorrhage (SAH) on the activation of polymorphonuclear neutrophils (PMN) in response to receptor-dependent stimulation with N-formyl-l-methionyl-l-leucyl-l-phenylalanine and TNFalpha or non-receptor-dependent stimulation with phorbol 12-myristate 13-acetate. METHODS: CSF from 12 patients with SAH due to ruptured cerebral aneurysm was collected. Samples of CSF were drawn at different time points. CSF from 6 healthy subjects receiving spinal anesthesia served as the control group. After stimulation of PMN the generation of reactive oxygen intermediates was analyzed on a flow cytometer. RESULTS: In the presence of CSF, PMN showed a significant suppression of the oxidative burst following stimulation compared to stimulation without CSF. The reduction of the oxidative burst following stimulation was higher in the presence of CSF from patients with SAH. After pretreatment at 56 degrees C, the extent of the suppression observed following receptor-dependent stimulation and CSF from patients with SAH was similar to that seen after stimulation with CSF from healthy individuals. CONCLUSIONS: These data show that the presence of CSF resulted in a suppression of neutrophil oxidative function. A more distinct depression was seen in the presence of CSF from patients with SAH. We suggest a complex physiological inhibitory and protective mechanism against unfavorable activation of PMN by CSF.

Ultrasonic blood flow volume assessment in the extracranial internal carotid artery in arteriovenous malformations.

Angle-independent ultrasound assessment of the volume flow in the extracranial internal carotid artery (ICA) is a new approach to evaluate the perfusion status of the human brain. Normal values using a new technical device (Quantix ND, Cardiosonix Ltd, Israel) and correlation analysis to quantitative CBF measurements were recently published. Aim of this study was to evaluate this device in arteriovenous malformations where cerebral blood flow is known to be increased. Five patients suffering from large supratentorial arteriovenous malformations (AVM) could be examined. All patients showed pre-operatively elevated flow volumes in the internal carotid artery on the side harbouring the pathological lesion compared with normal values evaluated in 50 volunteers. The contralateral internal carotid artery showed volume flow values within the normal limit. After surgical resection of the malformation normal values could be measured in all patients. Pathological elevated increases in cerebral blood flow can be evaluated by ultrasonic blood flow volume assessment in the extracranial internal carotid artery. Therefore, the Quantix ND seems a valuable tool in diagnosing cerebral hyperemia.

Normal values of volume flow in the internal carotid artery measured by a new angle-independent Doppler technique for evaluating cerebral perfusion.

BACKGROUND: Cerebral blood flow is an important parameter when monitoring critically ill patients. Blood flow volume within the internal carotid artery (ICA) was shown to be correlated with the cerebral blood flow. The aim of our study was to provide normal values of the internal carotid artery volume flow using this new technology (QuantixND, Cardiosonix Ltd., Israel). METHOD: The QuantixND System is an angle-independent Doppler system that employs two digital high resolution ultrasound heads within one probe in an defined angle to each other. Thus several flow velocities within the vessel and the vessel diameter can be measured. 77 healthy patients (41 women, 36 men) were included and divided into age groups of ten-year intervals (mean age 48.9 years). Internal carotid artery flow was evaluated as well as physiological and hematological parameters (hematocrit, arterial blood pressure etc). FINDINGS: We found that the blood flow volume in the ICA decreased significantly with age. No side-to-side effects as well as no gender-related differences could be observed. There was no influence of hemoglobin, hematocrit and blood pressure in this healthy population. CONCLUSIONS: There is an age-related decrease in blood flow volume with age that can be easily and exactly determined by the use of the new angle-independent Doppler technique.

Quality of life after decompressive craniectomy in patients suffering from supratentorial brain ischemia.

BACKGROUND: Decompressive craniectomy in patients suffering from severe ischemic stroke in the middle cerebral artery territory (MCA) decreases mortality to near 30%. Additionally functional outcome in patients after early craniectomy seems to be better than in patients without surgery. The aim of this study was to investigate the quality of life of patients who were treated with a decompressive craniectomy for severe ischemic stroke. METHODS: We retrospectively investigated the patient records of 48 patients (26 men, mean age 48 years) suffering from ischemic strokes who underwent craniectomy since 1993. We registrated the preoperative neurological status, the diagnostic data as well as the operative procedure. The outcome was assessed using the Barthel Index, the Glasgow outcome score and a questionnaire to assess the quality of life according to Blau consisting of eleven items at follow-up. FINDINGS: The mortality rate was 26%, age correlated to mortality (44.5 versus 60.3 years GOS 1, mean, p<0.0006). Craniectomy without dura patch correlated to mortality (58% versus 14% GOS 1 with dura patch, p<0.005). The quality of life index was 6 points mean. The quality of life index did neither differ significantly between patients with left or right sided lesions nor in patients with and without aphasia. 83% of the surviving patients and/or dependents would agree to surgery in the future. CONCLUSION: Despite the fact that some patients remain in a poor neurological condition, quality of life after decompressive surgery for ischemic stroke seems to be acceptable to the patients.

Internal carotid artery volume flow correlates to rCBF measurements.

BACKGROUND: There is no simple, cost effective bedside method available for measuring global cerebral blood flow (CBF) rapidly and repeatedly. METHOD: Based on the ultrasound technique a device was developed to measure flow volume per unit of time in the internal carotid artery. The system utilizes dual beam, angle-independent Doppler technology, and employs simultaneous sampling and full spectrum determination. The aim of this study was to evaluate this device in comparison with cerebral blood flow measurements using the well established Xenon(133) clearance technique. FINDINGS: 10 patients suffering from SAH were included. 20 measurements were performed. CBF was measured employing the Xenon(133) clearance technique. Velocity profiles across the ICA were obtained with the high-resolution FlowGuard Doppler ultrasound flow system (Cardiosonix Ltd., Israel). According to the statistical analysis the ICA flow correlated significantly to the mean rCBF15 index of the hemisphere (p<0.0001). CONCLUSIONS: This new device seems to be promising for monitoring cerebral blood flow in critically ill neurological and neurosurgical patients.

Comparison of the Claassen and Fisher CT classification scale to predict ischemia after aneurysmatic SAH?

BACKGROUND: Delayed cerebral ischemia (DCI) is an important cause of morbidity and mortality after aneurysmatic subarachnoid hemorrhage (SAH). The severity of SAH, reflected by the amount of blood in the initial CCT, is a well-established predictor of DCI and infarction. The Fisher CT scale is widely used to predict DCI, but recent studies criticised the scale due to the fact that this scale does not differentiate between intracerebral blood clots and intraventricular hemorrhage. Thus Claasen et al. recently proposed a new grading scale to predict DCI. The aim of this study was to compare clinical scales with the CT findings and to verify this newly developed scale in a different population in order to predict DCI.[nl] PATIENTS AND METHODS: We selected from our databank of patients suffering from aneurysmatic SAH 292 cases who had been treated between 1995 and 2000. The data acquisition included clinical data, radiological diagnostic data, the postoperative surgical course as well as a follow-up according to the Glasgow outcome scale.[nl] RESULTS: 83 out of 292 patients (28.5 %) developed ischemic lesions on the CT scans reflecting DCI. The severity of SAH according to the Hunt and Hess grading, the Fisher CT scale and the Claassen CT scale correlated statistically significant to DCI. All three scales showed an increasing odds ratio, but the most consistent increase was demonstrated by the Fisher scale.[nl] CONCLUSIONS: The newly proposed Claassen CT scale provides no additional information and seems not to be superior compared to the well-established Fisher scale to predict DCI.

The value of routine electroencephalographic recordings in predicting postoperative seizures associated with meningioma surgery.

We analyzed the incidence of postoperative seizures in patients undergoing craniotomy for meningioma removal in order to determine whether EEG recordings are able to predict the incidence of postoperative seizures. We included 102 patients who had undergone surgery on intracranial meningiomas. Pre- and postoperative EEG images were divided into groups showing epileptiform activity including spikes or sharp waves, focal slowing, and normal activity. Follow-up was carried out using a standardized telephone questionnaire by an independent investigator after a mean of 889 days. Seizure outcome was determined by patient reports to the interviewer. Preoperatively obtained, abnormal EEGs correlated significantly to preoperative seizures (P<0.0005), but neither preoperative nor postoperative EEGs correlated to the incidence of postoperative seizures. It would seem that, while evaluation of some clinical parameters revealed a statistically significant correlation, pre- and early postoperative EEGs after meningioma surgery are not useful in determining the risk of postoperative seizures.

[ARDS and severe brain injury. Therapeutic strategies in conflict]. / ARDS und schweres Schädelhirntrauma. Therapiestrategien im Konflikt.

The development of adult respiratory distress syndrome (ARDS) complicates the treatment of patients with severe head injury, since special therapeutic strategies for both conditions might lead to a "conflict of interest". We report on the intensive care treatment of a young man who suffered severe brain injury (Glasgow Coma Scale = 3) due to a traffic accident and simultaneously developed ARDS from the aspiration of gastric content. We performed extensive monitoring of cerebral hemodynamics and metabolism (intracranial pressure measurement, jugular bulb oxymetry, estimation of arterial-jugular bulb lactate concentration difference) to prevent cerebral hypoxia and to control cerebral hyperemia. The application of a "lung protective strategy" with "permissive hypercapnia" led to a conflict, since the development of cranial hyperemia combined with cranial hypertension a few days after trauma, warranted the concept of controlled, temporary hyperventilation. Therefore, we applied a pumpless extracorporeal lung assist to improve carbon dioxide elimination. Furthermore, we started the ventilation in the prone position, since arterial oxygenation continued to deteriorate, although there is a lack of data describing the effect of a prone position on acute cerebral injury. Positioning the patient prone, we observed a prompt increase in intracranial pressure, which resulted in pharmacological intervention (mannitol). Treating the patient by intermittent prone position, by continuous extracorporeal lung assist and aerosolized prostacyclin administration in the following period, lung function improved and ARDS was treated successfully. After withdrawing the analgo-sedation the patient's vigilance rose continuously. The patient was transferred to a rehabilitation ward 33 days after admission to the intensive care unit. The combination of ARDS and severe brain injury needs special treatment, which includes extensive monitoring techniques to find a solution for therapeutic conflicts.

Early S-100B serum level correlates to quality of life in patients after severe head injury.

PURPOSE: S-100B protein is a new possible indicator of brain damage after severe head injury. In outcome assessment there is an increasing focus on measures of health outcome incorporating the person's own perspective. Therefore, the aim of the study was to investigate the correlation of early S-100B serum level to the quality of life. METHOD: fifty-one patients with severe head injury were included in a prospective study. Blood samples were taken on admission (mean 2.5 hours). The outcome was assessed at follow-up using the Glasgow Outcome Scale and a questionnaire according to Blau to assess the quality of life. RESULTS: high serum concentrations of S-100B on admission correlate to unfavourable outcome according to the GOS (4.9 micro g/l vs 1.6 micro g/l, mean, p < 0.0008). In addition, the S-100B serum concentrations on admission correlate to quality of life in the survivor group. Patients with S-100B serum levels < or = 0.5 micro g/l scored 71.4 points (mean) on the QoL index compared to patients with elevated S-100B concentrations, who scored 55.4 points (mean, p < 0.05). CONCLUSION: S-100B seems to be able to assess the extent of primary brain damage after trauma.

Glial and neuronal serum markers after controlled cortical impact injury in the rat.

The aim of this study was to investigate the time course and the correlation of glial fibrillary acidic protein (GFAP), protein S-100B, and neuron specific enolase (NSE) serum levels to the severity of traumatic brain injury in rats. Male Wistar rats (n = 65 S-100B, NSE group and n = 55 GFAP group) underwent a severe cortical impact injury (100PSI, 2 mm deformation). Blood samples were drawn directly after trauma, 1 h, 6 h, 12 h, 24 h, and 48 h post trauma as well as in sham operated animals directly after craniotomy, after 6 h and 48 h. Serum levels at different severities were estimated in 20 rats (45PSI, 75PSI, 2 mm deformation). We found a time-dependent release of NSE and GFAP into serum after trauma. The highest NSE values were detected six hours after trauma (31.5 micrograms/l, mean, p < 0.0001), the highest GFAP levels were measured one hour after trauma (0.079 microgram/l, mean, p < 0.0014). Additionally we found a close relationship between NSE serum levels and the severity of traumatic brain injury (45PSI = 12.7 micrograms/l, 75PSI = 16.17 micrograms/l, 100PSI = 28.45 micrograms/l, p < 0.05). S-100B serum levels showed an increase (0.92 microgram/l, p < 0.005) but no time-dependent release. S-100B and GFAP showed no relationship to trauma severity. Serum levels of GFAP, S-100B and NSE are significantly elevated in the early phase after experimental traumatic brain injury. In this experimental model of cortical impact injury only NSE, but not GFAP and S-100B serum levels are time-dependently correlated with the severity of cortical impact.

Dynamic correlation between tissue PO2 and near infrared spectroscopy.

Multimodal O2 monitoring including tissue pO2 measurements and near infrared spectroscopy (NIRS) are techniques increasingly employed for monitoring patients on neurosurgical intensive care units. NIRS measures a mixed venous arterial oxygen saturation, whereas tissue pO2 evaluates the oxygen pressure in the white matter. In contrast to the tissue pO2 measurements, the NIRS at the moment has not been completely established in clinical practice. We wanted to evaluate whether both techniques are monitoring different dynamic changes. Thirteen patients were included (SAH n = 3, TBI n = 10), 12 patients were male and 1 was female. Mean age was 34 years with a range from 16-76 years. Tissue pO2 probes (Licox, GMS, Germany) were implanted in the frontal lobe showing most pathological changes on the initial CT scan. A near infrared spectroscopy sensor (Invos, Somanetics, USA) was placed simultaneously at the patient's forehead. Due to the drift of the tissue pO2 probe, only data sets were taken into further account in which a tissue pO2 value above 15 mmHg was measured. 66 data sets were analyzed by calculating the spectral coherence with multi taper methods. The coherence of two independent white noise signals were defined as an observation by chance. The significance level for correlated frequencies was 90%. In the spectral long time regime (frequency > or = 0.02), more than 80% of the data sets showed a higher percentage of correlated frequencies as compared to the observation by chance. The assumption that tissue pO2 and near infrared spectroscopy probes are measuring different dynamic changes in neurosurgical intensive care patients could not be supported by our data.

Neuron-specific enolase serum levels after controlled cortical impact injury in the rat.

The aim of this study was to investigate the time course and the correlation of neuron-specific enolase (NSE) serum levels to the severity of traumatic brain injury in rats. Sixty-five male Wistar rats were subjected to severe cortical impact injury (100 PSI, 2 mm deformation). Blood samples were drawn directly after trauma and after 1, 6, 12, 24, and 48 h in the trauma group. In the sham operated levels animals samples were drawn directly after craniotomy and after 6 and 48 h. Additionally, NSE serum levels after controlled cortical impact at different levels of severity samples (45 PSI, 75 PSI; 2 mm deformity) were compared to sham-operated animals. The severity of the injury was not validated histopathologically. NSE serum levels were estimated with a commercially available enzyme immunoassay (LIA mat Sangtec). The control animals showed a NSE serum level of 8.82 microg/L (mean, n = 10) and the injured animals demonstrated a time-dependent release of NSE into the serum. The highest NSE serum values were detected 6 h after trauma (31.5 microg/L mean, n = 10). In addition, we found a close relationship between NSE serum levels and the severity of traumatic brain injury in the cortical impact model. NSE serum levels reflect in a time-dependent manner the severity of brain trauma induced by cortical impact model in rat.

[Fatal intracerebral gas gangrene in a 10-month-old child]. / Tödlich verlaufende intrazerebrale Gasbrandinfektion bei einem zehn Monate alten Kind.

Today, intracerebral infections by gas forming bacteria are very rare. They are mostly seen after penetrating injuries and more rarely after trivial trauma. Although prognosis of this kind of infection is severe, the general outcome of these patients after surgical and antibiotic treatment is good. We report a ten months old boy suffering a pecking injury just above the left ear with perforation of the temporal bone and dura. In between 48 hrs he developed a rapidly progressive gas gangrene encephalitis due to infection with C. perfringens and died despite of surgical and antibiotic treatment due to massive brain swelling and cardio-pulmonary failure.

Long term outcome after cervical foraminotomy.

We recently demonstrated the effectiveness of dorsal foraminotomy in lateral herniated cervical disc after 1 year follow-up in a prospective study.(1) The goal of this paper is to confirm these results concerning long term outcome. We carried out a prospective, consecutive study on 54 patients, operated on for lateral herniated cervical disc. We analysed demographic data, the case history, the neurological examination on admission and imaging data. Ninety per cent were followed up for 3.5 years postoperatively. According to their ratings on a pain scale the group were divided into favourable and unfavourable outcomes. These groups were analysed in relation to the patient's initial condition. At follow up, 90% of patients showed complete recovery or improvement. A long standing preoperative neurological deficit seems to be an important prognostic factor for unfavourable long term outcome after cervical foraminotomy.

S-100B protein serum levels after controlled cortical impact injury in the rat.

S-100B is described to provide information about the severity of brain damage in man. Estimation of serum markers appears to be an easy method of obtaining information regarding severity and outcome after head injury. However less is known about the post traumatic time course of this protein in the serum. The aim of this study was to provide further information about the posttraumatic enzymekinetik. 65 male Wistar rats were subjected to severe cortical impact injury (100 PSI, 2 mm deformation). Blood samples were drawn directly after trauma, then after 1 h, 6 h, 12 h, 24 h, and 48 h. In sham operated animals blood samples were drawn directly after craniotomy, then after 6 h and after 48 h. Also compared were S-100B serum levels at different severities in 20 rats (45 PSI, 75 PSI; 2 mm deformity) after controlled cortical impact to sham operated animals. S-100B serum levels were estimated with a commercially available enzyme immuno-assay (DAKO). The mean serum level in the sham group was 0.38 microg/l. Serum levels at 100 PSI differed statistically significantly directly after trauma up to 24 h. The 48 h S-100B levels showed no significant difference in the sham group. Serum levels at different severities differed significantly from the sham group, but did not differ concerning level of severity. The controlled cortical impact model is able to produce a raised serum level of the S-100B protein for 24 hours. Different trauma severities were not reflected.