Craniocervical manual lymphatic drainage and its impact on intracranial pressure - a pilot study.

BACKGROUND AND PURPOSE: Theoretical considerations and the results of animal studies indicate that manual lymphatic drainage (MLD) might have an impact on intracranial pressure (ICP). There is a lack of clinically qualitative investigations on patients with severe cerebral diseases. METHODS: Between April 2013 and January 2015 a prospective observational study was performed on patients who were undergoing intracranial pressure measurement and treatment with MLD. ICP, cerebral perfusion pressure, mean arterial pressure (MAP), heart rate and oxygen saturation were recorded continuously 15 min before the procedure, during MLD (22 min) and for 15 min after the procedure. For analysis the data treatment units were divided into two groups: patients with a mean baseline ICP <15 mmHg (group 1) and patients with a mean ICP ≥15 mmHg before MLD (group 2). RESULTS: A total of 133 treatment units (61 patients) were analysed (group 1 n = 99; group 2 n = 34). The mean baseline ICP was 10.4 mmHg overall, and 8.3 mmHg and 18.6 mmHg respectively in group 1 and group 2; ICP significantly decreased during therapy with MLD and this persisted during the follow-up period in group 2. MAP did not show any significant differences between the different periods. CONCLUSIONS: Our data showed a significant reduction of ICP during therapy with craniocervical MLD in patients with severe cerebral diseases.

Intracranial Pressure Changes During Intrahospital Transports of Neurocritically Ill Patients.

BACKGROUND: Intrahospital transport is associated with a high rate of complications. Investigations of this problem using neuromonitoring remain scarce. METHODS: This is a monocentric, prospective observational study. Patients with severe brain diseases and intracranial pressure (ICP) monitoring were included. Continuous monitoring of ICP, cerebral perfusion pressure (CPP), oxygen saturation (SpO2), heart rate, and mean arterial pressure was measured during seven different periods of intrahospital transport (baseline for 30 min, I = preparation, II = transport I, III = CT scan, IV = transport II, V = postprocessing, and follow-up for another 30 min). All complications were documented. RESULTS: Between July 2013 and December 2013, a total number of 56 intrahospital transports of 43 patients were performed from ICU to CT. Data recording was incomplete in six cases. Fifty transports have been taken into account for statistical analysis. Forty-two percent were emergency transports. Mean duration of the procedure was 17' (preparation), 6' (transport I), 9' (CT scan), 6' (transport II), and 15' (postprocessing), respectively. Mean ICP at baseline was 8.53 mmHg. Comparing all periods of intrahospital transport and the follow-up period to the baseline showed a significant increase of ICP only during CT scan (15.83 mmHg, p < 0.01), not during the transport to and from the radiology department. An overall complication rate of 36 % (n = 18) was observed. In 26 % (n = 13), additional ICP therapy was necessary due to an elevation of ICP above 20 mmHg. CONCLUSION: There is a considerable rate of complications during intrahospital transport of critically ill patients with severe brain diseases, with a significant increase of ICP during transport and CT scan. In one-fifth of all patients, additional therapy was necessary. From our point of view, transport of critically ill patients should only be performed by trained staff and under monitoring of ICP and CPP.

Intracranial pressure and cerebral perfusion pressure during apnoea testing for the diagnosis of brain death - an observational study.

BACKGROUND AND PURPOSE: Some authors have suggested a rise of intracranial pressure (ICP) during apnoea testing and the possibility of harm to patients. Data, however, have yet to be obtained. METHODS: Between October 2012 and May 2014 an observational study was performed on patients who received ICP measurements and who underwent brain death diagnosis. ICP, cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP) and heart rate were recorded continuously from 15 min before the start of brain death diagnosis (baseline), during clinical examination including apnoea testing, until 15 min after this procedure. RESULTS: A total of 16 clinical examinations for brain death including apnoea testing were performed on 13 patients. All patients had primary brain lesions. Mean ICP and mean CPP during the examination were 95 ± 27.7 mmHg and 13.5 ± 20.7 mmHg, respectively. ICP and MAP showed a strong and statistically significant correlation, with Pearson's correlation coefficients of more than +0.6 or less than -0.6 in 13 of the 15 examinations. CONCLUSION: Mean ICP even before brain death determination is increased excessively. Changes of ICP during apnoea show a clear correlation to the changes of MAP. Furthermore, CPP during the condition of brain death may not equal zero but may be positive thereby indicating some minor net influx of blood into the brain in some patients.

[Multilevel segmental interbody fusion versus vertebral body replacement: comparison of two operative methods]. / Mehrsegmentale interkorporelle Fusion vs. Wirbelkörperersatz: Vergleich zweier operativer Methoden.

BACKGROUND: The surgical techniques of interbody fusion and vertebral body replacement represent two concurrent options for multilevel anterior decompression and arthrodesis of the cervical spine. PATIENTS AND METHODS: In a retrospective study the data from 61 patients who received either interbody fusion (n = 38) as anterior cervical discectomy and fusion (ACDF) or vertebral body replacement (n = 23) (as anterior cervical corpectomy and fusion (ACCF) because of degenerative disc disease of the cervical spine were collected. RESULTS: The clinical outcome was better at all time points in the patient group with ACDF than in those with ACCF but with no statistically significant differences. The operated segments showed a more rapid fusion progress after ACDF during the time course in comparison to ACCF; however, there was no relationship between the grade of fusion and the clinical result. CONCLUSION: In direct comparison multisegmental interbody fusion showed better results with respect to the clinical outcome and bony fusion with a lower rate of complications than vertebral body replacement. However, the differences did not reach statistical significance.

[Mimikry of herpes encephalitis by glioblastoma multiforme]. / Mimikry einer Herpes-Enzephalitis durch Glioblastoma multiforme.

Herpes encephalitis (HSE) is an acute illness. Imaging is an important part of the diagnostic work-up of HSE. In early stages one can see a manifestation in the insular cortex as well as in the fornix. These MRI findings are rather typical for HSE. We present three cases treated in our hospital over the past ten years. In these cases the clinical symptoms and signs as well as the morphological findings were compatible with the HSE diagnostic criteria. Later on, a glioblastoma multiforme was found in all three cases.

Gravitational shunt units may cause under-drainage in bedridden patients.

OBJECTIVE: Implantation of a shunt in a hydrocephalic patient still carries a risk of complications such as over-drainage and under-drainage. Gravitational shunt units are especially designed to minimize the problem of over-drainage. Nevertheless, these valves carry a risk of under-drainage. The best choice of valve for a patient is still challenging. The purpose of this survey was to identify in which patients a gravitational shunt valve is liable to lead to under-drainage. METHODS: Patients with hydrocephalus entered prospectively into a data base were reviewed retrospectively. The patients were treated between January 2006 to the end of Feb 2007 and those experiencing under- or over-drainage were identified. RESULTS: Thirty-five ventriculo-peritoneal shunt systems were implanted in adult patients. The cause of the hydrocephalus was: normal pressure hydrocephalus in 18 patients, post-haemorrhagic following subarachnoid or intracerebral haemorrhage in 11, associated with a tumour in four and followed a head injury in two patients. Three different valves were used: an adjustable shunt valve with gravitational unit (Pro-GAV 0-20/25 in 21 patients), a gravitational shunt valve with fixed opening pressure (GAV 5/30 in nine patients) and an adjustable differential valve (Hakim medos in five patients). Four patients developed severe, valve-related under-drainage. Each had received a gravitational shunt valve and all were bedridden. In two of these patients it was necessary to change the valve. One patient who had received a differential valve, after regaining mobility developed severe over-drainage with bilateral subdural haematomas. Over-drainage was not seen in long-term bedridden patients with a differential shunt valve. CONCLUSION: If a bedridden patient with a gravitational shunt valve system lies with a slightly elevated head, this leads to activation of the gravitational unit and this may cause under drainage. As a result, we advise not using an anti-siphon devices in a patient who is bedridden for a long period.

Chiari malformation type I with concomitant persistent trigeminal artery -- report of an unusual case and a review of the current literature.

BACKGROUND: Chiari malformation type I is a stenosis of the subarachnoid space at the level of the foramen magnum due to a small posterior fossa and herniation of the cerebellar tonsils. We present here the unusual case of a Chiari malformation in conjunction with a persistent trigeminal artery and hypoplasia of the basilar artery, also known as a Saltzman anomaly. CASE REPORT: A 34-year-old female physician presented with recurrent headaches, bilateral weakness of deltoid muscles and numbness of the fingertips 3 to 5. A cranial MRI revealed a descent of the cerebellar tonsils to the level of C2 and a supracerebellar cyst. During surgery, a decompressive suboccipital craniectomy was performed. The supracerebellar cyst was fenestrated and the cerebellar tonsils were resected bilaterally. Two days after surgery the patient developed cranial nerve dysfunction and a right-sided hemiparesis. Cerebral angiography revealed a Saltzman type 1 anomaly with persistent primitive trigeminal artery and hypoplasia of the basilar artery. DISCUSSION: This is the first report in the literature about the coincidence of both unusual anomalies. The latest literature of both rare anatomy and the unusual clinical course will be discussed.

Endothelin-1 in plasma, cisternal CSF and microdialysate following aneurysmal SAH.

OBJECTIVE: Endothelin-1 (ET-1) is postulated to play an important role in the development of cerebral vasospasm (CVS) following SAH. This study was conducted to investigate the time course of ET-release in three different sources: CSF, plasma and microdialysate. METHODS: In a prospective study ET-1-concentrations were measured in plasma, cisternal CSF and microdialysate in 20 patients with aneurysmal SAH for at least 8 days after hemorrhage. RESULTS: ET-1 concentration in microdialysate was almost four times higher compared to CSF and plasma. (p<0.001) Only in CSF ET-1-release showed a significant increase over time with highest values on day 5 post ictus (p = 0.03). This was parallel to the increase of transcranial Doppler velocities. ET-1 in plasma and microdialysate did not change over time. CONCLUSION: ET-1 may have a different biological function in different biological tissues. Only ET-1 in CSF seemed to be associated with CVS.

[Recommendations for the management of patients with aneurysmal subarachnoid hemorrhage]. / Empfehlungen zum Management der aneurysmatischen Subarachnoidalblutung -- Sektion vaskuläre Neurochirurgie der Deutschen Gesellschaft für Neurochirurgie und Wissenschaftlicher Arbeitskreis Neuroanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin.

After SAH, primary and secondary complications are frequent and often require neurosurgical interventions to avoid secondary brain damage. The authors of the present paper have summarized the available data about the treatment modalities often used for patients with SAH. The present recommendations have been developed as a neurosurgical and neuroanestesiological consensus. Evidence from prospective, randomized, double blind, placebo-controlled studies support grade A recommendations (standard) for the prophylaxis and treatment of cerebral vasospasm with oral Nimodipine in good grade patients. For intravenous Nimodipine or for oral nimodipine treatment in poor grade patients, available data only support grade C recommendations (options). Despite the lack of data supporting standards (grade A) or guidelines (grade B), avoidance and rigorous treatment of hypotension and hypovolemia remains the mainstay in the prophylaxis and treatment of a delayed ischemic neurological deficit (DIND). Prophylactic hypervolemia or prophylactic hypertension and hypervolemia was shown to be ineffective in reducing symptomatic vasospasm and improving outcome (grade B). Therapeutic hypertensive hypervolemic hemodilution is recommended as a treatment of symptomatic vasospasm but no prospective studies are available (grade C recommendation). Suggested target values for moderate triple-H-therapy are CPP 80- 120 mmHg (MAP 90-130), CVP > 7 mmHg and Hk 0.25-0.40. Balloon angioplasty should be considered for treatment of DIND cause by focal, proximal cerebral vasospasm. There is no evidence supporting the routine use of antifibrinolyticals, steroids or anticonvulsive prophylaxis. Clinical data indicate that current prophylaxis and treatment of cerebral vasospasm is still insufficient and aggressive triple-H-therapy is associated with an increased incidence of complications.

Greater superficial petrosal nerve schwannoma.

Greater superficial petrosal nerve (GSPN) schwannoma is a very rare type of facial nerve schwannoma. Including our case, only 6 schwannomas have been reported to originate from the GSPN. Clinical features, imaging, diagnosis, differential diagnosis and treatment are discussed reviewing other cases in the pertinent literature.

Stereotactic aspiration and fibrinolysis of spontaneous supratentorial intracerebral hematomas versus conservative treatment: a matched-pair study.

OBJECTIVES: Since introduction of stereotactic aspiration and fibrinolysis into the treatment of deep-seated intracerebral hematomas by Hondo and Matsumoto 1984 this method has become widely used, and satisfactory morphological results are achieved. Nevertheless, whether the outcome is improved has not yet been investigated. MATERIAL AND METHOD: 17 patients with spontaneous intracerebral hematomas have been treated surgically; after angiographic exclusion of a vascular malformation stereotactic aspiration and fibrinolysis with 3 mg rTPA was performed. Between 1992 and 1995 104 patients were treated conservatively according to best medical treatment. From this group "matched pairs" with the surgical patients were set up concurring in primary (consciousness, size and location of the hematoma) and secondary parameters (age, sex, ventricular hemorrhage). Endpoint of the study was the Glasgow outcome score (GOS) six months after treatment. Data were analyzed statistically and p < 0.05 was considered significant. RESULTS: In respect of primary parameters complete concurrence and regarding secondary parameters far-reaching concurrence was achieved. In no parameter the surgical and conservative group were significantly different from each other. Six months after the ictus no significant difference between surgical and conservative treatment concerning GOS could be established. CONCLUSION: These results indicate that patients do not benefit from stereotactic aspiration and fibrinolysis of putamenal hematomas. For a final treatment recommendation a prospective randomised trial is required.

Surgical management of previously coiled intracranial aneurysms.

With the increased use of endovascular therapy in the treatment of ruptured intracranial aneurysms the number of incompletely coiled aneurysms presenting for further management either due to lack of universal durability of this method or due to recurrent rupture is increasing. Since 1998, seven patients with previously coiled aneurysms underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry. Indications for surgery, the surgical techniques used and patient outcome were analysed. Surgery of recurrent or residual aneurysms resulted in a good outcome in four and a moderate outcome in one patient. Despite early clipping after recurrent haemorrhage after coil occlusion one of the two patients died, the other one had a moderate outcome. Our experience indicates that good results are obtainable, although technical challenges are frequently encountered.

Nitric oxide metabolites in cisternal CSF correlate with cerebral vasospasm in patients with a subarachnoid haemorrhage.

BACKGROUND: The pathogenesis of cerebral vasospasm is likely to be multifactorial. Exposure of the adventitia of large cerebral arteries to blood breakdown products initiates a cascade of changes in both morphology and vasomotor regulation of the exposed vessels. The role of nitric oxide (NO) in development of cerebral vasospasm process is controversial. Basal cerebral vascular tone requires the continuous release of NO, nevertheless NO is involved in free radical mediated injury of endothelial cell membrane. Concentrations of nitrate/nitrite (stabile endproducts of NO metabolism) were studied in cisternal cerebrospinal fluid (cCSF) in patients suffering from aneurysmal subarachnoid haemorrhage (SAH). METHOD: 21 patients suffering from aneurysmal SAH were investigated. Treatment included aneurysm clipping, cisternal drainage of CSF and intravenous nimodipine in all patients as well as tripple H therapy when indicated. TCDS was performed on a daily basis. A mean flow velocity of more than 150 cm/sec and the development a delayed neurological deficit was defined as vasospasm. CSF samples were collected on the day of surgery and for the 7 days following. NO-M (nitrite and nitrate) were measured using a commercially available test kit. FINDINGS: 5 of 21 patients developed clinically symptomatic vasospasm. There was a significant difference in NO levels between the groups. Patients with cerebral vasospasm showed significantly higher levels of NO-M in CSF than patients with a uncomplicated follow-up between day 2 and 8. INTERPRETATION: Our preliminary results indicate that SAH leads to an increase in NO-M in CSF. This increase of NO-M significantly correlates with the flow velocities in TCDS measurement suggesting that NO plays an important role in the pathogenesis of cerebral vasospasm.

[Delayed appearance of posttraumatic cerebrospinal fluid fistulas as a cause of recurrent meningitis]. / Verzögertes Auftreten posttraumatischer Liquorfisteln als Ursache rezidivierender Meningitiden.

Immediate post-traumatic fistulas with rhinorrhea are well known after head injury with frontobasal trauma. Less attention is paid to the possibility of delayed onset of rhinorrhea after severe head injury. Unrecognised frontobasal injury may cause recurrent meningitis due to communication of CSF with the outside world. In the last 5 years, seven patients who developed rhinorrhea 2-25 years after trauma were treated in our department. All patients had been through at least two episodes of meningitis. Intermittent rhinorrhea was reported by four. In all cases, coronal bone window CT scan disclosed a bony defect of the anterior skull base, and in three cases an encephalocele was revealed on MRI. Treatment consisted of reconstruction of the anterior skull base with a pedicled galeal-pericranial flap via bifrontal craniotomy. Delayed traumatic CSF fistulas are not rare but must be considered in the differential diagnosis of recurrent meningitis.

[Delayed traumatic CSF-fistulas: a retrospective analysis]. / Verzögernd auftretende Liquorfisteln - eine retrospektive Analyse.

Immediate posttraumatic CSF-fistulas are a well known entity after severe head injury. Delayed onset of rhinorrhea is considered to be rare. In the last 5 years 7 patients were treated in our department, who developed rhinorrhea 2-25 years after trauma. All patients went through episodes of meningitis. In 4 cases intermittent rhinorrhea was reported. In all cases a bony defect of the anterior skull base was detected by coronal bone window CT-scan. In three of them an encephalocele was revealed by MR-scanning. Treatment consisted in reconstruction of anterior skull base with a pedicled galeal-pericranial flap via a bifrontal craniotomy and went out without any complications. Delayed rhinorrhea after severe head injury is not a rare curiosity. In cases of bony defects after head injury reconstruction of anterior skull base is recommended to prevent episodes of recurrent meningitis.

CLL cells in a brain metastasis of bronchial adenocarcinoma in a patient with three different neoplasms - case report.

OBJECTIVE: We report the case of a patient with three different malignancies who had a brain metastasis of bronchial adenocarcinoma with infiltrates of CLL lymphocytes and who had been operated for prostate cancer years before. - PATIENT AND RESULTS: A 72-year-old man was admitted to our department after a Jacksonian seizure. The MRI showed a left temporal mass lesion. The patient was suffering from chronic lymphocytic leukemia (CLL) for ten years, he had had surgery for prostate cancer eight years ago and the diagnosis of bronchial carcinoma was made during preoperative routine diagnostics. After neurosurgical intervention the histologic examination of the cerebral mass lesion disclosed metastasis of a PSA-negative adenocarcinoma with perivasal infiltrates of lymphocytic leukemic cells. - DISCUSSION: There are few reports about patients with three primary malignancies. CLL may play a role in enabling tumor cells to escape the immune response and could facilitate development of the prostate cancer and of a bronchial adenocarcinoma as secondary cancers in this patient. The combined occurrence of adenocarcinoma cells and CLL lymphocytes in the brain metastasis can be explained by impairment of the blood-brain-barrier in the carcinoma metastasis enabling extravasation of circulating leukemic cells.

[Pain of the trigeminal nerve as the first symptom of a metastasis from an oesohaguscarcinoma in Meckel's cave - case report]. / Trigeminusneuralgie als Erstsymptom einer Oesophaguskarzinom-Metastase im Cavum Meckeli - Fallbericht.

Pain in all three divisions of the trigeminal nerve is in over 65% of all cases the first symptom of a tumour in Meckel's cave. Tumors in this location make up only 0,5% of all intracranial tumours. The most common are trigeminal schwannomas and meningeomas. A metastases as a cause of trigeminal pain is a rare description in the literature so far. We describe a patient with trigeminal pain and a tumour in Meckels's cave shown in the MRI, who were operated in our department. The histological examination of the tumour resulted in the diagnosis of metastatic carcinoma of an until then unknown oesophaguscarcinoma. - Although metastatic tumours are rare, we could show with our case, that they have to be included in differential dignostic considerations.

MRI of acute experimental intracerebral hematoma.

The purpose of the study was to evaluate the ability of different MR-sequences to detect and delineate experimentally produced hyperacute intracerebral hematomas in rats. Twenty male Sprague-Dawley rats received a unilateral hematoma of various volumes by stereotactic injection of fresh autologous arterial blood into the right caudatoputamen. MRI was performed up to 30 min after-generation of each hematoma. We obtained coronal T2- and T1-weighted spin-echo images. Furthermore we acquired RF-spoiled 2D- and 3D-FLASH images. MR-images were evaluated for signal behavior, location, configuration, size, and volume of each hematoma on a dedicated work station. MR volumetry was correlated to volumetric data obtained from the serial stained histological sections. All hematomas produced signal abnormalities on all sequences in each case. In the majority of cases the hematomas were hypointense. RF-spoiled FLASH 2D- and 3D-sequences showed the best detection of the hematoma owing to their high sensitivity to susceptibility effects. The best correlation between MR- and histological volumetry was found on RF-spoiled FLASH 2D- (corr. 0.81), SE T2- (corr. 0.79), and T1- (corr. 0.74) weighted images. The lowest correlation index was found on the RF-spoiled FLASH 3D-images (corr. 0.51). Signal loss of hematomas on gradient-echo images and--to a lesser extent--spin-echo T2-weighted images due to susceptibility effects can reliably delineate an acute state, whereas conventional MR scans of ischemic stroke may be normal. MRI may thus be the imaging modality of choice in patients with acute brain attack, especially when it is planned to perform diffusion and perfusion MRI before thrombolytic therapy.