The role of computerized rheoencephalography in the assessment of normal pressure hydrocephalus.

The aim of this study was to determine the relationship between arterial compliance derived from rheoencephalography (REG), and the slope of the regression line between pulse amplitude and mean ICP (AMP/P) recorded during a lumbar infusion study. A hypothetical link between these two variables has been suggested in the past. Resistance to the outflow of cerebrospinal fluid (R(out)) and the slope of the amplitude pressure regression line (AMP/P) were calculated in 62 patients diagnosed with posttraumatic normal pressure hydrocephalus (NPH). In all patients, the changes in cerebral electrical impedance related to the pulsatile component of blood flow were studied noninvasively using computerized rheoencephalography. We classified the REG pulse-related waveform (REGpw) according to the number of the inflection points in the ascending branch, which are a manifestation of the elastic properties of the small arteries. In normal subjects, REGpw corresponded with only one inflection point in the ascending branch (category I). For the purpose of this study, we assumed that the presence of three or greater number of inflection points was characteristic of the regressive changes of the arterial wall (category II). The slope of the AMP/P in patients with the category I REGpw was significantly lower than that in patients with category II (p < 0.05). The association between REGpw category II and the increased slope of the aAMP/P regression line may be related to the transmission of the pulse pressure waveform arterial wall to the CSF compartment, which in turn depends on the elastic properties of the cerebral arteries. The outcome of shunting in patients with REGpw category I was significantly better than that in patients with category II, suggesting that small artery disease may be linked to worse clinical outcomes. Our study indicates that REG examination has potential clinical value in diagnosis and prognosis of NPH.

[Determination of melatonin concentrations in patients with consciousness disturbances after craniocerebral trauma. Preliminary communication]. / Badanie stezenia melatoniny u chorych z zaburzeniami swiadomosci po urazach czaszkowo-mózgowych. Doniesienie wstepne.

The study was performed in cooperation of the Department of Neurotraumatology and the Department of Clinical Biochemistry Jagiellonian University in Cracow. In patients with central nervous system injury, diagnosed upon computerized tomography scan, melatonin levels were measured. The most frequent reason of damage was severe craniocerebral trauma. Consciousness, assessed according to Glasgow Coma Scale, was between 3 to 13 points. Melatonin levels were measured at 8 a.m. The investigation could not demonstrate any correlations between consciousness disturbances after head injury and serum melatonin levels in the morning. To draw a final conclusion further experiments are necessary. They will help to explain the role of endogenous melatonin in patients after craniocerebral injury.

[Comparison of the clinical usefulness of magnetic resonance (MR), computer tomography )CT) and radiculography (R) in diagnosing lumbar discopathy]. / Porównanie uzytecznosci klinicznej rezonansu magnetycznego (RM), tomografii komputerowej (TK) i radikulografii (R) w rozpoznawaniu dyskopatii ledzwiowej.

The aim of the study was an assessment of the usefulness of magnetic resonance imaging (MRI), computed tomography (CT), and radiculography (R) in the diagnosis of lumbar discopathy. The accuracy of MRI, CT, and R for the diagnosis of lumbar herniated nucleus pulposus ws compared prospectively in 120 patients, undergoing surgical exploration. MRI was the most accurate test (100%) compared with CT (95%) and R (92.5%). The false positive rate was lowest for MRI (0%), followed by CT (5%) and R (7.5%). MRI proves very favorable compared with other currently available imaging modalities for diagnosis of lumbar herniated nucleus pulposus which allows to differentiate hernia and protrusion. MRI is noninvasive, has no known side effects and no radiation exposure. It is the procedure of choice for the radio-diagnosis of lumbar disc herniations.

[Brain stereotactic procedures in the Department of Neurotraumatology CM UJ in Cracow]. / Operacje stereotaktyczne guzów mózgu w materiale Kliniki Neurotraumatologii CM UJ w Krakowie.

Stereotactic procedures using Leksell frame have been performed in that Department since 1995, and as jet 199 such operations were carried out. The most frequent complication after stereotaxic biopsies was intracerebral haemorrhage occurring in 0.6 to 7.2% of cases, according to various authors. In the presented material it occurred in 1.3% of biopsies. Besides biopsy, the stereotactic procedures (105 cases) were applied for reducing the size or removal of tumours, including multiple tumours in one or both hemispheres, in one-step operations. The histological diagnoses were based on the examination of HE-stained smears, immunocytochemical reactions and electron microscopic studies. The effectiveness of the operations was assessed in control examinations (CT). The greatest group of cases undergoing stereotaxic surgery were metastatic tumours (47 cases, 61.3%), primary brain tumours were treated in 22 cases (28.57%), meningiomas in 4 (5.19%), abscesses in 3 cases (3.89%). In patients with metastatic tumours improvement was obtained in 97% of cases. One patient died from disseminated malignancies with cardiorespiratory failure. In the remaining patients no worsening of the objective status was noted after stereotaxic surgery.

[Associate professor Oscar Liszka, pioneer of surgery in Poland in the 40th anniversary of the first operation]. / Doc. dr hab. Oskar Liszka pionier stereotaksji mozgu w Polsce w 40 rocznice pierwszej operacji.

Oscar Liszka was the first in Poland who performed operations on human brain with the use of stereotactic apparatus. It took place in 1961 in the department of Neurosurgery in Cracow. He introduced Guiot-Gultingham method, which was modified in 1964 by Wicentowicz, Goscinski and Kunicki. Since 1964 stereotactic neurosurgical operations were carried out in the Department of Experimental and Clinical Medicine, Polish Academy of Sciences in Warsaw by E. Mempel. He introduced the original Talairach method and Coopers in Parkinson syndrome. Several years later, J. Bidzinski used the apparatus of Leksell at the Department of Neurosurgery, Medical Academy in Warsaw, stereotactic procedures were also performed by Mert and Bromowicz in Lodz, by Trojanowski and Turowski in Lublin, by Slosarek in Szczecin, by Sloniewski in Gdansk and by Harat in Bydgoszcz, as well Koszewski and Zabek in Warsaw. The treatments aimed at compensating for the profound loss of dopamine in the substantia nigra substantially limited the number of stereotactic operations from 1970 to 1980. Recent advancements in Computerized Axial Tomography and Magnetic Resonance imaging as well as in the histological techniques have led to new opportunities for a small stereo-static biopsy for histological diagnosis of profound brain tumors.

[Neurotrauma in treatment of nervous system injuries--principles in cooperating with anesthesiologists]. / Neurotraumatolog w leczeniu obrazen osrodkowego ukladu nerwowego--zasady wspólpracy z anestezjologiem.

After brain trauma neuronal degeneration results due to the combination of primary mechanical disruption of CNS parenchyma and the secondary pathophysiological events. The fact that the treatment can modified the clinical course and the final outcome, implies that is indeed a modifiable secondary neurodegenerative process which is caused by the mechanical injury. Contemporary in patients with craniocerebral trauma and with polytrauma our management is focused on prevention of secondary brain injury. On the accident scene that is crucial to appropriate ventilate the patient, stabilize blood pressure and prevent shock. The diagnostic tool of choice is CT, but made in the very early stage could revealed false negative scan. That could be the cause of missed beginning of intracranial pressure increase in artificially ventilated patients. Multimodality monitoring in highly specialized centers could enable early detection of such increase (ICP) and help in estimation of indication for surgical treatment. The mechanism, direct sequelae of head trauma and neurological symptoms dynamics are also important.

[Procedures for patients with brain injuries and GCS <8]. / Postepowanie z chorymi z urazami mnogimi i GCS < 8.

Epidemiologic date concerned to multiple injuries with concomitant brain injuries are presented. The basic mechanisms developing brain damage are pointed out and principles managing with patients for protection against secondary injuries. The necessity of treatment this kind of patients in intensive care centers with broad possibilities in monitoring and diagnostic equipment is defined.

[Experiments in evaluation of brain oxygenation and metabolism based on continuous bilateral SjO2 monitoring and metabolic glucose transformations in patients after severe cranio-cerebral injuries]. / Wlasne doswiadczenia w ocenie oksygenacji i metabolizmu mózgu na podstawie ciaglego obustronnego monitorowania SJO2 oraz przemiany metabolicznej glukozy u chorych po ciezkich urazach czaszkowo-mózgowych.

The study group consisted of 17 patients after severe cranio-cerebral injuries-in GCS below 8. Saturation in both jugular bulbs was measured by using fiberoptic catheters, the concentration of lactate taken from jugular bulbs was measured too. These values were compared to concentration in peripheral arteries. All measurements were started within the first 24 h after trauma and lasted 5 days. Diagnosis of intracranial pathology was established by using CT, which was done directly after admission to the hospital. Interdependence between the state of patient in GOS and variability saturation and concentration of lactate was showed. Desaturation occurred before the neurological sings of intracranial hypertension what had influence on way of treatment and diagnostics. Bilateral measurement of the saturation is more useful to make diagnostic unilateral measurement.

[Effect of general anesthesia induction on cerebral circulation in subacute and chronic subdural hematoma assesssed by computerized rheo-encephalography]. / Wplyw indukcji znieczulenia ogólnego na krazenie mózgowe w podostrym i przewleklym krwiaku podtwardówkowym na podstawie skomputeryzowanej reoencefalografii.

Cerebral circulation in 21 patients with subacute (SSH) and chronic subdural hematoma (CSH) were studied by computerized rheoencephalography before and after induction of general anesthesia. ECG and REG courses were sampled with a frequency of 62.5 Hz during a period of 15 minutes, and both sets of data points were fitted by an cubic polynomials. We introduced the classification of the REG pulse related waveform (PRW) according to the number of the inflection points in the anacrotic branch. The cases of normal pulse form, with almost vertical systolic upstroke corresponded with only one inflection point in the ascending branch (grade I). We assumed that the presence of three or greater number of inflection points reflected more gradual systolic rise, is characteristic for regressive changes of the arterial wall (grade II). The relative duration of the anacrotic branch was calculated. The first obtained result was the significant correlation between REG and clinical status. The unfavorable effect of induction on cerebral circulation corresponded with less favorable results of treatment. Our preliminary results indicate the clinical value of REG examination in the preoperative evaluation of the cerebral circulation.

[Post-traumatic bacterial meningitis]. / Pourazowe ropne zapalenia opon mózgowordzeniowych.

10 patients with posttraumatic bacterial meningitis were treated in the Department of Infectious Diseases of the Jagielloniam University--Collegium Medicum during the period of 63 months. Traffic accidents were responsible for 80% of all cases of trauma. The most common place of injury was the base of anterior cranial fossa. Infecting agent was established in 8 cases. Gram-positive aerobic cocci (Streptococcus pneumoniae, Enterococcus faecalis, and Enterococcus spp.) were found in 4 patients, Gram-negative aerobic cocci (Neisseria meningitidis) in 2 patients, and Gram-negative aerobic rods (Acinetobacter baumanii, Pseudomonas aeruginosa, Klebsiella spp, Escherichia coli) in 3 patients. Streptococcus pneumoniae was still highly sensitive to penicillin, ampicillin and cefotaxime. Enterococcus faecalis and Enterococcus spp. were sensitive to vancomycin and teicoplanin. Neisseria meningitidis was sensitive to penicillin, cefotaxime, amoxicillin/clavulonate. Gram negative aerobic rods were sensitive to third-generation cephalosporins, carbapenems and aminoglycosides. Among 10 patients treated for posttraumatic bacterial meningitis 1 patient died and in 1 preserved vegetative state was diagnosed. In 4 patients severe or moderate disabilities developed, however 4 recovered completely. 6 patients after regression of the CNS infection were qualified to neurosurgical intervention. In 3 patients reconstructive operation of the basis of anterior cranial fossa with tissue glue Beriplast P. was done, the recovery was complete. 3 patients didn't agree to surgical operation, and we don't know what has happened with them. They have not come to the control visit.

[Long-term good results of surgical treatment for spontaneous epi- and subdural hematoma in a female patient on maintenance hemodialysis]. / Dlugotrwaly dobry wynik leczenia operacyjnego spontanicznego krwiaka nad- i podtwardówkowego u chorej objetej programem powtarzanych hemodializ.

Spontaneous intracranial hematoma is not rare, but with bad prognosis, complication in patients on maintenance hemodialysis (HD). Diagnostic difficulties result from a fact that symptoms of acute hematoma such as headaches,, nausea, vomitis, apathy, sleepiness, parestesia and seizures may also suggest dysequilibrium syndrome, dialytic dementia as well as hypertensive encephalopathy. We describe a case of female patient with 20-year interview data of hypertension on HD since 1981 because of end-stage renal failure in a course of chronic glomerulonephritis, who developed spontaneous epi- and subdural hematoma four year ago in 47 age of life. Performed CT examination confirmed diagnosis and on the same day the patient underwent right frontoparietotemporal craniotomy and the hematoma was removed. During postoperative period, HD sessions were performed without heparin. After surgery the patient developed transcient hypertonia, epileptic sizures and left-sided paresis. Currently, 48 months after craniotomy the patient is fully rehabilitated, with normal blood pressure, without epileptic sizures or palsy. Gradually we discontinued anticonvulsans and antihypertensives.

CT-guided stereotactic biopsy of brain. Three years of experience.

In our center from 1995 up to now (08.06.99) we have performed 78 CT-guided stereotactic biopsies (SB) of brain. In all cases the stereotactic biopsy was performed as the first surgical, diagnostic procedure. Indications for SB were as follows (in brackets, the number of SBs): diffuse, inoperable tumor (43), tumor of central region of brain (19), multiple tumors (7), a change of the obscure nature in CT/NMR scan (15), stereotactic assistance of the "classic: craniotomy and surgery of tumor (4). Among 78 SBs in 49 cases the primary and in 13 cases--secondary (metastatic) brain tumors were diagnosed. In the remaining 16 cases nonspecific changes like gliosis or necrosis were found. Of 49 primary tumors 40 were gliomas. Different pathomorphological methods, including especially immunohistochemistry with GFAP, vimentin, p53, Ki-67, and topoisomerase II alpha if applied together, may at least partially help to overcome the problems of the differentiation of reactive and neoplastic gliosis. We found a grading system of gliomas according to Daumas-Duport very useful in interpretation of SB material. Our preliminary observations suggest that immunolabelling of the biopsy material by means of topoisomerase II alpha antibody may be very useful in SB since it gives technically very good results on smears and because on the grounds of what is known on this enzyme it is the "target" of many antineoplastic drugs and hence may indicate the potential sensitivity to drugs.

[Clinical observations concerning piracetam treatment of patients after craniocerebral injury]. / Spostrzezenia kliniczne leczenia nootropilem chorych po urazach czaszkowo-mózgowych.

Piracetam (Nootropil) is a cytoprotective to brain tissue and improving cerebral blood flow medicine. In the Department of Neurotraumatology we investigated results of piracetam treatment in a group of 100 succeeding patients admitted between 1995-96 due to craniocerebral injury. High doses (24-30 g per day) of this medicine have a positive effect on final result of treatment, when treatment is initiated immediately after the injury and described conditions are abided. We also showed usefulness of piracetam treatment in posthospital management.

Primary malignant lymphoma of brain. A review of four cases diagnosed by means of CT-guided stereotactic biopsy.

In a series of 66 CT-guided stereotactic biopsies (SB) of the brain performed in 1995-1998, four were found to be the primary non-Hodgkin's lymphomas (PCNSL). All cases were studied with immunohistochemistry (broad panel of antibodies; reactions performed mainly on cytological smears) and with the use of an electron microscopy. In an immunophenotyping all cases were positive for leukocyte common antigen (LCA) and 3/4 showed B-cell phenotype. Since the PCNSL are typically located in central, periventricular region of brain and the surgical removal does not bring any benefit, the stereotactic biopsy is a method of choice to make a definite diagnosis that opens the chances for implementation of chemo- and radiotherapy. The diagnostic difficulties that are derivatives of an extremely small amount of the available biopsy material were discussed and the role of the immunophenotyping and of the electron microscopy for avoiding the possible diagnostic mistakes was stressed. Cytological smears stained with H&E and the smears and histological slides with immunohistochemical reaction against glial fibrillary acidic protein (GFAP) showing sometimes extremely dense network of astrocytes mingled with neoplastic lymphoma cells are especially interesting and seem to suggest the involvement of astroglia in the pathogenesis of PCNSL.

[Treatment of iliac vein thrombosis by use of filter placed in the inferior cava vein in a female patient after reoperation of meningioma of the smaller section of the sphenoid bone]. / Leczenie przy pomocy "filtru" zakrzepu zyly biodrowej lewej siegajacego do zyly glównej dolnej u chorej po reoperacji oponiaka skrzydla malego kosci klinowej.

Deep phlebothrombosis is a one of the postoperative complications in neurosurgery in 90% localized in lower extremities. The brain contains the highest concentration of tissue thromboplastin compared with the other organs. That fact plays an important roll in pathophysiology of thrombo-embolic process in neurosurgery. The most frequent places of thrombogenesis are venous sinus of soleus muscle and gastrocnemius muscle, next: deep veins of crus, femoral veins and iliac veins. We describe the case of the efficient treatment of femoral vein and iliac vein thrombosis using filter placed under control of monitor in the inferior caval vein higher than the thrombus.

[Piracetam in severe cranio-cerebral injuries]. / Piracetam w ciezkich urazach czaszkowo-mózgowych.

A group of 100 patients treated immediately following a cranio-cerebral injury was analyzed. The patients, administered piracetam either in an intravenous infusion (GCS 3-8) or orally (GCS above 9), were divided into groups depending on the dose and clinical status. Piracetam participates in the activity of the majority of neurotransmitters, increases glucose and oxygen consumption in the ischaemic nervous tissue and increases blood flow through cerebral terminal vessels. In cranio-cerebral injuries, piracetam is employed to achieve cytoprotection and improve cerebral blood flow. In patients with neurological deterioration following the administration of 6-10 mg/day, no good results were obtained. A dose of 24-30 mg/day had a significant positive effect on therapeutic results providing certain conditions were met, such as ensuring proper partial oxygen pressure (oxygen therapy) and proper blood glucose levels. The use of piracetam is justified immediately after an injury; after the discharge oral piracetam therapy is recommended.

The Kluver-Bucy syndrome.

Evolution of psychological disorders following head injury including memory and other cognitive disorders are common. The best known are psychiatric disturbances of various kinds after lesions of the frontal lobes. Cognitive, behavioural and emotional disorders are not usually seen in patients with bilateral temporal lesions. In our Department of Neurotraumatology we have observed 4 patients with posttraumatic lesions localized bitemporally. They developed Kluver-Bucy syndrome-rarity in human pathology-combined with three or more of the following symptoms and signs: increased oral activity, hypersexuality, hypermetamorphosis, memory disorders, placidity, loss of people recognition, bulimia. Several symptoms responded dramatically to carbamazepine. We conclude that it may be a useful agent in the treatment of this unusual syndrome.

[Facial neuralgia (neuralgia n. V). Diagnosis and treatment]. / Rwa twarzy (neuralgia n. V). Rozpoznanie i leczenie.

We present evaluation and methods of treatment for "tic douloureux" (trigeminal neuralgia). Angio-Magnetic Resonance seems to be essential in establishment of neuro-vascular compression pathology. Present diagnostic increased number of surgical intervention from suboccipital craniectomy approach in micro-vascular decompression. In patients with contraindications for general surgery other techniques are being used to decrease pain sensation: RF thermocoagulation with the help of stereotactic procedure, percutaneous microcompression of the trigeminal ganglion, radiosurgery, electrical stimulation of the Gasserian ganglion. Current methods of imaging and new therapeutical achievements allow to dramatically reduce pain and discomfort in first days of trigeminal neuralgia.

[A case of severe recurrent trigeminal neuralgia]. / Przypadek uporczywej nawracajacej neuralgii nerwu trójdzielnego.

We present diagnostic and treatment procedure in the patient with trigeminal neuralgia lasting few years. Microvascular decompression on art. cerebellar superior relief the patient from pain.