Multiple cranial gunshot injuries without skull penetration.

We report on a 74 year old patient who was admitted to the Emergency Department of Cologne University after an attempt to commit suicide. Clinical examination showed no neurological deficits but two bleeding bullet holes in his head bilateral in the temporal areas initially suggesting a complete passage of a bullet through the head. The patient was able to answer questions but showed also a slight bleeding from his mouth while talking. Emergency CT showed a bullet between the internal and external lamina of the temporal bone on both sides and one bullet in the hard palate. With general anesthesia, all bullets were removed without complications, the wounds were sutured and general antibiotics were administered. The patient survived without neurological deficit and antidepressants were commenced. Examination of the gun revealed a Second World-War 7.65 mm Luger handgun with degenerated gun powder quality and humidity after 50 years storage in the patient s bedroom.

The High Rate CIS Auditory Brainstem Implant for Restoration of Hearing in NF-2 Patients.

AIM: Hearing preservation is one of the major goals of acoustic neuroma surgery. In NF-2 patients, bilateral hearing loss is frequently caused by the disease or results from its treatment. Several implant devices for electrical stimulation of the cochlear nucleus have been developed to restore serviceable hearing in these patients. We report our experience and results using a high rate continuous interleaved sampling (CIS) auditory brainstem implant (ABI). METHODS: Between June 1997 and May 2004, 24 NF-2 patients were managed by our group. In 20 patients an ABI was implanted successfully. The cochlear nucleus was located using anatomical landmarks and E-ABR recordings after resection of the neuroma via a retrosigmoid approach in the semi-sitting position. The 12-channel stimulating electrode array was inserted and fixed in the lateral recess. There were no surgical complications related to implantation apart from pseudomeningo that were managed by lumbar drainage. RESULTS: In one patient the electrode array became dislocated and this necessitated revision surgery which was successful. One patient failed to gain benefit from the implant. Overall, 70% of electrodes were found to be serviceable for auditory stimulation, 5.3% of electrodes were primarily nonauditory, and in 7.8% side effects during stimulation were observed. Lip reading was improved by more than 100% as a result of the additional auditory input. For many patients, comprehension of open speech was restored to a useful level. Almost all patients were able to perceive environmental sounds and tinnitus was masked. CONCLUSIONS: Restoration of hearing using ABIs in NF-2 patients is a safe and promising procedure for those who would otherwise be totally deaf. The high rate CIS speech processing strategy has proven to be very useful and effective in direct cochlear nucleus stimulation.

Health-related quality of life during the first year after severe brain trauma with and without polytrauma.

OBJECTIVE: The increasing number of patients surviving severe traumatic brain injury (sTBI) but with significant sensorimotor and neuropsychological deficits is a challenge to rehabilitation medicine. So far, most research initiatives have focused on mortality rates, physiological or economic parameters to estimate therapeutic effects of rehabilitation strategies. Investigations on health-related quality of life (HRQoL) after TBI with and without concomitant polytrauma are rare compared to other disorders. DESIGN/PATIENTS: A prospective study was conducted to investigate HRQoL using the SF-36 questionnaire in 49 patients with sTBI (Glasgow Coma Scale < 9 for more than 24 hours) with and without concomitant polytrauma 6 and 12 months after injury. RESULTS: The SF-36 score profiles 6 and 12 months after trauma were similar. Scores 12 months after trauma, however, were higher in 7/8 dimensions indicating an improvement over time. Similar observations were made for physical and mental sum scores. There was no difference in the SF-36 scoring pattern between the patients with isolated TBI and the patients with concomitant polytrauma, except for physical functioning after 12 months. CONCLUSION: While there is significant overall improvement of HRQoL over time, sTBI appears to bear major influence on post-traumatic HRQoL and outcome.

Trauma-associated inflammatory response impairs embryonic stem cell survival and integration after implantation into injured rat brain.

Pluripotent embryonic stem cells were shown to survive and differentiate into mature neuronal cells after implantation in experimental models of Parkinson disease and cerebral ischemia. Embryonic stem cell transplantation has also been proposed as a potential therapy for cerebral trauma, characteristic of massive loss of multiple cell types due to primary insult and secondary sequelae. Green fluorescent protein (GFP)-transfected murine embryonic stem cells were implanted into the ipsi or contralateral cortex of male Sprague-Dawley rats 72 h after fluid-percussion injury. Animals were sacrificed at day 5 or week 7 postimplantation. Brain sections were examined using conventional and fluorescent double-labelling immunohistochemistry. Five days after implantation, clusters of GFP-positive cells undergoing partial differentiation along neuronal pathway, were detected at the implantation site. However, after 7 weeks, only a few GFP-positive cells were found, indicating an extensive loss of stem cells during this time period. For the first time, we proved the observed cell loss to be mediated via phagocytosis of implanted cells by activated macrophages. Cerebral trauma, induced 3 days prior to implantation, has activated the inflammatory potential of otherwise immunologically privileged tissue. Subsequent cell implantation was accompanied by reactive astrogliosis, activation of microglia, as well as a massive invasion of macrophages into transplantation sites even if the grafts were placed into contralateral healthy hemispheres, remote from the traumatic lesion. Our results demonstrate a significant post-traumatic inflammatory response, which impairs survival and integration of implanted stem cells and has generally not been taken into account in designs of previous transplantation studies.

The effect of mitomycin C in reducing epidural fibrosis after lumbar laminectomy in rats.

OBJECT: Extensive epidural fibrosis after lumbar spine surgery might be an important underlying cause of failed-back syndrome. Based on previously obtained data, the effect of mitomycin C (MMC) in a concentration of 0.1 mg/ml on spinal epidural fibrosis in a rat laminectomy model was investigated in a large series. METHODS: Eighty adult Wistar rats underwent lumbar laminectomy. In 40 rats, MMC in a concentration of 0.1 mg/ml was locally applied to the laminectomy sites. No similar treatment was performed in the other 40 rats. At intervals from one to 12 weeks after laminectomy, both macroscopic and histological evaluations were performed. For radiological investigation, 10 rats underwent magnetic resonance (MR) imaging at 6 weeks postoperatively. Furthermore, the concentration of MMC in cerebrospinal fluid (CSF) and serum was determined 12 hours postoperatively in seven rats. Due to ease of absorption, high levels of MMC were rapidly detectable in serum, whereas the values obtained from the CSF were markedly lower. In the majority of MMC-treated laminectomy sites, epidural scarring was significantly reduced and dural adhesions were absent, in comparison with control sites (p < 0.001), as confirmed by MR images. Accordingly, the macroscopic dissection of epidural fibrous tissue to reexpose the dura mater was performed more easily and without severe bleeding in these rats. The healing of skin and the lumbar fascia was not affected, and dural leakage was not observed. All control sites showed dense epidural fibrosis with marked dural adherence. CONCLUSIONS: In this experimental model, it was shown that locally applied MMC in a concentration of 0.1 mg/ml effectively reduces epidural fibrosis and dural adherence without side effects in rats that underwent lumbar laminectomy.

Neurobehavioural deficits after severe traumatic brain injury (TBI).

OBJECTIVES: Debilitating neurobehavioural sequalae often complicate traumatic brain injury (TBI). Cognitive deficits, particularly of attention, memory, information-processing speed and problems in self-perception, are very common following severe TBI. METHOD: The Neurobehavioural Rating Scale (NRS) is a multi-dimensional clinical-based assessment instrument designed and validated to measure neurobehavioural disturbances following TBI. This study examined 41 patients who were admitted to the intensive care unit of the Department of General Neurosurgery at Cologne University Hospital after severe TBI between January 1995 and July 2003. All 27 items of the NRS were assessed 6 and 12 months post-injury. RESULTS: Subjects after severe TBI (GCS<9) showed relatively high overall scores on the NRS, reflecting a high degree of overall neurobehavioural dysfunction. NRS items did not change significantly between 6 and 12 months post-trauma for anxiety, expressive deficit, emotional withdrawal, depressive mood, hostility, suspiciousness, fatigability, hallucinatory behaviour, motor retardation, unusual thought content, liability of mood and comprehension deficit. There was a tendency of improvement for inattention, somatic concern, disorientation, guilt feelings, excitement, poor planning and articulation deficits. For conceptual disorganization, disinhibition, memory deficit, agitation, inaccurate self-appraisal, decreased initiative, blunted affect and tension even a tendency for further deterioration in the post-traumatic follow-up was detected. Changes between 6 and 12 months post-TBI were statistically significant for disorientation (improvement), inattention/reduced alertness (improvement) and excitement (deterioration). CONCLUSION: The data shows that neurobehavioural deficits after TBI do not show a general tendency to disappear over time. Some aspects related to self-appraisal, conceptual disorganization and affect may even deteriorate, thereby presenting a challenging problem for both the patients and relatives. This is in contrast to the parallel improvement of post-traumatic sensomotoric deficits.

The role of mitomycin C in reducing recurrence of epidural fibrosis after repeated operation in a laminectomy model in rats.

OBJECT: Extensive peridural fibrosis after lumbar spine surgery may contribute to poor outcome and recurrent symptoms leading to repeated operation. Secondary procedures are considerably hampered by the presence of scar tissue. Moreover, after excision of the peridural scar, the fibrous tissue may recur, leading to unsuccessful surgical outcome. Mitomycin C (MMC), an alkylating antibiotic substance isolated from Streptomyces caespitosus, potentially suppresses fibroblast proliferation after surgical intervention. The authors investigated the effect of MMC on the reformation of epidural fibrosis in a laminectomy model in rats. METHODS: Twenty-four Wistar rats underwent a repeated lumbar laminectomy 3 months after the first operation. In 12 rats, MMC in a concentration of 1 mg/ml was locally applied to the laminectomy site. No treatment was performed in the control group of the other 12 rats. All rats underwent clinical evaluation. Mobility ratings and any evidence of neurological deficit were recorded. Twelve weeks after the second operation, the animals were killed for histological examination. The extent of epidural fibrosis and dural adherence was evaluated. All MMC-treated animals showed reduced epidural scarring, compared with the control group. In nine MMC-treated rats (75%), dural adhesions were moderate. In contrast, all control sites showed dense epidural fibrosis with marked dural adherence. No side effects of the treatment were observed. CONCLUSIONS: In this experimental study, MMC in a concentration of 1 mg/ml locally applied significantly reduced recurrence of epidural fibrosis and dural adhesions without any side effects after repeated spinal surgery in a laminectomy model in rats.

Multimodal early onset stimulation combined with enriched environment is associated with reduced CNS lesion volume and enhanced reversal of neuromotor dysfunction after traumatic brain injury in rats.

This study was designed to determine whether exposure to multimodal early onset stimulation (MEOS) combined with environmental enrichment (EE) after traumatic brain injury (TBI) would improve neurological recovery and to elucidate its morphological correlates. Male Sprague-Dawley rats were subjected to lateral fluid percussion (LFP) brain injury or to sham operation. After LFP, one-third of the animals (injured and sham) were placed under conditions of standard housing (SH), one-third were kept in EE only, and one-third received EE + MEOS. Assessment of neuromotor function 24 h post-injury using a standardized composite neuroscore test revealed an identical pattern of neurological impairment in all animals subjected to LFP. Neuromotor dysfunction in SH animals remained on a similar level throughout the experiment, while improvements were noted in both other groups 7 days post-injury (dpi). On 15 dpi, reversal of neuromotor dysfunction was significantly better in EE + MEOS animals vs. SH- and EE-only groups. In parallel, the comparison of lesion volume in EE + MEOS- vs. EE-only vs. SH rats revealed that animals exposed to EE + MEOS had consistently the lowest values (mm3, mean +/- SD; n = 6 rats in each group) as measured in serial brain sections immunostained for neuron-specific enolase (5.2 +/- 3.4 < or = 5.5 +/- 4.1 < 9.5 +/- 1.9), caspase 3-active/C3A (5.9 +/- 4.0 < or = 6.4 +/- 3.9 < 10.3 +/- 1.8) and glial fibrillary acidic protein (6.0 +/- 3.4 < or = 6.5 +/- 4.3 < 10.7 +/- 1.2). This first report on the effect of EE + MEOS treatment strongly indicates that the combined exposure reduces CNS scar formation and reverses neuromotor deficits after TBI in rats.

Delayed bilateral craniectomy for treatment of traumatic brain swelling in children: case report and review of the literature.

INTRODUCTION: Head injury is the leading cause of accidental death in children. Recent reports have shown the benefit of decompressive craniectomy in children and the role of early timing has been emphasized. However, there is still a lack of data to determine the optimal time for performing craniectomy. CASE REPORT: In contrast to most reports in the literature, this case report demonstrates successful bilateral decompressive craniectomy in a 10-year-old girl with multiple posttraumatic intracranial lesions and massive traumatic brain swelling on the 8th posttraumatic day. CONCLUSIONS: Various pathophysiological mechanisms in the genesis of posttraumatic brain swelling make different treatment strategies necessary. Continuous monitoring of intracranial pressure (ICP), as well as serial cranial computed tomography (CCT), can help to differentiate between these mechanisms. Furthermore, repeated clinical and neurophysiological investigations are important for the timing of craniectomy.

Whipple disease confined to the central nervous system presenting as a solitary frontal tumor. Case report.

Whipple disease is a rare infection caused by the bacterium Tropheryma whippelii. Patients usually present with gastrointestinal symptoms or migratory arthralgias. Although symptomatic central nervous system (CNS) involvement frequently occurs, Whipple disease confined to the CNS is rare. The authors present the case of a 40-year-old man who was surgically treated for a symptomatic left frontal tumor that had the neuroimaging features of a low-grade glioma (LGG). A histopathological investigation revealed a perivascular accentuated inflammation with macrophages harboring PAS-positive diastase-resistant rods, which are distinctive features of cerebral Whipple disease. The patient received cotrimoxazole for 1 year postoperatively and recovered well. This case is exceptional because it represents an isolated cerebral manifestation of Whipple disease that presented as a solitary frontal tumor, thus raising the differential diagnosis of LGG. A review of diagnostic and therapeutic options in suspected cases is presented.

Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary?

BACKGROUND: The initial surgical management of chronic subdural hematoma (CSDH) is still controversial, and a standard therapy does not exist. Because of the advanced age and multiple medical problems of the patients, surgical therapy is frequently associated with complications. METHODS: A retrospective study was performed on 172 patients with CSDH, comparing the efficacy of three different primary surgical methods: drainage of hematoma through two different burr-holes without membranectomy (Group A, n = 38); enlarged craniectomy with a size of about 30 mm craniotomy with partial membranectomy and drainage (Group B, n = 121); and extended craniotomy with partial membranectomy and drainage (Group C, n = 13). RESULTS: Independent of surgical method, the general outcome of the patients was good. The rate of reoperation in the group of burr-hole drainage was 16%, slightly lower than in partial membranectomy with enlarged craniectomy or extended craniotomy with 18% and 23%, respectively. In patients with coagulopathy, the rate of reoperation was 41% (16/43), significantly higher than the rate in noncoagulopathic patients 12% (15/129). CONCLUSIONS: In this study, an extended surgical approach with partial membranectomy has no advantages regarding the rate of reoperation and the outcome. As initial treatment, burr-hole drainage with irrigation of the hematoma cavity and closed-system drainage is recommended. Extended craniotomy with membranectomy is now reserved for instances of acute rebleeding with solid hematoma.

Mitomycin C in preventing spinal epidural fibrosis in a laminectomy model in rats.

OBJECT: Extensive epidural fibrosis after lumbar surgery may be the underlying cause in most cases of failed-back surgery syndrome. Various materials have been used to prevent epidural fibrosis, but only moderate success has been shown. Mitomycin C, an alkylosing antibiotic substance isolated from Streptomyces caespitosus, potentially supresses fibroblast proliferation after surgery. In this study, the authors investigated the effect of mitomycin C by local application on spinal epidural fibrosis in a rat laminectomy model. METHODS: Five Wistar rats underwent laminectomy at cervical, thoracic, and lumbar levels. Based on data obtained from ophthalmological studies, mitomycin C was applied to the laminectomy sites in various concentrations (0.01, 0.05, and 0.1 mg/ml). One laminectomy site in each rat was left untreated and thus served as a control. Evoked potentials were measured pre- and postoperatively, and all rats underwent clinical evaluation. Mobility status and evidence of neurological deficit were recorded. Twelve weeks later, the rats were killed, and the spinal column, including surrounding muscle tissue, was removed en bloc, decalcified, and fixed in formaldehyde. Epidural fibrosis was evaluated histologically. In all mitomycin C-treated laminectomy sites, epidural scarring was significantly reduced compared with control sites. Remarkably, dural adhesions were absent in laminectomy defects treated with mitomycin C concentrations of 0.05 and 0.1 mg/ml. Moderate to marked epidural fibrosis with adhesion to the dura mater was noted at sites receiving 0.01 mg/ml of mitomycin C. All control sites showed dense epidural fibrosis with marked dura adherence. CONCLUSIONS: In this experimental model, mitomycin C applied locally at a concentration of 0.1 mg/ml effectively reduced epidural fibrosis, completely avoided dural adherence, and induced no side effects.

Facial F wave recording: a novel and effective technique for extra- and intraoperative diagnosis of facial nerve function in acoustic tumor disease.

OBJECTIVE: To investigate the diagnostic yield of facial F wave recording in patients with acoustic neurinomas intraoperatively and extraoperatively. Study design and setting Prospective study, comparative evaluation of facial F waves, transcranial magnetic stimulation of the facial motor cortex, blink reflex, and intraoperative online electromyographic activity. The study was performed in the neurosurgical department of a university hospital. RESULTS: Extraoperatively, only F wave latencies were closely correlated to tumor diameter as an independent variable. Intraoperatively, loss of F waves was specific for the development of a severe to total facial paresis postoperatively. A transient loss of F waves heralds an imminent danger of severe facial dysfunction. CONCLUSION: Facial F wave recording provides valuable information on the functional status of the nerve intra- and extraoperatively. SIGNIFICANCE: Facial F wave recording should be used as a standard electrodiagnostic technique in addition to transcranial magnetic stimulation and blink reflex recording. It seems particularly useful for intraoperative facial nerve monitoring.

Outcome of prolonged coma following severe traumatic brain injury.

PRIMARY OBJECTIVE: To assess the outcome of severe traumatic brain injury 1 year after trauma. RESEARCH DESIGN: Prospective study conducted at the neurosurgical department of a university hospital. METHODS AND PROCEDURES: A total of 24 patients were included. Outcome was assessed by means of Glasgow outcome scale, Barthel index, Functional independence measure (FIM) and Disability rating scale (DRS). Need of care and job ability were also evaluated. EXPERIMENTAL INTERVENTIONS: Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy. MAIN OUTCOMES AND RESULTS: Six patients died, three remained in a vegetative state, six were severely disabled, six were moderately disabled and three achieved a good recovery 1 year after injury. Mean Barthel index was 68.9, mean FIM was 88.3 and mean DRS 27.7. The majority of patients still were at least intermittently dependent on care. Most of the trauma survivors were unable to work. CONCLUSIONS: Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.

Biocompatibility and healing process of polyester meshes in the brain: in vivo examination in rats.

OBJECTIVES: To analyze the biocompatibility of multifilament polyester (PET) meshes used for the implantation of auditory brainstem implants in a standardized Wistar rat model (n=29). METHODS: The physical properties of the meshes were examined during surgery. Using a modified plastic embedding, the local tissue reaction and the stability of mesh position in the region of the fourth ventricle were evaluated in section series from day 3 to 64. The cellular reaction was further differentiated using transmission and scanning electron microscopy. RESULTS: PET meshes were stable for handling. However, sharp edges inevitably led to brainstem and cerebellar penetration in some cases. The meshes were preserved in situ in all section series. Positioning was stable with one exception. A sufficient fibroblast and collagen fiber encasement was reached after 14 days. In all cases, no further change was observed through day 64. The host-defense reaction was persistent and characterized by numerous macrophages and foreign-body giant cells. Bacterial infection occurred in three cases. CONCLUSIONS: PET meshes proved to have an acceptable biocompatibility regarding local-tissue reaction in the brain. Modified polymer structures should be developed to reduce risk of injury. Anti-inflammatory surface treatments and monofilament meshes could reduce the infection rate.

Comparison of MRI and electrophysiological studies for detecting brainstem lesions in traumatic brain injury.

The yield of magnetic resonance imaging (MRI) and electrophysiological studies in detecting brainstem lesions was assessed in 35 patients suffering from traumatic brain injury (Glasgow Coma Scale, 3-10). As an inclusion criterion, all patients had brainstem trauma as revealed by early MRI or electrophysiological studies. Of the 35 cases, 7 (20%) had brainstem lesions detected by MRI only, whereas in 10 patients (29%), electrophysiological examination disclosed impairment of brainstem function with normal MRI. In 18 (51%) subjects, both diagnostic techniques revealed brainstem lesions. The midbrain was the most common location of lesions. Masseter reflex recording had the highest yield (93%) of abnormal findings. No mismatch with respect to site and side of abnormality occurred between MRI and electrophysiological studies. Outcome analysis indicated an unfavorable course for the vast majority (83%) of patients, regardless of the diagnostic means disclosing traumatic brainstem injury. Therefore, both techniques are effective in disclosing traumatic brainstem injury, with diagnostic overlap in about 50% of cases. In contrast to MRI, electrophysiological investigation is easily performed and repeated at low cost in the setting of an intensive care unit, where such patients are typically hospitalized after trauma. In addition to electrophysiological assessment of brainstem function, MRI is recommended in each case having normal electrophysiological findings when brainstem injury is suspected.

Polyester meshes and adhesive materials in the brain: comparative research in rats to optimize surgical strategy.

OBJECT: The goal of this study was to determine the biocompatibility of polyester mesh electrode carriers for auditory brainstem implants with and without adhesives in a rat model. METHODS: Physical properties of the meshes were evaluated within the fourth ventricle region, both without (Group A) and with adhesives (muscle, Group B; oxidized regenerated cellulose [ORC], Group C; and fibrin glue, Group D). The stability of the mesh position, the healing process, and host defense reaction after 2 to 60 days were examined in series of tissue sections in which meshes were preserved in situ. The cellular reaction was further evaluated using electron microscopy. Although otherwise pliable, polyester meshes were too rigid when used with adhesives, especially fibrin glue or muscle. Also, the sharp edges of the meshes presented a risk of brainstem and cerebellar lesions. Regardless of the material, meshes induced persistent inflammatory tissue reactions characterized by numerous macrophages and foreign-body giant cells. After 14 days, the cellular response had resulted in sufficient fibroblast and collagen fiber encapsulation of the meshes and remained essentially unchanged thereafter. No influence of adhesives on the healing process was observed, and, unexpectedly, these substances did not reduce the risk of dislocation prior to adequate cellular encasement. In some rats in Groups A and C, purulent inflammation, in part with Gram-positive bacteria, occurred after 2 to 14 days. The ORC exhibited persistent swelling, introducing the risk of occlusive hydrocephalus and/or brainstem compression. CONCLUSIONS: Polyester meshes and various adhesives exhibited acceptable biocompatibility in terms of local tissue reaction. Adhesives reduced pliability of the meshes, however, and were ineffective in reducing the risk of dislocation. Handling characteristics could be improved by better mesh designs, and risk of infection could be reduced by both improved designs and surface treatment of the meshes with antibacterial agents.