Comparative biomechanical study of cervical spine stabilisation by cage alone, cage with plate, or plate-cage: a porcine model.

PURPOSE: To compare stability and subsidence associated with 3 types of cervical spine stabilisation. METHODS: The C3 to C4 vertebrae of 28 Polish pigs were used. Pigs with intact vertebrae (group 1) underwent standard anterior cervical discectomy (group 2), followed by stabilisation using a cage alone (group 3), a cage with plate (group 4), or a plate-cage (group 5). Cervical spine stability and subsidence were compared in all 5 groups. RESULTS: Stability was significantly increased after stabilisation by a cage with plate or a plate-cage, but not by a cage alone. The difference between stabilisation by a cage with plate and a plate-cage was not significant. Subsidence was maximal after the cage-alone stabilisation (3.1 mm), being 1.6 mm after the cage-with-plate and plate-cage stabilisations. CONCLUSION: Additional plating as a supplement to anterior interbody cervical cage stabilisation significantly improves segmental stability and subsidence.

[Acute tension pneumocephalus as a complication of surgical procedures of the posterior cranial fossa in prone position]. / Ostra prezna odma mózgowa jako powiklanie zabiegu w obrebie tylnej jamy czaszki w ulozeniu na brzuchu.

The authors describe a case of acute tension pneumocephalus (TP) developing as a complication of an operation in the posterior cranial fossa, in a boy aged 3 years with a large cystic tumour of the vermis, operated on in prone position with flexed head. The authors discuss the circumstances leading to development of tension pneumocephalus.

[Genetic studies of brain gliomas]. / Badania genetyczne glejaków mózgu.

Tumour origin and evolution currently is viewed as comprising a series of specific genetic events that take place in target cells and their clonal descendants. These events can be recognized at two levels: cytogenetic and molecular. The genetic results can be used as diagnostic and prognostic markers of neoplastic diseases. However, till now reports on the karyotypic characteristics of brain tumors are far from numerous. The most frequent cytogenetic alterations observed in primary brain tumors are losses or gains of chromosomes or chromosomal regions and presence of double minute chromosomes. Enhanced expression of several cellular oncogenes on human glioma cells lines were observed also.

[Acid-base equilibrium in cerebrospinal fluid following intracranial surgery]. / Równowage kwasowo-zasadowa w plynie mózgowo-rdzeniowym u chorych po zabiegach sródczaszkowych

In 48 patients the acid-base equilibrium in the CSF and blood was determined on the 2nd day after intracranial operation. In the postopertive period various disturbances of this equilibrium were found which were probably various stages of metabolic acidosis compensation in the CSF which was a reflection of metabolic (lactate) acidosis developing primarily in the damaged brain area. On the basis of determinations it was found that changes in the CSF of the type of metabolic acidosis (21 cases) corresponded most frequently to respiratory alkalosis in the blood (11 cases). Changes of the type of respiratory acidosis in the CSF(13 cases) corresponded usually to metabolic alkalosis in the blood (7 cases). The development of metabolic acidosis in patients in severe and moderately severe condition (19 cases) was associated with poor prognosis as to survival since the mortality in this group was 10 (about 53%). The favourable effect of dehydrating treatment may be due also to facilitation of passage of bicarbonates from the blood into the cerebral tissue and CSF since their level is increased in the blood during metabolic alkalosis (during a decrease in the extracellular space) resulting from dehydration.

[Disorders of acid-base equilibrium in the cerebrospinal fluid after intracranial operations]. / Dynamika zaburzen równowagi kwasowo-zasadowej w plynie mózgowo-rdzeniowym u chorych po zabiegach sródczaszkowych.

The authors collected 27 patients after intracranial operations in whom the cerebrospinal fluid was investigated at least 3 times during 10 days. The patients were divided into 2 groups--a group of 16 patients with favourable outcome, and a group of 11 patients who died. On the basis of arithmetical means of pCO2 and HCO3 values hypothetical curves of the course of acid-base equilibrium in the blood and cerebrospinal fluid were plotted in both groups during 10 days. In the initial period metabolic acidosis was found in the cerebrospinal fluid and respiratory alkalosis in the blood in both groups. After several days metabolic alkalosis developed in the group of patients with favourable outcome while the metabolic acidosis in the cerebrospinal fluid was balanced. In the group with unfavourable outcome metabolic alkalosis in the blood was less evident and metabolic acidosis in the cerebrospinal fluid was increased. The authors think that metabolic alkalosis in the blood has a compensatory effect on metabolic acidosis in the cerebrospinal fluid and brain.

The concept of cerebral circulatory-pressure index (CCPI).

The theoretical relations between blood pressure (MABP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP) as well as the new Cerebral Circulation-Pressure Index (CCPI) are presented in the paper. The special nomogram collecting all of these parameters was constructed. CPPI was defined as a quotient of CPP and ICP: [formula: see text] CCPI reflects the relationship between the systemic MABP and ICP and for ensuring the normal conditions of intracranial circulation the MABP must be at least 4 divided by 5 times higher than ICP. The low values of CCPI, if they are not immediately corrected, results on severe brain disability or even death. We didn't find till now what should be the upper limit of CCPI, which overcrossing may be danger for the patient, especially with impaired autoregulation. Based on analysis of patients operated due to intracranial disorders as brain tumours, spontaneous and traumatic haematomas as well as ruptured aneurysms we find that the values of CCPI over 3 have a good prognosis, between 3 and 2 is a field for intensive treatment consisting on decreasing ICP or increasing the systemic blood pressure or both. If CCPI is below 1.5 the prognosis is pessimistic and all the patients died. CCPI together with the nomogram are useful in current evaluation of the state of patients and of the efficacy of treatment and prediction of the treatment results.

[Infusion test in the selection of patients with hydrocephalus for the shunting]. / Test infuzyjny w kwalifikacji chorych z wodoglowiem do zalozenia zastawki.

The indications for the shunting of the patients with NPH are a matter of discussion. The measurement of the outflow resistance during the infusion test is one of the criteria for shunting. The authors present 38 patients with NPH in whom the lumbar constant-infusion test was carried out. The patients with the outflow resistance more then 13 mmHg/ml/min were selected for shunting. The results at least 4 months after operation are presented.

[Results of postoperative treatment of patients after brain tumor removal based on the cerebral circulatory pressure index (CCPI) in comparison with ICP and CPP]. / Wyniki pooperacyjnego leczenia pacjentów z usunietymi guzami mózgu w oparciu o mózgowy wskaznik krazeniowo-cisnieniowy (CCPI) i w porównaniu z ICP i CCP).

The aim of the study was the assessment of prognostic value of CCPI in relation to the results of treatment of patients with increased intracranial pressure after brain tumour operative treatment. The results of treatment of 107 patients with intracerebral tumours according to neurological state at the introduction of treatment (GCS) and initial values of ICP, CPP and CCPI as well as final results of treatment (GOS) are analysed. A special normogram collecting all of these parameters was constructed, as well as the directions of treatment depending on the areas of MABP, ICP and CPP were established. The CCPI seems to be more a sensitive and earlier signals suggesting the urgency and the direction of treatment than ICP and especially CPP alone. There seems to be a great consistence of the patient state evaluation according to GCS, GOS and CCPI which is also a prognostic factor. All the patients with initial CCPI below 1.5 died while all the patients with CCPI over 3.0 in good and very good neurological state, and all the patients with initial CCPI between 1.5 and 3.0 had neurological deficits.

[Analysis of own clinical material treated by conservative and aggressive control of intracranial hypertension]. / Analiza wlasnego materialu klinicznego przy zachowawczym i agresywnym zwalczaniu nadcisnienia wewnatrzczaszkowego.

These problems arising during the treatment of increased intracranial pressure (ICP) were analysed on the basis of own clinical material with consideration of different therapeutic methods--pharmacological and aggressive. Statistical analysis (contingency tables) showed that the treatment consisting of dexamethason, mannitol and furosemid was the most efficient in the group of patient with increased ICP in the range 15-30 mmHg. In patients with ICP in the range 30-50 mmHg, where other aggressive methods of treatment had failed, the most efficient treatment was cranio-dural decompression.

[Giant aneurysm of the internal carotid artery, stimulating parasellar tumor]. / Zespól guza okolosiodlowego wywolany olbrzymim tetniakiem tetnicy szyjnej wewnetrznej.

The authors report a case of a giant aneurysm of the internal carotid artery filling from the left internal carotid artery below the site of branching-off of the posterior communicating artery. The initial neurological, and ophthalmological signs and plain films of the skull suggested presence of an Erdheim's tumour. It is worth stressing that the onset of the clinical manifestations was at the age of 15 years, particularly in the form of progressing binasal hemianopsia with sparing of the lower temporal quadrant. The efficiency of the cerebral circulation was tested using Mathas' test, electroencephalography, ophthalmodynamometry and angiography. It was decided to ligate the left carotid artery although Mathas' test during angiography was not as positive. The boy tolerated the operation well. Ophthalmological examination demonstrated after 18 months normal visual fields and normal visual acuity. Further follow-up during 8 years demonstrated normal psychosomatic development of the boy.

Cerebral vasospasm detection by TCD after supratentorial brain tumours surgery.

Serial transcranial Doppler ultrasonography (TCD) studies were carried out in 61 patients, who had been operated due to supratentorial brain tumours. Among 61 cases have been 26 gliomas, 19 meningiomas and 16 metastases. The Mean Flow Velocity (MFV) exceeding 120 cm/s in Middle Cerebral Artery (MCA) and 90 cm/s in Anterior Cerebral Artery (ACA) has been admitted as pathognomonic for vasospasm. The vasospasm has been stated in 14 cases (23%)--10 gliomas and 4 meningiomas out of 61 patients. The vasospasm has been more intense in ACA on the operated (lesion) side than in MCA and on the non operated (opposite) side.

[Posttraumatic vasospasm and its treatment with nimodipine]. / Pourazowy skurcz naczyniowy i jego leczenie nimodypina.

The aim of our study was to compare the incidence and the time course of vasospasm as well as outcome of patients with tSAH. In group I there were 15 patients treated with nimodipine. Group II consisted of 20 patients in whom nimodipine was not used. All patients suffered from severe head injury, scored 8 points or less according to Glasgow Coma Scale. The initial CT scan revealed tSAH in all of them. Outcome was evaluated according to Glasgow Outcome Scale (GOS) three months after injury. Results were better (but not significantly) in patients in whom nimodipine was used, time course of vasospasm was less severe and follow-up CT scans did not reveal ischaemic infarcts connected with vasospasm.

[Familial occurrence of hemangioblastoma]. / Rodzinne wystepowanie naczyniaka plodowego.

Haemangioblastoma is a benign vascular neoplasm accounting for approximately 1-2% of all intracranial tumours. Patients with haemangioblastoma are aged usually about 40 years, the tumour is situated mostly in the cerebellum, more frequently in males. The tumour is a component of the Hippel-Lindau syndrome with familial-hereditary dominant aetiology, often associated with retinal angiomatosis, cysts of the pancreas and kidneys, renal carcinoma and phaeochromocytoma. A familial haemangioblastoma is reported in father and son. The father had the tumour in cerebellar vermis but the son had multiple tumours in cerebellum and medulla.

Tramadol for postoperative analgesia in intracranial surgery. Its effect on ICP and CPP.

An ideal analgesic for patients after craniotomy should neither cause respiratory depression, nor affect intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The aim of the study was to evaluate the effect of Tramadol (T) on ICP and CPP, as well as to determine its analgetic efficacy in patients (pts) after craniotomy. Thirty five pts aged 16 divided by 78 years (mean 46) entered the study. Twelve had GCS (Glasgow Coma Scale) scores < or = 8 and 23 pts had scores > or = 12. Fourteen pts were mechanically ventilated and 21 pts were breathing spontaneously (BS). Tramadol was injected i.v. at a dose of 0.75 mg/kg over 3 minutes in 11 pts (Group 1), 1.0 mg/kg over 5 minutes in 13 pts (Group 2) and 1.0 mg/kg over 10 minutes in 11 pts (Group 3) PaCO2 was measured before T in all pts and at 8 minute after injection in 21 BS pts. Heart rate (HR), mean arterial blood pressure (MBP), ICP, CPP and respiratory frequency (f) were registered before and in the 1st, 3rd, 8th, and 15th minute after T. Analgetic effect was evaluated in 22 conscious pts by comparing the pain intensity before and 30 minutes after T using a five-point verbal response scale. Mean control ICP was 17 mmHg. ICP over 15 mmHg was diagnosed in 15 pts (mean ICP equal 26 mmHg). Mean CPP for all 35 pts was 85 mmHg. There were no statistically significant changes in HR, MBP, ICP, and CPP after T in any particular group, nor were there changes in ICP in subgroups with normal and elevated ICP. No significant changes in PaCO2 and f were found in BS pts. Satisfactory analgesia was obtained in 50% of pts of Group 1, and in 88% of pts of Groups 2 and 3. We conclude that tramadol in doses of 0.75 mg/kg and 1.0 mg/kg i.v. does not affect ICP and CPP in adult postcraniotomy patients and seems to be a safe and effective analgesic at a dose of 1.0 mg/kg for postcraniotomy pain control.

[Management of patients with multiple intracranial aneurysms]. / Leczenie pacjentów z mnogimi tetniakami mózgu.

A retrospective analysis of 142 patients with multiple intracranial aneurysms operated on within eight years (1991-1998) was undertaken. In 82 patients multiple aneurysms were clipped during one procedure in the remaining 60 patients operation was performed in two stages. The clinical state of patients according to Hunt-Hess scale at the admission to the department was assessed, as well as the presence of blood on the initial CT scan according to Fisher scale and outcome according to Glasgow Outcome Scale. The operative results patients with multiple intracranial aneurysms are worse, than those with single aneurysm, which is connected with the necessity of wider exposure of cerebral vessels and possibility of bleeding from unclipped aneurysm, when operation is performed in two stages.

[Transcranial doppler ultrasonography monitoring in patients with intracerebral hematoma due to aneurysm rupture]. / Monitorowanie TCD u pacjentów z krwiakiem sródmózgowym w wyniku pekniecia tetniaka.

The aim of the study was to evaluate the influence of intracerebral haematoma due to aneurysmal rupture on vasospasm evaluated by transcranial Doppler ultrasound and outcome according to Glasgow Outcome Scale. 368 patients with ruptured intracranial aneurysm were admitted to the Department of Neurosurgery, Medical Academy in Wroclaw, between January 1, 1995 and June 30, 1998. Patients were divided into two groups. In group I there were 74 patients with subarachnoid haemorrhage and intracerebral haematoma. In group II 294 patients with subarachnoid haemorrhage. Despite intensive monitoring and treatment the outcome of patients with subarachnoid haemorrhage and intracerebral haematoma is worse than in patients with subarachnoid haemorrhage only.

[Diagnosis of blood flow disorders in the common carotid arteries by the ultrasonic Doppler method]. / Rozpoznawanie zaburzen przeplywu krwi w tetnicach szyjnych wspólnych metoda ultradzwiekowa oparta na zjawisku Dopplera.

The aim of this work was evaluation of the usefulness of the Doppler ultrasound method for detection of blood flow disturbances in carotid arteries. The investigations were done in 110 patients with symptoms of cerebral circulatory disorders. In 45 patients carotid arteriography was done. In 30 cases arterial reconstructive operations were performed. The curves of blood flow velocity in the common carotid arteries were recorded with a UDP-10 ultrasound blood flow detector. The obtained curves were subjected to morphological analysis and the mean momentary velocity of the systolic and diastolic flow wave was calculated. In 80% of cases with impaired patency of the carotid arteries demonstrated by angiography abnormal curves of blood flow velocity in the common carotid arteries were obtained. The method of ultrasound recording of blood flow velocity is non-invasive and safe and it is very useful for establishing indications to angiography and for postoperative control.

Arterial to end-tidal carbon dioxide difference during craniotomy in severely head-injured patients.

Clinical data suggest that cerebral blood flow (CBF) can be abnormally low within the first four to eight hours after severe head injury (SHI). An aggressive hyperventilation can additionally worsen CBF and provoke cerebral ischemia. Therefore an accurate PCO2 monitoring in SHI patients (pts) is necessary. PetCO2 failed to reflect PaCO2 in SHI pts treated in neurosurgical ICU. Up to now, the validity of PetCO2 monitoring in estimating PaCO2 during an acute posttraumatic craniotomy has not been studied. Forty five adult SHI pts operated on because of an acute intracranial posttraumatic haematoma within 8 hours after head trauma entered the study. The standard anaesthetic protocol included N2O/O2, fentanyl and pancuronium bromide anaesthesia, and mechanical ventilation with respiratory rate 10 divided by 12 bpm and tidal volume in mL = body weight (kg) x 10 - 100. After obtaining a stable PetCO2 arterial blood sample was taken for PaCO2 measurement and P(a-et)CO2 = PaCO2 - PetCO2 was calculated. P(a-et)CO2 ranged -9 divided by 20 mm Hg (5 +/- 6; mean +/- SD). P(a-et)CO2 between 2 mm Hg and 6 mm Hg was found in 17 (38%) patients only. A negative P(a-et)CO2 was stated in 20% of patients. No relationships between P(a-et)CO2 and pts age and mean arterial pressure were found. P(a-et)CO2 was higher in normocapneic pts than in hyperventilated ones and tended to decrease with an increase in heart rate. We can conclude that during an acute craniotomy in SHI pts, PetCO2 does not reflect accurately PaCO2 and the monitoring of adequacy of ventilation should be based on repeated or continuous measurements of an arterial PCO2.

Are the vasodilators needed in critical limb ischemia? Laser Doppler flowmetry study.

Twenty patients with critical limb ischemia, fulfilling the criteria of European Consensus of Critical Limb Ischemia, were included in the study. Fifteen healthy subjects served as the controls. Laser Doppler flowmetry method was applied to assess the peripheral skin microcirculation during provocation tests such as transcutaneous electrical nerve stimulation and veno-arterial reflex. In physiological conditions transcutaneous electrical nerve stimulation evokes short term, reversible increase of cutaneous blood flow during stimulation. Veno-arterial reflex is defined as an increase of precapillary resistance while standing or lowering of the extremity, mirrored by the reduction of skin perfusion. The results of the study justify the thesis, that the vasodilators may not be effective in the treatment of critical limb ischemia. Further trials directly assessing the influence of vasodilatating agents on microcirculation in critical limb ischemia are required.

[Pneumocephalus following facial injury]. / Pneumoencephalon jako nastepstwo obrazen twarzoczaszki.

Pneumocephalus or intracranial air its commonly detected following serious head injury and posterior fossa surgery. In laryngology the frequent reason of its appearance is also herniation of air through a break in the wall of skull due to advanced benign and malignant tumors. The pathophysiology involves the presence of craniodural fistula allowing ingress of air. A ballvalve mechanism may allow air to enter not exit the cranium or like in turned upside down bottle leak permit air entrance as fluid leaves the intracranial space. The presence of air is usually asymptomatic but caries a potential risk of increased intracranial pressure or meningitis which require an immediate therapy. Although various ways of treatment were reported prevention and early diagnosis are the most important. We report 3 cases of cerebral air that occurred secondary to the head trauma. The diagnosis every time promptly confirmed by skull roentgenogram or CT.