Clinical study of stereotactic subtentorial approach for brainstem puncture and drainage in the treatment of brain stem hemorrhage in elderly patients / 中华老年医学杂志

Objective:To observe the curative effect of stereotactic subtentorial approach for brainstem puncture and drainage on brain stem hemorrhage in elderly patients.Methods:The clinical data of elderly patients with brain stem hemorrhage admitted to the Department of Neurosurgery, Shangqiu First People 's Hospital from April 2018 to April 2022 were retrospectively analyzed.According to the inclusion and exclusion criteria, a total of 65 elderly patients with brainstem hemorrhage who were treated with stereotactic subtentorial approach for brain stem puncture and drainage, and had complete follow-up data within 90 days after operation were selected.The patient's data were reviewed.The operation time, hematoma clearance rate on the first day after operation, the drainage tube extraction of hematoma cavity, and the postoperative complications were recorded.The follow-up results at 30 days and 90 days after the operation were also recorded.The 30-day Glasgow outcome scale(GOS)was used to evaluate the short-term clinical outcomes of surviving patients, while the modified Rankin score was used to evaluate the neurological function recovery of surviving patients at 90 days.Results:The operation time of the 65 patients was 1.1-2.8 h, with an average of(1.9±0.4)h.On the first day after operation, CT scan showed that the hematoma clearance rate was(84.6±13.6)%.The drainage tube in hematoma cavity was removed within 3-5 days, and there was no puncture-related intracerebral hemorrhage or drainage tube-related intracranial infection after operation.During 30 days of follow-up, 9 patients died and 56 patients survived, with a survival rate of 86.2%.Among the surviving patients, 5 were temporarily in vegetative state and 51 were awake, with varoius degrees of disability.The preoperative hematoma volume of the surviving patients was significantly less than that of the dead patients, and the preoperative GCS score was significantly lower than that of the dead patients( Z=2.386, 2.009, P=0.017, 0.045). After 90 days of follow-up, 3 patients died and 53 survived, with a survival rate of 81.54%.Among the surviving patients, the neurological function of 22 patients recovered well, and the effective rate of clinical treatment was 41.51%. Conclusions:Stereotactic subtentorial approach for brain stem puncture and drainage is an effective and relatively safe surgical method for the treatment of brain stem hemorrhage in elderly patients.

Holmes Tremor After Brainstem Hemorrhage, Treated With Levodopa

Holmes tremor is a rare movement phenomenon, with atypical low-frequency tremor at rest and when changing postures, often related to brainstem pathology. We report a 70-year-old female patient who was presented with dystonic head and upper limb tremor after brainstem hemorrhage. The patient had experienced a sudden onset of left hemiparesis and right facial paralysis. Brain magnetic resonance imaging showed an acute hemorrhage from the brachium pontis through the dorsal midbrain on the right side. Several months later, the patient developed resting tremor of the head and left arm, which was exacerbated by a sitting posture and intentional movement. The tremor showed a regular low-frequency (1-2 Hz) for the bilateral sternocleidomastoid and cervical paraspinal muscles at rest. The patient's symptoms did not respond to propranolol or clonazepam, but gradually improved with levodopa administration. Although various remedies were attempted, overall, the results were poor. We suggest that levodopa might be a useful remedy for Holmes tremor. The curative or relieving effect of the dopaminergic agent in Holmes tremor needs more research.

BAEP and SEP for prediction of prognosis in brain stem hemorrhage patients / 中国基层医药

ObjectiveTo investigate the correlation of brainstem auditory evoked potentials(BAEP) and somatic evoked potentials (SEP) with therapeutic outcome of brain stem hemorrhage patients.MethodsBAEP and SEP were detected in the early period of 25 caees with brain stem hemorrhage by evoked potential instrument,and were surveilled dynamically.ResultsThere was good prognosis in the patients whose BAEP and SEP were normal in the first time and repeated detection.Poor prognosis happened in ones whose BAEP and SEP were abnormal in the first time and repeated detection.The difference was significant between them(P＜0.05).ConclusionCombined detection and dynamic surveillance of BAEP and SEP could predict accurately the curative result of patients with brain stem hemorrhage.

Clinical effect of the application of mechanical ventilation in brainstem hemorrhage complicated with respiratory failure / 中国基层医药

Objective To observe the clinical efficacy of ventilator-assisted breathing for the treatment of respiratory failure brainstem hemorrhage.Methods Clinical data of 29 cases of brainstem hemorrhage complicated with respiratory failure were retrospectively analyzed.Patients were treated with conventional symptomatic treatment based on ventilator-assisted breathing therapy and before and after treatment of ventilator-assisted breathing index changes were analyzed.Results After treatment,29 patients improved and discharged 11 patients(37.9％),and automatically discharged 10 patients(34.5 ％),8 patients died(27.5％);R,PaO2,PaCO2,SaO2 significantly improved than before treatment(t=4.932,4.393,3.784,3.297,all P＜0.05);compared with pre-treatment plasma albumin level,Glasgow score improved significantly(t=2.675,4.947,all P＜0.05),blood glucose level before and after treatment,peripheral blood leukocytes count had no statistically significant differences(t=1.037,0.852,all P＞0.05).Conclusion Ventilator-assisted respiratory therapy brainstem hemorrhage complicated with respiratory failure can significantly improve various respiratory indicators,improve the survival rate.

Traumatic Brainstem Hemorrhage Presenting with Hemiparesis

Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.

Clinical Analysis and Operative Management of Spontaneous Brain Stem Hemorrhage

Spontaneous brain stem hemorrhage usually results in higher mortality and morbidity with poorer prognosis than any other intracranial vascular lesions in spite of meticulous medical or surgical treatment. We have experienced 86 cases of spontaneous brain stem hemorrhage who were admitted to Wonju college of medicine from January 1983 to Octobr 1995. 33 cases were treated with operation and 53 cases with non-operative treatment. The results were as follows: 1) Clinical parameters in both operative and non-operative groups showed no significant differences. 2) Treatment results were better in the operative group. Operative treatment is recommended in cases of GCS score below 7, hematoma size larger than 10ml, young age, and normotensive patients. 3) Appropriate operative approaches should be considered according to the patient's status. Recently, we most frequently performed a stereotactic approach. 4) Better outcome was obtained when the patients were operated from 72 hours to one or two weeks following the h emorrhage. 5) Hypertension, old age, and GCS score above 7 showed no statistical differences in terms of outcome between the operative and non-operative groups.

Inteacerebral and Brain Stem Hemorrhage Following Evacuation of Chronic Subdural Hematoma and Hygroma

Two cases of intracerebral and brain stem hemorrhage occurring after evacuation of chronic subdural hematoma and subdural hygroma are reported. A patient who had undergone craniotomy with closed drainage for subdural hygroma had intracerbral and fatal brain stem hemorrhage in the immediate postoperative period. Despite rapid and intensive treatment, he died. The other patient had intracerebral hematoma following drainage of chronic subdural hematoma and left with severe disability. Possible pathogenic mechanisms leading to development of the postoperative intraparenchymal hemorrhage are suggested. Sudden increase in cerebral blood flow combined with defective autoregulation seemed the most likely pathogenic mechanism to be responsible for the postoperative hemorrhage. If close neurosurgical observation of patients and clinical awareness for the intraparenchymal hemorrhage after evacuation of chronic extracerebral fluid collections given, this devastating complication may be avoided.

Stereotactic Management of Spontaneous Infratenorial Hemorrhage: Part I:Stereotactic Evacuation and Gradual Urokinase Irigation for Spontaneous Brain Stem Hemorrhage

In spontaneous brain stem hemorrhage, efforts are being made to treat the hemorrhage by means of active medical treatment of intricate suboccipital craniectomy. But these efforts are still unsatisfactory in decreasing the high mortality and morbidity. Our recent efforts have got good results in the 11 cases of brain stem hemorrhage by removing the hemorrhage through the application of R.R.W. stereotactic system and gradual urokinase irrigation. The residual hemorrhage following the initial aspiration was completely evacuated by gradual urokinase irrigation through stereotactically placed catheter. Also this catheter was used for monitoring of intrahematomal intracranial pressure for an early stoppage of the increased intracranial pressure or early detecting of rebleeding. This kind of stereotactic evacuation and gradual irrigation with urokinase could remove the brain stem hemorrhage accurately and easily in a short time under the local anesthesia. Mean-while the normal brain tissue is subjected to less surgical trauma by this procedure, which can be interpreted as having a wide indication, a definite advantage, with a low mortality of 27.3%.

Experimential Brain Stem Compression

Patterns of brain-stem compression and secondary brain-stem evoked postentials were investigated to correlate with expanding mass volume and location in mass-induced supratentorial brain compression in cats in which the subjects were divided into four experimental group i.e., frontal, temporal, parietal, and occipital brain-compressed groups. Postmortem insepection of the brain-stem showed either unilateral or bilateral dorsal herniation of the brain in frontal and temporal brain-compressed groups and dorsolateral herniation in parietal and occipital brain-compressed groups, respectively. Microscopic examination revealed that the secondary brain-stem hemorrhages were mostly caused by venous bleeding secondary to venous congestion, the bleeding being more severe in occipital brain-compressed group. As the intracranial pressure was raised by expansion of a supratentorial balloon, the late components of the BSEP were suppressed first, followed by the suppression of the early components. In BSEP recording a significant change was observed in Vth wave with prolongation of latency and decrease in amplitude. This finding suggests that the midbrain is the most vulnerable to compression ischemia. In parietal group, the Vth wave started to be prolonged at 0.4ml of balloon expansion and totally disappeared at 1.8ml of expansion.

Stereotaxic Evacuation of Brain Stem Hemorrhage

Usually cases of brain stem hemorrhage reveal high mortality and poor prognosis in spite of meticulous medical or surgical treatment. Recently we experienced stereotaxic evacuation of brain stem hemorrhage with Brown-Robert-Wells(B.R.W.) system in four cases. If there were residual hemorrhage after initial aspiration, those were evacuated with Urokinase irrigation via stereotaxically placed catheter in the hematoma. The entry point of our operation get on the crossing point of midpupillary line and 1cm behind coronal structure. Preliminary results : 1) Volume of removed hematoma : 5ml(average). 2) Dates of urokinase irrigation : 2 to 4 days after operation. 3) No hydrocephalus, no surgical mortality. 4) Average Glasgow coma scale was improved from 6 in preoperative state to 12 in postoperative state. 5) Operation was performed within 24 hours. 6) Advantages of our procedure. (1) Accurate, simple and safe. (2) Under local anesthesia. (3) Less traumatic procedure. (4) Could remove hematoma completely with Urokinase.