[Cerebral circulatory autoregulation as a guide for controlling the parameters of assisted ventilation in acute severe brain injury].

The paper presents the results of cerebral circulation (CC) in 17 ventilated patients with severe brain injury in its acute phase. All the patients developed traumatic subarachnoidal hemorrhage, which was accompanied with angiospasm in the majority of cases. Doppler transcranial study (DTCS) was performed, by using the carotid compression test; the findings correlated with paCO2 and CV parameters. A dynamic study was performed every two days starting from their admission to an intensive care unit to the recovery from coma or normalization of CC parameters. The dilation and constriction components of the CC reserve were assessed from the results of this test and continued to be controlled during therapy. Thus, this paper shows the possibility of goal-oriented correction of CC autoregulation and optimization by selecting the parameters of assisted ventilation and by changing paCO2 under the guidance of Doppler transcranial study.

[Differential approach to the application of hyperventilation in acute period of severe brain injury in relation to cerebral circulation]. / Differentsirovannyi podkhod k primeneniiu giperventiliatsii v ostrom periode tiazheloi cherepno-mozgovoi travmy v zavisimosti ot sostoianiia mozgovogo krovotoka.

Seventeen patients with severe brain injury (Glasgow-8 Coma Scale 3-8 scores) complicated by traumatic subarachnoidal hemorrhage and severe cerebral hemodynamic disorders (hyperemia, vasospasm) were examined. Hyperventilation was performed in different phases of cerebral circulation under multiparametrical monitoring (intracranial pressure, cerebral perfusion pressure, jugular oximetry, Doppler study using the carotid compression test). The use of hyperventilation to eliminate intracranial hypertension in victims with brain hyperemia was shown to make cerebral circulation consistent with brain tissue oxygen demands and to improve the autoregulatory reserve of cerebral vessels. The application of hyperventilation to eliminate intracranial hypertension in vasospasm leads to a temporary reduction in intracranial pressure, but simultaneously causes cerebral circulatory changes that do not correspond to cerebral oxygen demands, as well as lowered cerebral perfusion pressure, which increases a risk for ischemic brain tissue lesion. This requires a strict rationale for the use of hyperventilation and for multiparametrical monitoring of cerebral functions, which includes jugular oximetry, Doppler transcranial study, and measurement of intracranial pressure throughout the hyperventilation period in order to prevent secondary brain lesion.

[Water electrolyte disorders in the postoperative clinical picture of basal-diencephalitic tumors]. / Vodno-élektrolitnye narusheniia v klinike posleoperatsionnogo perioda pri opukholiakh bazal'no-diéntsefal'noí lokalizatsii.

The paper deals with the relationship of homeostatic and motivational disorders in the postoperative clinical picture in basal-diencephalic tumors. The material included 354 clinical observations of: hypophysial adenoma (n = 135); craniopharyngioma (n = 71); tumors of the third ventricle (n = 88); basal meningiomas (n = 60). A comparative analysis of the findings allowed the authors to support that there are typical variants of changes in the patients' status, which reflect the nature of ion-osmotic disorders. The most significant mental disorders were transient hyperosmolar-hypernatriemic disturbances. The poor predictors were persistent hypernatriemia concurrent with evolving coma, systemic hemodynamic and respiratory disorders. Hyponatriemia is a better predictor of ionosmotic disorders, which requires a careful postoperative monitoring and a comparison of its findings with the specific features of intensive care performed.

[Cerebral low T3 syndrome]. / Mozgovoi sindrom nizkogo T3.

The authors studied the time course of changes in the parameters of the cerebral thyronergic system (total and free triiodthyronine (T3) and thyroxin (T4), thyroxine-binding globulin (TBG), thyroid-stimulating hormone (TSH) by radioimmunoassay (Immunotech, Czechia; CIS, France), proinflammatory cytokine of TNF-alpha by enzyme immunoassay (Innogenetic, Belgium) in the blood and cerebrospinal fluid (CSF) in 59 patients (37 males and 22 females whose age ranged from 21 to 64 years) in acute subarachnoidal hemorrhage due to arterial aneurysmal rupture. On admission, the condition of 47 (79.7%) was rated as grades III-VI according to the Hunt-Hess scale, which was responsible for high mortality rates (33.89% in the assessment of outcomes according to the Glasgow outcome scale). The causes of death were ischemic and hemorrhagic insults, edema of the brain, cerebral stem wedging. Laboratory findings were analyzed in relation to the clinical condition of patients, outcomes, and the degree of secondary vasospasm assessed by Doppler transcranial study by the average blood flow velocity in the middle cerebral artery. They revealed a significant depression of thyroidal metabolism with developed the total low T3 syndrome just before surgical treatment in patients with deterioration in the early postoperative period. The significant correlations found by the authors between the decreased blood T3 and TSH levels and 1) the severity of neurological disorders; 2) the degree of vasospasm, and 3) the outcome of disease, as well as negative correlations of elevated TNF-alpha levels not only in the blood, but also in CSF with the content of CT3, CT4 and with the severity of neurological symptomatology are indicative of the development of isolated syndrome in the brain, which is characterized by specific thyroidal metabolic disorders, which the author propose to call the cerebral low T3 syndrome (by taking into account the presence of the autonomic systems of thyroidal homeostatic provision).

[Involvement of thyroid hormones in mental recovery following severe craniocerebral trauma]. / Rol' tireoidnykh gormonov v protsesse vosstanovleniia psikhicheskoi deiatel'nosti posle tiazheloi cherepno-mozgovoi travmy.

To study a role of thyroid hormones in the recovery of mental performance, 71 patients (60 males, 11 females) aged 7 to 66 years (mean age 32.7 +/- 3.5) with severe brain injury (TBI). According to the stage of mental recovery (1--none; 2--elementary acts; 3--verbal contact; 4--spatial orientation; 5--intellectual and mnestic processes and emotional and personality traits), the study was divided into 5 series. Immunoradiometric assay of thyroid hormones (T3 and T4) and their free fractions (FT3 and FT4), thyroid-stimulating hormone (TSH), thyroxine-binding globulin (TBG), and prolactin (P) revealed significant alterations in thyroid metabolism at stages 1 to 4, which appeared as low T3 syndrome. The thyrotropin-releasing hormone (TRH) test made in study series 3 to 5 suggests that the patients have neuroendocrine dysfunctions at the mentioned recovery stages of mental functions of the brain. There was a close relationship of clinical parameters (mental time course) to alterations in the thyroid status and metabolism and to morphological impairments of brain tissues in their traumatic damage, which is evidenced by a correlation of the levels of blood and spinal fluid markers (neurone-specific enolase--NSE and protein S-100) of brain injury with psychopathological disorders (r = -0.96 and -0.6, respectively; p < 0.05) and by the assessment of TBI outcomes (r = -0.65 and -0.62, respectively; p < 0.05). Thus, the findings clinically confirm the neurotransmitter role of thyroid hormones at the stages of mental recovery. In addition, the results show that measurement of blood T3, FT3, TSH, T4, TBH, and NSE should be included into neurochemical monitoring in SBI as prognostically significant criteria. They also may serve as a basis for timely correction of thyroid metabolism.

[Problems in brain protection]. / Problemy zashchity mozga.

The main aim of intensive care in acute head injury and in the postoperative period is to prevent, detect, and revert a secondary neuronal injury. To maintain the optimum systemic and cerebrovascular functions can substantially promote this aim achievement. There are some new neuroprotective interventions that are currently under investigation. Although the major focus of recent cerebral protection researches has been on the development of receptor-specific drugs, this effort has resulted in better outcomes. At present, patients are well served by using more traditional techniques to prevent and treat cerebral ischemic events. Initial therapy should include interventions to improve cerebral perfusion and the oxygen-carrying capacity of blood. Once this is accomplished, measures should be made to monitor blood glucose concentrations and to treat fever. General anesthetic choice may be of great importance in monitoring intracranial pressure and seizure activity. However, if direct cerebral protection is desired, a barbiturate should be the anesthetic of choice. All these measures should increase the chance of patients to neurologically recover following hypoxia and ischemia.

[Nosocomial pneumonia in patients with severe craniocerebral trauma in intensive care units]. / Nozokomial'naia pnevmoniia u bol'nykh s tiazheloi cherepno-mozgovoi travmoi v otdalenii reanimatsii i intensivnoi terapii.

Eighty-three patients with severe craniocerebral injuries (CCI) were treated at Institute of Neurosurgery in 1999. Pulmonary infectious complications occurred in 16 of 25 patients with severe CCI. Early nosocomial pneumonia (NP) was diagnosed in 18% and the so-called late NP (associated with artificial ventilation of the lungs) in 35%. Coma longer than 4 days increased the incidence of NP to 62%. The main pathogens of NP are gram-negative aerobic bacteria (61%), the predominant agent being Pseudomonas aeruginosa (18.9%). 76% isolated microorganisms were multiresistant. The most significant risk factors as regards NP in patients with severe CCI were coma combined with bulbar and pseudobulbar disorders.

[Principles of intensive care during the acute period of severe craniocerebral trauma in children]. / Printsipy intensivnoi terapii v ostrom periode tiazheloi cherepno-mozgovoi travmy u detei.

Prospective analysis of the course of severe craniocerebral injury (CCI) in 37 children showed that the results of treatment depended on methods of intensive care. In children the outcome of CCI depends primarily on adequacy of maintaining effective cerebral bloodflow during the acute period of CCI irrespective of the terms and etiological factors of coma. Adequate cerebral perfusion pressure is attained with osmodiuretics, saluretics, and hemodynamic therapy. Hyperventilation is justified in cases with coma developing within 2 h after the injury; it should not lead to long (more than 1 h) decrease of PaCO2 below 28 mm Hg. The authors emphasize that every delayed decrease of consciousness after the injury should be thoroughly analyzed in order to rule out intracranial complications (epi/subdural and intracerebrai hematomas) in no more than 6 h, which is the maximal time allowed for decision making. Use of unapproved medical methods and drugs in children during acute period of severe CCI is ineffective and even hazardous, because it distracts the physician's attention to negligible details of treatment; in addition many of such drugs have side effects.

[Cerebral hemodynamics and metabolism in the acute stage of cerebral aneurysm rupture]. / Tserebral'naia gemodinamika i metabolizm v ostroi stadii razryva anevrizm golovnogo mozga.

The relationship between lipid peroxidation products and the severity of arterial spasm was studied in 86 patients. For this, the level of radical production, the content of the end lipid peroxidation product malonic dialdehyde and the overall antioxidative activity of lumbar cerebrospinal fluid were determined during 24-hour Doppler monitoring of blood flow in the middle cerebral and internal carotid arteries. Following subarachnoidal hemorrhage, the activation of lipid peroxidation processes was shown to correlate with the severity of arterial spasm and it is likely to contribute to the development of late ischemias. Nimotop used to treat patients with significant arterial spasm caused a reduction in the rate of free radical lipid peroxidation to that characteristic for patients with moderate spasm. The findings suggest that it is expedient of including antioxidants into the combined therapy of patients with acute subarachnoidal hemorrhage.

[The postoperative monitoring of intracranial pressure in patients in the acute period of aneurysmatic hemorrhage]. / Posleoperatsionnyi monitoring vnutricherepnogo davleniia u bol'nykh v ostrom periode anevrizmaticheskogo krovoizliianiia.

Changes in intracranial pressure (ICP) and cerebral circulation were evaluated from Doppler transcranial ultrasound (DTU) in 29 patients with spontaneous aneurysmal hemorrhage in acute rupture. There is a tendency for the pulse wave amplitude (PWA) of ICP to increase concurrently with higher ICP values (r = 0.768, p < 0.01), the tendency being smoother in patients with severe diffuse spasm (r = 0.573, p < 0.01). There was also a linear correlation between the ICP values and the pulse index of blood flow velocity (r = 0.783, p < 0.01). Evidence is given for the possibility of indirect assessment of ICP from DTU data and for that of indirect evaluation of cerebral perfusion from ICP monitoring data. In the latter case, the authors used a ICP PWA ratio. The findings suggest that the decrease in PWA/ICP values by less than 0.2 during intracranial hypertension and severe diffuse arterial spasm corresponds to the reduction in cerebral blood filling beyond the critical values.

[The use of a fiber-optic bronchoscope for the dynamic follow-up of the bulbar disorders in patients with tumors of the posterior cranial fossa]. / Primenenie fibroopticheskogo bronkhoskopa dlia dinamicheskogo kontrolia bul'barnykh narushenii u bol'nykh s opukholiami zadnei cherepnoi iamki.

Two case reports of patients operated for posterior fossa tumors complicated by postoperative hematoma are presented. In both cases patients underwent tracheostomy and were on ventilator for more than three weeks. Postoperative course was complicated by pneumonia and bronchitis. Fiberoptic bronchoscopy was performed to rule out lung complications. Fiberoptic laryngotracheoscopy was done for dynamic control of vocal cords paralysis and helped to make a decision regarding the time of the safe extubation.

[Endogenous intoxication and its treatment with sodium hypochlorite in neurosurgical patients]. / Endogennaia intoksikatsiia i ee lechenie s primeneniem gipokhlorita natriia u neiroreanimatsionnykh bol'nykh.

Blood plasma levels of medium-mass molecules (MMM), antioxidant activity (AOA), and malonic dialdehyde (MDA) were measured in 51 neurosurgical patients before and directly and 24 h after intravenous drip infusion of sodium hypochlorite (SHC) solution. Preliminary in vitro studies showed the most expressed drop of initially high MDA and MMM levels to be associated with an increase of AOA. It was observed at SHC concentration of 0.05 mg/ml, corresponding to infusion of SHC in a concentration of 600 mg/liter in 0.1 of the total circulating blood volume. Even a single dose of SHC alleviated endogenous intoxication and decreased the concentration of MMM and lipid peroxidation products. The proper AOA of the blood did not drop in this case, and in patients with initially low AOA it appreciably increased. Infusion of SHC normalized the values of Kp, which reflected its high detoxifying activity in endogenous poisoning caused mainly by inflammatory changes.