Intensive care management of head-injured patients in Europe: a survey from the European brain injury consortium.

OBJECTIVES: (a) to describe current practice in the monitoring and treatment of moderate and severe head injuries in Europe; (b) to report on intracranial pressure and cerebral perfusion pressure monitoring, occurrence of measured and reported intracranial hypertension, and complications related to this monitoring; (c) to investigate the relationship between the severity of injury, the frequency of monitoring and management, and outcome. METHODS: A three-page questionnaire comprising 60 items of information has been compiled by 67 centres in 12 European countries. Information was collected prospectively regarding all severe and moderate head injuries in adults (> 16 years) admitted to neurosurgery within 24 h of injury. A total of 1005 adult head injury cases were enrolled in the study from 1 February 1995 to 30 April 1995. The Glasgow Outcome Scale was administered at 6 months. RESULTS: Early surgery was performed in 346 cases (35%); arterial pressure was monitored invasively in 631 (68%), ICP in 346 (37%), and jugular bulb saturation in 173 (18%). Artificial ventilation was provided to 736 patients (78%). Intracranial hypertension was noted in 55% of patients in whom ICP was recorded, while it was suspected in only 12% of cases without ICP measurement. There were great differences in the use of ventilation and CPP monitoring among the centres. Mortality at 6 months was 31%. There was an association between an increased frequency of monitoring and intervention and an increased severity of injury; correspondingly, patients who more frequently underwent monitoring and ventilation had a less favourable outcome. CONCLUSIONS: In Europe there are great differences between centres in the frequency of CPP monitoring and ventilatory support applied to head-injured patients. ICP measurement disclosed a high rate of intracranial hypertension, which was not suspected in patients evaluated on a clinical basis alone. ICP monitoring was associated with a low rate of complications. Cases with severe neurological impairment, and with the worse outcome, were treated and monitored more intensively.

[An unusual form of neurosarcoidosis isolated in association with a tumoral lesion, chronic meningitis, hydrocephalus and hypothalamo-hypophyseal involvement]. / Une forme exceptionnelle de neurosarcoïdose isolée associant lésion tumorale, méningite chronique, hydrocéphalie et atteinte hypothalamo-hypophysaire.

A 30-year-old woman developed progressive left sided hemiparesis with intracranial hypertension signs. CT scan and MRI showed a large temporo parietal cystic mass with marked surrounding edema. Surgical excision was performed, and histological analysis revealed an inflammatory granuloma. No disease elsewhere was found and all classical causes of granulomas such as tuberculosis, toxoplasma, fungus infections, inflammatory diseases, lymphomas and cancers were excluded. No treatment was administered and she remained neurologically stable for two years. Afterwards, she developed chronic meningo-encephalitis, hypothalamic-pituitary dysfunction and hydrocephalus requiring decompression. Sarcoidosis was suspected, a steroid therapy was initiated, she gradually improved and a ventricular biopsy confirmed this diagnosis. Nervous system lesions complicate the course of sarcoidosis in 5 to 15% of patients and most commonly involve the cranial and peripheral nerves. CNS involvement is typically meningeal with a predilection for the hypothalamic region. Intracranial mass lesions are rare and their occurrence in the absence of disease elsewhere is still more unusual. Three presentations have been described: an isolated intra parenchymatous mass, multiples nodules, and subdural plaques, that can be mistaken for meningiomas, gliomas or metastases. When systemic manifestations of sarcoidosis are absent, the diagnosis is difficult, and Gd-enhanced MRI is now considered the diagnostic method of choice. However brain biopsy is sometimes necessary. Corticosteroids are the mainstay of therapy. Immunosuppressive agents are also used and brain irradiation has been tried in some refractory cases. Surgical approach may be indicated to establish tissue diagnosis, to perform decompression and to remove brain tumors.

The European Brain Injury Consortium survey of head injuries.

To provide a picture of contemporary practice, a survey was carried out of severely and moderately head injured patients admitted to 67 'neuro' centres in 12 European countries. 1,005 adult head injuries were recruited over a three month period. Sixty items of information on demography, clinical features, investigations, management and early complications were captured on a simple, two-page questionnaire and, information on outcome at six months on a third page. The median age of the subjects was 38 years, 74% were male and 51% injured in road traffic accidents; 57% of patients were transferred to the 'neuro' centre from another hospital. Assessment of clinical responsiveness was limited by the use of sedation and intubation and information from four early time points (pre-hospital, arrival at the Accident and Emergency department, post-resuscitation, and arrival at the 'neuro' unit) was combined to stratify the subjects as severe (58%), moderate (17%) or intermediate (19%). In 48% of patients classified the CT scan showed features of a 'mass lesion' and in 40% showed a subarachnoid haemorrhage. Fifty-five centres provided the data on outcome for 94% of the cases recruited in these centres six months after injury. 31% died, 3% were vegetative, 16% severely disabled, 20% moderately disabled and 31% had made a good recovery. Comparison of the data from different parts of Europe showed differences in the frequency of secondary transfer, cause of injury, occurrence of major extracranial injury, CT scan findings, intracranial operation, clinical severity of injury and utilisation of the components of intensive care and the occurrence of a favourable outcome, although the latter difference was not statistically significant when variations in the initial severity of injury were taken into account. The findings in the present survey are compared with newly analysed information for three previous large series: the International Data Bank involving the UK, the Netherlands and the USA, the North American Traumatic Coma Data Bank, and data from four centres in the UK. The comparisons showed substantial similarities and also differences that may reflect variations in policy for admission of the head injury to 'neuro' units, and evolution in methods of assessment, investigation and management. The effects of these differences on outcome requires further, rigorous prospective study.

[Primary central nervous system lymphomas. Diagnostic and prognostic effect of steroid-induced remission]. / Lymphomes primitifs du système nerveux central. Rôle diagnostique et pronostique des rémissions cortico-induites.

PURPOSE: Non-AIDS primary central nervous system lymphomas may respond totally or partially to corticosteroids. These corticoid-induced remissions seems to be very specific for this disease. They have been proposed as diagnostic test. The effect of these remissions on prognosis remains unknown. METHODS: A retrospective study was conducted. Corticosteroid sensibility, duration of survival, duration of disease free interval and type of treatment were compared between two groups of patients. The first one (group 1) included 44 patients in which exact diagnosis was made by stereotactic biopsy or surgery. The second group (group 2) included 5 patients exhibiting typical neuroradiological aspects of primary lymphoma in whom corticosteroid therapy produced a total regression of the lesions. RESULTS: In group 1, 29.1% of the lymphomas exhibited cortico-sensitivity. Duration of free interval of disease accounted for 75% of the overall duration of survival. Age was the only significant factor predicting remission (p = 0.019). The sole factor influencing total duration of remission was the type of treatment (p = 0.03). Duration of remission was significantly shorter in group 2 versus group 1 patients (p = 0.007). CONCLUSIONS: Duration of the first remission is of paramount importance on survival as well as the quality of first line therapy. In these conditions the absence of precise diagnosis due to corticoid-induced remissions could be dramatically deleterious.

p53 protein expression in grade II astrocytomas: immunohistochemical study of 100 cases with long-term follow-up.

p53 protein expression was evaluated by immunohistochemistry in a homogeneous series of 100 supratentorial grade II astrocytomas with long-term follow-up. The staining was positive in 72 cases. The proportion of p53 positive tumors was slightly higher in younger patients. The tumor regrowths which derived from p53 positive tumors were themselves p53 positive, and this p53 immunopositivity was often stronger than in the initial tumors. All of the 10 gemistocytic astrocytomas included in our series were p53 positive, and age more than histological type appeared decisive in prognosis. p53 protein expression did not quite reach statistical significance as an independent predictive variable in multivariate analysis, whereas survival was related with age, mass effect, surgery and tumor location. Only a tendency to a longer survival was observed on the curves in younger patients with mildly positive tumors.

Guidelines for treatment of head injury in adults. Opinions of a group of neurosurgeons.

There are a number of parallel activities world wide to devise guidelines for the treatment of head injuries. A Group of neurosurgeons from various European countries worked on guidelines during three informal meetings, which may serve as a base for discussion of national or local protocols. Three levels of certainty were distinguished: Measures that must be taken which such a high degree of certainty, that they have not seriously been challenged-principles. Measures, that should be taken, as there is reasonable evidence in the literature about its efficacy-recommendations and measures that may be taken, but proof of its efficacy is lacking-optional measures. Protocols based on these guidelines are felt to help young neurosurgeons in training, define neurosurgical needs for other specialities and enhance the general efficacy of care for the head injured patient including multiple injuries.

EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium.

Guidelines for the management of severe head injury in adults as evolved by the European Brain Injury Consortium are presented and discussed. The importance of preventing and treating secondary insults is emphasized and the principles on which treatment is based are reviewed. Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted. The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.

Primary Langerhans' cell histiocytosis of the central nervous system with fatal outcome. Case report.

An unusual case of primary parenchymal Langerhans' cell histiocytosis of the central nervous system is reported. The definitive diagnosis was obtained by ultrastructural detection of Birbeck granules and by immunohistochemical evidence of CD1a expression. Despite complete surgical resection, there was an early recurrence with multiple central nervous system metastases leading to a fatal outcome.

Lymphoplasmacyte-rich meningioma in a child. Case report.

A rare case of lymphoplasmacyte-rich meningioma observed in a young girl is reported. The first clinical manifestations of the disease were seizures. Neuroradiological images favored the existence of a meningioma. Abnormalities in the patient's blood chemistry, principally including hypergammaglobulinemia and inflammatory syndrome, were associated with the disease. The tumor was histologically confirmed as meningioma with massive infiltrates of type B lymphocytes. The pathophysiology of the conspicuous lymphoplasmacyte infiltrates, responsible for peripheral blood abnormalities, has remained poorly understood. Alternative diagnostic hypotheses of masses that mimic this type of meningioma are discussed.

Low-grade astrocytomas: prognosis factors and elements of management.

BACKGROUND: The literature provides information concerning prognosis of low-grade astrocytomas, but the series are quite heterogeneous in terms of clinical material, neuropathological evaluation, and statistical methods of analysis. Therapeutical indications are poorly defined. The last World Health Organization (WHO) histological classification provided a very precise definition of low-grade gliomas. METHODS: Taking into account a recent study of our own and literature data, management guidelines of these tumors were proposed. RESULTS: Grade I (pilocytic and subependymal giant cell astrocytomas) are surgically curable lesions. No adjuvant treatment is mandatory. Management of grade II astrocytomas is less clear-cut. Conservative management is probably possible in young patients without functional threat. The role of surgery on duration of survival has been properly established in very few series and was negative in many others. The role of radiotherapy has been demonstrated in a few subgroups of patients. In our study of ordinary astrocytomas, considering decades of age at diagnosis, survival curve analysis established three prognostic classes of age (before 50, between 50 and 60, and after 60 years of age). Based on our results and on recently published data, a branch decisional approach was proposed for management of grade II astrocytomas. Other grade II gliomas exhibit more favorable prognoses but could be managed in the same manner. CONCLUSIONS: Ordinary grade II astrocytomas constitute a paradigm of difficult differential management. Further pertinent information on these tumors could come from the field of tumor biology, or be provided by very large and homogeneous groups of patients.

[Supra-tentorial low-grade astrocytomas in adults. Prognostic factors and therapeutic indications. Apropos of a series of 141 patients]. / Astrocytomes de bas grade sus-tentoriels de l'adulte. Facteurs pronostics et indications thérapeutiques. A propos d'une série de 141 patients.

An abundant literature provides informations upon the prognosis of supratentorial low grade (grade II) astrocytomas, but the series are quite heterogeneous in terms of clinical material, neuropathological evaluation and statistical methods of analysis. So, outcome, prognostic factors and therapeutical indications are poorly defined. A retrospective study of 141 adults patients suffering ordinary low grade astrocytoma diagnosed in our unit between 1978 and 1988 was conducted. A follow up of 5 years or more, since neuropathological diagnosis, was mandatory for inclusion. Endpoint of statistical analysis was duration of survival. Results were expressed after uni and multivariates analysis. Clinical and morphological features of our series were comparable to those previously reported in the literature. Median survival time was 52 months. Considering age at diagnosis, survival curve analysis showed highly significant differences (p < 0.0001) and established three prognostic classes of age (before 50, between 50 and 60, and after 60 years of age). Comparisons of survival curves showed significant statistical differences (p < 0.0001) according to pretreatment functional status. Analysis of a clinical condition using a functional scale is more powerful, from a statistical point of view, than an individual analysis of each constituting parameters. In this series a good correlation was found between functional status and age at diagnosis. Neurological deficit was more correlated to age than to tumor location. Multivariate analysis, using the Cox model, defined some parameters acting independently on duration of survival: fronto-parietal location (p < 0.0001), pretherapeutical functional status (p < 0.001), age at diagnosis (p = 0.001), deepseated or multicentric tumor, mass effect (p < 0.01), frontal location (p < 0.02), total surgical removal (p < 0.05). Non significant parameters were: radiotherapy, time before diagnosis, age of onset, sex, contrast enhancement on CT scan. Our results are in agreement with previously reported data confirmed literature data concerning prognostic factors characteristics of the host (age), characteristics of the tumor (location) and expressing the influence of the tumor on the host (functional status). Our series documented prognostic clinical forms of these tumors (function of age, of performance status, and of tumor location). Our results confirm the relative inefficacy of therapeutic weapons, considering the population as a whole, on duration of survival. Based on our results and on recently published data, a decision tree analysis was proposed for management of grade II astrocytomas.(ABSTRACT TRUNCATED AT 400 WORDS)

[Training of surgeons for laboratory research]. / La formation des chirurgiens à la recherche en laboratorie.

A degree in surgical research has been set up in 1986 in France. It includes a one-year full time work in a research laboratory, and seminars (one to three days long, each). General surgical research objectives are gathered in a first seminar. Then, candidates select one among four optional subjects: biomaterials-artificial organs, transplantation, oncology, and neurosciences. Two prerequisites are necessary in order to register. The first is to write a research project according to standardized rules, and the second is to attend two seminars, one dealing with scientific communication and the other with methodology in clinical research. A nation-wide valid Academic degree is delivered to candidates who pass an oral presentation of their research report and who attended all seminars according to the optional subject that they selected. From 1986 to 1993, 434 students attended the formation. They came from different regions of France, proving the nation-wide characteristic of the degree, and some from foreign countries. Seminars were held in different French University towns. An increasing number of students become Ph.D.

Images and icons.

Modern images have became essential to our daily work because they provide high quality representations which, with admittedly some difficulties and pitfalls, allow detection and diagnosis of lesions and moreover inspire and guide every step of surgery. This place and value of the image as the main source of technical information required for the patient's management is straightforward and raises no major epistemological problem. However our use of images easily escapes critical thinking. Images may impose their own power and rationality. Medical images are powerful for the patient and for the doctor because they contain an unlimited source of explanation for the disease, they make disease and functional complaints, comprehensible. They are important for the surgeons because they offer an unique and irreplaceable guide to the lesions, they make it visible, they give shape and in fact reality to what in the patient, belongs to surgery. This power of medical images is irrefutable because, rather than mere representations, they are analogical reflexions of the real body with its real lesions, there is an ontological continuity between image and reality. For these and some other reasons we are tempted to give to images a consideration which should be due only to the patient himself. This temptation is idolatrous in nature. Under a number of different aspects this temptation pervades the entire field of medicine and might ultimately narrow our vision of patients, our vision of man.

[Stereotaxic biopsies of pineal tumors. Comments on their risk and implication apropos of 370 cases]. / Les biopsies stéréotaxiques des tumeurs de la région pinéale. Réflexions sur leur risque et leur rendement à propos de 370 cas.

370 stereotactic biopsies of pineal region tumors, from 15 neurosurgical centers in France have been reviewed with the goal to evaluate the mortality/morbidity rates and diagnostic yield of this procedure. The impact of neuroradiological means of localisation, the probe trajectory, the type of biopsy instrument, the time of shunting are discussed in order to maximize the diagnostic yield and minimize the mortality/morbidity rates. Stereotactic biopsy contribution, as compared to other diagnostic methods, in pineal region tumors was evaluated. The mortality rate was 1.3 % (5 patients of 370), 3 patients suffered severe neurological complication. In relation to the large number of patients in this study, we can assess that the mortality rate of stereotactic biopsy in this region doesn't significantly exceed that of stereotactic brain tumor biopsies in general.