[Early rehabilitation after cerebral lesions: indications, methods, results]. / Frührehabilitation nach akuten zerebralen Läsionen. Indikationen, Methoden, Ergebnisse.

Early neurological and neurosurgical rehabilitation after severe brain injury of traumatic, hemorrhagic, ischemic, neoplastic, inflammatory, or hypoxic origin fills the gap between acute treatment and traditional rehabilitation services. During the last years, specific treatment modalities began to develop, directed at the key problems of severely brain injured patients: for example, stabilization of vegetative regulation, treatment of spasticity, swallowing disorders, disturbances of perception and communication, coping, and conditioning of the relatives. Procedures are gradually emerging to facilitate assessment, documentation of progress, and results. Prognosis is still very uncertain, especially in patients in a vegetative state. As a rule of thumb, about three out of four patients will improve substantially during the treatment.

[Risk factors for posttraumatic fits and epilepsy]. / Risikofaktoren für posttraumatische Anfälle und Epilepsie.

There is still a considerable controversy about the usefulness of antiepileptic prophylaxis after traumatic brain injury. Overall incidence of posttraumatic fits and epilepsy's is well known, but an individual decision on prophylaxis requires knowledge about the individual risk. We performed a prospective observational study on 612 patients with traumatic brain injury of every degree of severity. Follow-up by phone call included 96.2% of the study population after 6 month and 91.2% after 36 month, respectively. The overall incidence for early fits (within 7 days after trauma), late fits (up to 36 month) and epilepsy (as defined by the International League Against Epilepsy) was 4.2%, 3.7% and 2.5%, respectively. These incidences increased according to the severity of the trauma, but the most powerful single predictor was intracranial hemorrhage. There was no significant difference related to the hemorrhage localisation. Development of epilepsy was much more common after late fits (48%) than after early fits (17%). These features established a hierarchy of risks for the development of epilepsy: no intracranial hemorrhage/no fit: 1% (4/437), intracranial hemorrhage/no fit: 8% (10/122), intracranial hemorrhage/early fit: 16% (3/19), intracranial hemorrhage/late fit: 53% (7/13). If prophylactic antiepileptic treatment is desired, but should be restricted to patients at high risk. These are patients with intracranial hemorrhage--are a well defined high risk group--when their first fit is a late fit.

[Post-traumatic seizure prevention--results of a survey of 127 neurosurgery clinics]. / Posttraumatische Anfallsprophylaxe--Die Ergebnisse einer Umfrage unter 127 neurochirurgischen Kliniken.

Starting in November, 1993, until January, 1994, we performed a survey among 127 Neurosurgical Departments in Austria, Germany, and Switzerland concerning the practice of antiepileptic prophylaxis in head injured patients. Seventy seven percent of the 12-item multiple choice questionnaires were completed and returned. They indicate a variety of attitudes towards prophylaxis for seizures: in 12% of the responding institutions, antiepileptic prophylaxis is given to every brain trauma patient, in 36%, no prophylaxis is carried out. and in 52% some patients receive prophylaxis while others do not. Penetrating injuries, intracranial haemorrhages and electroencephalographic abnormalities were the most frequent reasons why prophylaxis was initiated. Phenytoin is by far the most popular drug, given usually for at least three months, and in most cases monitored by routine serum level observations. Nevertheless, about three out of four neurosurgeons conceded that a general renunciation of antiepileptic prophylaxis after brain trauma might be justified. There is no uniform way in which patients are informed about a possible risk of seizures, as it may be relevant, for instance, in respect of driving abilities.

[Predictors of treatment success after microsurgical operation of lumbar intervertebral disk displacement]. / Prädiktoren des Behandlungserfolges nach mikrochirurgischer Operation lumbaler Bandscheibenvorfälle.

As far as medical decision making is based on weighing up individual risks and chances of a certain patient receiving a certain treatment, some knowledge is required about signs and symptoms which are associated with a certain outcome: they are called risk factors, or predictive factors. In lumbar intervertebral disc surgery, the most frequent undesired effect of the treatment is unsuccessfulness. Reviewing the literature about risk factors for unsuccessfulness, one recognizes a lot of unconfirmed or even contradictory findings. This inconsistency can possibly be attributed to the common use of a very simplified, unidimensional definition of the target variable "success of treatment". That is why we performed a prospective observational trial on 109 patients in whom the success of lumbar intervertebral disc microsurgery was assessed after half a year using six different target variables. The rate of treatment success varied considerably, from 44% (when "return to previous occupation" served as the target variable) to 91% (with regard to "subjective contentedness"). Further target variables were intensity of sciatica, intensity of low back pain, activities of daily living, and postoperative paresis, giving intermediate success rates. We were able to identify some risk factors (for instance, duration of sick leave and of the recent pain episode, preoperative paresis, intensity of psychosomatic complaints), each of them being relevant to some of the target variables, but none of them associated with all of the target variables. We conclude that the multidimensional rating of treatment successes seems to promote risk research in multidimensional diseases.

Peri-operative changes of cellular and humoral components of immunity with brain tumour surgery.

Nosocomial infections, which are not uncommon in neurosurgical intensive care medicine, may possibly be favoured by an impairment of immunological competence of the patient. In a prospective observational trial, we investigated several parameters of cellular and humoral immunity in 32 patients before and after resection of an intracranial tumour. We quantified the effects of operative procedure, dexamethasone pretreatment, and tumour type. Dexamethasone alone causes an increase of neutrophilic granulocyte count and monocytes, whereas IgG and eosinophilic granulocytes decrease as well as lymphocytes. CD4+ T lymphocytes (T helper cells) and CD8+ T lymphocytes (T cytotoxic/suppressor cells) were more severely affected than B lymphocytes. Dexamethasone and operation in combination act synergistically on T lymphocytes and IgG, while no synergism is obvious in other clinical test parameters. The skin sensitivity reaction was depressed accordingly. With intracerebral tumours (gliomas WHO grades II to IV), levels of T helper cells and eosinophilic granulocytes were lower, and levels of IgM and neutrophilic granulocytes were higher than with benign extracerebral neoplasms. Postoperative nosocomial infections of the lower respiratory tract occurred almost exclusively in patients subject to severe depression of T helper cells.

"Medical decision making" for repeated computed tomography in neurosurgical intensive care patients.

Multiple CT investigations in critical ill neurosurgical patients are useful for monitoring the course of the illness and for the early detection of complications. CT's however, are expensive and require transportation of the patient, which is often inconvenient and, in some cases, dangerous. The decision to perform CT scanning should be based on the quantitative knowledge of potential benefits and harms (as well as costs) of the procedure. In a prospective trial, in which 59 such decisions were considered, we found it to be absolutely necessary to order a CT-investigation whenever neurological deterioration occurs. Even in patients not showing changes of neurological symptoms, about 30% of CT findings gave reason for therapeutic intervention. Thus, in critical ill neurosurgical patients, especially in those under sedative medication and artificial ventilation, neurological findings alone are insufficient as sole criteria for the decision to order a CT scan. To optimize this decision more sensitive indicators of deterioration are needed.

Endoscopic stereotactic treatment of brain abscesses.

Treatment of brain abscess is still a subject of controversy. Craniotomy with primary extirpation and resection of the abscess membrane, burrhole craniotomy with puncture or insertion of a drain, marsupialization, or stereotactic aspiration are different therapeutic approaches. As a consequence of our experiences and results with neuro-endoscopic interventions we have introduced endoscopic stereotactic techniques in brain abscess treatment. Seven patients with brain abscesses were operated on stereotactically using an endoscope. In all cases the abscess contents were aspirated, while the abscess membrane was left in situ. The patients received postoperative antibiotic therapy according to microbial diagnosis. The longest follow-up period was 48 months. Six patients showed a marked improvement of neurological deficit after treatment. One patient died from sepsis caused by a bacterial endocarditis. The results emphasize that endoscopic stereotactic technique as a minimally invasive neurosurgical method can also be used for treatment of brain abscess.

[Idiopathic hydrocephalus in adolescence]. / Idiopathischer Hydrozephalus in der Adoleszenz.

BACKGROUND: Decompensation of chronic idiopathic hydrocephalus can occur at every age, but seems to be rather frequent in the middle of the second decade. From this observation, the question arises, whether or not in these cases a special manifestation of hydrocephalus occurs and, should the situation arise, whether this finding might influence the discussion about pathogenesis. METHODS: We give some casuistic material about six hydrocephalic patients who became symptomatic between their 12th and 16th year of life. RESULTS: All of these patients showed a tri-ventricular appearance of hydrocephalus as well as radiological signs of chronicly elevated intracranial pressure, while clinical signs and symptoms differed considerably. These findings are linked to the discussion of the pathogenesis of so-called aqueductal stenosis. CONCLUSIONS: Whenever, after normal development in childhood, symptoms like increasing headache, poor concentration, dizziness or disturbances of gait appear during puberty, X-ray diagnosis of the skull is recommended. If it shows the signs of chronic elevated intracranial pressure, further investigations are necessary.

[Epithelial cyst of the central nervous system. A rare abnormality]. / Die epitheliale Zyste des ZNS. Eine seltene Fehlbildung.

A cystic process in the right frontal lobe of the brain in a man of 35 years of age, and an intramedullary cyst in the upper cervical spinal cord in a 29-year old woman, are described. In both cases, the wall of the cyst consisted of mucosal cells and cells having cilia pointing to the inside, located on a thin tissue layer, the structure of which resembled that of a meningioma. Central nervous cysts of this kind are usefully classified together with other, similar cysts (bronchogenic, ependymal and others) as "epithelial cysts". They must be differentiated from neoplastic tumours. Analysis of the cystic contents can prove helpful.

[Research in risk assessment in neurosurgery]. / Risikoforschung in der Neurochirurgie.

Since the time of Hippocrates patients and their physicians have been highly interested in knowing whether, and with what degree of probability "undesirable events" will occur in the course of illness--whether without, in spite of, or because of therapy. In surgery especially, the concept of "risk" is a familiar one to all concerned. The present paper describes traditional and modern methods of quantifying risk and the goals of medical risk research. Application of the results of such research in practice is discussed and illustrated by examples from publications and the authors' own clinical research.

Prediction of secondary deterioration in comatose neurosurgical patients by serial recording of multimodality evoked potentials.

In 75 comatose neurosurgical patients suffering from various types of intracranial lesions, multimodality evoked potentials (auditory, somatosensory, visual) were serially recorded at short intervals in order to evaluate their usefulness for early detection of secondary deterioration in the clinical course. The best parameter for prediction of secondary deterioration (as estimated by pupillary status) was a diminution in amplitude or disappearance of the primary cortical SEP peak. Considering these parameters, sensitivity of the prediction of pupillary behaviour was 71%, specificity 84%. Additional consideration of SEP latencies or BAEP or VEP parameters did not further increase the efficacy of prediction. In cases of correct positive prediction, deterioration of SEP occurred 4 to 144 hours before the deterioration of pupillary physiology.

[Deep leg vein thrombosis after microsurgical intervertebral disk operation]. / Tiefe Beinvenenthrombose nach mikrochirurgischer Bandscheibenoperation.

In a prospective sequential trial we investigated the incidence of symptomatic deep vein thrombosis of the legs in 304 patients after microsurgical operation for lumbar intervertebral disc disease or osteogenic root compression. None of these developed signs or symptoms of deep vein thrombosis or pulmonary embolism, neither when receiving pharmacological prophylaxis, nor without it. Superficial phlebitis was found almost exclusively in patients with preexisting varicosis, developing mainly in the 3rd week after the operation.

[Normal pressure hydrocephalus. An evaluation 25 years following the initial description]. / Der Normaldruck-Hydrozephalus. Eine Bilanz 25 Jahre nach der Erstbeschreibung.

A quarter of a century after the first description of a condition known as "normal pressure hydrocephalus", there no longer exists serious doubt about the existence of this disease nor about the possibility of treating it surgically with success. Nevertheless, there is still no general agreement on the exact definition of this condition, nor is there confirmed knowledge regarding its pathogenesis. Approximately half of the cases still are designated "idiopathic" in as much as physicians have no clear concept of its etiology. Some progress has been reached concerning the indication for operation: the "resistance to outflow" of cerebrospinal fluid can be measured now exactly by fluid infusion tests and seems to be a valuable predictor of outcome after shunting procedures. Reviewing world literature of the past 25 years reveals: the most important symptom of normal pressure hydrocephalus is not dementia, but disturbances of gait. Patients suffering from dementia, but not from gait-disturbances, do not gain from cerebrospinal fluid shunting and do not need to be investigated by invasive diagnostic procedures. In patients who suffer from gait-disturbances with or without dementia, with or without urinary incontinence, and in whom computed tomography reveals enlargement of ventricles without pronounced cortical atrophy, there should be a measurement of intracranial pressure and of the resistance to cerebrospinal fluid outflow.

Circadian rhythms in the body temperatures of intensive care patients with brain lesions.

The body core temperatures of 31 patients suffering from severe cerebral lesions were measured. Evidence for the existence or nonexistence of circadian rhythms in these patients was found to be associated with diagnosis (acute versus chronic lesions), with the level of consciousness, and with neurological findings (such as best motor response and pupillary reaction), but not with heart rate, corneal reflex, initial Glasgow coma score (GCS), or outcome. This evidence came to light only after multiphasic mathematical transformations of the raw data.

Prognostic factors for lower respiratory tract infections after brain-tumor surgery.

Nosocomial infection of the lower respiratory tract is a frequent and serious complication after major operations. A 32% incidence of lower respiratory tract infections was found after brain-tumor surgery in 289 patients, with a 21% incidence of pneumonia. In 186 of these patients (Group A), five factors were identified which were associated with an increased risk of postoperative lower respiratory tract infection. These were: age, tumor type, cardiac insufficiency, preoperative disturbances of consciousness, and preoperative corticosteroid treatment. Based on these factors, a risk score was developed which correlated well with the incidence of infection in this group of patients. In a second group of patients (Group B), the derived risk score was applied and was found to possess a high degree of validity. As long as patients were intubated postoperatively, their freedom from infection decreased exponentially, with a half-life of 3.5 days.

[Spinal epidural hematoma in children and adolescents]. / Spinale Epidural-hämatome bei Kindern und Jugendlichen.

This paper describes the course of disease in an 11-year old boy with spinal epidural hematoma (SEH), and subsequently surveys 27 cases of SEH in children and young people. This group is compared in respect of aetiology, localization, symptoms and prognosis with the group of adults with SEH. This is followed by a suggestion of a nosological classification on aetiological lines taking the age distribution into consideration. The need for early operative decompression is stressed.

Infection of the intervertebral space following conventional and microsurgical operation on the herniated lumbar intervertebral disc. A controlled clinical trial.

Review of the literature reveals that considerable knowledge has accumulated on intervertebral space infection following lumbar disc surgery. This is based on more than 400 observations. There are, however, no unifying concepts regarding the pathogenesis of the condition. While the reported incidence has seemed to increase in the last three decades, we noticed a significant reduction in frequency of this important complication of lumbar disc surgery after introducing microsurgical techniques. The significance of this finding is discussed with respect to pathogenesis.

[Xanthofibrogranulomatosis with meningocortical involvement]. / Xanthofibrogranulomatose mit meningealer Beteiligung.

The history of a 52-year old female with xanthofibrogranulomatosis (X.) is presented. Clinical and pathologic-anatomical findings of this rare disease are described. We report the case, because of the unusual intracranial spread of the X.

[Problems in the tube feeding of neurosurgical intensive care patients. Incidence and course in different diets]. / Probleme der Sondenernährung neurochirurgischer Intensivpatienten. Häufigkeit und Verlauf bei unterschiedlichen Diäten.

In a prospective randomized trial we observed the incidence and the course of disturbances of gastrointestinal function in patients suffering from disturbances of consciousness due to acute cerebral lesions. Patients were fed by nasogastric tube using two different commercial preparations. Gastrointestinal problems were limiting this form of alimentation, but were influenced by means of diet.