Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen.

In a prospective, randomized, double-blind investigation of anticoagulant agents for prevention of deep vein thrombosis in patients undergoing operations at the lumbar-vertebral disc, 179 patients were randomly allocated to two groups. 87 patients received a fixed combination of low-molecular weight heparin 1,500 U-aPTT plus dihydroergotamine 0.5 mg (LMWH/DHE) once a day and additionally one injection of placebo per day, 92 patients received a fixed combination of sodium heparin 5,000 U plus dihydroergotamine 0.5 mg (HDHE) twice a day. Treatment was initiated two hours preoperatively in both groups and continued for at least seven days. Deep vein thrombosis (DVT), detected by the 125Iodine-labelled fibrinogen uptake-test, occurred in four patients treated with LMWH/DHE and in three patients with HDHE. In all seven patients phlebography was performed, confirming the diagnosis of DVT in one patient of the LMWH/DHE group and in two patients of the HDHE group, only. No increased bleeding was found in either group. Especially no neurological complications caused by epidural bleeding were observed. We therefore recommended to treat routineously all patients undergoing operations at the vertebral disc with antithrombotic agents. The advantages of the once daily regimen with low-molecular weight heparin include better patients' acceptance and less nursing time.

Cerebral aneurysms: assessment of 377 cases (1956-1982).

A review of 177 patients with cerebral aneurysms is made, out of whom 106 with ruptured aneurysms were examined, whose operational timing and prognostic chances were well documented (group B, 1979-1982) and in part updated to 1984. Furthermore, relevant data of a previous series of 200 cases of cerebral aneurysm, treated between 1956-1978 were used (group A). The patients were graded according to Hunt and Hess, assessing the risks involved. The percentages of recurrent bleeding were in group A 36.5% and 28% in group B. The incidence of vasospasm (as seen in angiography) was in group B 39.6% (42/106 patients). The highest rate of vasospasm in the spasm group division B was found to occur in the second and third week after subarachnoid haemorrhage and amounted to 64.7% and 62.5%. A pre-operatively present vasospasm had no negative effects on the mortality rate, but influenced the outcome for the survivors effectively. The total mortality in group A was 22.5% and in group B 11.7%. Timing of the operation among patients in Hunt and Hess-grades I and II needs to discussion. The surgical position of patients in grade V is also certain. What remains to be discussed and needs attention is grade III and patients in grade IVa. Here the time of operative intervention must be planned individually depending on the course of the neurological status.

Management of giant aneurysms.

Technical aspects and anatomical difficulties involved in the management of this entity and the risks associated give giant aneurysms a special place in the treatment of aneurysms as a whole. The direct attack needs careful planning and the right choice of instruments, especially clips. In spite of the progress in recent years, the rate of mortality is still very high. The indirect approach requires in many cases the occlusion of a major cerebral vessel, which in some cases could result in cerebral ischemia. However, by means of extra-intracranial by-pass operation this risk could be reduced. The method of balloon embolisation has progressed recently. This procedure brings the least discomfort to the patient. Results of this method of treatment must be observed critically for future assessment.

Cerebral aneurysms: assessment of 377 cases (1956-1982)

Os autores aprresentam revisäo de 177 pacientes com aneurisma observados durante o período de 1979 a 1982 (Grupo B) e dos quais 106 sofreram ruptura aneurismática. E feita comparaçäo com série prévia tratada de 1956 a 1978 (Grupo A), com 200 pacientes. Observou-se a classificaçäo de Hunt e Hess. No Grupo A, 36,5% sofreram ressangramento no Grupo B, 28%. Vasoespasmo foi observado (angiograficamente) em 42 de 106 pacientes do Grupo B (39,6%). Observou-se ainda que o vasoespasmo ocorreu preponderantemente na segunda e na terceira semanas após o sangramento inicial (64,7% - 62,5%). A presença de vasoespasmo pré-operatório näo mostrou efeito negativo quando relacionada ao índice de mortalidade, embora tenha influenciado no prognóstico e na recuperaçäo do paciente. A mortalidade do grupo A foi 22,5% e no grupo B, 11,7%. O cirúrgico para os pacientes classificados em grau I e grau II (Hunt e Hess) merece ainda discussäo. Pacientes em grau III e grau IV merecem atençäo especial: a indicaçäo cirúrgica deve ser planejada individualmente, dependendo da evoluçäo do quadro clínico-neurológico

Management of giant aneurysms

Os aneurismas gigantes merecem atençäo especial no que se refere a seus aspectos anatômicos, riscos e, principalmente, dificuldades técnicas ao seu manueio. A abordagem de tais aneurismas necessita de planejamento adequado e, sobremaneira, de material apropriado para sua clipagem. A mortalidade ainda permanece alta, apesar dos recentes progressos observados nos últimos anos. Por outro lado, a abordagem indireta requer, muitas vezes, oclusäo de um vaso cerebral importante, o que pode acarretar isquemia cerebral. Entretanto, por anastomose extra-intracraniana tais riscos podem ser diminuídos. O método de embolizaçäo por balöes tem-se mostrado eficaz. Este processo oferece menor incômodo ao paciente. Os resultados deste método devem ser observados criteriosamente para melhor avaliaçäo no futuro

[Percutaneous nucleotomy: an alternative to chemonucleolysis?]. / Perkutane Nukleotomie: eine Alternative zur Chemonukleolyse?

In this study, we compare two groups of patients treated with chemonucleolysis (CNL) (101 patients) and percutaneous nucleotomy (PN) (100 patients) for sciatic pains. Indications for treatment were drawn along similar lines. The patients treated with CNL originated from the Department of Neurosurgery, University Hospital in Mainz and underwent treatment between 1983 and 1987. The second group with PN were from the teaching hospital in Wiesbaden and were treated during 1987 and 1988. Postoperatively, 80% of the CNL group showed good results. However, postoperative progress was slow with back spasms as a common uncomfortable side effect. In 72% of the patients in the PN group, successful treatment was demonstrated with results occurring almost immediately after treatment.

Clinical follow-up after surgery of lumbar disc prolapses. A critical analysis.

A retrospective clinical study was made on 987 patients with lumbar disc disease treated by discectomy. All patients had been operated on in the Department of Neurosurgery (University-Hospital Mainz). 545 patients were males, and 442 females (1.2:1). Patients in the 4th decade of life were affected most often (33.5%). Perioperative complications occurred in 5.4%, with discitis as the single major complication (1.9%). 83% of all patients who underwent discectomy could return to their normal occupation.

Epidural spinal abscesses.

Fifteen cases of peridural empyemas are reported. 12 patients reported with motor dysfunction of the lower extremities and pain radiating from the spine. In one case, localized pain of the spine was discovered and in two cases there were no signs of spinal or radiating pain. Treatment in all cases was laminectomy and systemic antibiotic administration. Microbiological analysis showed staphylococcus aureus in 11 cases. 9 patients recovered with no neurological defects, two had major improvement of the paresis, and one died. Three patients with paraplegia recovered from the primary infection.

[Treatment of spontaneous intracerebral hemorrhage--operative or conservative?]. / Therapie spontaner intrazerebraler Blutungen--operativ oder konservativ?

The current treatment of spontaneous intracerebral hematomas is reviewed, and the results in the literature as well as our own experience on the subject are discussed. It is evident that modern diagnostic methods and follow-up observation periods have led to a sharp decline in the need for operative treatment. The diverse forms of clinical treatment and the remaining indications for neurosurgical intervention are presented.

Cerebral arachnoid cyst: a lesion of the child's brain.

39 patients with 42 arachnoid cysts have been reviewed in a retrospective study. All kinds of arachnoid cysts reported in the literature were also found in this study. These consist mainly of congenital primary and post-traumatic secondary cysts. Cysts which cause no major neurological deficits require conservative treatment of symptoms only. Cysts which cause major symptoms because of their space occupying nature, however, require surgical treatment. Craniotomy with removal of membranes to allow free physiological circulation of CSF is the treatment of choice in our hands. Cysto-peritoneal shunting is an alternative procedure for patients in a poor condition. More than 50% (23 out of 39 cases) were younger then 20 years of age, suggesting that these cysts are mainly congenital lesions of the brain.

[Chemonucleolysis. Method, indications and results. Review]. / Die Chemonukleolyse. Methodik, Indikationen und Ergebnisse. Ubersicht.

Since 1963 Chemonucleolysis [CNL] with discase and collagenase has served as a supplementation to the surgical approach in the treatment of prolapses of lumbar disks. The world-wide stated rates of successful treatments amount to about 70 per cent. For a further correction of the result surgical treatments are considered to be necessary in about 20 per cent of the cases. Our experience gained with these measures shows a success in 70 per cent of the patients. The frequency of operations still lies around 18 per cent in accordance with the international standard. This therapy, however, should not be considered to be a fully valid alternative or substitute. If exact indications are present, it can make a surgical intervention superfluous in selected cases.

Indication and contraindication for surgery of spontaneous intracerebral hematomas. Therapy and results.

The indication for surgery in spontaneous intracerebral hematoma is given when, in spite of the administration of dexamethasone in high dosage, an improvement of the initial neurological symptoms could not be observed, or if a worsening is seen. With the help of CT the size of the hematoma could be controlled so that if in comparison to initial findings an increase in mass displacement or herniation is observed, surgery should be performed immediately. In cases of deep coma with vegetative unstable states, as well as in cases of bleeding into the basal ganglia, surgery is contraindicated.