Impact of blunt chest trauma on outcome after traumatic brain injury- a matched-pair analysis of the TraumaRegister DGU®.

BACKGROUND: Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. METHODS: We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3-5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2-5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05. RESULTS: A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AISThorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI. CONCLUSIONS: Chest trauma in general, regardless of its initial severity (AISThorax= 2-5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered "at risk" and vigilance for the maintenance of optimal neuro-protective measures should be high.

Early perfusion computerized tomography imaging as a radiographic surrogate for delayed cerebral ischemia and functional outcome after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: To date, there is no immediate radiographic surrogate to quantify primary cerebral injury to identify patients at risk for delayed cerebral ischemia and poor clinical outcome after aneurysmal subarachnoid hemorrhage. Therefore, we investigated the relation of early cerebral perfusion-computerized tomography and clot volume with radiological events of delayed cerebral ischemia and clinical outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: Data from 2 cohorts of patients (51 in main, 28 patients in control cohort) with aneurysmal subarachnoid hemorrhage, receiving computerized tomography and perfusion-computerized tomography scanning <12 hours after ictus, were included. A risk group model for functional outcome was developed on the basis of early mean transit time (MTT) and volumetric blood clot measurements. The relation of the risk group model with subsequent MTT, angiographic vasospasm, new cerebral infarction, and functional outcome was analyzed. Actual and predicted functional outcomes based on the risk group model were compared in the control cohort. RESULTS: The risk group model correlated significantly with subsequent MTT measurements, cerebral infarction, and functional outcome. Odds for poor outcome were significantly higher in case of concomitant increase of early MTT and clot volumes, as opposed to exclusive early MTT or clot volume increase. For patients in the high- or low-risk groups, neurological outcome in the control cohort correlated significantly with predicted outcomes. CONCLUSIONS: Assessment of early cerebral perfusion and intracranial blood clot may serve as a radiographic surrogate for delayed cerebral ischemia and functional outcome in patients with aneurysmal subarachnoid hemorrhage using risk group modeling.

Coiling of a carotid cavernous sinus fistula via microsurgical venotomy: recommendation of a combined neurosurgical and endovascular approach.

INTRODUCTION: Endovascular treatment of a carotid cavernous fistula (CCF) via a transvenous approach is standard but, in rare cases, the standard approach is not feasible due to vessel occlusion or anomalies. In such cases it remains a challenge to find an alternative route for complete treatment. CLINICAL PRESENTATION: A 42-year-old patient presented with a symptomatic CCF (Barrow type C). An endovascular approach to the CCF was not possible due to abnormal venous vessel architecture, so a combined surgical and interventional approach was undertaken. A custom-tailored craniotomy was first performed to access the major sylvian vein. After venotomy and insertion of a microcatheter, the CCF was completely occluded by coiling and embolization conventionally. The symptoms regressed and had almost completely disappeared at follow-up. CONCLUSIONS: An individually tailored strategy with a combined surgical and endovascular approach enabled full treatment with minimal risk for the patient.

Local delivery of nimodipine by prolonged-release microparticles-feasibility, effectiveness and dose-finding in experimental subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: To investigate the effect of locally applied nimodipine prolonged-release microparticles on angiographic vasospasm and secondary brain injury after experimental subarachnoid hemorrhage (SAH). METHODS: 70 male Wistar rats were categorized into three groups: 1) sham operated animals (control), 2) animals with SAH only (control) and the 3) treatment group. SAH was induced using the double hemorrhage model. The treatment group received different concentrations (20%, 30% or 40%) of nimodipine microparticles. Angiographic vasospasm was assessed 5 days later using digital subtraction angiography (DSA). Histological analysis of frozen sections was performed using H&E-staining as well as Iba1 and MAP2 immunohistochemistry. RESULTS: DSA images were sufficient for assessment in 42 animals. Severe angiographic vasospasm was present in group 2 (SAH only), as compared to the sham operated group (p<0.001). Only animals within group 3 and the highest nimodipine microparticles concentration (40%) as well as group 1 (sham) demonstrated the largest intracranial artery diameters. Variation in vessel calibers, however, did not result in differences in Iba-1 or MAP2 expression, i.e. in histological findings for secondary brain injury. CONCLUSIONS: Local delivery of high-dose nimodipine prolonged-release microparticles at high concentration resulted in significant reduction in angiographic vasospasm after experimental SAH and with no histological signs for matrix toxicity.

Early CT perfusion measurement after aneurysmal subarachnoid hemorrhage: a screening method to predict outcome?

OBJECTIVE: The goal of the present study is to analyze the predictive impact of early CT-based perfusion measurement (CTP) on clinical outcome in patients suffering from aneurysmal SAH. METHODS: Fifteen patients with aneurysmal SAH received an early CTP measurement that was performed within the first 6 h after initial bleeding. According to a specific CTP protocol, mean transit time (MTT) and time to peak (TTP) were calculated bihemispherically and correlated with the clinical initial status according to the WFNS grade as well as with the Glasgow Outcome Scale (GOS) at the time of discharge. RESULTS: The MTT and TTP correlated highly significantly with the initial WFNS grade and the GOS at the time of discharge. Mean bihemispheric MTT was 3.4 s (2.8-4.1 s, SD: 0.5 s) for initially good-grade patients (WFNS° I-III) and 4.5 s (31.2-49.8 s) for poor-grade patients (WFNS° IV-V). ICP monitored in nine patients via EVD was documented within normal intracranial pressure as defined below 18 mmHg. CONCLUSION: The determination of MTT and TTP using early CTP measurements in patients suffering from aneurysmal SAH demonstrated a significant correlation with the initial neurological status and the early clinical outcome.

Intraoperative Doppler and Duplex sonography in cerebral aneurysm surgery.

PURPOSE: The aim of open surgery of cerebral aneurysms is to minimise the risk of infarction due to poor position of a clip while still securing the aneurysm from rebleeding. Whilst digital subtraction angiography (DSA) remains the gold standard for precise evaluation of the result, its invasiveness, risk of thromboembolic infarction, availability and time-consumption pose a significant limitation, and overall it is rarely used. The goal of the present study was to analyse the feasibility of intraoperative B-mode Duplex ultrasound in combination with Doppler sonography (DDS) to evaluate this issue. METHODS: A total of 44 aneurysms in 40 patients were investigated intraoperatively via B-mode and power Duplex sonography after clip positioning in a prospective setting. Data were then compared to postoperative angiography. RESULTS: In 38 cases DDS allowed for visualisation of aneurysm localisation, neck and diameter, as well as associated vessels, in accordance to preoperative DSA. This was confirmed by Duplex sonography in 94.7%. Further evaluation of each associated vessel after clip positioning was then enabled by Doppler sonography in 84.8%. Visualisation in terms of B-mode sonography was not successful in six cases due to multiple clips. CONCLUSION: DDS is an additional tool for immediate evaluation of clipping performance intraoperatively and can be used in simple cases with reliable results. In six cases Doppler-/Duplex-sonography did not illustrate the clipping result sufficiently. It is not yet able to replace DSA in aneurysms with complex configuration.

A cylindrical extracranial cranial base neurinoma of the hypoglossal nerve: a rare tumor with a rare localization: case report.

OBJECTIVE: Neurinomas of the hypoglossal nerve are very rare. They are mostly located intracranially or combined intra- and extracranially, resulting in the so-called dumbbell shape. The isolated extracranial localization of the neurinoma of the hypoglossal nerve adjacent to the cranial base as described in this case report is extremely rare. CLINICAL PRESENTATION: The 23-year-old patient presented with recurring headaches. She had right-sided hypoglossal nerve palsy for approximately 5 to 6 years. Magnetic resonance imaging revealed an extracranial tumor with contact to the cranial base originating from the hypoglossal nerve. INTERVENTION: The tumor was extirpated surgically and verified histologically as a schwannoma of the hypoglossal nerve. CONCLUSION: Pathologies of the hypoglossal nerve as such are very rare within the clinical landscape. When a tumor occurs, its shape and location must be analyzed to establish whether, or by which approach, surgical removal is feasible. Although very unusual, the mere extracranial occurrence of a hypoglossal neurinoma at the cranial base should be considered a differential diagnosis.