"No-reflow" phenomenon as a cause of hypoperfusion after severe head injury?

INTRODUCTION: Severe head injuries are known to cause secondary ischaemic brain damage. Ischaemia may develop due to transtentorial herniation or due to increased intracranial pressure leading to decreased perfusion. Compression of the brain due to extracerebral haematoma may cause hypoperfusion as well. METHODS: 29 patients with postraumatic transtentorial herniation were studied. Haematoma was urgently removed in these patients and CT and SPECT was performed on the 1st and 5th postoperative day. 26 patients had hypoperfusion on SPECT in the vicinity of the previous haematoma. Only 9 of them, however, had ischaemia on CT. There were 11 patients in whom the previous ischaemia seen on SPECT improved on the follow up SPECT examination. 10 of them had a good treatment result. CONCLUSION: A possible mechanism of hypoperfusion caused by compression of the brain may be a kind of "no-reflow" phenomenon which is known from pathophysiology of classical brain ischaemia. Patients in whom the collateral blood flow overcomes the decreased perfusion in the microcirculation should have a better outcome. (Tab. 1, Fig. 1, Ref. 13).

Cerebral perfusion pressure and spect in patients after craniocerebral injury with transtentorial herniation.

We present a group of 29 consecutive head injured comatose patients with the syndrome of transtentorial herniation. All patients had urgent surgery and then continuous monitoring of ICP, CPP, blood pressure and jugular bulb oximetry was instituted. Two postoperative CT and SPECT examinations were performed in each patient. 15 patients had a normal CPP (> 70 mmHg) throughout the postoperative period, 80% of them had a favourable outcome. On the other hand 14 patients had decreased CPP lasting at least one hour and only 36% of them had a favourable outcome (p < 0.05). Similar relationships were found comparing GOS in patients with normal and increased ICP (> 20 mmHg) and normal and decreased SjO2 (< 55%). All but 3 patients had ischaemia on SPECT. Ischaemia improved on the 2nd SPECT in 11 patients and 10 (91%) of them had a favourable outcome. GOS (mean follow up 9 months) is: 12 patients good, 5 moderately disabled, 2 vegetative, 10 died. We conclude that SPECT is able to disclose even reversible ischaemic changes. In these patients all effort has to be made to keep CPP on normal levels. Improvement in cerebral perfusion is related to a better outcome.

Lumbar disc surgery in regional anaesthesia--40 years of experience.

Lumbar disc operations have been performed in Brno since 1952 and from the very beginning they are performed under regional anaesthesia. Since 1965 until 1999 about 16,000 operations for herniated discs have been performed here. The number of operations doubled with the foundation of the second neurosurgical department in Brno in 1992. Lumbar disc surgery represents 25% of the operation spectrum in our department. Epidural anaesthesia is advantageous for less risk of some complications compared with general anaesthesia and enables communication between the surgeon and the patient. Other advantages are: less visible bleeding in the operative field due to the lateral position and the fact that the surgeon can sit during the operation. On a long-term basis we found 4-5% had further surgery for reccurent problems. Objective neurological evaluation 6 weeks after the operation showed improvement in 92% of patients. The patients themselves consider their status as very good or satisfactory in 82% (median 3 years after the operation). Besides a correctly performed operation we emphesize also the role of correct diagnosis (good correlation between the patient's problems and CT scan finding) for a good treatment result.

[Traumatic intracranial hemorrhage with a clinical temporal conus syndrome]. / Traumatické nitrolební krvácení s klinickým syndromem temporálního konusu.

The authors investigated a consecutive group of 14 patients treated at the Neurosurgical Clinic on account of traumatic intracranial haemorrhage, admitted with the clinical temporal conus syndrome (GCS 3-5, ipsilateral or bilateral mydriasis, failure of vital functions). All had emergency operations and at the intensive care unit the cerebral perfusion pressure and the saturation in the jugular bulb was monitored continuously. On the first and fifth day after surgery a check-up CT and SPECT examination was made. Only two patients had ischaemia during the first CT check-up, while 11 patients had impaired perfusion on the first SPECT. Improving perfusion on the check-up SPECT was the sign of a favourable prognosis, while ischaemia on the first CT was in both instances fatal. The Glasgow Outcome Score (GOS) six months after the injury was as follows: 9 patients had a good result, 2 patients were moderately disabled 3 patients died. The authors consider the following as basic prerequisites of a favourable outcome: not only early operation but also monitoring and treatment of impaired cerebral perfusion.