Treatment of acute ischemic brain infarction with the assistance of local intraarterial thrombolysis with recombinant tissue-type plasminogen activator.

BACKGROUND: Cerebral infarction is usually due to arterial occlusion. Prompt treatment with thrombolytic drugs can restore blood flow and improve recovery from an infarct. PURPOSE: To evaluate the clinical efficacy and safety of local intraarterial thrombolysis with recombinant tissue-type plasminogen activator (rtPA) in patients with acute middle cerebral artery (MCA) infarctions within 6 hours of the onset of symptoms. MATERIAL AND METHODS: Sixteen patients (10 females and six males) aged from 42 to 61 years, with acute MCA territory infarcts were selected for treatment with local i.a. rtPA up to 6 hours after the onset of symptoms. Patient selection was based on clinical examination, computed tomography (CT), and digital subtraction angiography (DSA). A clinical evaluation was performed before treatment, at the time of discharge, and 90 days post-procedure on the basis of modified Rankin and NIHSS scores. Controls (n = 16, nine females and seven males) aged from 51 to 70 years were treated only with intravenous anticoagulation using i.v. heparin infusion. The control group was evaluated with multidetector CT (MDCT) angiography performed on entry to the study and at 2-4 hours afterwards. RESULTS: Eight patients (50%) achieved a modified Rankin score of 2 or less as the primary outcome after 90 days follow-up. The secondary clinical outcome at 90-day follow-up was as follows: NIHSS score < or =1, three (19%) of the patients; NIHSS score > or =50% decrease, nine (56%) of the patients. A recanalization rate of 75% was achieved in 12 of the 16 treated patients, but only 12.5% in two of the 16 patients in the control group. Intracerebral hemorrhage occurred in two (12.5%) of the patients in the treatment group, but in only one patient (6%) in the control group. There were no deaths in the treated group after thrombolysis up to the time of discharge; however, during the 90-day follow-up, two patients died compared to three patients in the control group (19% vs. 12.5% mortality rate). CONCLUSION: Patients with cerebral infarction who were treated within 6 hours of onset using intraarterial rtPA thrombolysis had a significantly improved clinical outcome 90 days after the procedure compared to patients treated only with intravenous anticoagulation.

Emergency Use of Stent and rtPA with Mechanical Cloth Defragmentation for a Thromboembolic Complication during GDC Coil Treatment of an Acutely Ruptured Basilar Tip Aneurysm.

Thrombotic occlusion of both posterior cerebral arteries occurred during embolization of an acutely ruptured basilar tip aneurysm. Intracranial stenting and continuous superselective infusion of rtPA was administered combined with mechanical clot fragmentation to reestablish normal vessel flow. DSA disclosed that normal vessel patency was achieved within 30 min. There were no adverse events related to rtPA administration and the patient recovered from the embolization with minor neurologic deficit as present before the procedure.

Peritumoral angiogenesis around primary and metastatic brain neoplasms. Morphometric analysis.

In an interface between brain tumour and surrounding tissue there occur simultaneously two very important phenomena. On the one hand there is a proliferation of peritumoral vessels penetrating into the neoplasm in which they make alike tumoral vessels. On the other hand, neoplastic cells penetrate from the tumour into the vicinity along peritumoral vessels. To determine the influence of the histological type of different brain tumours, their malignancy degree as well as location in the central nervous system on peritumoral vessels morphological appearance, the detailed morphometric analysis was carried out. The morphological examination and computerised morphometric analysis were conducted on 166 primary and metastatic CNS neoplasms taken during routine neurosurgical procedure. It turned out that the peritumoral angiogenesis depends predominantly on the malignancy of brain tumours. This angiogenesis may be modified by local environmental factors--it is more evident within the white matter than in the cerebral cortex. One of the important factors may be reactive peritumoral astrogliosis. There is no specific CNS region predisposed to the development of peritumoral angiogenesis.

[Brain stem auditory evoked potentials in brain death state]. / Sluchowe pniowe potencjaly wywolane w stanie smierci mózgu.

The authors studied auditory brainstem evoked potentials (BAEP) in 27 organ donors aged 40 to 68 years treated in neurosurgery units in Szczecin and Grenoble. Abnormal results were found in all cases. In 63% of cases no evoked action potentials were obtained, in 34% only the 1st wave was obtained, and in two cases evolution was observed with activity extinction. The authors believe that in the process of shaping of BAEP morphotic extinction begins from the later waves to earlier ones in agreement with the rostrocaudal direction of extinction of the functions or brain midline structures, and in a single study various findings may be obtained.

[Spinal reflexes in the determination of brain death]. / Odruchy rdzeniowe w przypadkach z rozpoznana smiercia mózgu.

The authors present the results of spinal cord function evaluation in organ donors by examination of reflexes. The knee reflex and ankle jerk, as well as abdominal reflex and foot withdrawal reaction were tested in 31 donors. At least one of the above was seen in 25 individuals. It is suggested on the basis of data obtained not to hamper the transplant procedure in cases of tested reflex persistency when brain death is revealed on relevant examination.

[First-hand experiences in trans-sylvian microsurgery of the posterior part of the circulus arteriosus and end-part of the basilar artery]. / Wlasne doswiadczenia ze stosowaniem przezsylwialnego mikrochirurgicznego dostepu do tylnej czesci kola tetniczego mózgu i koncowego odcinka tetnicy podstawnej.

The authors present the technique and the obtained results of surgical treatment of vascular malformations in the upper part of the basilar artery in 14 patients using a trans-sylvian microsurgical approach. The techniques of subfrontal and subtemporal approaches are compared.

[Intracranial pressure in cases of non-traumatic cerebral hematoma-- personal observations and review of the literature]. / Cisnienie wewnatrzczaszkowe w przypadkach nieurazowych krwiaków sródmózgowych--obserwacje wlasne i analiza pismiennictwa.

The analysis of intracranial pressure records in 95 cases of non-traumatic intracerebral haematoma is presented. In 74 cases continuous recording was done. No correlation was found between the values of this pressure and consciousness disturbances. Three types of pressure change patterns were demonstrated: type A - low or normal values unchanging in 43 cases, type B - high initial values with normalization during conservative treatment, type C - very high initial values which decreased after operation in only some patients.

[Non-traumatic cerebral hematoma and the mechanisms of intracranial volume compensation]. / Nieurazowy krwiak sródmózgowy a mechanizmy wewnatrzczaszkowej kompensacji objetosciowej.

The results are presented of measurements of the intracranial pressure, pressure instability index and shifting of ventricular structures in 42 patients with non-traumatic intracerebral haematoma. Only the value of the instability index showed a correlation with the state of consciousness. For a more complete assessment of the state of sufficiency of the intracranial pressure compensation mechanism all these parameters should be analysed jointly.

[Effect of elimination of supratentorial aneurysms by micro- surgical method on early structural and functional changes near the operation site]. / Wplyw wylaczenia tetniaków nadnamiotowych sposobem mikrochirurgicznym na wczesne, strukturalne i czynnosciowe zmiany w otoczeniu miejsca operacji.

On the basis of neurological, psychological and computed tomographic studies of the head early consequences of microsurgical elimination of supratentorial brain aneurysms were analysed in a group of 37 patients. It was shown that this method of aneurysm treatment may lead to brain oedema near the operation site. Oedema development was observed most frequently in cases of prolonged pressure exerted by spatulae on the brain tissue during the operation, aneurysm location in the anterior cerebral artery system and in cases operated on from 4 to 10 days after subarachnoid haemorrhage.

[Diagnosis of progressive open internal hydrocephalus in patients after cranio-cerebral injuries and subarachnoid hemorrhage]. / Rozpoznawanie postepujacego otwartego wodoglowia wewnetrznego u chorych po urazach czaszkowo-mózgowych i krwotokach podpajeczynówkowych.

Late internal hydrocephalus has been diagnosed in 68 (44%) out of 154 patients treated for the ruptured cerebral aneurysms, and in 37 (31%) out of 120 patients, who underwent cranio-cerebral trauma. To establish the indications for shunts, CT scans of the skull, tomoventriculography, and infusion tests have been carried out in 38 patients. It has been found, that increased transparency of the areas below cerebral ependyma, the lack of cerebral cortex sulci, and imaging of the temporal horns together with internal hydrocephalus in CT scans indicate an active process and are indications to shunting. If there are no signs of active process in CT scans despite of the presence of hydrocephalus, tomoventriculography should be performed to establish more fully the indications to shunting.

[Effects of classical and microsurgical methods of exclusion of cerebral aneurysms on the structural and functional changes near the operation site]. / Wplyw klasycznego i mikrochirurgicznego sposobu wylaczania tetniaków mózgu na strukturalne i czynnosciowe zmiany w otoczeniu miejsca operacji.

The effects of classical and microsurgical methods of exclusion of supratentorial intracranial aneurysms on the development of ischaemic changes at the site of approach to the aneurysm were studied. In cases of internal carotid artery aneurysms and middle cerebral artery aneurysms the use of microscope reduced the occurrence of ischaemic changes at the site of approach. In cases of aneurysms of the anterior cerebral artery system the frequency of these changes was similar with both methods. The size and location of these changes and the degree of psychical changes caused by them were similar with both methods.

[Our method of management of the cases of intracranial hematoma--late results of the treatment]. / Wlasna metoda postepowania w przypadku nieurazowego krwiaka sródmózgowego--odlegle wyniki leczenia.

An original method of qualification for surgical treatment of patients with non-traumatic intracerebral haematoma is described. The qualification is based on the main elements of the intracranial volume compensation: 1. function of midline structures (F), 2. intracranial pressure features (I), 3. midline structure shift (S). The FIS method was applied in 134 patients; 83 of them were treated surgically and 51 were treated conservatively. The control group comprised 60 patients treated surgically or conservatively with qualification based on other criteria. The use of the FIS method in the preliminary management of patients with non-traumatic intracerebral haematoma made possible a great increase of the survival rate and improvement of the late results of treatment.

[Dominance of cerebral hemispheres and visual space-hand localization]. / Dominacja pólkuli mózgu a wzrokowa lokalizacja przestrzenna reczna.

The visual space-hand localization from each eye and by each hand was examined by means of a localizer. Two kinds of examination were performed: one checked the initial, the other the postexercise localization. The dominance of the cerebral hemispheres was determined by psychological tests. No dependence of the behaviour of the visual hand localization on the domination of a given hemisphere was shown.

[Effect of classic exclusion of middle cerebral artery aneurysm on late structural and functional changes in the vicinity of the operation site]. / Wplyw klasycznego wylaczenia tetniaka tetnicy srodkowej mózgu na pózne strukturalne i czynnosciowe zmiany w otoczeniu miejsca operacji.

On the basis of neurological, psychological and computed tomographic examinations of the head late consequences are presented of classical exclusion of middle cerebral artery aneurysm. It was demonstrated that compression of the brain with a spatula and the extent of shifting apart of the walls of the lateral fissure of the brain during the operation may lead to ischaemic changes in the temporal lobe near the lateral fissure. These changes may cause impairment of mental efficiency late after the operation. It was shown also that during the operations for aneurysms of the middle cerebral artery at the site of its division the approach by forcing apart the fissure over the site of division would be less damaging than the approach along the trunk of the artery.

[Visual evoked potentials in patients with a history of non-traumatic intracranial hemorrhage]. / Badanie wzrokowych potencjalów wywolanych u chorych po przebytym odlegle nieurazowym krwiaku sródmózgowym.

The authors present the results of preliminary investigations of visual evoked potentials in patients long after intracerebral haemorrhage. In 32 studied patients prolongation was observed of the latency of waves N1 and N2 as well as P1, and this prolongation was more pronounced in the case of stimulation of the eye contralateral to the hemisphere with the lesion. This asymmetry of latency occurred with similar irregularity in case with all locations of the lacuna, with the exception of the occipital lobe. In the latter case a much greater prolongation of Ni and Pi latency on the affected side.

[Analysis of the effects of various methods of classical exclusion of anterior cerebral artery aneurysms on late structural and functional changes in relation to the various approaches]. / Analiza wplywu róznych metod klasycznego wylaczania tetniaka ukladu tetnic przednich mózgu na pózne, strukturalne I czynnosciowe zmiany z róznymi sposobami dojscia.

The effects were analysed of various techniques of classical exclusion of aneurysms in the anterior cerebral artery system on the late therapeutic result and on the development of ischaemic lesions in the area of approach to the aneurysm. The approaches used were: interhemispheric, fronto-temporal and fronto-temporo-sphenoidal, and the aneurysms were excluded with a ligature or metal clip. The best method of approach was chosen after analysis of late results of neurological, psychological and CT studies. It was demonstrated that pressure of a spatula during the operation may produce permanent ischaemic changes at the site of the pressure which may lead to persistence of psychic disturbances late after the operation. It was shown also that the most favourable classic technique of operation in cases of aneurysms in this portion is the fronto-temporo-sphenoidal approach with use of a metal clip.

[Our method of projecting onto the skull surface the intracranial lesions diagnosed by computerized tomography]. / Wlasna metoda okreslania na powierzchni glowy rzutu uszkodzen wewnatrzczaszkowych stwierdzanych tomograficznie-komputerowo.

The author presents an own method for the projection onto the surface of the skull of intracranial lesions demonstrated by means of computerized tomography. The method makes possible a more precise and sparing craniotomy and calculation of the irradiation field in case of radiotherapy. The advantage of the method is its easy availability and independence of computerized calculations. It may be applied only to CT images.