Hypopituitarism following severe traumatic brain injury.

Although hypopituitarism is a known complication of traumatic head injury, it may be under-recognized due to its subtle clinical manifestations. To address this issue, we determine the prevalence of neuroendocrine abnormalities in patients rehabilitating from severe traumatic brain injury (Glasgow Coma Scale < or = 8). 76 patients (mean age 39 +/- 14 yr; range 18-65; 53 males and 23 females; BMI 25.8 +/- 4.2 kg/m2; mean +/- SD) with a severe traumatic brain injury, an average of 22 +/- 10 months before this study (median, 20 months), underwent a series of standard endocrine tests, including TSH, free T4, T4, T3, prolactin, testosterone (males), estradiol (females), cortisol, ACTH, GH, and IGF-I. All subjects also underwent GH response to GHRH + arginine. Growth hormone deficiency (GHD) was defined as a GH response < 9 microg/L to GHRH + arginine and was confirmed by ITT (< 3 microg/L). Pituitary deficiency was shown in 24% of the patients (18/76). 8% (n = 6) had GHD (GH-peak range [GHRH + arginine]: 2.8-6.3 microg/L; GH-peak range [ITT]: 1.5-2.2 microg/L; IGF-I range: 62-174 microg/L). 17% (n = 13) had hypogonadism (total testosterone < 9.5 nmol/L and low gonadotropins in 12 males; low estradiol, and low gonadotropins in 1 female). Total testosterone levels did not correlate with BMI or age. 2 males with hypogonadism also showed a mild hyperprolactinemia (33 and 41 ng/ml). 3% (n = 2) patients had partial ACTH-deficiency (cortisol-peak [ITT] 392 and 417 nmol/L) and 3% (n = 2) had TSH-deficiency. In summary, we have found hypopituitarism in one-fourth of patients with predominantly secondary hypogonadism and GHD. These findings strongly suggest that patients who suffer head trauma must routinely include neuroendocrine evaluations.

Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients.

To study the functional outcomes of patients with cervical herniated intervertebral discs with radiculopathy but without signs of cervical myelopathy using a retrospective cohort study design. The patients were retrospectively identified by chart reviews. Inclusion criteria were (a) cervical radiculopathy with defined neurological disturbances (sensory disorder, reflex abnormalities, and motor weakness); (b) a spinal computed tomograph scan or magnetic resonance image demonstrating neuroradiologic abnormalities (soft or hard disc); and (c) completion of conservative physical and pharmacological treatment. Of 119 consecutive patients who were treated at the Departments of Neurology and Neurosurgery, University of Erlangen-Nuremberg, between January 1, 1985, and December 31, 1995, 60 patients met the inclusion criteria and were prospectively assessed, with an average follow-up time of 5.5 years. The patients were interviewed with regard to their daily activities, ability to work, and the surgical treatment they had undergone. A complete neurological examination also was performed. In 88.3%, the onset of disease was acute and in 11.7% subacute or chronic. The most common signs and symptoms were brachialgia (98.3%), neck pain (93.3%), sensory disorders (88.3%), reflex abnormalities (61.7%), and motor weakness (51.7%). The neuroimaging procedures demonstrated a disc prolapse (soft disc) in approximately 90% and spondylotic osteophytes (hard disc) in approximately 10%. During an average follow-up time of 5.5 years (range, 4.6 months-10.6 years) 39 (65%) patients had been treated using only conservative methods (COG = conservatively treated group), and 21 (35%) patients had undergone surgery (ventral discectomy) (SUG = surgically treated group). Brachialgia was completely or essentially improved in 100% of the COG and 95.1% of the SUG. Sensory disorders remitted completely or markedly in 97% of the COG and 75% of the SUG. The reflex abnormalities normalized or improved in 59.2% of the COG and in 53.3% of the SUG. Motor weakness improved in 94.1% of the COG and in 50% of the SUG. Neck pain was difficult to treat. It improved in only 36.1% of the COG and in 20% of the SUG. Occupational capacity was lost in 10% of the COG and in 38.9% of the SUG. In a self-rating scale, 89.7% of patients in the COG did not feel disabled in their everyday activities, compared with 66.7% of the patients in the SUG. Patients with a herniated cervical intervertebral disc with radiculopathy can be treated conservatively with good results, although a residual intermittent neck pain syndrome often persists. The patients in the SUG, who initially showed more severe and long-lasting neurological disturbances, were improved at the time of examination, although with more marked residual disorders. Surgery is indicated only when appropriate conservative treatment for a reasonable time has failed.

Slow rhythmic oscillations of blood pressure, intracranial pressure, microcirculation, and cerebral oxygenation. Dynamic interrelation and time course in humans.

BACKGROUND AND PURPOSE: Various biological signals show nonpulsatile, slow rhythmic oscillations. These include arterial blood pressure (aBP), blood flow velocity in cerebral arteries, intracranial pressure (ICP), cerebral microflow, and cerebral tissue PO2. Generation and interrelations between these rhythmic fluctuations remained unclear. The aim of this study was to analyze whether stable dynamic interrelations in the low-frequency range exist between these different variables, and if they do, to analyze their exact time delay. METHODS: In a clinical study, 16 comatose patients with either higher-grade subarachnoid hemorrhage or severe traumatic brain injury were examined. A multimodal digital data acquisition system was used to simultaneously monitor aBP, flow velocity in the middle cerebral artery (FVMCA), ICP, cerebral microflow, and oxygen saturation in the jugular bulb (SjO2). Cross-correlation as a means to analyze time delay and correlation between two periodic signals was applied to a time series of 30 minutes' duration divided into four segments of 2048 data points (approximately 436 seconds) each. This resulted in four cross-correlations for each 30-minute time series. If the four cross-correlations were consistent and reproducible, averaging of the original cross-correlations was performed, resulting in a representative time delay and correlation for the complete 30-minute interval. RESULTS: Reproducible cross-correlations and stable dynamic interrelations were found between aBP, FVMCA, ICP, and SjO2. The mean time delay between aBP and ICP was 6.89 +/- 1.90 seconds, with a negative correlation in 81%. A mean time delay of 1.50 +/- 1.29 seconds (median, 0.85 seconds) was found between FVMCA and ICP, with a positive correlation in 94%. The mean delay between ICP and SjO2 was 9.47 +/- 2.21 seconds, with a positive correlation in 77%. Mean values of aBP and ICP did not influence the time delay and dynamic interrelation between the different parameters. CONCLUSIONS: These results strongly support Rosner's theory that ICP B-waves are the autoregulatory response of spontaneous fluctuations of cerebral perfusion pressure. There is casuistic evidence that failure of autoregulation significantly modifies time delay and the correlation between aBP and ICP.

Cerebral hemodynamics in subarachnoid hemorrhage evaluated by transcranial Doppler sonography. Part 2. Pulsatility indices: normal reference values and characteristics in subarachnoid hemorrhage.

In previous publications on the diagnostic value of transcranial Doppler sonography (TCD), conflicting results concerning predictive capacities for evaluating vasospasm by measuring flow velocities were reported, and the necessity to examine pulsatility indices (PIs) was stressed. PIs are known to give useful information on cerebral hemodynamics in cases of stenosis of the extracranial internal carotid artery and cerebral arteriovenous malformations. Whether the examination of PIs can give additional information in cases of subarachnoid hemorrhage (SAH) and allow prediction of impending delayed ischemic deficits (DIDs) is still unclear. Normal reference values for the Gosling pulsatility index, the Pourcelot resistance index, and the first Fourier pulsatility index were established in a series of 97 normal subjects. A significant increase in the indices was found as age increased, and there was a strong relation between the indices. There were no statistically significant differences between the right and left sides. An inverse relation was found between the flow velocity and PIs in the middle cerebral artery. In a prospective study of 455 follow-up TCD examinations in 66 SAH patients treated routinely with nimodipine, three different groups were analyzed separately: Group I, patients without DIDs; Group II, patients with DIDs; and Group III, patients with neurological deficits not strictly classifiable as DIDs. The analysis of all three groups together showed a typical time course after the onset of SAH: initially elevated PIs normalized around the tenth day after bleeding. According to Fisher grading, the amount of subarachnoid blood influences the increase in PIs significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral hemodynamics in subarachnoid hemorrhage evaluated by transcranial Doppler sonography. Part 1. Reliability of flow velocities in clinical management.

During recent years, the management of subarachnoid hemorrhage (SAH) has changed, resulting in an increase in early operations and routine administration of nimodipine. Both influenced the indication for transcranial Doppler sonography (TCD). Furthermore, investigations detected discrepancies between Doppler findings and neurological status. In a prospective study, the reliability of TCD was investigated in patients with SAH treated with intravenously administered nimodipine. Patients with large hematomas were excluded. Neurological deficits immediately after surgery or within the first 48 hours were classified as not delayed, and therefore not necessarily due to vasospasm. The most remarkable points of this study are that there is no significant difference between the flow velocities for Hunt and Hess Grades I and II when compared with those for Grade III, and that Grades IV and V seem to be affiliated with the lowest velocities. When the flow velocities of 11 patients who developed delayed ischemic deficits (DIDs) were compared with those of patients with no deficit, no significant difference was seen. A significant increase in velocity in the days before the onset of DID was found only in 3 of 11 cases. Eight patients showed either constant high or constant low velocities or even, in some cases, decreasing time courses. High flow velocities did not necessarily mean impending neurological deficits: 8 of 66 patients tolerated flow velocities over 200 cm/s. Therefore, it no longer seems to be justified to proclaim that TCD is able to predict neurological deficits, although it is doubtless able to detect vasospasm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intensive therapy of elderly patients in neurosurgery. Specifics of the postoperative phase in advanced age]. / Intensivtherapie älterer Patienten in der Neurochirurgie. Besonderheiten der postoperativen Phase in höherem Lebensalter.

INTRODUCTION: Postoperative intensive care of the elderly neurosurgical patient differs considerably from that of the younger patient. INVESTIGATION: Analysis of 106 patients aged between 68 and 92 years. RESULTS: In addition to the cardiopulmonary risk factors, the age-specific changes in the brain have an effect on the spectrum of postoperative complications. Age-related atrophy of the brain and in increase in the fragility of blood vessels due to degenerative processes increase the risk of subdural and intracerebral hemorrhage. The amount of time spent in the intensive care unit as a percentage of overall hospitalization is, at 50%, appreciably greater than that of younger patients. Intensive monitoring, including intracranial pressure and transcranial Doppler ultrasonography are useful for detecting intracranial complications at an early stage. CONCLUSIONS: Despite the appreciably greater duration of postoperative intensive care in the elderly, the overall outcome is comparable with that seen in younger patients in many neurosurgical conditions.

Blood velocity in the ophthalmic artery in normal subjects and patients with endophthalmitis.

Some ocular diseases lead to temporary changes in the ocular blood circulation. This study was undertaken to evaluate changes in the blood-flow velocity of the ophthalmic artery in patients with endophthalmitis. With pulsed Doppler sonography the blood velocity of the ophthalmic artery was measured in 50 normal subjects and in ten patients with bacterial endophthalmitis. In normal subjects blood velocity decreased with increasing age, and the average systolic/diastolic blood velocity in cm/sec were 38.8 +/- 6.3/11.6 +/- 4.7 in the 18-50-year-old age group and 28.3 +/- 4.6/6.7 +/- 3.3 in the 51-88-year-old age group. Endophthalmitis produced increased systolic/diastolic blood velocity in the ophthalmic artery in the affected eyes in cm/sec (99.7 +/- 15.5/26.6 +/- 10.5 in the 16-50-year-old age group; 60.4 +/- 8.8/16.6 +/- 4.8 in the 51-83-year-old age group). Some patients showed similar changes in the unaffected fellow eyes. The noted elevation of the blood velocity in unaffected eyes may be due to the bilaterally projected parasympathetic fibers of the oculomotor nerve.

[Pulsed Doppler ultrasonography of the ophthalmic artery in proliferating diabetic retinopathy]. / Gepulste Doppler-Sonographie der A. Ophthalmica bei Retinopathia diabetica proliferans.

In 19 patients with bilateral proliferative diabetic retinopathy we examined the blood velocity in the ophthalmic artery with pulsed ultrasound and analyzed the outline of the pulse curve with the fast fourier transformation. The data were compared with the results in 50 normal objects. Patients with diabetic proliferative retinopathy showed increased systolic blood velocities (p less than 0.05), decreased diastolic blood velocities (p less than 0.05) and an alteration in the outline of the pulse curve (p less than 0.001). These changes can be due to diabetic-induced decrease in the elasticity of the wall of the ophthalmic artery and to microangiopathic alterations in the choroid. In some patients in the course of the ophthalmic artery, we saw localized peaks in the blood velocity, which can be interpreted as local stenosis in the ophthalmic artery.

Implantation of a reservoir for recurrent subdural hematoma drainage.

In a prospective study 144 adult patients with chronic subdural hematomas were randomly divided into three treatment groups after burr-hole evacuation. The two commonly used procedures (external closed system drainage and aspiration and irrigation without any drainage) were compared to a modified technique: permanent subdural drain with subcutaneous reservoir. After the hematoma was washed out with saline solution, a silicon catheter with multiple perforations was introduced into the subdural cavity and connected to a Rickham reservoir, fixed in the frontoparietal burr hole. In patients who showed secondary deterioration or enlargement of the residual hematoma as proven by computed tomographic scan, the reservoir was punctured and the subdural fluid aspirated. The great advantage of this method is that it is practicable at the bedside as well as in the outpatient department, thus making it possible to reduce the number of additional operations. The incidence of symptomatic residual or recurrent hematoma was similar in all three groups. The reoperation rate was 4-fold greater in the groups treated with conventional therapy, when compared to the group with the implanted system. At the same time there was no indication that the implantation of the drain was less safe, as judged by the incidence of seizures and infections.

[Blood flow velocity in the ophthalmic artery measured using transbulbar Doppler sonography]. / Blutflussgeschwindigkeit in der A. ophthalmica durch transbulbäre Dopplersonographie.

Blood-flow velocity in the ophthalmic artery was examined at different orbital depths by pulsed ultrasound (4 MHz). Blood-flow velocity was influenced by patient age and showed a decrease in the vicinity of the eye. Forty-one normal subjects had an average systolic and diastolic blood-flow velocity of 36.5 and 10.9 cm/s at a 36 mm depth.

[Clinical testing of impulse-gustometry as a new method of gustometry (author's transl)]. / Klinische Erfahrungen mit der Impulsgustometrie, einer neuen elektrischen Geschmacksprüfung im vergleichenden klinischen Einsatz.

For the first time in clinical routine testings impulse-gustometry was used in comparison to normal chemical or electrogustometric methods. Loss of taste caused by tympanoplasty, radiation of tumors in head and neck and accompanying facial nerve palsies was tested. The exactly defined location of the stimulus is known advantage in electrogustometry. Impulse-gustometry, however, is able to stimulate different taste sensations like the chemical methods. The sensible sensation, therefore, is eliminated. The stimulating pulses ranged between 0,5 and 2,0 ms at frequencies of 10 to 300 cps. Like with Krarup's method in impulsegustometry there is not always a taste sensation.