Cell index--a new parameter for the early diagnosis of ventriculostomy (external ventricular drainage)-related ventriculitis in patients with intraventricular hemorrhage?

UNLABELLED: Temporary intraventricular catheters for managing acute obstructive hydrocephalus caused by intraventricular haemorrhage carry a high risk of developing ventriculostomy-related ventriculitis (VRV). The aim of this prospective study was to validate a new parameter for the early detection of an intraventricular infection. METHODS: Patients with external ventricular drainage due to intraventricular haemorrhage were enrolled in this prospective study. Leucocytes and erythrocytes in cerebrospinal fluid (CSF) and peripheral blood as well as bacteriological and chemical analysis of both were examined daily. The ratio of leucocytes to erythrocytes in CSF and leucocytes to erythrocytes in peripheral blood was calculated (so called cell index (CI)) and these values were compared with the "conventionally diagnosed" drain-associated ventriculitis. Furthermore, the CI values of the non-ventriculitis and ventriculitis group were compared using the t-test with adjustment for unequal variances (Welch test). RESULTS: Thirteen patients with an external ventricular drainage (EVD) expected to be in place for more than seven days were enrolled. Seven patients developed a bacteriologically proven VRV (time 0) within 12 days (mean 8.57). Diagnosis of VRV by CI was possible up to 3 days (mean 2.28) prior to conventional diagnosis. P values (Welch test) showed a significant difference on days -3 (P = 0.03), -2 (P = 0.03) and -1 (P = 0.012) - i.e. 3, 2 or 1 day, respectively, prior to the time point when the CSF culture grew staphylococci -, when compared with the mean cell indices of the controls, and a highly significant difference on time 0 (P < 0.001). CONCLUSION: The calculated CI allows the diagnosis of nosocomial VRV in patients with intraventricular haemorrhage at a very early point of time.

Cerebral vasospasm and ischaemic infarction in clipped and coiled intracranial aneurysm patients.

The influence of the treatment modalities (clipping/coiling) on the incidence of vasospasm and ischaemic infarction in aneurysm patients is still judged controversially. The purpose of this study was to analyse and compare retrospectively cerebral vasospasm and ischaemic infarction, as well as neurological deficits and outcome within a large population of clipped and coiled patients with ruptured and unruptured aneurysms. Within a 2-year period, a total of 144 interventions (53 clipping/91 coiling) entered the study. Daily bilateral transcranial Doppler sonographic monitoring was performed to observe vasospasm development. All cerebral computed tomography (cCT) and magnetic resonance imaging (MRI) scans were reviewed with respect to occurrence and localization of ischaemic infarctions. Focal neurological deficits were recorded and clinical outcome was evaluated using the Glasgow Outcome Scale. Statistical analysis included the use of multivariate logistic regression models to find determinants of vasospasm, ischaemic infarction and neurological deficits. Altogether, vasospasm was detected after 77 (53.5%) interventions, 61.8% in females (P < 0.01). Clipped patients significantly more often exhibited vasospasms (69.8 vs. 44.0%, P < 0.005) and were treated 1 week longer at the intensive care unit (P < 0.005). Seventy-seven patients (53.5%) developed ischaemic infarctions, 62.3% after clipping and 48.4% after coiling (P > 0.05). In the multivariate analysis, aneurysm-rupture was the strongest predictor for vasospasm and vasospasm was the strongest predictor for infarction. Neurological deficits at discharge (46.5%) were independent of treatment modality, the same applied for the mean Glasgow Outcome Scores. There was no significant difference in mortality between surgical and endovascular treatment (9.4 vs. 12.1%). Whilst the vasospasm incidence was significantly higher after surgical treatment, ischaemic infarctions were only slightly more frequent. The incidence of neurological deficits and clinical outcome was similar in both treatment groups.

Quality of life in patients after meningioma resection.

OBJECTIVES: To evaluate quality of life in patients after tumour resection, to assess different dimensions of quality of life, to compare a newly designed questionnaire with the Nottingham Health Profile. SUBJECTIVE: A non-selected neurosurgically treated series of patients with meningiomas was investigated with reference to quality of life as a judgement of one's own needs and concerns and subjective disease dependent perception. METHODS: A postal survey was sent out to 155 patients who underwent resection of a meningioma between 1977 and 1993 at our clinic. The survey consisted of the specifically designed "Innsbruck Health Dimensions Questionnaire for Neurosurgical Patients" IHD(NS) and the Nottingham Health Profile NHP. The data were put into categories and analysed statistically (Chi-square, Mann Whitney U, Kruaskal-Wallis H-tests). RESULTS: 82 patients (53 female, 29 male) responded (response rate 59%). 10 had died and 7 had moved. The majority of patients (50/61% on NHP and 49/59.7% on IHD) had mild to moderate impairment of quality of life. 20% of the patients showed moderate to severe impairment of the dimensions: physical handicap and energy level. Physical impairment correlated to tumour size. This group was characterised by mainly belonging to the over 70ies age group and taking anti-epileptics. CONCLUSIONS: The quality of life impairments in most patients after tumour resection can be classified as mild to moderate. However, other disease and age effects are difficult to distinguish without a control group. The IHD(NS) correlated well with the NHP questionnaire.

Human immunodeficiency virus type 1 induces expression of complement factors in human astrocytes.

Since the brain is separated from the blood immune system by a tight barrier, the brain-resident complement system may represent a central player in the immune defense of this compartment against human immunodeficiency virus (HIV). Chronic complement activation, however, may participate in HIV-associated neurodegeneration. Since the level of complement factors in the cerebrospinal fluid is known to be elevated in AIDS-associated neurological disorders, we evaluated the effect of HIV type 1 (HIV-1) on the complement synthesis of brain astrocytes. Incubation of different astrocytic cell lines and primary astrocytes with HIV-1 induced a marked upregulation of the expression of the complement factors C2 and C3. The synthesis of other secreted or membrane-bound complement proteins was not found to be altered. The enhancement of C3 production was measured both on the mRNA level and as secreted protein in the culture supernatants. HIV-1 laboratory strains as well as primary isolates were capable of inducing C3 production with varied effectiveness. The usage of viral coreceptors by HIV-1 was proved to be a prerequisite for the upregulation of C3 synthesis, which was modulated by the simultaneous addition of cytokines. The C3 protein which is secreted after incubation of the cells with HIV was shown to be biologically active as it can participate in the complement cascade.

Culture supernatants of patient-derived Aspergillus isolates have toxic and lytic activity towards neurons and glial cells.

Infection of the central nervous system by the ubiquitous fungi Aspergillus spp. is a life-threatening disease. Therefore we investigated the mechanism of brain damage by fungal infection. To examine whether secretory factors of Aspergillus isolates derived from patients can induce death of different brain cells, culture supernatants of Aspergillus fumigatus, Aspergillus flavus, Aspergillus terreus and Aspergillus niger were added to different astrocytes as well as to the neuroblastoma cell line SK-N-SH, and to the microglial cell line CHME. All four fungal species were shown to secrete toxic factors with neurons being most sensitive against these factors. Very low amounts and short incubation times are sufficient to induce irreversible cell damage, indicating that secreted factors might also affect distant brain regions. Further characterization of the toxic factors revealed that A. fumigatus and A. terreus produced small, heat-stable components whereas the toxic activity of A. niger filtrates was triggered by a high molecular mass factor which could be inactivated by heat. The active component of A. flavus had a molecular mass similar to that of A. niger but was heat-stable and had a significantly lower activity. Taken together these results indicate that secretion of different necrotizing factors might contribute to brain lesions in patients with cerebral aspergillosis.

Inflammation marker 7,8-dihydroneopterin induces apoptosis of neurons and glial cells: a potential contribution to neurodegenerative processes.

Since neopterin is elevated in the cerebrospinal fluid of patients with inflammatory neurological disorders we investigated the source of neopterin in the brain and a possible contribution of biological active pteridines to the development of brain lesions. Astrocytic, neuronal and microglial cell lines were shown to be negative for neopterin production even after stimulation with interferon-gamma (IFN-gamma) indicating that infiltrating monocytes/macrophages might be responsible for neopterin level in CNS. Whereas neopterin did not affect viability of brain cells, its derivative 7,8-dihydroneopterin (7,8-DHN) induced dose-dependently cellular apoptosis in astrocytes and neurons probably via enhancement of nitric oxide synthase (iNOS) expression. This mechanism might represent a possible link between inflammation in the brain and neurodegeneration.

Suboccipital decompressive surgery in cerebellar infarction.

In a retrospective study 100 consecutive patients with cerebellar apoplexy were evaluated with regard to presenting symptoms, diagnostic and therapeutic strategies according to changes in the clinical condition of the patients. The results of decompressive suboccipital craniectomy in patients with a cerebellar infarction is also evaluated in this retrospective study as the valency from use the Glasgow-Coma-Score as prognostical factor and monitoring instrument in patients with a cerebellar stroke. Different therapeutic modalities were critically analyzed. Outcome was sgnificantly influenced by age (p = 0.003), localisation and size of the lesion (p = 0.004), space-occupying character on computed tomography (p < 0.001), the progressive appearance of brainstem dysfunction and reduction of the level of consciousness as measured with the Glasgow Coma Scale (p < 0.001). We were able to show that the GCS is a valid instrument for the evaluation of the clinical course of patients with cerebellar stroke since a statistically significant relationship exists between the GCS prior to surgical intervention and outcome. In patient with a GCS < 12 a reduction of mortality by 15% was obtained by surgical intervention and the outcome as measured by the GOS was significantly improved.

Surgery combined with dopamine agonists versus dopamine agonists alone in long-term treatment of macroprolactinoma: a retrospective study.

We retrospectively analysed the long-term treatment results (median 8 years) of 31 patients with macroprolactinoma. 17 patients were treated by pituitary surgery (group 1) followed by long-term dopamine agonist therapy whereas 14 patients received long-term dopamine agonist therapy alone (group 2). 2 patients of group 1 and 1 patient of group 2 had external pituitary irradiation because of progressive disease. The two groups were comparable with respect to age, gender and initial prolactin (PRL) levels. At the end of the observation period dopamine agonist dosage could be reduced by 50% in group 1 and by 39.3% in group 2. Pituitary function did not change substantially during therapy. Complete remissions (no visible tumour in CT or MRI, normal PRL levels under current dopamine agonist medication) were achieved in 23.5% of group 1 vs. 21.4% of group 2, partial remissions (reduction of PRL and tumour size) in 35.3% vs. 64.3%, stable disease in 23.5% vs. 7.1% and progressive disease in 17.7% vs. 7.1% (differences not significant). Visual field defects showed 28.4% remissions (complete and partial) in group 1 versus 50% in group 2. Dopamine agonist therapy could be stopped definitively in only 1 patient of group 2 with an invasive macroprolactinoma. Initial surgical reduction of tumour load followed by medical therapy does not seem to guarantee a better long-term outcome than dopamine agonist therapy alone if the patient responds to and tolerates dopamine agonist therapy. Surgery should be reserved for non-responders, drug-intolerant or non-compliant patients, and for those with acute severe neurological compromise.

Prevention of local scar formation after operative discectomy for lumbar disc herniation.

This was a prospective study. The study evaluated the use of Preclude Spinal Membrane to inhibit peridural fibrosis and reduce fibroses-related problems after first-time lumbar discectomy. Peridural scarring causes tethering of dura and nerve roots. Following discectomy Preclude Spinal Membrane was applied to patients of first group (10 patients). The second group (10 patients) was operated on without Preclude Spinal Membrane. Outcome was evaluated with MRI, 3 and 6 month after operation for all patients. No peridural or epidural scar tissue could be found in patients with Preclude Spinal Membrane, in the control group who were operated on without the preclude Spinal Membrane scar tissue of varying degree with complete enclosure of the nerve roots and dura was found.

Local application of antimycotics in mucormycosis cerebri: a case report.

A 65 year old man was found to have mucormycosis cerebri during immunosuppression after treatment of hairy cell leukaemia with 2-chlorodeoxyadenosine. Although mucormycosis cerebri has a poor prognosis, the patient survived after systemic administration of high dose amphotericin B, extensive excision of the abscess, and additional local application of amphotericin B with the help of an absorbable gelatin sponge.

Terson's syndrome in spontaneous subarachnoid hemorrhage: a prospective study in 60 consecutive patients.

Sixty consecutive patients with spontaneous subarachnoid hemorrhage (SAH) were prospectively studied by means of indirect funduscopy to address the question of incidence and prognostic implications of Terson's syndrome (TS) after SAH. Terson's syndrome was diagnosed in 10 (16.7%) of 60 patients and was associated with subarachnoid rebleeding in seven of 10. No correlation was found between anatomical localization of the ruptured aneurysm and TS laterality. Case fatality was nine (90%) of 10 in patients with TS compared to five (10%) of 50 in non-TS patients. It is concluded that TS is not infrequent (16.7%) in spontaneous SAH and has a poor prognosis, often heralding subarachnoid rebleeding.

Toxic shock syndrome in transsphenoidal neurosurgery.

An overlooked toxic shock syndrome (TSS) may lead to a fatal outcome. In neurosurgery a transsphenoidal approach with post-operative nasal tamponade may promote toxic shock syndrome without signs of local wound infection. By discussing the case history of a patient after hypophysectomy by the transsphenoidal route, we propose that after the appearance of the first signs of toxic shock syndrome, quick removal of the nasal tamponade is a life saving procedure.

Response of cerebrospinal fluid pressure to continuous positive airway pressure in volunteers.

The effect of a 10-min period of continuous positive airway pressure (CPAP) of 12 cm H2O on lumbar cerebrospinal fluid pressure (CSFP), cerebral perfusion pressure (CPP), central venous pressure (CVP), mean arterial pressure (MAP), heart rate (HR), and end-tidal carbon dioxide (ETCO2) was studied in eight volunteers. CSFP increased (7 +/- 4 control vs 11 +/- 4 mm Hg; P < 0.001; mean +/- SD) and CVP increased (2 +/- 2 control vs 5 +/- 3 mm Hg; P < 0.001; mean +/- SD) when CPAP of 12 cm H2O was applied. CPP decreased slightly during CPAP (79 +/- 13 vs 74 +/- 19 mm Hg; P < 0.05; mean +/- SD), whereas MAP, HR, and ETCO2 remained unchanged. The findings of our study suggest that changes in CSFP and CPP due to moderate levels of CPAP, although statistically significant, are probably of only minor clinical importance.

[Meningiomas of the cerebellopontile angle]. / Kleinhirnbrückenwinkelmeningeome.

Meningiomas of the cerebellopontine angle are the second most frequent type of tumours in that region and constitute more than one-third to one-half of all meningiomas of the posterior cranial fossa. On account of their vulnerable position in relation to the cranial nerves and due to the lack of available space, good postoperative results and a minimum of cranial neurological deficits can be achieved only if they are identified well in time and surgically removed. Basing on case histories and follow-ups of 15 selected patients, preoperative and postoperative symptoms of meningiomas of the cerebellopontine angle are discussed, possible misinterpretations pointed out and recommendations worked out to achieve an early clarification or surgical treatment.

[Vitreous hemorrhage after acute subarachnoid hemorrhage in cerebral aneurysm]. / Glaskörperblutung nach akuter Subarachnoidalblutung bei cerebralen Aneurysmen.

In four cases we investigated the rare phenomenon of "Vitreous hemorrhage after rupturing of cerebral aneurysms". We try to point out the etiology and mechanisms of hemorrhage as well as to discuss diagnostic measurements and therapeutic management.

[Regression of neurologic deficits after nerve root lesions caused by lumbar intervertebral disk hernia]. / Regressionstendenz neurologischer Defizite nach Nervenwurzelläsionen durch lumbale Diskusherniationen.

In a clinical study 123 patients with severe neurological dysfunction were selected from the 2000 patients operated on for lumbar disc herniation in the years 1980-1984. We investigated the recovery of the neurological functions and try to discuss the factors influencing the recovery as well as the possible causes for the persistence of symptoms.

Incidence of nervous system Borrelia burgdorferi infection in patients with lumboradicular syndrome.

We investigated 103 consecutive patients primarily admitted to our Department of Neurosurgery (36 women, age: median 44, range 21-79; 67 men, age: 47, range 19-77) suffering from low back pain radiating into one or both legs. Neurological examination combined with computer tomography and lumbar myelography revealed lumbar-disc herniation in 74, vertebrostenosis in 10 and relapsed disc herniation in 9 patients. In 9 patients the diagnosis of pseudoradicular syndrome was established without definite neuroradiological morphological evidence. Two patients were diagnosed as having polyneuropathy, and 1 patient suffered from a nervus ischiadicus lesion due to a gluteal abscess. CSF of all patients was examined according to a fixed routine schedule (cells, protein, sugar, immunoglobulins, IgG index). Antibodies to Borrelia burgdorferi were found in the serum and CSF of 5.8%, and in the serum alone of 2% of patients. Intrathecally produced specific antibodies were detected in 3 patients (2.9%) with neuroradiological evidence of disc or spinal-canal disease, indicating the coexistence of previous CNS infection by B. burgdorferi with lumbar-disc herniation. None of the patients showed CSF pleocytosis; thus, in no case was acute radiculitis due to B. burgdorferi infection diagnosed.

[The CT-controlled treatment possibilities in intervertebral disk prolapses]. / CT-kontrollierte Behandlungsmöglichkeiten bei Bandscheibenvorfällen.

A CT-controlled method for the treatment of lumbar and cervical disc prolapse is described. Compared with fluoroscopically controlled percutaneous lumbar discectomy, percutaneous treatment of the L5/S1 disc by a dorsal approach is possible even in the presence of high iliac crests, as is described in this paper. In the cervical region the risk of iatrogenic damage is reduced. In a small group of 42 patients, an attempt has been made to remove disc material which is intraforaminal, intraspinal, subligamentous or sequestered. Amongst 79 patients with lumbar and 15 patients with cervical disc prolapse treatment was successful in 85% (after 17 months of observation) and 93% (after 12 months of observation). These figures refer to the early results from a new method. The success of the method will have to be assessed after a larger number of patients has been treated and there has been a longer period of observation.