Mean hemoglobin concentration after acute subarachnoid hemorrhage and the relation to outcome, mortality, vasospasm, and brain infarction.

Lower mean hemoglobin (HGB) levels are associated with unfavorable outcome after spontaneous subarachnoid hemorrhage (SAH). Currently, there is no cutoff level for mean HGB levels associated with unfavorable outcome. This study was conducted to evaluate a threshold for mean HGB concentrations after SAH, and to observe the relation to outcome. The medical records of 702 patients with spontaneous SAH were reviewed. Predictors of outcome were proved by univariate analysis. Predictors with p<0.1 were included in a multivariate binary logistic regression model. Cutoff points for mean HGB levels were calculated by receiver operating characteristic curve analysis. Mean HGB was 11.9 g/dl (±standard deviation [SD] 1.7 g/dl) in patients with favorable outcome compared to 10.8 g/dl (±SD 1.1g/dl) in patients with unfavorable outcome (p<0.001). The highest Youden's index value was found for a HGB cutoff at 11.1 g/dl. In a binary logistic regression model, predictors of unfavorable outcome were identified as an initially high Hunt-Hess grade (odds ratio [OR]: 7.7; 95% confidence interval [CI]: 4.4-13.4; p<0.001), cerebral infarction on a CT scan during hospital stay (OR: 3.8; 95% CI: 2.0-7.3; p<0.001), rebleeding during the hospital stay (OR: 3.5; 95% CI: 1.6-8.0; p=0.002), mean HGB concentration <11.1g/dl (OR: 3.3; 95% CI: 2.0-5.3; p<0.001), and hydrocephalus (OR: 2.3; 95% CI: 1.4-3.7; p=0.001). In conclusion, a mean HGB concentration <11.1 g/dl during the hospital stay was associated with unfavorable outcome after acute SAH.

The mechanisms of energy crisis in human astrocytes after subarachnoid hemorrhage.

BACKGROUND: Calcium (Ca2+) is a cofactor of multiple cellular processes. The mechanisms that lead to elevated cytosolic Ca2+ concentration are unclear. OBJECTIVE: To illuminate how bloody cerebrospinal fluid (bCSF) from patients with intraventricular hemorrhage causes cell death of cultured human astrocytes. METHODS: Cultured astrocytes were incubated with bCSF. In control experiments, native CSF was used. Cytosolic Ca2+ concentration was measured by fura-2 fluorescence. Apoptosis and necrosis were evaluated by staining with Hoechst-3342 and propidium iodide. RESULTS: Incubation of astrocytes with bCSF provoked a steep Ca2+ concentration peak that was followed by a slow Ca2+ rise during the observation period of 50 minutes. Necrosis, but not apoptosis, was induced. Blockade of ATP-sensitive P2 receptors with suramin inhibited the bCSF-induced initial Ca2+ peak and necrosis. Blockade of P1 receptors with 8-phenyltheophylline or of N-methyl-D-aspartate receptors with D(-)-2-amino-5-phosphopentanoic acid had no significant effect. Preincubation with xestospongin D, a blocker of inositol 1,4,5-trisphosphate receptors, prevented the initial Ca2+ rise and reduced the rate of necrosis. Preemptying of the endoplasmic reticulum with thapsigargin protected astrocytes from the bCSF-induced Ca2+ peak. Inhibition of mitochondrial permeability transition pores opening with cyclosporin A reduced the rate of astrocytic necrosis significantly, although it did not influence the initial Ca peak. CONCLUSION: bCSF elicits a steep, transient Ca rise when administered to human astrocytes by activation of ATP-sensitive P2 receptors and subsequent inositol 1,4,5-trisphosphate-dependent Ca release from endoplasmic reticulum. This massive Ca overload leads to subsequent mitochondrial permeability transition pores opening and necrosis of the cells.

Cerebrospinal fluid lactate concentration after withdrawal of metabolic suppressive therapy in subarachnoid hemorrhage.

Hyperglycolysis is a known phenomenon after severe subarachnoid hemorrhage (SAH) and after brain injury. It is characterized by decreased oxidative metabolism and relatively increased anaerobic glycolysis. Metabolic suppressive therapy reduces the cerebral metabolic rate of oxygen (CMRO(2)) and the cerebral metabolic rate of glucose (CMRGluc). If CMRO(2) is suppressed after SAH, withdrawal of metabolic suppressive therapy could lead to the accumulation of lactate. In this project, we assessed the relationship between the withdrawal of metabolic suppressive therapy and cerebrospinal fluid (CSF) lactate concentration. A prospective observational database containing 262 patients with SAH was retrospectively analyzed. CSF lactate levels were compared with the daily dose of metabolic suppressive therapy. Outcome was assessed with the Glasgow Outcome Scale (GOS). In 56% of patients an increase in CSF lactate (mean: 3.2 ± 0.9 mmol/L) after withdrawal of metabolic suppressive therapy was observed. Mean Glasgow Outcome Score (GOS) was lower in patients with an increase in CSF lactate concentration (>0.5 mmol/L) after withdrawal of metabolic suppressive therapy (p = 0.095). In 88% of patients who died during the first 30 days after SAH, a CSF lactate elevation of more than 0.5 mmol/L after withdrawal of metabolic suppressive therapy was found (p = 0.071).

Intracerebral hemorrhage in the very old: future demographic trends of an aging population.

BACKGROUND AND PURPOSE: In most European societies and in the United States, the percentage of patients ≥80 years has been rising over the past century. The present study was conducted to observe this demographic change and its impact on patients with intracerebral hemorrhage (ICH). METHODS: We reviewed patients' data with the diagnosis of ICH from January 2007 to December 2009. All data were collected out of a prospective stroke registry covering the entire state of Hesse, Germany. Incidence rates and absolute numbers of patients with ICH for 2009 to 2050 were calculated. RESULTS: Of 3448 patients, 34% had an age ≥80 years. Hospital mortality was 35.9% for patients ≥80 years and 20.0% for patients <80 years. Unfavorable outcome (modified Rankin Scale score >2) was more often found in patients ≥80 years compared with patients <80 years (84.9% versus 74.8%). By the year 2050, the proportion of all patients with ICH ≥80 years will be 2.5-fold higher than in 2009. The total number of ICH cases will increase approximately 35.2% assuming that ICH probability stays the same. The number of patients who die in the hospital will increase approximately 60.2%. The total number of patients with severe disability due to ICH will increase approximately 36.8%. CONCLUSIONS: If current treatment strategies according to age remain unchanged, an increase of in-hospital mortality and a higher proportion of patients who need lifelong care after ICH can be expected in the coming decades.

Real time analysis of brain tissue by direct combination of ultrasonic surgical aspiration and sonic spray mass spectrometry.

Direct combination of cavitron ultrasonic surgical aspirator (CUSA) and sonic spray ionization mass spectrometry is presented. A commercially available ultrasonic surgical device was coupled to a Venturi easy ambient sonic-spray ionization (V-EASI) source by directly introducing liquified tissue debris into the Venturi air jet pump. The Venturi air jet pump was found to efficiently nebulize the suspended tissue material for gas phase ion production. The ionization mechanism involving solely pneumatic spraying was associated with that of sonic spray ionization. Positive and negative ionization spectra were obtained from brain and liver samples reflecting the primary application areas of the surgical device. Mass spectra were found to feature predominantly complex lipid-type constituents of tissues in both ion polarity modes. Multiply charged peptide anions were also detected. The influence of instrumental settings was characterized in detail. Venturi pump geometry and flow parameters were found to be critically important in ionization efficiency. Standard solutions of phospholipids and peptides were analyzed in order to test the dynamic range, sensitivity, and suppression effects. The spectra of the intact tissue specimens were found to be highly specific to the histological tissue type. The principal component analysis (PCA) and linear discriminant analysis (LDA) based data analysis method was developed for real-time tissue identification in a surgical environment. The method has been successfully tested on post-mortem and ex vivo human samples including astrocytomas, meningeomas, metastatic brain tumors, and healthy brain tissue.

The prediction of 30-day mortality and functional outcome in spontaneous intracerebral hemorrhage with secondary ventricular hemorrhage: a score comparison.

The original ICH (oICH) score was tested in different populations and showed good accuracy in the prediction of outcome and 30-day mortality after spontaneous ICH. The oICH was developed to stratify patients with all types of spontaneous intracerebral hemorrhage (SICH). Several modifications of the oICH score exist in the literature.In the current study, we tested the oICH score, two modified ICH scores, and the IVH score on a cohort of 171 patients with SICH and mandatory secondary intraventricular hemorrhage (IVH). Receiver-operating characteristic (ROC) curves were plotted, and the areas under the curves (AUC) were calculated for each score.The calculated AUCs for the prediction of 30-day mortality in the cohort were 0.736, 0.816, 0.805, and 0.836 for the original ICH, the mICH-A, the mICH-B, and the new IVH score, respectively. The best AUC for functional outcome was observed for the mICH-B score (0.823). For the mICH-A and the IVH score, an AUC of 0.811 was calculated.The scores that include the quantification of IVH or the grading of hydrocephalus show good accuracy in the prediction of 30-day mortality and functional outcome at 6 months in SICH with secondary IVH.

Pituitary insufficiency after operation of supratentorial intra- and extraaxial tumors outside of the sellar-parasellar region?

Recent studies investigating pituitary function after non-sellar brain tumor surgery showed that up to 38.2% of patients have pituitary insufficiency (PI). It has been assumed that the operation causes the PI, but preoperative hormone testing, which would have been necessary to prove this assumption, was not performed. The objective of this study is to answer the question if indeed microsurgery is the culprit of PI in patients with operatively treated non-sellar brain tumors. In this prospective trial, 54 patients with supratentorial non-sellar tumors were included. The basal levels of cortisol, prolactin, testosterone, estrogen, IGF-1, fT3, fT4, STH, TSH, ACTH, FSH, and LH were recorded preoperatively on days 1 and 7 after surgery. If basal hormone screening revealed an abnormality, a releasing hormone assay was performed. Before surgery, 24 of the 54 patients (44.4%) already had PI. Additional 25 patients showed either hypocortisolism or hypothyreoidism. As those patients had been pre-treated with dexamethasone and L-thyroxine, these findings were considered not to represent PI but drug effects. Hormone testing on days 1 and 7 after surgery revealed no changes. With 44.4% PI is a frequent finding in brain tumor patients already before surgery. The factors causing preoperative PI remain yet to be identified. The endocrine results after surgery are unchanged which rules out that surgery is the cause of PI.

Clinical and methodological precision of spinal navigation assisted by 3D intraoperative O-arm radiographic imaging.

OBJECT: In recent years, the importance of intraoperative navigation in neurosurgery has been increasing. Multiple studies have proven the advantages and safety of computer-assisted spinal neurosurgery. The use of intraoperative 3D radiographic imaging to acquire image information for navigational purposes has several advantages and should increase the accuracy and safety of screw guidance with navigation. The aim of this study was to evaluate the clinical and methodological precision of navigated spine surgery in combination with the O-arm multidimensional imaging system. METHODS: Thoracic, lumbar, and sacral pedicle screws that were placed with the help of the combination of the O-arm and StealthStation TREON plus navigation systems were analyzed. To evaluate clinical precision, 278 polyaxial pedicle screws in 139 vertebrae were reviewed for medial or caudal perforations on coronal projection. For the evaluation of the methodological accuracy, virtual and intraoperative images were compared, and the angulation of the pedicle screw to the midsagittal line was measured. RESULTS: Pedicle perforations were recorded in 3.2% of pedicle screws. None of the perforated pedicle screws damaged a nerve root. The difference in angulation between the actual and virtual pedicle screws was 2.8° ± 1.9°. CONCLUSIONS: The use of the StealthStation TREON plus navigation system in combination with the O-arm system showed the highest accuracy for spinal navigation compared with other studies that used traditional image acquisition and registration for navigation.

Spontaneous intracerebral hemorrhage with ventricular extension and the grading of obstructive hydrocephalus: the prediction of outcome of a special life-threatening entity.

BACKGROUND: Primary spontaneous intracerebral hemorrhage (SICH) with secondary intraventricular hemorrhage (IVH) accounts for the highest in-hospital mortality after stroke. OBJECTIVE: To analyze predictors and the role of acute hydrocephalus in outcome, especially 30-day mortality or an unfavorable outcome at 6 months. In addition, a new risk stratification tool for SICH- IVH was developed. METHODS: Hospital charts of 104 of 110 SICH-IVH patients were retrospectively analyzed. All patients underwent at least 1 external ventricular drainage. Multivariate logistic regression analysis was used to identify independent prognostic predictors for 30-day mortality and outcome. Outcome was determined by the modified Rankin Scale. On the basis of the independent predictors, we developed an IVH scoring system. The IVH score was tested with prospective data from 51 patients and was compared with established intracerebral hemorrhage scoring systems. RESULTS: An initial SICH volume of 60 cm³ or greater, severe hydrocephalus, Glasgow Coma Scale score of 8 or less, and age 70 years and older were independent outcome predictors. Different cutoff values for the prediction of 30-day mortality and functional outcome were defined. The IVH score was best for the prediction of 30-day mortality. CONCLUSION: Severe hydrocephalus is an independent predictor of 30-day mortality in SICH with ventricular extension. The IVH score is a simple and reliable tool for predicting 30-day mortality.

2-Octyl-cyanoacrylate for wound closure in cervical and lumbar spinal surgery.

It is claimed that wound closure with 2-octyl-cyanoacrylate has the advantages that band-aids are not needed in the postoperative period, that the wound can get in contact with water and that removal of stitches is not required. This would substantially enhance patient comfort, especially in times of reduced in-hospital stays. Postoperative wound infection is a well-known complication in spinal surgery. The reported infection rates range between 0% and 12.7%. The question arises if the advantages of wound closure with 2-octyl-cyanoacrylate in spinal surgery are not surpassed by an increase in infection rate. This study has been conducted to identify the infection rate of spinal surgery if wound closure was done with 2-octyl-cyanoacrylate. A total of 235 patients with one- or two-level surgery at the cervical or lumbar spine were included in this prospective study. Their pre- and postoperative course was evaluated. Analysis included age, sex, body mass index, duration and level of operation, blood examinations, 6-week follow-up and analysis of preoperative risk factors. The data were compared to infection rates of similar surgeries found in a literature research and to a historical group of 503 patients who underwent wound closure with standard skin sutures after spine surgery. With the use of 2-octyl-cyanoacrylate, only one patient suffered from postoperative wound infection which accounts for a total infection rate of 0.43%. In the literature addressing infection rate after spine surgery, an average rate of 3.2% is reported. Infection rate was 2.2% in the historical control group. No risk factor could be identified which limited the usage of 2-octyl-cyanoacrylate. 2-Octyl-cyanoacrylate provides sufficient wound closure in spinal surgery and is associated with a low risk of postoperative wound infection.

Parenteral and enteral nutrition in the management of neurosurgical patients in the intensive care unit.

The iatrogenic malnutrition of neurosurgical patients in intensive care units (ICU) is an underestimated problem. It may cause a decrease in plasma albumin and oncotic pressure, leading to an increase in the amount of water entering the brain and increased intracranial pressure (ICP). This study was conducted to test the hypothesis that combined high-protein parenteral and enteral nutrition is beneficial for neurosurgical patients in ICU. A total of 202 neurosurgical patients in ICU (mean age+/-standard deviation, 56 years+/-16 years; male:female=1.2:1) were studied. Two consecutive 1-year time periods were compared, during which two different nutritional regimens were followed. In the first time period (Y1) patients were given a low-protein/high-fat formulation parenterally, followed by a standard enteral regimen. In the second time period (Y2) a protein-rich, combined parenteral and enteral diet was prospectively administered. The Glasgow Outcome Score was measured at 3-6 months after discharge. The following clinical parameters were recorded during the first 2 weeks after admission: ICP; albumin; cholinesterase (CHE); daily hours of ICP > 20 mmHg and cerebral perfusion pressure<70 mmHg; and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. It was found that overall albumin (32.4 g/L+/-4.1g/L vs. 27.5 g/L+/-3.6g/L) and CHE was higher during Y2, although the total energy supply, glucose and fat intake was lower. Higher GOS scores were seen when patients had lower APACHE II scores and received the Y2 nutritional regimen. During Y2, the total hours of ICP > 20 mmHg were fewer. With the Y2 nutrition, maintenance of adequate cerebral perfusion required less catecholamine medication and colloidal fluid replacement. Therefore, adequate nutrition is an important parameter in the management of neurosurgical patients in ICU.

The prediction of long-term outcome after subarachnoid hemorrhage as measured by the Short Form-36 Health Survey.

The Glasgow Outcome Scale (GOS) score is widely used to assess outcome after a subarachnoid hemorrhage (SAH). Patients who have recovered fully or with a mild disability (GOS scores 4 and 5) frequently complain about difficulties in conducting their daily activities. The Short Form-36 (SF-36) Health Survey is a questionnaire that assesses outcomes in multiple categories. This study was conducted to compare the quality of outcome assessment between the SF-36 Health Survey and GOS scores. A total of 128 patients with SAH (all data expressed as mean+/-standard deviation) aged 53.1+/-12.1 years, and a mean Hunt and Hess grade on admission of 2+/-1, were retrospectively included in the study. Medical charts were reviewed to assess previous medical history, location of the aneurysm and the presence of vasospasm. The SF-36 and GOS scores were collected in structured interviews approximately 5 years (+/-2 years) after the SAH. The SF-36 data were compared to a historical healthy control cohort of 2,474 individuals. The results showed that 52% of patients experienced a favourable outcome after SAH (GOS scores 4 and 5). Vasospasm was recorded in 25% of patients. However, the average SF-36 results were lower in all tested categories for patients after SAH than the healthy normal controls. None of the SF-36 categories except physical function correlated significantly with the GOS score. Aneurysm location did not have an impact on SF-36 data. Patients after a SAH assessed as GOS score 5 are significantly impaired in social functioning and general health. We conclude that patients continue to suffer neuropsychological deficits years after a SAH. The GOS score is a rough outcome measure that primarily focuses on physical functioning. SF-36 is a useful tool to include in the neuropsychological outcome assessment of patients with SAH.

Pituitary insufficiency after traumatic brain injury.

After traumatic brain injury (TBI), patients present with psychological disorders that may be explained by post-traumatic pituitary insufficiency (PI). The goal of this study was to determine the relationship between hypopituitarism, neuropsychological changes and findings on CT scans after TBI. Hospital charts of 55 TBI patients were screened for age, Glasgow Coma Scale (GSC) score, hypoxia or hypotension. The first two CT scans were analyzed for hemorrhagic lesions. Basal levels of the following hormones were recorded: cortisol, prolactin, estradiol, testosterone, insulin-like growth factor 1 and free thyroxine. Hormonal stimulation tests were performed either if the basal hormone screening revealed an abnormality or if the patient answered "yes" to at least one question in the non-evaluated neuropsychological questionnaire. Overall, 14 out of 55 patients (25.4%) presented with PI; one of them with two hormonal deficits. Growth hormone deficit, hypothyroidism and hypocortisolism were found in one, one and two patients, respectively. Neuropsychological complaints were present in 67% of the patients and were associated with intracerebral hemorrhagic lesions and not PI. Neuropsychological complaints after TBI are more frequent than PI. Brain tissue damage is most important than PI in the development of psychological changes after TBI.

Cytosolic Ca2+ oscillations in human cerebrovascular endothelial cells after subarachnoid hemorrhage.

Molecular mechanisms of cerebral vasospasm after subarachnoid hemorrhage (SAH) include specific modes of cell signaling like activation of nuclear factor (NF)-kappaB and vascular cell adhesion molecules (VCAM)-1 expression. The study's hypothesis is that cisternal cerebral spinal fluid (CSF) from patients after SAH may cause Ca(2+) oscillations which induce these modes of vascular inflammation in an in vitro model of human cerebral endothelial cells (HCECs). HCECs were incubated with cisternal CSF from 10 SAH patients with confirmed cerebral vasospasm. The CSF was collected on days 5 and 6 after hemorrhage. Cytosolic Ca(2+) concentrations and cell contraction as an indicator of endothelial barrier function were examined by fura-2 microflurometry. Activation of NF-kappaB and VCAM-1 expression were measured by immunocytochemistry. Incubation of HCEC with SAH-CSF provoked cytosolic Ca(2+) oscillations (0.31+/-0.09 per min), cell contraction, NF-kappaB activation, and VCAM-1 expression, whereas exposure to native CSF had no significant effect. When endoplasmic reticulum (ER) Ca(2+)-ATPase and ER inositol trisphosphate (IP3)-sensitive Ca(2+) channels were blocked by thapsigargin or xestospongin, the frequency of the Ca(2+) oscillations was reduced significantly. In analogy to the reduction of Ca(2+) oscillation frequency, the blockers impaired HCEC contraction, NF-kappaB activation, and VCAM-1 expression. Cisternal SAH-CSF induces cytosolic Ca(2+) oscillations in HCEC that results in cellular constriction, NF-kappaB activation, and VCAM-1 expression. The Ca(2+) oscillations depend on the function of ER Ca(2+)-ATPase and IP3-sensitive Ca(2+) channels.

Arteriovenous differences of oxygen and transcranial Doppler sonography in the management of aneurysmatic subarachnoid hemorrhage.

After subarachnoid hemorrhage (SAH) the detection of hemodynamically significant vasospasm is frequently difficult, especially in comatose patients. Most clinicians use transcranial Doppler sonography (TCD) to detect increasing mean blood flow velocities in the basal arteries as markers of cerebral vasospasm, without accounting for the effects of sedation and variations in blood pressure or pCO(2). This study was conducted to test the hypothesis that the arteriovenous difference of oxygen (avDO(2); in terms of % volume) could also be useful for the evaluation of vasospasm. A total of 22 SAH patients (M : F = 1 : 1.75, age 58+/-10 years, median Hunt and Hess grade 4) were prospectively enrolled. All patients were sedated with continuous doses of midazolam/fentanyl and/or propofol. TCD studies and avDO(2) measurements were conducted at the same time or in close succession. The blood flow velocity of the middle cerebral artery was recorded. A cranial CT scan was conducted if the avDO(2) increased by at least 0.8%. Overall, 82 measurements were recorded in 22 patients between days 1 and 13 after SAH. TCD mean flow velocities increased as expected. In contrast, avDO(2) decreased until post-hemorrhage day 4 before it increased again. Overall, after SAH, avDO(2) was significantly lower than in normal individuals. Cerebral infarction occurred primarily in patients with a maximal change of avDO(2) of more than 1%. TCD velocities alone are poor indicators of the severity of vasospasm. In contrast, daily avDO(2) seems to be a more robust parameter. However, collection of additional metabolic information is warranted.

Cerebral energy failure after subarachnoid hemorrhage: the role of relative hyperglycolysis.

After subarachnoid hemorrhage (SAH) cerebral metabolism is significantly impaired. Hyperglycolysis describes the reduction of oxidative metabolism followed by a relative increase of anaerobic glycolysis to maintain energy supply. This phenomenon is known in head injury but has not as yet been shown after SAH. This study was conducted to test the hypothesis that hyperglycolysis is present in SAH patients and is associated with vasospasm. A total of 105 measurements were conducted on 21 SAH patients (age 49+/-15 years, median World Federation of Neurosurgical Societies Grade 4) over the first 5 days following admission. Arteriovenous differences were calculated for oxygen (avDO2) and glucose (avDGlc). Relative hyperglycolysis was defined as metabolic ratio (MR=avDO2[mmol/L]/avDGlc[mmol/L])<3.44. Jugular-venous saturation for oxygen (SjvO2), mean arterial blood pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP) were monitored. Relative hyperglycolyis was recorded in 34% of studies after SAH. In hyperglycolytic studies both jugular-venous lactate and SjvO2 were significantly elevated (jugular-venous lactate 14.9+/-9.9 vs. 11.8+/-5.5 mg/dL, p=0.04; SjvO2: 70.0+/-18% vs. 81.7+/-9%, p=0.002). Relative hyperglycolysis is associated with outcome after SAH. In patients who died after SAH almost 50% of studies showed hyperglycolysis, whereas patients who survived without neurological deficit had no hyperglycolytic events. Relative hyperglycolysis is a common event after SAH. It may be associated with relative hyperemia but most importantly with outcome.

How to get 133Xe into solution for blood flow studies: a technical note with an emphasis on neurosurgical patients.

OBJECTIVE: 133Xe has been widely used for measuring blood flow in various organs. Because an injectable solution of 133Xe is not commercially available, a technique is presented that allows both the production of the radiopharmaceutical and the drawing of individualized patient doses. METHOD: A system was designed to crush ampoules of 133Xe gas inside a sealed cylinder containing sodium chloride injection 0.9%. RESULTS: 133Xe ampoules of different sizes and filled with different activities were crushed within the system. The steel cylinder shielded 98% of the radiation. With 34 GBq 133Xe a total of 20 studies of cerebral blood flow were performed. No bacteriological contamination of the drawn doses was detected. CONCLUSION: The crusher system allows the efficient and safe production of an injectable solution of 133Xe with sodium chloride 0.9%.

S-100B and NSE: markers of initial impact of subarachnoid haemorrhage and their relation to vasospasm and outcome.

S100-B and neuron specific enolase (NSE) are known predictors of outcome in head injured and stroke patients. This study was conducted to test the hypothesis that S-100B and NSE can predict the development of vasospasm and outcome within the first 3 days after subarachnoid haemorrhage (SAH). Fifty-one SAH patients (mean age 51+/-11 years, male : female ratio 1.0 : 1.6, mean World Federation of Neurological Surgeons [WFNS] Grade 3+/-1.5) were included in the study. S100-B and NSE were recorded in venous blood across the first 3 days post-SAH. Vasospasm was diagnosed if mean blood flow velocity of the middle cerebral artery was greater than 120 cm/s and Lindegaard ratio >3. Glasgow Outcome Score (GOS) and cranial CT scans were recorded at 6 months. Normal, intermediate and high S-100B values were seen in 24%, 51% and 25% of patients, respectively. In patients with S-100B>1 microg/L, Fisher Grade 4 and WFNS 4-5 were both seen in 77% of cases. S-100B was significantly higher in those patients who did not develop vasospasm. In addition, S-100B values were significantly higher in those patients who died than in those with unfavourable or favourable outcome. NSE was normal, intermediate and high in 82%, 8% and 10% of patients, respectively. Patients with WFNS 4-5 and/or Fisher Grade 4 had significantly higher NSE values than all others. Across the first 3 days after SAH, measuring S-100B is useful to predict outcome and vasospasm.

Posttraumatic vasospasm: the epidemiology, severity, and time course of an underestimated phenomenon: a prospective study performed in 299 patients.

OBJECT: The purpose of this prospective study was to evaluate the cumulative incidence, duration, and time course of cerebral vasospasm after traumatic brain injury (TBI) in a cohort of 299 patients. METHODS: Transcranial Doppler (TCD) ultrasonography studies of blood flow velocity in the middle cerebral and basilar arteries (VMCA and VBA, respectively) were performed at regular intervals during the first 2 weeks posttrauma in association with 133Xe cerebral blood flow (CBF) measurements. According to current definitions of vasospasm, five different criteria were used to classify the patients: A (VMCA > 120 cm/second); B (VMCA > 120 cm/second and a Lindegaard ratio [LR] > 3); C (spasm index [SI] in the anterior circulation > 3.4); D (VBA > 90 cm/second); and E (SI in the posterior circulation > 2.5). Criteria C and E were considered to represent hemodynamically significant vasospasm. Mixed-effects spline models were used to analyze the data of multiple measurements with an inconsistent sampling rate. Overall 45.2% of the patients demonstrated at least one criterion for vasospasm. The patients in whom vasospasm developed were significantly younger and had lower Glasgow Coma Scale scores on admission. The normalized cumulative incidences were 36.9 and 36.2% for patients with Criteria A and B, respectively. Hemodynamically significant vasospasm in the anterior circulation (Criterion C) was found in 44.6% of the patients, whereas vasospasm in the BA-Criterion D or E-was found in only 19 and 22.5% of the patients, respectively. The most common day of onset for Criteria A, B, D, and E was postinjury Day 2. The highest risk of developing hemodynamically significant vasospasm in the anterior circulation was found on Day 3. The daily prevalence of vasospasm in patients in the intensive care unit was 30% from postinjury Day 2 to Day 13. Vasospasm resolved after a duration of 5 days in 50% of the patients with Criterion A or B and after a period of 3.5 days in 50% of those patients with Criterion D or E. Hemodynamically significant vasospasm in the anterior circulation resolved after 2.5 days in 50% of the patients. The time course of that vasospasm was primarily determined by a decrease in CBF. CONCLUSIONS: The incidence of vasospasm after TBI is similar to that following aneurysmal subarachnoid hemorrhage. Because vasospasm is a significant event in a high proportion of patients after severe head injury, close TCD and CBF monitoring is recommended for the treatment of such patients.