Effects of temporary clipping during aneurysm surgery.

OBJECTIVE: Intraoperative aneurysm rupture is associated with a high morbidity and mortality. Temporary vessel occlusion is an integral part of aneurysm clipping to avoid intraoperative hemorrhage. The information concerning the role of temporary occlusion regarding the development of cerebral vasospasm is sparse. The aim of this study was to provide more information in this field. METHODS: We operated on 292 patients suffering from cerebral aneurysms. The data were reviewed from a prospectively collected databank, which includes information about the severity of subarachnoid hemorrhage, as well as transcranial Doppler data and surgical data such as temporary occlusion. RESULTS: In 50% of our patients, temporary occlusion was performed during surgery. Twenty-nine percent showed an ischemic lesion in the CCT post-operatively, and in 58% of these patients, temporary occlusion was performed (versus 47% without temporary occlusion, p = 0.09). The mean occlusion time was longer in patients with radiologic signs of infarction. Furthermore, patients having unfavorable outcome showed a longer temporary occlusion time. Thirty-four percent of patients who underwent temporary vessel occlusion developed vasospasm postoperatively (versus 20% without temporary occlusion, p < 0.006). Temporary occlusion time correlated to the development of vasospasm as defined by transcranial Doppler flow velocity. Forty-eight percent of the patients treated using temporary occlusion suffered from middle cerebral artery aneurysm (versus 22% without temporary occlusion, p < 0.0001). An increased blood flow velocity was mostly seen in this region (p < 0.003). CONCLUSION: According to our results, it seems to be the possible that temporary vessel occlusion is an additional factor in aggravating vasospasm after aneurysmatic subarachnoid hemorrhage.

Quality of Life following Surgery for Malignancies of the Anterior Skull Base.

Radical surgery combined with postoperative radiation is recommended to achieve the best outcomes in patients suffering from malignant anterior skull base tumors. However, information on the impact of such treatment on the quality of life of these patients is sparse. This retrospective study evaluated quality of life in patients with anterior skull base malignancies after transdural resection and radiotherapy. At follow-up, 36% of the patients were alive (mean survival time, 39 months). Only 45% of the patients were able to work in their previous occupation a mean of 15 months after surgery. At follow-up, 58% of the patients had a recurrent tumor. The mean quality of life index was 42 points (range, 0 to 100). The lowest values were on the job item, and the highest mean value was on the family item. All patients, dependents, or both would agree to surgery in the future. Based on these findings, quality of life after transdural surgery for the treatment of anterior skull base malignancies seems to be low.

Molecular mechanisms of cerebral vasospasm following aneurysmal SAH.

Cerebral vasospasm following aneurysmal vasospasm has been the subject of intensive research. However the underlying pathophysiological mechanisms remain obscure. This article should summarize the present state concerning smooth muscle contraction, endothelial dysfunction, inflammatory changes, gene expression, in the genesis of vasospasm following aneurysmal subarachnoid hemorrhage.

Comparison of craniotomy and craniectomy in patients with acute subdural haematoma.

Despite the increasing acceptance of craniectomy in patients with traumatic brain injury, the value of early decompressive craniectomy in patients with acute subdural haematoma is still under debate. In this retrospective study, we reviewed 180 patients with traumatic acute subdural haematoma, 111 of whom were treated with haematoma evacuation via craniotomy and 69 of whom were treated with early decompressive craniectomy. Due to the higher incidence of signs of herniation for patients in the craniectomy group, the mortality rate in this group was higher than that in the craniotomy group (53% vs. 32.3%). However, overall there was no significant difference in outcome between the two groups. Age and clinical signs of herniation were significantly associated with an unfavourable outcome, regardless of the type of surgery. Decompressive craniectomy did not seem to have a therapeutic advantage over craniotomy in traumatic acute subdural haematoma.

The history and present status of deep hypothermia and circulatory arrest in cerebrovascular surgery.

After the development of deep hypothermia and circulatory arrest for cardiothoracic procedures in the late 1950s, this technique was adopted by several neurosurgeons as an aid to complex cranial surgery. Woodhall and colleagues described its first use for a neurosurgical procedure in 1960. Although their case did not involve a cerebrovascular procedure, the technique was subsequently used for the surgical treatment of cerebrovascular lesions, especially complex and giant aneurysms as well as large and solid hemangioblastomas. At the beginning, incorporation of this technique into common neurosurgical practice was impeded by several factors. For example, postbypass coagulopathy had been a serious source of morbidity. Furthermore, the need for cooperation among multiple subspecialties and the requirements for expensive equipment had further limited the availability of this technique. Subsequent improvements in the technique and advances in the equipment designed for cardiopulmonary bypass have led to its more widespread use starting in the 1980s. Hypothermic circulatory arrest has been described in several reports as a safe and useful tool in the treatment of large and giant aneurysms. Nevertheless, improvements in endovascular procedures and further refinement in skull base surgical techniques have limited the indications for circulatory arrest and deep hypothermia. The authors describe the history of hypothermia and circulatory arrest, its implementation in cerebrovascular surgery, and the changes in indications for and results of its use over time.

Pyogenic spinal infections and outcome according to the 36-item short form health survey.

OBJECT: Pyogenic vertebral infections are rare. In most papers investigators have focused on risk factors, clinical characteristics, and diagnostic findings, and discussed different management strategies. The optimal strategy for dealing with spinal infections, however, remains controversial. Additionally, outcome data regarding quality of life (QOL) after pyogenic spinal infections are sparse. The aim of this study was to provide further data in this field. METHODS: The authors retrospectively investigated 62 patients suffering from pyogenic spinal infections. In 37 patients (59%), lumbar lesions were observed; thoracic and thoracolumbar infections were documented in 19 (31%) and a cervical infection was demonstrated in six patients (10%). Overall 28 patients (45%) underwent conservative treatment, and 34 (55%) underwent surgery with or without the placement of instrumentation. At follow-up examination the authors recorded each patient's satisfaction as well as QOL according to the 36-Item Short Form Health Survey. Quality of life after treatment of pyogenic spine infections did not reach the level of the normative sample. Most patients continued to suffer some sort of pain. Despite different indications, the surgically treated patients experienced a slightly better QOL and self-reported satisfaction levels, as well as a statistically significant better outcome, than patients treated conservatively. CONCLUSIONS: The results obtained in the present study suggest that surgery, especially in conjunction with the placement of instrumentation, may be more beneficial than conservative treatment in patients with a spinal infection.

ICAM-1 and VCAM-1 expression following aneurysmal subarachnoid hemorrhage and their possible role in the pathophysiology of subsequent ischemic deficits.

BACKGROUND: The pathophysiology of ischemic cerebral lesions following aneurysmal subarachnoid hemorrhage (SAH) is poorly understood. There is growing evidence that inflammatory reactions could be involved in the pathogenesis of such delayed occurring ischemic lesions. The aim of this study was to evaluate adhesion molecules with regard to these lesions following SAH. METHODS: Serum and cerebrospinal fluid (CSF) samples were taken daily from 15 patients up to day 9 after SAH and evaluated for intercellular adhesion molecule-1 (ICAM-1) and vascular adhesion molecule-1 (VCAM-1). RESULTS: CSF and serum samples correlated well during nearly the whole time course (p < 0.0001). A secondary increase in ICAM-1 and VCAM-1 in the serum and CSF correlated with an increase in flow velocity in the transcranial Doppler (p > 0.0001 and p < 0.007) but not to a delayed lesion in the CT scan. CONCLUSION: We believe that inflammatory processes are involved in the pathogenesis of cerebral vasospasm but they might only be a part of a multifactorial pathogenesis.

High re-bleeding rate in young adults after subarachnoid haemorrhage from giant aneurysms.

Low re-bleeding rates within the first 14 days of aneurysmal subarachnoid haemorrhage are reported in young patients. Furthermore, re-bleeding rate for giant aneurysms does not exceed 20% according to the literature. Our own clinical impression is that the re-bleeding rate seems to be much higher in giant aneurysms than reported, particularly in young patients. The aim of this study was to evaluate re-bleeding rate after subarachnoid haemorrhage following rupture of giant aneurysms in a younger population. We reviewed records of 23 patients who were treated in our institution for subarachnoid haemorrhage from giant aneurysms between 1994 and 2003. By definition, the aneurysms were larger than 25 mm in diameter. Five patients were younger than 40 years of age at the time of the aneurysmal subarachnoid haemorrhage. All younger patients (<40 years of age) showed re-bleeding after the first subarachnoid haemorrhage within the first 14 days of the initial event. In four patients (20%) older than 40 years at the time of the haemorrhage re-bleeding could be observed within the first 14 days of subarachnoid haemorrhage. We can confirm the re-bleeding rate of approximately 20% in patients suffering from subarachnoid haemorrhage (SAH) in the group of patients older than 40 years of age. However, younger patients seem to be at much higher risk of re-bleeding from giant aneurysms.

Possible role of the C-reactive protein and white blood cell count in the pathogenesis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

The delayed ischemic neurologic deficit (DIND) is a common and potentially devastating complication in patients who have sustained subarachnoid hemorrhage (SAH). Recent evidence suggests that various constituents of the inflammatory response may be critical in the pathogenesis of this ischemic complication. The aim of this study was to evaluate the possible relationship between the C-reactive protein (CRP)/white blood cell (WBC) count and DIND. A total of 88 patients with acute SAH were included. CRP and WBC count were estimated on a daily basis. Outcome was evaluated 1 year after the initial ictus according to the Glasgow Outcome Scale. CRP levels on days 5, 6, 7, and 8 were statistically significantly higher in the group of patients developing a DIND (P < 0.025, P < 0.016, P < 0.011, P < 0.0002). WBC counts were higher in this patient group on days 1, 4, 5, 6, and 7 (P < 0.0253, P < 0.0087, P < 0.00167, P < 0.0026, P < 0.0045). Overall CRP values were higher with increasing severity of the initial ictus according to the Hunt and Hess Scale and to the outcome according to the Glasgow Outcome Scale from day 3 on. A statistically significant relationship between WBCs and outcome could not be observed. The presented data do not prove that WBCs and CRP values have a direct contribution to the pathogenesis of ischemic complications following SAH, but it supports the assertion that inflammation may present a common pathogenic pathway in the development of such complications.

Ventricular tapping seems to have no influence on S-100B and NSE serum concentrations.

Serum markers, e.show $132#g., the protein S-100B and neuron-specific enolase (NSE), are recognized to give additional information about the extension and prognosis of brain damage. In some of these patients it is necessary to insert a ventricular drain. Whether the cannulation of the ventricle falsifies the serum concentrations of these markers is unknown. The aim of this study was to get further information in this field. In this prospective study we included 19 patients. All patients underwent ventricular tapping and insertion of a ventricular drain. Serum samples for estimation of S-100B and NSE were collected before, directly after and 6 h after insertion. In addition we investigated the cerebrospinal fluid (CSF) directly after and 6 h after insertion. All patients but one showed no significantly increased S-100B or NSE serum concentration after insertion of the drainage. The concentrations in the CSF were significantly higher. One patient showed increasing concentrations of the markers in all samples reflecting ongoing brain damage. The serum values of S-100B and NSE seem not to be falsified by insertion of a ventricular drain. Therefore the prognostic value of these serum markers seems to be preserved despite the surgical manipulation.

Hyperemia following aneurysmal subarachnoid hemorrhage: incidence, diagnosis, clinical features, and outcome.

OBJECTIVE: Hyperemia is a known phenomenon after aneurysmal subarachnoid hemorrhage, but only a few reports describe and analyze hyperemia in these patients. This could be the result of diagnostic difficulties in order to identify elevated cerebral blood flow; thus, it seems that hyperemia could be an underdiagnosed clinical state. The aim of the study was to evaluate this phenomenon in comparison with clinical outcome and imaging data in order to describe the frequency of hyperemia after subarachnoid hemorrhage and maybe improve clinical diagnosis. DESIGN: Retrospective analysis of our cerebral blood flow and transcranial Doppler sonography data bank. SETTING: . Neurosurgical/Anesthesiological intensive care unit University of Regensburg, Regensburg, Germany. PATIENTS AND PARTICIPANTS: A total of 37 patients were included (24 women and 13 men). All patients suffered from aneurysmal subarachnoid hemorrhage. MEASUREMENTS AND RESULTS: Standard transcranial Doppler ultrasonography, as well as the Xenon(133) clearance technique for cerebral blood flow measurements, was employed. We observed 37 increases of flow velocities in 37 patients according to Doppler ultrasonography. In order to distinguish between ischemia and hyperemia a Xenon(133) regional cerebral blood flow examination was performed. Global hyperemia was detected in 5 patients (14%). Hyperemia correlated only to favorable outcome ( p=0.01) and fewer ischemic lesions in the computed tomography ( p<0.05). CONCLUSION: The results indicate that while global hyperemia is a frequent phenomenon that cannot be detected by standard Doppler ultrasonography or clinical examination, hyperemic cerebral blood flow values following aneurysmatic subarachnoid hemorrhage are correlated to favorable outcome.

Lack of correlation between Xenon133 and near infrared spectroscopy/indocyanine green rCBF measurements.

In recent literature there are some reports describing cerebral blood flow measurements by a near infrared spectroscopy-based technique with indocyanine-green as an absorbant. To our knowledge there is no systematical study which evaluates this technique in comparison to absolute cerebral blood flow measurements. Ten patients suffering from head injury (n = 9) or subarachnoid hemorrhage (n = 1) were included. Twenty measurements of cerebral blood flow were performed, employing a Xenon133 clearance technique. Near-infrared spectroscopy measurements were performed with the Somanetics 4100 System. Indocyanine-green was given at a total dose of 0.2 mg kg-1 bodyweight intravenously. The indocyanine-green curve was compared to cerebral blood flow measurements according to rising time and area under the curve as suggested in the literature. No correlation between the indocyanine-green clearance curve and the Xenon133 cerebral blood flow measurements could be found. Neither the area under the curve (p = 0.93) nor the rising time (p = 0.75) showed a statistically significant correlation. The near-infrared spectroscopy based indocyanine-green clearance curve measurement method of cerebral blood flow seems not to give reliable results using simple mathematical models (area under the curve and rising time). In view of our findings, we have serious reservations in the potential of this technique.

Pain resolution after lumbar disc surgery is influenced by macrophage tissue infiltration. A prospective consecutive study on 177 patients.

The aim of this study was to assess the influence of inflammatory reactions in herniated lumbar disc specimens on pain resolution after lumbar disc surgery. Disc specimens of 200 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Preoperatively each patient received a verbal rating scale (VRS) for classification of the pain level and general clinical data were recorded prospectively. Varying amounts of macrophages could be demonstrated. Eighty-nine percent of patients could be followed up for a mean period of 7 months. A statistically significant correlation between the histologically observed macrophage infiltration and postoperative pain grading according to the VRS was found. Patients with evidence of inflammatory reactions rated their postoperative complaints lower than patients with no evidence of inflammatory reactions on the VRS (P = 0.04). In our study, a statistically significant correlation between inflammatory changes in the herniated lumbar disc specimen and outcome after lumbar disc surgery could be demonstrated.