Role of single photon emission computed tomography and transcranial Doppler ultrasonography in clinical vasospasm.

This report presents our experience with Transcranial Doppler (TCD) ultrasonography and Single Photon Emission Computed Tomography (SPECT) in the assessment of patients with aneurysmal subarachnoid haemorrhage (SAH). It was designed to evaluate clinical vasospasm with both TCD and SPECT and determine their diagnostic value. Twenty-eight consecutive patients were examined with both TCD and SPECT, performed within 24 hours of each other. They had a total of 45 TCDs and 46 SPECT scans. Eight patients (29%) developed clinical vasospasm, noted from day 2 to day 11 post subarachnoid haemorrhage; these patients underwent TCDs and SPECT scans when the diagnosis of vasospasm was made. Twenty patients (71%) did not demonstrate clinical vasospasm throughout their hospital stay and underwent TCDs and SPECT scans within the first 2 weeks of their SAH, mostly between day 2 and day 10, the period of greatest risk for vasospasm. TCD and SPECT sensitivity for clinical vasospasm was 100% and 50% respectively, their specificity was only 20% and 60%. TCD sensitivity for symptomatic vasospasm was found to be excellent, whereas SPECT was not found to be as useful. We conclude that TCD is the preferred method in the evaluation of patients with subarachnoid haemorrhage.

Continuous intrathecal baclofen infusion by a programmable pump in 131 consecutive patients with severe spasticity of spinal origin.

We began this study to determine the efficacy and safety of intrathecal baclofen (ITB) delivered by a programmable pump for the treatment of severe spasticity of spinal cord origin. One hundred fifty two patients with severe spasticity of spinal origin, refractory to oral baclofen, or who experienced intolerable side-effects were given a test dose of ITB. Only those who had a satisfactory response were considered to be appropriate for pump implantation. All but one of the 152 patients had a satisfactory response, and the pump was implanted in 131 patients. Pre- and postoperative spasticity scores were compared and analyzed. The mean Ashworth score for rigidity decreased from 4.2 preoperatively to 1.3 (p < 0.0005) on ITB. The spasm score decreased from a mean of 3.4 to 0.6 (p < 0.0005). Reduction of spasticity resulted in improved levels of physical activity, decreased pain, and augmentation of sleep. Drug-related complications included constipation, muscular hypotonia, urinary retention, erectile dysfunction, nausea, dizziness, drowsiness, hypotension and bradycardia as well as tolerance to baclofen. Some patients experienced post-spinal puncture headaches. Catheter-related problems included occlusions, breaks, punctures, and dislodgments. Superficial pump pocket infection, pocket erosion, cerebrospinal fluid (CSF) leak, post-spinal puncture headache, and meningitis were some of the procedure-related complications. Two pumps flipped and another pump valve was stuck. We conclude that long-term intrathecal baclofen by an implanted programmable pump is a safe and effective method of treating severe intractable spinal spasticity.

Continuous intrathecal baclofen infusion delivered by a programmable pump for the treatment of severe spasticity following traumatic brain injury.

The aim of this study was to determine the efficacy and safety of intrathecal baclofen (ITB) delivered by a programmable pump for the chronic treatment of severe spasticity due to traumatic brain injury (TBI). Eight patients with severe spasticity following TBI, refractory to oral baclofen or who experienced intolerable side effects, were screened. The first five patients were enrolled in a research protocol that was approved by the Institutional Review Board for Human Research at Boston University Medical Center. The other three patients were evaluated after the FDA approved the therapy for spasticity of cerebral origin. Results showed that the mean Ashworth score for rigidity in the legs decreased from 4.4 preoperatively to 1.3 (p < 0.05) on ITB. In the arms, the Ashworth score decreased from 2.7 to 1.5 (p < 0.05). Reduction of spasticity resulted in improved levels of physical activity and locomotion and ease of care. Complications consisted of muscular hypotonia, areflexic bladder and urinary retention, erythema, and breakdown of the skin over the pump. Our results suggest that long-term intrathecal baclofen by an implanted programmable pump is a safe and effective method of treating severe intractable spasticity arising from traumatic brain injury.