Long-term outcomes following decompressive craniectomy for severe head injury.

BACKGROUND: Severe head injury is one of the commonest indications for neurosurgical intervention. For the neurosurgeon, the operative last resort in cases of generalised brain oedema of traumatic origin is the decompressive craniectomy. Is it possible to use predictive factors to ascertain what degree of success, in terms of both the acute and long-term outcome, is to be expected in patients who undergo this treatment? METHODS: The clinical records of 131 patients treated with decompressive craniectomy for severe head injury were evaluated. All patients were operated on between September 1997 and September 2005 in the neurosurgical department of the Unfallkrankenhaus Berlin. A follow-up examination was carried out 49 +/- 25 months after the initial trauma. The clinical outcome was compared with several patient and radiographic factors to establish if any of these showed a relationship to the long-term outcome. FINDINGS: A significant relationship was demonstrated between quality of outcome and the Glasgow Coma Scale score on admission. Quality of outcome was similarly related to the age of the patient, the condition of the basal cisterns and the degree of midline shift in the initial cranial computed tomography. Factors which correlated with poor outcome included pupil reactivity on admission, established clotting disorders and posttraumatic hydrocephalus internus. Hyperglycaemia and initial acidosis were also associated with a poor outcome. CONCLUSIONS: The clinical outcome in patients with a severe head injury is to a great degree determined by the extent and type of the primary injury. When considering decompressive hemicraniectomy as a treatment for raised intracranial pressure following traumatic brain injury, the predictive factors detailed here should be taken into consideration.

The role of cerebrospinal fluid flow study using phase contrast MR imaging in diagnosing idiopathic normal pressure hydrocephalus.

BACKGROUND: The purpose of this prospective study was to identify the ability of cerebrospinal fluid flow study using phase contrast MR imaging to replace the invasive methods currently used to establish the diagnosis of idiopathic normal pressure hydrocephalus (iNPH). MATERIALS AND METHODS: Between January 2003 and April 2005, 61 patients with clinical symptoms fitting the Hakim triad and a dilated ventricular system on CT underwent a intrathecal infusion test and cerebrospinal tap test. All patients also had a phase contrast MRI to determine the CSF flow rate in the aqueduct. Shunted patients were followed postoperatively up to 12 months. The pre- and postoperative symptomatic condition was evaluated using the clinical Kiefer score. The outcome was calculated by the NPH Recovery Rate. FINDINGS: Patients were classified into 41 with iNPH and 20 patients with brain atrophy. Thirty-nine iNPH patients were shunted and two patients refused surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. In patients screened for clinical symptoms and ventriculomegaly on CT imaging, an aqueduct-CSF flow rate greater than 24.5 ml/min was found to be statistically specific for a diagnosis of iNPH. CONCLUSIONS: The measurement of the CSF flow rate in the aqueduct by using the phase contrast MRI technique is a highly specific pre-selective method for diagnosing iNPH.

[Idiopathic normal-pressure hydrocephalus. Flow measurement of cerebrospinal fluid using phase contrast MRI and its diagnostics importance]. / Idiopathischer Normaldruckhydrozephalus. Liquorflussmessung mittels Phasenkontrast--RT und ihre diagnostische Bedeutung.

AIM: The measurement of CSF flow in the aqueduct has been a focus of interest since the development of MR imaging (MRI) techniques for this purpose in diagnosing idiopathic normal-pressure hydrocephalus (iNPH).The purpose of this prospective study was to determine the ability of this diagnostic tool to replace invasive methods in establishing the diagnosis of iNPH. PATIENTS AND METHODS: Between January 2003 and April 2005, 61 patients with the Hakim triad of clinical symptoms and dilated ventricular systems underwent the intrathecal infusion test, cerebrospinal tap test, and phase-contrast MRI to measure CSF flow rate in the aqueduct. Shunted patients were controlled 12 months postoperatively. Pre- and postoperative clinical symptoms were evaluated with the Kiefer score. Outcome was calculated according to the NPH recovery rate. RESULTS: According to these criteria the patients were classified into groups of 41 with iNPH and 20 with brain atrophy. Of the iNPH patients, 39 were shunted and two did not agree to surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. The aqueductal CSF flow rate of these patients was statistically analyzed and showed that a flow rate of more than 24.5 ml/min is 95% specific to iNPH. CONCLUSIONS: Measurement of the CSF flow rate in the aqueduct using phase-contrast MRI is a highly specific preselective method for diagnosing iNPH.

Multiple intracranial hydatidosis.

BACKGROUND: Multiple intracranial hydatidosis (MIH) is a rare disease, with serious neurological manifestations, high recurrence and a mortality rate comparable sometimes to malignant disease. The causes of multiple infestations and their mechanisms are not clearly understood. Several attempts at classification are reported in the literature, but the diversity in location of these cysts in the brain and other organs, their appearance and recurrence rates remain largely unexplainable. OBJECTIVE: Multiple intracranial hydatidosis (MIH) is reported in a series of patients to evaluate their incidence, localization, complications treatment and recurrences. In this study we tried to explain the mechanism of multiple infestations, and to propose a new classification. METHODS: This was a retrospective study of thirty-four patients with MIH, treated between 1976 and 1999. The diagnosis was made mainly by CT scan and confirmed by surgery. MIH following iatrogenic rupture of a solitary cyst in the brain was excluded. Hydatid cysts were removed by the method described by Arana-Iñiguez (1973) using Dowling's technique. Histopathological examination was used to confirm the presence of scolices. The patients were followed-up for 3-14 years. RESULTS: Twenty six patients (76.4%) were under the age of 20 years with a male to female ratio of 1.0:1.83. Clinically, patients with cysts exhibited features of increased intracranial pressure and focal neurological deficit. The cysts had a diameter between 2 to 120 millimeters. Histopathological examination showed that 63.6% of the cysts were fertile. Eleven patients (46.4%) achieved a good outcome. The operative mortality rate was 10.7%. Overall mortality was 17.6%. Five patients had more than one recurrence, which appeared after 3 months to 3 years. CONCLUSION: MIH are rare; to date only 77 reported cases have been encountered. To have such a high incidence in Iraq raises the possibility of a different strain of Echinococcus granulosis. A suggestion is made regarding terminology and classification.