Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Imaging and therapy of degenerative spine diseases--a neurosurgeon's view.

Diagnostic imaging and therapy of degenerative spine disease are presented from a neurosurgical standpoint. No single image modality is considered to be the solution to the wide variety of pathology. We caution against the overestimation of MRI. An individualised, patient- and problem-oriented, surgical approach is advocated.

[Adenomatous hypophyseal apoplexy. Clinical, diagnostic and therapeutic aspects of a frequently misdiagnosed emergency state]. / Die adenomatöse Hypophysenapoplexie. Klinische, diagnostiche und therapeutische Aspekte einer oft verkannten Notfallsituation.

Pituitary adenoma apoplexy was considered an acute life-threatening condition until more benign and even asymptomatic courses were found by advanced neuroimaging procedures. Necrosis and hemorrhage in the pituitary adenoma can cause acute enlargement of the tumor. sometimes with rupture of the tumor capsule and bleeding into the subarachnoid space and surrounding parts of the brain. Clinical symptoms include acute or subacute headache in combination with signs of meningeal irritation and neuroophthalmological and cerebral dysfunction. Severe panhypopituitarism may be an additional complication. Acute blindness due to compression of the optic chiasm and symptomatic compression of basal cerebral arteries require immediate transsphenoid tumor resection. If panhypopituitarism is suspected, immediate hormone substitution is necessary.

Treatment of patients with severe head injury by triamcinolone: a prospective, controlled multicenter clinical trial of 396 cases.

The present studies were conducted to test whether the outcome of severe head injury is improved by early administration of the synthetic corticosteroid triamcinolone. In a prospective, double-blind, multicenter clinical trial, 396 patients with severe head injury were randomized to a steroid group (n = 187) receiving 200 mg triamcinolone acetonide (Volon A soluble) i.v. within 4 h after trauma, followed by 3 x 40 mg/day i.v. for 4 days, and 3 x 20 mg/day i.v. for a further 4 days, and a placebo group (n = 209) receiving injections which did not contain any active drug. The placebo group was subjected to the same standard treatment procedures. Clinical features were not different between the groups upon admission to hospital. Subdural hematoma, epidural hematoma, and focal supratentorial contusion were among the most frequent diagnoses. The result of treatment with triamcinolone was assessed at discharge from the hospital and at 1 year after trauma, using the Glasgow Outcome Scale. Differences in favor of steroid treatment could be detected with regard to the patients' condition at discharge (P = 0.0634). More patients with steroids had a good recovery (49.2% vs 40.7%), and fewer died (16.0% vs 21.5%). Differences in outcome were even more pronounced (P < 0.0145) in patients with a focal lesion and a Glasgow Coma Score on admission of < 8 (n = 93). In this group, 34.8% of the patients made a good recovery, as against 21.3% of the placebo group; mortality was also lower in the verum group (19.6% vs 38.3%). The results indicate that a major subgroup of patients with severe head injury benefits from early administration of triamcinolone. Efficacy of the treatment can be expected, in particular, in patients with a focal cerebral lesion and a Glasgow Coma Score of < 8 on admission. Administration of steroids beginning at the scene of an accident would therefore be beneficial in these cases.

[The diagnosis of lumbar disc prolapse--computer tomographic and myelographic findings (author's transl)]. / Die Diagnostik des lumbalen Bandscheibenvorfalls. Computertomographische und myelographische Ergebnisse.

Seventy-seven patients with back pain and suspected disc prolapse were examined by computer tomography, and 41 have in addition myelograms. In 26 patients surgery was performed. The accuracy of computer tomography in the diagnosis of disc prolapse was greater than 86%, with additional myelography it was greater than 95%. Difficulties in diagnosis using computer tomography were encountered with recurrent disc prolapses. CT of the disc should be performed with a high resolution scanner using a slice thickness of 2 mm before myelography is considered. Definitely abnormal CT findings make myelography unnecessary.

[Computed tomography and/or ventriculography? (author's transl)]. / Computer-Tomographie und/oder Ventrikulographie?

It is discussed if in intracranial tumors, especially in tumors of the posterior cranial fossa, a CT and/or a ventriculography should be practiced. We have made investigations of 134 patients, 93 of whom were children up to 14 years of age. Each case was undertaken computed tomography as well as ventriculography. The results are clearly demonstrating the superiority of computed tomography compared with ventriculography. Ventriculography is a surgical intervention stressing the patients, side-effects may occur, and sometimes serious complications are caused. Modern computed tomography is producing pictures of high quality, which are highly sufficient for neurosurgical intervention. Very rarely additional angiography has to be performed. The diagnosis of intracranial tumors can fully be established by computed tomography, whereas ventriculography is no longer necessary.

Do we need ventriculography in the era of computed tomography?

The question is posed whether in the investigation of intracranial tumors, particularly in the posterior cranial fossa, CT and/or ventriculography should be practiced. We investigated 134 patients (93 were children up to the age of 14 years), all of whom had had both computed tomography and ventriculography. The results clearly demonstrate the superiority of CT compared with ventriculography. Ventriculography is a surgical intervention with risk for the patient; side effects may occur and serious complications can sometimes arise. Modern CT is producing pictures of high quality which are entirely sufficient for neurosurgical intervention. Very rarely does additional angiography have to be performed. The diagnosis of intracranial tumor can be fully established by CT and ventriculography is no longer necessary.

Possibilities and limitations of rehabilitation after traumatic apallic syndrome in children and adolescents.

Report on long-term follow-up studies in 23 children and 2 adolescents who survived severe brain injury and a resulting apallic syndrome. Neurological examinations and psychiatric observations were performed in all patients, and psychological tests were administered whenever possible. EEGs were recorded in all cases, and 11 patients had CT scans. 6 patients died after surviving the acute phase. 2 survived in state of stabilized unconsiousness. Recovery from the apallic syndrome was observed in 17 patients, but complete recovery did not occur in a single case. 7 patients (group A) retained severe handicaps, and the other 10 (group B) demonstrated les serious residual deficits. With a few exceptions, neurological deficit correlated with permanent psychological damage. The patients of group A presented a fairly uniform set of neurological deficits characterized by severe quadiparesis, dysarthria and other signs of permanent cerebellar dysfunction. psychological disorders included permanent aphasia (3 patients) and a major reduction on intelligence (4 patients). These patients retained a capacity for emotional response but were never able to attend school, and they remained dependent on their families or on institutions. The patients in group B demonstrated less severe permanent neurological deficits but a similar pattern of central paralysis combined with cerebellar dysfunction. These patients were able to finish their scholastic education in either a normal or special school and to work in a sheltered workshop in most cases. Only 3 patients were able to hold a job performing rather simple tasks. Duration of the initial syndrome - coma and fully developed apallic syndrome - proved to be the most significant single criterion for estimating prognosis. Rate of recovery also provided some indication of prognosis. The CT scan has proved its value in documenting localized and diffuse brain damage in later stages. We believe that CT will play an increasingly important role in establishing diagnosis as well as prognosis in the early phase.

[Assessment of brain atrophy by computer tomography (author's transl)]. / Die Beurteilung hirnatrophischer Prozesse mit Hilfe der Computertomographie.

Computer tomograms from 512 patients with brain atrophy were analysed according to standardized criteria. Exact studies of the outer and inner CSF spaces allowed a redefinition of this disease entity. The limits of change related to the physiological process of aging were established. In addition, an attempt was made to correlate CT findings with EEG tracings and psychiatric criteria.

CT evaluation of the CSF spaces of healthy persons.

Changes in the width of the CSF space throughout life were studied in CT scans of 170 healthy individuals. The internal and external CSF spaces were evaluated using parameters which can also be employed in routine clinical studies. Tables of normal values for the CSF spaces at various ages are presented.

[Diagnostic possibilities and limitations of CT and angiography in the diagnosis of cerebro-vascular malformations (author's transl)]. / Möglichkeiten und Grenzen der Computer-Tomographie und Angiographie in der Diagnostik cerebraler Gefässmissbildungen.

The diagnosis and differential diagnosis of 891 cases of intracranial hemorrhage with rupture into the ventricles or with subarachnoid extension is discussed on the basis of CT and angiography. Both methods are complementary exams, in the indication for the study as well as in the diagnostic result. The limitations of both methods in the diagnosis of vascular malformation with and without acute hemorrhage are presented.

Intracranial lipoma. Diagnostic and therapeutic considerations.

Eleven cases of intracranial lipoma, diagnosed during life by computerized tomography (CT) scanning, are presented. Clinical symptoms related to the lesions were present in eight. The CT scan established the diagnosis of intracranial lipoma on the basis of typical x-ray absorption and location. Only dermoid cysts and teratomas may produce a similar CT appearance. In cases of intracranial lipoma, a direct surgical approach is seldom necessary, although in certain locations, lipomas may cause blockage of cerebrospinal fluid pathways and require a shunt operation.

The diagnostic value of computed tomography in orbital diseases. A cooperative study of 520 cases.

Computed tomography (CT) has given us a new method for examining the orbit and its contents. The indications for the application of computed tomography in ophthalmology are considered: suspected orbital tumors, unilateral exophthalmos, pareses of the ocular muscles, traumatic lesions and malformations in the region of the orbit. The findings in 520 cases of orbital lesions examined in this study are reported and the differential diagnosis is discussed. Considerable improvement and greater accuracy in diagnosis have been achieved in the field of ophthalmology by using computed tomography. Early tumor visualization is possible without risk or discomfort to the patient.