CT prognostic factors in acute subdural haematomas: the value of the 'worst' CT scan.

The relationship between radiological findings and outcome in patients with acute posttraumatic subdural haematomas (SDH) has been based on CT obtained upon hospital admission. This study was undertaken to investigate the effects on prognosis of SDH patients of lesions not present on admission, but detected by subsequent CT. We have also studied those findings present on admission CT that could predict worsening of the associated lesions. From 1 May 1989 to 30 April 1996, we admitted 206 patients harbouring acute SDH of thickness 5 mm or more. The admission GCS score ranged from 3 to 15. Each patient underwent CT on admission (always within 3 h from injury). Follow-up CT was performed within 12-24 h after injury and in the following days (an average of 4.3 examinations for each patient). These examinations were reviewed by a neuroradiologist and the 'worst' CT was determined. We defined the 'worst' examination as that showing the largest haematoma thickness/midline shift and/or with the most extensive degree of parenchymal damage. Clinical factors related to prognosis in this series are age, hypoxia/hypotension, GCS motor score and pupillary abnormalities. Time from injury to treatment was found relevant only in patients with isolated SDH. CT findings on admission that correlated with outcome were haematoma thickness, midline shift and status of the basal cisterns. Prognosis was also worsened by the presence of associated lesions; SAH alone or associated with brain contusions. The last of these was the single most powerful predictor of worse outcomes (Odds ratio 0.37, p < 0.004). Whereas the first CT showed parenchymal associated damage in 56 patients, the 'worst CT' showed such damage in 105 patients. Presence of SAH on admission was found significant (p < 0.02) in predicting evolving parenchymal damage. Haematoma thickness, midline shift, status of the basal cisterns and presence of SAH are related to outcome when identified on the initial (early) CT examination. However, early (within 3 h from injury) CT under-estimates the ultimate size of parenchymal contusions. Patients with SAH on early CT are those at highest risk for associated evolving contusions. The use of sequential CT should be included in the routine management of head-injured patients.

131I radioconjugated antibodies for the locoregional radioimmunotherapy of high-grade malignant glioma--phase I and II study.

Locoregional radioimmunotherapy (LR-RIT) was administered to 111 patients (20 were recruited in a phase I and 91 in a phase II study) with malignant gliomas: 1 patient with oligodendroglioma, 7 patients with anaplastic oligodendroglioma, 2 with grade II astrocytoma, 10 with anaplastic astrocytoma and 91 with glioblastoma, amounting to 58 newly diagnosed and 53 recurrent tumours. The 131I-labelled monoclonal antibodies BC-2 and BC-4 were used in order to recognize stromal and intracellular glycoprotein tenascin, an antigen present particularly in glioblastoma. The patients were enrolled between February 1990 and December 1997 after conventional therapy. The radiopharmaceutical was injected directly into the tumour site. Sequential scintigraphies demonstrated a high and enduring uptake in the tumour. The mean irradiation dose in the tumour was 300 Gy per cycle. In the group of 74 phase II glioblastoma patients the clinical responses were as follows: 10 patients with stable disease (SD), 9 with partial responses (PR), 23 with no evidence of disease (NED) and 1 patient with complete response (CR). The median survival was 19 months. The response rate (CR + PR + NED) was 17.8% for those patients with bulky lesions, with a median survival of 17 months, but 66.6% for patients with small lesions, with a median survival of 25 months. Better outcomes were recorded in cases with less aggressive diseases: oligodendroglioma, anaplastic oligodendroglioma and anaplastic astrocytoma. We conclude that fractionated LR-RIT can be safely performed, with promising results especially in patients with minimal disease.

Cisternography in combination with single photon emission tomography for the detection of the leakage site in patients with cerebrospinal fluid rhinorrhea: preliminary report.

The site of leakage in a patients with rhinorrhea of various origin may be difficult to identify. The aim of our paper is to evaluate the contribution of cisternography in combination with single photon emission tomography (SPECT) to identify the fistulous track. From 1/1/1992 to 30/11/1997 we studied 20 patients with rhinorrhea posing a challenging diagnostic problem as to identification of the leakage site. Two mls of Indium DTPA (In 111) were injected into the subarachnoid space by the lumbar route. The tracer was followed by planar scintigraphy until it reached the cranial base and subsequently the SPECT acquisition started. A fistula was demonstrated in all of our cases including patients with no active leakage at the time of examination, patients with no bone defects on thin sliced CT scanning or patients with a normal MRI. At surgery the fistulous track was confirmed in all but two cases when a bilateral fistula was operatively identified only on one side. In conclusion whenever a CT scanning fails to demonstrate significant bone defects and MRI does not localize a fistulous track, SPECT cisternography via the lumbar route proved in our experience to be a reliable examination for a precise diagnosis.

Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: a prospective study of 65 patients.

BACKGROUND: Patients who have an acute subdural hematoma with a thickness of 10 mm or less and with a shift of the midline structures of 5 mm or less often can be treated nonoperatively. We wonder whether the knowledge of the clinical status both in the prehospital determination and on admission to the neurosurgical center can predict the need for evacuation of subdural hematomas as well as the computed tomographic (CT) parameters. METHODS: From January 1, 1994, to May 31, 1996, 65 comatose patients harboring an acute subdural hematoma of 5 mm or more and not brain dead were admitted to our intensive care unit. Of the 65 patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CT, and intracranial pressure parameters. During the study period, the use of long-lasting paralytic agents has been eliminated to allow detection of clinical deterioration in the Glasgow Coma Scale (GCS) score from the prehospital determination to the hospital admission assessment. RESULTS: Of the 15 patients initially managed conservatively, two were subsequently operated on because of evolving parenchymal hematomas. When comparing demographic, clinical, and CT parameters between the surgical group of patients and the patients initially conservatively treated, hematoma thickness (mean, 17.1 mm vs. 7.5 mm, p < 0.0001) and shift of the midline structures (mean, 12.8 mm vs. 4.7 mm, p < 0.008) were predictive of the need for surgery. A statistically significant change in the GCS score between prehospital determination and admission assessment was shown in the surgical group of patients (mean GCS score, 8.4 vs. 6.7, p < 0.01), and it was not present (mean GCS score, 7.3 vs. 7.2) in the patients initially conservatively treated. Functional outcomes were present in 23 cases (35.4%); functional outcomes in the initially conservatively treated patients were reached by 10 patients (66.7%). CONCLUSIONS: Nonoperative management for selected cases of acute subdural hematomas is at least as safe as surgical management. GCS scoring at the scene and in the emergency room combined with early and subsequent CT scanning is crucial when making the decision for nonoperative management. This strategy requires that administration of long-lasting sedatives and paralytic medications be avoided before the patient arrives at the neurosurgical center.

Local application of radiolabeled monoclonal antibodies in the treatment of high grade malignant gliomas: a six-year clinical experience.

BACKGROUND: Infusion of radiolabeled monoclonal antibodies (MAbs) directly into a tumor or into the site of disease after surgery concentrates a high quantity of antibody and radioisotope in the neoplastic tissue. The strong irradiation delivered by this method can result in control of high grade malignant gliomas. METHODS: Antitenascin MAbs BC-2 and BC-4 labeled with 131I (mean dose, 1998 MBq) were injected into 105 patients with malignant glioma by means of an in-dwelling catheter. Multiple courses (up to six) were given. The patients underwent MAb treatment after their tumors were minimized by surgery, radiotherapy, and, in recurrent lesions, a second operation. Data is presented in this article for 62 evaluable patients with high grade malignant gliomas (58 glioblastomas and 4 anaplastic astrocytomas), of which 31 were newly diagnosed tumors and 31 were recurrent lesions. In 40 cases the disease was minimal at the time of MAb injection, and in 22 cases a macroscopic remnant was present. RESULTS: There were very few adverse effects, all of which were minor. The treatment yielded a significant extension of patients' median survival (23 months) and of the disease free time to relapse (12 months). Favorable objective responses were recorded as follows: 9 partial responses, 3 complete responses, and 20 with no evidence of disease. A response rate of 51.6% was calculated for all assessable patients. The most important factor in obtaining beneficial outcomes was limited extension of the neoplasm at the time of therapy. CONCLUSIONS: In selected patients, locoregional radioimmunotherapy can be included in a multimodal strategy to control high grade malignant gliomas and produce favorable results.

S-phase evaluation with bromodeoxyuridine in lymphocytes from cattle infected with bovine leukemia virus (BLV).

Bromodeoxyuridine (BrdUrd), an analogue of thymidine, can be detected by means of monoclonal antibodies and utilized as a marker of the S-phase. In this paper a determination of the S-phase in BLV+ cattle with lymphocytosis has been performed by incorporating bromodeoxyuridine in the DNA. This evaluation was compared to the DNA content, demonstrating that i) bromodeoxyuridine incorporation is a reliable marker of S-phase in BLV+ cattle with lymphocytosis and ii) cytofluorimetry is the method of choice, together with immunocytochemistry, to demonstrate bromodeoxyuridine incorporation.