Spontaneous intracerebral hemorrhage. Prognostic factors in 896 cases.

To determine the prognostic value of etiology and localization in spontaneous intracerebral hemorrhage, 896 patients with spontaneous intracerebral hemorrhage, as proven by CT, operation or autopsy, were retrospectively studied using univariate data analysis. Etiologies were hypertension in 63.5%, cerebrovascular malformations in 8.5% and abnormal hemostasis in 15% of the patients. In 23% no etiology was determined. Main localizations were cerebral lobes in 49.2%, basal ganglia in 34.4%, brain stem in 6.9%, cerebellum in 6.7% and primary intraventricular in 2.3% of the patients. Ventricular extension was present in 47.0%. A higher case fatality correlated with: 1) ventricular extension (P < 0.00001), 2) increasing age (P = 0.00005), 3) surgical treatment (P = 0.00010), 4) localization in basal ganglia (P = 0.0108) and 5) hypertension as only etiology (P = 0.01471). A lower case fatality was found in patients with cerebrovascular malformations (P = 0.00006) and when the hemorrhage was localized to the cerebral lobes (P = 0.0050). We conclude that etiology and localization are of prognostic value in spontaneous intracerebral hemorrhage.

Diagnosis of spinal arteriovenous malformations by MRI at 1.0 T.

Eight patients were examined by magnetic resonance imaging (MRI) at 1.0 T; seven had an angiographically proved spinal intradural arteriovenous malformation and one had a hemangioblastoma of the spinal cord. Myelography was also performed in five and computed tomography (CT) in four patients. The clinical and radiological findings are presented. MRI revealed the location and extent of the lesion. Myelomalacia, edema, and hematomyelia were demonstrated in three patients. In our opinion MRI is the method of choice for the diagnosis of spinal arteriovenous malformation and facilitates spinal angiography, whereas myelography and CT do not provide any further information.

Prognostic value of evoked potentials and clinical grading in primary subarachnoid haemorrhage.

In a retrospective study of 64 patients suffering from primary subarachnoid haemorrhage (SAH), the clinical grading according to Hunt and Hess as well as the initial findings of brainstem auditory evoked potentials (BAEP) and median-nerve somatosensory potentials (SEP) were correlated with each other and with disease outcome to determine the prognostic value of evoked potential testing in comparison to the initial clinical grading according to Hunt and Hess. All patients were treated in a neurological intensive care unit. Normal evoked potentials usually indicate a favourable course. Alterations of SEP and BAEP increase in parallel with the severity of clinical findings. Unilateral or bilateral loss of SEP or BAEP indicates a poor prognosis. Clinical and electrophysiological findings show a close correlation, but only BAEP provide prognostic information beyond Hunt/Hess grading. In SAH patients, clinical grading was well as evoked potentials correlate significantly with outcome. Use of both clinical and EP rating improves prognostic accuracy.

Pilocytic astrocytomas of the posterior fossa. A follow-up study in 33 patients.

The extent of resection in pilocytic astrocytoma of the posterior fossa often remains undefined and the indications for further treatment in incompletely resected tumours are a matter of debate. It has been also realized that the problem of hydrocephalus in patients with pilocytic astrocytoma of the posterior fossa has not yet been solved and the diagnostic impact of postoperative CT findings remains questionable. We retrospectively reviewed the data from 33 patients harbouring a pilocytic astrocytoma of the posterior fossa to evaluate the impact of surgical technique in terms of radicality and of postoperative imaging results upon prognosis and adjunctive treatment. In addition, the issue of hydrocephalus was considered and related to different treatment modalities. Thirty patients underwent surgical treatment whereas 3 had open biopsy of the tumour. Macroscopically gross total resection of the tumour was performed in 20 patients, whereas resection was partial in 10. Follow-up was obtained in 29 patients for a period which ranged between 2 and 184 months (85 months +/- 56 months). Outcome was good in 24 patients who had only slight neurological deficit and poor in 3 patients, who were severely disabled. Two patients died during the follow-up period. Recurrent tumour growth occurred in 2 cases with incompletely resected tumours. From the series presented, it was concluded that long-term follow-up with CT seems mandatory in cases with contrast-enhancing residual tumour. Recurrent tumour growth should be assumed in postsurgical patients with an enlarging area of enhancement shown in follow-up CT studies. Permanent ventriculoperitoneal shunting is required in certain patients with pre- or postoperative hydrocephalus.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcranial doppler and (15)O-H2O-positron emission tomography findings in patients with acute brain infarction and middle cerebral artery stenosis.

Transcranial Doppler (TCD) is a useful noninvasive tool for the assessment of the state of main intracranial arteries. Since present techniques for quantitative measurement of regional tissue perfusion (CBF) are invasive and expensive, the question was raised as to whether TCD could also be used to estimate CBF under normal and pathologic conditions. We compared TCD with CBF measurements using (15)O-H2O-positron emission tomography in 26 patients with either acute cerebral infarction or MCA mainstem stenosis and in 6 controls. No correlation was found between any blood velocity parameter and positron emission tomography blood flow values in middle cerebral artery territory neither in cerebrovascular patients nor in controls. We conclude that TCD cannot be used to quantitatively determine regional tissue perfusion. For optimal evaluation of brain blood supply, TCD should be coupled with a CBF imaging technique.

[The prognostic value of AEP and SEP values in subarachnoid hemorrhage. An analysis of 64 patients]. / Zur prognostischen Wertigkeit von AEP- und SEP-Befunden bei Subarachnoidalblutung. Eine Analyse an 64 Patienten.

In 64 patients with confirmed subarachnoid haemorrhage the clinical grading according to Hunt and Hess was compared to the initial findings of BAEP und SEP to elicit possible prognostic statements. Clinical and electrodiagnostic findings showed a high correlation. Patients without or with only slight alterations of amplitude and/or latency generally showed a favourable course. Recurrent haemorrhages or internal complications which can be decisive for outcome cannot be predicted by clinical or electrodiagnostic findings. The alterations of BAEP and SEP increase parallel to severity of clinical findings. Bilateral loss of BAEP or SEP indicates poor prognosis. Prognostic statements can be made with certainty only in cases with primary poor clinical condition (Hunt-Hess Grade IV-V) and marked alterations of evoked potentials.

[Rupture and successful operation of mycotic aneurysm of the superior cerebellar artery]. / Ruptur und erfolgreiche Operation eines mykotischen Aneurysmas der A. cerebelli superior.

We report on a case with mycotic aneurysm of the superior cerebellar artery which developed four months after treatment of infective endocarditis. Although the course of illness was complicated by rupture and recurrent bleeding, the patient was successfully treated by surgery.

Effect of propentofylline on regional cerebral glucose metabolism in acute ischemic stroke.

In a randomized double-blind placebo-controlled study in 30 patients with acute ischemic stroke, the effect of the adenosine uptake blocker propentofylline on regional brain glucose metabolism (rCMRglu) was investigated using repeated positron emission tomography (PET) with 2-[18F]fluoro-2-deoxy-D-glucose (FDG). Treatment was initiated within 48 h after onset of symptoms. The clinical course was followed for 3 months. In the propentofylline group, after 14 days rCMRglu was increased in the infarct by 37.3% and was practically unchanged in other brain regions, whereas in the control group glucose metabolism had decreased in all regions (1.4-13.4%). These differences were significant between the two groups [Analysis of variance (ANOVA) p = 0.005]. Although there was a trend toward greater clinical improvement in the propentofylline-treated patients, this did not reach statistical significance. The results correspond to experimental data showing that propentofylline improves energy metabolism in cerebral ischemia. A clinical trial is needed to determine whether this new therapeutic principle can be successfully used in acute human stroke.

[B-scan ultrasound findings in the carotid bifurcation area of hemodialysis patients]. / B-Scan-sonographische Befunde im Bereich der Karotisbifurkation von Hämodialysepatienten.

Using B-mode ultrasonography, the frequency of carotid atherosclerosis was investigated prospectively in 50 patients on maintenance haemodialysis compared to healthy controls. The patients showed significantly more atheromatous plaques at the carotid bifurcation, as well in the internal and external carotid artery (chi-square-test, p less than 0.05). There was no statistical difference between normotensive patients on haemodialysis and the control group, but hypertensive patients showed statistically significant more plaques of the cervical vessels (chi-square-test, p less than 0.05). Therefore, atheromatous plaques in haemodialysis patients appear to be due to hypertension rather than to maintenance dialysis.

[Fibromuscular dysplasia as a cause of cerebral infarct]. / Die fibromuskuläre Dysplasie als Ursache zerebraler Insulte.

Fibromuscular dysplasia (FMD) is a non-atheromatous, non-inflammatory, segmental arteriopathy of unknown etiology. Fibroplasia of the tunica media is most common. After the renal arteries, the carotid arteries are most frequently affected. Angiographically beaded and tubular stenoses are seen. Complete occlusions and spontaneous dissection of the carotid arteries occur. The angiopathy causes general symptoms such as headache and vertigo, but also recurrent TIA and ischemic cerebral infarction. We examined 15 patients (12 female) suffering from FMD and stroke. The diagnosis of FMD was based on angiographic findings in all cases. 13 patients made a good recovery and seven of them could be discharged from hospital without any neurological deficit. Apart from conservative treatment, primary percutaneous or operative angioplasty may be necessary in some cases in spite of the mostly benign outcome of the disease. Acetylsalicylic acid should be given in all cases.

[Diagnosis and prognosis of acute cerebellar infarcts. A retrospective study]. / Zur Diagnostik und Prognose von akuten Kleinhirninfarkten. Eine retrospektive Studie.

37 patients with acute cerebellar infarction were analysed retrospectively. Diagnosis of cerebellar infarction cannot be made by clinical symptoms alone rather together with CT and MRT displaying the localisation and size of the lesion. Evoked potentials do predict clinical outcome more accurately than EEG or doppler sonography do.

[Clinical and pathologic-anatomic findings in acute basilar thromboses. A study of 30 autopsy verified cases]. / Klinische und pathologisch-anatomische Befunde bei akuten Basilaristhrombosen. Eine Untersuchung an 30 autoptisch gesicherten Fällen.

In a retrospective study of 30 cases with fatal basilar artery thrombosis we compared clinical and autopsy findings for clinicopathological correlation. There are only few clinical symptoms which point to a definite localisation and extent of thrombosis or cerebral infarction. In most cases loss of consciousness and hemi- or tetraparesis are due to pontine or mesencephalic infarction. Palsy of the facial nerve suggests infarction of the pons. The incidence of cranial nerve involvement is too low to allow localisation of infarction. There was no case showing infarction of the diencephalon or the medulla oblongata when pontine or mesencephalic structures were intact. Moreover, these infarctions remained clinically silent. No clinical predictors of outcome could be defined. Even in patients without detectable impairment of consciousness or stenosis of the vertebral arteries, the disease may prove fatal.

[Neurologic complications caused by anticoagulants and fibrinolytic agents]. / Neurologische Komplikationen durch Antikoagulantien und Fibrinolytika.

We examined 126 patients, of whom 54 had suffered brain hemorrhage, 33 subdural hematoma, 18 subarachnoid bleeding, nine spinal hemorrhage and twelve hematoma with peripheral deficits. Neurologic disorders were seen in patients subject to therapy with coumarins 2-4 years after initiating therapy, whereas hemorrhages under heparine and streptokinase regimes were observed after only a few days. Clotting values were below a therapeutic range in only some of the cases. A clinical diagnosis should be verified by CT scanning. Blood clotting normally recovers after discontinuation of anticoagulation or fibrinolysis. Surgery will improve the prognosis in many cases of subdural hematoma or spinal hemorrhage; conservative treatment in cases of intracerebral, subarachnoid, and peripheral hemorrhage. A 70-percent lethality was recorded for patients suffering a cerebral hemorrhage. More than a third of patients with subarachnoid bleeding and less than a third of cases with subdural hematoma died. While peripheral lesions tended to improve, spinal hemorrhage often resulted in irreversible paraplegia. By respecting contra-indications for anticoagulation therapy and limiting the duration of such regimes the risk of hemorrhage within the CNS and other nerve structures may be reduced. Interactions with other drugs precipitating clotting disorders should also be taken into account.

[Spontaneous pontine hemorrhage. An analysis of 38 cases]. / Die spontane Ponsblutung. Eine Analyse von 38 Fällen.

In 38 patients suffering from spontaneous pontine hemorrhages arterial hypertension was the most common risk factor. 31 patients, of whom 30 died, suffered centro-paramedian pontine hemorrhage leading to coma, hypertensive crisis, respiratory failure, cardiac arrhythmia, miosis and tetraparesis. Most cases showed involvement of the mesencephalon [17] and fourth ventricle [14]. The other seven patients demonstrated dorsotegmental [5] or hemipontine [2] hemorrhages with complex neuroophthalmologic signs, other cranial nerve lesions, and ataxia or hemiparesis; all these patients survived, some even without neurological deficit. In most cases, arteriosclerotic hemorrhages of pontine vessels occurred; in rare cases arterial malformations [4] and anticoagulants [4] were responsible for the bleeding. Clinical signs, CT scans and MRT investigations led to the diagnosis. EEG and evoked potentials allowed statements regarding localisation and prognosis. Treatment was limited in most cases to conservative intensive care; in one case a ventricular shunt was implemented, and in two cases pontine hemorrhages in the presence of arteriovenous and cavernous angiomas were removed.