Surgical Treatment for Primary Brainstem Hemorrhage to Improve Postoperative Functional Outcomes.

BACKGROUND: It remains controversial whether primary brainstem hemorrhage (PBH) should be managed conservatively or treated promptly by surgical evacuation of the hematoma. In the present study, we discuss 5 cases of PBH that were treated surgically and the ability of surgical management to improve postoperative functional outcomes. METHODS: The 4 patients with pontine and medullary hemorrhage underwent surgery via the lateral or midline suboccipital and trans-rhomboid fossa approach in the half-sitting position. The patient with a midbrain hemorrhage underwent surgery via the subtemporal approach in the supine lateral position. We analyzed the postoperative functional outcomes 1 week after surgery and the modified Rankin scale scores 6 months after discharge. RESULTS: Three patients with disturbance of consciousness experienced improvement in their level of consciousness. Four patients with hemiparesis improved in motor function. Oculomotor nerve function improved in 2 of 3 cases. Facial nerve function improved in 2 of 2 cases. Spontaneous respiration improved in 1 patient. The postoperative modified Rankin scale scores improved in all 5 cases. CONCLUSIONS: Because of the good results with these 5 patients with PBH, this surgical strategy could be encouraged with exclusion criteria for early initiation of rehabilitation strategies. We hope to increase our number of patients to accumulate further evidence.

Improvement of Respiratory Depression in a Patient with Primary Medullary Hemorrhage Following Removal of Hematoma in the Half-sitting Position.

Primary medullary hemorrhage is a rare event that may result in ataxic respiration. Although it remains controversial whether primary medullary hemorrhage should be managed conservatively or surgically, recent advancements in neuroimaging and microsurgical techniques have shown promise for improving outcomes and prognosis following surgery. The present report discusses the case of a 70-year-old woman admitted to our institution due to sudden-onset nausea and vomiting. The patient underwent surgical removal of a right medullary hematoma for the treatment of daytime respiratory depression and nocturnal apnea while in the half-sitting position. Following surgery, her spontaneous respiration improved, and she was discharged with independent gait. Despite the risk of venous air embolism, accumulating evidence suggests that the half-sitting position is suitable for brainstem surgery because gravity-assisted blood and irrigation drainage from the surgical field allows for cleaner dissection and reduces the need for bipolar coagulation.

Effect of acute hypoxic preconditioning on qEEG and functional recovery after cardiac arrest in rats.

Acute hypoxic preconditioning (AHPC) can confer neuroprotection from global cerebral ischemia such as cardiac arrest. We hypothesize that acute neuroprotection by AHPC will be detected early by quantitative EEG (qEEG) entropy analysis after asphyxial cardiac arrest (aCA). Cerebral ischemia lowers EEG signal randomness leading to low entropy. A qEEG entropy index defined as the duration when the entropy measure is 15% below uninjured baseline entropy is used as a measure of injury. We compared 3 groups of adult Wistar rats: (1) untreated controls that were subjected to 5 min of aCA and were resuscitated (n = 5); (2) AHPC-treated group with 10% FI O2 for 30 min, then 25 min of room air, 5 min of aCA followed by resuscitation (n = 5); and (3) a surgical sham group (no aCA) (n = 3). Functional outcome was assessed by neurodeficit score (NDS) which consisted of level of consciousness, cranial nerve, motor-sensory function, and simple behavioral tests (best = 100 and brain dead = 0). We found that increasing entropy index of injury at 0-5 h from return of spontaneous circulation (ROSC) is associated with worsening NDS at 24 h (linear regression: r = 0.81, P < 0.001). The NDS of the group sham (84.7 +/- 2.8) (mean +/- SEM) and AHPC group (84.6 +/- 2.9, P > 0.05) was better than control injury group (52.2 +/- 8.4, P < 0.05) (ANOVA with Tukey test). We therefore conclude that AHPC confers acute neuroprotection at 24 h, which was detected by qEEG entropy during the first 5 h after injury.