Cerebral microdialysis: perioperative monitoring and treatment of severe neurosurgical patient.

The early signs of brain ischemia are key indicators of secondary brain injury and their recognition on time can ultimately save life. Direct recording of cerebral ischemia is possible using the method of cerebral microdialysis (CM). This paper presents results of the five-year experience in applying this method at University Department of Neurosurgery, Sarajevo University Clinical Center in Sarajevo. In this observational prospective clinical study, the treatment and outcome of 51 patients with subarachnoid hemorrhage (SAH) and traumatic intracranial hemorrhage (tICH) undergoing neurosurgery and consequently treated conservatively at Neurosurgical Intensive Care Unit (NICU) were analyzed. All patients were followed up by unified monitoring at NICU and additionally by the CM method. Between December 2006 and September 2010, CM monitoring was performed in 51 patients: 18 patients with SAH and 33 patients with tICH. In all patients, samples were obtained on 367 occasions, yielding a total of 3314 samples for biochemical parameters (mean 64.98 per patient, range 42-114 samples). Positive correlation was found between glucose level and outcome at one-year follow up (when glucose level was lower, the patient Glasgow Outcome Scale (GOS) score was worse). The correlation coefficient for glycerol was negative (r=-0.81), and so was for the lactate/pyruvate ratio. There was a significant difference in patient outcome in favor of the group of patients monitored by use of CM in terms of poor and good outcome graded according to GOS score 12 months after the injury compared with the group of patients not monitored with CM (P<0.028). According to our experience, we believe that CM enables early initiation of appropriate therapeutic strategies to overcome cerebral ischemia and secondary brain damage, eventually leading to better patient outcome.

[Subarachnoid hemorrhage: neurosurgical treatment modalities and etiological analysis]. / Subarahnoidalna hemoragija: Modaliteti neurohirurskog tretmana i analiza uzroka.

INTRODUCTION: The subarachnoid hemorrhage (SAH) is excess presence of blood in the subarachnoid space. The most frequent cause of SAH is cerebral aneurysm rupture and neurotrauma. The treatment strategy is specific for the different forms of SAH but all therapeutic options are based on the prevention of secondary ischemic brain injury generating after initial hemorrhage. OBJECTIVE: To point out the varieties of SAH etiology and different modalities of its treatment, especially presenting the aneurismal SAH. PATIENTS, METHODS AND RESULTS: The retrospective-prospective study was performed at the Department of Neurosurgery in Sarajevo (DNS). Over a span of two years, from January 1st 2003 to December 31st 2004, 161 patients with etiologically different SAH were treated. The higher number of patients was treated during 2004 compared with a year before, respectively 101 and 60 patients. Totally, eighty three patients were operated on (52%, 83/161). The surgery was performed in 60% (61/101) of cases in the second year but only 37% in the first year of study (22/60). The most frequent cause of SAH was the rupture of cerebral aneurysm (48%). The other causes were trauma (28%), brain arteriovenous malformations (4, 3%) and hypertension with atherosclerosis (1.8%). The cause is not found in 18% of cases (29/161) and this SAH category is defined as an idiopathic SAH. A total of 64 patients with ruptured aneurysms were operated on by the author (KD) during two years 17 in 2003, and 47 in 2004. DISCUSSION: We use the defined treatment protocols for the different forms of SAH which are based on current knowledge and particulars of locality aiming to decreased possibilities of repeated bleeding and delayed ischemia. The higher number of patients with aneurysmal SAH compared to those with traumatic SAH was admitted. The reason for this is the fact that systematic management of patients with cerebral aneurysms in Bosnia and Herzegovina has been doing exclusively in our Department. CONCLUSION: The number of treated patients with SAH, especially aneurismal SAH, is significantly increased in DNS during two last years. Our patients received the standard and current treatment which implies micro neurosurgery and conservative care at the separate Neurosurgical intensive care unit. The introduction of endovascular neurosurgery and developing of neuroanesthesia as a subdiscipline is expected to increase the quality of our serves.