A long course of chronic subdural haematomas

Summary The authors present 8 cases of chronic subdural haematoma with a history of illness longer than 1 year. They appeared among 92 cases of chronic subdural haematoma treated in the Neurosurgical Department of the Medical Academy of ód.The course of the illness and the results of surgical treatment are presented. The authors think that intracranial hypotension can play an important role in predisposing to such cases of chronic subdural haematoma, which present with a long history.     

Venous malformation in the posterior fossa: Guidelines for treatment

Summary Venous malformations in the posterior fossa are relatively rare. Although the introduction of CT and MRI has made them easier to detect, their treatment is still controversial. Based on our experience with six patients and a review of the literature, we have tried to establish guidelines for their treatment. Since they have a benign natural course and may provide venous drainage in the posterior fossa, venous malformation found incidentally, unruptured venous malformation with nonhaemorrhagic complications, and those accompanied by small intracerebellar haematoma of less than 2 cm in diameter due to their rupture, should be treated conservatively unless they are associated with a coexistent malformation. Venous malformation with intracerebellar haematoma larger than 3 cm or reexpansion of the haematoma due to rebleeding should be treated surgically by evacuation of the haematoma. Resection of venous malformations in the posterior fossa should be restricted to cases in which the malformation is small and does not serve as a functional venous drainage route. Radiation therapy, including the gammaknife, may be a treatment of choice in the future.     

Symptomatic subacute subdural haematoma following spontaneous acute subdural haematoma

Summary Two patients with non-traumatic acute subdural haematoma were observed, initially without surgical intervention. Eleven days after the onset, each patient developed hemiparesis and an increase in severity of headache. Serial computed tomography scans demonstrated that the initial hyperdense haematomas became hypodense with a definite increase in volume. The term symptomatic subacute subdural haematoma was proposed to properly define this pathological process, which necessitated removal of the haematoma in the subacute stage. The mechanism of increase in the volume of the haematoma is discussed.     

Posterior fossa ependymomas in adults

Summary Sixteen patients with posterior fossa ependymomas are presented. This tumour is relatively uncommon in adults and is usually associated with a relatively benign course when compared with other posterior fossa glial tumours. The natural history and treatment of these tumours is discussed.     

Percutaneous twist-drill craniostomy for the treatment of chronic subdural haematoma

Summary A consecutive series of 65 adult patients with chronic subdural haematoma was reviewed to ascertain the efficacy of twist-drill craniostomy and closed-system catheter drainage. In all patients but two the percutaneous evacuation of the haematoma alone was enough to bring about their recovery.Infections or neurological complications were never observed. Pneumocephalus was likewise absent in all patients. Therefore this technique should be recommended as the first intention management of the disease, particularly in elderly patients.     

Head-injured adult patients with GCS of 3 on admission — Who have a chance to survive?

Summary The authors analysed a series of 111 adult patients admitted to the Department of Neurosurgery, Medical University of ód directly after trauma with initial GCS of 3 points. 74% of them had intracranial haematoma, mainly subdural, and were treated surgically within the first 3 hours after trauma. 8 patients had no abnormalities on CT scans.99 (89%) patients died 2 to 30 days after injury, 8 (7%) survived in a vegetative state, and only in 4 (4%) was a satisfactory result noted, but 2 of them had a stable neurological deficit. 3 of these 4 patients had epidural haematomas and 1 had not abnormalities on repeated CT examinations.We conclude, that among patients with GCS of 3 on admission, only those without major CT abnormalities or with epidural haematoma have a chance of survival. Cases with cerebral leasions on the initial CT examination have an invariably bad prognosis. They could be taken into account as a potential organ donor from the very moment of admission, but only after cerebral circulatory arrest occured and brain death has been proved according to internationally accepted standarts.     

A clinical comparison of non-traumatic acute subdural haematomas either related to coagulopathy or of arterial origin without coagulopathy

Summary ¶Background. Non-traumatic acute subdural haematomas enable study of the morbidity and mortality due to the haematoma without the effect of trauma. Whereas it is known that coagulation disorders worsen the outcome of spontaneous intracerebral haematomas, this has not been studied in non-traumatic acute subdural haematomas. Methods. In a series of 13 non-traumatic acute subdural haematomas admitted to our department between January 1995 and March 2002, we had 9 coagulopathy associated haematomas and 3 haematomas corresponding to the syndrome of spontaneous acute subdural haematoma of arterial origin. Both groups were compared. Findings. Age and gender distribution were comparable. The bleeding source was a cortical artery in 2 of the 2 non-coagulopathy related haematomas operated on, but also in 2 of the 4 coagulopathy associated haematomas that underwent surgery. The average haematoma thickness was higher in the coagulopathy related haematomas. The mean Glasgow Coma Score on admission was 7,7 and the mortality rate was 55,6% in the coagulopathy related group. In the non-coagulopathy related haematomas the mean Glasgow Coma Score was 12,0 and the mortality rate 33,3%. The latter mortality rate corresponds well to that of a historical group of spontaneous acute subdural haematomas of arterial origin collected from the literature. Interpretation. The outcome was worse in the non-traumatic acute subdural haematomas that were associated with a coagulation deficiency. While in all non-traumatic acute subdural haematomas the interval to surgery should be minimized, early recognition and urgent correction of coagulation deficiencies is certainly indicated.Published online May 19, 2003     

Outcome following acute subdural haematoma

Summary An analysis and long-term follow-up of 136 patients with acute subdural haematoma diagnosed or operated on within 72 hours after injury confirmed the poor outcome: 27 patients (20 percent) made a useful recovery, 13 (10 percent) are severely disabled, and 95 died (70 percent). One patient is still in a vegetative state. The poor outcome in those injuries requiring surgery in the first 24 hours suggests that the term acute subdural haematoma should be limited to this group. Earlier diagnosis and operation on acute subdural haematomas without severe primary brain injury may obviously save a few more patients. However, with very early admissions the number of patients with severe primary brain injury goes up; thus the poor outcome for acute subdural haematoma is likely to remain high.     

Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: A case-control study

Summary Surgical intervention in supratentorial intracerebral haemorrhage (ICH) is still controversial. We assessed the value of haematoma evacuation with a case-control study. 145 consecutive patients with supratentorial spontaneous ICH without tumour or vascular abnormalities were analysed. Haematoma evacuation was performed in 24 patients. Age, sex, Glasgow Coma Scale (GCS), level of consciousness, pupillary reaction on admission, localisation, aetiology and volume of the haematoma, presence of ventricular blood, and Glasgow Outcome Scale (GOS) on discharge were analysed. From statistical analysis 40 patients >80 years and with haematoma volume <10ml, who were always treated conservatively, were excluded. Prognostic factors retained from a multiple regression model with the dichotomised GOS scale (GOS 1–3, 4+5) as response variable were GCS, haematoma volume and location. The only difference between all medically treated and operated patients was haematoma volume, which was larger in the operated patients. All 24 evacuated cases could be matched to a medically treated control regarding age, haematoma volume and location, GCS, and pupillary reaction. Significant differences between the two groups could not be detected. Outcome was not different between the two groups. After separating the sample into patients with and without ventricular haemorrhage, there was no different outcome between the two groups either. We conclude that haematoma evacuation did not improve outcome in supratentorial spontaneous ICH. Since haematomas were evacuated mainly in clinically deteriorating patients, our data suggest that the only effect of haematoma evacuation is to stop progressive deterioration rather than to improve overall clinical outcome.     

Discharge criteria from intensive care unit in brain injured patients

Summary Objective. We investigated the value of information on clinical features and intensity of treatment activity in the Intensive Care Unit (ICU) in predicting the need for further interventions after a patient is discharged from the Intensive Care Unit. Our aim was to assess if this could aid in making decisions about transfer to an Immediate Care Unit (sub-ICU).Methods. We studied 39 patients with acute brain damage (traumatic or vascular causes). They ranged in age from 15 to 75 years and none had an associated spinal cord injury. The SAPS II, Glasgow Coma Scale (GCS), length of stay in ICU, duration of hospital stay and daily NEMS scores were recorded for each patient. We recorded the activities performed after transfer to an sICU, including complications that required active life-saving treatment. The role of each factor was assessed by using the odds ratio (OR), and with linear logistic regression.Findings. 8 of the 39 patients developed a complication in the Sub-ICU. A linear logistic regression analysis demonstrated that the principal features having significant predictive value were:a) age, with an increase in risk of over 10 times for patients that were older than 50 (p=0.011);b) SAPS II scores 50 points, with 24 times an increase in risk (p=0.002); andc) a GCS score 5 points, with an increase in risk of almost 7 times (p=0.024).Interpretation. Complications in Sub-ICU are less likely in patients younger than 50 and who have SAPS II and GCS scores within predetermined limits. These indices can help in making decisions about discharge of a patient from ICU to Sub-ICU.     

Acute subdural haematoma in adults: an analysis of outcome in comatose patients

Summary The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of ód with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18–30 year old had lower mortality — 25%, while patients above 50 revealed 75% mortality.Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery — those with quickly developing haematomas and intracranial hypertension — had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma.Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.     

Sex hormone binding and peritumoural oedema in meningiomas: Is there a correlation?

Summary 136 patients older than 70 years, admitted to our neurosurgical ward directly after head trauma, were analysed. 40% of them were admitted with low GCS, below 9 points, and showed a mortality of 85%. 45 patients had intracranial mass lesions — the commonest was subdural haematoma, with a low incidence of epidural haematomas. In patients admitted with GCS above 12, mortality was 20%, mainly due to pneumonia. Satisfactory results were achieved in 30% of trauma victims. From patients with intracranial space occupying lesions and GCS below 9 points on admission practically all died, despite aggresive surgical treatment and intensive care. Thus, especially in departments with limited resources, therapy can be limited, or even no therapy may be introduced in this group. Surgical treatment can be limited only to patients who are conscious on admission. In patients with non-surgical lesions, low GCS — below 9 points — leads to mortality of 80%, and in this group we propose aggresive intensive care for 24 hours and the limitation of further maximal therapy only to those, who significantly improve within this period of time. If the patient has a non-surgical lesion and is conscious after trauma, aggresive treatment of extracranial complication is the most important, because brain injury can usually be well tolerated by these patients. If pneumonia or heart complications do not occur this group of old patients often have a good prognosis.     

Follow-up computerized tomography (CT) scans in moderate and severe head injuries: Correlation with Glasgow coma scores (GCS), and complication rate

Summary Background: The wide availability of computerized tomography (CT) scan has popularized its use in initial and follow-up evaluations of head trauma patients. Follow-up CT scans of clinically stable patients, however, may not provide additional information, but could potentially subject the patients to secondary injuries. The authors investigated the correlation between CT scans and Glasgow coma score (GCS), and complication rate during follow-up CT scans in an attempt to dissuade clinicians from obtaining unnecessary follow-up CT scans. Methods: The medical records of 180 patients with blunt head trauma were retrospectively reviewed. Only patients (117) with moderate and severe head injuries were included in the study. A total of 319 follow-up brain CT's for 94 patients were obtained. Results: The change in CT scans was compared to the GCS the day of the scan. These two variables were found to be positively correlated by Chi-square analysis (²=81.2; < 0.001). CPP trend was found also be correlated with CT scan evolution by the Chisquare analysis ( < 0.001). When patients had unchanged or improved GCS, 73.1% had improved or the same CT appearance. When patients had a worse GCS, the CT was worse in 77.9%. A 16.9% (54/319) complication rate was documented during the follow-up scans (hemodynamic instability, increased intracranial pressure, desaturation, and agitation). This rate was higher in severe head trauma (GCS 3–8) patients than in moderate head injury (GCS 9–12) patients. Hemodynamic instability was the most common complication, which comprises 42.6% (23/54) of all complications. Conclusion: Because of the correlation between the CT scan appearance and the clinical status, as well as the detrimental effect of mobilizing critically ill patients, the authors urge the use of follow-up CT scans only in patients with clinical deterioration unexplained by ICP changes alone.     

Surgical treatment of “Hindbrain Related” syringomyelia: New data for pathogenesis

Summary 52 patients with hindbrain related syringomyelia underwent surgical treatment. All patients underwent primary reconstructive surgery at the craniovertebral junction. Terminal ventriculostomy was performed as the secondary operation in 2 cases. The surgical treatment arrested progression of signs in 33 (63.5%), stabilized disease in 9 (17%) cases. Postoperative deterioration occurred in 8 (15%) cases. Mortality was 4% (2 patients).Percutaneous or intra-operative injection of myodil and gas into the syrinx, as well as CT, revealed the existense of communication with the 4th ventricle in 14 patients. Investigation of cerebrospinal and syrinx fluid revealed increased level of IgG, IgM or IgA in the syrinx fluid in 16 out of 22 patients. Immunohystological examination of pia mater revealed specific staining for IgG. Thus, syrinx formation may be due to synergic action of hydrodynamic and immunopathological mechanisms. Results indicate that early surgical treatment is preferable to patients with hindbrain anomalies and hydromyelia. We consider primary reconstructive operation at the posterior fossa as the preferred surgical management of hindbrain related syringomyelia.The paper was presented at the European Congress of Neurosurgery, Moscow, June 23–28, 1991     

Use of the prone oblique position in surgery for posterior fossa lesions

Summary Background. The lateral suboccipital approach has been conventionally performed with the lateral, park-bench, or sitting position and the midline suboccipital approach has been performed in the prone position. We attempt to show the advantages of the prone oblique position in the surgery for posterior fossa lesions.Methods. Twenty-two patients with posterior fossa lesions underwent surgery in the prone oblique position. The patients were fixed in the prone position while the operating table was rotated to raise the patients shoulder. The surgeon sat beside the downward-shifted contralateral shoulder of the patient. With the lateral suboccipital approach, the neck of the patient was rotated to the side of the lesion. With the midline sub-occipital approach, the neck was not rotated.Findings. With the lateral suboccipital approach, this position spread the transverse axis of the suboccipital triangle and eliminated the interference of the patients shoulder, providing an operative field that is wider than the lateral position or park bench position in all cases. With the midline suboccipital approach, this position enabled the surgeon to operate on lesions located in the upper half of the posterior fossa, such as fourth ventricular lesions or infratentorial lesions, without the need for a looking up posture with overhanging of the operative microscope.Conclusion. The prone oblique position offers the operator a panoramic view of the posterior fossa.     

Construct validity

Background: This study was undertaken to establish construct validity of the Xitact LS500, a virtual reality laparoscopic cholecystectomy simulator. The primary research statement is: The clip-and-cut task on the Xitact LS500 virtual reality laparoscopic cholecystectomy simulator mimics the surgical procedure of the clipping and cutting of the cystic duct and artery during the laparoscopic cholecystectomy adequately. Methods: According to the level of experience of the surgeon, an expert group opinion was formed resulting from 37 surgeons having performed over 100 laparoscopic cholecystectomies, and a novice group opinion was formed resulting of 37 surgeons having no experience at all with performing laparoscopic cholecystectomy. Participants received an instructed hands-on tour on the Xitact simulator and performed three formal simulation runs. Results: The novice group is younger and more surgeons are female. Performance scores in the expert group are significantly higher on the second (p value 0.011) and third (p value 0.005) run, compared to the novices scores. Experts are significantly faster on completion of all three runs. There is an increase in score over runs in both groups, which is statistically significant in the expert group. Less than one-third of surgeons in either group are able to correctly predict their performance score as generated by Xitact. Both experts and novices feel it is useful to train with Xitact LS500 in the surgical curriculum. Conclusions: Three hypotheses, formulated to operationalize the primary research statement, could be answered affirmatively. Although further validation studies are needed, the Xitact LS500 simulator seems to be able to discriminate between expert and novice surgeons in this research setting, and thus the construct for this setting is considered to be valid.     

Stereotactic anatomy of the posterior cranial fossa a study of the transcerebellar approach to the brainstem

Summary The stereotactic transcerebellar (suboccipital) approach to the brainstem is one of the most accessible routes to reach targets located in the pons or in the medulla oblongata. Its use requires a perfect knowledge of the stereotactic anatomy of the posterior cranial fossa, and a standard reference system related to structures of the brainstem itself which can easily be visualized by Nuclear Magnetic Resonance.The present work consitsts in a three-dimensional variability study of the human posterior cranial fossa with its main contents, based on the investigation of 30 normal specimens (hemifossae). A new stereotactic reference system is proposed for the pons and the medulla, comprising three orthogonal planes: the midsagittal plane, the IVth ventricular floor plane and the pontomedullary junction plane.A standard safety access tunel was defined for the transcerebellar approach to the pons and, with some limitations, to the medulla. A complementary investigation, based upon angiographic studies, was carried out to define a safe entry zone to the posterior cranial fossa of the occipital bone beneath the transverse venous sinus.Winner of the 1989 Upjohn Prize of the EANS.     

The “R.A.R.E.” Technique <Emphasis Type="Italic">(Reverse and Repositioning Effect):</Emphasis> The Renaissance of the Aging Face and Neck

Considering the fixed points of the face (Fig. 1), and in light of the fact that gravity is one of the main factors involved in aging, a new alternative concept in cosmetic surgery is discussed in this paper. In our approach, rejuvenation of the face and neck involves two completely separate procedures. The whole face must be treated homothetically, with an upward (vertical) and deep (subperiosteal) approach, to preserve facial proportions and distances, thus preserving the original facial identity. The facial portion of our rejuvenation surgery becomes a single en bloc and closed procedure, correcting the sagging tissue in the lateral sector, between the fixed zones which must be preserved. The Malaris portion of the Orbicularis Oculi Muscle, (through its strong connections with the skin and the malar fat) has become the key tool of the rejuvenation of the whole face. Then, neck surgery becomes a completely distinct procedure, and is to be performed in an oblique/horizontal direction. We now seek to preserve the very firmly attached neck zones, which are the attachment of the posterior border of the fibrous platysma onto the S.C.M. (Sterno-Cleido-Mastoidien muscle). This will permit a more conservative and less aggressive neck surgery, without any sub-platysmal disection. Over 200 RARE procedures have been performed during almost four years. Improvement in terms of facial rejuvenation is dramatic and the technique is quite safe and predictable. The only possible difficulty involves the patients temporary initial concern about early postoperative appearance. Presented at ASAPS Boston, 2003; (International Symposium Paper Winner). This article was initially submitted for publication in 3rd quarter, 2003.**Homothetia (adj: homothetic): From homos: same; and thesis: position. A geometric term which means conservation of the relations and distances of different points of a figure, after its displacement (syn: to act in concert or in harmony). Homothetia preserves the identity of components during movement, without deformation or change. (Figs. 2A, B, 3A, B).     

Neurosurgical intensive care improves outcome after severe head injury

Summary The present study compares the clinical outcome, as expressed by the Glasgow outcome scale, of two groups of severely head injured patients treated before (49 patients) and after (72 patients) the establishment of a neurosurgical intensive care (NIC) unit at the department of neurosurgery, Uppsala University Hospital. The number of good recoveries increased significantly after the establishment of the NIC. This was confirmed by univariate analysis (p<0.05) and by multivariate analysis using the logistic regression model to adjust for differences between the two groups of patients (p<0.05, p<0.005). The most striking improvement was found in patients with a Glasgow coma motor score (GCS M)4 on admission. In this subgroup of patients the good recoveries increased from 15% to 52%. The object of NIC is basically to prevent or minimize secondary brain damage, and it seems logical that the effect of such care is most obvious in GCS M4 patients in whom a good outcome can be anticipated if secondary damage can be prevented or minimized.In conclusion, the present study shows that improved clinical outcome after severe head injury can be achieved by organizing an NIC unit with a well trained staff capable of providing this care 24 hours a day using established methods of surveillance and treatment.     

Changes of local brain tissue oxygen pressure after vasopressin during spontaneous circulation

Summary. Background. Brain tissue oxygen pressure (PbtO₂) correlates to cerebral blood flow (CBF) during spontaneous circulation, with one important regulator being nitric oxide (NO). Although it is established that arginine vasopressin (AVP) improves CBF and global cerebral oxygenation during cardiopulmonary resuscitation, it is unknown whether similar beneficial effects are present during spontaneous circulation. The purpose of this study was to investigate the effects of AVP with and without pre-treatment with the NO synthase inhibitor N-omega-nitro-L-arginine methyl ester (L-NAME) on local brain tissue oxygenation in a beating heart model.Methods. Following approval of the Animal Investigational Committee, nine healthy piglets underwent general anaesthesia, and were instrumented with a probe in the cerebral cortex to measure PbtO₂. Each animal was assigned to receive AVP (0.4U·kg^–1), and after a wash-out period, L-NAME (25mg·kg^–1 over 20min) followed by AVP (0.4U·kg^–1). After each AVP administration, nitroglycerine (25µg·kg^–1 over 1min) as a NO donor was infused to test the vascular reactivity independently from NOS inhibition.Findings. Three minutes after administration of AVP, PbtO₂ increased significantly (P<.05; mean±SEM, 31±11 versus 43±14mmHg, +39%), compared with baseline. After pre-treatment with L-NAME, the changes of PbtO₂ after AVP were not significant (32±11 versus 28±10, –13%) when compared with the baseline.Conclusion. In this beating heart porcine model, local brain tissue oxygenation was improved after AVP alone, but not after inhibition of NO synthesis with L-NAME.