Indications for surgical treatment of cerebellar haemorrhage and infarction

Summary This report summarizes the outcome of 56 patients with cerebellar lesions of vascular origin, 40 patients with cerebellar infarction, and 16 with spontaneous cerebellar haemorrhage. All patients had computerized tomography: occlusive hydrocephalus was diagnosed in 75% of patients with cerebellar haemorrhage and in 23% with cerebellar infarction.Nine out of 10 patients survived after early surgical evacuation of the haematoma and 4 of them recovered completely. Two patients underwent only external ventricular drainage (EVD), one died after 2 days, and the other recovered with a moderate deficit. Three of 4 medically treated patients died within one week; all had developed occlusive hydrocephalus. The fourth medically treated patient recovered completely; consciousness had never deteriorated nor had occlusive hydrocephalus developed.Among 40 patients with cerebellar infarction, 13 developed progressive deterioration of consciousness; 7 of them underwent decompressive craniectomy of the posterior fossa and survived. One patient had only external ventricular drainage and died. Four out of the 5 medically treated patients died during the acute phase.From these observations and several reports in the literature, it is concluded that both cerebellar haemorrhage and infarction should be operated on as soon as progressive deterioration of consciousness develops. This occurs more frequently in patients with cerebellar haemorrhage than with cerebellar infarction. Individual decisionmaking in each case necessiates intensive neurosurgical observation.     

Cerebellar haemorrhage: Management and prognosis

Of 26 patients with CT confirmed intracerebellar haematoma, 17 had ventricular drainage performed and 7 patients had the haematoma evacuated.Eleven patients died. Mortality was clearly related to state of consciousness. Seven out of 8 non-comatose patients survived but 10 out of 18 comatose patients died. As there was no incidence of deterioration immediately following placement of a ventricular drainage, the actual risk of upward transtentorial herniation seemed low. Absence of evoked potentials in 6 patients accurately predicted a fatal outcome but normal SEP and BAEP were of lesser value for predicting survival.     

Results of routine ventriculostomy with external ventricular drainage for acute hydrocephalus following subarachnoid haemorrhage

Summary We reviewed the results of ventriculostomy with external ventricular drainage in patients with acute hydrocephalus complicating subarachnoid haemorrhage. Of 194 consecutive patients with subarachnoid haemorrhage admitted during the past eight years, 52 (27%) developed hydrocephalus within 72 hours of the ictus. Patients with acute hydrocephalus were in grades III to V (Hunt and Hess) at the time of evaluation and all patients with hydrocephalus underwent ventriculostomy within 24 hours of diagnosis. Twenty-six patients improved within 24 hours of cerebrospinal fluid drainage and 17 of these patients underwent surgery, nine of whom did well (Glasgow Outcome Scale 1 and 2). All 18 patients who did not improve within this period, including one who worsened, died. In eight patients the response to ventriculostomy was considered as undetermined, because of the proximity of the drain insertion to a definitive surgical procedure, and all of them had an excellent outcome (Glasgow Outcome Scale 1). Of 32 patients in grades IV and V, 17 did not improve and all of them died. Eight of the 15 patients in these grades, who were in the improved or undetermined categories, did well. Five patients (10%) developed meningitis. All patients with this complication had drainage for more than four days. Seven patients (14%) had a rebleed during the drainage. All except one patient with a rebleed had no surgery or delayed surgery and in six of them recurrent haemorrhages occurred after more than 24 hours of drainage.We conclude that routine ventriculostomy with external ventricular drainage should be considered for all patients with altered sensorium and acute hydrocephalus following subarachnoid haemorrhage. The complications of ventriculostomy can be reduced if it is followed by early definitive surgery. No benefit is derived by prolonging the drainage beyond 24 hours in patients in grades IV and V if there has been no improvement in this period, and prolonged drainage may contribute to recurrent haemorrhages and meningitis.     

Surgical complications of chronic subdural haematoma: A 5‐year audit

Objective: To review the outcome of surgical treatment for chronic subdural haematoma (CSDH) at a local neurosurgical centre, with emphasis on major treatment‐related complications. Method: A total of 108 patients received operations for chronic subdural haematoma at the University of Hong Kong Medical Centre between January 1995 and December 1999. Medical records and imaging studies were studied retrospectively. Patients’ clinical features and treatment modalities were analysed and major postoperative complications, including mortality, haematoma recurrence, infection and epileptic seizure, were studied. Results: All 108 patients underwent burr hole craniostomy for the drainage of CSDH; one patient also underwent formal craniotomy. Recurrence occurred in six (5.5%) patients, seizure in two (1.8%) and intracranial infection in one (0.9%). There were four deaths, giving rise to a mortality of 3.7%. All four patients who died were elderly and had presented in an unconscious state and died subsequently of chest infection after surgery. Conclusion: Although surgical drainage of CSDH is often considered to be a straightforward, effective and safe procedure, it is not entirely without risks. The surgical outcome of the present series is in accordance with the current standard of neurosurgical care.     

Multiple supratentorial epidural haematomas after posterior fossa surgery

Postoperative epidural haematoma distant to a site of craniotomy is a rare but possibly hazardous complication. We report a 31-year-old female who presented with a history of chronic hydrocephalus due to fourth-ventricular plexus papilloma. Following resection of the posterior fossa tumour with intraoperative placement of a ventricular drainage, she consecutively developed four supratentorial epidural haematomas at different locations, all necessitating evacuation. The clinical manifestations ranged from subtle neurological deficits to signs of tentorial herniation; the ultimate outcome was complete recovery. Rapid tapering of CSF pressure after long-standing hydrocephalus and clotting disorders could be implicated as causative factors. We stress the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication.     

Laser-assisted endoscopic third ventriculostomy for obstructive hydrocephalus: technique and results in a series of 40 consecutive cases

BACKGROUND AND OBJECTIVES: To report a case series of endoscopic third ventriculostomy (ETV) using laser in 40 consecutive patients with obstructive hydrocephalus. STUDY DESIGN/MATERIALS AND METHODS: Under stereotactic and endoscopic guidance, multiple perforations in the ventricular floor using a 1.32 microm neodymium-yttrium/aluminum/garnet (Nd-YAG) or a 0.805 microm diode laser unit and removal of intervening coagulated tissue ensued with a 4-6 mm opening between third ventricle and basilar cisterns. RESULTS: The procedure could be completed in all cases. A transient complication occurred in five cases. In 39 patients (mean follow-up 28 months), 31 (79%) had a favorable outcome. Failure occurred in six patients, requiring permanent shunting leading to complete recovery, and two patients remained in a poor clinical status despite ETV. CONCLUSIONS: Laser-assisted ETV is a safe and efficient procedure for the treatment of obstructive hydrocephalus. Laser is advantageous in cases of distorted anatomy and may reduce technical failures.     

Prognostic factors and long-term outcome following surgical treatment of 76 patients with spontaneous cerebellar haematoma

Background  

Although large spontaneous cerebellar haematomas are associated with high mortality, surgical treatment may be life-saving. We evaluated the clinical outcome and identified prognostic factors in 76 patients with cerebellar haematoma, all treated with suboccipital decompression, haematoma evacuation and external ventricular drainage.     

External ventricular drainage for treatment of rapidly progressive posthemorrhagic hydrocephalus.

Twenty-seven newborn infants (birth weight, 1503 +/- 776 g; gestational age, 31 +/- 3 wk) (mean +/- standard deviation) with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure were treated by external ventricular drainage. The progression of hydrocephalus was arrested during the drainage period in each patient. The drainage was kept in place for 23 +/- 9 days, the longest drainage period being 48 days. In 16 of 23 surviving patients, progressive ventricular dilation recurred after removal of the drainage, requiring a definitive shunt implantation (nine ventriculoatrial, seven ventriculoperitoneal). For the remaining seven infants, no further therapy was necessary. Implantation of the permanent shunt was done days 28 to 88 (body weight, 2400 +/- 950 g). Bacterial cultures from cerebrospinal fluid and/or the tip of the ventriculostomy catheter were negative in 175 instances and positive in 11 instances (7 patients). No clinical or biochemical evidence of ventriculitis was noted. Four of the 27 patients died of causes unrelated to external ventricular drainage. Twenty-three infants survived. Seventeen of 23 survivors suffered from intraventricular hemorrhage Grade 3; in 7, neurological and developmental outcomes were classified as normal; 9 patients experienced mild to moderate paresis and/or mild to moderate developmental delay; and only 1 patient was severely retarded. Six patients with parenchymal lesions had severe motor and/or developmental handicaps. We consider external ventricular drainage an effective and safe therapy in newborn infants with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure. The ultimate outcome, however, depends mainly on the mode and the extent of the primary brain lesion.     

Lesions of the corpus callosum in hydrocephalic patients with ventricular drainage — a CT-study

Summary Patients with ventricular drainage may develop lesions of the corpus callosum. In order to study frequency, pathogenesis and clinical relevance of callosal lesions, 301 routine CT investigations of 79 patients with ventricular drainage were reviewed. Hypodense lesions in the anterior part of the corpus callosum were observed in 7 patients with longstanding hydrocephalus of variable origin, in 2 cases the corpus callosum was slightly swollen. All 7 patients showed signs of forced ventricular drainage. The callosal alterations were clinically inapparent and potentially reversible. Knowledge of these lesions is important to avoid misinterpretation.     

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients

Background. We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres. Method. Each centre provided data about patients clinico-radiological findings, management, and outcomes, which were retrospectively reviewed. Findings. A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, 8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05). Interpretation. acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1cm) seems to be a guide to indicate surgical evacuation of the haematoma.     

The management of spontaneous primary intracerebral haemorrhage

Intracerebral haemorrhage (ICH) accounts for around 10–20% of all strokes and results from a variety of disorders. ICH is more likely to result in death or major disability than ischaemic stroke or subarachnoid haemorrhage. Rapid imaging allows early diagnosis and characterization of the localization and severity of the haemorrhage. Patients with significant acute ICH should be managed in a critical care unit. Treatment entails general supportive care, control of blood pressure and intracranial pressure, prevention of haematoma expansion and, where indicated, neurosurgical intervention. In those patients whose bleed extends into the ventricular system or who have infratentorial bleeds are at increased risk of associated hydrocephalus, rapidly increasing intracranial pressure requiring urgent CSF drainage. The 30-day mortality from intracerebral haemorrhage ranges from 35–52%. Among survivors, the prognosis for functional recovery depends upon the location of haemorrhage, size of the haematoma, level of consciousness, the patient's age, and overall medical condition.     

Role of endoscopic third ventriculostomy in patients with communicating hydrocephalus: an evaluation by MR ventriculography

Post-tubercular meningitic hydrocephalus (TBMH) and post-traumatic hydrocephalus (PTH) is often considered a contraindication for endoscopic third ventriculostomy (ETV), as it is mostly of communicating type in these cases. The aim of the present study was to define the role of ETV in patients with communicating hydrocephalus. Ten consecutive patients of TBMH, PTH and postneurocysticercus (NCC) hydrocephalus were formed the study group. Diagnosis of communicating hydrocephalus was made using magnetic resonance ventriculography (MRV). If contrast was seen coming out from the ventricular system into the basal cisterns, it was considered as communicating hydrocephalus. Patients with clinical and imaging evidence of raised intracranial pressure and failed medical treatment were taken up for ETV. All patients were studied by preoperative and postoperative MRV. Success of the procedure was assessed by the improvement in clinical and imaging parameters on postprocedure follow-up in all these cases. Technically successful ETV was performed in all 10 patients. Overall success rate of ETV in communicating hydrocephalus was 70% (n = 7). The shunt surgery was performed in the remaining three patients with ETV failure. One patient developed complication following postoperative MRV and was managed conservatively. We conclude that ETV is effective in post-TBM, post-traumatic communicating and post-NCC communicating hydrocephalus and should be considered as initial surgical option for cerebrospinal fluid diversion in these patients. MRV is a relatively safe technique to ascertain the patency of subarachnoid space as well as ETV stoma.     

Hydrocephalus and vasospasm after subarachnoid hemorrhage from ruptured intracranial aneurysms

The incidence of hydrocephalus and vasospasm and the relationship between them were analyzed retrospectively in 87 patients with subarachnoid hemorrhage from ruptured intracranial aneurysms. Sixty-seven per cent of the patients showed ventricular enlargement on a computed tomographic scan done within 30 days of the hemorrhage; in patients whose first scan was done within 3 days of the hemorrhage, 63% seemed to have ventricular enlargement by a neuroradiologist's interpretation. Shunts were required in 14% of the patients because of delayed neurological deterioration or enlarging ventricles; 3% required ventriculostomy shortly after admission. Seventy-four per cent of the patients had angiographic spasm on an angiogram done within the first 30 days after hemorrhage. Sixty-two per cent of the patients had both hydrocephalus and vasospasm: 22% had neither. Five per cent had hydrocephalus, but no spasm; 11% had spasm, but no hydrocephalus. Hydrocephalus and vasospasm were significantly associated (P less than 0.01, chi2). These data document a high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage. They also emphasize that these two sequelae of subarachnoid hemorrhage are closely linked, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.     

Clinical and CT scan assessment of benign versus fatal spontaneous cerebellar haematomas

Summary We have studied 15 cases of spontaneous intracerebellar haematomas in 9 males and 6 females. A significant correlation between the clinical presentation and the CT scan features of benign and fatal haemorrhages of the cerebellum is presented.Diagnostic computerized tomographic studies were performed in a mean interval of 31 hours after the initial symptoms. 60% were diagnosed and treated in less than 24 hours; 11 patients had haematomas larger than 3 cm, and 5 (45%) of these cases died with evidence of irreversible brain-stem damage. Twelve (80%) showed compression of the fourth ventricle, 9 (60%) obliteration of the brainstem cisterns and 8 (53%) ventricular dilatation.8 cases were treated with surgery; 50% of them showed neurological improvement, including two cases with signs of brain-stem compression. 7 patients who were treated conservatively were followed closely with repeated CT scans, which showed that resolution of the mass effect and isodensity of the haematomas occurred within 9 to 15 days, with a mean of 11 days, after the initial CT scan. An increased mortality was observed with haematomas larger than 3cm (73%), hydrocephalus (45%) and intraventricular haemorrhage (40%). Smaller haematomas without CT scan evidence of obliteration of the brain-stem cisterns or hydrocephalus had a better outcome.     

Neurosurgical aspects of cerebral cryptococcosis

Eleven patients with raised intracranial pressure caused by cerebral cryptococcosis developed complications requiring neurosurgical operations. Two patients were fully conscious on admission, and 9 had impaired consciousness, four of whom were comatose. Seven patients were found to have hydrocephalus only. Two patients had cerebral edema initially, and 2 had cystic lesions. One of the latter developed subdural effusion. All patients eventually developed progressive hydrocephalus requiring placement of a ventriculoperitoneal shunt. Four patients were initially treated by external ventricular drainage. When external ventricular drainage was used initially, there were no associated complications; however, there was a high incidence of complications (4 of 7 patients) when a ventriculoperitoneal shunt was placed as the initial treatment. Of the 11 patients, 10 (91%) survived; of these 9 (82%) made an excellent recovery and 7 (64%) returned to their original work. The patient who died had been receiving steroid therapy for hypopituitarism.     

The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis of 108 patients

The effects of continuous drainage of cerebrospinal fluid (CSF) on vasospasm and hydrocephalus were analyzed retrospectively in 108 patients with subarachnoid hemorrhage (SAH) who were operated on for ruptured aneurysms within 48 hours of their onset. Ninety-two of these patients underwent a procedure for CSF drainage (cisternal drainage, ventricular drainage, lumbar drainage, or a combination of these). The duration, the total volume, and the average daily volume of CSF drainage were 10.4 +/- 7.0 days (mean +/- SD). 2034 +/- 1566 ml, and 190 +/- 65.3 ml, respectively. Patients with a greater drainage volume at a lower height of drainage in the early period after SAH developed more cerebral infarctions later (P less than 0.025). The relationship between the total volume of CSF removed and shunt-dependent hydrocephalus was determined to be statistically significant (P less than 0.005). Cerebral infarction and hydrocephalus after SAH were also found to be statistically associated (P less than 0.001). Thus, continuous cerebrospinal fluid drainage should not be performed too readily in patients with SAH, because the removal of a large amount of CSF can induce cerebral vasospasm as well as hydrocephalus.     

Effect of nonoperative treatment on the outcome of patients with posttraumatic hydrocephalus

OBJECTIVE: To compare the outcome of non-operative treatment with the outcome of surgical intraventricular drainage for patients with posttraumatic hydrocephalus including complications, mortality and favorable outcome. METHODS: Thirty-nine patients were assigned to a nonoperative treatment group and 38 patents to a surgical intraventricular drainage group. Each patient's outcome was evaluated 3 years after treatment by using Glasgow Outcome Scale. RESULTS: In the nonoperative treatment group the rate of favor able outcome (good recovery or mild disability) was 89.74% (35 of 39 patients) and the mortality was 2.56% (1 of 39 patients). In the surgical intraventricular drainage group the rate of favorable outcome was 71.05% (27 of 38 patients) and the mortality was 13.16% (5 of 38 patients; P<0.05). Mortality was not significantly different between the two groups. CONCLUSIONS: Nonoperative treatment may be better than surgical intraventricular drainage for patients with posttraumatic hydrocephalus.     

颅内压监测下脑室外引流、腰大池引流治疗脑室岀血的疗效观察

目的 探讨颅内压监测下脑室外引流、腰大池引流治疗脑室岀血的疗效.方法 以本院就诊的重型脑室出血患者为研究对象.随机分成试验组和对照组.试验组给予颅内压监测下行脑室外引流;腰大池引流,对照组根据患者症状、体征和CT扫描结果 进行脑室外引流、腰大池引流.比较两组预后、并发症(颅内感染、脑积水、脑疝、再出血)、脑室引流时间、住院时间的差别.结果 ①试验组疗效显著优于对照组,差异有统计学意义(χ2＝9.621,P＜0.05);②试验组颅内感染、脑积水和脑疝发生率显著低于对照组,差异有统计学意义(P＜0.05);③试验组脑室引流时间和住院时间均显著低于对照组,差异有统计学意义(P＜0.05).结论 颅内压监测下脑室外引流、腰大池引流治疗脑室岀血疗效好,可减少并发症,降低住院时间.     

Urokinase infusion for severe intraventricular haemorrhage

Summary The purpose of this study was to explore in patients with intraventricular haematomas the effectiveness and complication rate of a treatment protocol including standard ventriculostomy and application of urokinase via the catheter.Our series includes 16 patients with severe CT-diagnosed intraparenchymal and predominantly intraventricular haemorrhages. In all cases, ventricular drainage was performed. Urokinase treatment was started immediately with intraventricular infusions of 10,000 U urokinase in 5 ml sterile physiological saline every 12 hours. Twelve patients had an excellent outcome, three good and one poor. There were no complications related to urokinase therapy. Side efects of the infusion volume were profuse sweating and headache which were present at 10 ml total infusion volume, but disappeared after reduction to 5 ml. A group of five patients with comparable lesions treated only with ventriculostomy served as controls. Two of them had a good outcome, two a poor one and one died. The late results in the urokinase-treated group were also favourable. Only one of the patients developed hydrocephalus and was shunted. In the control group, two patients required shunting for delayed hydrocephalus.We conclude that this protocol for urokinase treatment is safe and effective and can be used in almost all patients with intracerebroventricular haemorrhage.     

The management of spontaneous primary intracerebral haemorrhage

Intracerebral haemorrhage (ICH) accounts for around 10–20% of all strokes and results from a variety of disorders. ICH is more likely to result in death or major disability than ischaemic stroke or subarachnoid haemorrhage. Rapid imaging allows early diagnosis and characterization of the localization and severity of the haemorrhage. Patients with significant acute ICH should be managed in a critical care unit. Treatment entails general supportive care, control of blood pressure (BP) and intracranial pressure (ICP), prevention of haematoma expansion and, where indicated, neurosurgical intervention. Those patients whose bleed extends into the ventricular system or who have infratentorial bleeds are at increased risk of associated hydrocephalus, rapidly increasing ICP requiring urgent cerebrospinal fluid drainage. The 30-day mortality from ICH ranges from 35% to 52%. Among survivors, the prognosis for functional recovery depends upon the location of haemorrhage, size of the haematoma, level of consciousness, and the patient's age and overall medical condition.