Bertil Romner

Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study.

OBJECTIVETo investigate the role of prophylactic hyperdynamic postoperative fluid therapy in preventing delayed ischemic neurological deficits attributable to cerebral vasospasm. METHODSWe designed a prospected, randomized, controlled study and included 32 patients with subarachnoid hemorrhage. Sixteen patients received hypervolemic hypertensive hemodilution fluid therapy; the other 16 patients received normovolemic fluid therapy. All patients were monitored for at least 12 days, with clinical assessments, transcranial Doppler recordings, single-photon emission computed tomographic (SPECT) scanning, and routine computed tomographic scanning. For fluid balance monitoring, a number of blood samples were obtained on a daily basis and continuous central venous pressure and mean arterial blood pressure measurements were performed for both groups. All patients received intravenous nimodipine infusions between Day 1 and Day 12. End points of this study were clinical outcomes, clinically evident and transcranial Doppler sonography-evident vasospasm, SPECT findings, complications, and costs. Clinical examinations (using the Glasgow Outcome Scale) performed 1 year after discharge, together with neuropsychological assessments and SPECT scanning, were the basis for the evaluation of clinical outcomes. RESULTSNo differences were observed between the two groups with respect to cerebral vasospasm (as observed clinically or on transcranial Doppler recordings). When regional cerebral blood flow was evaluated by means of SPECT analysis performed on Day 12 after subarachnoid hemorrhage, no differences were revealed. One-year clinical follow-up assessments (with the Glasgow Outcome Scale), including SPECT findings and neuropsychological function results, did not demonstrate any significant group differences. Costs were higher and complications were more frequent for the hyperdynamic therapy group. CONCLUSIONNeither early nor late outcome measures revealed any significant differences between the two subarachnoid hemorrhage treatment models.

Traumatic brain damage in minor head injury: relation of serum S-100 protein measurements to magnetic resonance imaging and neurobehavioral outcome.

OBJECTIVE The present study was conducted to validate S-100 protein as a marker of brain damage after minor head injury. METHODS We studied 50 patients with minor head injuries and Glasgow Coma Scale scores of 13 to 15 in whom computed tomographic scans of the brain revealed no abnormalities. Serum levels of S-100 protein were measured at admittance and hourly thereafter until 12 hours after injury. Magnetic resonance imaging and baseline neuropsychological examinations were performed within 48 hours, and neuropsychological follow-up was conducted at 3 months postinjury. RESULTS Fourteen patients (28%) had detectable serum levels of S-100 protein (mean peak value, 0.4 microg/L [standard deviation, +/- 0.3]). The S-100 protein levels were highest immediately after the trauma, and they declined each hour thereafter. At 6 hours postinjury, the serum level was below the detection limit (0.2 microg/L) in five (36%) of the patients with initially detectable levels. Magnetic resonance imaging revealed brain contusions in five patients, four of whom demonstrated detectable levels of S-100 protein in serum. The proportion of patients with detectable serum levels was significantly higher when magnetic resonance imaging revealed a brain contusion. In patients with detectable serum levels, we observed a trend toward impaired neuropsychological functioning on measures of attention, memory, and information processing speed. CONCLUSION Determination of S-100 protein levels in serum provides a valid measure of the presence and severity of traumatic brain damage if performed within the first hours after minor head injury.

Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries

BACKGROUND The Scandinavian Neurotrauma Committee was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients. METHODS A MEDLINE search identified 475 papers dealing with the management of minimal, mild, and moderate head injuries. Forty-two studies presenting class II evidence on the initial management of such injuries were reviewed and management guidelines were developed. RESULTS Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness, Glasgow Coma Scale score of 15) can be safely discharged. Routine early computed tomographic scan is recommended in cases with mild injuries (history of loss of consciousness, Glasgow Coma Scale score = 14-15) and patients with normal scans may be discharged. Computed tomographic scan and admission is mandatory in moderate injuries (Glasgow Coma Scale score = 13). All patients harboring additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced. CONCLUSIONS The Scandinavian Neurotrauma Committee suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild, and moderate head injuries.

Traumatic Brain Damage: Serum S-100 Protein Measurements Related to Neuroradiological Findings

This study was designed to investigate the correlation between S-100 protein serum measurements and neuroradiological findings in patients with head injury. We studied 278 patients with minor, moderate, and severe head injuries and 110 controls with no history of neurological disease. The study recruited patients from three Scandinavian neurotrauma centers. Serum levels of S-100 protein were measured at admittance, and computed tomographic scans of the brain were obtained within 24 h postinjury in all patients. In a subgroup of 45 patients with minor head injuries, magnetic resonance imaging was also performed. Increased serum level of S-100 protein was detected in 108 (39%) patients, and CT scan demonstrated intracranial pathology in 25 (9%) (brain contusion n = 13, subdural hematoma n = 6, epidural hematoma n = 2, traumatic subarachnoid hemorrhage n = 2, and brain edema n = 2). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (92%) compared to those without (34%). The negative predictive value of an undetectable S-100 serum level was 0.99. Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning.

The clinical value of serum S-100 protein measurements in minor head injury: a Scandinavian multicentre study

Purpose: This study of patients with minor head injury was designed to investigate the relation of S-100 protein measurements to computed tomograpy (CT) findings and patients outcomes. Increased serum levels of this protein were hypothetized to predict intracranial pathology and increased frequency of post-concussion symptoms. Methods: One hundred and eighty-two patients were studied with Glasgow Coma Scale scores of 13-15. The study recruited patients from three Scandinavian neurotrauma centres. Serum levels of S-100 protein were measured at admittance and CT scans of the brain were obtained within 24 hours postinjury in all patients. Outcome was evaluated with the Rivermead Postconcussion Symptoms Questionnaire (RPQ) 3 months after the injury. Results: Increased serum level of S-100 protein was detected in 69 (38%) patients, and CT scan demonstrated intracranial pathology in 10 (5%) (brain contusion in seven, epidural haematoma in two, traumatic subarachnoid haemorrhage in one). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (90%) compared to those without (35%). The negative predictive value of an undetectable S-100 level was 0.99. Sixty-two per cent reported one or more post-concussion symptoms at follow-up. A trend was observed towards an increased frequency of post-concussion symptoms among patients with detectable serum levels. Conclusions: Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning. Increased S-100 serum levels may be more related to post-concussion symptoms caused by mild traumatic brain injury than to symptoms of psychological origin.PURPOSE This study of patients with minor head injury was designed to investigate the relation of S-100 protein measurements to computed tomograpy (CT) findings and patients outcomes. Increased serum levels of this protein were hypothetized to predict intracranial pathology and increased frequency of post-concussion symptoms. METHODS One hundred and eighty-two patients were studied with Glasgow Coma Scale scores of 13-15. The study recruited patients from three Scandinavian neurotrauma centres. Serum levels of S-100 protein were measured at admittance and CT scans of the brain were obtained within 24 hours postinjury in all patients. Outcome was evaluated with the Rivermead Postconcussion Symptoms Questionnaire (RPQ) 3 months after the injury. RESULTS Increased serum level of S-100 protein was detected in 69 (38%) patients, and CT scan demonstrated intracranial pathology in 10 (5%) (brain contusion in seven, epidural haematoma in two, traumatic subarachnoid haemorrhage in one). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (90%) compared to those without (35%). The negative predictive value of an undetectable S-100 level was 0.99. Sixty-two per cent reported one or more post-concussion symptoms at follow-up. A trend was observed towards an increased frequency of post-concussion symptoms among patients with detectable serum levels. CONCLUSIONS Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning. Increased S-100 serum levels may be more related to post-concussion symptoms caused by mild traumatic brain injury than to symptoms of psychological origin.

Quantification of post-concussion symptoms 3 months after minor head injury in 100 consecutive patients

Abstract Post-concussion symptoms (PCS) (such as headaches, irritability, anxiety, dizziness, fatigue and impaired concentration) are frequently experienced by patients who have sustained a minor head injury (MHI). The post-concussion syndrome has been defined as a clinical state where 3 or more symptoms persist for more than 3 months. This report focuses on the quantification of PCS according to the Rivermead Postconcussion Symptoms Questionnaire (RPQ). We studied 100 consecutive patients with MHI and normal computed tomography of the brain. At 3 months after injury, 62% reported the presence of one or more symptoms, and 40% fulfilled the diagnostic criteria for post-concussion syndrome. Patients with post-concussion syndrome had significantly (P < 0.001) higher RPQ scores (mean 19.1, SD 11.9) than those without (mean 1.2, SD 1.8). Patients on sick leave owing to the injury reported significantly (P = 0.05) higher RPQ scores (mean 10.3, SD 13.2) than those not on sick leave (mean 5.5, SD 8.6). We observed no association between age, gender, cause of injury, severity of injury, duration of amnesia and RPQ score. RPQ score provides useful information about the severity of PCS regardless of whether the diagnostic criteria for the post-concussion syndrome are met or not.

Increased serum concentrations of protein S-100 after minor head injury: a biochemical serum marker with prognostic value?

1 Quinn N, Hallet M. Doses standardisation of botulinum toxin. Lancet 1989;i:964. 2 Schantz EJ, Johnson EA. Dose standardisation of botulinum toxin. Lancet 1990;335:421. 3 Brin MF, Blitzer A. Botulinum toxin: dangerous terminology errors. Journal of the Royal Society ofMedicine 1993;86:493-4. 4 Marsden CD. Botulinum toxin: dangerous terminology errors. Journal of the Royal Society ofMedicine 1993;86:494. 5 Pickett AM, Hambleton P. Dose standardisation of botulinum toxin. Lancet 1994;344: 474-5. 6 Hambleton P, Pickett AM. Potency equivalence of botulinum toxin preparations. J7ournal of the Royal Society of Medicine 1994;87:719.

Adjustable valves in normal-pressure hydrocephalus: a retrospective study of 218 patients.

OBJECTIVE We sought to assess the value of adjusting shunt valve opening pressure, complications, and outcomes with the use of an adjustable shunt valve in the treatment of patients with normal-pressure hydrocephalus (NPH). METHODS In a single-center retrospective study, 231 adjustable valves (range, 30-200 mm H2O) were the first shunt implantations in 147 patients with idiopathic NPH (INPH) and 71 patients with secondary NPH (SNPH). The effect of adjustment on gait disturbance, cognitive impairment, urinary incontinence and other symptoms were evaluated, and an improvement index was created. RESULTS In the INPH group, 138 adjustments were performed in 49.0% of the patients (average, 0.94 adjustments/patient). For the SNPH group, 49 adjustments were performed in 32.4% of the patients (average, 0.69 adjustments/patient). The reasons for adjustment were overdrainage in 48 patients (25.7%), underdrainage in 98 patients (52.4%), subdural hematoma in 37 patients (19.8%), and other reasons in 2 patients (2.1%). Clinical status improved after 56 (49.1%) of all 114 adjustments, whereas 23 (42.6%) of 54 minor (< or = 20 mm H2O) and 33 (66.0%) of 50 larger adjustments improved the patients clinical status. The correlation of the improvement index with the size of the individual adjustments was not significant. Complications occurred in 43 (19.7%) of 218 patients, valve malfunction occurred in 3 patients (1.3%), infection occurred in 14 patients (6.4%), and nontraumatic subdural effusion occurred in 15 patients (6.9%; 8 were treated by adjustment alone). The 5-year shunt survival rate was 80.2%. Outcomes were excellent or good in 71 (78.9%) of 90 patients with INPH and in 30 (69.8%) of 43 patients with SNPH. CONCLUSION Noninvasive, particularly consecutive, minor or single larger adjustments to the valve opening pressure can further improve outcome in patients with NPH who undergo shunting.

Determination of Wall Tension in Cerebral Artery Aneurysms by Numerical Simulation

Background and Purpose— Cerebral artery aneurysms rupture when wall tension exceeds the strength of the wall tissue. At present, risk-assessment of unruptured aneurysms does not include evaluation of the lesions shape, yet clinical experience suggests that this is of importance. We aimed to develop a computational model for simulation of fluid-structure interaction in cerebral aneurysms based on patient specific lesion geometry, with special emphasis on wall tension. Methods— An advanced isogeometric fluid-structure analysis model incorporating flexible aneurysm wall based on patient specific computed tomography angiogram images was developed. Variables used in the simulation model were retrieved from a literature review. Results— The simulation results exposed areas of high wall tension and wall displacement located where aneurysms usually rupture. Conclusion— We suggest that analyzing wall tension and wall displacement in cerebral aneurysms by numeric simulation could be developed into a novel method for individualized prediction of rupture risk.

Computation of Hemodynamics in the Circle of Willis

Background and Purpose— Wall shear stress (WSS) and pressure are important factors in the development of cerebral aneurysms. We aimed to develop a computational fluid dynamics simulator for flow in the complete circle of Willis to study the impact of variations in vessel radii and bifurcation angles on WSS and pressure on vessel walls. Methods— Blood flow was modeled with Navier-Stokes equations as an incompressible newtonian fluid within rigid vessel walls. A model of the circle of Willis geometry was approximated as a network of tubes around cubic curves. Pulsatile inlet flow rates and constant outlet pressure were used as boundary conditions. Results— The simulations confirmed that differences in vessel radii and asymmetric branch angles influence WSS magnitude and spatial distribution. High WSS occurred at locations where aneurysms are frequent and in anatomic variants known to be associated with an increased risk for aneurysm development. Conclusions— Computational fluid dynamics analysis can be applied to the complete circle of Willis and should be used to study the pathophysiology of this complex vascular structure, including risk factors for aneurysm development. Further development of the method should include simulations with flexible vessel walls.