Dieter Woischneck

Classification of Severe Head Injury Based on Magnetic Resonance Imaging

SummaryObject. In 1991 a new pioneering classification of severe head injuries had been proposed, based on CT findings. Unfortunately CT cannot visualise all lesions. Especially brain stem lesions may escape CT in spite of modern equipment, but may be demonstrated by MRI. The high incidence of CT negative but MRI positive posttraumatic brain stem lesions has already been demonstrated in a limited number of cases. A statistically significant evaluation is still missing. Therefore we have investigated a series of 102 comatose patients, in whom a statistical evaluation of MRI findings and their correlation with mortality and outcome of survivors was possible. Patients and Methods. MRI was obtained within 8 days after servere head injury in 102 patients with a minimum of 24 hours of coma. The location of the lesions, identified by a neuroradiologist who was unaware of the clinical findings, was correlated with mortality, outcome of surviors and duration of coma. The correlation was analysed statistically. Follow-up ranged from 3 months to 3 years with a mean of 22 months. Four groups of lesions gave significant correlations: Grade I lesions were lesions of the hemispheres only; Grade II lesions were unilateral lesions of the brain stem at any level with or without supratentorial lesions; Grade III lesions were bilateral lesions of the mesencephalon with or without supratentorial lesions. Grade IV lesions were bilateral lesion of the pons with or without any of the foregoing lesions of lesser grades. Results. Mortality increased from 14% in grade I lesions to 100% in grade IV lesions. The Glasgow outcome score differed significantly for each grade. The mean duration of coma increased from 3 days in grade I patients to 13 days in grade III. The correlations between the lesions grade I to IV with mortality, outcome of survivors and duration of coma were highly significant. Conclusion. The statistically significant correlations between the 4 groups of severe head injury patients, as identified by MRI, with mortality and outcome of survivors justify a new classification based on early MRI findings.

Brain stem lesions after head injury.

Abstract There is little knowledge on the morphology of the brain stem in survivors of head injury, as CT fails to show brain stem lesions, and neuropathological data is only available from autopsies. As magnetic resonance imaging (MRI) sheds new light on morphological lesions of the brain, the authors investigated 100 patients with a severe head injury. MRI was performed in a prospective study within the first seven days after head injury while the patients were still in coma and on ventilation. Relating the location of the lesions as depicted by MRI with the initial CT scan and outcome, death appeared to be closely linked to the phenomenon of bilateral pontine lesions. The extent of supratentorial lesions had no bearing on survival at all in the absence of brain stem lesions. Altogether the brain stem was affected in 52%. Obviously the occurrence of bilateral upper pontine lesions is of highest predictive value for a fatal outcome. Severe destruction of supratentorial white matter as demonstrated by MRI is not related to increased mortality, as long as the brain stem is spared. [Neurol Res 2002; 24: 145-146]

Efficiency of the Glasgow Outcome Scale (GOS)-Score for the Long-Term Follow-Up after Severe Brain Injuries

The Glasgow Outcome Scale (GOS)-Score is the most widely used instrument for measuring outcome in head injury research. Its reliability is seen controversial because of its simplicity. The study analyzes the correlation between the levels 3 to 5 of recovery to medical data, psychology and quality of life (QOL) 4 to 8 years after the accident. 34 patients, suffered from a severe brain injury (BI) 4 to 8 years ago, were reexamined by a psychological test battery and by evaluating of QOL (using self developed items for private and social activity). Test results and GOS-Score additionally were correlated to data from the phase of intensive care. Patients, still alive 4 to 8 years after injury, ranged mainly between the GOS-Scores 3 to 5 of recovery. Consequently, other scores (like Ranchos los Amigos, Barthel Index, GOAT) failed in measuring the outcome after such a long time. Different parameters from the phase of intensive care correlate significantly with the patients GOS-Score: coma length, isolated brain injury versus additional extracranial injury, compression of the basal cisternes on the initial CCT. Different psychological test results and the patients quality of life correlate significantly with the GOS-Scores from 3-5. These correlations could be shown in xy and yx-direction by different mathematical models. It is concluded, that GOS-levels 3-5 of recovery correlate to the essential medical data from the initial phase after the accident and to a detailed psychological evaluation years after injury.

Head Trauma in Children, Part 3: Clinical and Psychosocial Outcome After Head Trauma in Children

With the aim of determining long-term outcome, the authors approached 38 families (average 2.1 years after trauma) with a questionnaire, following the acute-clinical treatment of head trauma of their children. Long-term damage was restricted almost exclusively to patients presenting with a Glasgow Coma Score ≤8. Paresis (16%), cranial nerve damage (13%), incontinence (5%), or coordinative disturbances (18%) continued. The older children stated that they influenced their life to a great extent (11%). Furthermore, many had mental and cognitive problems that occur quite frequently even in children with light head trauma and often only manifest after release from hospital. This causes problems and results in inferior performance (26%), especially at school, which is further complicated through lengthy periods of absence. The parents, especially, mentioned behavioral problems such as social withdrawal or aggressive demeanor, which led to tension also inside the family. A persistent vegetative state is rare after head trauma in children.

Desmopressin Acetate in Intracranial Haemorrhage

Introduction. The secondary increase in the size of intracranial haematomas as a result of spontaneous haemorrhage or trauma is of particular relevance in the event of prior intake of platelet aggregation inhibitors. We describe the effect of desmopressin acetate as a means of temporarily stabilising the platelet function. Patients and Methods. The platelet function was analysed in 10 patients who had received single (N = 4) or multiple (N = 6) doses of acetylsalicylic acid and 3 patients (control group) who had not taken acetylsalicylic acid. All subjects had suffered intracranial haemorrhage. Analysis was performed before, half an hour and three hours after administration of desmopressin acetate. Statistical analysis was performed by applying a level of significance of P ≤ 0.05. Results. (1) Platelet function returned to normal 30 minutes after administration of desmopressin acetate. (2) The platelet function worsened again after three hours. (3) There were no complications related to electrolytes or fluid balance. Conclusion. Desmopressin acetate can stabilise the platelet function in neurosurgical patients who have received acetylsalicylic acid prior to surgery without causing transfusion-related side effects or a loss of time. The effect is, however, limited and influenced by the frequency of drug intake. Further controls are needed in neurosurgical patients.

Health-Related Quality of Life After Spontaneous Subarachnoid Hemorrhage Measured in a Recent Patient Population

OBJECTIVE This study sought to determine the impact of spontaneous subarachnoid hemorrhage (SAH) on health-related quality of life (HRQOL). METHODS Data were taken retrospectively from 601 patients (219 male, 382 female) treated between 1998 and 2008. Questionnaires concerning HRQOL were circulated prospectively, and the responses from 253 patients (81 male, 172 female) were analyzed. The questionnaires comprised the standardized Short-Form 36 (SF-36) and Short-Form 12 (SF-12) Health Surveys, a number of nonstandardized questions, and visual analogue scales. Statistical analysis of the results was exploratory, using unifactorial ANOVA (Scheffe), multivariate analyses of variance. RESULTS The HRQOL is reduced considerably by SAH and remains so for a period of 10 years. Physical and emotional domains are primarily affected, but also cognitive functions, including memory and concentration in particular. Similarly, certain roles are affected that prove difficult to rehabilitate after acute care and cause serious debility in the long term. The Hunt and Hess Scale, Glasgow Outcome Scale, and seizures were found to have the greatest impact on HRQOL. CONCLUSIONS Documentation of HRQOL after 6 to 12 months is useful because patients are often found to have a diminished HRQOL in the absence of a clear physical impairment. Because psychological, emotional, cognitive, and social functioning influence HRQOL in the long term, efforts at rehabilitation should focus in particular on improving such factors. Documentation of HRQOL is a useful, additive tool for consolidating and evaluating the outcome, and a treatment end point after SAH, respectively.

Cognitive performance following spontaneous subarachnoid haemorrhage versus other forms of intracranial haemorrhage.

Abstract Objective. The exact cause of cognitive deficits following intracranial haemorrhage is unclear. This prospective study examines the abilities after spontaneous subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and chronic subdural haematoma (SDH) to elucidate the cognitive outcome. Patients and methods. Ninety-nine patients with SAH (N = 60), ICH (N = 25), and SDH (N = 14) were followed up for an average of 6 and 12 months post-haemorrhage. Cognitive tests were used to examine attention, memory, concentration, and executive function. Following were used for analysis: 1. the percentage of patients falling below the 25th percentile per test, 2. the general development from the first to second test point and 3. the incidence of significant changes between the test points. Significance was established as p ≤ 0.05. Results. All three types of haemorrhage resulted in deficits as concerns abstract language (53%–75%). The processing speed was below the normal levels in more than 70% of the patients tested. The cognitive performance of SAH patients was similar to that of patients with SDH and ICH patients after 6 months. The number of patients with outcomes falling below the 25th percentile (to some extent more than 75% in patients post-SAH) is high in all patient groups and mostly decreases over the course. Nevertheless, patients with SAH reveal improvements in many more areas than with ICH and SDH (p ≤ 0.006). Conclusions. The cognitive impairments following SAH, ICH and SDH deficits appear to develop in a similar way regardless of the type of haemorrhage. Cognitive improvement is most pronounced in patients with SAH.

Head injury in children: has a change in circumstances caused an increase in treatment numbers?

The number of hospitalizations for head injuries in children is rising. The exact causes remain unclear. We analyzed data of children aged between 0 and 18 years who sustained a head injury between 2010 and 2011. The analysis focused on data related to demographics, trauma mechanism, clinical course, results of imaging scans, concomitant injuries, and outcome. A total of 794 inpatient cases of head injury were treated. The leading mechanism of injury was a fall (at home) primarily at the age of 1 to 4 years (46.5%), with the majority of the children sustaining a mild brain injury (764, 96.2%). Neurosurgery was performed in 21 (2.64%) cases; average hospital stay was 2.9 days (range: 0-68 days). This study is not able to confirm that children are increasingly being brought to the hospital by their parents because of new trauma mechanisms or parents’ uncertainty, nor can we confirm that the number of nonaccidental injuries is rising.

Long-Term Health-Related Quality of Life After Spontaneous Nontraumatic Subarachnoid Hemorrhage: Self and Proxy Reports in a 10-Year Period

BACKGROUND This study sought to examine health-related quality of life several years after spontaneous nontraumatic subarachnoid hemorrhage. Recent studies report impairments to be improved as far as normal levels. We question such an improvement in our own patient population over a period of 10 years. METHODS The Medical Outcomes Study 36-Item and Medical Outcomes Study 12-Item Short-Form Health Surveys on health-related quality of life were used to question 236 patients and 235 proxies. The patients were assigned to 5 groups according to the time that had elapsed since their hemorrhage: 1 year N = 22, 2 years N = 36, 5 years N = 86, 8 years N = 61, and 10 years N = 31. Analyses of variance (ANOVA, Kruskal-Wallis) and correlation (Spearman, Kendall tau) were used in an exploratory approach. Significance was established as P ≤ 0.05. RESULTS Over a period of 10 years, health-related quality of life is found to be impaired, and is reported as such by the patients themselves and their proxies. Comparison of the mean values between the groups, ie, 1, 2, 5, and 10 years, revealed no significant differences in health-related quality of life. The calculations with a view to correlations between the group means and time since hemorrhage also produced only very weak correlations of no significance. CONCLUSIONS Health-related quality of life is impaired over a period of 10 years. Spontaneous nontraumatic subarachnoid hemorrhage should be regarded as a chronic cerebrovascular condition.

Respiratory function after lesions in medulla oblongata

Abstract Objectives: To evaluate the correlation of lesions of the brain as visualized in cranial magnetic resonance imaging (MRI) and the ability of spontaneous respiration. Methods: In a prospective concept, cranial MRI after traumatic brain injury or spontaneous intracerebral hemorrhage was performed in 250 subjects at an early stage. All MRI findings were correlated with respiratory conditions on the day of examination. Sedation was performed only to facilitate toleration of the artificial ventilation, as and when necessary. Spontaneous respiration could hence be registered clinically. Results: Thirteen subjects (5.2%) had no spontaneous respiration. In these cases, a bilateral lesion of the distal medulla oblongata could be displayed. In four of these cases, no additional injuries of the brainstem were detected. These subjects awoke 2 days after the impact with tetraparesis and apnea. Combined lesions of the medulla oblongata and other brainstem regions were found in nine subjects. All these patients died without awakening. In the absence of a bilateral lesion of the caudal medulla oblongata, spontaneous respiration was always possible. A unilateral lesion of the caudal medulla oblongata was visualized in one patient who had the ability of spontaneous respiration. Conclusions: This work confirms the presence of autonomous respiratory centers within the caudal medulla oblongata that allows sufficient adequate respiration in coma. Respiration ceases in the presence of a bilateral lesion of this area.