E. Donauer

Intraventricular haemorrhage caused by aneurysms and angiomas

SummaryMore than 200 intraventricular haematomas (IVH) have been treated in the Homburg Neurosurgical University Clinic since computed tomography was available and facilitated the diagnosis.Among 200 consecutive cases, which are analysed and presented in this publication, there were 71 patients with subarachnoid haemorrhage (SAH)-58 of whom with angiographically and/or pathologically verified aneurysms-, and 21 cases with intraventricular angiomas. IVH without concomitant intracerebral haematoma (ICH) and without evidence of SAH is highly suggestive of intraventricular angioma.In our experience panangiography [if available digital subtraction angiography (DAS)] should be done as soon as possible in all cases of IVH. It is a precondition for early diagnosis and operative elimination of the source of bleeding, because the retrospective analysis of our material shows that rebleeding is by far the highest single risk factor in cases with IVH caused by aneurysms or angiomas.We therefore recommend early microsurgical occlusion of the aneurysms and exstirpation or intravascular embolisation of the angioma.The best survival rate (76%) was achieved in IVH cases caused by angiomas. In aneurysms with IVH the survival rate was 35%, in IVH caused by other diseases 37%. The worst prognosis occurs in SAH with IVH without proven aneurysm or angioma. The survival rate of this group was only 8%.

Prognostic factors in the treatment of cerebellar haemorrhage

SummaryA prospective study for the treatment of cerebellar haemorrhage was conducted in a non-selected group of 33 patients. All patients with cerebellar haemorrhage arriving at the Department of Neurosurgery at Homburg/Saar have been included in this study, also those in bad condition, with high risk factors, and the aged. All of them required intensive care respectively intensive supervision.The following management protocol has been established.I.Cases with small haemorrhage, in good clinical condition, without hydrocephalus and/or occlusion of the basal cisterns: intensive supervision, operative intervention only if they deteriorate into one of the following groups.II.Cases with hydrocephalus — even if not yet pronounced — but without occluded basal cisterns and without major tonsillar herniation: pressure monitored ventricular drainage, which opens at 15 mm Hg and thus prevents higher CSF pressure developing.III. a):Cases with large haematoma, occluded basal cisterns and/ or tonsillar herniation, but without severe general risk factors, as a first step: pressure monitored ventricular drainage; as a second step, if they do not improve soon after the normalization of the ventricular pressure: open surgical evacuation of the haematoma, which also decompresses the posterior fossa. If present and possible, causative vascular malformations may be dealt with at the same session.III. b):Same intracranial situation, but patients with severe general risk factors: pressure monitored ventricular drainage only.IV.Cases with causative aneurysm or angioma, who initially had been treated conservatively or by ventricular drainage: secondary operation of the vascular malformation after stabilization of the general conditions. Overall mortality was 33%. For the 13 men — median age 58 (27–83) — the initial average Glasgow Coma Scale (GCS) grade was 9.2 and the median haematoma diameter 3.7 cm. For the 20 women — median age 53 (17–80) — the corresponding figures were 10.4 GCS and 3.4 cm.Of the 13 men 6 died (mortality 46%; total Karnofsky scale 37.6). Of the 20 women 5 died (mortality 25%; total Karnofsky scale 57.5).The worst prognosis related to patients with an additional intraventricular haemorrhage and men aged between 50 and 70 years with an admission GCS of less than 7 and occluded cisterns. Early loss of consciousness, additional ventricular bleeding, brain stem extension of the haemorrhage, occluded perimesencephalic cisterns and severe systemic disease — diabetes mellitus, liver cirrhosis from alcohol abuse with resulting coagulation disorders — were the main factors which led to unfavourable outcome.The results of our study, which are presented in detail in this paper, allow recommendations for our therapeutic strategy.

Colloid Cysts of the Third Ventricle: Open operative approach or stereotactic aspiration?

Colloid cysts of the third ventricle can cause hydrocephalus if they grow to the point where they occlude the foramina interventricularia. The operative approach via a craniotomy used to be the common method of treating these lesions. Now, in the era of CT- and MR-scanning, stereotactic aspiration should be preferred as an ideal method of simultaneously diagnosing and treating colloid cysts. Unlike open surgery, aspiration of colloid masses poses hardly any risk for the patient. Ten cases successfully treated by this technique are presented.

Experimental hydrocephalus and hydrosyringomyelia in the cat: Radiological findings

SummaryFourty-six cats were made hydrocephalic and hydromyelic by means of an intracisternal kaolin injection. In 17 other cats hydrocephalus and syringohydromyelia were achieved by operative occlusion of the foramina Luschkae of the fourth ventricle. In both the kaolin treated animals and the animals whose outlets of the fourth ventricles were operatively obstructed a progressive dilatation of the ventricles and central canal occurred, which could be demonstrated and followed in 30 animals by ventriculography, myelography and/or contrast filling of the hydromyelic central canal. Coinciding with the dilatation of the central canal the clinical picture of a raised intracranial pressure due to obstructive hydrocephalus improved.The presented results suggest that the dilated central canal acts as a kind of natural by-pass between the ventricles and the spinal subarachnoid space.In order to determine the role of spinal kaolin arachnoiditis on spinal cyst formation and central canal dilatation in 13 animals, kaolin was locally applied in the lower thoracic region. The local spinal kaolin arachnoiditis had no influence on central canal dilatation or cyst formation.

Cavum vergae cyst as a cause of hydrocephalus, “Almost Forgotten”?

SummaryCavum vergae cysts (CVC) are cerebral midline malformations, which usually have no clinical manifestations. In rare cases, however, non-communicating cysts can cause hydrocephalus by obstruction of the aqueduct. Initially, from 1930 to 1960 operative treatment consisted in open cysto-ventriculostomy,i.e. establishing a communication between CVC and the ventricles, via a transventricular approach. In the era of CT, symptomatic treatment of the hydrocephalus by ventriculo-atrial or ventriculo-peritoneal sunts is preferred. All the wellknown complications of shunting are encountered. Based on the experience of our cases of CVC with clinical manifestations, we here propose a definitive causal treatment which can be achieved by draining the cyst contents into the ventricles via a stereotactically introduced catheter.

Prospective comparative study of the effectiveness of epidural morphine and ropivacaine for management of pain after spinal operations.

Summary. Objective: Evaluation of the effectiveness of local application of morphine or ropivacaine for treatment of local and radicular pain after lumbar disc operations. Critical review of the literature about the possibilities of management of postoperative pain after spinal operations. Methods: A total of 113 patients were randomly given 5 mg morphine sulfate (N=42), 10 ml 0,25% ropivacaine (N=42) or physiological NaCl solution (N=21) locally after lumbar disc operation before wound closure. Postoperative lumbar and radicular pain was scored by the patients from 0 to 10 and registered on the evening of the day of operation and on the 1., 2., 3., and 5. days. Mean pain numbers of the 3 groups have been compared, subdivided into local lumbar and in radicular pain. Our own results have been compared with the results of reports in the literature. Results: In our own study the morphine group had less lumbar and less radicular pain on all 5 days than both of the two other groups. This difference was statistically significant on days 0, 1, 2, and 3. The ropivacaine group was on all days less effective than the morphine group, better than the placebo group on the operation and first day, but the difference against the placebo group was statistically not significant. Conclusion: Local application of 5 mg morphine sulfate is effective in prevention or reduction of postoperative lumbar and radicular pain after lumbar disc operations. Ropivacain is less effective. The routine application of epidural morphine at the end of spinal operations can be recommended. It also can be justified to try to prolong the morphine effect by mixing it into a paste as described by Needham and by Hurlbert, and to irrigate the operative field with ropivacaine at the end of the operation.

Syringomyelia: a brief review of ontogenetic, experimental and clinical aspects

The generally accepted definition of syringomyelia is that it is a chronically progressive illness characterized by the presence of cavities or syrinxes in the spinal cord. As manifold as the terminology of syringomyelia are the hypotheses of the etiology. Now-adays with MRI without and with gadolinium it is possible to recognize intramedullar cavities safely, the MR especially the cine-MR provides information on pathophysiological details of the flow and intracavitary pressure dependant pulsations of the CSF. Animal models and the findings of own experimental studies have enabled us to study a form of syringomyelia which very closely resembles that brought about by dysrhaphic malformations in the human being and to examine the effectiveness of certain types of surgical therapy.In this paper the term syringomyelia is only used for dysrhaphic cavities in the medulla. After our experience with 61 patients with syringomyelia now we perform the operative decompression of the craniocervical transition as the first step in the operative treatment of the progressive syringomyelia combined with severe craniocervical malformations. In cases with insufficient treatment response we suggest the tyringoarachnoid shunting of persisting large intramedullar cavities.

Intrathecal administration of netilmicin in gentamicin-resistant ventriculitis.

SummaryIn ventriculitis caused by Gentamicin-resistant staphylococcus aureus and staphylococcus epidermidis, Netilmicin was administered intrathecally to 19 patients under continuous control of the Netilmicin concentration in cerebro-spinal fluid (CSF). This therapy was able to bring these otherwise letal infections under control, usually within 10 days.Pharmacokinetic studies with different doses have shown that doses of 2 × 3 mg are to be recommended in moderately severe cases of ventriculitis, and in most severe infections 3 × 3 mg daily intraventricularly for adults. In infants daily intraventricular injections of 2 × 0,4–0,5mg Netilmicin are a sufficient dose to produce an effective antibiotic concentration level.

Prognostic value of SSEP in early aneurysm surgery after SAH in poor-grade patients.

Abstract We evaluate the prognostic value of somatosensory evoked potentials (SSEP) in poor-grade patients after early surgery for aneurysmal subarachnoid hemorrhage compared to the Hunt and Hess (H&H) and WFNS scales. Ninety patients with angiographically proven aneurysms graded H&H IV or V were evaluated retrospectively. The aneurysms of 72 patients were clipped. In 53 out of 72 patients 147 SSEP examinations were recorded. The SSEP were classified according to the central conduction time (CCT) and the number of cortical potentials. Outcome was determined according to the Glasgow Outcome Scale. To evaluate the predictability of the SSEP to clinical grading scales receiver operating characteristic (ROC) analysis was done. The H&H scale did not demonstrate statistically significant predictability for poor-grade patients. The WFNS scale predicted the outcome for only one group (survival/death) (p = 0.035). Predictability of outcome by the SSEP was statistically confirmed. Normal CCT indicated a potential for a good recovery, but not consistently so. Bilaterally enhanced CCT was predictive of a poor outcome. Bilateral lack of cortical responses was always related to fatal outcome. ROC analysis confirmed that SSEP are superior to clinical grading scales in determining prognosis in poor-grade patients. In doubt, whether early aneurysm surgery or conservative treatment in a poor-grade patient should be done, SSEP will be helpful.

Permanent ventriculostomy in cats. Technical note.

SummaryA commercial ventriculostomy reservoir has been modified for use in cats. It allows repeated ventricular punctures in chronic experiments.