Georg Nowak

Early management in poor grade aneurysm patients

SummaryAneurysm surgery began in Lübeck only in 1986 when the department was completely reorganized. Early operation in the good grade patients (I–III, according to Hunt and Hess) was performed. In every case we also discussed the feasibility of operating on the poor grade patients (Hunt and Hess IV and V).During a five-year period (1986–1991) a total of 277 SAH patients were admitted to the department. 109 (39%) patients arrived in a poor grade (Hunt and Hess IV or V), 12 of these patients died within hours of admission. 25 patients, who presented with a large intracerebral and/or subdural haematoma, were urgently operated upon by haematoma evacuation and aneurysm clipping. An external ventricular drainage was performed on 72 patients. Of the ventriculostomy group 33 patients improved and 27 were operated upon. In 17 of the 39 patients without improvement after CSF-drainage we decided to operate.Overall 69 patients were surgically treated (craniotomy, aneurysm clipping) and 40 were not. The mortality rate in the surgical cases was 16 (23%) compared with 30 (75%) without operation.It is concluded that poor grade aneurysm patients can achieve a better outcome with active treatment based on immediate ventriculostomy and optimal haemodynamic parameters after haematoma evacuation and early occlusion of the aneurysm.

A New System for Cutting Brain Tissue Preserving Vessels: Water jet cutting

The water jet cutting system allows transaction and dissection of biological structures with little bleeding. Structures of higher tissue rigidity remain unchanged while softer tissues are mechanically dissected. In brain tissue, all vessels larger than 20 microns are left intact after the passage of the jet stream with a pressure of up to 5 bar, and therefore vessels can be isolated selectively from the surrounding tissue. Oedema is present adjacent to the cut and no increase of temperature occurs.

Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases.

During a six-year period (1986–1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery, Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8 %) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2 %). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6 %). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%).We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.

Dural arteriovenous malformation in the anterior cranial fossa

Two cases of dural arteriovenous malformation (AVM) at the base of the anterior cranial fossa are described. In both cases an intracerebral hematoma following the rupture of the AVM was the first indication of the disease. In one case, the malformation was supplied both by the anterior ethmoidal artery and frontopolar artery draining into the superior sagittal sinus. In the second case, the right anterior ethmoidal artery with draining veins into the superior sagittal sinus and sphenoparietal sinus was the feeding vessel. Surgical evacuation of the hematoma and excision of the malformation was performed on both patients. The typical clinical signs and radiological findings are described. A review of the pertinent literature is given.

Acute subdural haematoma from ruptured intracranial aneurysms

SummaryAcute subdural haematoma (SDH) secondary to a raptured intracranial aneurysm is a rare event. Out of a total of 292 patients with a verified aneurysm (period 1986–1992) in five cases SDH was the diagnosis on CT-evaluation. One patient was in such a bad condition that no treatment was indicated. The remaining four patients were operated on: craniotomy and haematoma evacuation in two cases, craniotomy for haematoma evacuation and aneurysm-clipping in the other two cases. Two patients died and two achieved a good outcome.

HELLP syndrome with haemaglobin vasospasm

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP syndrome) is a life threatening, severe complication of pre-eclampsia with typical laboratory findings. An unusual case of a 36-year-old woman with HELLP syndrome and the initial complication of intracerebral haemorrhage is presented. The diagnosis of HELLP syndrome was confirmed by elevated liver enzymes, low platelets, increased total bilirubin and increased lactate dehydrogenase. The intracranial haematoma was removed with good neurological recovery ensuing. However, this case was complicated by cerebral vasospasm on the eleventh day, confirmed by cerebral angiography and computer tomographic findings. The patient died from brain swelling. Possible vasospam should be considered during the treatment of patients with HELLP syndrome.

Acute bleeding into a filum terminale ependymoma

We present a case of a 63-year-old male patient who was admitted to our hospital due to an acute compression syndrome of the cauda equina. He had complained about a sciatica for at least one year. CT-diagnosis appeared to be negative, whereas a lumbar myelogram revealed a complete block at L2/3. Emergency surgery was performed, and an ependymoma of the filum terminale was removed into which it had bled massively. The case is compared to the literature findings. These relate ependymomas in the described region with acute onset more often to symptoms caused by subarachnoid bleeding. Mechanical and/or histopathological factors are discussed as the cause of acute bleeding. Spinal ependymomas represent a rare event compared to other neurosurgical diseases. Even more seldom are tumors of this kind causing an acute cauda equina compression syndrome.

A multifocal cerebellar and supratentorial medulloblastoma in an adult

Medulloblastoma is one of the most common tumours of the posterior fossa in childhood. It occasionally occurs in young adults, but it is very rare in patients older than 50 years [2]. They usually appear unilocular. Except for the more frequent cases of diffuse dissemination, only two cases of multifocal cerebellar localization of medulloblastoma are described. This is the ®rst observation of a multifocal cerebellar and supratrentorial medulloblastoma in an adult older than 50 years at the moment of diagnosis.

Induced hyperthermia in brain tissue: comparison between contact Nd:YAG laser system and automatically controlled high-frequency current

Concerning hyperthermia treatment, knowledge of time-temperature and of temperature distributions within tumor volumes is essential to obtain a maximal therapeutic effectivity. New techniques are developed to overcome these difficulties. Two different heat sources, the contact Nd:YAG laser system and the automatically controlled highfrequency current are investigated. In a defined volume of 1 cm3, the laser system reaches 45°C after 1.8 s exposition with 15 W output power. The highfrequency current reaches 45°C after 48 s exposition with 18.75 W output current. Both heat sources present an exponential decrease of the temperature profile depending on the distance and prove efficient for inducing anti-tumoral hyperthermia. The tissue heat clearence is compensated for by intermittent laser and highfrequency current application.

Spontaneous recovery of an aqueductal stenosis.

The case of a 17-year-old male with hydrocephalus caused by aqueductal obstruction is presented. A ventriculo-peritoneal shunt was implanted and later removed due to an infection. In the clinical follow-up no deterioration was observed. No further surgery was necessary. The repeat-MRI showed spontaneous resolution of the hydrocephalus with a normal aqueduct.