Harald Barth

Cerebral edema leading to decompressive craniectomy: An assessment of the preceding clinical and neuromonitoring trends

Abstract The aim of this study was to examine the pre-operative clinical and neuromonitoring courses in patients with a decompressive craniectomy to assess and to compare clinical and neuromonitoring signs indicating extensive cerebral edema. We conducted a retrospective analysis of the clinical signs and courses of simultaneous monitoring of intracranial pressure (ICP) and cerebral oxygenation (PtiO2) in 26 consecutive patients who were sedated and treated with a decompressive craniectomy due to extensive cerebral edema after aneurysmal subarachnoid hemorrhage (SAH) (n = 20) or severe head injury (SHI) (n = 6). Pathological monitoring trends always preceded clinical deterioration. In 18 of 26 patients extensive cerebral edema was indicated solely by increasing ICP >20 mmHg or decreasing PtiO2 < 10 mmHg or both. Anisocoria occured in only 8 of 26 patients. As opposed to SHI patients, 9 of 20 SAH patients showed decreasing PtiO2 as first warning sign clearly before neurological deterioration or ICP increase. This series shows the utility of combined ICP and PtiO2 monitoring in patients who develop extensive cerebral edema. Pathological monitoring trends indicate deterioration prior to clinical signs which offers a wider therapeutical window. PtiO2 monitoring appears to be particularly valuable after aneurysmal SAH as adjunct to ICP monitoring and CT imaging.

Spinal cord compression caused by idiopathic intradural arachnoid cysts of the spine: review of the literature and illustrated case

Intradural spinal arachnoid cysts with cord compression are rare. When becoming symptomatic they cause variable symptoms involving gait disturbance, paraparesis or tetraparesis and neuropathic pain, decreasing significantly the patients’ life quality. The extension of such cysts averages 3.7 vertebral bodies. The diagnosis is clinical and radiological with the use of MRI, CT myelography or a combination of both. The best treatment option is complete removal of the cyst. However, even when paresis is regressing there is no good recovery from neuropathic pain. Laminectomy approach can cause postoperative complications especially when the cyst(s) expand(s) in more than one level. Alternatively, a cyst fenestration can be performed, including the levels of the maximal spinal cord compression. The clinical outcome is as good as after the cyst resection enabling the patient to walk again. The neuropathic pain may persist and require medication. A clinical case is presented, and the literature is reviewed. In the present case we report a patient with intradural arachnoid cysts extending from T6 to L2 and causing severe gait ataxia as well as neuropathic pain and hypaesthesia. The spinal-cord was compressed at T8 and T12. Surgical treatment with partial cyst resection in the compressed levels with an interlaminar approach brought similar results as complete resection. The patient was able to walk without help which was not possible before surgery. The cysts’ extension is impressive as well as the minimal operative procedure.

Special features of subarachnoid hemorrhage of unknown origin: a review of a series of 179 cases

Abstract Objectives: The aim of this study was to work out the special features of subarachnoid hemorrhage (SAH) of unknown origin in respect of diagnostic evaluation, clinical course, and outcome in a large cohort of patients. Methods: We reviewed the data of 179 patients with SAH of unknown origin during 1991 and 2008. The differentiation between perimesencephalic (PM-SAH) and non-perimesencephalic SAH (NON-PM-SAH) was done under consideration of the bleeding pattern on CT scanning. Results: Among 1226 treated patients with spontaneous SAH over a time period of 17 years, a bleeding source remained undetected on first digital subtraction angiogram (DSA) in 179 patients (16·7%) — 47 PM-SAH (26·3%) and 132 NON-PM-SAH (73·7%). The clinical signs of patients with PM-SAH were less marked compared to those with NON-PM-SAH, equally to the Hunt and Hess grade. magnetic resonance imaging (MRI) and MR angiography had 100% negative findings for non-aneurismal bleeding sources in all patients. Second DSA revealed a bleeding source in the NON-PM group in 10·8%. The clinical course of the patients with NON-PM-SAH showed a significantly higher rate of complications and a mortality of about 10%. The outcome was excellent in the PM group, in contrast to a fatal course in 13 cases in the NON-PM group. Discussion: PM-SAH imposed with a mild clinical course and an excellent outcome, without severe complications. In contrast to this, NON-PM-SAH has a significant higher rate of dreaded complications and mortality. It is crucial to make an exact diagnosis of PM-SAH, considering CT scanning during the first 24 hours after occurrence of symptoms and the radiological features.

Intracranial and Spinal Melanotic Schwannoma in the Same Patient

Melanotic schwannoma is a nerve sheath tumor composed of melanin — producing cells with ultrastructural features of Schwann cells, which is very rare. These tumors can appear intracranially and less common in the spinal canal. The prognosis is usually good although cases with metastases and death are described in the literature.We present the unusual and rare case of a young man with a spinal melanotic schwannoma at L5/S1 who presented 30 months later with an intracranial melanotic schwannoma.

Intrazerebrale Blutung nach systemischer Thrombolyse bei Patienten mit Verschluß der A. centralis retinae Bericht über 2 Fälle

Die Therapie mit Thrombolytika ist unter strenger Indikationsstellung ein bewährtes Behandlungskonzept. Die häufigste Komplikation ist die Blutung. Dabei gehören intrakraniale Blutungen zu den seltenen, jedoch aus prognostischer Sicht zu den ernsthafteren, vital bedrohlichen Komplikationen. Im Zeitraum von 58 Monaten fanden sich unter 361 Patienten mit einem spontanen intrazerebralen Hämatom 22 Patienten (6,1%), bei denen sich die Blutung nach einer systemischen Thrombolysetherapie entwickelt hatte. Bei 2 Patienten erfolgte diese Therapie beim Verschluß der A. centralis retinae. Ein Patient verstarb, der zweite überlebte mit schweren Behinderungen. Eine Rekanalisation mit Verbesserung des Visus ließ sich bei dem Patienten, der die Blutung überlebte, akut nicht erreichen. Die Risikofaktoren einer systematischen Thrombolysetherapie sind gegenüber dem Spontanverlauf der Erkrankung bei der Indikationsstellung kritisch gegeneinander abzuwägen. Die selektive bzw. superselektive lokale Thrombolyse ist bei gleich strenger Indikationsstellung der systemischen vorzuziehen und mit einer geringeren Komplikationsrate behaftet.Pharmacological thrombolysis is a valuable therapeutic modality for embolic arterial occlusion. Nevertheless, thorough evaluation of the indications is imperative to avoid serious complications. The most frequent complication is hemorrhage. Of these, the intracerebral hemorrhages are rare, but when they do occur they are an immediate threat to life they are accompanied by very severe complications, and they have an extremely poor prognosis. Within 58 months 361 patients were treated at our neurosurgical clinic with intracerebral hematomas. In 22 patients (6.1%) the hematoma developed as a complication of systemic thrombolysis. Two of these patients had been treated for occlusion of the central retinal artery. One patient died: the other survived but was severely disabled. The latter patient experienced no benefit from the thrombolysis as for as the underlying ophthalmologic disease was concerned. These worrying examples stress the necessity for careful evaluation of risk factors and the natural history of the underlying disease for which systemic thrombolysis is indicated. Local selective (or superselective) thrombolysis is preferable to the systemic procedure, provided that the indications are equally strictly observed and are less likely to lead to severe complications.

De novo development of intraosseous cavernous hemangioma

Intraosseous cavernous hemangiomas are rare and not often multifocal. De novo development of a skull cavernous hemangioma has not been described previously. We present a 20-year-old man who was operated upon for a skull cavernoma in the right frontal area and developed a new lesion 3 years later in the right occipital region. The first lesion was removed completely and the postoperative course was uneventful. Histology showed an intraosseous cavernous hemangioma. MRI follow-up revealed a new lesion in the right occipital region. At the time of the first operation this lesion was not seen on CT or MRI scan. Surgical removal was performed and histology again showed a cavernous hemangioma. The patient seems to be unique and it is important to keep young patients with the diagnosis of cavernous hemangioma under close follow-up. This supports the experience from parenchymatous cavernous hemangiomas that this malformation may become a dynamic disease.

Effects of Potassium Channel Openers in Isolated Human Cerebral Arteries

The objective of this study was to compare the relaxant effects of the K+ channel openers pinacidil and lemakalim in isolated human pial arteries with the effects of the dihydropyridines nifedipine and nimodipine and the prostacyclin analog iloprost. Relaxation was measured in vessels contracted by 40 mmol/L K+. In contrast to the potent and consistent relaxant effects of nifedipine, nimodipine, and iloprost, the potency of pinacidil and lemakalim proved to be highly variable and inversely correlated with the onset velocity of the preceding contractions of K+ as well as with the endothelium-dependent relaxation of carbachol. Thus, in contrast to dihydropyridines and iloprost, pinacidil and lemakalim selectively elicited potent relaxations in those arteries that exhibited signs of altered vascular wall functions.

Continuous Measurement of Cerebral Oxygenation with Near-Infrared Spectroscopy after Spontaneous Subarachnoid Hemorrhage

Objective. The aim of our prospective study was to investigate the applicability and the diagnostic value of near-infrared spectroscopy (NIRS) in SAH patients using the cerebral oximeter INVOS 5100C. Methods. Measurement of cerebral oximetry was done continuously after spontaneous SAH. Decrease of regional oxygen saturation (rSO2) was analyzed and interpreted in view of the determined intrinsic and extrinsic factors. Changes of rSO2 values were matched with the values of ICP, tipO2, and TCD and the results of additional neuroimaging. Results. Continuous measurement of rSO2 was performed in nine patients with SAH (7 females and 2 males). Mean measurement time was 8.6 days (range 2–12 days). The clinical course was uneventful in 7 patients without occurrence of CVS. In these patients, NIRS measured constant and stable rSO2 values without relevant alterations. Special findings are demonstrated in 3 cases. Conclusion. Measurement of rSO2 with NIRS is a safe, easy to use, noninvasive additional measurement tool for cerebral oxygenation, which is used routinely during vascular and cardiac surgical procedures. NIRS is applicable over a long time period after SAH, especially in alert patients without invasive probes. Our observations were promising, whereby larger studies are needed to answer the open questions.

Risk of recurrent intracerebral hemorrhages

Abstract Intracerebral hemorrhage (ICH) occurs in about 10%-15% of all strokes, and hypertension and cerebral amyloid angiopathy (CAA) are the main underlying causes. There is often controversy regarding surgical evacuation especially in elderly patients. Follow-up of these patients and regulation of hypertension is important to prevent re-bleeding. The number of recurrent hematomas will increase with time of follow-up. We reviewed 968 patients with an ICH treated in our Department and 48 patients with recurrent hemorrhages (4.9%). The mean interval between the first and the second hemorrhage was three years (one month to 10 years). Clinical outcome after a second hemorrhage was severe and only 50% of patients were operated on the second hemorrhage compared to 77% (37/48) of patients who were operated on the first hemorrhage.

Continuous intra-arterial infusion of nimodipine at the onset of resistant vasospasm in aneurysmal subarachnoidal haemorrhage. Technical report

Abstract Cerebral vasospasm complicating the aneurysmal subarachnoid haemorrhage is a well known medical entity. The delayed ischemic neurological deficits (DINDs) as a result of vasospasm, remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options either medical or interventional, fail to reverse the vasospasm, continuous intra-arterial infusion of nimodipine through catheters direct in the spastic arteries, presents a promising treatment modality. We treated in our clinic four patients with severe aneurysmal subarachnoid haemorrhage and refractory vasospasms with continuous nimodipine infusion via catheters in both internal carotid arteries and discussed the efficacy of the method presenting an illustrative case and discussing the effect based on doppler examinations.