Henry Troupp

Prognosis for Patients with Severe Brain Injuries

Intraventricular pressure recording has been a standard procedure in the neurosurgical clinic, University Central Hospital, Helsinki, Finland, since 1964. Up to 31 December 1970, 250 recordings had been performed, 90 of these on brain-injured patients. Intraventricular pressure correlates well with survival or death of the patient but will not predict the quality of survival. However, other criteria seem to correlate well with the quality of survival. The results of a prospective study of 50 patients between 1 January 1967 and 31 December 1969 are reported. Clues to vegetative survival are very low arterial Pco2 after a free airway has been established, a high respiratory minute volume, temperature above 39°C, Cheyne-Stokes breathing, and extension rigidity in adults. When a reliable prognosis can be established that the patient is going to survive only as a vegetative wreck it is highly doubtful if the whole might of modern intensive therapy should be applied.

Arteriovenous malformations of the brain: Prognosis without operation

SummaryA series of 137 unoperated patients with arteriovenous malformation of the brain is reported upon. Median time between onset of symptoms and end of follow-up period was 8 years; median length of follow-up period from date of diagnosis was 4 years and 7 months. Frontal, temporal and occipital malformations seemed to have a better prognosis than parietal, central or infratentorial ones: one out of 52 patients in the former group and 13 out of 85 in the latter died from a haemorrhage caused by the malformation. It is pointed out that there are no reports anywhere on large, unselected series of conservatively treated patients with arteriovenous malformation of the brain, and that criteria for operation are too subjective at present with unjustified assumptions that the natural prognosis is gloomy.

Brain creatine kinase in blood after acute brain injury.

Severe cold injury of the brain increased significantly both total creatine kinase and the corresponding brain isoenzyme (CKBB) activity in confluens sinuum samples. CKBB could be detected also in peripheral blood a few hours after severe brain injury in eight of 12 patients. Finding of CKBB in human plasma may prove a useful indicator of severe brain injury.

Hormone treatment of meningiomas: lack of response to medroxyprogesterone acetate (MPA): a pilot study of five cases

SummaryMedroxyprogesterone acetate (MPA) has been used in high doses as hormone treatment for metastatic breast cancer. We treated five intracranial meningiomas with MPA expecting that MPA would reduce the volume or decrease the growth rate. All five patients were postmenopausal women, aged 47 to 73 years. Before treatment, the growth rate of each tumour was assessed by two consecutive CT scans (CT 1 and CT 2). Tumours 1 to 4, histologically benign meningiomas, grew slowly as the tumour volumes were not found to increase in 21 to 45 months between CT 1 and CT 2. Tumour 5 was an anaplastic meningioma the rapid growth of which was evident in 8 weeks between CT 1 and CT 2. After CT 2, MPA was given 1,000 mg intramusculary once weekly for 17 to 29 weeks until CT 3 which showed the response. Tumours 1 to 4 had neither reduced in volume nor developed necroses, and tumour 5 continued its fast growth at the same rate as before.

Subarachnoid haemorrhage: long-term follow-up results of late surgical versus conservative treatment.

During 1964-9, 178 patients with subarachnoid haemorrhage from a single intracranial arterial aneurysm were allocated at random to receive operative or conservative treatment at an average of seven weeks after bleeding. During the follow-up fatal rebleeding episodes occurred in six of the 86 patients treated surgically and 16 of the 92 treated conservatively. This difference was significant. Fatal rebleeding occurred on average 40 months after the first episode. Deaths from all causes occurred in 17 of the 86 patients treated surgically and 22 of the 92 treated conservatively. Life-table analysis of the chances of surviving 1, 5, and 11 years gave probabilities of 95 and 91%, 87 and 86%, and 76 and 75% in the two treatment groups respectively. Of the 139 patients alive after a mean follow-up of nine years, 130 (94%) were fully independent in their daily lives, and only 43 (31%) were unable to work. The method of treatment did not affect the quality of survival. The results show that fatal rebleeding may occur even many years after the first episode. Nevertheless, if the patient is in good condition seven weeks after a haemorrhage from a single intracranial arterial aneurysm the outcome is good irrespective of whether operation is performed at this late stage.

Intraventricular pressure after administration of dehydrating agents to severely brain-injured patients: is there a rebound phenomenon?

SummaryIn the years 1964 to 1970, 95 brain-injured patients had intraventricular recordings in the Neurosurgical Clinic of the Helsinki University Central Hospital. Their files and records were perused to see if there was any evidence of rebound after the administration of dehydrating agents-mannitol, urea or glycerol. In 10 recordings with a starting pressure of 16–30 mmHg and in 14 recordings with a starting pressure of 31–60 mmHg no evidence of rebound was found (Fig. 2). For the results in recordings with starting pressures under 16 mmHg or above 60 mmHg see Fig. 1 and Fig. 3. It is concluded that though rebound-i.e. the pressure rising higher than the original pressure when the effect of the dehydrating agent has worn off-has been shown to exist in healthy dogs and in patients with a normal intracranial pressure (Einspruch and Clark; McQueen and Jeanes; Nash, Orth, and Smolik), the present study makes it highly doubtful whether the phenomenon exists at all in severely injured human beings. It is concluded that fear of rebound need not deter one from using dehydrating agents for short-term purposes.

ARTERIOVENOUS MALFORMATIONS OF THE BRAIN: Prognosis without operation

Our knowledge of the natural history of artcriovcnous malformations of the brain is very scanty; there are only a few reports that touch upon this question (af Bjorkesten & Troupp 1959, Paterson & Mch‘issock 1956, Pool 1862, Potter 1955, Svien, Olive & Angulo-River

Intraventricular pressure in the final stages of a severe brain injury.

SummaryBetween 1964 and 1970, inclusive, 250 intraventricular pressure recordings were performed in the Neurosurgical Clinic of the Helsinki University Central Hospital. 95 of these patients had severe brain injuries. Of these, 17 patients died while the recording was in progress, and these patients form the series analysed here. In five instances the intraventricular pressure fluctuated considerably, and no pattern could be established. In the remaining 12, before respiratory arrest, there was a rise in pressure, usually above 100 mmHg, after which the pressure would drop 5–90 minutes later; respiratory arrest sometimes occurred at about the same time as the sudden rise in pressure, sometimes more than an hour later.It is suggested that this rise and subsequent drop to a level only 10–20 mmHg lower than the blood pressure indicates the death of the supratentorial part of the brain; this, of course, means that any subsequent therapeutic efforts are exclusively for medico-legal or for transplantation purposes.From experience with two patients, it is suggested that death of the brain is accompanied by a sharp drop in pHcsf.

Reliability of partial ligation in the treatment of intracranial arterial aneurysm.

There are at present two schools of thought concerning the treatment of intracranial aneurysms: one favours carotid ligation in the neck, the other a direct intracranial attack. In Scandinavia, the latter method is the one generally used, and it can be adapted in several ways: by closure of the neck of the aneurysm with thread ligation or metal clip, by trapping, by proximal clipping of the artery carrying the aneurysm ( L o g u ~ , 1956), or by wrapping of the aneurysm with muscle, acryl ( D u t f o n , 1959), or other materials. Theoretically, occlusion of the neck of the aneurysm seems to be the best method, and can be expected to give complete protection from recurrent haemorrhagc (Norl tn & Oliuecrona, 1953). It is also reasonable to expect a fair degree of safety from partial ligation, sincc it has been shown that most of the ruptures occur at the fundus or the sides of the aneurysmal sac (Crawford, 1959). A s evcry neurological surgeon knows, it is not always technically feasible to treat an aneurysm radically; and knowledge of the expediency and safety of the partial ligation of such aneurysms is important. Accordingly, we decided to compare the course of two groups of patients: those who had complete occlusion of the aneurysm as shown by control angiography, and those in whom part of the aneurysm was still filling.

A retrospective study on the effects of low and high doses of betamethasone on severe closed head injury

SummaryA retrospective analysis of 113 patients with severe head injuries (unconscious for six hours or more) showed no difference in the outcome for 59 patients treated with low doses of betamethasone compared to the outcome for 54 patients treated with high doses of betamethasone. There was no difference in the number of useful recoveries (low dose, 21/59; high dose, 20/54) and the mortality rates were about the same (low dose, 29/59; high dose, 31/54). There were three deaths from infectious complications in the patients treated with high doses of betamethasone.