Karel Máca

The influence of mild hypothermia on ICP, CPP and outcome in patients with primary and secondary brain injury

Aim of this study was to examine the hypothesis that only a subgroup of patients with lesser primary brain damage after severe head injury may benefit from therapeutic hypothermia. We prospectively analysed 72 patients with severe head injury, randomized into groups with (n = 37) and without (n = 35) hypothermia of 34 degrees C maintained for 72 hours. The influence of hypothermia on ICP, CPP and neurological outcome was analysed in the context of the extent of primary brain damage. Patients with normothermia and primary lesions (n = 17) values: GCS on admission 5 (median), ICP 18.9 (mean), CPP 73 (mean), GOS 4 (median). Patients with normothermia and extracerebral hematomas (n = 20): GCS 4, ICP 16, CPP 71, GOS 3. Patients with hypothermia and primary lesions (n = 21): GCS 4,62, ICP 10, 81, CPP 78,1, GOS 4. Patients with hypothermia and extracerebral hematomas (n = 14): GCS 5, ICP 13.2, CPP 78, GOS 5. Hypothermia decreased ICP and increased CPP regardless of the type of brain injury. Hypothermia was not able to improve outcome in patients with primary brain lesions but this pilot study suggests that it significantly improves outcome in patients with extracerebral hematomas.

Prevalence of Propionibacterium acnes in Intervertebral Discs of Patients Undergoing Lumbar Microdiscectomy: A Prospective Cross-Sectional Study

Background The relationship between intervertebral disc degeneration and chronic infection by Propionibacterium acnes is controversial with contradictory evidence available in the literature. Previous studies investigating these relationships were under-powered and fraught with methodical differences; moreover, they have not taken into consideration P. acnes’ ability to form biofilms or attempted to quantitate the bioburden with regard to determining bacterial counts/genome equivalents as criteria to differentiate true infection from contamination. The aim of this prospective cross-sectional study was to determine the prevalence of P. acnes in patients undergoing lumbar disc microdiscectomy. Methods and Findings The sample consisted of 290 adult patients undergoing lumbar microdiscectomy for symptomatic lumbar disc herniation. An intraoperative biopsy and pre-operative clinical data were taken in all cases. One biopsy fragment was homogenized and used for quantitative anaerobic culture and a second was frozen and used for real-time PCR-based quantification of P. acnes genomes. P. acnes was identified in 115 cases (40%), coagulase-negative staphylococci in 31 cases (11%) and alpha-hemolytic streptococci in 8 cases (3%). P. acnes counts ranged from 100 to 9000 CFU/ml with a median of 400 CFU/ml. The prevalence of intervertebral discs with abundant P. acnes (≥ 1x103 CFU/ml) was 11% (39 cases). There was significant correlation between the bacterial counts obtained by culture and the number of P. acnes genomes detected by real-time PCR (r = 0.4363, p<0.0001). Conclusions In a large series of patients, the prevalence of discs with abundant P. acnes was 11%. We believe, disc tissue homogenization releases P. acnes from the biofilm so that they can then potentially be cultured, reducing the rate of false-negative cultures. Further, quantification study revealing significant bioburden based on both culture and real-time PCR minimize the likelihood that observed findings are due to contamination and supports the hypothesis P. acnes acts as a pathogen in these cases of degenerative disc disease.

Cerebral Perfusion Pressure and Spect in Patients after Craniocerebral Injury with Transtentorial Herniation

We present a group of 29 consecutive head injured comatose patients with the syndrome of transtentorial herniation. All patients had urgent surgery and then continuous monitoring of ICP, CPP, blood pressure and jugular bulb oximetry was instituted. Two postoperative CT and SPECT examinations were performed in each patient. 15 patients had a normal CPP (> 70 mmHg) throughout the postoperative period, 80% of them had a favourable outcome. On the other hand 14 patients had decreased CPP lasting at least one hour and only 36% of them had a favourable outcome (p < 0.05). Similar relationships were found comparing GOS in patients with normal and increased ICP (> 20 mmHg) and normal and decreased SjO2 (< 55%). All but 3 patients had ischaemia on SPECT. Ischaemia improved on the 2nd SPECT in 11 patients and 10 (91%) of them had a favourable outcome. GOS (mean follow up 9 months) is: 12 patients good, 5 moderately disabled, 2 vegetative, 10 died. We conclude that SPECT is able to disclose even reversible ischaemic changes. In these patients all effort has to be made to keep CPP on normal levels. Improvement in cerebral perfusion is related to a better outcome.

Endoscopic Pituitary Surgery—Our Experience

The endoscopic approach to the sellar region is easy, safe, time-saving, and without septal or sublabial complications.

The use of mild hypothermia in the prevention of the secondarybrain injury.

According to our hypothesis, only a subgroup of patients with a lesser extent of primary brain damage after severe head injury (particularly those with extracerebral hematomas) may benefit from therapeutic hypothermia. We have prospectively analyzed 72 patients with severe head injury who were randomized into a group with (n = 37) and without (n = 35) 34°C hypothermia maintained for 72h. The influence of hypothermia on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and neurological outcome was analyzed in the context of the extent of the primary brain damage. Mean values recorded in the patients were as follows. Patients with normothermia and primary lesions (n = 17): Glasgow Coma Scale (GCS) on admission 4.59, ICP 18.88, CPP 73.71, Glasgow Outcome Scale (GOS) 3.47. Patients with normothermia and extracerebral hematomas (n = 20): GCS 4.0, ICP 16.6, CPP 70.85, GOS 2.9. Patients with hypothermia and primary lesions (n = 21): GCS 4.62, ICP 10.81, CPP 78.1, GOS 3.71. Patients with hypothermia and extracerebral hematomas (n = 14): GCS 4.5, ICP 13.21, CPP 78.43, GOS 4.64. Hypothermia was able to decrease ICP and increase CPP in both groups of patients regardless of the type of brain injury. Hypothermia was not able to improve outcome in patients with primary brain lesions; however, it was able to significantly improve outcome in patients with extracerebral hematomas who were threatened mostly by secondary ischemic brain damage.