Katsumi Isobe

Outcome prediction in severe head injury: analyses of clinical prognostic factors

Retrospective analysis of 272 patients with severe head injury was performed. Patient age, Glasgow Coma Scale (GCS) score, pupillary abnormalities, impaired oculocephalic response, presence of subarachnoid haemorrhage, and multiplicity of parenchymal lesions on computerised tomography (CT) were examined. The CT findings were divided into 2 groups, diffuse brain injury (DBI) and mass lesion, according to the classification of the Traumatic Coma Data Bank. The DBI, basically, has no high or mixed density lesion more than 25 ml on CT, and was classified into 4 subgroups: DBI I includes injuries where there is no visible pathology; DBI II includes all injuries in which the cisterns are present with a midline shift of less than 5 mm; DBI III includes injuries with swelling where the cisterns are compressed or absent and the midline shift is less than 5 mm; DBI IV includes injuries with a midline shift of more than 5 mm. The mass lesions were categorised into 3 subgroups: epidural haematoma; acute subdural haematoma; and intracerebral haematoma. Outcomes were determined at 6 months following trauma using the Glasgow Outcome Scale. All DBI I patients recovered well. In the DBI II group, age, GCS score and detection of multiple parenchymal lesions on CT were significantly correlated with outcome. For the DBI III and IV groups, the only significant prognostic factor was the GCS score. In patients with a mass lesion, the GCS score was the only significant prognostic factor in the epidural haematoma group, but the GCS score and the presence of subarachnoid haemorrhage were predictive factors in the acute subdural haematoma group. Outcomes were unfavourable in the majority of patients with intracerebral haematoma. GCS score could predict outcome in all groups. The confidence of the outcome prediction ranged from 75.8 to 92.1%, depending on logistic regression analysis.

Dissecting aneurysms of the posterior inferior cerebellar artery.

The authors present three cases of dissecting aneurysms of the posterior inferior cerebellar artery (PICA). A literature search revealed only three previous cases. Analysis of these six cases showed a unique clinical picture. Three patients developed subarachnoid hemorrhage, and the other three had ischemia. All patients complained of occipital headache or neck pain, regardless of the initial symptoms. Heralding episodes were recorded in four cases. Angiography showed a characteristic fusiform dilatation of the PICA and a narrowing proximal to and distal to the lesion. Various surgical treatments were performed in five cases. Intraoperative observation showed a sausage-like swelling of the PICA or one of its branches with various discoloration depending on the age of the intramural clot. The outcomes were favorable.

Effects of Intravascular Volume Expansion on Cerebral Blood Flow in Patients with Ruptured Cerebral Aneurysms

To clarify the effect of intravascular volume expansion on cerebral blood flow (CBF) in patients after subarachnoid hemorrhage (SAH), we performed 55 pairs of regional CBF measurements using the xenon-133 inhalation method before and after volume expansion in 35 patients with ruptured cerebral aneurysms. CBF was calculated as the hemispheric mean value of the initial slope index. To accomplish volume expansion, we transfused 500 ml of 5% human serum albumin in half an hour. After volume expansion with albumin, the hemoglobin value decreased significantly (P less than 0.005). Volume expansion did not change the mean arterial blood pressure. During the first 2 weeks after SAH, CBF decreased significantly after volume expansion (P less than 0.005). During the 3rd week after SAH and subsequently to the 4th week after SAH, volume expansion produced no change in CBF. In patients with symptomatic vasospasm, CBF decreased significantly after volume expansion (P less than 0.005). In patients without symptomatic vasospasm, volume expansion produced no change in CBF. The results of this study suggest that increasing the intravascular volume above normal by volume expansion does not increase CBF or reverse symptomatic vasospasm.

Vasospasm and regional cerebral blood flow (rCBF) in patients with ruptured intracranial aneurysm: serial rCBF studies with the xenon-133 inhalation method

To clarify the relationship of vasospasm to the reduction of cerebral blood flow (CBF) and the delayed ischemic neurological deficit, serial rCBF studies with the use of the xenon-133 inhalation method were conducted in 35 postoperative patients with ruptured intracranial aneurysms. The CBF was calculated as an initial slope index (ISI) derived from the desaturation curve of each head probe, and the hemispheric mean value of the ISI (mean ISI) was calculated in both hemispheres. The mean ISI in the hemisphere ipsilateral to the operation was low compared to that of the contralateral hemisphere. In relation to the presence of vasospasm, angiographic findings were classified into the following five types: diffuse, peripheral, proximal-severe, proximal-mild, and no spasm. Patients with vasospasm of the diffuse, peripheral, and proximal-severe types showed a markedly decreased mean ISI, and vasospasm of the diffuse type caused the greatest degree of reduction. The mean ISI of the patients who developed delayed ischemic neurological deficit (DIND) due to vasospasm was significantly decreased (37.4 +/- 4.6) compared to that of the patients who did not develop DIND (52.2 +/- 5.6). None of 3 cases of no spasm and only 1 of 14 cases of proximal-mild spasm developed DIND. On the other hand, all of 4 cases of diffuse, 2 of 3 cases of peripheral, and 2 of 6 cases of proximal-severe spasm developed DIND. Thus, if these three types of vasospasm are joined together as severe vasospasm, 8 of 13 cases with severe vasospasm developed DIND. These results suggest that severe vasospasm causes a reduction of CBF and that the reduced CBF brings about DIND.

Non-invasive Follow-up Studies of Stroke Patients with STA-MCA Anastomosis; Computerized Topography of EEG and 133-Xenon Inhalation rCBF Measurement

Publisher Summary This chapter explains that the efficiency of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis can be studied by adopting two objective and noninvasive methods for assessment; one is the computerized topography electroencephalogram (CT-EEG), and the other is the regional cerebral blood flow (rCBF) study with the 133-xenon inhalation method. This study includes 32 patients who underwent STA-MCA anastomosis for their cerebral ischemic processes (24 males and eight females, mean age 53 years, range 23–71 years). The patency of the anastomosis is confirmed by postoperative angiography in all patients. Pre- and postoperative EEG recordings are made in all cases and each of these recordings is analyzed with CT-EEG. The results of these CT-EEG studies are compared with the results of clinical evaluation and of the serial rCBF studies with the133-xenon inhalation method. In preoperative CT-EEGs, 11 out of 32 patients are clearly visualized high voltage foci in slow wave bands (delta and/or theta) in the symptomatic hemisphere, which is defined as “high voltage slow focus” (HVSF). The serial CT-EEG studies revealed that all of the preoperative HVSFs remained unchanged even after bypass surgery.

Prognostic Value of Continuous ICP Monitoring, Computerized EEG Topography, and Regional CBF in Communicating Hydrocephalus

Various investigations have been proposed for determining the true diagnosis and outcome of “so-called” normal pressure hydrocephalus (NPH), but most of them were investigations concerning the extracerebral environment, mainly CSF dynamics. We have proposed new methods to find out the true indications for a shunt operation in NPH. This method was designed to give information on the reversibility of disturbed cerebral function due to hydrocephalus. The reliability of such conventional methods and our new technique were compared in this report.

Analysis of 260 Cases of Severe Head Injury — Did an Aggressive Treatment Improve the Functional Outcome?

Two-hundred and sixty consecutive patients of severe head injury (GCS ≦ 8) were retrospectively analyzed in regards to the efficacy of the aggressive treatment (AT). Those were divided into two groups: group A; 131 patients treated without AT and group B; 129 treated with AT. The patient transfer time was significantly shorter in group B (p<0. 001), but the outcome at 6 months after injury did not differ in two groups. The mortality rate in the patients under 20 years of age was significantly lower in group B (p<0. 05). In addition, the earlier transfer and the younger age were related to better outcome in the patients, who talked prior to deterioration.

Analysis of 150 Cases with Chronic Subdural Hematoma in Adult on the Factors Related to Functional Outcome

One hundred and fifty cases with chronic subdural hematoma (CSDH) in adult were retrospectively analyzed in order to elucidate the factors responsible for long-term functional outcome. The mean age was 63 years. All the patients underwent burr hole and irrigation surgery with external drainage of a short duration. The follow-up periods ranged from 6 months to 7 years. The outcome was evaluated by Karnofsky scale. Seven cases (4.6%) had recurrence of CSDH and 11 (7.3%) had intracranial complications, such as epidural hematoma (3.3%) and intracerebral hematoma (1.3%). Four cases (2.7%) had systemic complications. These complications were significantly responsible for poor outcome. In addition, brain atrophy, which was defined as ventricular dilatation and/or subdural effusion on the follow-up CT, was the other factor responsible for poor outcome in the patients of CSDH without complications. Therefore, the poor outcome may be related to brain atrophy and potential cerebral ischemia in those patients.

Megadolichobasilar anomaly associated with subarachnoid hemorrhage. A case report.

脳底動脈における病的拡張・蛇行はmegadolichobasilar anomaly (MBA) と総称されている.MBAは, 椎骨脳底動脈系の脳虚血症状, あるいは隣接する脳神経や脳幹部の圧迫症状により発症することが多いが, クモ膜下出血 (SAH) を起こすことは稀とされている.われわれは, MBAの破綻によりSAHを起こし, 水頭症に対する脳室ドレナージや脳室腹腔シャントなどの治療にもかかわらず, 繰り返すSAHによって死亡したMBAの1例を経験したので, 若干の検討を加えて報告する.破綻したMBAに対する直達手術は, 手技的に困難なことから, 1例の報告もないが, 椎骨動脈のproximal ligationと頭蓋内外物吻合術の組み合わせは, MBAの血流動態を変化をさせることにより, MBAの破綻によるSAHの再発を予防することが可能と考えられた.

Isolated fourth ventricle. Report of an adult case with an unusual clinical course

Reported here is an adult case of isolated fourth ventricle with an unusual clinical course. A 62-year-old female had undergone lateral ventriculo-peritoneal (V-P) shunting for communicating hydrocephalus which was related to aneurysmal subarachnoid hemorrhage (SAH). Serial computed tomography (CT) scan demonstrated small lateral ventricles, but the fourth ventricle was not enlarged yet. Approximately three months later, she had undergone the craniotomy for acute traumatic subdural hematoma (ATSDH). Following the surgery, the symptoms of posterior fossa mass lesion, such as nystagmus, swallowing disturbance, had developed with gradual onset. CT scan revealed disproportionate enlargement of the fourth ventricle, which was treated by fourth V-P shunting. Ultimately, this patient recovered well and returned to normal life.