Matthias Holzschuh

S-100 serum levels after minor and major head injury.

BACKGROUND S-100, a protein of astroglial cells, is described as a marker for central nervous system damage. The aim of this study was to evaluate whether the marker could give information about the severity and possibility of functional recovery after minor and severe head injury. METHODS Thirty patients after severe head injury (Glasgow Coma Scale score < 9) and 11 patients after minor head injury (Glasgow Coma Scale score > 12) were included. In each case, blood samples were drawn within 6 hours after injury. Outcome was estimated at hospital discharge using the Glasgow Outcome Scale. RESULTS All patients who sustained minor head injury had reached a favorable outcome by the time they were discharged from the hospital. Their mean S-100 serum level was 0.35 microg/L. Patients who sustained severe head injury and were classified as having an unfavorable outcome (31%) showed a mean serum concentration of 4.9 microg/L, whereas patients classified as having a favorable outcome (69%) had a mean S-100 level of 1.2 microg/L. All groups differed significantly (p < 0.05). CONCLUSION S-100 appears to be a promising marker for the severity of head injury and neuronal damage.

Monitoring of Cerebral Oxygen Metabolism in the Jugular Bulb: Reliability of Unilateral Measurements in Severe Head Injury

To investigate the reliability of unilateral jugular venous monitoring and to determine the appropriate side, we performed bilateral jugular venous monitoring in 22 head-injured patients. Fiberoptic catheters were placed in both jugular bulbs. Arterial and bilateral jugular venous blood samples were obtained simultaneously for in vitro determination of jugular venous oxygen saturation (SJO2), arterial minus jugular venous lactate content difference (AJDL), and modified lactate-oxygen index (mLOI). Ischemia was assumed if one of the following pathologic values occurred at least unilaterally: SJO2 <54%, AJDL <−0.37 mmol/L, mLOI >0.08. The sensitivity of calculated unilateral monitoring in detecting ischemia was evaluated by comparing the incidence detected unilaterally with that disclosed bilaterally. The mean and maximum bilateral SJO2 differences varied between 1.4% and 21.0%, and 8.1% and 44.3%, respectively. The bias and limits of agreement (mean differences ± 2 SD) between paired samples were 0.4% ± 12.8%. There was no significant variation in bilateral SJO2 differences with time. Decreasing cerebral perfusion pressure (r = −0.559, P < 0.001) and arterial Pco2 (r = −0.342, P < 0.001) were associated with increasing bilateral SJO2 differences. Regarding AJDL, the maximum bilateral differences varied between 0.04 mmol/L and 1.52 mmol/L. The bias and limits of agreement were −0.01 ± 0.18 mmol/L. At best, 87% of ischemic events were disclosed by monitoring on the side of predominant lesion or, in diffuse injuries, on the side of the larger jugular foramen (computed tomographic [CT] approach). We conclude that in severe head injury, even calculated unilateral jugular venous monitoring has an unpredictable risk for misleading or missing data. Therefore, the reliability of unilateral jugular venous monitoring appears suspicious. For diagnosing ischemia the CT approach is recommended.

Dynamic changes of cerebral oxygenation measured by brain tissue oxygen pressure and near infrared spectroscopy.

The aim of this study was to find out whether a correlation exists between changes in brain tissue oxygen pressure (ti-pO2) and hemoglobin oxygenation (HbO2) measured by near-infrared spectroscopy. We studied 10 patients with severe head injury. A ti-pO2 monitoring device was introduced in the frontal white matter as soon as possible after administration. Additionally a NIRS sensor was placed at the forehead. All data were recorded simultaneously. Changes of the ti-pO2 curve were defined as events with the following criteria: > 10% change from the baseline value, > 3 min duration, clearly not an artifact. 137 events were found with a mean change of ti-pO2 of 8.3 +/- 10.2 mmHg. In 77.4% we observed a corresponding change of the HbO2. In 7 patients we found a good correlation (r > 0.7) between change ti-pO2 and change HbO2. In 3 patients the correlation was poor. The reason for poor correlation might be poor signal quality of the NIRS sensor or inhomogenous distribution of ischemic areas in the whole brain. We conclude that under the condition of a stable NIRS signal and a diffuse brain lesion, changes of ti-pO2 are well reflected by NIRS.

Is there a clinical correlate to the histologic evidence of inflammation in herniated lumbar disc tissue

Study Design. The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histologic results were compared with prospectively obtained clinical data. Objectives. To assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. Summary of Background Data. It is postulated that in addition to nerve root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. However, the clinical relevance of the histologically described inflammatory infiltrates is not defined clearly. Methods. Disc specimens from 44 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Before surgery, severity of pain was classified in each patient according to a visual analog scale, and general clinical data were recorded prospectively. Results. Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical analysis, no statistically significant correlation between the histologic evidence of macrophage infiltrates and the pain grading scale or the clinical data was noted. Conclusions. There is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimens and the obtained clinical data.

Does the choice of outcome scale influence prognostic factors for lumbar disc surgery?: A prospective, consecutive study of 121 patients

From January to June 1994, we operated conventionally on 121 consecutive herniated lumbar disc patients as part of a prospective study. We analysed general data, case histories, neurological findings on admission and all data from imaging investigations and therapy. In addition, all patients received a questionnaire based on the Low Back Outcome Score. Most of the patients (93%) were followed-up for 1 year postoperatively in the same manner. On the Prolo Scale, we obtained a good result in 70%; 76% had a good Low Back Outcome Score. Predictive factors are different for different outcome scales. The preoperative duration of pain, the preoperative duration of paresis and smoking seem to be general predictive factors.

Macrophage tissue infiltration, clinical symptoms, and signs in patients with lumbar disc herniation. A clinicopathological study on 179 patients.

Summary It is postulated that in addition to nerve-root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. The clinical relevance of the histologically described inflammatory infiltrates is, however, not clearly defined [8, 22]. It was the aim of this study to assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histological results were compared to prospectively obtained clinical data. Disc specimens of 179 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Pre-operatively each patient received a visual analogue scale for classification of the pain level and general clinical data were recorded prospectively. Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical workup no statistically significant correlation between the histological evidence of macrophage infiltrates and the pain grading scale or the clinical data could be found. In our study there is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimen and the obtained clinical data.

Rapid evaluation of S-100 serum levels. Case report and comparison to previous results

The aim of this case report is to describe the time course of S-100 serum levels of a patient, after severe head injury, whose blood sample could be drawn very soon after injury. The results were compared to a group of patients in which a correlation between S-100 serum levels and outcome after traumatic brain injury could be demonstrated. Blood samples were taken on admission (mean 2.3 hours), 6, 12 and 24 hours after trauma and then every 24 hours up until and including the fifth day. The outcome was estimated on discharge using the Glasgow Outcome Scale. The S-100 serum level of the patient described in the case report with a favourable outcome had initially risen to 10.0 micrograms/l and showed a rapid decline. In the previous group, patients with unfavourable outcome had a S-100 serum level of 7 micrograms/l mean concerning the first probe (after 2.3 hours mean) compared to 1.5 micrograms/l mean (after 2.23 hours mean) in patients with favourable outcome (p < 0.05). In comparison to the literature, there seems to be differences regarding the enzyme liberation in stroke and head injury. Therefore, S-100 serum levels need to be interpreted with regard to collection time and underlying pathology.

Comparison of changes in cerebral blood flow and cerebral oxygen saturation measured by near infrared spectroscopy (NIRS) after acetazolamide.

SummaryThe present study compares the change of cerebral blood flow and HbO2 measured by near-infrared spectroscopy (NIRS) after administration of 1000 mg acetazolamide intravenously. CBF studies in 21 patients with ischaemic cerebrovascular disease were performed routinely with the133Xenon technique. Additionally the local HbO2 was recorded by NIRS. A rest study was followed by a second study after the administration of 1000 mg acetazolamide. In 18 patients we observed an increase of 30.8% of CBF and 4.7% of HbO2, 3 patients showed a decrease of CBF and 2 patients a simultaneous decrease of HbO2. We did not find a correlation between the absolute values of CBF and HbO2 at rest or after stimulation. However, a positive correlation (r=0.71, p < 0.05) between the change of CBF and HbO2 could be detected. Assuming a threshold value of normal CBF reactivity of 30% and 4% HbO2 reactivity we found for NIRS a sensitivity of 0.88 and a specificity of 0.75.The results demonstrate that changes of CBF can be detected with NIRS and the algorithm of the used monitor is able to calculate the intracranial part of the signal. So, NIRS can be used as non-invasive screening method to test the cerebrovascular reserve capacity.

Cerebral blood flow and cerebrovascular reserve 5 years after EC-IC bypass

CBF-studies using the Xenon-133-inhalation technique were performed in 18 patients with a unilateral carotid artery occlusion, 5.4 years after a STA-MCA procedure. For comparison we used the CBF data of 29 patients with the same diseases who had had conservative treatment for a variable period of time. CBF was measured during rest and after the intravenous administration of 1 g acetazolamide. During rest we found a significant interhemispheric difference in both groups. After activation with acetazolamide this difference disappeared in the bypass group, but not in the conservatively treated patients. Our data show that the bypass procedure obviously affects the vascular reserve capacity in a positive way over a long period of time. One criteria for success of STA-MCA procedures might be the cerebral reserve capacity tested with CBF-studies under activation.

Clinical evaluation of the InnerSpace fibreoptic intracranial pressure monitoring device

OBJECTIVE The aim of this study is the clinical evaluation of the intraparenchymal ICP monitor InnerSpace OPX 100. METHODS Sixty-four Inner Space OPX 100 transducers in 51 patients with severe head injury (42), intracranial spontaneous bleeding (6) or hypoxia (3) were studied. The transducer was placed in the frontal white matter. Thirty-nine patients received one catheter, eleven patients two catheters and one patient three catheters. The study period ranged from 10 hours-25 days; total study time was 421.5 days (mean duration 6.6 days). RESULTS In nine cases (14.1%) an inadequate location of the ICP transducer was found, but the accuracy of the measurement was not influenced. Dislocation of the transducer occurred in eight cases (12.5%) due to inadequate handling. A failed transducer was observed in four cases (6.3%) because of a damaged optical fibre (1) or inadequate handling (3). In one patient (1.9%) a minor local infection developed. In eleven cases (17%) a haematoma around the ICP sensor was observed. Six haematomas were small; five haematomas were larger than 1 cm in diameter. In two patients a large frontal haematoma developed after exchange of the transducer. Operative evacuation was necessary in both cases. Zero shift was below 2 mmHg in all catheters. CONCLUSION It is concluded that the InnerSpace intraparenchymal ICP monitor is a reliable device: the rate of catheter related intracerebral haematomas, however, is not acceptable. This could be improved by a better fixation of the catheter in the burr hole in order to avoid micromovements of the transducer.