R. A. Frowein

Cerebellar haemorrhage: management and prognosis.

Of 26 patients with CT confirmed intracerebellar haematoma, 17 had ventricular drainage performed and 7 patients had the haematoma evacuated.Eleven patients died. Mortality was clearly related to state of consciousness. Seven out of 8 non-comatose patients survived but 10 out of 18 comatose patients died. As there was no incidence of deterioration immediately following placement of a ventricular drainage, the actual risk of upward transtentorial herniation seemed low. Absence of evoked potentials in 6 patients accurately predicted a fatal outcome but normal SEP and BAEP were of lesser value for predicting survival.

Primary brain stem lesions caused by closed head injuries

Traumatic lesions of the brain stem are of two types: primary, which are considered to be caused at the moment of impact, and secondary, associated with supratentorial mass lesion. Of the 239 patients with a serious head injury who showed a severe disturbance of consciousness upon admisision and who had CT scan carried out immediately, 21 cases were considered to have a primary brain stem lesion with initial CT scan. A primary brain stem lesion was found in 21 of 239 (8.8%) of patients with serious head injury. Their injuries were caused primarily by traffic accidents. Sixteen of the 21 cases showed not only brain stem lesions but also other brain injuries such as cerebral contusion of the white and gray matter, callosal injury, intraventricular hemorrhage, and subarachnoid hemorrhage, which are considered to be caused by a diffuse shearing injury. Five cases who showed a single injury to the brain stem with no other brain lesions were considered to have a pure brain stem lesion. Primary brain stem lesions were observed on the dorsal side of the midbrain, where they can be differentiated from secondary brain stem lesions. These lesions are considered to result from the shearing mechanism in and around the brain stem very close to the tentorial edge, or to an injury of the lower brain stem by hyperextension of the cervical vertebrae. The prognosis of patients with a primary brain stem lesion was usually unfavorable, except in those with a single brain stem lesion.

Intracranial intradural epidermoids and dermoids: Surgical Results of 38 Cases

SummaryThis report covers 38 Cases of intradural dermoids (4 cases) and epidermoids (34 cases). In most cases the clinical course extended over several years. At the time of admission to the clinic only 9 patients had purely local symptoms; symptoms from adjacent areas were present in 15 cases and elevated intracranial pressure in 13.Of the 35 operated patients, 16 were able to work again, and 7 died after the operation. Best results are achieved in cases involving young patients, in cases where the tumor is situated in the cerebral hemisphere, and in cases where the tumor can be totally removed.In recent years advances in diagnostic, surgical and anaesthetic techniques have lowered the lethality rate. Computed tomography is especially useful for an early diagnosis.ZusammenfassungBei der Analyse des Krankheitsverlaufs von 38 Patienten mit intraduralen Dermoiden (4 Patienten) und Epidermoiden (34 Patienten) zeigte sich eine in der Regel lange Vorgeschichte über mehrere Jahre.Nur 9 der Patienten kamen mit einem Lokalsyndrom zur Aufnahme, bei 15 bestand zusätzlich ein Nachbarschaftssyndrom und bei 13 Zeichen der intrakraniellen Drucksteigerung.Von 35 operierten Patienten wurden 16 wieder arbeitsfähig. 7 verstarben postoperativ. Die besten Resultate konnten bei jungen Patienten, bei hemisphärennaher Tumorlage und totaler Tumorresektion erreicht werden.Im Laufe der Jahre wurde durch Verbesserung von Diagnostik und Operationstechnik die postoperative Letalität gesenkt.Eine frühzeitige Diagnose wird durch die Computertomographie erleichtert.

Multimodality evoked potentials and early prognosis in comatose patients

In 112 comatose patients somatosensory, visual and auditory evoked potentials were registered within 36 hours after the onset of coma or admission. Main causes of coma were head injury, and intracerebral and subarachnoid haemorrhage. The initial bilateral loss of any evoked potential was associated with a mortality of 98%. Normal somatosensory evoked potentials were associated with a survival rate of 74%, while normal visual and normal auditory evoked potentials had a survival rate of 60% and 66%, respectively. It is concluded that SEPs can be valuable for the prognosis of coma after primary brain lesions.

Assessment of coma reliability of prognosis

SummaryOn the basis of earlier observations of a large number of serious head injuries, and taking into account the age of the patient at the time of the accident, we calculated the period of coma following which the chances of survival sank below 5%. We have now compared these results with our observations of the past 4 years, during which intensive therapy has remained essentially the same, with the exception that Dexamethason is now used to a greater extent. No significant change in the chances of survival for longlasting coma patients was observed. The percentage of patients who remained in coma for a period longer than that set by the 5% limit and who nevertheless survived was now only 2.5% for uncomplicated open and closed brain injuries; for the cases of intracranial hematoma 5%; and for patients delivered to hospital with coma III 6%.Comparisons of our observations with those reported on in the literature showed no large degree of agreement. This was largely the result of our restrictive definition of the term ‘coma’; in the literature this word is usually used to include states which we would regard as belonging to ‘clouding of consciousness’, such as the apallic syndrome.We would like to emphasize that the 5% limit as defined here is in no way a real borderline; rather it should be viewed as a help in deciding whether, in a particular case, intensive therapy can be continued with reasonable hope of success. But in each individual case the doctor must decide whether the treatment should be continued, even if the patient has already passed the point at which his statistical chances of survival have sunk below 5%. A decision of this kind can never be based on survival statistics alone. Indeed, our individual courses illustrate that in cases of only light coma with stable or easily stabilized vegetative functions, even a coma which exceeds the limit for that age group can be followed by a good or complete recovery.Moreover important information for diagnostic purposes may come from other sources, for instance the early improvement of the EEG as a result of the normalization of the initially dominant delta and subdelta frequencies (Steinmann 1978 (36), Miltner and Wickboldt 1978 (29)).The use of CT has probably led to earlier diagnoses of hematoma than were previously possible, but this has been counteracted by a larger number of contusions with hematoma.Our observations in recent years do not lead us to believe that our former 5% limit is in need of change; its reliability has been demonstrated.ZusammenfassungAuf Grund unserer früheren Beobachtungen bei einer großen Zahl schwerer Schädel-Hirn-Verletzungen war, unter besonderer Berücksichtigung des Lebensalters, diejenige Koma-Dauer analysiert worden, an welcher die Überlebenschance unter 5% sinkt. Es wurde jetzt ein Vergleich mit den Verlaufsbeobachtungen der letzten 4 Jahre vorgenommen, in denen die Grundzüge der Intensivtherapie beibehalten, lediglich in vermehrtem Maße Dexamethason gegeben worden war. Es ergibt sich, daß keine wesentliche Änderung in der Überlebenschance bei langdauerndem Koma beobachtet wurde. Die Zahl der Patienten, die die früher definierte 5% Schwelle mit ihrer Koma-Dauer überschritten und doch überlebt haben, betrug bei den unkomplizierten gedeckten und offenen Hirnverletzungen jetzt nur 2,5%, bei den intrakraniellen Hämatomen 5%, bei Verletzten, die mit einem Koma III in die Klinik eingeliefert wurden, 6%.Ein Vergleich unserer Beobachtungen mit denjenigen der Literatur zeigt keine gute Übereinstimmung. Dies beruht im wesentlichen auf unserer sehr restriktiven Anwendung der Definition Koma (Definition S. 67). Dieser Begriff wurde in der Literatur bisher gewöhnlich weiter ausgelegt unter Einbeziehung von Stadien, die wir bereits zur Bewußt-seinstrübung rechnen, wie das apallische Syndrom.Wir möchten unterstreichen, daß die von uns definierte 5% Schwelle keine absolute Grenze darstellt. Sie muß als eine Entscheidungshilfe angesehen werden, ob im Einzelfall eine Intensivtherapie fortgesetzt werden kann mit einer begründeten Aussicht auf Erfolg.Der behandelnde Arzt muß im einzelnen Fall entscheiden, ob die Behandlung fortgesetzt werden soll, auch wenn die 5% Schwelle der Erholungschance erreicht und überschritten ist. Eine solche Entscheidung kann niemals auf einer statistischen Schwellen-Beobachtung allein basieren.Unsere Einzelverläufe zeigen vielmehr, daß bei leichteren Koma-Graden und/oder bei stabilem oder leicht stabilisierbarem Vegetativum ein längeres Koma, als die altersgebundene 5% Schwelle angibt, mit guter bis vollständiger Erholung überlebt werden kann.Hierbei ist auch die frühzeitige Besserung des Hirnstrombildes, in Form des Rückgangs der anfangs dominierenden delta und subdelta Frequenzen, eine prognostisch wichtige Information (Steinmann, 1978 (36), Miltner and Wickboldt, 1978 (29)).Unsere Beobachtungen der letzten Jahre geben zu einer Veränderung der bisher definierten 5% Schwelle keine Veranlassung, obgleich durch die Ausnutzung der CT-Diagnostik in einigen Fällen eine wahrscheinlich frühzeitige Hämatomdiagnose als früher möglich war, andererseits aber auch mehr Kontusionen mit Hämatomen festgestellt wurden.

Incidence of spinal cord injury in the Federal Republic of Germany.

2. The German Workmens compensation (BG) is a compulsory accident insurance organisation representing 19.3 million workers. The total number of SCI compensated for the first time amounted to 183 cases, fatal cases excluded. This figure includes only cases with a residual minimum disability to work of more than 20%. Cases registered by the General Local Health Insurance (AOK) are excluded. The incidence of work-related SCI is 6.8 per million insured persons per year.

Brain death : practicability of evoked potentials

Multimodally evoked potentials were registered in 85 patients who fulfilled the criteria for brain death. While samatosensory and visual evoked potentials have been found to be of limited value for the diagnosis of brain death, the stepwise abolition of brain stem auditory evoked potentials (BAEP) confirmed brain death in 26 out of 85 patients, i. e. 31%.Registration of the abolition of BAEP is concluded to be a safe and acceptable confirmatory test. It is, however, more feasible for institutions, in which BAEP are analysed routinely. In spite of all efforts sequential BAEP could not be used for the diagnosis of brain death in the majority of cases either because of absence of reproducible responses at the initial registration or because the patient was already apnoic at the time of the initial BAEP. Assuming that bilateral preservation of wave I has the same significance as the stepwise abolition of BAEP, since it also proves the integrity of the peripheral receptor, BAEP are relevant for the declaration of brain death in approximately 30% of patients.

Heart rate variability and the reaction of heart rate to atropine in brain dead patients

SummaryHeart rate variation and the atropine test as an expression of the bulbar parasympathetic activity might complete the clinical examination in the diagnosis of brain death, but are certainly unreliable as confirmatory tests.

EARLY DYNAMICS OF ACUTE EXTRADURAL AND SUBDURAL HEMATOMAS

In a retrospective study volumes of 42 extradural and 102 subdural traumatic hematomas were evaluated. Results were related with the time interval between injury and initial CT scan, outcome, coma grade and subject age. Mean volumes were found to increase with time after the injury. In the first hour volumes of 8 intracranial hematomas were hardly space consuming, while they became clearly space consuming in the second and in later hours after the injury. It was therefore concluded that it should not take longer than one hour until a CT scan be performed when an intracranial post-traumatic hematoma is suspected in the comatose patient.

Traumatic disc prolapses.

SummaryTraumatic disc lesions are uncommon not only in lumbar but also in the cervical region. They are, nevertheless, a reality. In adults they occur almost exclusively where there is previous damage to the disc. Therefore, the trauma has always the significance of only transitory, not definitive deterioration in this illness.Such a traumatic effect could be demonstrated in four patients out of 1,771 lumbar disc operations as definite (0.2%) and in 7 patients (0.4%) as possible. In 15 patients (0.9%) the effect remains doubtful.An analysis of the cause of the illness in 600 patients with cervical disc operations showed a definite influence of trauma in 12 (2%) and a possible influence in 10 (1.6%). In 4 patients the effect remains doubtful (0.6%).