R. Alday

Sequential computerized tomography changes and related final outcome in severe head injury patients

SummaryThe authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan.92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%).Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes.Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.

Prognostic Factors on Hospital Admission after Spontaneous Subarachnoid Haemorrhage

Summary Background and Objective. Factors related to prognosis after subarachnoid haemorrhage (SAH) have been mainly extracted from surgical series, and only few authors have considered these factors in total management or population series. Though the level of consciousness is a major determinant of outcome after subarachnoid haemorrhage, there is not a consensus about which classification should be used to define it. The objective of this study was twofold. Firstly to find which factors recorded on hospital admission relate to outcome determining their relative importance in a non-selected series of patients suffering from aneurysmal SAH admitted to our centre, and secondly to assess the validity of the WFNS clinical scale for predicting the final result. Methods. A series of 294 patients consecutively admitted to Hospital 12 de Octubre Madrid between January 1990 and June 2000 with the diagnosis of aneurysmal SAH were retrospectively reviewed. All factors possibly related to prognosis were recorded on hospital admission. Outcome was measured by means of the Glasgow Outcome Scale measured one month after hospital discharge. Relationship between factors and outcome was evaluated by univariate and logistic regression multivariate analysis. Results. Although several factors appeared related to prognosis in the univariate analysis, only the age, the level of consciousness defined by the WFNS scale and the presence of global brain hypodensity on the initial CT scan had a significant prognostic influence in the logistic regression model. Global brain hypodensity was strongly related to mortality. Since a number of factors associated with poor outcome in the univariate analysis are related to age, their influence could be explained by the difficulty of recovery of the ageing brain. The WFNS grading scale failed to predict significant differences in outcome between some of its grades. Conclusions. Age and clinical grade on admission are the most important factors influencing the final outcome of patients suffering aneurysmal SAH. A reappraisal of the WFNS grading scale should be considered as no significant differences in outcome were found between some of its grades.

Brain oedema in patients with intracranial meningioma. Correlation between clinical, radiological, and histological factors and the presence and intensity of oedema.

SummaryThe authors analysed the correlation between different clinical, radiological, and pathological variables and the presence and intensity of brain oedema associated to intracranial meningioma in 400 consecutive patients studied by computerized tomography (CT).The following factors did not show significant correlation with brain oedema development: the age and sex of the patient, the occurrence of focal deficits, the presence of skull changes (endostosis, exostosis, osteolysis), the occurrence of tumour calcification, the density of the tumour on plain CT scan, the presence of a cystic component, the pathological subtype of meningioma (both conventional and non-conventional), and the presence of histological features of tumour aggressiveness, such as an increased vascularization, high cellularity, high mitotic index, pleomorphism, necrosis, and brain infiltration.Factors showing a statistically significant correlation with the presence and intensity of brain oedema at the bivariate analysis were: the presence of symptoms (p < 0.001), the duration of the clinical history (p < 0.05), the location and size of the tumour (p < 0.001), the type (heterogeneous vs homogeneous), and intensity of tumour contrast enhancement (p < 0.001), the presence of irregular tumour margins (p < 0.001), and the existence of focal low density intratumoural areas (p < 0.001).The multivariate analysis using only clinical parameters showed that the group of variables with the highest power for predicting the presence of brain oedema (concordance level of 76.8%) included: the presence of symptoms, the occurrence of seizures (focal or generalized), the presence of an intracranial hypertension syndrome, and the age of the patient. The multivariate analysis using only anatomico-radiological parameters showed that the model which included the size of the tumour, the intensity of contrast enhancement, the tumour margins, and meningioma location, predicted the presence of brain oedema in 80.8% of the cases.Though the results of the present study do not definitively support any of the major physiopathological theories proposed to explain brain oedema formation in patients with intracranial meningioma, some findings could favour the so-called hydrodynamic theory.

The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.

BACKGROUND Since 1999, the Italian guidelines have been used at our department for the management of patients with mild head injury (MHI). According to these guidelines, a computed tomography (CT) scan should be obtained in all patients with coagulopathy and these should routinely undergo strict observation during the first 24 hours after injury; in addition they should have a control CT scan before discharge. With the increased use of anticoagulant therapy in the elderly population, admitting patients in such treatment with a MHI to the emergency rooms has become very common. The aim of our study was to evaluate the need of performing a control CT scan in patients on anticoagulation treatment who showed neither intracranial pathology on the first CT-scan nor neurologic worsening during the observation period. METHODS We prospectively analyzed the course of all patients on anticoagulation treatment consecutively admitted to our unit between October 2005 and December 2006 who suffered from a MHI and showed a normal initial CT scan. All patients underwent strict observation during the first 24 hours after admission and had a control CT scan performed before discharge. RESULTS One hundred thirty-seven patients were included in this study. Only two patients (1.4%) showed hemorrhagic changes. However, neither of them developed concomitant neurologic worsening nor needed admitting or surgery. CONCLUSION According with our data, patients on anticoagulation treatment suffering from MHI could be managed with strict neurologic observation without routinely performing a control CT scan that can be reserved for the rare patients showing new clinical symptoms.

A comparison of different grading scales for predicting outcome after subarachnoid haemorrhage.

SummaryBackground. Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale.Method. A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by χ2 statistics. ROC curves were plotted for the different scales and their areas compared.Findings. Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH.Interpretation. Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.

Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II

Utilidad de la TAC secuencial y la monitorizacion de la presion intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesion inicial Tipo I-II

Meningiomas of the basal posterior fossa. Surgical experience in 80 cases

INTRODUCTION Despite recent improvements in microsurgical and radiotherapy techniques, treatment of basal posterior fossa meningiomas still carries an elevated risk of morbidity. We present our results in a series of patients with this type of tumor and review the recent literature looking for the results obtained with different approaches and the new tendencies and algorithms proposed for managing these challenging lesions. MATERIAL AND METHODS We analyzed retrospectively the clinical presentation and outcome of 80 patients consecutively operated between 1979 and 2003 for basal posterior fossa meningioma (foramen magnum tumors excluded). All patients had preoperative CT scans and the majority MRI studies. A total of 114 operations were performed including two-stage operations, reoperation for recurrence, CSF diversion, and XII-VII anastomosis. The most commonly used approaches were lateral suboccipital retrosigmoid, subtemporal-transtentorial, frontotemporal pterional and supra-infratentorial presigmoid. Thirteen patients received postoperative radiotherapy. RESULTS There were 59 (73.7%) women and 21 men (mean age = 51.5 years; range = 18-78 yrs). Most common presenting symptoms were cranial nerve dysfunction, gait disturbances and intracranial hypertension. The mean duration of symptoms was 2.9 years. 70% of the tumors were over 3 cm in size. Fifty patients (62.5%) had a complete resection, 22 (27.5%) subtotal resection (> 90% tumor volume removed), and 8 (10%) only partial resection. Postoperative complications included hematoma, CSF leak, and infection. Fifty four (67.5%) patients developed new or increased cranial nerve deficits and 12.5% somatomotor, somatosensory or cerebellar deficits immediately after surgery with subsequent improvement in most cases. Following initial surgery 67 patients made a good recovery, 10 developed variable degrees of disability and 3 died. Eleven patients died later in the course for tumor recurrence with or without reoperation, malignant meningioma or unrelated causes. There were 9 recurrences in the subgroup of patients having complete resection initially (mean follow-up = 8.6 years). The majority of patients having initial subtotal or partial resections have been managed without reoperation during a mean follow-up period of 6.5 years (radiosurgery and/or observation). DISCUSSION AND CONCLUSION Current microsurgical and radiotherapy techniques allow either a cure or an acceptable control of basal posterior fossa meningiomas. In patients with tumor invasion of the cavernous sinus, extracranial extension, violation of the arachnoidal membranes in front of the brainstem, or encasement and infiltration of major arteries, a subtotal excision seems preferable followed by observation and/ or radiosurgical treatment. Apart from the patients age and the clinical presentation (symptomatic or not), the size and secondary extensions of the tumor must be taken into account for planning treatment in the individual patient.

Dural arteriovenous fistula presenting as brainstem ischaemia

SummaryDural arteriovenous fistulas presenting with ascending myelopathy are characterised by the presence of an abnormal retrograde drainage through spinal veins. The authors present a case of cranial dural arteriovenous fistula causing brainstem dysfunction secondary to venous hypertension, treated by surgical interruption of the pial venous drainage which resulted in complete clinical and radiological resolution of the brainstem lesion.

Hemorragia subaracnoidea no filiada: comparación de diferentes patrones de sangrado y evolución a largo plazo

Resumen Introduccion La hemorragia subaracnoidea idiopatica (HSAI) o no filiada representa en torno al 15–30% de todas las hemorragias subaracnoideas. Sobre la base de la TC craneal realizada en el momento del diagnostico inicial y dependiendo del patron de sangrado subaracnoideo los enfermos con HSAI se pueden clasificar en tres grupos: a) pacientes con TC normal y diagnostico mediante puncion lumbar (HSAITCN); b) pacientes con patron perimesencefalico puro (HSAIPM) y c) pacientes con patron de sangrado subjetivo de rotura aneurismatica (HSAIPA). Esta clasificacion de los enfermos con HSAI podria permitir establecer diferencias de manejo y pronosticas. Objetivos Describir las caracteristicas clinicas y radiologicas de estas tres poblaciones de pacientes y analizar su evolucion final a medio y largo plazo, comparandola ademas con la observada en la poblacion de pacientes con hemorragia subaracnoidea aneurismatica (HSAAN). Material y metodos Se analizan retrospectivamente las historias clinicas de 122 pacientes con HSAI ingresados consecutivamente en el Hospital 12 de Octubre, entre 1990 y 2000. Se consideraron portadores de HSAI todos los enfermos en los que la primera angiografia completa de cuatro vasos no mostro la presencia de aneurismas o lesiones vasculares responsables del sangrado. Los enfermos fueron clasificados segun el patron de sangrado en TAC normal, patron de sangrado perimesencefalico puro (HSAIPM) segun los criterios de Van Gijn y cols., y patron de sangrado aneurismatico (HSAIPA). Se repitio el estudio angiografico cuando: a) el estudio inicial fue de insuficiente calidad o incompleto, b) o se aprecio vasoespasmo y c) en los pacientes que presentaron HSAIPA en la TC inicial. Se recogieron diferentes caracteristicas clinicas, radiologicas, asi como complicaciones surgidas durante el ingreso. La evolucion final fue determinada mediante la escala de evolucion de Glasgow (GOS). Con el proposito de comparar las caracteristicas clinicas, radiologicas y la evolucion de los enfermos con diferentes patrones de HSAI con los enfermos que presentaban HSAAN, se revisaron tambien las historias de los 294 pacientes diagnosticados de HSAAN en el mismo periodo de estudio. Resultados El 27% de los enfermos ingresados por hemorragia subaracnoidea espontanea fue diagnosticado como HSAI. De estos, 41 % de los enfermos correspondian al patron HSAIPA, el 39% HSAIPM y el 20% HSAITCN. La edad media es muy similar en los diferentes subgrupos de HSA, estando en torno a los 55 anos. Es de destacar la mayor frecuencia de varones en los grupos con HSAITCN y HSAIPM. En comparacion con la HSAAN, la HSAI se caracteriza porque los enfermos presentan con mucha menor frecuencia un mal grado clinico, y tambien fue poco frecuente la perdida de conciencia en el momento del sangrado en los enfermos. La frecuencia de complicaciones fue menor en los sujetos con HSAI que los enfermos con HSAAN, con una frecuencia de isquemia y resangrado mucho menor (5 y 6% respectivamente). Dentro de la HSAI, los enfermos con patron HSAIPA son los que presentan complicaciones con mayor frecuencia. La evolucion es excelente en los enfermos con HSAITCN y HSAIPM, y algo peor en los enfermos con HSAIPA (mediana de seguimiento 5,8 anos). Sin embargo, no existieron diferencias significativas entre los tres grupos. Conclusiones El presente estudio confirma que la frecuencia de HSAI en nuestro medio se situa en el limite alto de la mostrada previamente en la literatura, replicando los resultados previamente publicados por nuestro grupo. Los pacientes con HSAI tienen un mejor pronostico y menor riesgo de complicaciones que los enfermos con HSAAN, siendo particularmente bueno o excelente el de los enfermos con HSAIPM y HSAITCN. Los pacientes con HSAIPA presentan un cuadro clinico inicial mas grave, probablemente relacionado con la mayor cuantia del sangrado, asi como con una mayor frecuencia de complicaciones sistemicas, isquemia cerebral e hidrocefalia. Sin embargo, si se confirma la ausencia de lesiones responsables del sangrado, el pronostico a largo plazo es similar al de los otros dos subgrupos de pacientes con HSAI.

Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM ☆

Resumen Introduccion La TC craneal ha sido el metodo mas extendido en la evaluacion de enfermos que han sufrido trauma craneal. Sin embargo, es poco sensible en la identificacion de lesion axonal difusa y lesiones en fosa posterior. La RM craneal es una prueba potencialmente mas sensible pero de dificil realizacion en estos enfermos, hecho que ha impedido la generalizacion de su uso. Objetivos Comparar la capacidad de identificacion de lesiones intracraneales postraumaticas por parte de las dos pruebas diagnosticas en enfermos con TCE grave y moderado, y determinar que caracteristicas radiologicas en la TC se asocian a la presencia de LAD en RM y su gravedad clinica. Material y metodos Se incluyen en el estudio 100 enfermos con TCE moderado y grave a los que se ha realizado RM craneal dentro de los primeros 30 dias tras el trauma craneal. Se recogieron todas las variables clinicas potencialmente relacionadas con el pronostico de los enfermos, asi como los datos del TC inicial segun la clasificacion de Marshall y cols. La RM fue evaluada de manera ciega por dos neurorradiologos que ignoraban al resultado de la TC inicial y la situacion clinica inicial del paciente. Se recogieron todas las lesiones que presentaban, asi como su clasificacion segun la clasificacion de lesiones asociadas con LAD, descrita por Adams. Se compararon los hallazgos en TC y RM, evaluando la sensibilidad de cada prueba con respecto a los diferentes hallazgos. Se estudiaron los hallazgos relacionados con la presencia de LAD en RM, mediante estudio univariable, usando la prueba de χ2 y correlaciones simples. Resultados La RM es mas sensible que la TC para las lesiones en sustancia blanca cerebral, cuerpo calloso y tronco. Ademas, detecta mayor numero de contusiones. La presencia de lesion axonal difusa depende del mecanismo de produccion del trauma, siendo mas frecuente en traumas de mayor energia, sobre todo en los accidentes de trafico, bien sea con automovil o moto/bici. En cuanto a las caracteristicas radiologicas asociadas a LAD la mas claramente relacionada es la hemorragia intraventricular. La presencia de dano cada vez mas profundo y mayor puntuacion en la escala de Adams se asocia a menor puntuacion en la GCS y GCS motora, y por consiguiente peor nivel de conciencia y mayor gravedad del trauma inicial, confirmando el modelo de Ommaya.