Vilém Juráň

Lumbar Disc Surgery in Regional Anaesthesia – 40 years of Experience

Summary Lumbar disc operations have been performed in Brno since 1952 and from the very beginning they are performed under regional anaesthesia. Since 1965 until 1999 about 16000 operations for herniated discs have been performed here. The number of operations doubled with the foundation of the second neurosurgical department in Brno in 1992. Lumbar disc surgery represents 25% of the operation spectrum in our department. Epidural anaesthesia is advantageous for less risk of some complications compared with general anaesthesia and enables communication between the surgeon and the patient. Other advantages are: less visible bleeding in the operative field due to the lateral position and the fact that the surgeon can sit during the operation. On a long-term basis we found 4–5% had further surgery for reccurent problems. Objective neurological evaluation 6 weeks after the operation showed improvement in 92% of patients. The patients themselves consider their status as very good or satisfactory in 82% (median 3 years after the operation). Besides a correctly performed operation we emphesize also the role of correct diagnosis (good correlation between the patients problems and CT scan finding) for a good treatment result.

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.

Early Dynamics of Interleukin-6 in Cerebrospinal Fluid after Aneurysmal Subarachnoid Hemorrhage

Background Subarachnoid hemorrhage (SAH) is a severe condition associated with high mortality. Early brain injury (EBI) plays an important role in the pathophysiology of SAH, and inflammation is a major contributor to EBI. Inflammation is a widely studied topic in both experimental and clinical conditions; however, just a few clinical studies have focused primarily on the early inflammatory response after SAH, and detailed information about the association between the dynamics of early inflammatory response with main clinical characteristics is lacking. This study analyzes the early dynamics of inflammatory response after SAH and evaluates the possible associations between the markers of early inflammatory response and main clinical characteristics. Patients and Methods A total of 47 patients with a diagnosis of aneurysmal SAH within the last 24 hours were enrolled in the study. All treatments, including treatment of aneurysm (surgery/coiling) and implantation of a drainage system (external ventricular drainage/lumbar catheter), were conducted in the same way as in other patients with this diagnosis. Blood and cerebrospinal fluid (CSF) samples were collected three times a day for 4 days. The dynamics of proinflammatory cytokines were assessed, and associations between levels of the proinflammatory cytokines interleukin (IL)‐6, IL‐1&bgr;, or tumor necrosis factor (TNF)&agr; and main clinical characteristics were evaluated using linear mixed‐effect models. Results The CSF levels of IL‐6 were massively increased initially after SAH (up to 72 hours) with an additional increase in later phases (after 72 hours), but there was high variability in IL‐6 levels. A significant association was noted between the Glasgow Outcome Scale score and both overall levels of IL‐6 (p = 0.0095) and their dynamics (p = 0.0208); the effect of the Hunt and Hess scale was borderline (p = 0.0887). No association was found between IL‐6 levels and Fisher grade, modality of treatment (surgery, coiling, no treatment), and later development of cerebral vasospasm. Plasmatic levels of IL‐6 increased slightly, but no significant association was found. The levels of IL‐1&bgr; and TNF&agr; were within the physiologic range in both CSF and plasma. Conclusions Early dynamics of IL‐6 in CSF are associated with a patienSymbols outcome. But it is difficult to use IL‐6 alone for outcome prediction due to its high variability. The question is whether the dynamics of IL‐6 could be used in combination with other early markers associated with brain injury. More detailed research is required to answer this question. Symbol. No caption available.

The Influence of Mild Hypothermia on the Incidence of Vasospasms in Patients After Severe Subarachnoid Hemorrhage

According to some reports, hypothermia could decrease the incidence and severity of vasospasms in patients after severe subarachnoid hemorrhage (SAH) [Hunt and Hess (HH) IV and V]. We have analyzed 15 patients (HH IV and V) after SAH from a ruptured intracranial aneurysm. In 8 patients the aneurysm was embolized during the first 4 days, 3 patients were operated on because of an intraparenchymal hematoma and their aneurysm was clipped, and the other 4 patients were initially treated conservatively. In all patients mild hypothermia (34°C for 72 h) had been started immediately after their admission by the means of cooling blankets. Monitoring of intracranial pressure (ICP) (intraventricular), cerebral perfusion pressure (CPP), and jugular bulb oximetry was instituted, and transcranial Doppler ultrasonography (TCD) examination was performed every day. Intracranial pressure, CPP, and jugular bulb oximetry were maintained within the normal range in all patients. In 10 patients, however, severe vasospasms with infarctions on the computed tomography scan occurred (during day 5 and 16 after SAH). Transcranial Doppler showed increased velocities only in 6 of these patients. All 10 patients with vasospasms died within 6 months after SAH. One patient remained vegetative, 1 was severely disabled, and 3 had a good outcome (2 of these had intraparenchymal hematoma). Hypothermia applied immediately after SAH does not seem to decrease either the incidence or the severity of vasospasms in HH IV and V patients after SAH.