Library

Notes: Summary The effect of the complement-derived polypeptide C3adesArg as a mediator of inflammation in the central nervous system was examined. Twenty-five anesthetized cats received 4 mg of this polypeptide by intraventricular injection, 20 cats who served as controls received saline. Cerebrospinal fluid (CSF) was sampled 3 h after intraventricular injection and the brains were removed. For assessment of the permeability of the blood-brain barrier the CSF penetration of four antibiotics, which were given intravenously, was measured. Five control animals were employed for each antibiotic (tobramycin, ampicillin, imipenem, fosfomycin), whereas six C3adesArg-treated animals were used for each antibiotic and seven for tobramycin. Besides CSF levels of glucose, the prostanoids 6-keto-prostaglandin F1α, thromboxane B2 and prostaglandin E2 were measured. The morphological examinations in the CSF sediments and histological brain sections in the C3adesArg-treated animals disclosed a distinct inflammation with leptomeningeal and perivascular infiltration of polymorphonuclear granulocytes compared to normal findings in the controls. The CSF/serum ratios of all of the antibiotics were markedly elevated compared to controls, indicating a blood-brain barrier disruption. The levels of all prostanoids were significantly higher in the treatment group than in the control group, whereas the glucose levels were lower. These findings are in accordance with a granulocytic meningitis as seen in some infections at the acute stage. It is concluded that C3adesArg acts as a mediator of inflammation in the central nervous system.

Notes: Summary Among a series of 224 patients with aneurysmal subarachnoid haemorrhage (SAH) admitted over a period of three years, 52 patients were prospectively treated with intrathecal tissue plasminogen activator (rTPA). All of these patients were admitted and operated on within 72 h after SAH. SAH was confirmed by CT scan and the volume of blood accumulated in the basal cisterns was graded according to Fisher's scale. All patients had a SAH according to Fisher's grade III, as a prerequisite for inclusion into the study. In 21 patients additional intraventricular bleeding was detectable on CT scan. The diagnosis of a single intracerebral aneurysm as the bleeding source was established by pan-angiography, which also excluded additional cerebro-vascular malformations. The control group consisted of 68 patients, which were also treated within 72 h after SAH. Age and sex distribution as well as the clinical patterns were comparable to the rTPA group. In all patients the aneurysm was clipped using standard microsurgical techniques. After the aneurysm had been excluded from the parent vessel, 10 mg of rTPA, dissolved in 10 ml of its solution fluid, were slowly instilled into the basal cisterns in the treatment group. In patients with additional severe intraventricular bleeding, 5–10 mg of rTPA were injected into the ventricles via an intraventricular catheter at the end of the operation. Apart from the intrathecal application of the thrombolytic substance, the surgical protocol was identical in the patients of the control group. During the postoperative period, the patients in both groups were examined neurologically and by transcranial Doppler on a daily basis. CT scans were performed on days 1, 2, 5, 10 postoperatively and immediately prior to discharge. Final clinical grading for this study was performed three months after surgery and the patients were graded according to the Glasgow Outcome Scale. The occurrence of clinical signs of delayed ischaemic deficits (DID), attributable to the occurrence of cerebral vasospasm, was the only defined endpoint of the study. Radical blood clot removal, verfied by serial CT scans was achieved in all patients treated using the intrathecal thrombolytic agent. Overall results in the rTPA group at three months postsurgery were as follows: 39 patients (75%) were in grade I, 7 in grade II (13.5%), and 6 patients (11.5%) were in grade III GOS. Delayed ischaemic deficits, attributable to the occurrence of vasospasm were apparent in 4 patients (8%), in whom clinical symptoms were moderate in two patients and severe in another two. Three patients responded well to moderate hypertensive-hypervolaemic treatment resulting in an increase of their systolic arterial pressure up to 160 mm Hg. In none of these three patients cerebral infarction and/or permanent neurological deficits developed. In one patient with spasmogenic infarction of the middle cerebral artery territory in complete hemiparesis persisted. The overall results in the control group were as follows: 44 patients (64%) were in grade I GOS postoperatively, 6 in grade II (9%), 14 in grade III (21%), 1 in grade IV (1.5%), and three patients (4%) had died. DID attributable to the development of vasospasm developed in 16 patients (23.5%). DID were transient in 9 patients (13%) resolving completely after induction of hypertensive and hypervolaemic therapy. In four patients (6%) neurological deficits persisted despite vigorous treatment, and 3 patients (4%) died from spasmogenic cerebral infarction. From the results of this first prospective study of a single bolus injection of rTPA in patients with aneurysm rupture, it is concluded, that intrathecal thrombolysis is an effective and safe method for removal of intracisternal blood accumulations after SAH resulting in a significant reduction of symptomatic vasospasm and DID. With regard to the radicality of blood clot removal achievable by the use of rTPA it is furthermore concluded, that conversion of a SAH according to Fisher grade III into a SAH of Fisher grade II is sufficient for significant reduction of the incidence of posthaemorrhagic DID, avoiding the necessity of complete pharmacological blood clot evacuation and the use of higher concentrations of rTPA or continuous irrigation of the subarachnoid space.

Notes: Summary The EC-IC Bypass Study Group could not detect any benefit from surgery compared to medical management in the prevention of stroke in 1985 [15]. During the past years surgical revascularization was re-evaluated and considered as an appropriate treatment for a small subgroup of patients with recurrent focal cerebral ischaemia and impaired haemodynamics. This retrospective study examines the long-term benefit and patency rate of bypass. We present a follow-up of 5.6 years of 47 patients, all of whom underwent byupass surgery after 1985. Forty patients suffered recurring transient ischaemic attacks due to uni- or bilateral internal carotid artery occlusion. Examination included neurologic status, TCD with CO2 or Diamox challenge, angiography, CT and SPECT scans. Neurological improvement was seen in 23% of patients with better results after early surgery, a worsening in 22% suffering further ischaemic events on a postoperative average of 2.8 years. Patency rate for vein graft material was 50%, for the STA-MCA procedure 91%. Occlusion of the vein graft occurred on an average after 1.4 years, other anastomosis after 2.7 years. We conclude that only few patients derived long-term benefit from EC-IC bypasses. Functioning of the bypass worsens over time, suggesting a role for surgery predominantly in the first year of ischaemic events due to insufficient collateral supply. Actual indications for bypass surgery may be patients with failure of maximal medical therapy and progressive ischaemia and haemodynamic compromise.

Notes: Summary 32 cases of negative exploration in a joint follow-up series of 3,032 lumbar disc operations are described. Data from 15 hospitals were analyzed by means of questionnaires and computer-aided analysis. Detailed information is given about pre as well as intraoperative findings. The causes of negative lumbar disc exploration can be divided into two groups. 1. Genuine misdiagnosis where other causes are responsible for the symptoms, and 2. poor technique where despite genuine disc prolapse no evidence was found at operation. The most important causes in the first group were osteochondrotic compression, distended epidural veins, and root tension. The results are less favourable in these patients than in the overall series but, compared to the other complicated courses, the results were markedly better. A review of the literature is given, the possible causes for negative explorations are discussed, and a directive is established for the surgical procedure in cases where an expected prolapse is not found at operation.

Notes: Summary Cranio-cervical stabilization using preformed Luque rectangles supplemented by autologous bone grafts was performed in 18 patients. Stability at the cranio-cervical junction had been impaired by a number of diseases including rheumatoid arthritis in 12 patients, metastatic tumour in 5 patients and post-operative swan neck deformity in one patient. In all patients immediate stabilization as well as long-term bony fusion could be achieved, paralleled by improvement of the preoperative neurological condition in differing degrees. Surgery related complications were rare, although, considering the patient population treated, medical and anaesthesiolgical complications as a result of accompanying diseases may pose serious problems. The technical details of the surgical procedure are discribed and its application for the treatment of cranio-cervical instability is discussed.

Notes: Summary In this retrospective study, the results of surgery were examined in 25 patients, 65 years of age or older, suffering from malignant tumour growth along the cervical spine. The group consisted of 17 men and 8 women. The mean age was 73 years, ranging from 66 to 88 years. The pathology identified was metastasis in 23 patients, and plasmocytoma in two. The tumour localization involved a single segment of the cervical spine in 12 patients, two segments in 8 patients, three segments in 4 patients, and four segments in one patient. Pre-operatively, 8 patients (32%) suffered solely from severe pain. 6 patients (24%) showed severe pain and radicular nerve compression. 5 patients (20%) had incomplete para- or tetraparesis but were able to walk, and again 6 patients (24%) had incomplete para- or tetraparesis, and were unable to walk. A multitude of accompanying systemic diseases was present in the majority of patients. Evaluation of the peri-operative risk profile was performed using the American Society of Anaesthesiology (ASA) Grading of Physical Status Score. Operation consisted of microsurgical tumour removal, usually incorporating a single- or multi-level vertebrectomy, with radical epidural decompression, and grafting with bone cement followed by an appropriate osteosynthesis. Of the whole cohort of patients treated, four patients were still alive at the time of the last follow-up evaluation. 21 patients died. Four patients died within seven days after surgery. The remaining 17 patients died during the follow-up period. All of these patients died from systemic spread of their primary cancer. The results of surgery in terms of postoperative neurological outcome were as follows: 11 patients or 44% were improved by surgery. 7 patients (28%) were unchanged, three patients (12%) became worse, and four patients (16%) died. With regard to functional outcome, 73% of the patients with severe pre-operative neurological deficits showed significant postoperative amelioration of symptoms. 19 patients became ambulatory until the final stage of their disease. It is concluded, that according to the results of this limited study, a general nihilistic or purely conservative approach for the treatment of elderly patients suffering from secondary malignancy of the cervical spine is not justified. With proper patient selection, aggressive surgery leads to significant amelioration of pre-operatively existing neurological deficits and long-term ambulation in a considerable percentage of the patients.

Notes: Summary In 44 patients with complex degenerative, traumatic, neoplastic and infectious disorders of the cervical spine an aggressive surgical approach was used, consisting of Spondylectomy, radical microsurgical decompression and osteosynthesis. The patient group consisted of 23 patients with multisegmental cervical spondylosis, 9 patients with primary or metastatic malignant tumour disease spread along the cervical spine, 6 patients with complex cervical trauma and 6 patients with infection affecting one or more cervical segments. Considering the heterogenity of the group of patients treated, a multitude of neurological symptoms and signs were present. Excruciating pain was the predominant symptom in 84% of the patients, followed by sensory and motor signs of varying degrees in 77% and 65% respectively. Involvement of the long tracts was present in 51%, gait disturbance in 49% and bladder disfunction in 28%. Considering the nature of the underlying disease, in the group with multisegmental cervical spondylosis (MSCS), advanced cervical myelopathy was the predominant clinical symptom, whereas in those patients with trauma, tumour or infection, pain was the leading symptom, followed by disturbed motor and/or sensory function. Altogether 59 vertebrae have been removed in the 44 patients. In 28 patients spondylectomy was performed at one level, in 15 patients at two levels and in one female tumour patient at three levels. In 34 patients an iliac crest bone graft was used and in 10 patients bone cement. Within the observation period, solid fusion was achieved in all patients. In one tumour patient screw loosening was demonstrable at follow-up, but the fusion remained stable. 2 patients with infectious disease required re-operation due to significant loosening of screws and plates. However, after re-stabilization solid fusion was achieved. Considering amelioration of specific pre-operative symptoms and signs, excruciating pain responded best to the stabilizing procedure, with improvement in over 90% of the patients, followed by improvement of sensory and motor deficits in 85% and 82% respectively. Improvement in pre-operative gait disturbance could be achieved in 81% of the patients, while disturbance of bladder function is less likely to improve after surgery with a positive response in only 58%. None of the patients became neurologically worse after surgery. With regard to the underlying disease, patients with MSCS and tumour had the best results with overall improvement in 62% and 75% respectively. While in patients with infection improvement could be achieved in 58%, improvement in trauma patients was demonstrable in only 34% while in 66% the pre-operative clinical status remained unchanged. The surgical technique is described in detail, the results and four illustrative cases representing the therapeutic spectrum of this technique are presented. The necessity of strict adherence to microsurgical techniques for decompressive epidural surgery is especially stressed, as this is considered, apart from adequate osteosynthetic technique, to be the most important surgical factor determining the postoperative result in this challenging group of patients.

Notes: Summary The results of microsurgery for degenerative disease of the cervical spine are reported in 84 consecutive patients being 65 years of age or older at the time of surgery. Patients were suffering from either soft or hard disc disease or from advanced forms of cervical myelopathy. In 60 patients microsurgical resection of the involved cervical disc and posterior osteophytes was performed followed by anterior fusion. Spondylectomy, microsurgical decompression and osteosynthesis was performed in 24 patients with multi-level cervical stenosis. A multitude of accompanying systemic diseases was present in almost all patients. Evaluation of the peri-operative risk profile of the patients was performed using the American Society of Anesthesiology (ASA) Grading of Physical Status Score. In 82 patients a complete follow-up was available. Two patients died within seven days after surgery from heart attack and pulmonary embolism. Three patients died during the observation period from causes unrelated to their cervical disease or to surgery. Overall surgical results were as follows: 66 patients (79%) were improved by surgery. 14 patients (17%) were unchanged, two patients (2%) became worse, and two patients (2%) died. Postoperative recovery was significantly correlated to the pre-operative neurological status. Neither age, nor the pre-operative ASA score had a significant influence on the postoperative outcome. The incidence of peri-operative systemic complications was significantly correlated to the pre-operative physical status of the patients according to the ASA score. No significant correlation towards an increase of peri-operative complications with higher grades of pre-operative neurological deficits or with increasing age of the patients could be found. It is concluded, that surgery of degenerative disease of the cervical spine, even in advanced cases, and with aggressive forms of surgical treatment, can be performed in a safe and effective manner in elderly patients, resulting in a significant relief of pre-operative clinical symptoms and signs in the majority of patients.

Notes: Summary Recent experimental studies have shown, that the endothelium of cerebral vessels undergoes significant changes after subarachnoid haemorrhage which may lead to biochemical changes at the endothelial surface with disturbance of the delicate homeostasis of vasodilating and vasoconstricting mechanisms which are thought to be responsible for preservation of the tones of the cerebral vasculature. Ultrastructural studies incorporating different forms of microscopic observations of the endothelium after SAH representing a prerequisite for further investigations on the pathogenesis of cerebral vasospasm are scarce. This experimental study was performed in order to investigate and define more precisely the pathomorphological changes at the endothelial surface of the basilar artery of dogs after experimental SAH. Two separate injections of autologous blood into the cisterna magna within 72 hours resulted in extensive angiographic narrowing of the diameter of the basilar artery of all animals. Histological studies of the basilar artery including light microscopic, transmission electron microscopic, scanning electron microscopic and freeze cracking microscopic examinations demonstrated severe pathomorphological changes at the endothelial surface. These consisted mainly of infolding and corrugation of the endothelium, disorientation and desquamation of endothelial cells as well as of vacuolation and ingrowth of fibrous tissue between the endothelial and muscular layer. No pathomorphological changes could be observed in the muscular layer. As the described post-haemorrhagic ultrastructural changes of the endothelium of cerebral vessels in spasm are likely to represent the morphological basis of the delayed form of cerebral vasospasm future research on its pathogenesis should primarily focus on the structural and biochemical changes taking place at the endothelial surface of the cerebral vasculature after SAH.

Notes: Summary In a retrospective study the clinical management of 74 patients with aneurysmal subarachnoid haemorrhage (SAH) admitted in grade IV and V Hunt and Hess was examined. 39 patients (53%) were admitted within 24 hours after SAH, 29 patients (39%) between 24 and 72 hours after SAH, and 6 patients 8%) later than this time interval. The ruptured aneurysms were located at the anterior communicating artery complex in 34 patients (46%), on the middle cerebral artery in 19 patients (26%), on the internal carotid artery in 12 patients (16%) and at the vertebro-basilar artery complex in 9 patients (12%). In 38 patients (51%) no surgical attack on the aneurysm was performed. 19 (50%) of these patients were in grade IV on admission and 19 (50%) in grade V. In 36 patients (49%) the aneurysm was clipped. Of these patients 29 (81%) were in grade IV and 7 (19%) in grade V. Of the 38 patients in whom no aneurysm surgery was done, 37 patients died, representing a mortality rate of 97%, one patient survived in grade III Glasgow Outcome Scale (GOS). Concerning the outcome in those patients with aneurysm clipping, of 19 patients in grade IV operated on early, 10 patients (53%) made a good recovery, 3 (16%) were left severely disabled and 6 patients (31%) remained in a vegetative state or died. Of the 10 patients in grade IV with delayed surgery 4 (40%) were in grade I and II postoperatively, 2 (20%) in grade III, and again 4 (40%) in grade IV and V GOS. None of the 4 patients in Hunt and Hess grade V in whom early surgery was done achieved a good postoperative outcome. 2 patients survived in grade III GOS, and another 2 patients died. Only three patients admitted in grade V survived long enough to be subjected to delayed surgery. Of these patients one survived without deficit, one survived severely disabled and one patient died. From the data presented the following conclusions are drawn: 1. Without surgery the chance of survival in poor-grade aneurysm patients is almost non existent 2. Patients admitted in grade V have a uniformly poor prognosis with a very high mortality whether surgery is done or not, and whether surgery is performed early or late. 3. Patients in grade IV represent a distinct group with a better prognosis than those in grade V, justifying an aggressive surgical management. 4. Early surgery in grade IV patients leads to better results than delayed surgery especially in terms of overall management morbidity and mortality. 5. In order to further improve the results of management of poor-grade aneurysm patients early referral to neurosurgical centres is mandatory.