RESUMEN
Despite more than 30 years of clinical use, questions remain about the safety of xenon gas in Xenon-CT cerebral blood flow (XeCTCBF) studies. In particular, xenon's effect on brain oxygen (PbtO2) in comatose patients is not well defined. Our objective was to assess the effect of a 4.5-min inhalation of 28 % stable xenon on several physiologic variables, including intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO2 in comatose patients (Glasgow Coma Scale [GCS] ≤ 8). Thirty-seven comatose patients who underwent 73 XeCTCBF studies were identified retrospectively from a prospective observational database. Changes in MAP, HR, SaO2, EtCO2, ICP, CPP, and PbtO2 measured at the start of xenon administration and every minute for 5 min thereafter were assessed. The maximum change in each variable also was determined for each scan to tabulate clinically relevant changes. Statistically, but not clinically significant changes in MAP, HR, and EtCO2 were seen. Xenon had no effect on ICP, and a small, but clinically insignificant decrease in CPP and PbtO2, was observed. There was a varied response to xenon in most measured variables. Clinically significant changes in each were infrequent, and readily reversed with the cessation of the gas. We conclude that xenon does not appear to have a clinically significant effect on ICP, CPP, and PbtO2 and so appears safe to evaluate cerebral blood flow in comatose patients.
RESUMEN
This summary of the last session of the First Neurocritical Care Research Conference reviews the discussions about research priorities in neurocritical care. The first presentation reviewed current projects funded by the National Institute of Neurological Disorders and Stroke at the National Institutes of Health and potential models to follow including an independent Neurocritical Care Network or the creation of such a network with the goal of collaborating with already existing ones. Experienced neurointensivists then presented their views on the most common and important research questions that need to be answered and investigated in the field. Finally, utility of clinical registries was discussed emphasizing their importance as hypothesis generators. During the group discussion, interests in comparative effectiveness research, the use of physiological endpoints from monitoring and alternate trial design were expressed.
Asunto(s)
Ensayos Clínicos como Asunto , Cuidados Críticos/métodos , Enfermedades del Sistema Nervioso/terapia , Proyectos de Investigación , Ensayos Clínicos como Asunto/métodos , Ensayos Clínicos como Asunto/tendencias , Investigación sobre la Eficacia Comparativa , Humanos , Investigación/tendenciasRESUMEN
BACKGROUND: The impact of osmotic therapies on brain oxygen has not been extensively studied in humans. We examined the effects on brain tissue oxygen tension (PbtO(2)) of mannitol and hypertonic saline (HTS) in patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension. METHODS: 12 consecutive patients with severe TBI who underwent intracranial pressure (ICP) and PbtO(2) monitoring were studied. Patients were treated with mannitol (25%, 0.75 g/kg) for episodes of elevated ICP (>20 mm Hg) or HTS (7.5%, 250 ml) if ICP was not controlled with mannitol. PbtO(2), ICP, mean arterial pressure, cerebral perfusion pressure (CPP), central venous pressure and cardiac output were monitored continuously. RESULTS: 42 episodes of intracranial hypertension, treated with mannitol (n = 28 boluses) or HTS (n = 14 boluses), were analysed. HTS treatment was associated with an increase in PbtO(2) (from baseline 28.3 (13.8) mm Hg to 34.9 (18.2) mm Hg at 30 min, 37.0 (17.6) mm Hg at 60 min and 41.4 (17.7) mm Hg at 120 min; all p<0.01) while mannitol did not affect PbtO(2) (baseline 30.4 (11.4) vs 28.7 (13.5) vs 28.4 (10.6) vs 27.5 (9.9) mm Hg; all p>0.1). Compared with mannitol, HTS was associated with lower ICP and higher CPP and cardiac output. CONCLUSIONS: In patients with severe TBI and elevated ICP refractory to previous mannitol treatment, 7.5% hypertonic saline administered as second tier therapy is associated with a significant increase in brain oxygenation, and improved cerebral and systemic haemodynamics.
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Química Encefálica/efectos de los fármacos , Lesiones Encefálicas/tratamiento farmacológico , Diuréticos/farmacología , Hipertensión Intracraneal/tratamiento farmacológico , Manitol/farmacología , Consumo de Oxígeno/efectos de los fármacos , Solución Salina Hipertónica/farmacología , Adulto , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/metabolismo , Interpretación Estadística de Datos , Femenino , Escala de Coma de Glasgow , Hemodinámica/efectos de los fármacos , Humanos , Hipertensión Intracraneal/etiología , Presión Intracraneal/fisiología , Masculino , RecurrenciaRESUMEN
Growing skull fractures (GSF) are rare in adults. We report the case of an adult who was found to have a GSF 50 years after head trauma. This case highlights the need to consider GSFs in the differential diagnosis of adults with intradiploic skull lesions.
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Duramadre/patología , Fracturas Craneales/diagnóstico , Neoplasias Craneales/diagnóstico , Traumatismos Craneocerebrales/complicaciones , Craneotomía/métodos , Diagnóstico Diferencial , Duramadre/cirugía , Trastornos del Crecimiento/etiología , Trastornos del Crecimiento/patología , Humanos , Masculino , Anamnesis , Persona de Mediana Edad , Fracturas Craneales/clasificación , Resultado del TratamientoRESUMEN
A major obstacle in surgical neuro-oncology is differentiating the interface between tumor and normal brain. Twenty-two brain tumors were evaluated preoperatively with magnetic resonance imaging. Intraoperative ultrasonography was used to guide surgical resection of these tumors, and results were compared with surgical and pathologic findings. Ultrasound tumor volume estimates were larger than T1 gadolinium-enhanced and T1 non-gadolinium-enhanced volumes, but these differences did not reach statistical significance. Similarly T2 volumes were larger than the corresponding sonographic volumes, except for the subset of low-grade gliomas, and in that instance the difference was small, but again the differences were not statistically significant. Ultrasonography enhanced identification of infiltrating tumor cells beyond falsely underestimated tumor margins as defined by T1 images. Ultrasound images helped differentiate edema as seen on T2 images from solid tumor and normal brain. The information gained from ultrasound images can be used to enhance tumor resection and improve patient survival and quality of life.
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Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/patología , Glioma/diagnóstico por imagen , Glioma/patología , Imagen por Resonancia Magnética , Adolescente , Adulto , Anciano , Neoplasias Encefálicas/cirugía , Distribución de Chi-Cuadrado , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Cuidados Preoperatorios , UltrasonografíaAsunto(s)
Aneurisma Roto/cirugía , Aneurisma Intracraneal/cirugía , Complicaciones Posoperatorias/mortalidad , Hemorragia Subaracnoidea/cirugía , Aneurisma Roto/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Aneurisma Intracraneal/mortalidad , Masculino , Microcirugia , Persona de Mediana Edad , Examen Neurológico , Hemorragia Subaracnoidea/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
A case of actinomycotic brain abscess is presented. Conservative treatment by prolonged administration of antibiotics after needle biopsy showed complete resolution of the abscess. Previously reported cases suggest that definitive treatment requires excision or open surgical drainage of the abscess. The case presented suggests an alternative approach to treating this unusual cause of brain abscess.
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Actinomicosis/tratamiento farmacológico , Absceso Encefálico/tratamiento farmacológico , Penicilina G/administración & dosificación , Sulfadiazina/administración & dosificación , Actinomicosis/diagnóstico , Absceso Encefálico/diagnóstico , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Lóbulo Occipital/patología , Tomografía Computarizada por Rayos XRESUMEN
Before the advent of computed tomography, intraventricular hemorrhage (IVH) from any source was thought rare and invariably fatal. Although intraventricular blood is readily identifiable with computed tomography, there has been little systematic study of its significance in blunt head trauma. Forty-three patients with traumatic IVH were prospectively identified in 1 year at Harborview Medical Center (University of Washington). Most were victims of motor vehicle accidents and suffered severe head injuries. IVH occurred alone in two patients; superficial contusions and subarachnoid hemorrhage were the most common associated finding. Blood was present in only one or both lateral ventricles in 25 patients; only the 3rd or 4th ventricles in 4 and all ventricles in 14 instances. There were 3 intracerebral hematomas and 14 basal ganglion hemorrhages. All of the former and half of the latter communicated with the adjacent lateral ventricle. Extra-axial hematomas appeared more common when only the lateral ventricles were involved, whereas corpus callosum or brain-stem hemorrhage appeared more likely when all the ventricles were involved. Acute hydrocephalus was rare, and ventricular drainage was needed in only four cases. Intracranial pressure (ICP) was elevated (> 15 mm Hg) in 46% of patients. The amount of IVH was related inversely with the Glasgow Coma Scale, but not with increased ICP. The presence of IVH indicated a poor outcome, with only half of the patients being independent at a 6-month follow-up. Poor outcome was associated with increasing age, low admission Glasgow Coma Scale, the presence of space occupying lesions if only the lateral ventricles were involved, and hemorrhage in all four ventricles.(ABSTRACT TRUNCATED AT 250 WORDS)
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Hemorragia Cerebral/cirugía , Ventrículos Cerebrales/cirugía , Traumatismos Cerrados de la Cabeza/cirugía , Hidrocefalia/cirugía , Tomografía Computarizada por Rayos X , Actividades Cotidianas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Tronco Encefálico/diagnóstico por imagen , Tronco Encefálico/cirugía , Hemorragia Cerebral/diagnóstico por imagen , Ventrículos Cerebrales/lesiones , Niño , Cuerpo Calloso/diagnóstico por imagen , Cuerpo Calloso/cirugía , Drenaje , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Traumatismos Cerrados de la Cabeza/diagnóstico por imagen , Humanos , Hidrocefalia/diagnóstico por imagen , Presión Intracraneal/fisiología , Masculino , Persona de Mediana Edad , Examen Neurológico , Complicaciones Posoperatorias/diagnósticoRESUMEN
The authors report two cases of symptomatic cerebral vasospasm following resection of an acoustic neuroma and a left sphenoid wing meningioma. Vascular spasm was documented by transcranial Doppler and angiography studies. Both patients responded to hypervolemic therapy. Possible mechanisms contributing to this rare complication are discussed.
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Ataque Isquémico Transitorio/etiología , Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Neuroma Acústico/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Adulto , Anciano , Arteria Carótida Interna/diagnóstico por imagen , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico por imagen , Ataque Isquémico Transitorio/terapia , Masculino , Complicaciones Posoperatorias/terapia , RadiografíaRESUMEN
We report two right-handed patients who underwent resection of intrinsic glial tumors from the nondominant hemisphere, face motor cortex. Both patients underwent preoperative assessment with computed tomography and magnetic resonance imaging localizing the tumor in the inferior region of the Rolandic cortex. With the patients under general anesthesia and without muscular paralysis, the tumor volume was determined by intraoperative ultrasound and resective surgery accomplished with the aid of cortical and subcortical stimulation mapping techniques. Radical resection of the tumor from the face motor cortex was achieved in both patients. A transient contralateral facial weakness and apraxia were noted in each patient, and this resolved within 6 to 8 weeks following surgery. Removal of intrinsic tumors involving the nondominant face motor cortex may be safely achieved using brain mapping techniques to localize inferior Rolandic cortex and avoid resection of the hand motor cortex and descending subcortical motor pathways. Permanent disability will be prevented due to the bilateral representation of face motor function at the neocortical level. However, due to language localization in cortical zones contiguous with the dominant hemisphere, face motor cortex, we do not recommend resection of this region.
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Mapeo Encefálico/métodos , Neoplasias Encefálicas/cirugía , Corteza Motora/fisiopatología , Adolescente , Neoplasias Encefálicas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Operativos/métodosRESUMEN
The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.
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Astrocitoma/secundario , Neoplasias Encefálicas/patología , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Meduloblastoma/secundario , Adolescente , Astrocitoma/terapia , Médula Ósea , Neoplasias Óseas/secundario , Neoplasias Encefálicas/terapia , Neoplasias Cerebelosas/patología , Neoplasias Cerebelosas/terapia , Niño , Preescolar , Terapia Combinada , Femenino , Humanos , Lactante , Recién Nacido , Neoplasias Pulmonares/secundario , Metástasis Linfática , Masculino , Meduloblastoma/terapia , Neoplasias Retroperitoneales/secundario , Estudios RetrospectivosRESUMEN
Apart from choriocarcinoma, involvement of the central nervous system (CNS) by gynecologic malignancy is rare. A 10-year retrospective review at the University of Washington Medical Center (Seattle, WA) and Swedish Hospital and Medical Center Tumor Registry (Seattle, WA) identified 14 patients with cerebral metastases from ovarian carcinoma. Median age at diagnosis of cerebral metastases was 52.5 years. Median interval from the diagnosis of ovarian carcinoma to the diagnosis of CNS metastases was 14.5 months. Seven patients had received cisplatin therapy before CNS relapse. Seven patients underwent second-look procedures before developing CNS metastases; in three, results were negative. Eight patients had evidence of extraperitoneal spread to other sites at the time of CNS relapse. Clinical manifestations included motor weakness, seizures, headache, confusion, and speech disturbance. All lesions were contrast enhancing on computed tomography (CT) scans and were located in the cerebral hemispheres. Nine patients had single lesions, five of whom underwent surgical resection of the lesion with histologic confirmation of metastases from the primary site. Median survival was 2 months in patients receiving radiation therapy alone and 17 months in patients who received surgery and radiation. Median survival of the entire series was 3 months. The presence of multiple cerebral metastases or evidence of extraperitoneal spread elsewhere in the body was adversely associated with survival. The prognosis of patients with cerebral metastases from ovarian carcinoma appears poor. However, early diagnosis by routine CT scanning followed by surgical resection and radiation may improve overall survival in a select group of patients.
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Neoplasias Encefálicas/secundario , Carcinoma/secundario , Neoplasias Ováricas , Adulto , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/terapia , Carcinoma/diagnóstico , Carcinoma/mortalidad , Carcinoma/terapia , Cisplatino/uso terapéutico , Terapia Combinada , Femenino , Humanos , Neoplasias Pulmonares/secundario , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Ováricas/tratamiento farmacológico , Neoplasias Ováricas/mortalidad , Neoplasias Ováricas/patología , Estudios Retrospectivos , Tasa de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
Fifty-one surgical decompressions without nerve transposition for ulnar neuropathy were performed in 46 patients. All of the patients were men with an average age of 59 years at the time of surgery. The follow-up range was between 5 and 32 months (average, 17.8 months). The disease involved the nondominant arm in 24 patients (52%) and was bilateral in 5 (11%). In 23 cases (50%), no predisposing condition could be identified, whereas 15 patients (33%) abused alcohol and 8 patients (17%) had diabetes mellitus. Fifty-seven percent of the patients helped by surgery had symptoms for less than 1 year, whereas only 30% of patients with symptoms for more than 1 year had symptomatic improvement. The relative magnitude of the slowing of ulnar nerve conduction velocity across the elbow was not significantly correlated with the success of decompression in relieving symptoms. Ulnar nerve conduction velocities across the elbow were 36.13 +/- 11.76 m/s in those responding to surgery and 38.97 +/- 13.91 m/s in those not responding (c = 0.06, dF = 50, P less than 0.3). A total of 37 patients showed symptomatic improvement after decompression. Simple decompression of the ulnar nerve was performed under local anesthesia without transposition of the nerve. In all of these cases, compression of the nerve occurred predominantly in the epicondylar groove. Narrowing of the nerve in the groove was present in 28 cases (55%); scar tissue was found adhering to the nerve in 21 cases (41%); and two pseudoneuromas were found (4%). Forty-one operations (80%) resulted in symptomatic improvement, typically noted by the patient within the first month postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)
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Síndromes de Compresión Nerviosa/cirugía , Nervio Cubital , Adulto , Anciano , Codo , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Atrofia Muscular/etiología , Síndromes de Compresión Nerviosa/complicaciones , Síndromes de Compresión Nerviosa/fisiopatología , Transferencia de Nervios , Conducción Nerviosa , Neurocirugia/métodos , Pronóstico , Estudios Retrospectivos , Nervio Cubital/fisiopatología , Nervio Cubital/cirugíaRESUMEN
A patient with a traumatic carotid cavernous fistula was successfully treated by a direct surgical approach after failed endovascular balloon occlusion. Surgical identification of the fistula and confirmation of its obliteration were achieved with intraoperative angiography. Dissection, control of bleeding, and carotid blood flow were facilitated by temporary balloon occlusion of the cavernous carotid artery. The combination of surgery, intraoperative angiography, and interventional radiologic techniques may improve the management of intracavernous vascular lesions.
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Fístula Arteriovenosa/terapia , Enfermedades de las Arterias Carótidas/terapia , Cateterismo , Seno Cavernoso , Angiografía Cerebral , Anciano , Fístula Arteriovenosa/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Humanos , MasculinoRESUMEN
A 25-year-old woman exhibited swelling of the scalp and a bony defect of the skull from which Mycobacterium tuberculosis was cultured. The case is reported, and the literature is reviewed.
Asunto(s)
Tuberculosis Osteoarticular/cirugía , Adulto , Femenino , Humanos , Radiografía , Tuberculosis Osteoarticular/diagnóstico por imagen , Tuberculosis Osteoarticular/fisiopatologíaRESUMEN
Twenty-two patients with primary or metastatic brain tumors were evaluated with computerized tomography (CT) and intraoperative ultrasound. Tumor volume was estimated using a geometric formula based on CT and intraoperative ultrasound measurements. In most cases, tumor margins were marked with indigo carmine injected by ventricular cannula or with Silastic ventricular catheters placed under ultrasonographic control. Nine tumors had previously been operated on and irradiated (Group A). In this group, intraoperative ultrasound tended to overestimate the tumor volume compared to CT (intraoperative ultrasound findings 141.39% +/- 37.73% of CT findings (mean +/- standard deviation]. Sixteen patients were operated on for the first time (Group B), and in this group the volume estimates were comparable (intraoperative ultrasound findings 101.69% +/- 24.65% of CT findings). The difference between the means was statistically significant (p less than 0.01). Ultrasonography improved intraoperative delineation of tumor margins, as depicted by CT, thus maximizing the extent of resection; however, with recurrent tumors, intraoperative ultrasound tended to overestimate the tumor volume. Gliosis may account for this difference.
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Neoplasias Encefálicas/diagnóstico , Glioma/diagnóstico , Tomografía Computarizada por Rayos X , Ultrasonografía , Adolescente , Adulto , Anciano , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Femenino , Glioma/diagnóstico por imagen , Glioma/cirugía , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana EdadRESUMEN
Computerized tomography (CT) infusion scanning can confirm the presence or absence of an aneurysm as a cause of spontaneous intracerebral hemorrhage. Eight patients who presented with spontaneous hemorrhage were examined using this technique. In five patients the CT scan showed an aneurysm which was later confirmed by angiography or surgery; angiography confirmed the absence of an aneurysm in the remaining three patients. This method is an easy effective way to detect whether an aneurysm is the cause of spontaneous intracerebral hemorrhage.