[How do physicians code the motoric variable of the Glasgow-Coma-Score?]

A mere 14% gave the right answer according the guidelines: Code the "best motoric answer" of the "upper limb". 86% coded the Glasgow-Coma-Score for the motoric variable falsely and inconsistently. Additionally, the rate of correct answers were higher in physicians in training (37.5%) than in qualified and certified emergency doctors (5%). Emergency doctors post training stated in 68% instances that the variable should be coded according to the neurological results at the upper or lower extremity. Furthermore, they stated that the worst neurological result should be coded (43%). From our data, it appears that the coding of the motoric variable is not done according to the guidelines or is done inconsistently. There are compelling reasons for coding the worst result. However, this procedure is contrary to the guidelines presented by literature. These guideline have never been withdrawn. Emergency doctors obviously code the motoric variable of the Glasgow-Coma-Score with knowledge about the pathophysiology of traumatic brain injuries. The Glasgow-Coma-Score is used for coding the level of consciousness at the site of accident, on admission, for prognosis, in clinical studies and in forensic controversies. Its sensitivity for depth of coma depends on the quality of coding the motoric answer. We interviewed 165 emergency doctors (in training and post training) about the guidelines for coding the motoric variable of the Glasgow-Coma-Score.

[The histological confirmation of diffuse axonal injury in severe brain injury survivors]

Diffuse axonal injury (DAI) plays a major role after traumatic brain injury (TBI). Its imaging is based on computed tomography (CT) or magnetic resonance imaging (MRI). However, DAI is a histological diagnosis. Histopathological findings on survival after TBI are very rare. Hence, it is unclear whether the neuroradiological findings are of clinical relevance. Cerebral specimens were taken in 24 patients with TBI requiring surgery. The presence of histopathological evidence for DAI was evaluated. Specimens were taken from an extracranial brain prolapse (n = 2) and from peripheral parts of a brain contusion (n = 22). Histological findings were correlated to the clinical course and the neurological status. A clinical follow-up was carried out 6 months after the surgery using the Glasgow Outcome Score (GOS). The study was approved by the local ethics committee. Specimens taken were temporal (n = 11), frontal (n = 8), parietal (n = 4) and cerebellar (n = 1). The incidence of DAI within these specimens was 30% (7 with DAI, 17 without DAI). DAI was verifiable up to 3 days after trauma. There was no correlation between DAI and Marshall classification in CT. The period of coma was longer in subjects with DAI. There was no difference in GOS in the case of a verified DAI. These results enforce the prognostic and neuroradiologic relevance of DAI. However, it is debatable whether the pathomorphologic findings in CT or MRI represent the histological findings of DAI. We suggest a multicentre study for further clarification.

[Comparison of younger and elder patients after multiple trauma]

The purpose of this study was to clarify any influences by age on the outcome after multiple trauma. 520 patients (age > 20 years) were analysed after inclusion in a 3-year national multi-centre study for polytrauma injured subjects. The patients were recruited from 10 German neurosurgical university departments. Criteria for inclusion were head injury and coma at the time of admittance. The elderly were mostly injured by falls, and showed more often intracranial injuries and fractures of the pelvis. The majority of intracranial injuries were characterised by acute subdural haematomas in the elderly and contusions in younger patients. Hence, craniotomy within the first 24 hours was found more often in the elderly. There was a significant trend towards a craniotomy and placement of a pressure catheter in younger patients compared with the elderly. There were significantly lower values for the Glasgow Outcome Scale (GOS) in the elderly, especially in terms of lethality. The depth of coma was a strong predictor for GOS in both groups.

[Cranial magnetic resonance imaging and serum marker S-100 for expert opinions in severe brain injuries]

Detailed imaging of the brain is necessary to come to an expert opinion on the consequences of severe brain injuries (BI). As lesions are not visualised on computerised tomography, magnetic resonance imaging (MRI) data and serum marker S-100 are currently favoured. Our study analyses the predictive qualities of MRI and S-100 for the outcome in severe BI in 100 patients. The location of brain stem lesions identified with the aid of MRI significantly correlated with the outcome. Special types of brain stem lesions could be distinguished. S-100 was a rough measure for the amount of destruction of CNS tissue, but the exact location of the destroyed tissue appeared to be more significantly related with the outcome than its volume. For an expert opinion on severe BI, follow up MRI after brain injury can definitely not exclude relevant lesions. Early MRI is recommended.

[First description of an intradural disc herniation at the C7-T1 level]

41 cases of cervical intradural disc herniation have been reported in the literature, none at the C7-T1 level. We describe a case of myelopathy after a fall. The female patient suffered an ataxia of the legs in combination with unilateral C8 cervicocephalgia and hypaesthesia. Magnetic resonance imaging revealed a space-occupying lesion at C7-T1, so we suspected a tumour. After a dorsolateral approach, an intradural disc herniation was found. Six months after the operation, the patient is free of complaints.

[Optimized image processing with modified preprocessing of image data sets of a transparent imaging plate by way of the lateral view of the cervical spine]

PURPOSE

To improve the diagnostic quality of lateral radiographs of the cervical spine by pre-processing the image data sets produced by a transparent imaging plate with both-side reading and to evaluate any possible impact on minimizing the number of additional radiographs and supplementary investigations.

MATERIAL AND METHODS

One hundred lateral digital radiographs of the cervical spine were processed with two different methods: processing of each data set using the system-imminent parameters and using the manual mode. The difference between the two types of processing is the level of the latitude value. Hard copies of the processed images were judged by five radiologists and three neurosurgeons. The evaluation applied the image criteria score (ICS) without conventional reference images.

RESULTS

In 99 % of the lateral radiographs of the cervical spine, all vertebral bodies could be completed delineated using the manual mode, but only 76 % oft the images processed by the system-imminent parameters showed all vertebral bodies. Thus, the manual mode enabled the evaluation of up to two additional more caudal vertebral bodies. The manual mode processing was significantly better concerning object size and processing artifacts. This optimized image processing and the resultant minimization of supplementary investigations was calculated to correspond to a theoretical dose reduction of about 50 %.

CONCLUSION

The introduction of optimized organ programs for the upper and lower cervical spine based on the 12-bit data of the images should improve the evaluation of the lateral radiograph of the cervical spine without reducing the latitude value.

Classification of severe head injury based on magnetic resonance imaging

OBJECT

In 1991 a new pioneering classification of severe head injuries had been proposed, based on CT findings. Unfortunately CT cannot visualise all lesions. Especially brain stem lesions may escape CT in spite of modern equipment, but may be demonstrated by MRI. The high incidence of CT negative but MRI positive posttraumatic brain stem lesions has already been demonstrated in a limited number of cases. A statistically significant evaluation is still missing. Therefore we have investigated a series of 102 comatose patients, in whom a statistical evaluation of MRI findings and their correlation with mortality and outcome of survivors was possible.

PATIENTS AND METHODS

MRI was obtained within 8 days after servere head injury in 102 patients with a minimum of 24 hours of coma. The location of the lesions. identified by a neuroradiologist who was unaware of the clinical findings, was correlated with mortality, outcome of surviors and duration of coma. The correlation was analysed statistically. Follow-up ranged from 3 months to 3 years with a mean of 22 months. Four groups of lesions gave significant correlations: Grade I lesions were lesions of the hemispheres only; Grade II lesions were unilateral lesions of the brain stem at any level with or without supratentorial lesions; Grade III lesions were bilateral lesions of the mesencephalon with or without supratentorial lesions. Grade IV lesions were bilateral lesion of the pons with or without any of the foregoing lesions of lesser grades.

RESULTS

Mortality increased from 14% in grade I lesions to 100% in grade IV lesions. The Glasgow outcome score differed significantly for each grade. The mean duration of coma increased from 3 days in grade I patients to 13 days in grade III. The correlations between the lesions grade I to IV with mortality, outcome of survivors and duration of coma were highly significant.

CONCLUSION

The statistically significant correlations between the 4 groups of severe head injury patients, as identified by MRI, with mortality and outcome of survivors justify a new classification based on early MRI findings.

Present status of neurosurgical trauma in Germany

Exact epidemiological data on head injury in Germany are limited and based on data from death certificates, the Federal Board of Statistics (Bundesamt für Statistik), small regional cohort studies, and health insurance. With a population of 82 million people there had been 279,029 head injuries admitted to hospital in Germany in 1996. The majority had the diagnosis. "concussion," which refers to completely reversible lesions. Head injury caused the deaths of 9415 patients in 1996, which amounts to a mortality of 11.5 per 100,000 inhabitants. At the same time there were 135 independent neurosurgical units, all of which had a computerized tomography scanner available. Of all fatal cases, however, 68.4% died before they reached a hospital. The exact cost is difficult to assess, because head injury causes more costs than only the hospital stay and rehabilitation.

[Magnetic resonance imaging diagnosis of craniobasal cerebrospinal fluid fistulas by 3D-CISS sequence]

Recently, a Magnetic Resonance Imaging (MRI)-technique has been developed to diagnose the exact anatomical location of fistulas of the cerebrospinal fluid (CSF). This method is called 3D-constructive interference steady state-sequence (CISS) but it is not well known in clinical practice. Aim of the study was the evaluation of specificity and sensitivity of CISS-MRI. 12 patients with rhinoliquorrhea after head injury (n = 7) or skull base tumours (n = 5) were examined by CISS-MRI. The examinations were performed with a 1.5 T whole body MRI scanner in prone position and coronal plane sections. In cases of CSF leckage the sensitivity for detection of a CSF fistula was 100%. In comparison with intraoperative findings, specificity was 100%: in all cases, a dural lesion in anatomical correlation to MRI was detected. Further advantages of this method are its non-invasive character, no need for contrast application, no radiation exposure, and exact localisation of additional anatomical findings (brain herniation, brain contusions).

[Initiation of rehabilitation after surgery for herniated lumbar disk: pilot study of efficacy from the viewpoint of the surgical hospital]

The initiation of rehabilitation after lumbar disc surgery in Germany is up to the operating hospital. A decision between outpatient and inpatient rehabilitation is possible. Until now this decision is not based on scientific data but on the individual experience of the hospital. This prospective study compares the effect of outpatient and inpatient therapy: In 65 patients medical and psychosocial data were collected shortly before operation, 1 week and 6 months after surgery. Of these patients, 42 underwent inpatient, 21 outpatient rehabilitation, 2 patients renounced rehabilitation. The outpatient and inpatient rehabilitation groups showed no significant difference in testing before or shortly after the operation concerning subjective state of health and somatic findings. Some 6 months later, long term outcome was identical, i.e. the groups did not differ in psychosocial or medical respects. However, the inpatient rehabilitation group had taken significantly longer to return to work. This pilot study stresses the importance of further research on rehabilitation after lumbar disc surgery. It should be shared by surgeons and rehabilitation experts.

Early magnetic resonance imaging of brainstem lesions after severe head injury

OBJECT

The availability of magnetic resonance (MR) imaging data obtained in comatose patients after head injury is scarce, because MR imaging is somewhat cumbersome to perform in patients requiring ventilation and because, in the first hours after injury, its relevance is clearly inferior to computerized tomography (CT) scanning. The authors assessed the value of MR imaging in the early postinjury period.

METHODS

In this prospective study MR imaging was performed in 61 consecutive patients within 7 days after they suffered a severe head injury. An initial CT scan had already been obtained. To understand the clinical significance of the lesions whose morphological appearance was identified with MR imaging, brainstem function was assessed by registration of somatosensory and auditory evoked potentials. Brainstem lesions were visualized in 39 patients (64%). Bilateral pontine lesions proved to be 100% fatal and nonbrainstem lesions carried a mortality rate of 9%. In singular cases circumstances allowed for a clear clinical distinction between primary and secondary brainstem lesions. On MR imaging all lesions were hyper- and hypointense after intervals longer than 2 days. Within shorter intervals (< 2 days) after the injury, primary lesions appeared isointense on MR imaging. In one secondary brainstem lesion there were no traces of blood.

CONCLUSIONS

Because mean intracranial pressure (ICP) levels in patients without brainstem lesions were similar to those in patients with brainstem lesions, the authors conclude that it was not mainly increased ICP that accounted for the high mortality rates in patients with brainstem lesions. The authors also conclude that brainstem lesions are more frequently found in severe head injury than previously reported in studies based on neuropathological or CT scanning data. Early MR imaging after head injury has a higher predictive value than CT scanning.

Efficiency of the Glasgow Outcome Scale (GOS)-Score for the long-term follow-up after severe brain injuries

The Glasgow Outcome Scale (GOS)-Score is the most widely used instrument for measuring outcome in head injury research. Its reliability is seen controversial because of its simplicity. The study analyzes the correlation between the levels 3 to 5 of recovery to medical data, psychology and quality of life (QOL) 4 to 8 years after the accident. 34 patients, suffered from a severe brain injury (BI) 4 to 8 years ago, were reexamined by a psychological test battery and by evaluating of QOL (using self developed items for private and social activity). Test results and GOS-Score additionally were correlated to data from the phase of intensive care. Patients, still alive 4 to 8 years after injury, ranged mainly between the GOS-Scores 3 to 5 of recovery. Consequently, other scores (like Ranchos los Amigos, Barthel Index, GOAT) failed in measuring the outcome after such a long time. Different parameters from the phase of intensive care correlate significantly with the patients GOS-Score: coma length, isolated brain injury versus additional extracranial injury, compression of the basal cisternes on the initial CCT. Different psychological test results and the patients quality of life correlate significantly with the GOS-Scores from 3-5. These correlations could be shown in xy and yx-direction by different mathematical models. It is concluded, that GOS-levels 3-5 of recovery correlate to the essential medical data from the initial phase after the accident and to a detailed psychological evaluation years after injury.

Clinical predictors of the psychosocial long-term outcome after brain injury

The correlation of clinical with psychological and social data is an attempt to find predictors of the definite long-term outcome after brain injury. 34 patients were reexamined 3 to 8 years after the accident using a number of psychological tests. Additionally, life quality was defined and evaluated. Only patients with an initial Glasgow Coma Scale-Score of 3-12, an intracranial traumatic lesion on computertomography and age 16-65 years at the time of accident were included in this study. Patients exhibited a uniform pattern of disturbances in psychosocial long-term outcome. These disturbances were compared with initial clinical data: memory, attention and learning were significantly correlated with the duration of coma and the presence of additional extracerebral injuries. From the initial computerized tomography, the findings 'compression of basal cisterns' and 'intracerebral contusion' showed to be predictors of the cerebral function. Late social status and behavior, defined as quality of life, were clearly related with initial clinical findings. In conclusion, there are early clinical predictors of the long term social and psychological outcome after brain injury.

[Bicycle rider's ulnar nerve paralysis]

The ulnar neuropathy in bicycle riders is a less common occurrence, due to a local damage of the nerve on the level of the ulnar tunnel. It has been described in neurological literature only a few times, and hence its good prognosis is not sufficiently known. Within a short time two patients of this disease were transferred to our clinic for operation. After a local space-occupying growth in the tunnel could be excluded by MR or sonography of the wrist, we discouraged performance of an operative procedure. The patients' complaints and the neurological deficits vanished in a few weeks. Ulnar neuropathy in bicycle riders is therefore a syndrome for which even in the case of severe deficit an operation is not recommended.

The anterior inferior cerebellar artery (AICA): clinical and radiological significance

It is well known that the anterior inferior cerebellar artery (AICA) is difficult to visualize radiologically. As the analysis of 50 clinical cases shows, although the main branches of the AICA at the level of the basilar artery can be analyzed angiographically, the peripheral course is only vaguely visible. We examined 26 brains (postmortem) after selective resin-injection and preparation under an operation-microscope. Our results: 1. There is a reciprocal relationship between the development of the AICA and the PICA. 2. We can draw no conclusions concerning the pattern of the AICA of one side to the pattern on the other side. 3. The size of the AICA at the level of the basilar artery gives an indirect indication of the peripheral course. 4. The AICA and the cranial nerves are in a constant relationship to each other. Consideration of these relationships can help in the interpretation of angiograms done before microsurgical operations in the area of the cerebello-pontine angle.

[The topography of the atrium ventriculi and its microsurgical importance]

Microsurgical anatomy of the atrial region of the side cerebral ventricles was studied on 100 brain hemispheres. The variations in the form of the atrial walls, especially the structures comprising the anterior atrial wall were analysed in respect to the microsurgical possibilities. According to the anatomical results a microsurgical approach was described: the interhemispheric transatrial approach for lesions of the trigonal atrial region. Advantages and disadvantages, possibilities and limits of this approach in comparison to alternative approaches are discussed.