Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical management

BACKGROUND

The optimal treatment of hypertensive supratentorial intracerebral hemorrhage is still debated. Some studies have shown no improvement in survival or functional outcome after surgery when compared to conservative management while others have shown otherwise.

METHODS

This study was a prospective trial, matching patients for hematoma volume and Glasgow Coma score on admission.

RESULTS

There were a total of 34 patients. Seventeen were treated conservatively and 17 surgically. There was no significant difference between the two groups in terms of age, GCS, hematoma volume, or presence of intraventricular blood. At 3, 6, and 12-month follow-up, they were assessed using the Modified Barthel Index by a blinded observer. There was no difference between the two groups at 3, 6, or 12 months follow-up. The mortality rate was similar in the two groups.

CONCLUSIONS

Based on this study and review of the literature, we cannot recommend routine evacuation of clots to treat these hemorrhages.

Panhypopituitarism due to pituitary cyst of Rathke's cleft origin--two case reports

INTRODUCTION

Rathke's cleft cysts are cystic sellar and suprasellar lesions, characteristically lined by a single layer of ciliated cuboidal or columnar epithelium.

CLINICAL PICTURE

We report 2 patients who presented with gastrointestinal symptoms and were initially investigated for dyspepsia. However, attention was subsequently drawn to persistent hyponatraemia that led to the diagnosis of panhypopituitarism due to Rathke's cleft cyst.

TREATMENT

Transsphenoidal surgery followed by drainage of the cyst and partial excision of the cyst wall in both patients.

OUTCOME

No recurrence of the lesions over a mean follow-up of 16 months. There has been an improvement of the hypothalamo-pituitary-adrenal axis in 1 patient and the hypothalamo-pituitary-thyroid axis and visual fields in the other.

CONCLUSION

Symptomatic Rathke's cleft cysts are rare and can occasionally cause panhypopituitarism. Ideal management of these cysts is unclear, but aspiration followed by partial excision of the cyst wall seems the best initial option.

Nitric oxide and subarachnoid hemorrhage: elevated level in cerebrospinal fluid and their implications

OBJECTIVE

Nitric oxide (NO) plays an important role in the pathogenesis of neuronal injury after brain ischemia, and decreased levels of NO have been implicated in the pathogenesis of vasospasm after subarachnoid hemorrhage (SAH). In this study, we measured the ventricular cerebrospinal fluid (CSF) NO levels in patients with SAH and correlated the levels with clinical grade and middle cerebral artery velocities measured with transcranial Doppler ultrasound.

METHODS

All patients with spontaneous SAH documented on computed tomography and with an external ventricular drain inserted within 24 hours of hemorrhage were included in the study. A total of 16 patients were studied between August 1999 and August 2000. CSF was collected serially at the time of surgery and subsequently at daily intervals. It was collected during the time that the external ventricular drain remained patent and in situ. NO levels were measured by photometric analysis by using a nitrite/nitrate assay kit (Cayman Chemical, Ann Arbor, MI).

RESULTS

The peak NO level in patients with SAH ranged from 9.96 to 168.16 micromol, with a median of 36.93 micromol. The levels were significantly elevated as compared with the control group (5.16 micromol, P < 0.05). The median NO level in patients with poor-grade SAH was 67.14 micromol as compared with 27.42 micromol in patients with good-grade hemorrhage (P < 0.05). No correlation was seen between CSF NO levels and middle cerebral artery velocities. The median NO level was 33.2 micromol in patients with a poor outcome as compared with 30.25 micromol in patients with a good outcome (P > 0.05).

CONCLUSION

This study showed that NO levels are elevated after spontaneous SAH, and the degree of elevation is higher in patients with poor-grade SAH.

Spontaneous subarachnoid haemorrhage and outcome--results from Tan Tock Seng Hospital, Singapore

AIM OF STUDY

To ascertain the number of cases of spontaneous (aneurysmal) subarachnoid haemorrhage presenting to Tan Tock Seng Hospital, Singapore, over a one year period, the demographics of the patients involved, their treatment and their eventual outcome.

METHOD

A retrospective study from June 1995 to June 1996.

RESULTS

There were 62 patients admitted over this period with an average of 5 patients per month. Their ages ranged from 9 to 85 years with a mean of 54 years. All 62 patients underwent 4-vessel cerebral angiograms. Forty-three patients (69%) underwent clipping of their aneurysms. Twelve patients (19%) had negative angiograms. Four patients (6%) underwent coiling of their aneurysms via interventional neuroradiology techniques. Patients with subarachnoid haemorrhage of Grades 1 to 3 on the WFNS (World Federation of Neurological Surgeons) grading had a favourable outcome (Glasgow Outcome Score of 4 and 5) in 85% of the cases. The overall mortality rate for the operated group (all grades) was 11%. However for the group with good WFNS grading, namely the Grade 1 to 2 groups, there were no deaths. Twenty-four percent of patients developed clinically symptomatic vasospasm. Eighteen percent of patients required ventriculo-peritoneal shunting for hydrocephalus secondary to the subarachnoid haemorrhage. The overall management mortality (operated and non-operated cases) was 14% for proven aneurysmal and angiographically-negative spontaneous subarachnoid haemorrhage. These results are comparable to that of other reputable centers reported in the literature.

Young Investigator's Award: induction of apoptosis following traumatic head injury in humans

Apoptosis or programmed cell death plays an important role in many developmental and pathological processes of the central nervous system. In head injury, apoptosis has been recently implicated in many studies on animal brain samples the phenomenon of apoptotic gene expression (bax and bcl-2). Twenty specimens of contused brain tissue (temporal and frontal lobe) from 20 patients who underwent emergency craniotomy and removal of mass lesions were obtained from May to October 1997. The samples collected were immediately snap frozen in liquid nitrogen and stored at -80 degrees C. Immunohistochemical analysis was performed to detect the expression of bcl-2, bax and p53 using standard avidin-biotin complex second antibody conjugate methodology utilising commercially available primary and secondary antibodies. The average age of cohort was 46.24 +/- 22.17 years, the average Glasgow Coma Scale on admission was 9.19 +/- 4.72, and the average duration from injury to collection of the sample was 20.62 +/- 40.57 hours. There was documented hypoxia and hypotension seen in 5 of the 20 patients (25%). Significant levels of bax protein expression were noted in all samples, and p53 expression in 30% of samples. No bcl-2 expression was observed. Our study showed that for the first time the strong expression of the pro-apoptotic gene (bax) and low levels of the anti-apoptotic gene (bcl-2), thus implicating the mechanism of apoptosis in brain injury following trauma. The use of agents to inhibit apoptosis may be beneficial in head injury patients.

A study on the efficacy of intraventricular urokinase in the treatment of intraventricular haemorrhage

Twenty-one patients with intraventricular haemorrhage were randomized to two treatment groups. Both groups had bilateral external ventricular drains inserted, but only the treatment group received 50,000 IU urokinase instilled into the ventricles. The clinical and radiological progress, and 1- and 6-month outcomes were compared. The group that received urokinase treatment was shown to have an improved outcome, with a lower mortality and a lower incidence of hydrocephalus requiring shunt insertion. No haemorrhagic complications were seen in either group, although the treatment group had a slightly increased rate of drain-related ventriculitis.

Outcome of patients with traumatic brain injury managed on a standardised head injury protocol

A standardised protocol in the management of severe head injury in our hospital enables pre-determined critical care-paths and consistent treatment regimes to be instituted. In Singapore there has been no previously reported data on the outcome of severely head injured patients. Over a 6-month period, 48 consecutive patients who were enrolled in our severe head injury protocol were prospectively studied. In addition to demographic and outcome data, physiologic measurements obtained from a computerised patient information system (Carevue Hewlett-Packard 9000) were analysed to determine the mean cerebral perfusion pressure (CPP) and intracranial pressure (ICP) achieved throughout the protocol period. Median Glasgow Coma Score for all patients on admission to the protocol was 6 (range 4 to 8). The mean age was 34.46 +/- 15.03 years with a male to female ratio of 43:5. The average duration of treatment on the protocol was 110.73 hours. Initial ICP measured was 25.5 +/- 19.68 mmHg. Outcome was measured at 6 months post-injury using the Glasgow Outcome Score. Favourable outcome (GOS 4-5) was seen in 29 of 48 patients (60.4%) while 12 out of 48 (25%) had an unfavourable outcome. There was a mortality of 14.6% (7 of 48 patients). Patients who survived had a higher mean CPP (P = 0.00005), a lower initial ICP and a mean ICP (P = 0.007 and 0.0009). The use of a protocol with standardised treatment goals in the management of traumatic brain injury allows for the optimal use of limited resources and provides consistency in treatment. Good outcome is related to early aggressive resuscitation to prevent hypotension and hypoxia, prompt evacuation of surgical mass lesions and the maintenance of an adequate cerebral perfusion pressure. Our results are comparable with that reported in other established neurotrauma systems.

Simultaneous emission transmission tomography using technetium-99m for both emission and transmission

This phantom study investigates whether attenuation maps from transmission data degraded by increased noise from subtraction of emission counts can still provide useful attenuation correction in the regular and obese chest. Technetium-99m was used for both emission and transmission on a triple head simultaneous emission transmission tomography (Tc-Tc SETT) system. Fanbeam transmission counts were computed by subtracting emission counts estimated from the two parallel collimator heads. Radioactive decay was used to simulate organ counts from injections of 900 and 400 MBq sestamibi for regular and obese chest sizes. Line source activity was 350 MBq. Control attenuation maps were obtained with no emission activity. Noise control included catering for negative and zero transmission counts, pre-filtering and segmentation of mu maps. Pre-filtering was tried before and after subtraction and before and after setting negative pixels to zero. Mean+/-SD count/pixel at the heart in anterior transmission projections was typically 33+/-18 for the regular and 1+/-7 for the obese chest. For the obese chest, pre-filtering before resetting negative counts best preserved mean mu in soft tissue and lung. Tc-Tc SETT mu mean+/-SD for the regular chest were 0.144+/-0.012 and 0.058+/-0.004 for soft tissue and lung and for the obese chest, 0.152+/-0.075 and 0.059+/-0.017. The accuracy of the Tc-Tc SETT bullseye plots for the regular chest was the same as with control map attenuation correction and 3 times better than with no correction. For the obese chest it was as good as with control map correction only if mu map segmentation was applied. Tc-Tc SETT soft tissue and lung mu in 28 patient studies indicated that segmentation is practical for a wide range of chest sizes. Tc-Tc SETT on a triple-head system offers an accurate, inexpensive method of attenuation correction for the majority of chest sizes.

Surgical excision of intracranial arteriovenous malformations after preoperative embolisation with N-butylcyanoacrylate

The aim of this study was to determine the usefulness of preoperative embolisation of intracranial arteriovenous malformations (AVMs) with N-Butylcyanoacrylate (NBCA) since the introduction of this interventional neuroradiology technique in March 1994 at Tan Tock Seng Hospital, Singapore. Twenty-one patients who underwent complete surgical excision of their AVMs (proven on postoperative angiograms) were studied. Eight patients had preoperative embolisation with NBCA prior to surgical excision of their AVMs. Thirteen patients had excision of their AVMs without preoperative embolisation and these were used as the control group. The parameters studied were the patient's AVM characteristics, the amount of blood loss and the length of operative time. Statistically significant reduction in blood loss occurred in Spetzler and Martin Grade 3 and 4 AVMs but not in Grade 1 and 2 AVMs undergoing preoperative embolisation with NBCA. Operative time was reduced in Grade 3 and 4 AVMs but not in Grade 1 and 2 AVMs, although this was not statistically significant. Preoperative embolisation of AVMs is hence a useful and important adjunct in the management of patients with Grade 3 and 4 AVMs of the brain undergoing conventional open microneurosurgery.

Brain abscesses: review of 30 cases treated with surgery

Thirty patients with brain abscesses who were treated at the Department of Neurosurgery, Tan Tock Seng Hospital, Singapore, during the period July 1989 to July 1993, were reviewed. There were seven females and 23 males with mean follow up duration of 19 months. The predisposing factors identified were otogenic infections in 10 cases (33%), paranasal sinus infection in 2 cases (7%) and congenital heart disease in 6 cases (20%). All cases underwent aspiration or excision of the abscess. Repeat operations were carried out if the abscess reaccumulated. A total of 49 aspirations and 16 excisions were performed. Twenty-five patients (84%) made a good recovery, three patients (10%) were moderately disabled, one patient (3%) was severely disabled and one patient (3%) died. There was no postoperative haemorrhage or wound infections. Two patients (7%) developed hydrocephalus and three (10%) had seizures postoperatively.

Immunochemical properties of Naja naja atra (Taiwan cobra) phospholipase A2 using polyclonal and monoclonal antibodies

The immuno-chemical properties of Naja naja atra phospholipase A2 (NNA-PLA2) were studied by using the chemically modified PLA2 derivatives and the PLA2 homologues toward anti-NNA-PLA2 polyclonal and monoclonal antibodies. Anti-NNA-PLA2 polyclonal antibodies inhibited the enzymatic activity of NNA-PLA2 and Hemachatus haemachatus DE-I by 87% and 68%, respectively. However, the enzymatic activities of Naja nigricollis CMS-9 and notexin were not significantly affected by the polyclonal antibodies. Competitive enzyme immunoassay revealed that the affinity of NNA-PLA2 for polyclonal antibodies was 330-fold higher than that of Hemachatus haemachatus DE-I. Naja nigricollis CMS-9 and notexin failed to inhibit the binding of NNA-PLA2 to polyclonal antibodies. This implies that the epitope(s) of NNA-PLA2 might comprise some substituted residues in the sequence of PLA2 homologues. Three monoclonal antibodies against NNA-PLA2 were prepared by a hybridoma technique. Two of these monoclonal antibodies inhibited the enzymatic activity of NNA-PLA2, but the other did not. Removal of the N-terminal octapeptide affected the epitope interacting with these monoclonal antibodies. Selective modification of tyrosine residues at positions 3 and 63 or lysine residues at positions 6 and 65 induced a substantial reduction in affinity of NNA-PLA2 for polyclonal and monoclonal antibodies. The three monoclonal antibodies failed to recognize PLA2 homologues. The comparison of the sequence of NNA-PLA2 to those of PLA2 homologues showed that most of the amino acid substitutions of PLA2 homologues occur in the spatially nearby region of the N-terminal region and residues at positions 63 and 65.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculoma of the brain--report of 2 cases and review of literature

Tuberculomas of the brain are relatively uncommon in developed countries nowadays. We report the only two cases that were seen in our Department in the last five years. Both patients presented with seizures and were found to have space occupying lesions on cranial CT scanning. They had no past history of tuberculosis, no evidence of current extracranial tuberculosis and the diagnosis of tuberculoma was made at the time of surgical excision. Underdiagnosis of tuberculoma of the brain is likely to occur in industrialised countries where tuberculosis is rare. The radiological investigation of choice is CT scanning with contrast enhancement and the presence of a target lesion is considered to be pathognomonic of a tuberculoma. Most tuberculomas of the brain can be treated medically with antituberculous chemotherapy. We recommended obtaining a definitive histological diagnosis with CT-guided stereotactic techniques prior to commencing antituberculous therapy. Surgical excision is necessary in patients with raised intracranial pressure secondary to the lesion and not responding to medical therapy.

CT-directed BRW stereotactic neurosurgery: local experience with 42 cases

Initial experience with the Brown-Roberts-Wells (BRW) computed tomographic (CT)-guided stereotactic system is reported. Forty-two procedures were performed over a 22-month period on 21 female and 20 male patients (one patient had a repeat procedure). Their ages ranged from 11 years to 89 years. These included 21 stereotactic biopsy procedures, 2 stereotactic implantations of third ventricular catheters through the foramen of Monro for intraventricular opiate insertion in terminal cancer patients, 2 stereotactic aspirations for brain abscess, 10 stereotactic aspirations of intracerebral haematomas, 3 stereotactic aspirations of cystic brain tumours, 1 stereotactic placement of a fourth ventricle-peritoneal shunt and lastly 3 stereotactic craniotomies. Successful targeting was achieved in all cases. There was one operation-related complication which resulted in uncontrollable intracerebral haemorrhage and ultimately led to the patient's demise.

A convenient method to differentiate the monoclonal antibodies with differing immunochemical properties

Three monoclonal antibodies (mAbs) against Naja naja atra phospholipase A2 (PLA2) were prepared by hybridoma technique. Of which two mAbs, 1E531 and 5F92 inhibited the enzymatic activity of PLA2, but 5F6F10 did not. 1E531 and 5F92 nearly exhibited the same binding patterns which was different from that observed with 5F6F10 toward the chemically modified derivatives and homologous variants of PLA2 as revealed by enzyme immunoassay. This suggests that, based on the results of comparative analysis on their relative reactivity with modified derivatives and PLA2 homologues, the mAbs with different immunochemical properties could be differentiated.

Nosocomial infections in a neurosurgery department

A three month prospective survey of nosocomial infections in a Neurosurgery Department was carried out. Results showed that the overall nosocomial infection rate was 6.7 per 100 patient discharges with the rate of infected patients being 4.6 per 100 discharges. Patients in intensive care had two times the risk of acquiring a nosocomial infection then patients in non-intensive care. Both respiratory tract and urinary tract infections accounted for the majority (89.1%) of the nosocomial infections. 69.7% of lower respiratory tract infections were associated with the use of endotracheal tube and/or ventilatory assistance. Similarly, 87.5% of urinary tract infections were associated with the use of indwelling catheters. It is hoped that preventive measures introduced or reemphasized just before and after the study will serve to further lower the nosocomial infection rate in the Neurosurgery Department.