[Intracranial aneurysm and dysplasia of elastic tissue: pre- and postoperative problems]

From two cases of patients presenting a cerebral aneurysm associated with a dysplasia of elastic tissue, one a Marfan's syndrome, the other an anetoderma, this paper relate the post-operative, essentially cardio-vascularly and pulmonary complexities and define the elements of the pre-operative check-up.

[Neurogenic pulmonary edema, complication of meningeal hemorrhage: report of 4 cases]

Neurogenic pulmonary edema (NPE) observed in 4 patients admitted in Neurosurgical Intensive Care au SAH by ruptured a vascular malformation. This complication is unusual (1.9%) and has been observed in comatose patients. For 3 patients, NEP resorption was rapid, from 12 to 72 hours with a treatment by CCPV with a P.E.E.P. and with restoring the hemodynamical parameter. The drug must be discussed according to eventual deleterous side effects on cardiac output and systemic resistances. The early hemodynamical study argues for an essentially hemodynamical mechanism due to the brutal symphatic discharge created by cerebral lesions and increasing. ICP, more than a toxic lesionnal edema, as the Weidner's study shows it in ultrastructural analysis of sheep lungs.

[A rare and severe complication of meningeal hemorrhage: spinal arachnoiditis with paraplegia]

This observation relates a case of spinal arachnoiditis with paraplegia, for a 56 year old patient hospitalized for a S.A.H. by a ruptured aneurysm of the P.I.C.A. This patient present some complications, requiring a prolonged ventilatory support with a tracheostomy, a ventricular shunt for hydrocephalus. The treatment is only surgical, and the corticosteroids delay the evolution, but without successful outcome.

[Blood coagulation disorders in intracerebral hematoma caused by rupture of intracranial angioma. Incidences on hemorrhagic recurrence]

In 34 patients admitted in Neurological Intensive Care Unit, for a cerebral hematoma by ruptured arterio-venous malformation, are present in 26 patients, on the first day. In many cases, the APTT is increased and this can be respected. These disorders do not seem to modify the incidence of delayed hemorrhage, except for the severe perturbances, related to a DIC or an hepatic deficiency. In these cases, the delayed hemorrhage must be prevented by transfusions of platelets and/or freeze fresh plasma.

[Intracerebral hematoma caused by rupture of intracranial angioma. Analysis, prognosis and clinical course of 35 comatose patients admitted to intensive care units]

The outcome of 35 patients in deep coma (GSS less than 7) due to an intracerebral hematoma following ruptured arteriovenous malformation (AVM) and admitted to a neurosurgical intensive care unit is reviewed. Eighty percent of these patients had a cerebral AVM and 20% had an AVM in the posterior fossa. All had a medical treatment of increase intracranial pressure (ICP). Twenty-four patients or 68.6% had an early surgical treatment or some days further and 13 had a good outcome, six had a persistent coma or a residual neurological deficit and five died. Four patients or 11.4% had an endovascular embolisation therapy and three had no satisfactory results and one died; all had a new intracranial hemorrhage with hematoma. Seven patients were not treated: four died before 48 hours of hospitalisation, one is in persistent coma and two are waiting an endovascular embolisation, alive but with a neurological deficit. The results suggest that neurosurgical treatment are a safe and effective means for treatment of these AVM with compressive intracranial hematoma.

A controlled study of Dextran 40: effect on cerebral blood flow and metabolic rates in acute head trauma

A controlled double-blind evaluation of the effects of Dextran 40 at different concentrations on cerebral blood flow (CBF), cerebral oxygen consumption (CMRO2) and cerebral lactate production (CMRLact) was carried out. We studied 40 patients in coma due to recent head injury. Concentrations of Dextran solution were not significantly related to variations in CBF and metabolic rate over the period of infusion. The lack of effect of the Dextran infusion may be explained by the absence of global brain ischemia in these patients at the time of the study. The very low initial CBF values were a consequence of brain metabolic depression and not a sign of global ischaemia. The rheological benefits of treatment with Dextran 40 in head injured patients should preferably be investigated using techniques which permit detection of local changes in CBF and metabolism.

Transient drug-induced abolition of BAEPs in coma

Combined infusion of high doses of lidocaine and thiopental in a comatose patient induced major latency and amplitude BAEP changes, which progressed to complete BAEP abolition. Responses returned to normal after drugs were discontinued. EEGs during the episodes showed long-lasting periods of activity suppression, but were never isoelectric. BAEPs are resistant to hypothermia and barbiturates, but must be interpreted cautiously in patients treated with a combination of anesthetic drugs that includes lidocaine.

Brain-stem monitoring. I. A system for high-rate sequential BAEP recording and feature extraction

A computerized system is proposed for the continuous automatic monitoring of BAEPs in the intensive care unit or in the operating room. A new adaptive optimal digital filtering technique has been developed to allow BAEP recording with 200-400 stimulations, i.e., within 10-20 sec only, every 2 min. This method permits a selective cancellation of the major artifacts as soon as they occur: electrical interference and myogenic activities which are commonly encountered in such environments. An algorithm for automatic peak detection (waves I-V) has been implemented, and the whole system has been evaluated in terms of reduction of the intra-individual variability of latencies and amplitudes. Some clinical examples of comatose patient monitoring are briefly presented to illustrate the performance and the reliability of the system.

Brain-stem monitoring. II. Preterminal BAEP changes observed until brain death in deeply comatose patients

Preterminal BAEP changes were studied until brain death in 8 head-injured patients out of a series of 38 comas monitored by means of a system allowing high-rate sequential recording. Two different modalities of BAEP degradation were disclosed: (1) simultaneous latency increase of all components associated with a decrease of cerebral perfusion pressure (CPP), consistent with ongoing ischaemia of the posterior fossa; (2) deterioration of brain-stem components (waves III-V) with preserved or even enhanced wave I. The latter pattern was not consistently associated with any haemodynamic change and might be related to mechanical factors causing rostro-caudal deterioration of brain-stem function. The time course of BAEP degradation ranged from a few minutes to more than 10 h. In the case of slow preterminal evolution definitely pathological trends were identified even when individual BAEPs were still within normal limits. Such trends would have remained unnoticed in single BAEP records. Hypothermia and anaesthetic drugs were found to induce falsely alarming BAEP changes very similar to those seen during preterminal evolution. Our results suggest that continuous brain-stem monitoring could be helpful for management of comatose head-injured patients.