Disturbances of the coagulatory system in patients with severe cerebral trauma. I

This is an investigation into thromboplastin time, partial thromboplastin time, plasma thrombin time, fibrinogen, and platelets in 30 patients with severe brain injury over 7--14 days. Platelets showed a very marked initial decrease and a slow return to normal around the seventh day. Fibrinogen was initially lowered in most of the cases, and raised from the second day onward. Changes in the other laboratory values were less definite. Latent signs of consumption coagulopathy were not accompanied by bleeding disorders, or by disseminated intravascular coagulation at autopsy. The severity of laboratory value changes clearly correlated with the extent of brain damage, and was significantly higher when the patient did not survive the first week after injury.

Origin and localization of Evans blue extravasations in acutely-induced hypertension in cats

An intravital-microscopic study on cat pial vessels for the localization of Evans blue extravasation during acute hypertension was performed. The onset of extravasation was seen 10 sec to 2 min after the beginning of hypertension. The localization of initial extravasation turned out to be little venules, not arterioles. Venular congestion by an overload of venous outflow seemed to be the origin of extravasation.

The sausage-string phenomenon in acutely induced hypertension--arguments against the vasospasm theory in the pathogenesis of acute hypertensive encephalopathy

Pial microcirculation was observed in cats during acutely induced blood pressure increase using the window technique. Measurements of arteriolar diameter changes in situations of preserved and altered cerebrovascular autoregulation were made, when diffuse vasoconstriction and sausage-like dilation, respectively, occurred. Comparison of percentage changes of narrow segments between sausage-like dilated arterioles and diffusely constricted (= autoregulating) vessels gave evidence that a failure of autoregulation in this situation is not associated with vasospasm but with dilation. Individual narrow segments did not constrict more--but on an average even rather less--than diffusely constricted vessels. Evans blue extravasation occurred only with dilation, never with vascular constriction. From these data it is concluded that extravasation due to acute blood pressure increase is not of ischemic nature, but a consequence of high filtration pressure due to arteriolar and venous congestion.

[Pial vessel reactions in acute hypertension--an intravital microscopic study and its clinical relevance to traumatic brain oedema (author's transl)]

A fluorescence-angiographic investigation is presented of pital vessel reactions to acute drug-induced hypertension in cats. Observations and documentation were carried out by an intravital-microscopic technique. Acute hypertension, where pressure values of 220 to 260 mm Hg were reached within 10 to 20 sec, was followed by marked vasodilatation: Arterioles under 50 mu in diameter and capillaries were dilated to between 200 to 300% of the resting diameter, whilst arterioles of 50 to 100 mu showed an increase of 50 to 60%. Reddening of veins and acceleration of the blood flow occurred. Vasodilatation persisted after the blood pressure values had returned to normal. In connexion with investigations of the blood pressure immediately after a head injury, the role of acute hypertension in the development of hydrostatic brain oedema is discussed.

Brain edema in acute arterial hypertension. I. Macroscopical findings

Observation of brain edema formation after acute drug-induced arterial hypertension-investigation in 15 cats. Intravital staining with astraviolet-FF and Evans-blue showed two different types of BBB-dysfunction, the one diffuse and without protein extravasation, the other multilocular and protein-rich, both localized in the cortical grey matter during the first 5 min after beginning of hypertension. The formation of protein-rich extravasation appeared to be dependent on the percentage increase of blood pressure, less on the peak of its absolute value.

[External ventricular drainage--a new aspect in the operative treatment of head injury (author's transl)]

It is not only for CSF-removal in conservative treatment of oedema and control of the effectiveness of osmo-onco-therapy, contricosteroids, anticholinergics and aldosterone-antagonists, that external CSF drainage in severe cerebral trauma has proved of value. It has also made it possible to assess objectively the indications for bitemporal craniotomy in raised intracrainial pressure with an acute midbrain syndrome caused by tentorial herniation. Continuous monitoring of ICP permits an intervention at the right time and prevents one from operating too late, namely at a moment, when manifest neurological signs already indicate cerebral decompensaervative steps failing, a bitemporal craniectomy is indicated: in this way we lower intracranial pressure, liberate the rostral brain stem out of its strangulation and improve cerebral perfusion and metabolism.

[Proteolytic enzyme activity in the cerebrospinal fluid after head injury--a preliminary report (author's transl)]

Report on seven cases of severe head injury, where proteolytic enzyme activity in the ventricular fluid was measured within a period of eight days. The result was positive in four cases. This finding is discussed in relation to clinical features and morphology. Earlier reports and these results are considered.

The role of cerebral perfusion pressure as origin of brain edema in acute arterial hypertension

In a series in 8 cats, cerebral perfusion pressure (CPP) was evaluated over a period of 5 min after production of an acute arterial hypertension. The mean percentual increase of blood pressure, CPP and ICP equalled 100%. the fact, that ICP does not play any role in acute hypertension, indicates that an abrupt elevation of filtration pressure within the capillaries must be the decisive factor leading to edema.

Serum globulin changes in patients with craniocerebral trauma

Investigations of serum total protein, albumin, alpha-1, alpha-2, alpha-2M, beta- and gamma-globulin changes are reported in 48 patients with craniocerebral trauma. Only alpha-2 and alpha-2M globulins showed important variations, the first rising to three to four times normal values (112% on average) and directly correlating with the amount of tissue lesions. Alpha-2M changes were rather irregular with a tendency to severe decrease during the first days in patients with a bad prognosis. Reasons for non-regular changes of alpha-2M are discussed. Alpha-1 globulin showed a similar though less marked increase. Gamma globulin, on average, was diminished in the first week.

[Changes of serum proteins after craniocerebral trauma - comparison of alpha 2 and alpha 2M (author's transl)]

Quantitive estimations of serum proteins, including Alpha 2M globulin, from 34 patients suffering from craniocerbral trauma have been carried out. The mean value curves over a period of two weeks following trauma are presented graphically. After severe injuries, depending on the size of the cerebral lesions, an increase in Alpha 2 of prognostic significance has been observed. Levels of Alpha 2M do not correlate directly with Alpha 2 globulin, and tend to fall initially. Falls in the first three days after injury may be prognostically significant from the point of view of the prediction of a lethal outcome. There are no significant changes in the levels of total protein, albumin, Beta globulin or Gamma globulin, but Alpha 1 globulin follows the curve of Alpha 2, although to a less marked degree. Correlations between serum protease activites and increases in Alpha 2 due to enzymatically active complexes are unconnected with Alpha 2M, a decrease in which indicates increased inhibitor activity and exhaustion of the inhibitor system.

[A contribution to the pathophysiology of post-traumatic brain oedema (author's transl)]

The aim of this paper is to contrast new results obtained on the activities of lysosomal proteases in the brain of traumatized animals with the previously held opinions concerning the development of post-traumatic brain oedema. Two hours after a standardized head injury in the cat, acid and neutral proteases were determined in the brain homogenate. Total as well as free activity, especially of the neutral proteases, were markedly increased after head injury, a circumstance indicating the important role of lysosomes in the development of post-traumatic brain oedema. It is postulated that not hypoxia alone, but primary or secondary disturbance of lysosomal function is the predominant factor in the development of brain oedema. Release of enzymes -- especially proteases -- causes irreversibility of initial vascular oedema by autolysis of cellular structures.

[The use of the "anti-G-suit" during operations in the sitting position as a treatment of postural hypotension.(author's transl)]

The use of the "Anti-G-Suit" in patients with postural hypotension is described. Acute falls in the blood pressure during operations in the sitting position can be successfully treated with the aid of an external counterpressure garment reaching from ankles to xiphoid process. The mean increase in systolic blood pressure was about 60% in hypotensive and 17% in normotensive control patients. A reciprocal relation between pre-treatment blood pressure and its increase after use of the "G-Suit" was noticed. In contrast to previous practice, we were able to operate on all hypotensive patients in poor condition. The effect of external counterpressure on the lower part of the body can be explained by increase of peripheral resistance and decrease of vascular flow, resulting in better venous return, displacement of the circulating blood above the diaphragm and augmentation of systolic blood pressure.