Complications and pitfalls of neuroendoscopic surgery in children

OBJECT

Neuroendoscopic surgery is being used as an alternative to traditional shunt surgery and craniotomy in the management of hydrocephalus and intracranial fluid-filled cavities. In this study, the authors evaluated the incidence and type of complications occurring after neuroendoscopic procedures that were performed in a consecutive series of pediatric patients at a single institution to determine the effectiveness of neuroendoscopy in such patients.

METHODS

Four hundred ninety-five neuroendoscopic procedures were consecutively performed in 450 pediatric patients at one institution over a 10-year period. Charts were retrospectively reviewed. A complication was defined as follows: 1) any postoperative neurological deficit that was not observed before surgery; 2) any event occurring during surgery that resulted in the procedure being aborted; or 3) any adverse event occurring within 7 days postsurgery that resulted in a modification of the normal postoperative care. However, headache, vomiting, and fever without cerebrospinal fluid (CSF) pleocytosis were not considered complications. Complications were observed in 40 (8.1%) of 495 procedures. Two patients had two complications. One patient died of diffuse brain edema following endoscopic biopsy sampling of a basal ganglia tumor (mortality rate 0.2%). Other complications observed were abandonment of the procedure in eight cases, CSF leakage in 11 (with associated wound infection in one), intraventricular hemorrhage in six (with external drainage needed in four), intraparenchymal hemorrhage in three, subdural collection in eight (with subdural-peritoneal shunt placement needed in seven), transient oculomotor palsy in two, and transient hemiparesis in one.

CONCLUSIONS

Many complications can be avoided by determining the correct diagnosis and using suitable techniques and instruments. Most complications can be managed conservatively and do not produce long-term morbidity. Complex procedures in most patients and simple procedures in patients with preoperative risk factors carry the highest hazard. Every attempt should be made to optimize the surgical technique. The most serious and potentially the most lethal complication remains arterial bleeding from injury to the basilar artery complex.

Pure pineal germinomas: analysis of gender incidence

OBJECTIVE

Pure pineal germinomas have been rarely reported in girls. Gender incidence and differences of pure pineal germinomas are not well known. The authors report a series of pure pineal germinoma and its gender characteristic is reviewed.

METHODS AND RESULTS

Of a total of 50 germ cell tumors operated on between 1988 and 2004 we found 26 cases (median age at diagnosis, 12 years) of pineal germ cell tumors. Of these, 14 cases (male/female ratio: 13/1) were pure pineal germinomas, and 12 cases (male/female ratio: 12/0) were non-germinoma germ cell tumors. In pure pineal germinomas, the main clinical presentations were intracranial hypertension and cranial nerve dysfunction. Imaging studies disclosed a homogeneous type of tumor (n = 10) and associated hydrocephalus (n = 6). Cases were managed with biopsy and subsequent radiation therapy and chemotherapy. After a follow up of 10 years, pure germinoma cases have no neurological deficits and tumor recurrence. The literature on gender incidence of pure pineal germinomas is analyzed and possible causes are discussed.

CONCLUSIONS

Although rare, pure pineal germinoma can be found in female subjects. On the basis of the literature review, the male/female ratio in cases of pure pineal germinoma is between 5:1 and 22:1 (mean 14:1). In our series, the male/female ratio was 13:1.

Pure intramedullary spinal cord metastasis secondary to gastric cancer

Pure intramedullary spinal-cord metastases (ISCM) are a rare manifestation of cancer. We report a case of ISCM from gastric cancer. A 68-year-old man, treated with total gastrectomy for a gastric cancer, presented 9 months later with paresis of the left arm, pain and dissociated sensory loss. Magnetic resonance imaging revealed a pure intramedullary lesion at the C3-C5 level. After surgical resection, pathological findings revealed an undifferentiated adenocarcinoma of gastric origin. To our knowledge, this is only the second report of ISCM from gastric cancer in the literature.

Primary meningeal pheochromocytoma: case report

OBJECTIVE AND IMPORTANCE

Intracranial pheochromocytomas are extremely rare tumors. Reported cases include metastatic tumors without known cases of primary pheochromocytomas.

CLINICAL PRESENTATION

A female patient with a history of a surgically treated adrenal pheochromocytoma presented 23 years later with headache, nausea and blood hypertension. A head CT scan demonstrated a right temporoparietal meningeal heterogeneous lesion with a surrounding hyperdense ring. No other lesions were disclosed.

INTERVENTION

The lesion developed in the inner and outer surface of the dura without brain infiltration and it was totally resected. The patient is free of disease 6 years after brain surgery.

CONCLUSION

To our knowledge this is the first reported case of a primary meningeal pheochromocytoma.

Use of ultrasonic aspiration for dural opening in cranial reoperations: technical note

OBJECTIVE

Dural detachment from the brain in cranial reoperations has been accomplished previously by selective coagulation and the cutting of brain-dural adhesions. The results of ultrasonic aspiration during tumor surgery or brain cutting procedures led the authors to speculate that the detachment of the dura mater from brain tumors by applying the Cavitron ultrasonic surgical aspirator (Valleylab, Boulder, CO [formerly Cavitron, Inc., Stamford, CT]) to the brain-dura mater interface could be used to reduce bleeding and facilitate dural opening during cranial reoperations.

METHODS

Ten patients underwent a second craniotomy for epilepsy surgery (five cases of extended temporal lobectomy and five cases of extended extratemporal lesionectomy). The use of ultrasonic aspiration and its effects on brain separation from the dura mater were examined.

RESULTS

Intraoperative use of the Cavitron ultrasonic surgical aspirator during dural opening produced immediate blanching of the dura mater and enhanced visualization of the cortical surface without distortion of the brain anatomy.

CONCLUSION

Incremental dural opening and brain visualization is achieved by careful application of ultrasonic aspiration directly into the brain-dura limit, producing immediate regional dural devascularization. Use of this technique reduces cortical and dural bleeding and enhances the ease and effectiveness of brain visualization.

Cervical cyst of the ligamentum flavum and C7-T1 subluxation: case report

A patient with progressive gait disturbance resulting from a cyst of the cervical ligamentum flavum associated with C7-T1 listhesis is reported. Surgical removal of the cyst improved the patient's myelopathy. Intraspinal degenerative cysts are preferentially located in the lumbar region:unusual is the cervical localization. Differential diagnosis includes ligamentum flavum cyst, synovial and ganglion cysts. Association between degenerative intraspinal cysts and listhesis is discussed. To our knowledge, this is the first case of cyst of the ligamentum flavum associated with cervical subluxation.

Lateral Ventricle Tumors: Surgical Strategies According to Tumor Origin and Development— A Series of 72 Cases

OBJECTIVE:

Optimal surgical management in lateral ventricle tumors remains controversial. We conducted a retrospective study of patients with these lesions treated with a surgical strategy on the basis of tumor origin: primary or secondary ventricular and associated transependymal development.

METHODS:

A total of 72 patients underwent surgery for lateral ventricle tumors. The mean patient age was 39 years (range, 6 mo to 78 yr). Raised intracranial pressure occurred in 53% of patients, followed by mental disturbances or psychiatric symptoms (32%) and motor deficits (21%). The transcortical approach was used in 44 patients, and an interhemispheric approach was used in 28 patients; a transcallosal approach was used in 16 patients, and a parasplenial approach was used in 12 patients. Neuropsychological tests were performed in selected patients.

RESULTS:

Total resection was performed in 82% of patients. Sixty-five percent of tumors were benign and low-grade tumors. There was no surgical mortality, and the morbidity rate was 11%. Postoperative epilepsy (5.9%) was significantly increased in the transcortical group. The mean follow-up period was 55 months; 59% of patients achieved good recovery and moderate disability. In postoperative neuropsychological testing sessions, deficits in verbal memory were observed in six patients (8%). Final morbidity correlated well with preoperative clinical condition and pathological diagnosis.

CONCLUSION:

Lateral ventricle tumors can be treated best by careful selection of the approach according to tumor origin and development. Overall, the transcallosal approach is preferred, but in patients with transependymal growth or large primary or secondary ventricular tumors, the transcortical is a better option.

Correlation between Withdrawal Symptoms and Medication Pump Residual Volume in Patients with Implantable SynchroMed Pumps

OBJECTIVE:

To investigate whether patients with implantable SynchroMed pumps (Medtronic, Inc., Minneapolis, MN) develop symptoms of drug withdrawal at residual medication volumes that exceed 2 ml (the alarm residual volume recommended by the manufacturer).

METHODS:

The data sheets of 88 patients with implantable SynchroMed pumps were retrospectively reviewed. The following parameters were analyzed: development of symptoms of drug withdrawal; drugs used in the pump; disease state; drug residual volume in the pump; intake of orally administered medications; time of development of withdrawal symptoms; drug flow volume through the pump; daily intrathecally administered drug dose; and drug concentration in the pump.

RESULTS:

Of 88 patients, 21 (24%) consistently developed symptoms of drug withdrawal 1 to 7 days before the drug residual volume reached a mean of 2.7 ml (range, 2.1–3.8 ml; median, 2.6 ml). Symptoms first developed 1 to 18 months after surgery. In all patients, symptoms of drug withdrawal subsided after pump refill and did not recur after the alarm volume was increased to 4 ml. Symptom development did not correlate with intake of orally administered medication, drug flow volume through the pump, intrathecally administered drug dose, drug concentration in the pump, drugs used in the pump, or disease state.

CONCLUSION:

Some patients develop symptoms of drug withdrawal at residual volumes that exceed 2 ml. We could not identify factors that predict this occurrence. Withdrawal symptoms did not recur when the alarm volume was increased to 4 ml.

Transcranial Doppler in infantile cerebrospinal fluid disorders: clinical validity

The present study was designed to investigate a possible relationship between transcranial Doppler sonography (TCD) parameters with infantile hydrocephalus and other types of cerebrospinal fluid (CSF) abnonnalities, i.e. arrested hydrocephalus and essential ventriculomegaly. TCD parameters in the major arteries of the circle of Willis were studied in hydrocephalic children (n = 12) before and after insertion of a ventricular shunt device. It was correlated with TCD parameters of children with CSF disorders (n = 13), in whom no surgery was performed. Also, TCD parameters were assessed in control cases (n = 10). Mean values for medial cerebral artery (MCA) flow velocities were higher in the essential ventriculomegaly (75.38 +/- 4.1) and in the control group (73.93 +/- 3.4) compared with hydrocephalic children (64.13 +/- 5.3). All hydrocephalic children had a higher mean MCA pulsatility index (RI) (1.08 +/- 0.13) and resistance index (RI) (0.64 +/- 0.17) values than the essential ventriculomegaly group (PI: 1.03 +/- 0.48; RI: 0.63 +/- 0.13) and the control group (PI: 0.84 +/- 0.32; RI: 0.57 +/- 0.23). Analysis of all TCD parameters disclosed its usefulness only after a particular and thorough evaluation of the TCD results with special emphasis in the clinical correlation of every case.

Cavum septum pellucidum and its increased prevalence in schizophrenia: a neuroembryological classification

Thirty-two female (mean age=52.9 years [SD=9.2]) patients with a diagnosis of residual schizophrenia and 19 female (mean age=51.1 years [SD=12.7]) control subjects were studied through cerebral Magnetic Resonance Imaging. Along the entire surface of the septum pellucidum, 1-mm coronal slices were performed in all subjects. The authors classified the cavum septum pellucidum into three types based on embryological development. The prevalence of a cavum was significantly higher in the patients with schizophrenia (Chi square 6.112. p < 0.05). No other significant associations with previously described morphological brain changes were found. Although this result was found in previous reports (DeGreef et al., 1992; DeLisi et al., 1993), our discussion focused on the neurodevelopmental theory of the septum pellucidum and its possible association with schizophrenia.

Outcomes of Cubital Tunnel Surgery among Patients with Absent Sensory Nerve Conduction

OBJECTIVE

To report the outcomes of cubital tunnel surgery for patients with absent ulnar sensory nerve conduction.

METHODS

The charts of 34 patients who exhibited clinical symptoms of ulnar nerve entrapment at the elbow and who had electromyography-confirmed prolonged motor nerve conduction across the cubital tunnel in association with absent sensory nerve conduction were reviewed. The mean age was 63 years, and the mean symptom duration was 17 months. Four patients had bilateral symptoms. Surgery was performed for 38 limbs, i.e., neurolysis for 21 limbs and subcutaneous transposition for 17 limbs. Fifteen limbs demonstrated associated ulnar nerve-related motor weakness. The mean postoperative follow-up period was 4 years (range, 3 mo to 11 yr).

RESULTS

Sensory symptoms (i.e., pain, paresthesia, and two-point discrimination) improved in 20 limbs (53%), and muscle strength improved in 2 limbs (13%). Improvements in sensory symptoms were not related to patient age, symptom duration, cause, severity of prolonged motor nerve conduction, select psychological factors, associated medical diseases, associated cervical pathological conditions, or type of surgery. Improvements in sensory symptoms were significantly decreased among patients who had experienced cervical disease for more than 1 year and patients with bilateral symptoms.

CONCLUSION

Patients with cubital tunnel syndrome who have absent sensory nerve conduction seem to experience less improvement of sensory symptoms after surgery, compared with all patients with cubital tunnel syndrome described in the literature. Bilateral symptoms and delayed surgery secondary to associated cervical spine disease seem to be significant negative factors for postoperative improvement of sensory symptoms. Sensory symptoms improved similarly among patients who underwent neurolysis or subcutaneous transposition

Pure subcutaneous seeding from medulloblastoma

The authors present a patient with subcutaneous tumors associated with a desmoplastic medulloblastoma. This 6-year-old male who had previously undergone total removal of a cerebellar medulloblastoma was admitted because of new tumoral masses in the abdominal wall and the nuchal area. Ultrasound imaging demonstrated that both lesions were in the subcutaneous tissue. Both tumors were in the vicinity of the surgical incisions, which implies that they were implanted during previous procedures. Pathologic examination of the tumors obtained from gross surgical resection revealed medulloblastoma but with less advanced differentiation compared with the primary neoplasm. This report discusses unusual pure limited subcutaneous metastases of medulloblastoma. The objective of this report is to bring into consideration this presentation of medulloblastoma to the neurologic differential diagnosis.

Tonsillectomy without craniectomy for the management of infantile Chiari I malformation

OBJECT

The authors report their experience with 15 pediatric patients who underwent resection or shrinkage of the cerebellar tonsils without craniectomy or laminectomy, for the management of Chiari I malformation.

METHODS

The procedure was performed in six boys and nine girls with a mean age of 10 years. Thirteen patients presented with the congenital form of this disorder and two patients with Chiari I malformation caused by lumboperitoneal shunting. Clinical complaints included headaches (seven patients), scoliosis (four patients), numbness of the extremities (four patients), and upper-limb weakness (two patients). Two patients presented with failure to thrive and one with vocal cord palsy. Eight patients (six girls and two boys) had syringomyelia. The patients' symptoms had developed within a mean time period of 21 months (range 1-70 months). In all patients the cerebellar tonsils were exposed through a dura mater-arachnoid incision at the occipitoatlantal space. In seven patients the tonsils were resected and in the remaining eight patients the tonsils were shrunk by coagulating their surfaces. All patients improved postoperatively. Gliosis with cortical atrophy was observed in the resected neural tissue. Syringomyelia was reduced in seven of eight patients. The mean length of the follow-up period was 7 months.

CONCLUSIONS

Removal of herniated cerebellar tonsils can be sufficient for alleviating symptoms in patients with Chiari I malformations.

Symptomatic supratentorial arachnoid cysts in children

This study was undertaken to evaluate the clinical and radiologic long-term outcome of symptomatic primary arachnoid cysts in pediatric patients. Thirty-three children, ranging from 2 months to 17 years of age (mean age, 6 years) were treated. Craniotomy and fenestration of the cyst were used for temporal fossa and midline cysts in 24 patients (73%); later, two patients required shunt placement. Shunting device implantation was performed for cerebral convexity cysts in nine patients (27%), and two patients required a subsequent craniotomy and fenestration of the cyst. Four patients (12%) required additional surgery because of clinical progression rather than for cyst enlargement. Eleven patients (33%) experienced a cyst reduction of more than 50% compared with the original size on imaging studies. There was a significant correlation with the alleviation of symptoms (P < 0.005), regardless of the treatment used. Complete alleviation of symptoms was achieved in all patients after treatment, regardless of cyst reduction. Long-term follow-up of 70 +/- 9.3 months demonstrated no recurrence of symptoms or progressive enlargement of the arachnoid cyst in all children.

Evidence of the subcommissural organ in humans and its association with hydrocephalus

A group of structures in the human central nervous system (CNS) represents a noteworthy dilemma for the neuroscientist, particularly to the neuroanatomist. In this paper an attempt is made by extensive review of the literature to give an account of the significance of the subcommissural organ (SCO) in humans and its possible relationship with cerebrospinal fluid (CSF) disorders. The subcommissural organ is a gland located in the diencephalic plate caudal to the pineal organ that covers the anterior part of the posterior commissure. Histologically, it is a highly differentiated ependyma. After birth, the SCO undergoes regressive changes, and in the adult human only remnants of the specialized SCO cells can be found. The Reissner's fiber (RF) may be regarded as a pure secretory product of the SCO. Only a few vertebrate species have been reported to lack an RF, namely the bat, camel, chimpanzee, and man. Nonetheless, a successful immunoreaction against a proteinaceous compound of the fetal human SCO has been performed. Recently, new interest was elicited regarding SCO and its possible implication in the pathogenesis of hydrocephalus. The objective of this review is to bring into consideration the relevance of the SCO to the neurosurgical scenario.

Pediatric granulomatous cerebral amebiasis: a delayed diagnosis

We present four cases of cerebral amebae infection treated at our neurosurgical department. Patient 1 was a 12-year-old male with skin lesions of 2 years' progression involving the midface. He received a corticosteroid course, and, after that, he presented a right body hemiparesis. Patient 2 was a 5-year-old male, with a past surgical history of fibula fracture and osteomyelitis of 1-year evolution, associated with lesions of the surrounding skin that presented with partial seizures. Patient 3 was a 3-year-old female who presented with a stroke-like episode and with partial seizures. Patient 4 was a 6-year-old male who had ulcerative lesions in the face of 1-year evolution. After a corticosteroid course, he presented with right-body hemiparesis. All patients were human immunodeficiency virus-negative and died 1 month or less after surgery because of progressive evolution of the disease. Histopathology revealed granulomatous amebic encephalitis. All patients revealed infection from Balamuthia mandrillaris (Leptomyxiidae). Treatment consisting of pentamidine, clarithromycin, fluconazole, and 5-fluorocytosine was ineffective. Although extremely uncommon, granulomatous amebic encephalitis should be considered in the differential diagnosis of cerebral lesions while nonspecific, associated granulomatous skin lesions support the diagnosis of amebiasis.

Distal slit valve and clinically relevant CSF overdrainage in children with hydrocephalus

INTRODUCTION

Distal slit valve (DSV) is a system designed for the treatment of hydrocephalus. It has been assumed that, by dispensing with an anti-siphon (AS) mechanism, the DSV induces a set of clinical symptoms associated with fluid overdrainage in patients. Nonetheless, there is no published evidence to support this assumption.

MATERIALS AND METHODS

Thus, to determine whether such an association is valid, we reviewed the records of 101 hydrocephalic patients (150 procedures) who had DSVs placed at our institution. The records of 40 hydrocephalic patients (69 procedures) in whom anti-siphon devices (AS) were placed were also reviewed.

RESULTS

One DSV patient presented with slit ventricle syndrome (SVS) and low intracranial pressure (ICP). No DSV patients had postoperative subdural collection. One AS patient had a postoperative subdural collection. Thirty-one DSV patients (31%) each required one revision, and 8 (8%) required more than one revision. Twelve AS patients (30%) required one revision and 8 AS patients (20%) required more than one revision. No significant differences were found between the DSV and AS groups in number of revisions, infections or overdrainage.

CONCLUSION

We did not find a direct correlation between clinically relevant CSF overdrainage and DSV.

Functional assessment of children with cerebral palsy following limited (L4-S1) selective posterior rhizotomy--a preliminary report

OBJECTIVE

Selective Posterior Rhizotomy (SPR) is effective for reducing spasticity in children with cerebral palsy (CP). Nonetheless, extensive sensory deafferentation associated with this procedure can lead to prolonged postoperative hypotonia that delays the functional recovery of the patient. As lumbar rhizotomy provokes suprasegmental hypotonia, we hypothesized that reducing the extent of the deafferentation to the roots of L4-S1 levels would reduce the risk of postoperative hypotonia.

METHODS AND RESULTS

Five patients with spastic cerebral palsy (4 males and 1 females, age range: 4-12 years) underwent limited selective dorsal rhizotomy (LSDR) of three (L4-S1) dorsal roots. All patients were able to walk independently prior to surgery. Functional assessments of these patients were performed pre and post operatively. Assessments included spasticity evaluation, passive range of motion, and sagittal plane kinematics of the hip, knee, and ankle during walking. Following surgery, reduced spasticity, increased passive range of motion and improved joint motion during walking was observed. Specifically, peak hip and knee extension and peak ankle dorsiflexion increased while peak plantarflexion decreased.

CONCLUSIONS

Strength and motor control were not adversely affected by this procedure in any of the subjects and all patients actually demonstrated improvements. Previous studies have demonstrated that LSDR is highly effective in reducing spasticity and achieving functional outcome in spastic children. The results of this study demonstrated improved function during walking as assessed using gait analysis techniques.

Acute spinal cord swelling in a child with Chiari II malformation

We report on a patient with Chiari II malformation who developed acute cervical myelopathy and brainstem dysfunction following a shunt failure. A brain and spine magnetic resonance image obtained immediately after admission evidenced swelling of the medulla and upper cervical spinal cord. After emergency placement of an external ventricular drain, the swelling receded, the child's respiratory pattern improved and the motor function of his upper and lower extremities progressively returned to its normal condition. The case reported here suggests that in patients with Chiari type II malformation, spinal cord swelling might have a similar pathophysiology to the periventricular edema observed in the supratentorial compartment, and thus may be independent of the early stages of syringomyelia or syringobulbia.

Cerebral aspergillosis in children. Report of three cases

Between March and December of 1997, 3 cases of infantile cerebral aspergillosis appeared in our hospital. All patients presented some kind of immunosuppression associated with clinical findings of intracranial hypertension. After surgery, all cases were histopathologically confirmed and had positive cultures of Aspergillus. The first case was a patient with a history of subtotal resection of supratentorial ependymoma which presented a new enhancing mass on a control CT scan. Brain tumor recidiva was suspected, although, an Aspergillus granuloma was encountered on the tumor bed. Both other cases were found in patients who underwent transplantation: one presented multiple cerebral lesions after a renal transplant, and the other, after a bone marrow transplant, developed a rhinocerebral aspergillosis. The discussion was focused on the clinical findings, images and treatment of this cerebral infectious disease.

[Morphological changes of the corpus callosum in schizophrenia]

Morphological brain alterations have long been noted in schizophrenia, although it is unclear whether they are a consequence of an early disturbance in brain development or represent a deterioration of a normal brain structure. The purpose of the present study is to establish a relationship between corpus callosum (CC) surface and perimeter. A female right handed schizophrenic group (n = 31) was compared with a control group (n = 25) of comparable sex, age (range: 40-68 years) and handedness on measures of the CC area from a midsagittal T1 weighted image magnetic resonance imaging. Patients completed DSM IV criteria for Residual Schizophrenia. Patients with a known history of brain injury or neurologic illness were excluded. All had received neuroleptic drugs but no electroconvulsive treatment. Control and schizophrenic groups were subdivided into two age-ranges (E1 < or = 54 years and E2 > 54 years). Mean +/- SE (cm2) of CC surface in controls E < or = 54 and E > 54 were respectively 7.09 +/- 0.42 and 8.97 +/- 0.62 (p < 0.01) and in schizophrenics E < or = 54 and E > 54 were respectively 7.61 +/- 0.24 and 6.60 +/- 0.29 (p < 0.05). Among control and schizophrenic E > 54 sub-groups there were significant differences (p < 0.01). Statistically significant differences among sub-group values were obtained through analysis of variance. Correlation coefficient (r) between age and surface in control and schizophrenic groups were respectively 0.55; p < 0.05 and -0.45; p < 0.02. Our results provide evidence that chronic female schizophrenic patients have diminished CC surface and altered proportionality among surface and perimeter, that increases with age. However, in the control group, there is an increment of corpus callosum surface without altered perimeter proportionality.

Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP)

OBJECTIVE

Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3-8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented.

MATERIALS AND METHODS

Thirty-six patients sustaining blunt head trauma and fitting our strict clinical and radiographic diagnosis of DAI were enrolled in our study. Inclusion criteria were severe head injury patients who did not regain consciousness after the initial impact, and whose CT scan demonstrated characteristic punctate hemorrhages of < 10 mm diameter at the greywhite junction, basal ganglia, corpus callosum, upper brainstem, or a combination of the above. Patients with significant mass lesions and documented anoxia were excluded. Their intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were compared to a control group of 36 consecutive patients with severe non-penetrating non-operative head injury, using the Analysis for Variance method.

RESULTS

Eighteen (50.0%), six (16.7%), and twelve (33.3%) patients had types I, II, and III DAI, respectively. The admission Glasgow Coma Score (GCS) was higher for types I and II than for type III DAI. ICP was monitored from 23 to 165 hours, with a mean ICP for 36 patients of 11.70 mmHg (SEM = 0.75) and a range from 4.3 to 17.3 mmHg. Of all ICP recordings, of which 89.7%, (2421/2698) were < or = 20 mmHg. Average mean arterial pressure (MAP) was 96.08 mmHg (SEM = 1.69), and 94.6% (2038/2154) of all MAP readings were greater than 80 mmHg. Average cerebral perfusion pressure (CPP) was 85.16 mmHg (SEM = 1.68), and 90.1% (1941/2154) of all CPP readings were greater than 70 mmHg. This is compared to the control group mean ICP, MAP, and CPP of 16.84 mmHg (p = 0.000021), 92.80 mmHg (p = 0.18), and 76.49 mmHg (p = 0.0012). No treatment for sustained elevated ICP > 20 mmHg was needed for DAI patients except in two; one with extensive intraventricular and subarachnoid hemorrhage who developed communicating hydrocephalus, and another with ventriculitis requiring intrathecal and intravenous antibiotic treatments. Two complications, one from a catheter tract hematoma, and another with Staph epidermidis ventriculitis, were encountered. All patients, except type III DAI, generally demonstrated marked clinical improvement with time. The outcome, as measured by Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) was similarly better with types I and II than type III DAI.

CONCLUSION

The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.