Cerebrospinal s100-B: a potential marker for progressive intracranial hemorrhage in patients with severe traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is associated with cerebrovascular dysfunction and changes of the blood-brain barrier (BBB) function. Although knowledge about the function of the BBB would be of high interest, non-invasive neurodiagnostic tools are still lacking. In this context it has been shown, that the astrocytic protein S100-B is a significant parameter for neuronal damage. However, there is only poor knowledge about the dynamics of S100-B in cerebrospinal fluid (CSF) and serum of patients with severe TBI. Therefore, the aim of this study was to analyze intrathecal and systemic concentrations of S100-B in patients with severe TBI in correlation to the development of progressive intracranial hemorrhage (PIH) as well as to the CSF/serum albumin ratio (Q subsetalb), as functional parameter of the BBB.

PATIENTS AND METHODS

In patients, suffering from severe TBI (GCS =or<8pts) and respectively healthy control patients, albumin for calculating the CSF/serum albumin ratio (Q subsetalb) as well as S100-B protein were analyzed in CSF and serum. Samples were collected immediately after placement of a ventricular catheter and 12h, 24h, 48 h and 72 h after TBI. S100-B was quantified using Elecsys S-100 superset assay (Roche superset Diagnostics; Mannheim, Germany). Volume measurements of focal mass lesions based on CT images taken during the first 72 h after TBI were obtained according to the Cavalieri's Direct Estimator method.

RESULTS

21 TBI-patients and respectively 10 healthy controls were enrolled. In patients exhibiting a mean ICP >15 mmHg (n = 15) CSF levels of S100-B were significantly increased on admission (819 +/- 78 pg/ml) compared to patients with ICP =or<15 mmHg (n = 6, 175 +/- 12 pg/ml) as well as to the control group (n = 10, 0.8 +/- 0.09 pg/ml). In the group with ICP >15 mmHg 8 patients developed PIH A positive correlation was found between CSF S100-B and ICP (r2 = 0.925, p<0.001). Furthermore a positive correlation between serum S100-B and Q subsetalb was found for each sampling point (r superset2 = 0.793, p<0.001).

CONCLUSIONS

The cerebrospinal and serum concentration of S100-B in patients with severe TBI was evaluated. Monitoring cerebrospinal S100-B might help to prospectively identify patients with PIH.

Cerebrospinal IL-10 concentration is elevated in non-survivors as compared to survivors after severe traumatic brain injury

OBJECTIVE

The intrathecal posttraumatic inflammation contributes to secondary brain damage as well as to the induction of neuroreparative mechanisms. In this context release of interleukin-10 (IL-10) has been reported to play a major role. However, initial IL-10 concentration in CSF remains incompletely characterized. Therefore, the aim was to analyze Il-10 in CSF and serum of patients early after TBI.

METHODS

For control, 10 volunteers receiving spinal puncture were enrolled. In patients with severe TBI (GCS<8 pts.), CSF and serum was drawn within 90+/-45 min after intraventricular catheter insertion (0 h), as well as 12 h, 24 h and 48 h after TBI. Albumin for assessing Blood-Brain-Barrier (BBB) function and IL-10 (IMMULITE, DPC Biermann, Bad Nauheim, Germany) were analyzed.

RESULTS

23 patients were enrolled. 15 survived and 8 deceased within 24h. In controls, CSF IL-10 was below detection limit (<5 pg/ml). In contrast, IL-10 was elevated significantly in non-survivors at 0 h vs. survivors and controls (30+/-6 vs. 9+/-1 vs. <5 pg/mL). This was accompanied by a significant increase of serum IL-10 in both groups at 0 h vs. controls (survivors: 30+/-6 pg/mL, non-survivors: 48+/-8 pg/mL, controls: 10+/-7 pg/mL, p<0.001). Survivors revealed signs of a mild BBB dysfunction during the entire observation period. In contrast, non-survivors presented a severe BBB breakage.

CONCLUSIONS

We demonstrated an analysis of IL-10 CSF and serum concentration after TBI. These data support an intrathecal IL-10 synthesis. Although the significant increase of IL-10 might indicate a bad outcome of TBI, responsible mechanisms still have to be elucidated.

Recurrent ischemic colitis in a patient with leiden factor V mutation and systemic lupus erythematous with antiphospholipid syndrome

Ischemic colitis results from insufficient blood supply to the large intestine and is often associated with hypercoagulable states. The condition comprises a wide range presenting with mild to fulminant forms. Diagnosis remains difficult because these patients may present with non-specific abdominal symptoms. We report a 51- year-old female patient with known Leiden factor V mutation as well as systemic lupus erythematous along with antiphospholipid syndrome suffering from recurrent ischemic colitis. At admission, the patient complained about abdominal pain, diarrhea and rectal bleeding lasting for 24 hours. Laboratory tests showed an increased C-reactive protein (29.5 mg/dl), while the performed abdominal CT-scan revealed only a dilatation of the descending colon along with a thickening of the bowel wall. Laparotomy was performed showing an ischemic colon and massive peritonitis. Histological examination proved the suspected ischemic colitis. Consecutively, an anti-coagulation therapy with coumarin and aspirin 100 was initiated. Up to the time point of a follow up examination no further ischemic events had occurred. This case illustrates well the non-specific clinical presentation of ischemic colitis. A high index of suspicion, recognition of risk factors and a history of non-specific abdominal symptoms should alert the clinicians to the possibility of ischemic disease. Early diagnosis and initiation of anticoagulation therapy or surgical intervention in case of peritonitis are the major goals of therapy.

Zweizeitige bilaterale Klavikulafraktur

In this case report we present treatment strategies and the functional and cosmetic outcome in a case of midclavicular fractures. A 20-year-old patient suffered from nearly identical fractures of the left and right clavicle with a time interval of 2 years following snowboard falls. The first fracture was treated conservatively leading to an unsatisfactory course and result. This was the reason why 2 years later the contralateral fracture was treated by intramedullary nailing using an elastic titanium nail. The functional and cosmetic outcome of this treatment was excellent. In cases of clavicular fractures elastic stable intramedullary nailing (ESIN) is a minimally invasive technique leading to fast analgesia resulting in a high level of mobility and ultimately a pleased patient. If the indication is right, intramedullary nailing can be a helpful operation technique which complements the already established procedures (conservative and plate osteosynthesis) in cases of dislocated clavicular fractures.

Diagnostik und Behandlungsregime der traumatischen dorsalen Schulterluxation

In contrast to anterior dislocations, traumatic dorsal shoulder dislocation is a rare complication of upper extremity injuries. If the diagnosis is overseen and treated incorrectly, severe mobility restrictions might be the consequence for the injured individual. Hence, the aim of this article is to demonstrate the adequate diagnostic and therapeutic management and to critically discuss the literature.

Timing of cervical spine stabilisation and outcome in patients with rheumatoid arthritis

One complication of rheumatoid arthritis (RA) is the involvement of the cervical spine (CS). Although prophylactic stabilisation is recommended, the timing at which this should occur is poorly defined. The aim of our study was to evaluate the course of neurological symptoms in terms of the timing of surgery. A total of 34 patients with RA and CS involvement were surgically stabilised. These patients were classified using the Ranawat (RW) score both preoperatively and at an average of 54 months post-operatively. For each patient, the presence of atlantoaxial and subaxial subluxation as well as vertical migration of the odontoid was recorded. The anterior atlantodental interval was also assessed pre- and post-operatively. Improvement was obtained in 20 patients, the clinical situation remained unchanged in three patients and three patients manifested disease progression. In terms of the RW score, the 16 patients with pre-operative RW grades I-II showed no deterioration at the post-operative follow-up, with 13 of these patients showing an improvement; the 12 patients with pre-operative RW grades IIIA-IIIB did not show any improvement of neurological symptoms at follow-up, although seven of these patients subjectively assessed the symptoms to be less severe after surgery; three other patients showed a worsening of symptoms. Our results suggest that preventive stabilisation of CS in RA leads to acceptable results, although the complications of the surgery are obvious. However, early operative treatment may delay the detrimental course of cervical myelopathy in RA.

Early diagnosis of colorectal cancer: a preventive task in occupational health

Morbidity of colorectal cancer is still accreting; therefore in 2003 a total of 57000 patients fell ill and about 28000 died due to colorectal carcinoma. According to the etiology, many different factors are currently in discussion. However, as in about 25-30% of the cases familial clustering can be observed one of the most probable might be the genetic predisposition. Nevertheless only in 3% of all cases this predisposition is also scientifically assured. The high average age of manifestation raised the question if there might be also an occupational relationship for colorectal carcinoma in tense of an occupational disease. Therefore there is sight for occupational health to contribute to early diagnosis of colorectal carcinoma within the scope of routine check-up, health management and research of occupational diseases.

[The presence of family members in the trauma room]

The fate of multiple trauma patients is witnessed by a considerable number of relatives. Although numerous studies report that the patient's course and treatment success are dependent on the family's confidence as well as its clarification over the clinical situation, scientifically based guidelines for contact with relatives in the context of acute care following severe traumatic injuries do not yet exist. The current guidelines of the European Resuscitation Council recommend the concept of "on scene" presence for the integration of the relatives into acute care in situations of circulatory and heart failure, thus recommending the presence of relatives during acute medical care. This article discusses this concept and argues for a possible assignment of management of trauma care for severe and gravely injured patients.

Aggressive scapular chondroblastoma with secondary metastasis--a case report and review of literature

Chondroblastoma is a benign bone tumor, accounting for approximately one percent of all benign bone tumors. It mostly occurs in typical locations such as long bones. Malignant transformation including metastasis has been described in only a few cases. Therefore, we report a unique case of chondroblastoma with tumor manifestation in the 7th decade of life, location of the tumor in the scapula and occurrence of metastasis in the soft tissue of the mandible branch. Due to aggravation of the clinical course, a scapula en bloc resection was performed. The differential diagnosis is discussed and the current literature concerning malignant transformation of chondroblastoma is reviewed.

[Tension pneumopericardium--a rare complication in multiply injured patients]

Thoracic injury is a relevant and common complication in multiply injured patients. Typical patterns of injury comprise rib fractures, serious lung trauma as well as diaphragmatic and aortic rupture. In contrast, posttraumatic tension pneumopericardium following blunt thoracic trauma is a very rare complication. However, if unrecognized it might provoke cardiac tamponade and death. For the development of a pneumopericardium, free air follows the vessel bundles up to the pericardium. Hence, if the number of ruptured alveoli is high, or these alveoli are placed close to the heart, and if additional risk factors, such as high inspiratory ventilation pressure, are present, a tension pneumopericardium can induce cardiac tamponade. The aim of this report is to illuminate diagnostic and therapeutic strategies for posttraumatic pneumopericardium by presentation of a case from our trauma centre and a critical discussion of the present literature.

Cerebral perfusion pressure for prediction of recurrent intracranial hypertension after primary decompressive craniectomy

BACKGROUND

Decompressive craniectomy (DC) with dural grafting may be performed in patients with moderate (Glasgow-Coma-Scale [GCS] score 9-12 points) or severe traumatic brain injury (TBI; GCS score <or= 8 points) and threatening herniation. However, its effectiveness especially after primary craniectomy is still discussed due to missing evidence of improved outcome. The objectives of this study were to show the incidence of recurrent intracranial hypertension after primary DC, to identify predictive parameters for secondary DC, and to evaluate the long-term neurological performance 12 months after TBI.

METHODS

Between 01/1997 and 06/2001 all consecutive patients admitted with moderate or severe isolated TBI were enrolled in this study. They were treated according to the guidelines of the European Brain Injury Consortium, and the American Association of Neurosurgical Surgeons (AANS) for the management of severe TBI. Process and clinical data as well as every intervention were registered prospectively. The long-term neurological status was reassessed using the Glasgow Outcome Score (GOS) 12 months after TBI. Statistical comparison was performed using Mann-Whitney-U test, and multivariate testing by means of logistic regression analysis.

RESULTS

Fifty-one (43 males, 8 females; median age 51.4 years) of 119 isolated TBI patients were included. Ten patients (8 males, 2 females; median age 38.4 years) underwent secondary extended or contralateral DC in their clinical course. Three of them (30%) died at a median of 1 day after revision respectively 6 days after TBI. According to univariate analysis, secondary DC significantly correlated with arterial hypotension (p = 0.020) and otorrhagia at admission (p = 0.041), skull base fracture (p = 0.011) and decreased maximum cerebral perfusion pressure (CPP; p = 0.006) after primary surgery. Multivariate analysis identified decreased maximum CPP as the only independent predictive parameter (p = 0.036) for secondary DC and unfavourable GOS after 12-months follow-up.

CONCLUSION

Arterial hypotension, otorrhagia at admission and skull base fractures are negatively influencing the mortality and morbidity of patients with isolated moderate or severe TBI. However, only decreased maximum CPP may independently indicate secondary DC after primary craniectomy in case of recurrent intracranial hypertension.

Funktionelle Cine-MRT des Kolon: Darstellung und Quantifizierung der Darmmotilität

PURPOSE

To develop and evaluate a method to visualize and quantify large bowel motility using functional cine MRI.

METHODS

Fifteen healthy individuals (8 males, 7 females, 20 to 45 years old) with no history or present symptoms of bowel disorders were enrolled in a functional cine MRI examination at 6 a. m. after a starving phase for at least eight hours before and after oral administration of Senna tea (mild stimulating purgative). Two consecutive sets of repeated measurements of the entire abdomen were performed using a 1.5 T MRI system with coronal T2-weighted HASTE sequences anatomically adjusted to the course of the large bowel. A navigator technique was used for respiratory gating at the level of the right dorsal diaphragm. The changes in diameter (given in cm) were measured at 5 different locations of the ascending (AC), transverse (TC) and descending colon (DC), and assessed as parameters for the bowel motility.

RESULTS

The mean values as a statistical measure for large bowel relaxation were determined. Before ingestion of Senna tea, the mean diameter measured 3.41 cm (ascending colon), 3 cm (transverse colon) and 2.67 cm (descending colon). After the ingestion of Senna tea, the mean diameter increased to 3.69 cm (ascending colon) to 3.4 cm (transverse colon) and to 2.9 cm (descending colon). A statistically significant difference was demonstrated with the Wilcoxon test (level of confidence 0.05). For the determination of dynamic increase, the changes of the statistical scatter amplitude to the mean value were expressed as percentage before and after the ingestion of Senna tea. Thereby, an increase in variation and dynamic range was detected for the AC (112.9 %) and DC (100 %), but a decrease in the dynamics for the TC (69 %).

CONCLUSION

A non-invasive method for the assessment of bowel motility was developed for the first time. The use of functional cine MRI utilizing a prokinetic stimulus allowed visualisation and quantification of large bowel motility. Further studies have to determine whether this technique is clinically relevant.

[Computed tomographic findings in carpal tunnel syndrome]

Morphometric measurements of the carpal bones were carried out in 32 patients with carpal tunnel syndrome (CTS) and in 47 normal persons, using high resolution CT. Measurements of distances and areas were carried out at the entry of each carpal tunnel and at its narrowest point. In idiopathic CTS there were no significant differences in these measurements from normal carpal measurements. The situation was different in ten patients with nonidiopathic CTS; in these CT showed the cause of median compression reliably. Our results suggest that there are no indications for performing CT of the wrist in idiopathic CTS, but that valuable information may be expected from CT in cases of nonidiopathic CTS.

[Morphometry using computerized tomography of the wrist in idiopathic carpal tunnel syndrome. Comparison of pre- and postoperative findings]

Alteration of carpal morphometry after surgical release of the carpal tunnel was investigated in 22 patients with idiopathic carpal tunnel syndrome, using pre- and postoperative computed tomography. The morphometric evaluation showed an increase in carpal volume which was due to a palmar soft-tissue prolapse in 90% and to an increase of the carpal arch cross sectional area in about 10%. The carpal tunnel release caused a palmar opening of the canal most commonly at the pisiform bone. There was also a variation in form and an increase in volume of Guyon's canal. The results are discussed and related to the postoperative complaints.