Hagen B. Huttner

Background and Purpose— The objective was to analyze the feasibility of a lumbar drainage (LD) for a communicating malresorptive hydrocephalus in patients with supratentorial hemorrhage (intracerebral hemorrhage) accompanied by severe ventricular involvement (intraventricular hemorrhage) who required an external ventricular drain (EVD). Methods— In this retrospective study, 16 patients received an EVD and concurrent LD and were compared with 39 historical patients treated with EVD alone. The duration of required EVD and need for permanent ventriculoperitoneal-shunt were analyzed. Results— LD was inserted after 12 (4 to 18) days. In LD-treated patients, the LD was capable to replace repeated EVD exchanges, resulting in a shorter EVD-duration (12 versus 16 days) compared with patients treated with EVD alone. The overall duration of extracorporal cerebrospinal fluid drainage was longer (16 days EVD versus 21 days EVD+LD) and the frequency of ventriculoperitoneal-shunt lower (18.75% versus 33%; P Conclusion— Our data suggest that LD is safe and feasible for treatment of nonpersistent communicating hydrocephalus after intracerebral hemorrhage. After adequate treatment of the occlusive hydrocephalus using an EVD in the acute phase, LD discloses an alternative for further extracorporal cerebrospinal fluid drainage.

Fragestellung: In dieser Studie wird prospektiv die diagnostische Wertigkeit des kontrastmittelverstärkten Ultraschalls (ce-US) mit der Magnetresonanztomographie (MRT) bei Patienten mit Verdacht auf Dermato- oder Polymyositis evaluiert. Methoden: Bei 35 Patienten (23 weiblich, 12 männlich; Alter: 51±16 Jahre) mit vermuteter Dermato- oder Polymyositis wurden die klinisch betroffenen Skelettmuskeln mit ce-US und MRT untersucht. Die Skelettmuskelperfusion wurde mittels Powerdopplersonographie nach i.v. Gabe eines Ultraschallkontrastmittels (Levovist, Schering AG, Berlin) quantifiziert. Durch Analyse von Wiederanflutungskinetiken des Ultraschallkontrastmittels wurden die Perfusionsparameter Blutfluss, lokales Blutvolumen und Blutflussgeschwindigkeit gemessen. Diese Ergebnisse wurden mit denen der MRT und der Muskelbiopsie verglichen. Receiver operating characteristic (ROC)-Analysen wurden zur Ermittlung des optimalen Schwellenwertes für die Diagnose einer Myositis herangezogen. Ergebnisse: Bei 11 Patienten lag eine histologisch gesicherte Dermato- oder Polymyositis vor. Bei diesen Patienten waren Blutflussgeschwindigkeit (P=.01), Blutfluss (P=.001) und lokales Blutvolumen (P=.002) signifikant höher als bei den Patienten ohne histologische Bestätigung des Myositisverdachts. Signalsteigerungen auf T2-gewichteten MR-Aufnahmen zeigten sich bei allen Patienten mit histologisch gesicherter Myositis. Sensitivität, Spezifität, positiver (PPV) und negativer prädiktiver Wert (NPV) der MRT für den Myositisnachweis waren 100%, 88%, 77% und 100%. Der mittels ce-US bestimmte Blutfluss war der beste sonographische Parameter für die Diagnostik einer Myositis mit einer Sensitivität, Spezifität, PPV und NPV von 73%, 91%, 80% und 88%. Schlussfolgerungen: Der ce-US kann geeignete Parameter zur Diagnostik einer Dermato- oder Polymyositis bestimmen, die vergleichbare prädiktive Werte wie die MRT erreichen.

Object: Only limited data exist addressing the long-term outcome of patients with ganglionic hemorrhage complicated by intraventricular hemorrhage (IVH) and hydrocephalus that requires an external ventricular drain (EVD). The aim of this study was to compare the long-term outcome of patients with pure ganglionic hemorrhage and those requiring an EVD due to additional IVH and hydrocephalus. Methods: For this study, 116 patients with supratentorial ganglionic hemorrhage and occlusive hydrocephalus were screened. To avoid any bias the authors excluded all patients with nonprimary intracerebral hemorrhage as well as those who received no treatment. Forty patients with IVH and subsequent hydrocephalus were examined, and 40 more patients with pure ganglionic hematomas were matched with regard to age, sex, Glasgow Coma Scale score, need for mechanical ventilation, and, in particular, hematoma volume. Outcome analysis was performed using the Barthel Index and the modified Rankin Scale (mRS). The mean hematoma volume was 25.3 ± 15.2 ml. The overall long-term outcome was unfavorable (mRS Score 4–6) in 59% of all patients. Good outcome (mRS score < 4) was observed in 25 (62.5%) of 40 patients with hematoma volumes less than 25 ml, compared with eight (20%) of 40 who had hematoma volumes greater than 25 ml (p < 0.05, chi-square test). The need for an EVD was not associated with a worse long-term outcome in patients with comparable hematoma volumes. In contrast, the duration of treatment in the intensive care unit was longer for patients with EVDs than for those who had pure ganglionic hematomas (16 [range 5–29] days compared with 8 [range 2–19] days; p < 0.05, Mann–Whitney U-test), regardless of hematoma volume. Conclusions: The long-term outcome of treated patients with supratentorial ganglionic hemorrhage with ventricular involvement and occlusive hydrocephalus is comparable to that of patients with similar hematoma volumes but no IVH.

Background and Purpose— Intracerebral hemorrhage (ICH) is the most serious and potentially fatal complication of oral anticoagulant therapy (OAT). Still, there are no universally accepted treatment regimens for patients with OAT-ICH, and randomized controlled trials do not exist. The aim of the present study was to compare the acute treatment strategies of OAT-associated ICH using vitamin K (VAK), fresh frozen plasma (FFP), and prothrombin complex concentrates (PCCs) with regard to hematoma growth and outcome. Methods— In this retrospective study, a total of 55 treated patients were analyzed. Three groups were compared by reviewing the clinical, laboratory, and neuroradiological parameters: (1) patients who received PCCs alone or in combination with FFP or VAK (n=31), (2) patients treated with FFP alone or in combination with VAK (n=18), and (3) patients who received VAK as a monotherapy (n=6). The end points of early hematoma growth and outcome after 12 months were analyzed including multivariate analysis. Results— Hematoma growth within 24 hours occurred in 27% of patients. Incidence and extent of hematoma growth were significantly lower in patients receiving PCCs (19%/44%) compared with FFP (33%/54%) and VAK (50%/59%). However, this effect was no longer seen between PCC- and FFP-treated patients if international normalized ratio (INR) was completely reversed within 2 hours after admission. The overall outcome was poor (modified Rankin scale 4 to 6 in 77%). Predictors for hematoma growth were an increased INR after 2 hours, whereas administration of PCCs was significantly protective in multivariate analyses. Predictors for a poor outcome were age, baseline hematoma volume, and occurrence of hematoma growth. Conclusions— Overall, PCC was associated with a reduced incidence and extent of hematoma growth compared with FFP and VAK. This effect seems to be related to a more rapid INR reversal. Randomized controlled trials are needed to identify the most effective acute treatment regimen for lasting INR reversal because increased levels of INR were predisposing for hematoma enlargement.

Introduction Our objective was to investigate the feasibility of lumbar drainage (LD) as a new therapeutic approach for the treatment of communicating hydrocephalus in patients with supratentorial...

Background and Purpose: Up to 30% of patients with supratentorial intracerebral hemorrhage (ICH) require mechanical ventilation during the course of treatment. For these patients, tracheostomy is necessary in cases of protracted weaning. As only limited data exists about predictors for a tracheostomy in patients with ICH, the aim of this study was to investigate the incidence of tracheostomy and clinical findings that increase the risk for a tracheostomy in patients with supratentorial hemorrhage. Methods: A total of 392 patients with supratentorial ICH were analyzed. The parameters age, gender, Glasgow Coma Scale on admission, ganglionic or non–ganglionic localization, presence of ventricular hemorrhage, hydrocephalus, and hematoma volume were investigated. The effects on the end-point tracheostomy were analyzed using multivariate regression analyses. Results: The overall need for tracheostomy was 9.9%, in patients with ganglionic hemorrhage 16.3%, in patients with non–ganglionic hemorrhages 2.8%. The risk for tracheostomy was increased tenfold in patients who developed hydrocephalus. The presence of ventricular blood, in general, showed no significant impact on the need for tracheostomy, whereas hemorrhage extending into the third and fourth ventricles in conjunction with hydrocephalus increased the risk for tracheostomy. The hematoma volume correlated positively with the risk for tracheostomy. Conclusions: Our study demonstrates that approximately 10% of patients with ICH require tracheostomy during the course of their disease. Ganglionic hemorrhages and the development of hydrocephalus are predisposing factors for tracheostomy.