Acta neurochirurgica. Supplement
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Acta Neurochir. Suppl. · Jan 2004
Clinical TrialProspective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.
Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. ⋯ The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.
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Acta Neurochir. Suppl. · Jan 2004
Clinical trials in traumatic brain injury: current problems and future solutions.
Over the past decade many neuroprotective agents have been developed with the hope of being able to improve outcome in patients with traumatic brain injury. Unfortunately, none of the phase III trials performed have convincingly demonstrated efficacy in the overall population. A common misconception is that consequently these agents are ineffective. ⋯ It is proposed to differentiate the point of dichotomization according to prognostic risk profile, in order to maintain statistical power. Solutions described may be expected to enhance chances of demonstrating benefit of potentially effective neuroprotective agents in future studies. The complexity of problems occurring in clinical trial design and analysis in TBI is such that a strong and sustained multidisciplinary input and effort is required from all experts involved in the field of neurotrauma.
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Acta Neurochir. Suppl. · Jan 2004
Gamma knife surgery for epilepsy related to hypothalamic hamartomas.
Drug resistant epilepsy associated with hypothalamic hamartoma (HH) can be cured by microsurgical resection of the lesion. Morbidity and mortality risks of microsurgery in this area are significant. Gamma Knife Surgery's (GKS) reduced invasivity seems to be well adapted. In view of the severity of the disease and risks of surgical resection it is crucial to evaluate GKS for this indication. A first retrospective study has shown a very good safety and efficacy level but for a more reliable evaluation a prospective study would be required. ⋯ Our first results indicate that GKS is as effective as microsurgical resection and very much safer. GKS also allows to avoid the vascular risk related to radiofrequency lesioning or stimulation. The disadvantage of radiosurgery is its delayed action. Longer follow-up is mandatory for a serious evaluation of the role of GKS. Results are faster and more complete in patients with smaller lesions inside the 3rd ventricle (grade II). The early effect on subclinical discharges turns out to play a major role in the dramatic improvement of sleep quality, behaviour, developmental acceleration at school.
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Acta Neurochir. Suppl. · Jan 2004
The role of inflammatory processes in the pathophysiology and treatment of brain and spinal cord trauma.
Traumatic injury to the brain and spinal cord results in an early inflammatory response that is initiated by the release of proinflammatory cytokines followed by the infiltration and accumulation of polymorphonuclear leukocytes (PMNLs). The role of the inflammatory cascade on traumatic outcome remains controversial. Pleiotropic cytokines appear to function both protectively and destructively. ⋯ Hypothermia has been reported by various groups to be neuroprotective in brain and spinal cord trauma. We studied the effect of therapeutic hypothermia on cerebral IL-1beta concentrations, PMNL accumulation and iNOS activity after traumatic brain injury (TBI) and spinal cord injury (SCI). Based on current data therapeutic hypothermia may protect in models of traumatic injury by modulating deleterious inflammatory processes.
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Microneurosurgery and radiosurgery have made tremendous progress in terms of increasing efficacy and reducing treatment related mobility. Both techniques have clear indications; however, there is still competition between the two modalities in a variety of diseases. In all instances, this rivalry should be replaced by the concept of using both methods as complementary. Skull base tumours, metastases as well as certain AVMs are good candidates for this approach.