Neurosurgical stereomorphometry in vivo - method description and error measurement

Rules of geometry and stereomorphometry are often applied to narrow and deep neurosurgical approaches. Methods of research are based on the direct cadaver measurements, radiological analysis and intraoperative measurements. Newly developed devices allow direct morphometry to be performed in vivo, during the operation. We describe the use of the neuronavigation system Stealth Station by Medtronic for such stereomorphometric measurements and evaluate the precision of the described method

Czynniki rokownicze śmiertelności po operacji pękniętych tętniaków tętnicy szyjnej wewnętrznej

Background and purpose An analysis of predictors of mortality in patients with ruptured intracranial aneurysm is an important aspect in the assessment of outcome. The aim of the study was to analyse factors determining mortality risk after the surgical treatment of ruptured internal carotid artery (ICA) aneurysm. Material and methods This study comprised 242 patients operated on between 1997 and 2006 in the Neurosurgery Department of the Medical University Hospital in Gdansk, Poland. Multivariate logistic regression, ROC curves (for model assessment as a mortality classifier) and population attributable risk for contribution of individual factor mortality explanation were used to assess factors related to in-hospital mortality. Results 14.9% of patients died postoperatively. In univariate analysis, increased risk of death was related to the Glasgow Coma Scale score, WFNS score, Hunt-Hess and Fisher grade, preoperative neurological deficit, delayed cerebral ischaemia (DCI), trapping and bypass operative method. Multivariate analysis revealed two independent predictors of in-hospital mortality: DCI and Hunt-Hess grade. 91% of mortality risk was attributed to grade 4 or 5 in Hunt-Hess scale and DCI. The dominant predictor of survival was the Hunt-Hess scale. Increase by one grade in the Hunt-Hess scale resulted in two-fold increase of in-hospital mortality risk. Conclusions Postoperative mortality after ICA aneurysm rupture is determined by clinical status at admission and the occurrence of DCI.Wstęp i cel pracy Analiza czynnikowa śmiertelności wśród chorych z pękniętym tętniakiem wewnątrzczaszkowym stanowi ważny aspekt w ocenie wyników leczenia. Celem pracy była analiza czynników mających wpływ na zwiększone ryzyko zgonu po operacji krwawiącego tętniaka tętnicy szyjnej wewnętrznej. Materiał i metody W badaniu wzięło udział 242 chorych operowanych w latach 1997—2006 w Klinice Neurochirurgii Gdańskiego Uniwersytetu Medycznego. Czynniki rokownicze śmiertelności w tej grupie analizowano za pomocą wieloczynnikowej regresji logistycznej, porównania krzywych ROC (celem oceny poprawności całego modelu jako klasyfikatora śmiertelności) i wskaźników ryzyka przypisanego populacji (PAR) dla wskazania udziału poszczególnych czynników w wyjaśnieniu śmiertelności. Analizowano jedynie przypadki zgonów występujące w trakcie hospitalizacji. Wyniki Śmiertelność pooperacyjna wyniosła 14,9%. W analizie jednoczynnikowej ryzyko zgonu zależało od: stopnia w skali śpiączki Glasgow, punktacji w skali WFNS, Hunta–Hessa, Fishera, przedoperacyjnego deficytu neurologicznego, rozpoznania opóźnionego niedokrwienia mózgu (delayed cerebral ischaemia — DCI), metody operacyjnej polegającej na zamknięciu naczynia lub wytworzeniu obejścia naczyniowego. Spośród nich analiza wieloczynnikowa wyłoniła dwie niezależne zmienne, które miały istotny wpływ na śmiertelność: DCI oraz stan kliniczny pacjentów przy przyjęciu mierzony w skali Hunta-Hessa. Stopień 4. i 5. w tej skali oraz rozpoznanie DCI odpowiadały za 91% ryzyka zgonu po operacji tętniaka tętnicy szyjnej wewnętrznej. Dominujące znaczenie w przewidywaniu przeżycia miała skala Hunta-Hessa. Ocena stanu klinicznego chorego o jeden stopień wyżej w tej skali zwiększała ponaddwukrotnie ryzyko zgonu pooperacyjnego. Wnioski Śmiertelność pooperacyjna po pęknięciu tętniaka tętnicy szyjnej wewnętrznej uwarunkowana jest stanem klinicznym przy przyjęciu i wystąpieniem DCI

Zastosowanie metody Kinesio Taping w zespole bolesnego barku

Introduction. The painful shoulder syndrome is becoming an increasingly frequent pathology for both sexes at different ages. Its diagnosis and treatment still cause many problems. They result from a complicated anatomical and biomechanical structure, rich innervation and diversity of symptoms of the shoulder dysfunction.Aim. The assessment of Kinesio Taping method impact on pain reduction and improvement in muscle strength and range of the shoulder motion in patients with painful shoulder syndrome.Material and methods. The study included 20 patients, in whom during the clinical examination carried out by a specialist of orthopedics and traumatology, a painful shoulder syndrome was recognized. Patients were evaluated by the numerical pain scale of NRS, muscle strength Lovett scale and range of motion in the shoulder joint by goniometry. The study was carried out on qualification day and in the period from 5 to 7 days after the Kinesio Taping method.Results. 55% of the respondents were women (mean age 66 years), 45% were male (mean age 62.7 years). The level of pain perception in patients after treatment was 35% lower than before the Kinesio Taping method. The largest increase in mobility (11.72%) was found in the shoulder joint extension motion. Muscle strength after treatment increased from 15% to 20%.Conclusions. Kinesio Taping reduces pain and improves muscle strength, but is it not a method that significantly improves the range of motion in the joint.Wstęp. Zespół bolesnego barku jest coraz częstszą patologią dotyczącą obu płci w różnym wieku. Diagnostyka oraz leczenie zespołu bolesnego barku wciąż nastręcza wiele problemów. Wynikają one ze skomplikowanej struktury anatomicznej i biomechanicznej, bogatego unerwienia oraz różnorodności objawów dysfunkcji stawu barkowego.Cel pracy. Ocena wpływu metody Kinesio Taping na zmniejszenie dolegliwości bólowych i poprawę siły mięśniowej i zakresu ruchomości stawu barkowego u pacjentów z zespołem bolesnego barku.Materiał i metodyka. Do badania włączono 20 chorych, u których na podstawie badania klinicznego przeprowadzanego przez specjalistę ortopedii i traumatologii, został rozpoznany zespół bolesnego barku. Pacjentów poddano ocenie dolegliwości bólowych wg numerycznej skali NRS, siły mięśniowej wg skali Lovetta oraz zakresu ruchomości w stawie barkowym metodą goniometrii. Badanie było przeprowadzane w dniu kwalifikacji oraz w okresie od 5 do 7 dni po zastosowaniu metody Kinesio Taping.Wyniki. Badania przeprowadzono wśród 20 osób. 55% badanych to kobiety (średnia wieku 66 lat), 45% stanowili mężczyźni (średnia wieku 62, 7 lat). Poziom odczuwania bólu u pacjentów po terapii był o 35% mniejszy niż przed zastosowaniem metody Kinesio Taping. Największy przyrost ruchomości (11, 72%) stwierdzono w ruchu wyprostu w stawie ramiennym. Siła mięśniowa po terapii wzrosła od 15% do 20%.Wnioski. Kinesio Taping zmniejsza dolegliwości bólowe oraz zwiększa siłę mięśniową, lecz nie jest metodą, która znacząco wpływa na poprawę zakresu ruchomości w stawie

The challenges of hypervolemic therapy in patients after subarachnoid haemorrhage

Purpose The triple-H therapy is widely used for cerebral vasospasm (CV) prevention and treatment in patients after subarachnoid haemorrhage (SAH). However, this practice is based on low level evidence. Aim of this study was to evaluate errors in fluid administration, fluid balance monitoring and bedside charts completeness during a trial of triple-H therapy. Materials and methods An audit of the SAH patient charts was performed. A total of 508 fluid measurements were performed in 41 patients (6 with delayed cerebral ischaemia; DCI) during 14 days of observation. Results Underestimating for intravenous drugs was the most frequent error (80.6%; 112), resulting in a false positive fluid balance in 2.4% of estimations. In 38.6% of the negative fluid balance cases, the physicians did not order additional fluids for the next 24h. In spite of that, the fluid intake was significantly increased after DCI diagnosis. The mean and median intake values were 3.5 and 3.8l/24h respectively, although 40% of the fluid balances were negative. The positive to negative fluid balance ratio was decreasing in the course of the 14 day observation. Conclusions This study revealed inconsistencies in the fluid orders as well as mistakes in the fluid monitoring, which illustrates the difficulties of fluid therapy and reinforces the need for strong evidence-based guidelines for hypervolemic therapy in SAH

Expression pattern of ISL-1, TTF-1 and PAX5 in olfactory neuroblastoma

Olfactory neuroblastoma (ONB) is a rare neoplasm of the sinonasal area with neuroendocrine differentiation. ISL-1, TTF-1 and PAX5 are transcription factors that are frequently upregulated in tumors showing neuroendocrine differentiation. The aim of our study was to evaluate these markers in a group of ONBs. We included 11 ONBs from 4 large university hospitals. Immunohistochemical expression of TTF-1, PAX5 and ISL-1 was evaluated. TTF-1, ISL-1 and PAX5 were expressed in 3/11 cases (27.27%, h-score: 3-45), 7/11 cases (63.64%, h-score: 23-200), and in 3/11 cases (27.77%, h-score 3-85), respectively. The patient with the strongest PAX5 reactivity exhibited an aggressive clinical course with rapid dissemination to the spine and death shortly after the diagnosis. No significant correlation in the expression of PAX5 and TTF-1 (ρ = 0.43; p = 0.18) was observed. ISL-1 is widely expressed in tumors with neuroendocrine differentiation and therefore of limited value in their differential diagnosis. TTF-1 positivity does not exclude the diagnosis of primary ONB, although usually only a small percentage of cells are positive. PAX5 expression is infrequent (27.27%) in ONB; however, if present it can be associated with a very aggressive clinical course

Original paper expressiOn pattern Of isl-1, ttf-1 and pax5 in OlfactOry neurOblastOma

Olfactory neuroblastoma (ONB) is a rare neoplasm of the sinonasal area with neuroendocrine differentiation. ISL-1, TTF-1 and PAX5 are transcription factors that are frequently upregulated in tumors showing neuroendocrine differentiation. The aim of our study was to evaluate these markers in a group of ONBs. We included 11 ONBs from 4 large university hospitals. Immunohistochemical expression of TTF-1, PAX5 and ISL-1 was evaluated. TTF-1, ISL-1 and PAX5 were expressed in 3/11 cases (27.27%, h-score: 3-45), 7/11 cases (63.64%, h-score: 23-200), and in 3/11 cases (27.77%, h-score 3-85), respectively. The patient with the strongest PAX5 reactivity exhibited an aggressive clinical course with rapid dissemination to the spine and death shortly after the diagnosis. No significant correlation in the expression of PAX5 and TTF-1 (ρ = 0.43; p = 0.18) was observed. ISL-1 is widely expressed in tumors with neuroendocrine differentiation and therefore of limited value in their differential diagnosis. TTF-1 positivity does not exclude the diagnosis of primary ONB, although usually only a small percentage of cells are positive. PAX5 expression is infrequent (27.27%) in ONB; however, if present it can be associated with a very aggressive clinical course

Extent of anterior clinoidectomy for clipping of carotid-ophthalmic aneurysms predicted on three-dimensional computerised tomography angiography

Aim of study. We aimed to verify the value of computerised tomography angiography (CTA) on predicting the extent of anterior clinoidectomy that is optimal for particular carotid-ophthalmic aneurysms (COAs).Clinical rationale for study. The anterior clinoid process (ACP) often impedes the complex microsurgery of COA. Complete removal of the ACP ensures safe clipping; however, it also may increase the risk of severe complications. The probability of performing a successful partial anterior clinoidectomy could be evaluated by preoperative CTA.Materials and methods. 28 patients with either a ruptured (n=4) or unruptured COA were included in this prospective, single-centre, observational study. One aneurysm was giant, two were large, and the rest were smaller. Successful aneurysm clipping was the aim in all cases. The anterior clinoidectomy was preoperatively planned on multiplanar three-dimensional reconstructions of CTA images (3D-CTA) which resembled the typical view of a frontotemporal craniotomy. Finally, the predicted clinoidectomywas compared to the extent of the actual clinoidectomy.Results. 21 aneurysms (75%) projected superolateral or superior. The ACP was completely and selectively resected in 25% (7 of 28) and 67.9% of patients (19 of 28) respectively. Optic nerve (ON) unroofing was always performed in the case of total anterior clinoidectomy, but accompanied only 8 of 19 selective clinoidectomies (p = 0.03). The extent of the actual clinoidectomy was predicted by the 3D-CTA-based preoperative planning in 17 of 27 cases (63.0%). Particularly, prediction of the osteotomy was correct in 85.7% of complete, 62.5% of selective lateral, and 57.1% of medial clinoidectomy. None of the radiological and clinical factors determined the correlation between the planned and the actual extent of ACP removal. There was one incomplete occlusion among 23 obtained follow-up CTAs.Conclusions. The predictive value of 3D-CTA on the extent of anterior clinoidectomy still remains unsatisfactory; it is limited by the individual variability of COA and its surrounding structures.Clinical implications. Currently, the role of 3D-CTA planning is restricted to educational purposes only

Effect of sevoflurane on cerebral perfusion pressure in patients with internal hydrocephalus

 BACKGROUND: Due to its confirmed neuroprotective properties, sevoflurane is one of a few anaesthetics used for neuroanaesthesia. Its effects on the cerebral and systemic circulations may be of particular importance in patientswith intracranial pathology. This study aimed to evaluate the effect of sevoflurane at concentrations lower than 1 MAC on cerebral perfusion pressure (CPP) in patients with internal hydrocephalus.METHODS: The study was conducted on14 patients with internal hydrocephalus, who underwent ventriculo-peritoneal shunt implantation. After inserting the catheter into the lateral cerebral ventricle, sevoflurane, at 1.1 and 2.2 vol%, was initiated at two successive 15-minute intervals. The intracranial pressure (ICP) was continuously measured; special attention was focused on the values prior to and at the end of each observation period. The following parameters were monitored: mean arterial pressure (MAP), CPP, heart rate, end-tidal CO2 concentration, core body temperature, and the inspiratory and end-expiratory concentrations of sevoflurane.RESULTS: The HR and MAP decreased during successive observation intervals compared to baseline values. Likewise, the CPP decreased from 75.6 ± 2.8 mm Hg to 72.2 ± 2.6 mm Hg to 70.2 ± 0.8 mm Hg. The baseline value for ICP was 16.3 ± 0.6 mm Hg and increased to 17.7 ± 0.8 and 18.9 ± 0.5 mm Hg during the next observation periods.CONCLUSIONS: Sevoflurane administered ata concentration below 1MAC to patients with internal hydrocephalus increases the ICP and decreases the MAP, which leads to adecrease in CPP. The CPP decrease is more dependent on depressing the systemic circulatory system than an increased ICP. BACKGROUND: Due to its confirmed neuroprotective properties, sevoflurane is one of a few anaesthetics used for neuroanaesthesia. Its effects on the cerebral and systemic circulations may be of particular importance in patientswith intracranial pathology. This study aimed to evaluate the effect of sevoflurane at concentrations lower than 1 MAC on cerebral perfusion pressure (CPP) in patients with internal hydrocephalus.METHODS: The study was conducted on14 patients with internal hydrocephalus, who underwent ventriculo-peritoneal shunt implantation. After inserting the catheter into the lateral cerebral ventricle, sevoflurane, at 1.1 and 2.2 vol%, was initiated at two successive 15-minute intervals. The intracranial pressure (ICP) was continuously measured; special attention was focused on the values prior to and at the end of each observation period. The following parameters were monitored: mean arterial pressure (MAP), CPP, heart rate, end-tidal CO2 concentration, core body temperature, and the inspiratory and end-expiratory concentrations of sevoflurane.RESULTS: The HR and MAP decreased during successive observation intervals compared to baseline values. Likewise, the CPP decreased from 75.6 ± 2.8 mm Hg to 72.2 ± 2.6 mm Hg to 70.2 ± 0.8 mm Hg. The baseline value for ICP was 16.3 ± 0.6 mm Hg and increased to 17.7 ± 0.8 and 18.9 ± 0.5 mm Hg during the next observation periods.CONCLUSIONS: Sevoflurane administered ata concentration below 1MAC to patients with internal hydrocephalus increases the ICP and decreases the MAP, which leads to adecrease in CPP. The CPP decrease is more dependent on depressing the systemic circulatory system than an increased ICP.

Wpływ propofolu na prędkość przepływu krwi w tętnicy środkowej mózgu (VMCA) u chorych z niepękniętym tętniakiem wewnątrzczaszkowym podczas indukcji znieczulenia ogólnego

Background: The estimated prevalence of unruptured intracranial aneurysms is 3%. Standard monitoring does not enable one to assess the influence of anaesthetics on the factors determining intracranial homeostasis. Thanks to transcranial Doppler ultrasonography, middle cerebral artery flow velocity (VMCA), reflecting cerebral blood flow, can be measured. The aim of the study was to assess the effects of propofol on intracranial homeostasis in patients with unruptured intracranial aneurysms during the induction of anaesthesia based on VMCA changes. Methods: The study encompassed 21 patients (group II) anaesthetised for elective craniotomy due to unruptured intracranial aneurysms. The control group (group I) included 21 patients who underwent discoidectomy. VMCA, as well as HR, MAP, etCO2, and SpO2 were monitored at the following time points: T0 — onset of study; T1 — after 1 minute; T2 — onset of preoxygenation; T3 — after 1 minute of preoxygenation; T4 — administration of fentanyl; T5 — 1 minute after fentanyl; T6 — administration of propofol; T7 — 1 minute after propofol; T8 — intubation; T9 — 1 minute after intubation; T10 — 2 minutes after intubation. Results: In both groups, no changes in mean HR, etCO2 and SpO2 were observed at the successive time points of observation. In groups I and II, an MAP decrease between T6 and T7 and an MAP increase between T7 and T9 were noted. There were no intergroup differences in mean values of MAP at the times of observation. In both groups and bilaterally, a VMCA decrease was recorded between T6 and T7 and an increase between T7 and T8. There were no intergroup differences in mean values of VMCA at the times of observation. In both groups, a weak correlation between VMCA and MAP changes was found bilaterally. Conclusions: Propofol depresses the cerebral circulation during the induction of anaesthesia. The presence of an unruptured aneurysm does not affect the reactivity of the cerebral vessels during the induction of anaesthesia with propofol.Background: The estimated prevalence of unruptured intracranial aneurysms is 3%. Standard monitoring does not enable one to assess the influence of anaesthetics on the factors determining intracranial homeostasis. Thanks to transcranial Doppler ultrasonography, middle cerebral artery flow velocity (VMCA), reflecting cerebral blood flow, can be measured. The aim of the study was to assess the effects of propofol on intracranial homeostasis in patients with unruptured intracranial aneurysms during the induction of anaesthesia based on VMCA changes. Methods: The study encompassed 21 patients (group II) anaesthetised for elective craniotomy due to unruptured intracranial aneurysms. The control group (group I) included 21 patients who underwent discoidectomy. VMCA, as well as HR, MAP, etCO2, and SpO2 were monitored at the following time points: T0 — onset of study; T1 — after 1 minute; T2 — onset of preoxygenation; T3 — after 1 minute of preoxygenation; T4 — administration of fentanyl; T5 — 1 minute after fentanyl; T6 — administration of propofol; T7 — 1 minute after propofol; T8 — intubation; T9 — 1 minute after intubation; T10 — 2 minutes after intubation. Results: In both groups, no changes in mean HR, etCO2 and SpO2 were observed at the successive time points of observation. In groups I and II, an MAP decrease between T6 and T7 and an MAP increase between T7 and T9 were noted. There were no intergroup differences in mean values of MAP at the times of observation. In both groups and bilaterally, a VMCA decrease was recorded between T6 and T7 and an increase between T7 and T8. There were no intergroup differences in mean values of VMCA at the times of observation. In both groups, a weak correlation between VMCA and MAP changes was found bilaterally. Conclusions: Propofol depresses the cerebral circulation during the induction of anaesthesia. The presence of an unruptured aneurysm does not affect the reactivity of the cerebral vessels during the induction of anaesthesia with propofol

Radiation safety awareness among medical staff

Background: The common access to imaging methods based on ionizing radiation requires also radiation protection. The knowledge of ionizing radiation exposure risks among the medical staff is essential for planning diagnostic procedures and therapy. Evaluation of the knowledge of radiation safety during diagnostic procedures among the medical staff. Material and Methods: The study consisted of a questionnaire survey. The questionnaire consisted of seven closed-ended questions concerning the knowledge of the effects of exposure to ionizing radiation as well as questions related to responder's profession and work experience. The study group included a total of 150 individuals from four professional groups: nurses, doctors, medical technicians, support staff. The study was carried out in the three largest hospitals in Gdańsk between July and October 2013. Results: The highest rates of correct answers to questions related to the issue of radiation protection were provided by the staff of radiology facilities and emergency departments with 1-5 years of professional experience. The most vulnerable group in terms of the knowledge of these issues consisted of individuals working at surgical wards with 11-15 years of professional experience. Conclusions: Education in the field of radiological protection should be a subject of periodic training of medical personnel regardless of position and length of service