Severe diffuse brain injury. Justifiability of decompressive craniectomy

Objective: To study the possibility of improvement of response to treatment of injured persons with severe diffuse brain injury (SDBI) through the intracranial pressure (ICP) monitoring and active correction of intracranial hypertension (ICH) with the use of decompressive craniectomy (DC).Material and methods: A prospective analysis of response to treatment of 57 injured persons with SDBI was carried out. The first period of research (2000 – 2005): 34 patients. The second period (2006 – 2012): 23 patients. The main criterion of enrolment to the research is a severe brain injury (8 points or less according GSC scale). L.F. Marshall classification of diffuse injury to brain was used. ICP measurement during the second period was carried using the parenchymal sensors on the monitor Brain Pressure Monitor REF HDM 26.1/FV500 Spiegelberg (Germany).Results: Augmentation of signs of axial and lateral dislocation with the transition from type I to type IV of SDBI of the brain is related to the increased rate of detection and intensity of ICH. ICH was discovered among 25% of patients with type II of SDBI, and among 57% with type III and 80% with type IV of SDBI. Average ICP in the group of injured persons with type II of SDBI constituted (14.4±6.6) mm Hg, with type III – (30±20.6) mm Hg, with type IV – (37.6±14.1) mm Hg.As long as the rate of ICH detection increases, the necessity to use more aggressive treatment methods increases as well, including the DC. DC was not used for type I and type II of SDBI. During the first period, DC was carried out only for 15.4% of injured persons with the injury of type IV. During the second period, DC was carried out for 42.9% of injured persons with type III and for 100 injured persons with type IV of SDBI. The average ICP in the group of injured persons with SDBI, who were subjected to DC, constituted (41±18.6) mm Hg prior to the operation and (20.1±18) mm Hg after the operation. DC fulfillment resulted in ICP reduction by a mean of 46.6%.Lethality during the first observation period constituted 52.9%, and during the second one – 39.1% (χ2=10.9; р<0.004). During the first period of research the benign outcome (good recovery + moderate disability according to the Glasgow outcome scale) was achieved among 17.7% of injured persons, and during the second period - among 26% (р<0.05).Conclusions: SDBI types according to L.F. Marshall classification that are determined on the basis of primary CT of brain, correlate with the ICH rate and intensity, lethality rate, and they must be taken into consideration when determining the treatment policy

Surgery for Triple Pathology of Giant Vestibular Schwannoma Associated with Carotid Artery Stenosis and Intracranial Aneurysm: Case Report

Here we report the case of a 56-year-old woman who presented with a highly unusual combination of three pathologies, namely a giant left-sided vestibular schwannoma, severe stenosis of the left internal carotid artery, and a right anterior cerebral artery aneurysm. The chosen approach comprised three consecutive surgical procedures, namely (1) aneurysm embolization, (2) carotid stenosis stenting, and (3) vestibular schwannoma excision. This approach avoided complications and achieved a satisfactory functional outcome. To the best of our knowledge, this combination of three conditions has not been previously reported in the English-language literature

Long-Term Treatment with Extended-Release Carbidopa– Levodopa (IPX066) in Early and Advanced Parkinson’s Disease: A 9-Month Open-Label Extension Trial

Background and Objective IPX066 is a multiparticulate extended-release formulation of carbidopa–levodopa, designed to produce prolonged therapeutic levodopa plasma concentrations. This 9-month open-label extension study assessed its long-term safety and clinical utility in early and advanced Parkinson’s disease (PD). Methods Participants were enrolled from two phase III IPX066 studies and one open-label phase II study. Early PD patients were titrated to an appropriate dosing regimen while advanced patients started with regimens established in the antecedent studies. Adjustment was allowed throughout the extension. Clinical utility measures included the Unified Parkinson’s Disease Rating Scale (UPDRS) and Patient Global Impression (PGI) ratings. Results Among 268 early PD patients, 53.4 % reported adverse events (AEs) and 1.1 % (three patients) discontinued due to AEs; the most frequent AEs were nausea (5.6 %) and insomnia (5.6 %). Among 349 advanced patients, 60.2 % reported AEs and 3.7 % (13 patients) discontinued due to AEs; the most frequent AEs were dyskinesia (6.9 %) and fall (6.6 %). At month 9 (or early termination), 78.3 % of early patients were taking IPX066 three times daily (median: 720 mg/day) and 87.7 % of advanced patients were taking IPX066 three or four times daily (median: 1450 mg/day). Adjusting for 70 % bioavailability relative to immediate-release (IR) carbidopa–levodopa, the median dosages correspond to *500 and *1015 mg/day of IR levodopa in early and advanced PD, respectively. Based on the plasma profiles previously observed in PD patients, the IPX066 regimens in the extension can be estimated to provide a levodopa Cmax (maximum plasma drug concentration) similar to or lower than that provided by IR regimens during the antecedent trials. UPDRS and PGI findings showed sustained treatment effects throughout the extension. Conclusion During 9 months of extended use, IPX066 exhibited a safety/tolerability profile consistent with dopaminergic PD therapy

Optimization of surgical treatment of combination of cerebral aneurysms and head magistral arteries stenosis and occlusion

Objective. Determination of the optimal strategy of surgical treatment of patients with a combination of cerebral aneurysms and head magistral arteries stenosis.Methods. 26 patients with combination of cerebral aneurysms and head magistral arteries stenosis, whose age was between 44 and 84 years, have been examined and treated in the Cerebrovascular Clinic of the Dnipropetrovsk Regional Hospital for the last 4 years. 21 of them were operated, 5 – abstained. 24 endovascular and 8 open operations were performed in different combinations.Results. All cases were divided into 3 groups according to the application different tactics of surgical treatment. Group 1 - 10 patients were operated in order to exclude cerebral aneurysm and revascularize head magistral arteries. Group 2 - 5 patients were operated to remove only the head magistral arteries stenosis. Group 3 - 6 patients were operated to exclude cerebral aneurysm alone. Functional outcomes evaluated by the modified Rankin scale and were the best in group 1.Conclusion. Surgical risks in case of treatment only one of pathology in case of combination of head magistral arteries stenosis and cerebral aneurysms may cause clinical manifestation of the other one. One-session surgical treatment of cerebral aneurysms and head magistral arteries stenosis based on data about the peculiarities of collateral bloodcirculation, cerebrovascular reserves, degree hemoperfusion deficit in different arterial basins is the best strategy of surgical treatment

Long-term treatment with extended-release carbidopa-levodopa (IPX066) in early and advanced Parkinson's Disease : a 9-month open-label extension trial

Background and Objective IPX066 is a multiparticulate extended-release formulation of carbidopa–levodopa, designed to produce prolonged therapeutic levodopa plasma concentrations. This 9-month open-label extension study assessed its long-term safety and clinical utility in early and advanced Parkinson’s disease (PD). Methods Participants were enrolled from two phase III IPX066 studies and one open-label phase II study. Early PD patients were titrated to an appropriate dosing regimen while advanced patients started with regimens established in the antecedent studies. Adjustment was allowed throughout the extension. Clinical utility measures included the Unified Parkinson’s Disease Rating Scale (UPDRS) and Patient Global Impression (PGI) ratings. Results Among 268 early PD patients, 53.4 % reported adverse events (AEs) and 1.1 % (three patients) discontinued due to AEs; the most frequent AEs were nausea (5.6 %) and insomnia (5.6 %). Among 349 advanced patients, 60.2 % reported AEs and 3.7 % (13 patients) discontinued due to AEs; the most frequent AEs were dyskinesia (6.9 %) and fall (6.6 %). At month 9 (or early termination), 78.3 % of early patients were taking IPX066 three times daily (median: 720 mg/day) and 87.7 % of advanced patients were taking IPX066 three or four times daily (median: 1450 mg/day). Adjusting for 70 % bioavailability relative to immediate-release (IR) carbidopa–levodopa, the median dosages correspond to *500 and *1015 mg/day of IR levodopa in early and advanced PD, respectively. Based on the plasma profiles previously observed in PD patients, the IPX066 regimens in the extension can be estimated to provide a levodopa Cmax (maximum plasma drug concentration) similar to or lower than that provided by IR regimens during the antecedent trials. UPDRS and PGI findings showed sustained treatment effects throughout the extension. Conclusion During 9 months of extended use, IPX066 exhibited a safety/tolerability profile consistent with dopaminergic PD therapy

Актуальні питання організації надання медичної допомоги, діагностики та лікування бойової хребетної та хребетно-спинномозкової травми

Introduction. In the modern conditions issues of diagnostics and treatment organizing at battle traumas are extremely important on stages of medical evacuation in the system of medical space in Ukraine.Materials and methods. 9 patients with battle traumas of the spine and spinal cord have been treated in Dnipropetrovsk Regional Clinical Hospital named after l.l. Mechnikov.Results and their discussion. Duration of medical evacuation was about 24 hours. Neurosurgical intervention was performed in 2 patients with gun-shot spinal injuries in the acute and early periods. Operation was not performed in one patient with anatomic rupture of the spinal cord. In 4 cases we considered diagnostic and treatment features of blast and mine-blast spinal traumas, caused by effect of the blast wave and the energy side impact. In 1 case we considered traumatic plexitis due to paravertebral injury of spinal roots. Stabilizing operation on cervical spine was performed in 1 patient in delayed period due to his condition severity.Conclusions. 1. Timely delivered medical care at the stage of medical evacuation determines success of treatment at battle traumas of the spine and spinal cord.2. Vertebral and spinal traumas at battle conditions have different biomechanics of damage that effects on diagnostics and treatment in injured persons.3. Effect of the side impact energy and blast wave is one of the leading factors of gum-shot injuries, blast and mine-blast traumas of the spine and spinal cord.Вступление. В современных условиях чрезвычайно актуальны вопросы организации диагностики и лечения боевой травмы на этапах медицинской эвакуации в системе медицинского пространства Украины.Материалы и методы. В Днепропетровской областной клинической больнице им. И.И. Мечникова лечили 9 пациентов по поводу боевой позвоночной и позвоночно-спинномозговой травмы.Результаты и их обсуждение. Продолжительность медицинской эвакуации до 24 ч. У 2 пациентов выполнено нейрохирургическое вмешательство по поводу огнестрельного ранения позвоночника в остром и раннем периоде. Один пострадавший не оперирован из-за анатомического разрыва спинного мозга. В 4 наблюдениях рассмотрены особенности диагностики и лечения по поводу взрывного и минно-взрывного повреждения позвоночника, вероятной причиной которого было действие ударной волны и энергии бокового удара. В 1 наблюдении отмечен травматический плексит вследствие паравертебрального повреждения корешков спинного мозга. Стабилизирующая операция на шейном отделе позвоночника выполнена у одного пациента в отсроченном периоде, в связи с тяжестью состояния.Выводы. 1. Своевременность оказания медицинской помощи на этапах медицинской эвакуации определяет успех лечения пострадавших по поводу боевой позвоночно-спинномозговой травмы.2. Позвоночная и позвоночно-спинномозговая травма, возникшая в боевых условиях, отличается биомеханикой повреждения, что влияет на диагностику и тактику лечения пострадавших.3. Действие энергии бокового удара и ударной волны является одним из ведущих факторов огнестрельных, минно-взрывных и взрывных ранений позвоночника и спинного мозга.Вступ. В сучасних умовах надзвичайно актуальними є питання формування організаційних підходів до діагностики й лікування бойової травми на етапах медичної евакуації в системі медичного простору України.Матеріали і методи. У Дніпропетровській обласній клінічній лікарні ім. І.І. Мечникова лікували 9 пацієнтів з приводу бойової хребетної та хребетно-спинномозкової травми.Результати та їх обговорення. Тривалість медичної евакуації 24 год. У 2 пацієнтів з приводу вогнепального поранення хребта здійснене нейрохірургічне втручання у гострому та ранньому періоді. В одного хворого за анатомічного розриву спинного мозку операцію не виконували. У 4 спостереженнях розглянуті особливості діагностики й лікування при вибуховому та мінно-вибуховому ураженні хребта, ймовірною причиною якого є дія ударної хвилі та енергії бічного удару. В 1 хворого відзначено травматичну плексопатію внаслідок паравертебрального ураження корінців спинного мозку. Стабілізуюча операція на шийному відділі хребта виконана в одного пацієнта у відстроченому періоді через тяжкість стану.Висновки. 1. Своєчасність надання медичної допомоги на етапах медичної евакуації забезпечує успіх лікування постраждалих з приводу бойової хребетної та хребетно-спинномозкової травми.2. Хребетна та хребетно-спинномозкова травма, що виникла за бойових умов, відрізняється біомеханікою ураження, що впливає на діагностику й тактику лікування постраждалих.3. Дія енергії бічного удару та ударної хвилі є одним з провідних складових вогнепальних, мінно-вибухових та вибухових поранень хребта та спинного мозку

Topical issues of organization of medical care, diagnostics and treatment of battle traumas of the spine and spinal cord

Introduction. In the modern conditions issues of diagnostics and treatment organizing at battle traumas are extremely important on stages of medical evacuation in the system of medical space in Ukraine.Materials and methods. 9 patients with battle traumas of the spine and spinal cord have been treated in Dnipropetrovsk Regional Clinical Hospital named after l.l. Mechnikov.Results and their discussion. Duration of medical evacuation was about 24 hours. Neurosurgical intervention was performed in 2 patients with gun-shot spinal injuries in the acute and early periods. Operation was not performed in one patient with anatomic rupture of the spinal cord. In 4 cases we considered diagnostic and treatment features of blast and mine-blast spinal traumas, caused by effect of the blast wave and the energy side impact. In 1 case we considered traumatic plexitis due to paravertebral injury of spinal roots. Stabilizing operation on cervical spine was performed in 1 patient in delayed period due to his condition severity.Conclusions. 1. Timely delivered medical care at the stage of medical evacuation determines success of treatment at battle traumas of the spine and spinal cord.2. Vertebral and spinal traumas at battle conditions have different biomechanics of damage that effects on diagnostics and treatment in injured persons.3. Effect of the side impact energy and blast wave is one of the leading factors of gum-shot injuries, blast and mine-blast traumas of the spine and spinal cord