BackgroundIn the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation.MethodsFrom 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge.ResultsFour hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated.ConclusionsThis study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

SummaryElevation of the head as a common practice to reduce raised intracranial pressure (ICP) has been discussed controversially of late. Some investigators were able to show that besides lowering ICP head elevation may also reduce cerebral perfusion pressure (CPP). For a new evaluation of optimal head position in neurosurgical care it would be of importance to know the influence of body position on cerebral perfusion.We therefore employed continuous jugular venous oximetry, monitoring cerebral oxygenation, to study the effect of 0°, 15°, 30°, and 45° head elevation on ICP, CPP and jugular venous oxygen saturation (SJVOz) in 25 comatose patients with reduced intracranial compliance.As expected, head elevation significantly reduced ICP from 19.8 ± 1.3 mmHg at 0° to 10.2 ± 1.2mmHg at 45°. Already at 30°92% of the possible effect on ICP was detected. There was no statistically significant change in CPP and SJV02 associated with varying head position. Individual reactions of CPP to changes in head position, however, were quite unpredictable. The data suggest that an individual approach to head elevation is to be prefered. A moderate head evelation between 15° and 30° significantly reduces ICP and, in general, does not impair cerebral perfusion. Jugular venous oximetry may be used to optimize ICP, CPP and cerebral oxygenation.

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

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Comatose patients run a high risk of developing cerebral ischaemia which may considerably influence final outcome. It would therefore be extremely useful if one could monitor cerebral blood flow in these patients. Since there is a close correlation between the arteriovenous difference of oxygen and cerebral blood flow, it was a logical step to place a fiberoptic catheter in the jugular bulb for continuous measurement of cerebrovenous oxygen saturation. We have monitored cerebral oxygenation in 54 patients, comatose because of severe head injury, intracerebral haemorrhage or subarachnoid haemorrhage. Normal jugular venous oxygen saturation (SJVO2) ranges between 60 and 90%. A decline to below 50% is considered indicative of cerebral ischaemia. Spontaneous episodes of desaturation (SJVO2 < 50% for at least 15 min) were frequent during the acute phase of these insults. Many of these desaturation episodes could be attributed to hyperventilation, even though considered moderate. Likewise, insufficient cerebral perfusion pressure and severe vasospasm were found to be important causes of desaturation episodes. In many instances, tailoring of ventilation or induced hypervolaemia and hypertension were capable of reversing these low flow states. The new method of continuous cerebrovenous oximetry is expected to contribute to a better outcome by enabling timely detection and treatment of insufficient cerebral perfusion.

BACKGROUND The transsphenoidal approach to the skull base has enjoyed increasing popularity for surgery of the sellar region avoiding brain retraction and causing few severe complications. While vitally important vessels in this region show a high degree of variability, some anatomical variants might be involved in characteristic complications. OBSERVATIONS We present the case of a 40-year-old female patient with acromegaly due to a pituitary adenoma that was transsphenoidally operated. Postoperatively, the patient presented with bilateral unresponsive mydriasis, loss of consciousness and tetraparesis. An MRI showed well-circumscribed bilateral paramedian thalamic infarctions which indicated a rare Percheron-like artery. At 2-year follow-up examination the patient was dramatically improved but with a profound impact on her ability to interact with the world. LESSONS The basilar artery or perforators might be injured during dissection of suprasellar lesions. This vascular territory is essential to interaction of the brain with the outside world. We conclude that we will approach future suprasellar adenomas strictly intracapsularly.

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