The relatively rare occurrence and uncertainty about pathogenesis of intradurally displaced disc herniations stimulated an anatomico-pathological study into intradural disc herniations. The relation between the ventral dura and posterior longitudinal ligament in the cervical, thoracic, lumbar and sacral regions were examined macroscopically and microscopically, and ventral and dorsal dural thickness was compared in 20 adult autopsies on patients who died from various causes; in addition, 20 late abortions and newborn cadavers were investigated in the same way. In this study, a total of 40 autopsies has shown that the ventral dura is most frequently and firmly attached to the posterior longitudinal ligament at the L4-L5 level and these adhesions may be congenital. In the adult cadavers dorsal dura was found to be thicker than the ventral dura in the lumbar and lower cervical interspaces. Three personal clinical cases of intradurally herniated disc prolapse are shortly described and the diagnosis and management of this pathology discussed.

A series of 75 children with traumatic extradural haematomas operated on at our Department between 1982 and 1988 were analysed in detail. The overall mortality rate was 17%. CT scan constituted a valuable tool for an early and correct diagnosis, and the mortality rate declined to 9% in the post-CT era. The outcome was found to be predominantly affected by the preoperative neurological status, by the duration of the time interval between onset of coma and surgical intervention, and mainly by the presence of associated brain lesions.

During the last three years, seven patients with severe intraventricular hemorrhage admitted to our clinic were treated with direct intraventricular infusion of urokinase. In each case, hemorrhage extended into the entire ventricular cavity and cast formation as well as an expansion of third and fourth ventricles were found. On the average, both the third and fourth ventricles became clear on the third day and the lateral ventricle on the ninth day after hemorrhage. Five of the seven patients showed good recovery or only moderate disability, and two died. Infection, convulsion, rebleeding, and peripheral or secondary hemorrhage due to the side effects of urokinase was not encountered during therapy. We conclude that this procedure can be applied effectively and safely in severe intraventricular hemorrhage.

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological finds are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Evoked potential conduction times in brain stem auditory (BCT) and central somatosensory pathways (CCT) were recorded from 23 normal subjects and 101 patients with severe head injury. Abnormalities in the CCT and the BCT findings correlated with the clinical indices of brain damage (coma score, motor response, pupil response, and spontaneous and reflex eye movements) in the head-injured patients and each correlated with outcome at 6 months from the injury. The CCT in the “best” hemisphere produced the strongest correlation with outcome (P<0.001). The correlation of the CCT with outcome was stronger in the 47 patients examined 2 to 3 days after the injury (P<0.001) compared to the 34 patients examined within 24 hours after the injury (P<0.02). No such difference was noted for the BCT. Serial studies within the first 2 weeks of injury did not show a consistent pattern and repetition of the investigation over this period did not provide any additional information. We used an INDEP-SELECT discriminant analysis program to determine whether information from the evoked potential data could improve prediction of outcome based on clinical data alone. With the addition of the CCT, the predictive accuracy (expressed as the correct classification probability) increased only slightly from 77 to 80%, and the difference was not significant. We conclude that central somatosensory and auditory brain stem conduction times provide useful prognostic information in paralyzed or sedated patients, but when neurological examination is feasible the benefits of evoked potential analysis do not justify the effort involved in data collection.

This study was designed to assess the feasibility of intrathecal gadolinium-enhanced magnetic resonance cisternography (MRC) for the evaluation of the presence or absence of communication of cranial arachnoid cysts with the cerebrospinal fluid (CSF) pathways of the central nervous system (CNS). This prospective study included 20 patients (12 males and 8 females) with a mean age of 37 years, who had, as a group, 22 intracranial arachnoid cysts identified on prior CT and/or MR examinations. Routine pre-contrast cranial MR imaging was followed by the intrathecal administration of 0.5 cc gadopentetate dimeglumine (GD) (Magnevist, Schering, Germany). Immediate and delayed (24 h) MR cisternography was then carried out. Eleven of 22 arachnoid cysts showed immediate CSF communication by the demonstration GD-contrast enhancement of the cyst fluid on the immediate post-injection scan. Contrast enhancement of the cyst was observed only on delayed MRC in six patients. MR imaging in five patients demonstrated no contrast enhancement of the arachnoid cysts on either immediate or delayed imaging. Six patients had mild transient post-procedure headache that was relieved by oral analgesics within 24 h. No serious immediate or chronic adverse effects or complications relating to the intrathecal contrast administration were observed. This study showed the relative safety, feasibility and reliability of low-dose intrathecal GD MR imaging in the demonstration of the communication or non-communication of intracranial arachnoid cysts with the CSF pathways of the CNS. In the future, this may have bearing on the selection for surgery of patients with intracranial arachnoid cysts presenting with clinical signs and symptoms potentially related to the location and mass effect of the cyst.

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