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Biomedical subjects

W Hacke

Publications and source records attributed to W Hacke.

At least 181 records · Page 10Linked to original sources
PubMed1996

The value of intracranial pressure monitoring in acute hemispheric stroke.

BACKGROUND AND PURPOSE: Persistently elevated intracranial pressure (ICP) has been associated with poor clinical outcome after severe brain injury, such as neurotrauma, intracerebral hemorrhage, and subarachnoidal hemorrhage. Although ICP monitoring is increasingly being used in intensive care treatment of patients with ischemic stroke, its value has not been established. PATIENTS AND METHODS: The clinical course of 48 patients with the clinical signs of increased ICP due to large hemispheric or middle cerebral artery territory infarction defined by CT and subjected to ICP monitoring was prospectively evaluated. Epidural ICP probes were inserted ipsilaterally to the site of primary brain injury in all and also contralaterally in seven patients. Initial clinical presentation was assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma Score (GCS). All patients were treated according to a standardized treatment protocol for elevated ICP. ICP values were correlated with the clinical presentation at the time point of deterioration, with outcome, and with CT findings. Different treatment strategies to lower ICP were analyzed as to their effectiveness. RESULTS: Only nine of the 48 patients survived the infarct (19%). The cause of death was transtentorial herniation with subsequent brain death in all 39 patients. The patients' mean SSS on admission was 20.6 (survivors 21.5 +/- 5.6, nonsurvivors 19.8 +/- 6.5). In all patients clinical signs of herniation preceded the increase in ICP. Patients with ICP values > 35 mm Hg did not survive. CT changes did not always correspond with the measured ICP values. All medical strategies to lower ICP, including osmotherapy, hyperventilation, THAM-buffer, and barbiturates, were initially effective, but only in a minority of patients was ICP control sustained. CONCLUSIONS: ICP monitoring of large hemispheric infarction can predict clinical outcome. Pharmacologic intervention had no sustained effect. ICP monitoring was not helpful in guiding long-term treatment of increased ICP. It remains doubtful that ICP monitoring in acute ischemic stroke has a positive influence on clinical outcome.

Acute Disease↗
PubMed1996

Decompressive craniectomy in a rat model of "malignant" cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach.

Acute ischemia in the complete territory of the carotid artery may lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Although clinical data suggest that patients benefit from undergoing decompressive surgery for acute ischemia, little data about the effect of this procedure on experimental ischemia are available. In this article the authors present results of an experimental study on the effects of decompressive craniectomy performed at various time points after endovascular middle cerebral artery (MCA) occlusion in rats. Focal cerebral ischemia was induced in 68 rats using an endovascular occlusion technique focused on the MCA. Decompressive craniectomy was performed in 48 animals (in groups of 12 rats each) 4, 12, 24, or 36 hours after vessel occlusion. Twenty animals (control group) were not treated by decompressive craniectomy. The authors used the infarct volume and neurological performance at Day 7 as study endpoints. Although the mortality rate in the untreated group was 35%, none of the animals treated by decompressive craniectomy died (mortality 0%). Neurological behavior was significantly better in all animals treated by decompressive craniectomy, regardless of whether they were treated early or late. Neurological behavior and infarction size were significantly better in animals treated very early by decompressive craniectomy (4 hours) after endovascular MCA occlusion (p < 0.01); surgery performed at later time points did not significantly reduce infarction size. The results suggest that use of decompressive craniectomy in treating cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. By performing decompressive craniectomy neurosurgeons will play a major role in the management of stroke patients.

Animals↗
PubMed1996

Spontaneous resolution of a large spinal epidural hematoma: case report.

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical evacuation of the hematoma. We report a case of spontaneous spinal epidural hematoma that was probably associated with aspirin intake. The initial clinical signs and symptoms included sharp, left-sided neck pain and weakness of the left arm. The initial magnetic resonance image showed a spinal epidural hematoma extending from C2 to C6, with compression of the myelon. This case is remarkable for dramatic clinical improvement within 12 hours and the magnetic resonance imaging documentation of complete resolution within 3 days. For each patient with a stable or improving neurological status, conservative management monitored by magnetic resonance imaging might be the treatment of choice.

Aged↗
PubMed1996

[Clinical procedures in brain infarct and differential diagnosis].

The outcome of stroke improves significantly, when recognized and treated within 3 hours and in certain cases not later than 6 hours. In addition, secondary preventive measures potentially ameliorate the fate of the patient as well, especially when the cause of stroke is known. In this first article we outline the practical diagnosis and evaluation of stroke, both in the acute stage and thereafter. The differential diagnosis is also considered.

Cerebral Infarction↗
PubMed1996

[Intensive care in acute ischemia].

Therapy of ischemic infarction has changed enormously during the last decade. This is due to an increase of pathophysiological knowledge on cerebrovascular disease, new diagnostic and intensive-care methods and success in thrombolytic therapy strategies; new neuroprotective drugs are on the way to be used on a routine base. The old fatalistic attitude towards treatment of stroke can nowadays not be justified. The success of stroke treatment is dependent on a fast and consequent therapeutic performing: patients with ischemic stroke who reach the hospital within six hours after onset of symptoms are candidates for thrombolysis. If certain inclusion criteria are fulfilled. Increasingly intracranial pressure is one of the major problems during the acute phase. Anti-edema treatment follows a stepwise scheme. In some selected cases we perform hemicraniectomy. Besides the routine intensive-care monitoring, further monitoring is necessary by evoked potentials, brain pressure probes and Doppler ultrasound.

Acute Disease↗
PubMed1996

[Carotid TEA and perioperative thrombolysis: a new concept in therapy of acute ischemic stroke].

In seven carotid-related acute hemispheric strokes with simultaneous embolic occlusion of the middle cerebral artery thrombolysis with urocinase or rt-PA was performed preoperatively (n = 3) or intraoperatively (n = 4) after carotid endarterectomy. Four patients recovered totally, three patients showed a remarkable improvement and were able to walk postoperatively. The combination of carotid endarterectomy and thrombolysis (simultaneous or staged) is a new option in the emergency treatment of an acute carotid-related stroke and should be evaluated in prospective interdisciplinary studies.

Adult↗
PubMed1996

Severe stroke.

Severe stroke is an emergency and requires rapid neurological assessment and diagnosis. CT scan is the first diagnostic step with the aim of finding out the extent, localization and possible pathophysiology of ischaemia in order to direct specific diagnostic and therapeutic options. An intracranial haemorrhage must be excluded. Early CT signs, including the size of the hypodensity and brain swelling, are important prognostic markers. Extracranial and transcranial Doppler sonography are valid for primary assessment of vascular pathophysiology and haemodynamics in most cases. Cerebral angiography should be performed if acute occlusion of the basilar artery or middle cerebral artery trunk is suspected and intra-arterial thrombolysis is a potential therapy. Intravenous thrombolyis has been proven to be effective in improving outcome in severe stroke; it is safe if the exclusion criteria are strictly applied. Prevention of secondary complications of stroke include general medical treatment with control of blood pressure, infections and cardiac and respiratory function, anti-coagulation. anti-oedematous treatment and surgical decompressive therapy for cerebellar and MCA space-occupying infarcts. Monitoring in the ICU is recommended. The medical therapy of intracerebral haemorrhage consists of control of ventilation and blood pressure, seizure prevention and anti-oedema treatment. Treatment of secondary ICH due to anti-coagulation or thrombolysis consists of administration of specific antidotes and the correction of the coagulopathy. Ventricular drainage should be performed when there is marked ventricular dilatation due to obstruction or blood in the ventricles. Most patients with cerebellar haemorrhage of more than 3 cm in diameter should undergo surgery to avoid brain-stem compression and hydrocephalus. In younger patients, non-dominant hemisphere putaminal and lobar haemorrhages with lateral displacement of midline structures and extensive oedema should be evacuated if the patient's level of consciousness deteriorates rapidly, or if the elevation of ICP cannot be controlled pharmacologically, and herniation is incipient. New techniques such as stereotactic and endoscopic evacuation still need to be tested prospectively. Patient selection for surgery should be cautious considering age, clinical status and possible contraindications such as cerebral amyloid angiopathy and coagulation disorders. Stroke therapy is rapidly becoming a focus of research and major changes in diagnostic and therapeutic options can therefore be expected.

Cerebral Hemorrhage↗
PubMed1995

Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS)

OBJECTIVE: To evaluate the efficacy and safety of intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. DESIGN: Randomized, prospective, multicenter, double-blind, placebo-controlled clinical trial. SETTING: A total of 75 hospitals in 14 European countries. PATIENTS: A total of 620 patients with acute ischemic hemispheric stroke and moderate to severe neurologic deficit and without major early infarct signs on initial computed tomography (CT). INTERVENTION: Patients were randomized to treatment with 1.1 mg per kilogram of body weight of rt-PA (alteplase) or placebo within 6 hours from the onset of symptoms. OUTCOME MEASURES: Primary end points included Barthel Index (BI) and modified Rankin Scale (RS) at 90 days. Secondary end points included combined BI and RS, Scandinavian Stroke Scale (SSS) at 90 days, and 30-day mortality. Tertiary end points included early neurologic recovery (SSS) and duration of in-hospital stay. Safety parameters included mortality and incidence of intracranial or extracranial hemorrhage. RESULTS: The distribution of demographic variables was similar among patients in the rt-PA and placebo treatment arms in both the intention-to-treat (ITT) analysis and the explanatory analysis for the target population (TP). A total of 109 patients (17.4%) were included in the trial despite major protocol violations but excluded from the TP. There was no difference in the primary end points in the ITT analysis, while the TP analysis revealed a significant difference in the RS in favor of rt-PA-treated patients (P = .035). Of the secondary end points, the combined BI and RS showed a difference in favor of rt-PA-treated patients in both analyses (P < .001). Neurologic recovery at 90 days was significantly better for rt-PA-treated patients in the TP (P = .03). The speed of neurologic recovery assessed by the SSS was significantly better up to 7 days in the ITT analysis and up to 30 days for the TP in the rt-PA treatment arm. In-hospital stay was significantly shorter in the rt-PA treatment arm in both analyses. There were no statistically significant differences in the mortality rate at 30 days or in the overall incidence of intracerebral hemorrhages among the rt-PA and placebo treatment arms in either analysis. However, the occurrence of large parenchymal hemorrhages was significantly more frequent in the rt-PA-treated patients. CONCLUSIONS: Intravenous thrombolysis in acute ischemic stroke is effective in improving some functional measures and neurologic outcome in a defined subgroup of stroke patients with moderate to severe neurologic deficit and without extended infarct signs on the initial CT scan. However, the identification of this subgroup is difficult and depends on recognition of early major CT signs of early infarction. Therefore, since treating ineligible patients is associated with an unacceptable increase of hemorrhagic complications and death, intravenous thrombolysis cannot currently be recommended for use in an unselected population of acute ischemic stroke patients.

Acute Disease↗
PubMed1995

Rare diseases mimicking acute vertebrobasilar artery thrombosis.

Acute ischaemia of the vertebrobasilar circulation leads to a variety of clinical manifestation and is mostly due to cardiogenic or artery-to-artery embolism. We describe four neurological emergency situations involving vertebrobasilar artery aclusion of other origins; basilar migraine, extrinsic compression by rheumatoid inflammatory tissue, generalized vasculitis in subacute rheumatic fever and basilar artery dissection. The differential diagnosis of acute vertebrobasilar artery occlusion may have an important impact on patient management.

Acute Disease↗
PubMed1995

Serial somatosensory and brainstem auditory evoked potentials in monitoring of acute supratentorial mass lesions.

OBJECTIVE: To determine the relevance of serial evoked potentials (brainstem auditory evoked potentials and somatosensory evoked potentials) and clinical parameters (pupillary response and intracranial pressure) in patients with acute supratentorial mass lesions. DESIGN: Prospective case series of comatose patients with acute supratentorial mass lesions. SETTING: Neurocritical care unit of a tertiary care center. PATIENTS: Thirty consecutive patients with the following study inclusion criteria: a) clinical and computed tomography evidence of an acute supratentorial mass lesion; b) implantation of an intracranial pressure monitoring device; and c) a persistent comatose state during the observation period. INTERVENTIONS: Brainstem auditory evoked potentials, somatosensory evoked potentials, intracranial pressure, and pupillary responses were recorded at the time of three particular events: a) immediately after implantation of an epidural intracranial pressure monitoring device; b) during intracranial pressure therapy; and c) at termination of intracranial pressure therapy. Evoked potential results were ranked into three categories: a) normal on both sides; b) abnormal or absent on one side; and c) evoked potentials on both sides abnormal or absent. Spearman's rank correlation was performed to analyze serial recordings. Cross tables were generated to determine the prognostic value of evoked potentials and clinical parameters. Fisher's exact test was applied to calculate statistical significance. MEASUREMENTS AND MAIN RESULTS: Intracranial pressure values correlated with pupillary responses and brainstem auditory evoked potentials during and at the termination of intracranial pressure therapy. Pupillary findings correlated with brainstem auditory evoked potentials only at the time of termination of intracranial pressure therapy. There was no correlation between somatosensory evoked potentials and clinical parameters. Pupillary responses indicated a good or poor recovery during and at the termination of intracranial pressure therapy. Brainstem auditory evoked potentials and intracranial pressure values distinguished between good and poor outcome only at termination of intracranial pressure therapy. Somatosensory evoked potential results did not predict outcome. CONCLUSIONS: Shortly after manifestation of supratentorial mass lesions, the results of evoked potentials and clinical parameters indicate increased intracranial pressure and incipient transtentorial herniation but do not predict sequelae. Our results indicate that after institution of effective therapy, pupillary abnormalities and brainstem auditory evoked potentials serve as valuable prognostic predictors. In contrast, somatosensory evoked potentials reflect neither therapeutic efficacy nor outcome in our patient population.

Acute Disease↗
PubMed1995

Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial.

OBJECTIVE: Space-occupying hemispheric infarctions, requiring neurocritical care treatment, demonstrate high mortality and morbidity rates. This study was performed to determine the beneficial effects of decompressive craniotomy on mortality and morbidity rates. DESIGN: Open, nonrandomized, control trial. Outcome was rated at discharge from the hospital (Glasgow Outcome Scale) and at follow-up (Barthel Index, Oxford Handicap Scale). SETTING: Patient recruitment from the Department of Neurology, University of Heidelberg (primary care center) over 65 months. PATIENTS: Thirty-two patients were prospectively selected for surgical treatment; 21 patients were treated conservatively. INTERVENTIONS: Extended craniotomy and dura patch enlargement were performed in all surgically treated patients. MEASUREMENTS AND MAIN RESULTS: At discharge, the outcome of six (18.8%) of 32 surgically treated patients was good compared with 0 (0%) of 21 conservatively treated patients. Fifteen (46.9%) of 32 surgically treated patients were moderately to severely disabled compared with five (23.8%) of 21 conservatively treated patients, and 11 (34.4%) of 32 surgically treated patients died compared with 16 (76.2%) of 21 conservatively treated patients. At follow-up in surgically treated patients, the Barthel Index (mean 62.6) showed an excellent level of daily activity in one patient, minimal assistance (Barthel Index of > or = 60) in 15 patients, and dependency in five patients. The Oxford Handicap Scale indicated no handicap in one patient, moderate handicaps in 15 patients, and moderately severe handicaps in five patients. In the control group, all five surviving patients needed assistance and all but one patient demonstrated a moderately severe handicap. CONCLUSIONS: Hemicraniotomy may improve survival in massive hemispheric stroke victims, decreasing mortality rates to < 35%. The disability rate remains high (24%), although some patients seem to benefit significantly.

Adolescent↗
PubMed1995

Decompressive craniectomy for cerebral infarction. An experimental study in rats.

BACKGROUND AND PURPOSE: Acute ischemia in the territory of the carotid artery can lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Thus far, only anecdotal experience with supratentorial ischemia treated by decompressive craniectomy has been reported; and there are no published experimental data dealing with this kind of therapy in acute supratentorial stroke. In this study, we present our results on the effect of decompressive craniectomy in an endovascular model of cerebral infarction in rats. METHODS: Focal cerebral ischemia was induced in 50 rats using an endovascular occlusion technique of the middle cerebral artery. Decompressive craniectomy was performed in 30 animals: in 15 animals after 1 hour and in the remaining 15 animals 24 hours after vessel occlusion. Twenty animals were not treated by decompressive craniectomy (control group). RESULTS: Mortality in the nontreated group was 35%, whereas none of the animals treated by decompressive craniectomy died. Neurological behavior, weight loss, and infarction size were all significantly better in the animals treated by decompressive craniectomy, regardless of whether they had been treated after 1 or 24 hours (P < .01). CONCLUSIONS: Our results suggest that decompressive craniectomy for cerebral ischemia not only reduces mortality but also significantly improves outcome and reduces infarction size, probably because of increased perfusion pressure through leptomeningeal collaterals. This experimental study suggests that a controlled study of decompressive craniectomy in patients with acute internal carotid or middle cerebral artery occlusion would be worthwhile. By performing decompressive craniectomy in a small, selected group of patients, neurosurgeons may play an important role in the management of these patients.

Acute Disease↗
PubMed1995

Does arterial recanalization improve outcome in carotid territory stroke?

BACKGROUND AND PURPOSE: We sought to determine whether early (< 8 hours) or delayed (8 to 24 hours) recanalization after stroke may be an independent variable in the improvement of clinical outcome in patients with occlusion of the middle cerebral artery. METHODS: We prospectively studied 77 patients by combined Scandinavian Stroke Scale score at admission, repeated computed tomography and angiography before and after thrombolytic treatment at < 8 hours after stroke onset, and transcranial Doppler ultrasound 24 hours later. We tested an association between clinical and neuroradiological baseline characteristics, recanalization, and outcome as assessed by the modified Rankin Scale 4 weeks after stroke and determined the effect of recanalization on mortality and good outcome (Rankin Scale grades 0 to 3) by multiple logistic regression analyses. RESULTS: Recanalization rates at 8 and 24 hours after stroke correlated with sites of occlusion (middle cerebral artery branch, 73% and 73%, trunk, 27% and 38%, respectively; intracranial internal carotid artery bifurcation, 14% and 14%; P = .002), collaterals (good, 43% and 51%, respectively; scarce, 17% and 19%, respectively; P = .01), and Scandinavian Stroke Scale score at admission (P = .002). Six of 6 patients with delayed recanalization had good outcomes. Recanalization at < 8 hours after symptom onset had no independent predictive value for good outcome (P = .69). Recanalization at 24 hours increased the proportion of good outcomes from 23% to 75% in a subgroup of patients. Recanalization did not independently affect mortality (P > .15). CONCLUSIONS: Even if delayed, arterial recanalization may improve clinical outcome in a subgroup of patients with middle cerebral artery occlusion.

Adult↗