Biomedical subjects
Publications and source records attributed to W J Bock.
We describe the case of a giant aneurysm on the basilar artery not treated surgically after the first subarachnoid hemorrhage causing obstructive hydrocephalus 12 years later by growing. The problems of pathogenesis of growing aneurysms are discussed.
336 cerebral aneurysms were treated during the past 18 years. Amongst these, 30 patients harboured aneurysms in vertebro-basilar circulation and form the subject material to be analysed. 17 were non-surgically treated whilst 13 cases received surgical treatment. In the group of non-surgical treatment, 6 were found in a moribund stage on admission, 9 had rebled during hospitalization and died. 2 other patients with large or giant aneurysms were treated palliatively and conservatively. They still survived over 18 months, 12 aneurysms were surgically clipped and 1 was wrapped with muscle. 2 of them died 1 week postoperatively due to pulmonary embolism. Risk factors are discussed. In contrast to the aneurysms of other circulatory territories vertebro-basilar aneurysms should be operated at the earliest possible opportunity; waiting does not provide an additional advantage to offset the risk of high mortality and morbidity after recurrent haemorrhage and vasospasm in this region.
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Tumours in the posterior fossa in children only present minor problems in diagnosis since the introduction of the computerized tomogram, but in postoperative follow-up studies it is rather difficult to distinguish between the various findings in the posterior fossa. This holds true especially for medulloblastomas and ependymomas. Operative changes in the anatomical structures, metal-clips, scar-like changes, post-radiation sclerosis and other findings are reasons why it is almost impossible to diagnose early recurrence of these tumours. In order to obtain more information after operation, CT findings were studied in 36 children with tumours in the posterior fossa. The findings are summarized and discussed.
The paper deals with computertomographic and morphological studies in patients who died suffering from brain ischaemia, haemorrhagical infarction and haemorrhages. These examinations were done in identical sections. Methodically computerized tomograms in living patients, postmortal tomograms, brain sections and macrosections were used. Not in all cases corresponding findings were observed, due to the following factors 1. Size of the lesion 2. Localisation 3. Time of examination 4. Premortal alterations. The different factors are discussed in detail.
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Electroencephalographic (EEG) investigations were done in 36 patients with intracranial aneurysms, before and after surgery. Thirty five of them suffered from subarachnoid hemorrhage (SAH). Pre-operatively, there was no correlation between patients' age or sex and localisation of the aneurysm or degree of EEG disturbances. The most frequent finding was a generalised slowing, the degree of which depended on the time from bleeding to EEG. Focal abnormalities were due to spasms of the vessels or intracerebral haematomas. There was a high correlation with neurological deficits. Post-operatively, EEG disturbances became worse in 21 cases. Generalised and focal abnormalities increased. These were due to focal oedema and the operative approach. The EEG could be correlated very well with the findings from other investigative methods (CT scanning, angiography). The EEG, as a functional method, showed very well the whole state of the brain after bleeding and after operation.
In the first six months of 1977 156 patients with craniocerebral injuries underwent computerized tomography. Twelve had severe deficits which led to neurosurgical interventions. Only five had space-occupying haematomas. CT was useful in detecting neurosurgical complications, whereas EEG was useful in staging the severity of the trauma. The two methods, the functional one of EEG and the morphological one of CT, are complementary, especially with regard to the posttraumatic course. The clinical symptoms are reflected by EEG better than by CT.
Even after the introduction of the computerized tomogram, midline tumours in infants may give diagnostic problems. In the present study 41 children with tumours in the midline were investigated by both computerized tomography and encephalotomography. The results could be divided into two groups, according to the method and according to the localization of the space-occupying lesion. The diagnostic procedure may be restricted to computerized tomography in cases with direct signs (density differences, contrast enhancement). In cases showing indirect signs on the computerized tomogram (dislocation of ventricles or cisterns or both), further investigation would appear to be valuable. Encephalotomography is the method of choice in patients with negative or uncertain CT findings and contradictory clinical symptomatology.
Electroencephalographic investigations were done in 24 patients suffering from medulloblastoma. All underwent subtotal or total removal of the tumour and a shunt procedure, foowed by irradiation therapy. The most frequent pre-operative finding was general slowing, the degree of which could be correlated to the amount of papilloedema and obstructive hydrocepalus. In about one third of the patients we found abnormal rhythmic theta and delta activities, especially marked in the occipital regions. This could be explained by the pathogenesis of hydrocephalus in the child. In the acute post-operative stage in some cases only the general slowing was worse. A return to normal of the EEG disturbances was seen in the later post-operative course and after irradiation therapy. This return to normal seemed to depend only on the time factor, but not on the mode of treatment.
Tumours in the sellar region may still present diagnostic problems. We therefore compared encephalotomographic and CT findings in sellar tumours and 91 patients were examined by both methods. For clinical purposes and operative treatment the degree of compression of the hypothalamus is of great importance. Encephalotomographic and CT findings are analysed and demonstrated. In cases of density differences between tumour and brain tissue shown by contrast enhancement, more information on the inner structure of a tumour (cystic or solid) can be obtained by computerized tomography. But if these are no density differences or/and contrast enhancement, tumour diagnosis is made easier by encephalotomography because of the great efficiency of this method.
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Sixty-six patients with tumours in the sellar region were examined. All were operated on either by the transfrontal or the transsphenoidal route. Pre- and postoperative longitudinal electroencephalographic investigations were performed. Preoperative electroencephalograms showed a normal frequency content in cases of intrasellar tumours or those reaching the chiasma. Nearly all cases had irregularities in the temporal regions. Tumours compressing the third ventricle had slower average frequencies and a general slowing in all cases. Besides these alterations unilateral delta waves or bitemporal dysrhythmic groups were sometimes found. A connection between extension of the tumour and its histological nature could not be found, but the operative approach influenced the electroencephalographic disturbances enormously. After a transfrontal approach and removal of the tumour the electroencephalogram was unchanged. Sometimes a mild transient bitemporal slowing was present. But after a transfrontal operative approach a general slowing was common, usually with focal marked slow activity in the right fronto-temporal area.
The authors report on 200 cervical percutaneous cordotomies in 146 patients who were suffering from intractable pain. In order to assess the success rate and the incidence of relapse, the neurological findings immediately post-operatively were compared with the results of a later follow-up. The prospect of success in the treatment of pain appears to depend on the anatomical representation in the spino-thalamic tract of the region of the body which is involved. The incidence of complications and the mortality are compared with the observations of other authors and with the results of open cordotomy.
The diagnostic value of encephalotomography and computer tomography in neuroradiology of midline tumors is discussed. Characteristic differences of both methods are summarized. The following conclusions of clinical importance are derived from our experiences: 1. Computer tomography is the most valuable method in the diagnostic procedure of midline tumors. Encephalography is not necessary is cases with density differences of tumor and surrounding brain tissue or contrast enhancement. 2. Encephalotomography should be performed in cases with dislocation of cisternes and ventricles without density differences or contrast enhancement. 3. Encephalotomography is the method of choice in patients with unclear computer tomography and contradictory clincial symptomatology.
The importance of correlation of pathological specimen sections and computer tomograms is postulated emphazising examination of the same sectional level. First results are reported and false positive and false negative diagnoses are discussed.