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Publications and source records attributed to Z Kotwica.
This article highlights the treatment of choice of chronic subdural hematoma. The importance, effectiveness, and low complication rate of minimally invasive procedure by burr holes and closed-system drainage is discussed.
The authors analysed a series of 111 adult patients admitted to the Department of Neurosurgery, Medical University of Lódź directly after trauma with initial GCS of 3 points. 74% of them had intracranial haematoma, mainly subdural, and were treated surgically within the first 3 hours after trauma. 8 patients had no abnormalities on CT scans. 99 (89%) patients died 2 to 30 days after injury, 8 (7%) survived in a vegetative state, and only in 4 (4%) was a satisfactory result noted, but 2 of them had a stable neurological deficit. 3 of these 4 patients had epidural haematomas and 1 had not abnormalities on repeated CT examinations. We conclude, that among patients with GCS of 3 on admission, only those without major CT abnormalities or with epidural haematoma have a chance of survival. Cases with cerebral lesions on the initial CT examination have an invariably bad prognosis. They could be taken into account as a potential organ donor from the very moment of admission, but only after cerebral circulatory arrest occurred and brain death has been proved according to internationally accepted standards.
The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of Lódź with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18-30 year old had lower mortality-25%, while patients above 50 revealed 75% mortality. Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery-those with quickly developing haematomas and intracranial hypertension-had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma. Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.
The author reports a patient with a fatal subarachnoid and intracerebral hemorrhage from a middle cerebral artery aneurysm, which apparently developed de novo. 18 years before, the patient was operated for an anterior communicating artery aneurysm and, during this procedure, an anterior cerebral artery was ligated. Hemodynamic disturbances due to anterior artery occlusion are suggested as the cause of new aneurysm formation.
136 patients older than 70 years, admitted to our neurosurgical ward directly after head trauma, were analysed. 40% of them were admitted with low GCS, below 9 points, and showed a mortality of 85%. 45 patients had intracranial mass lesions--the commonest was subdural haematoma, with a low incidence of epidural haematomas. In patients admitted with GCS above 12, mortality was 20%, mainly due to pneumonia. Satisfactory results were achieved in 30% of trauma victims. From patients with intracranial space occupying lesions and GCS below 9 points on admission practically all died, despite aggressive surgical treatment and intensive care. Thus, especially in departments with limited resources, therapy can be limited, or even no therapy may be introduced in this group. Surgical treatment can be limited only to patients who are conscious on admission. In patients with non-surgical lesions, low GCS--below 9 points--leads to mortality of 80%, and in this group we propose aggressive intensive care for 24 hours and the limitation of further "maximal" therapy only to those, who significantly improve within this period of time. If the patient has a non-surgical lesion and is conscious after trauma, aggressive treatment of extracranial complication is the most important, because brain injury can usually be well tolerated by these patients. If pneumonia or heart complications do not occur this group of old patients often have a good prognosis.
We report histologically different gliomas occurring simultaneously in both the cerebrum and cerebellum in a 53-year-old woman. One tumor was a cerebellar astrocytoma, and the second was a temporal glioblastoma multiforme. Two months after the removal of both tumors, the third lesion, located in the basal ganglia, was found on a computed tomographic examination, but it was not verified histologically. We recommend a biopsy of one tumor when a diagnosis of multiple brain tumors is established based on a computed tomographic examination, in order to avoid the misdiagnosis of multicentric gliomas as brain metastases.
The authors analysed the clinical and surgical results in 131 patients treated for unilateral chronic subdural haematoma. 71% of patients had a history of head trauma, 34% were addicted to alcohol. In 18% of cases the clinical course mimicked cerebral stroke. All patients were treated by burr holes and closed-system drainage lasting for 24-48 hours. There were 4 deaths, 3 from ischaemic stroke, and 1 from subdural empyema. 19 patients revealed postoperative complications--intracranial hypotension, cerebral oedema, and haematoma recurrence being the commonest. Follow-up revealed that 83% of patients were healthy, 10% had stable neurological deficit, and 7% presented epileptic fits.
The authors compared the results of preoperative computer-assisted myelography (CAM) with surgical findings in 45 patients with suspected cervical disc disease. In 98% CAM gave full and proper diagnosis confirmed by surgery. Only in one patient, the preoperative diagnosis was extraspinal tumour, and surgery revealed prolapsed nucleus pulposus lying freely on the anterior wall of the dural sac. In authors's opinion, CAM is sufficient for planning of surgical treatment in cervical disc disease, and other radiological studies, myelography or nuclear magnetic resonance tomography are usually not necessary.
In the years 1980-1987 in the Neurosurgery Department, Medical Academy in Lódź in 21 patients aged 12 to 59 years covering of cranial vault bone defects over 100 cm2 of area was done using of cranioplasty polypropylene-polyester knitted fabric Codubix. The size of the implanted prostheses was from 100 to 430 cm2. The time from bone defect occurrence to cranioplasty was from 4 weeks to 18 years. Cranial defects resulted from treatment of trauma complications in 10 cases, treatment of intracranial tumours in 7, aneurysms in 2 and intracranial infections in 2 cases. The follow-up after cranioplasty was from 3 to 10 years. In 18 cases (85.7%) good and very good therapeutic results were obtained. Three patients required removal of prosthesis because of purulent complication, in 2 of these cases high risk of infection was present before the operation. Codubix prosthesis was particularly useful for filling giant of cranial bones.
Out of 130 patients operated upon for chronic subdural haematoma, 9 presented with epileptic fits before surgery. 5 patients suffered generalized, and 4 partial seizures. The early operative results were very good, and follow-up lasting for at least 3 years revealed that 7 patients were seizure free, and only two of them continued with epileptic seizures. However 7 patients, who did not suffer epilepsy before the evacuation of haematoma developed epilepsy within the first year after surgery. The overall incidence of postoperative epilepsy was 7%. The authors suggest that the capsule of the haematoma plays an important role in the incidence of epilepsy after surgical treatment of chronic subdural haematoma.
The authors report a case of transitional cell meningioma of the convexity which destroyed a large portion of the calvarium and invaded subcutaneous tissue. The tumour was totally removed and a large cranial defect/430 cm2 in size/was filled with a polypropylenopolyester knitted prothesis "Codubix" with an excellent result. The problems of chronioplastic closure of such an unusually large skull defect and the advantages of the use of the material "Codubix" are discussed.
Prolonged recording of intracranial pressure (ICP) was performed on rats subjected to middle cerebral artery (MCA) occlusion. ICP was repeatedly recorded before and after occlusion of the vessel via a narrow catheter placed in the cisterna magna. MCA occlusion was followed by an increase in ICP, and a pressure peak occurred after 12-24 h in all animals. Subsequently, essentially two patterns of ICP changes were observed. These seemed to be related to the severity of neurological deficits and extension of the infarct area. In the most severely affected animals, raised ICP was noted throughout the 1st week after MCA occlusion; in rats with reversible neurological deficits, ICP returned to normal values after the first peak at 12-24 h. The present investigation shows that prolonged ICP recording is feasible in MCA-occluded rats. The MCA occlusion model in rats is well characterized. Thus, ICP registration can be used in conjunction with other methods for evaluating treatment against increased ICP.
This investigation was designed to study the dynamics of energy-related metabolites (i.e., lactate, pyruvate, inosine, and hypoxanthine) in the extracellular fluid (ECF) of the striatum and in cisternal cerebrospinal fluid (CSF) during the first 6 h after middle cerebral artery occlusion (MCAO) using microdialysis. Ischemia induced a dramatic increase in the ECF levels of lactate, inosine, and hypoxanthine, while pyruvate did not change significantly. The major part of these changes occurred during the first 10 min after MCAO. Inosine tended to normalize towards the end, while lactate and hypoxanthine remained elevated throughout the experiment. There was no increase of the energy-related metabolites in CSF during the experiment. It was concluded that lactate, inosine, and hypoxanthine appear to be useful ECF markers of the compromised energy state of the brain during ischemia. Because the metabolites did not appear in CSF during the first 6 h after MCAO, such measurements seem not to be useful for early detection of a disturbance in energy metabolism.
To assess the clinical manifestation of chronic subdural haematoma (CSH) the authors retrospectively analysed the files of 131 adult patients treated in the Department of Neurosurgery Medical Academy of Lódź. In 14 patients the illness had a sudden onset, suggesting cerebral stroke. 50% of patients had symptoms of raised ICP, there were no differences between young and older patients. In patients older than 40 years focal neurological deficits were more frequent, and in 13% of them focal signs were homolateral to CSH. In 9 patients the lesion produced symptoms of transtentorial herniation within a very short period. The authors think that despite the great progress in neuroradiology and neurosurgery, the condition may still be overlooked if the clinical picture does not suggest an intracranial space-occupying growth.
One-hundred and thirty-one patients with chronic subdural haematoma were treated by burr holes and closed system drainage. Four patients died, and in 19 patients postoperative complications were noted: intracranial hypotension in eight, cerebral oedema in four, haematoma recurrence in three, bronchopneumonia in three, and intracerebral haematoma in one. The high risk groups were those in grade III and IV on admission, and the elderly. Follow-up revealed that more than 80% of patients recovered completely, 10% still had neurological or mental deficits and 7% suffered epileptic seizures.
Head injuries of children between 4-16 years in the first hour after the trauma have been studied. The neurological examination was completed by CT-scan. Glasgow Coma Score (GCS) as well as Glasgow Outcome Scale (GOS) were also applied and proved to be very helpful. Our findings show a significantly frequent occurrence of epidural haematomas. Their treatment in patients with GCS above 8 was in 90% successful.
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The authors compared the results of a retrospective analysis of two groups of head-injured patients who had coexistent pelvic or lower extremity fractures. One group was treated with early osteosynthesis within the first 12 hours after trauma, simultaneously with neurosurgical treatment, while the second group was treated neurosurgically and osteosynthesis was postponed for 4 to 10 days. The second group revealed a higher mortality, which was due to fat embolism. We conclude that early osteosynthesis is the treatment of choice in patients with coexistent head injury and lower extremity fractures.