THE WESTERN JOURNAL OF MEDICINE
*
NOVEMBER 1990
*
153
*
Kissoon N, Walia MS: The critically ill child in the pediatric emergency department. Ann Emerg Med 1989; 18:30-33 McLaurin RL, Schut L, Venes JL, et al (Eds): Pediatric Neurosurgery-Surgery of the Developing Nervous System. Philadelphia, Pa, WB Saunders, 1989 Pellock JM, Myer EC: Neurologic Emergencies in Infancy and Childhood. New York, NY, Harper & Row, 1984 Tunnessen WW Jr: Irritability, chap 9, In Signs and Symptoms in Pediatrics, 2nd ed. Philadelphia, Pa, JB Lippincott, 1988, pp 42-49
Surgical Treatment of Spasticity IN RECENT YEARS new surgical techniques have been developed that are effective in alleviating spasticity in selected patients. A decade ago, selective dorsal rhizotomy was reported to be effective in alleviating spasticity in children with cerebral palsy; the procedure has since been modified. This neurosurgical operation reduces spasticity by cutting selected posterior nerve rootlets on the basis of intraoperative electrical stimulation and electromyographic recordings. In recent years, interest in this procedure has grown in the United States, and it is being done in several neurosurgical centers across the country. Objective documentation and quantification of the results of this operation as measured by electrophysiologic techniques, physical therapy assessments, and sophisticated gait laboratories are now available. The procedure is clearly not a panacea for cerebral palsy. It does, however, decrease spasticity, which for some children is a source of major disability. For nonambulatory patients, the operation can increase range of motion; improve sitting, dressing, and positioning; and may lead to gains in functional mobility. For ambulatory patients, it can increase stride length and walking velocity; improve motion about the thighs, knees, and ankles; and ameliorate footfloor contact. Patients need to be carefully selected with emphasis on ascertaining the clinical importance of obstructive spasticity. Most commonly, cerebral palsy has been the underlying condition, although occasionally patients with spasticity due to myelomeningocele, multiple sclerosis, or head or spinal cord trauma may also benefit. When chronic pain and spasticity complicate the care of patients with stroke or spinal cord injury, microsurgical lesions at the dorsal root entry zone have been shown to be effective in reducing tone and in alleviating pain. LESLIE D. CAHAN, MD Irvine, California
REFERENCES Cahan LD, Adams JM, Perry J, et al: Instrumented gait analysis of selective dorsal rhizotomy. Dev Med Child Neurol 1990, in press Fasano VA, Broggi G, Barolat-Romana G, et al: Surgical treatment of spasticity in cerebral palsy. Child's Brain 1979; 4:289-305 Kundi M, Cahan L, Starr A: Somatosensory evoked potentials in cerebral palsy after partial dorsal root rhizotomy. Arch Neurol 1988; 46:524-527 Peacock WJ, Arens LJ: Selective posterior rhizotomy for the relief of spasticity in cerebral palsy. South Afr Med J 1982; 62:119-124 Sindou M, Jeanmonod D: Microsurgical DREZ-otomy for the treatment of spasticity and pain in the lower limbs. Neurosurgery 1989; 24:655-670 Storrs BB: Selective posterior rhizotomy for treatment of progressive spasticity in patients with myelomeningocele-Preliminary report. Pediatr Neurosci 1987; 13:135-137
Use of High-Dose Glucocorticoids in Acute Head and Spinal Cord Injuries THE EFFICACY OF GLUCOCORTICOIDS in the treatment of acute head and spinal cord injuries has been uncertain. In both instances, experimental work has suggested that these drugs would have a beneficial effect. The results have been mixed, though, when the effect of these drugs has been studied clinically. In patients with acute head injuries, the
549
5
glucocorticoids appear to reduce mortality but do not improve outcome and do not make the control of intracranial pressure easier. Similarly, with acute spinal cord injuries, no difference in outcome exists between patients treated with standard or those with high-dose methylprednisolone. The reason that much of the data have been inconclusive has been related to deficiencies in the design of the studies in which the use of glucocorticoids was investigated. These shortcomings in clinical studies have included a reliance on retrospective studies, inadequate controls, unsatisfactory randomization, a failure to blind aspects of studies, a lack of objective evaluation, an insufficient number of patients, and the inclusion of unqualified patients. Many of these problems in experimental design would seem to have been overcome in the recently completed second National Acute Spinal Cord Injury Study. In this multicenter, randomized, double-blind, and controlled study of 487 patients with acute spinal cord injuries, patients received either methylprednisolone sodium succinate, naloxone hydrochloride, or placebo. Methylprednisolone was administered in the form of a bolus dose of 30 mg per kg given over 15 minutes, followed in 45 minutes by an infusion of 5.4 mg per kg hourly for 23 hours. At six months' follow-up, those patients who had been administered methylprednisolone within eight hours of their injury had a substantial improvement in their neurologic status-motor, superficial pain, and touch sensation-compared with those who had received a placebo. This improvement occurred whether or not patients initially were judged to have either a complete or incomplete spinal cord lesion. The outcome in those patients given naloxone or methylprednisolone more than eight hours after their injury did not differ from that of those who had received a placebo. Major morbidity and mortality were similar in all groups of patients. The obvious question in light of the demonstrated efficacy of using glucocorticoids in patients with acute spinal cord injuries is whether or not a similar well-designed study is now justified in patients with acute head injuries. FRANKLIN C. WAGNER, Jr, MD Sacramento, California REFERENCES
Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injuryResults of the second National Acute Spinal Cord Injury Study. N Engl J Med 1990; 322:1405-1411 Cooper PR: A treatment of questionable efficacy, In Dailey RH, Callaham M (Eds): Controversies in Trauma Management. New York, NY, Churchill Livingstone, 1985, pp 3-15
Warning Leaks and Subarachnoid Hemorrhage RECENT IMPROVEMENTS IN OUTCOME after a subarachnoid hemorrhage have been attributed to advances in operative and anesthetic techniques, intensive perioperative care, and the recognition and treatment of secondary effects such as hydrocephalus, fluid-electrolyte disorders, and cerebral vasospasm. As perioperative therapy has improved outcome, perhaps the greatest risk to patients with ruptured intracranial aneurysms is inappropriate diagnosis and their delayed referral following a subarachnoid hemorrhage. The propensity of ruptured aneurysms to rebleed was well documented in the large cooperative studies of the 1970s and 1980s. Recent prospective studies from Scandinavia have substantiated early rebleeding rates from 13% to 22%, with a high percentage occurring within 24 hours of the initial hemorrhage. These studies confirmed earlier observations that the outcome after rebleeding is consider-
550
EPITOMES-NEUROSURGERY
550
EPITOMES-NEUROSURGERY
ably worse than after a single hemorrhage. Although magnetic resonance imaging is relatively insensitive to acute hemorrhage, aneurysms of greater than 5 mm are frequently visualized and the presence of methemoglobin in the subarachnoid space may be indicative of a previous subarachnoid hemorrhage. In addition, computed tomographic (CT) infusion may localize aneurysms at the circle of Willis with a high degree of sensitivity. A subset of patients of particular interest are those manifesting a "warning leak." A significant percentage of patients with subarachnoid hemorrhage will describe a transient event of sufficient severity to seek medical attention within three months preceding a major hemorrhage. The prevalence of warning leaks has been estimated at 28% to 59%; patients in this category generally had a worse overall outcome than persons presenting with their initial subarachnoid bleed. Headache was the most common presenting sign of a warning leak in all series, although oculomotor palsy, seizure, nuchal rigidity, transient neurologic impairment, and nausea have been associated with this syndrome. In a study of the characteristics of warning headaches in subarachnoid hemorrhage, most episodes were of sudden onset, localized, occasionally associated with other symptoms, and usually persisted for several days. Recently 34 patients with warning leaks of less than four weeks preceding a subarachnoid hemorrhage were among a retrospective series of 87 consecutive patients with ruptured intracranial aneurysm. Headache was nearly uniformly present at the time of the warning leak and was unilateral in 52% of patients with aneurysms arising from the internal carotid artery. The diagnosis was missed in all 17 patients who sought immediate attention. Among 9 pa-
tients diagnosed before the second hemorrhage, lumbar puncture (100%) was superior to CT scan (45%) in confirming the diagnosis. In 25 patients without diagnosis, a subarachnoid hemorrhage occurred in less than a week for 56% and overall mortality was 53%. Compared with patients presenting with an initial major hemorrhage or diagnosed before rebleeding, those with an undiagnosed warning leak had worse presenting grades, a worse outcome at three months, and a higher incidence of vasospasm and intracerebral hemorrhage. These data confirm the ominous significance of the warning leak in the natural history of intracranial aneurysms. A recent onset of severe headache or other symptoms potentially referable to a subarachnoid hemorrhage should be promptly evaluated by CT scan. A normal CT scan should be followed by lumbar puncture and a rapid referral for appropriate therapy if indicated. The widespread recognition of the warning leak represents perhaps the greatest area for potential improvement in the treatment of this disorder. MARC R. MAYBERG, MD
Seattle, Washington REFERENCES
Kassell NF, Kongable GL, Torner JC, Adams HP Jr, Mazuz H: Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke 1985; 16:587-590 LeBlanc R: The minor leak preceding subarachnoid hemorrhage. J Neurosurg 1987; 66:35-39 Newell DW, LeRoux PD, Dacey RG Jr, Stimac GK, Winn GR: CT infusion scanning for the detection of cerebral aneurysms. J Neurosurg 1989; 71:175-179 Rosenorn J, Eskesen V, Schmidt K, Ronde F: The risk of rebleeding from ruptured intracranial aneurysms. J Neurosurg 1987; 67:329-332 Verweij RD, Wijdicks EF, van Gijn J: Warning headache in aneurysmal subarachnoid hemorrhage-A case-control study. Arch Neurol 1988; 45:1019-1020
ADVISORY PANEL TO THE SECTION ON NEUROSURGERY SIDNEY TOLCHIN,
MD
Advisory Panel Chair CMA Scientific Board Representative La Mesa
DEWITT GIFFORD, MD Oakland MELVIN CHEATHAM, MD Ventura MICHAEL H. SUKOFF, MD Santa Ana DAVID S. KNIERIM, MD Loma Linda University
GERALD SILVERBERG, MD Stanford University FRANKLIN C. WAGNER, JR, MD University of California, Davis RONALD F. YOUNG, MD University of California, Irvine DONALD P. BECKER, MD University of California, Los Angeles
JOHN F. ALKSNE, MD University of California, San Diego CHARLES B. WILSON, MD University of California, San Francisco MARTIN H. WEISS, MD Section Editor University of Southern California
N. EDALATPOUR, MD Newport Beach
ULRICH BATZDORF, MD Los Angeles
PHILIPP M. LIPPE, MD San Jose
*
NOVEMBER 1990
*
153
*
Kissoon N, Walia MS: The critically ill child in the pediatric emergency department. Ann Emerg Med 1989; 18:30-33 McLaurin RL, Schut L, Venes JL, et al (Eds): Pediatric Neurosurgery-Surgery of the Developing Nervous System. Philadelphia, Pa, WB Saunders, 1989 Pellock JM, Myer EC: Neurologic Emergencies in Infancy and Childhood. New York, NY, Harper & Row, 1984 Tunnessen WW Jr: Irritability, chap 9, In Signs and Symptoms in Pediatrics, 2nd ed. Philadelphia, Pa, JB Lippincott, 1988, pp 42-49
Surgical Treatment of Spasticity IN RECENT YEARS new surgical techniques have been developed that are effective in alleviating spasticity in selected patients. A decade ago, selective dorsal rhizotomy was reported to be effective in alleviating spasticity in children with cerebral palsy; the procedure has since been modified. This neurosurgical operation reduces spasticity by cutting selected posterior nerve rootlets on the basis of intraoperative electrical stimulation and electromyographic recordings. In recent years, interest in this procedure has grown in the United States, and it is being done in several neurosurgical centers across the country. Objective documentation and quantification of the results of this operation as measured by electrophysiologic techniques, physical therapy assessments, and sophisticated gait laboratories are now available. The procedure is clearly not a panacea for cerebral palsy. It does, however, decrease spasticity, which for some children is a source of major disability. For nonambulatory patients, the operation can increase range of motion; improve sitting, dressing, and positioning; and may lead to gains in functional mobility. For ambulatory patients, it can increase stride length and walking velocity; improve motion about the thighs, knees, and ankles; and ameliorate footfloor contact. Patients need to be carefully selected with emphasis on ascertaining the clinical importance of obstructive spasticity. Most commonly, cerebral palsy has been the underlying condition, although occasionally patients with spasticity due to myelomeningocele, multiple sclerosis, or head or spinal cord trauma may also benefit. When chronic pain and spasticity complicate the care of patients with stroke or spinal cord injury, microsurgical lesions at the dorsal root entry zone have been shown to be effective in reducing tone and in alleviating pain. LESLIE D. CAHAN, MD Irvine, California
REFERENCES Cahan LD, Adams JM, Perry J, et al: Instrumented gait analysis of selective dorsal rhizotomy. Dev Med Child Neurol 1990, in press Fasano VA, Broggi G, Barolat-Romana G, et al: Surgical treatment of spasticity in cerebral palsy. Child's Brain 1979; 4:289-305 Kundi M, Cahan L, Starr A: Somatosensory evoked potentials in cerebral palsy after partial dorsal root rhizotomy. Arch Neurol 1988; 46:524-527 Peacock WJ, Arens LJ: Selective posterior rhizotomy for the relief of spasticity in cerebral palsy. South Afr Med J 1982; 62:119-124 Sindou M, Jeanmonod D: Microsurgical DREZ-otomy for the treatment of spasticity and pain in the lower limbs. Neurosurgery 1989; 24:655-670 Storrs BB: Selective posterior rhizotomy for treatment of progressive spasticity in patients with myelomeningocele-Preliminary report. Pediatr Neurosci 1987; 13:135-137
Use of High-Dose Glucocorticoids in Acute Head and Spinal Cord Injuries THE EFFICACY OF GLUCOCORTICOIDS in the treatment of acute head and spinal cord injuries has been uncertain. In both instances, experimental work has suggested that these drugs would have a beneficial effect. The results have been mixed, though, when the effect of these drugs has been studied clinically. In patients with acute head injuries, the
549
5
glucocorticoids appear to reduce mortality but do not improve outcome and do not make the control of intracranial pressure easier. Similarly, with acute spinal cord injuries, no difference in outcome exists between patients treated with standard or those with high-dose methylprednisolone. The reason that much of the data have been inconclusive has been related to deficiencies in the design of the studies in which the use of glucocorticoids was investigated. These shortcomings in clinical studies have included a reliance on retrospective studies, inadequate controls, unsatisfactory randomization, a failure to blind aspects of studies, a lack of objective evaluation, an insufficient number of patients, and the inclusion of unqualified patients. Many of these problems in experimental design would seem to have been overcome in the recently completed second National Acute Spinal Cord Injury Study. In this multicenter, randomized, double-blind, and controlled study of 487 patients with acute spinal cord injuries, patients received either methylprednisolone sodium succinate, naloxone hydrochloride, or placebo. Methylprednisolone was administered in the form of a bolus dose of 30 mg per kg given over 15 minutes, followed in 45 minutes by an infusion of 5.4 mg per kg hourly for 23 hours. At six months' follow-up, those patients who had been administered methylprednisolone within eight hours of their injury had a substantial improvement in their neurologic status-motor, superficial pain, and touch sensation-compared with those who had received a placebo. This improvement occurred whether or not patients initially were judged to have either a complete or incomplete spinal cord lesion. The outcome in those patients given naloxone or methylprednisolone more than eight hours after their injury did not differ from that of those who had received a placebo. Major morbidity and mortality were similar in all groups of patients. The obvious question in light of the demonstrated efficacy of using glucocorticoids in patients with acute spinal cord injuries is whether or not a similar well-designed study is now justified in patients with acute head injuries. FRANKLIN C. WAGNER, Jr, MD Sacramento, California REFERENCES
Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injuryResults of the second National Acute Spinal Cord Injury Study. N Engl J Med 1990; 322:1405-1411 Cooper PR: A treatment of questionable efficacy, In Dailey RH, Callaham M (Eds): Controversies in Trauma Management. New York, NY, Churchill Livingstone, 1985, pp 3-15
Warning Leaks and Subarachnoid Hemorrhage RECENT IMPROVEMENTS IN OUTCOME after a subarachnoid hemorrhage have been attributed to advances in operative and anesthetic techniques, intensive perioperative care, and the recognition and treatment of secondary effects such as hydrocephalus, fluid-electrolyte disorders, and cerebral vasospasm. As perioperative therapy has improved outcome, perhaps the greatest risk to patients with ruptured intracranial aneurysms is inappropriate diagnosis and their delayed referral following a subarachnoid hemorrhage. The propensity of ruptured aneurysms to rebleed was well documented in the large cooperative studies of the 1970s and 1980s. Recent prospective studies from Scandinavia have substantiated early rebleeding rates from 13% to 22%, with a high percentage occurring within 24 hours of the initial hemorrhage. These studies confirmed earlier observations that the outcome after rebleeding is consider-
550
EPITOMES-NEUROSURGERY
550
EPITOMES-NEUROSURGERY
ably worse than after a single hemorrhage. Although magnetic resonance imaging is relatively insensitive to acute hemorrhage, aneurysms of greater than 5 mm are frequently visualized and the presence of methemoglobin in the subarachnoid space may be indicative of a previous subarachnoid hemorrhage. In addition, computed tomographic (CT) infusion may localize aneurysms at the circle of Willis with a high degree of sensitivity. A subset of patients of particular interest are those manifesting a "warning leak." A significant percentage of patients with subarachnoid hemorrhage will describe a transient event of sufficient severity to seek medical attention within three months preceding a major hemorrhage. The prevalence of warning leaks has been estimated at 28% to 59%; patients in this category generally had a worse overall outcome than persons presenting with their initial subarachnoid bleed. Headache was the most common presenting sign of a warning leak in all series, although oculomotor palsy, seizure, nuchal rigidity, transient neurologic impairment, and nausea have been associated with this syndrome. In a study of the characteristics of warning headaches in subarachnoid hemorrhage, most episodes were of sudden onset, localized, occasionally associated with other symptoms, and usually persisted for several days. Recently 34 patients with warning leaks of less than four weeks preceding a subarachnoid hemorrhage were among a retrospective series of 87 consecutive patients with ruptured intracranial aneurysm. Headache was nearly uniformly present at the time of the warning leak and was unilateral in 52% of patients with aneurysms arising from the internal carotid artery. The diagnosis was missed in all 17 patients who sought immediate attention. Among 9 pa-
tients diagnosed before the second hemorrhage, lumbar puncture (100%) was superior to CT scan (45%) in confirming the diagnosis. In 25 patients without diagnosis, a subarachnoid hemorrhage occurred in less than a week for 56% and overall mortality was 53%. Compared with patients presenting with an initial major hemorrhage or diagnosed before rebleeding, those with an undiagnosed warning leak had worse presenting grades, a worse outcome at three months, and a higher incidence of vasospasm and intracerebral hemorrhage. These data confirm the ominous significance of the warning leak in the natural history of intracranial aneurysms. A recent onset of severe headache or other symptoms potentially referable to a subarachnoid hemorrhage should be promptly evaluated by CT scan. A normal CT scan should be followed by lumbar puncture and a rapid referral for appropriate therapy if indicated. The widespread recognition of the warning leak represents perhaps the greatest area for potential improvement in the treatment of this disorder. MARC R. MAYBERG, MD
Seattle, Washington REFERENCES
Kassell NF, Kongable GL, Torner JC, Adams HP Jr, Mazuz H: Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke 1985; 16:587-590 LeBlanc R: The minor leak preceding subarachnoid hemorrhage. J Neurosurg 1987; 66:35-39 Newell DW, LeRoux PD, Dacey RG Jr, Stimac GK, Winn GR: CT infusion scanning for the detection of cerebral aneurysms. J Neurosurg 1989; 71:175-179 Rosenorn J, Eskesen V, Schmidt K, Ronde F: The risk of rebleeding from ruptured intracranial aneurysms. J Neurosurg 1987; 67:329-332 Verweij RD, Wijdicks EF, van Gijn J: Warning headache in aneurysmal subarachnoid hemorrhage-A case-control study. Arch Neurol 1988; 45:1019-1020
ADVISORY PANEL TO THE SECTION ON NEUROSURGERY SIDNEY TOLCHIN,
MD
Advisory Panel Chair CMA Scientific Board Representative La Mesa
DEWITT GIFFORD, MD Oakland MELVIN CHEATHAM, MD Ventura MICHAEL H. SUKOFF, MD Santa Ana DAVID S. KNIERIM, MD Loma Linda University
GERALD SILVERBERG, MD Stanford University FRANKLIN C. WAGNER, JR, MD University of California, Davis RONALD F. YOUNG, MD University of California, Irvine DONALD P. BECKER, MD University of California, Los Angeles
JOHN F. ALKSNE, MD University of California, San Diego CHARLES B. WILSON, MD University of California, San Francisco MARTIN H. WEISS, MD Section Editor University of Southern California
N. EDALATPOUR, MD Newport Beach
ULRICH BATZDORF, MD Los Angeles
PHILIPP M. LIPPE, MD San Jose
