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Pediatrics. 2000 Nov;106(5):1070-9.
Variations in practice and outcomes in the Canadian NICU network: 1996-1997.
Lee SK, McMillan DD, Ohlsson A, Pendray M, Synnes A, Whyte R, Chien LY, Sale J.
Department of Pediatrics, University of British Columbia, British Columbia, Canada. shoonterchange.ubc.ca
BACKGROUND: Previous reports of variations in outcomes among neonatal intensive care units (NICUs) examined only specific subpopulations of interest (eg, very low birth weight [VLBW] infants <1500 g of birth weight [BW]). OBJECTIVES: We report on current practice and outcomes variations in a population-based national study of Canadian NICUs from January 8, 1996 to October 31, 1997. METHOD: Information on 20 488 admissions to 17 tertiary level NICUs across Canada was prospectively collected by trained abstractors using a standard manual of operations and definitions. Data were verified and analyzed in concert with a steering committee comprising experienced researchers and neonatologists. Patient information included demographic information, antenatal history, mode of delivery, problems at delivery, status of infant and problems at birth, illness severity (Clinical Risk Index for Babies, Score for Neonatal Acute Physiology, Score for Neonatal Acute Physiology-Version II), therapeutic intensity (Neonatal Therapeutic Intensity Scoring System [NTISS]), selected NICU practices and procedures, use of technology and resources, and selected patient outcomes. Patients were tracked until death or discharge home. RESULTS: The mean number of annual admissions to an NICU was 657, with 26% outborn infants. Fifty-three percent were <2500 g BW, 20% were <1500 g BW (VLBW), and 65% were preterm (<38 weeks' gestational age [GA]). Only 2% of mothers received no prenatal care. Antenatal steroids were given to 58%, but there was wide variation in use (23%-76%). Congenital anomalies were present in 14%, and 4% were small for GA (less than the third percentile). Admission illness severity was lowest among infants 33 to 37 weeks of GA and correlated with risk of death. Ninety-six percent of patients survived until discharge, but fewer survived at lower GA. No infant <22 weeks' GA survived. Seven percent of infants had at least 1 episode of infection, but 75% received antibiotics in the NICU. Forty-three percent received respiratory support, and 14% received surfactant. Nitric oxide was given to 150 term infants and to 102 preterm infants. Selected outcomes of VLBW infants were: survival rate (87%); chronic lung disease (26%); >/=stage 3 retinopathy of prematurity (ROP; 11%); >/=grade 3 intraventricular hemorrhage (IVH; 10%); nosocomial infection (22%); necrotizing enterocolitis (NEC; 7%). Sixty-nine percent of VLBW infants survived without major morbidity (>/=grade 3 IVH, chronic lung disease, NEC, >/=grade 3 ROP). The mean duration of NICU stay was 19 days. Forty-seven percent of infants were discharged from the hospital, and 43% were retrotransferred to a community facility before discharge home. Significant variation in practices and outcomes were observed in all aspects of NICU care. CONCLUSION: This study provides population-based information about NICU outcomes. Significant variation in NICU practices and outcomes was observed despite Canada's universal health insurance system. This national database provides valuable information for planning research, allocating resources, designing health and public policy, and serving as a basis for longitudinal studies of NICU care in Canada.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11061777&dopt=Abstract hemorrhage
No To Shinkei. 2000 Sep;52(9):833-6.
[Acute epidural hematoma caused by contrecoup injury]
[Article in Japanese]
Motohashi O, Tominaga T, Shimizu H, Koshu K, Yoshimoto T.
Department of Neurosurgery, Kohnan Hospital, Japan.
We report a rare case of the acute epidural hematoma caused by contrecoup injury. A 59-year-old woman came to our hospital on foot because of her head injury. She slipped on a stone and hit her occiput against the concrete floor without loss of consciousness. On admission she was alert and complained of dizziness and nausea without neurological deficits. She had a subcutaneous hematoma in the occiput. There was no Battle's sign nor cerebrospinal fluid leakage. Skull film revealed a linear fracture of the occipital bone. Computed Tomography(CT) of the brain showed the acute epidural hematoma at the left frontal region. She was treated conservatively and discharged 19 days after injury without neurological deficits. The mechanism of this lesion is speculated as follows: the deformation of the skull and the negative pressure produced in the frontal region with the occipital injury stripped the dura mater from the calvarium, which lead to the rupture and hemorrhage of the small interposed vessels resulting in the epidural hematoma.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11064873&dopt=Abstract hemorrhage
Neurosurgery. 2000 Nov;47(5):1081-9; discussion 1089-90.
Near-real-time guidance using intraoperative magnetic resonance imaging for radical evacuation of hypertensive hematomas in the basal ganglia.
Bernays RL, Kollias SS, Romanowski B, Valavanis A, Yonekawa Y.
Department of Neurosurgery, University Hospital of Zurich, Switzerland. bernaych.unizh.ch
OBJECTIVE: To report our preliminary clinical experience in treating patients with hypertensive hemorrhage in the basal ganglia using a minimally invasive approach facilitated by intraoperative real-time imaging of an open magnetic resonance imaging (MRI) system and a newly designed cutting suction device. METHODS: We developed an artifact-free device for use during intraoperative MRI consisting of a guiding base that locks into a burr hole, a side-cutting composite-based cannula connected to a standard aspirator, and a handpiece that allows aspiration strength to be regulated by the surgeon. Thirteen patients with hypertensive bleeding in the basal ganglia were included in the study. Outcome was evaluated by mortality, Glasgow Outcome Scale score, activities of daily living score, and Rankin score at 2 weeks and at a median of 4.2 months after the hemorrhage. RESULTS: In this group of 13 patients, complete evacuation was achieved in 8 patients (62%) and subtotal evacuation of 75 to 90% of the initial volume in 4 patients (31%); the evacuation was partial in 1 patient (8%). Vascular malformations were preoperatively excluded angiographically. There was no rebleeding during surgery or postoperatively, as demonstrated by immediate postoperative MRI and computed tomography on the 1st postoperative day. Hematomas were evacuated on median Day 4 after the hemorrhage, varying between Day 1 and Day 8; evacuation was performed on Day 21 after the hemorrhage in one patient. Twelve of the 13 patients survived during a median follow-up time of 4.2 months. Neurological function improved in 11 of the 12 patients eligible for assessment. One patient with an additional head injury died 15 days after surgery from pulmonary embolism. CONCLUSION: This study shows an excellent outcome with regard to mortality and a positive trend regarding neurological outcome for the specific group of patients with hypertensive hematomas in the basal ganglia. This minimally invasive approach is feasible in the open intraoperative MRI in combination with the cutting suction device developed in our institution. Online imaging is extremely helpful for planning, guiding, and real-time monitoring of the procedure.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11063100&dopt=Abstract hemorrhage
Cerebrovasc Dis. 2000 Nov-Dec;10(6):424-30.
Intrathecal administration of thrombin inhibitor ameliorates cerebral vasospasm. Use of a drug delivery system releasing hirudin.
Kudo A, Suzuki M, Kubo Y, Watanabe M, Yoshida K, Doi M, Kuroda K, Ogawa A.
Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.
The role of thrombin as a spasmogen after subarachnoid hemorrhage was evaluated using the intrathecally administered thrombin inhibitor hirudin, released from a drug delivery system (DDS) based on collagen in a canine vasospasm model. The DDS was implanted into the cisterna magna with autologous blood in the hirudin-treated group. The reduction in the angiographical diameter of the basilar artery was only 19% in the hirudin-treated group on day 7, showing a significant difference between hirudin-treated and nontreated groups (p < 0.01). These results suggest that thrombin is an important cause of vasospasm. The collagen DDS has great potential for treatment in the cerebrospinal fluid milieu. 2000 S. Karger AG, Basel
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11070371&dopt=Abstract hemorrhage
Cerebrovasc Dis. 2000 Nov-Dec;10(6):466-70.
Extracranial aneurysms of the posterior inferior cerebellar artery.
Abrahams JM, Arle JE, Hurst RW, Flamm ES.
Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pa., USA. jabrahaail.med.upenn.edu
OBJECTIVE: Extracranial aneurysms of the distal posterior inferior cerebellar artery (PICA) are extremely rare and sometimes difficult to diagnose without an adequate angiogram. We present the first series of 3 patients who were evaluated by the senior author and treated surgically. METHODS AND RESULTS: All 3 patients presented with subarachnoid hemorrhage (SAH). Clincial symptoms, included occipital headache, nuchal rigidity, abducens nerve palsy and rapid neurologic deterioration. A unilateral injection of the vertebral artery failed to show the distal contralateral PICA and the aneurysm in 1 patient. All patients underwent aneurysm clipping through a posterior fossa craniectomy and C-1 laminectomy. The aneurysms were located on the tonsillomedullary segment of the PICA, 10-12 mm below the level of the foramen magnum. CONCLUSIONS: It is important to adequately visualize the distal extent of both PICAs or these aneurysms may not be seen. Patients who present with SAH must have the entirety of both vertebral arteries evaluated to avoid missing these aneurysms. The aneurysms were located adjacent to the atlas necessitating an upper cervical laminectomy for adequate surgical exposure. In general, the patients did well postoperatively and none of the patients developed cerebral vasospasm. 2000 S. Karger AG, Basel
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11070378&dopt=Abstract hemorrhage
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