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Unter den 714 Schadelhirnverletzten, die von 1969 bis 1972 stationar behandelt wurden, fanden sich 111 mit Mittelhirnsyndrom (MHS). Davon wurden 99 vergleichenden klinischen Untersuchungen unterzogen. Alle Patienten wurden mit den gleichen Intensivmasnahmen und jeder zweite zusatzlich noch mit der hyperbaren Oxygenation (HO) behandelt. Der Vergleich zwischen den nur intensiv behandelten (Gruppe A) und den noch zusatzlich mit der HO behandelten Fallen (Gruppe B) ergab: 1. Die Uberlebenszeit war bei den Fallen der Gruppe B wesentlich langer. 2. Die Uberlebensrate war wesentlich groser in der Gruppe B sowohl bei den Fallen, die eine Kontusio, als auch bei denen, die eine intrakranielle Blutung als Ursache des MHS hatten. 3. Die Uberlebensquote war in den Altersklassen vom 1. bis 30. Lebensjahr wesentlich hoher bei den zusatzlich mit HO behandelten Patienten. Vom 40. Lebensjahr ab lies sich nur noch ein geringer Unterschied zugunsten der Falle der Gruppe B erkennen. 4. Am Ende der stationaren Behandlung waren in der Gruppe A 74% verstorben oder apallisch, in der Gruppe B 53%. Eine vollstandige Wiederherstellung wurde bei nur 6% der Gruppe A und bei 33% der Gruppe B festgestellt.

A case of traumatic arteriovenous fistula following rupture of the middle meningeal artery and epidural haematoma formation is reported. The underlying mechanisms responsible for this and the surgical consequences are discussed.

The object of this study was to ascertain the oxygen tolerance limit and the oxygenation state of the injured brain in man. While breathing air, oxygen and hyperbaric oxygen at pressures of 1.5 and 2.0 atmospheres absolute (ATA), the cerebral arteriovenous differences (AVD) for O2, glucose, lactate, pyruvate and blood gas pressures and pH values were measured. The balance of the cerebral glucose metabolism was calculated. The results showed that the injured brain did not tolerate the exposure to an oxygen pressure of 2.0 ATA for 10 to 15 min, but exposure to 1.5 ATA for 35–40 min was tolerated and had a favorable effect on the glucose or energy metabolism of the brain as well as on the clinical course. There was a distinctly increased cerebral glycolysis while breathing air indicating insufficient oxygen delivery to the brain. The change from breathing air to oxygen resulted in a distinct inhibition of cerebral glycolysis, which indicated improved cerebral oxygenation and energy production and gave evidence for a “Pasteur effect” regulating the glucose metabolism of the injured brain in man. At an inspiratory oxygen pressure of 1.5 ATA we had a nearly balanced cerebral glucose metabolism indicating an adequate cerebral oxygenation and energy formation. Further increase in inspiratory oxygen pressure to 2.0 ATA (performed only in group A) increased cerebral glycolysis considerably. This was assumed to be due to cerebral oxygen poisoning resulting in disturbed oxidative energy formation. Following this alteration an extreme reduction of the cerebral glucose uptake appeared, probably due to a disturbance of the specific glucose transport system. These metabolic alterations were not accompanied by seizures or any other clinical neurological manifestation. In group B, exposed to 1.5 ATA, such alterations of the cerebral glucose metabolism did not appear. A nearly balanced cerebral glucose metabolism was found at inspiratory oxygen pressures of 1.0 and particularly of 1.5 ATA, indicating an improved oxygenation and energy production of the affected brain. Finally, a renewed increase of the cerebral glycolysis occurred following the change from breathing oxygen to air. This again indicated an insufficient oxygen delivery to the affected brain.

The observations presented are based on 11 patients who had suffered from stroke caused by internal carotid occlusion. In all cases an anastomosis between the superficial temporal artery (STA) and a cortical temporal branch of the middle cerebral artery (MCA) was done. This resulted in a considerable additional blood supply from the external carotid to the affected middle cerebral circulation. The extent of the territory of the MCA irrigated by the STA depends upon the different anatomical configurations of the MCA. There was a considerable improvement in neurological status even in the chronic post-stroke stage. A topographical correlation between the postoperative angiographically identified increase of rCBF and the recovery or considerable improvement of neurological functions was not ascertained.

Thirty-five chronic stroke patients, who had internal carotid occlusion that resulted in considerable neurological deficit persisting for an average of 10 weeks, were studied. First, hyperbaric oxygen (HO) therapy was administered to each patient. Subsequently an extra-intracranial anastomosis operation was performed on 21 of these patients. Serial neurological examinations and EEG analyses were performed to assess the clinical course of the cerebral lesion. According to the effect of HO treatment and of the subsequent extra-intracranial anastomosis operation these patients were divided into three groups. Group I—15 of the 35 patients—showed a significant improvement of cerebral function and electrical brain activity at the conclusion of HO therapy. Subsequently an extra-intracranial anastomosis operation was performed on each patient of group I. This resulted in further recovery of cerebral function and electrical brain activity. Postoperative angiography revealed patency of the anastomosis in 14 of the group I patients. Group IIa (14 patients) had only little change in the neurological deficit and electrical brain activity at the conclusion of HO therapy as well as at later examinations. Extra-intracranial anastomosis operation was not performed on the six patients in group IIb who also revealed only little change in their condition at the conclusion to HO treatment. Subsequent extra-intracranial anastomosis operation was, however, performed on these six patients. Although postoperative angiography demonstrated a patent anastomosis in each of these six cases only little change in their status was observed subsequently. The 35 patients were clinically very similar and were in a chronic poststroke stage where spontaneous recovery rarely occurs. None of them manifested any clinical evidence of reversibility of the cerebral alteration before beginning HO therapy. These findings indicate that (a) EEG interval-amplitude analysis is of value for an objective assessment of the course of the cerebral lesion, (b) EEG analyses performed during HO treatment can help to differentiate between reversible and irreversible ischemic hypoxic alterations of the brain, (c) unilateral internal carotid occlusion can lead to neurological deficits and, in particular to bilateral EEG alterations with an accentuated reduction of electrical brain activity over the ipsilateral hemisphere, (d) chronic ischemic alterations of the brain can be improved by HO therapy and additional recovery can take place after subsequent extra-intracranial anastomosis, and (e) brain tissue can tolerate chronic ischemia leading to considerable neurological deficit for an average period of 3 months.

Eine breite Anwendung der Vertebralisangiographie zeigt, das Angiome haufiger als fruher angenommen an den Vertebralisstromkreislauf angeschlossen sind. Diese Arbeit befast sich hauptsachlich mit den supratentoriellen Angiomen, wobei auf Grund der arteriographischen Befunde hinsichtlich Lokalisation und Ausdehnung drei Gruppen unterschieden werden: Eine Sonderstellung nehmen die paramedianen und medianen Angiome insofern ein, als hier die optimale Methode der Totalexstirpation nicht moglich ist. In diesen Fallen haben wir versucht, durch Unterbindung der Hauptzuflusse, die Blutungsgefahr zu reduzieren und die Hirndurchblutung zu verbessern. Unsere operativen Resultate berechtigen zu folgenden Schlusfolgerungen: Bei den paramedianen Angiomen ist der Verschlus der zufuhrenden Arterie wie der A. cerebri post. und der A. chorioidea ant. insofern erfolgreich, als die Kontrastdarstellung der Angiome deutlich reduziert und die Hirndurchblutung angiographisch sichtbar verbessert werden kann. Bei den kombinierten kortikalen und subkortikalen Angiomen der Okzipitalregion kann man mit der Unterbindung der A. cerebri post. eine vollige Heilung erreichen in den Fallen, wo die Gefasmisbildung ausschlieslich von der Posterior versorgt wird. Bei den infratentoriellen Angiomen ist mit der Unterbindung zufuhrender Aste nur dann mit einem gunstigen Effekt zu rechnen, wenn die Versorgung in der Hauptsache von einem operativ zugangigen Gefasstamm, wie der oberen und unteren Kleinhirnarterie, erfolgt.

Bericht uber 3 Falle mit isolierter Sarkoidose des ZNS, die klinisch das Bild einer fortschreitenden intrakraniellen Raumforderung boten. Eine Patientin starb bereits praoperativ kurz nach der Aufnahme. Die beiden ubrigen Falle kamen einige Wochen nach der Operation ad exitum. Beide Falle wurden postoperativ mit Kortikosteroiden, Antibiotika und Tuberkulostatika behandelt. Wie der postoperative Verlauf und die Sektionsbefunde zeigten, hatte diese Therapie keine Wirkung.

Es wird ein Fall mit einer angeborenen aneurysmatischen Misbildung der Meningealarterie geschildert, die dem Subduralraum zugewandt war und von einem kleinen subduralen xanthochromen Liquorergus und einer Schadelasymmetrie in Form einer deutlich kleineren homolateralen Schadelhalfte begleitet war. Weiterhin lag bei dem Patienten ein akutes epidurales Hamatom vor, das zu seiner Klinikaufnahme Anlas gab. Diese Blutung stand jedoch in keinem Zusammenhang mit der meningealen Gefasmisbildung. Unter Wurdigung eigener Erfahrungen sowie der bisher veroffentlichten Falle mit Meningealarterienaneurysmen werden Grunde angefuhrt, die darauf hinweisen, das ein Teil der sogenannten traumatischen oder posttraumatischen Meningealarterienaneurysmen bereits vor dem jeweiligen Trauma auf dem Boden einer angeborenen Gefaswandschwache entstanden ist. Daher wird empfohlen bei der bisher weit haufigeren Diagnose „traumatisches Meningealarterienaneurysma“ den histologischen Wandaufbau des Meningealarterienaneurysmas und den Zeitraum, der zwischen Trauma und Aneurysmaexstirpation lag, zu beachten.

A completed stroke (CS) is most frequently due to an occlusive vascular lesion resulting in cerebral hypoxia, ischemia, or a combination of these.3 Whether in such post stroke states the neurologic disorder is due to reversible or irreversible neuronal alterations cannot be predicted. In case the neurons have lost their function but are still alive, it appears reasonable to assume that improving the oxygenation of the brain tissue either by increasing the oxygen concentration in the arterial blood or by in-creasing the cerebral blood supply may result in an improvement of the neurologic deficit.

Angiography and rCBF measurement by the various isotope clearance methods do not give information whether or to what extent changes in cerebral circulation are related to changes in neuronal functions. The latter, however, can be revealed by EEG and particularly by EEG analysis.

A 41-year-old Libyan woman with Moyamoya disease and persisting post-stroke neurological deficits was treated by a superficial temporal-middle cerebral artery (STA-MCA) anastomosis. The postoperative angiograms revealed that the STA was rapidly irrigating the territory of the middle cerebral artery including those regions that had been filled preoperatively via different networks of collaterals. Furthermore prompt venous drainage was seen to occur postoperatively. Following surgery EEG analyses revealed considerable increase in the electrical brain activity, and neurological examinations showed reversal of neurological deficits. The dependence of the postoperative neurological improvement on the increased cerebral blood supply through the new collateral channel could be demonstrated by the effect of temporary occlusion of the STA on the electrical brain activity.

Daily periodicity in man is controlled by selfsustained oscillators, which are independent from each other and possibly localized in the suprachiasmatic nuclei of the hypothalamus (3). These oscillators are influenced by exogenic periodic factors such as light-dark cycles or social cues (1). They cause a synchronization of the endogenous periodicity to a period of approximately 24 hours, which is in accordance with the period of the rotation of the earth (2). Patients, suffering from an apallic syndrome, who are in a state of “vegetative wakefulness” caused by a functional separation from brain cortex and stem or by an extensive destruction of the cortex, are protected against exogenous factors. The objective of this study was to investigate the degree of alteration of the circadian system by the apallic syndrome.

Experimental research has established in numerous instances that hypoxia of the spinal cord is one of the major facts causing functional disturbances and, finally, irreversible damage to the spinal cord. In this context, hypoxia may, for instance, be caused by circulatory disturbances in the spinal cord itself, by trauma, or by a compressive lesion. To this date, we have applied hyperbaric oxygenation treatment to four cases of compressive lesions of the spinal cord, thus treating hypoxia while at the same time avoiding any hypoxic damage to the spinal cord.

The natural history of recovery after completed stroke, its speed, its duration, and its final extent are still not accurately known. Most authors have observed neurological improvement in the chronic postapoplectic state until the third or sixth month after stroke. If this improvement is caused by recovery of brain function, metabolism in a perifocal, still reversible altered brain area must be investigated by neurological and brain metabolism follow-up studies.

An EIAB (superficial temporal to middle cerebral artery) was carried out in about 100 stroke patients with occlusive lesions in the internal carotid or middle cerebral artery. Angiographie, neurological, and EEG analytical follow-up examinations were regularly performed in these patients following surgery.

One hundred and twelve stroke patients with persisting neurological deficits due to occlusive lesions in the internal carotid or middle cerebral artery were studied. They were randomy assigned to a surgical or a medical treatment group. Each of the 112 patients underwent hyperbaric oxygenation (HO) treatment (consisting of a series of 15 single HO-sessions given daily) before either surgical treatment, i.e. extra-intracranial arterial bypass (EIAB), or medical treatment. Long term follow-up neurological and EEG analytical examinations were regularly carried out.

Since electromyography represents a nearly ideal method for establishing the degree of efficiency of HO in cases of spinal cord lesions, the development of the same four cases of compressive spinal cord lesions under HO treatment (see previous paper by Holbach et al.) underwent electromyographic control in addition to cliniconeurological check-up examinations.

The histological structure of Rathke's cyst having an epithelial mono- or multiple layer wall with glands and mucous secreting cells is indicative of their origin from the stomodaeum. These cysts are morphologically and genetically simialr to the so-called cysts of the foramen of Monro (colloid cysts of the third ventricle). According to Stochdorph, the origin of the latter cysts is from ectopic cerebral inclusions of the upper respiratory tract.

Umfassende histologische Untersuchungen des Hirnstammes bei Patienten mit traumatischen Mittel-Hirn-Schadigungen durch PETERS (10) ergaben, das primar traumatische Lasionen, wie Arterien-und Venenrisse im Mittelhirn nicht oder nur ganz kurz uberlebt werden. In allen Fallen, die langer uberlebten und in welchen es zu einem inkompletten oder kompletten akuten Mittelhirnsyndrom (MHS) mit tiefer Bewustlosigkeit, Streckkrampfen, Tonussteigerung der Streckmuskulatur auch zwischen den Krampfphasen und vegetativen Regulationsstorungen gekommen war, waren stets sekundare traumatische Veranderungen feststellbar. Die sekundaren Hirnstammalterationen waren bedingt durch eine deszendierende transtentorielle Herniation, der intrakranielle Hamatome und ein posttraumatisches Hirnodem zugrunde lagen. Die Folge der Mittelhirn-einklemmung war vorwiegend eine Verlegung der aus dem Mittelhirn und der oralen Brucke drainierenden Venen sowie eine Kompression der das Mittelhirn versorgenden Arterien, was zwangslaufig eine Durchblutungsstorung und damit eine hypoxische Hypoxidose des Mittelhirns verursacht. Dieser Sauerstoffmangelzustand des Gewebes lost den Circulus vitiosus: Sauerstoffmangel — Hirnodem — verstarkter Sauerstoffmangel — irreversible hypoxische Gewebsveranderungen - aus und fuhrt fast immer zu den fur den Krankheitsverlauf entscheidenden sekundar hypoxischen Gewebsschaden. Daher ist es gerade beim Auftreten des MHS eine der wichtigsten Aufgaben, fur eine Verbesserung der Oxygenierung des Hirngewebes zu sorgen.

A case of iatrogenic dissecting aneurysm in the cubital region causing secondary damage to the median nerve is reported. This aneurysm was caused by an attempted venipuncture, in what can be considered a minor procedure. Such a severe complication is very remarkable, for it has not been observed so far even in much more potentially hazardous procedures as, for instance, in the numerous arterial punctures in the cubital region being daily performed for retrograde angiography of the cerebral vessels. In this case the reduced blood coagulation is discussed as a causing factor of this unusual complication.

A completed stroke (CS) is most frequently due to an occlusive vascular lesion resulting in cerebral hypoxia, ischemia, or a combination of these (2). Whether in such post-stroke states the neurological disorder is due to reversible or irreversible neuronal alterations cannot be predicted. If the neurons have lost their function but are still alive, it appears reasonable to assume that improving the oxygenation of the brain tissue by increasing either arterial oxygen concentration or cerebral blood supply may result in an improvement of the neurological deficit.

A case of cerebral arterial aneurysm associated with renal failure is reported which was treated by surgery. The anaesthesiological and post-operative problems are discussed. Surgery of the aneurysm is urgently indicated in these cases on account of the increased risk of subarachnoid haemorrhage due to heparinization during haemodialysis. Pre-operative replacement of haemodialysis by peritoneal dialysis is advisable to facilitate the treatment of cerebral oedema, maintain the electrolyte and water balance and ensure adequate post-operative enteral and parenteral feeding. The choice of anaesthetic technique, the use of controlled hypotension, the treatment of hypertensive crises, laboratory tests and the post-operative care of these cases are discussed. Experience has shown that from the anaesthesiological point of view there is no contra-indication to neurosurgery or vascular surgery in cases of renal failure provided adequate precautions are taken.

Electroencephalography (EEG) is helpful in showing the effects of various treatments in patients with cerebral lesions. For this reason and encouraged by the findings of others (1, 4), we applied EEG several years ago to detect the effect of hyperbaric oxygen (HO) therapy in cases of brain trauma and cerebral infarction (2, 3). The conventional EEG examination and evaluation, however, complicated this task because of the rapidly increasing amount of data. We, therefore, used an automatic EEG-interval-amplitude-analysis-system, which is keyed to the visual evaluation of the EEG curve (5, 6); the system proceeds by measuring and counting, provides quantifiable and reproducible results, and permits an interpretation of the findings by means of customary EEG concepts.

A microsurgical anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery was carried out in 11 cases with internal carotid occlusion. This treatment was attempted following angiography of the intra- and extracranial cerebral arteries. After the microsurgical procedure for creating an extra-intracranial arterial anastomosis selective angiography of the homolateral external carotid circulation was performed. The analyses of the serial arteriograms showed, that a) a considerable blood supply from the external carotid circulation through the additional collateral pathway to the territory of the middle cerebral artery is possible, b) the extent of the area of the middle cerebral artery supplied by the superficial temporal artery is not only dependant upon a pressure gradient between the external carotid and the middle cerebral artery circulation, but also by the different anatomical variations of the middle cerebral artery.

A case of traumatic arteriovenous fistula following rupture of the middle meningeal artery and epidural haematoma formation is reported. The underlying mechanisms responsible for this and the surgical consequences are discussed.

Surgical treatment of our patients suffering from cavernous sinus fistula, certain types of aneurysms of the internal carotid artery and internal carotid artery stenosis involved either temporary or permanent occlusion of the affected internal carotid artery. Before interrupting the blood flow through the affected internal carotid artery, it is important to find out whether the collateral cerebral circulation can tolerate this inherent reduction of blood flow. We attempted to find a solution to this problem by studying the effects of carotid compression of the affected carotid artery on the EEG. Carotid compression tests (CCT) under different arterial oxygen pressures (aPO2) should clarify the question whether a positive clinical or EEG effect is an ischemic hypoxic reaction.

Inadequate perfusion to a portion of the brain results in neurologic deficit which appears to be primarily due to hypoxia.(4) If cerebral hypoxia, ischemia, or a combination of these lead only to temporary or slight neurologic deficit, reconstructive surgery of cerebral arteries is an accepted procedure. (6) There is, however, considerable pessimism regarding the value of surgery in patients with severe fixed neurologic deficit following stroke.(6,7) In such patients we really cannot predict whether their neurologic deficit results from reversible or irreversible hypoxia and/or ischemic alteration. We, therefore, have approached this problem by studying the effects of hyperbaric oxygen (HO) treatment and subsequently of an extra- intracranial arterial bypass (EIAB) on patients suffering from chronic cerebral ischemia.

The extra-intracranial bypass operation can lead to a constant improvement of cerebral blood flow in occlusive arterial disease of the brain. It remains unclear whether it is possible, by this means, to prevent transient ischemic attacks and to influence positively neurological impairment. However, the patient often regards the decrease of intellectual functions to be more drastic than the sensomotoric deficiencies.

Since 1966 40 hyperbaric oxygenation treatments (HOT) have been performed in cases with severe head injuries, marked posttraumatic or postoperative cerebral edema, acute cerebrovascular occlusions or grave meningitis. We have used a one man pressure chamber.