Primary and Secondary Brain Stem Lesions

139 Pages·1987·5.871 MB·English

by  Dr. György Csécsei, Dr. Oskar Hoffmann, Professor Dr. Norfrid Klug, Dr. Albrecht Laun, Dr. Robert Schönmayr, Professor Dr. Jan Zierski (auth.)

Primary and Secondary
Brain Stem Lesions
By
o.
C. Csecsei) Hoffmann) N. Klug) A. Laun)
J.
R.Schonmayr) Zierski
Acta Neurochirurgica
Supplementum 40
Springer-Verlag Wien New York
Dr. Gyorgy Csecsei
Dr. Oskar Hoffmann
Professor Dr. Norfrid Klug
Dr. Albrecht Laun
Dr. Robert Schonmayr
Professor Dr. Jan Zierski
Department of Neurosurgery, University of Giessen, Federal Republic of Germany
With 80 Figures
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(C 1987 by Springer-Verlag Wien
Softcover reprint of the hardcover 1s t edition 1987
Library of Congress Cataloging-in-Publication Data. Primary and secondary brain stem lesions. (Acta neurochirurglca. Supplementum, [SSN 0065-141~: 40).
Includes bibliographies. I. Bram stem-Diseases. 2. Brain stem--Hemorrhage. 3. Brain--Tumors--ComplicatIOns and sequelae. 4. Cerebrospinal fluid prcssure.
l. Csecsei, G. (Gyorgy), 1948-- . [I. Series. [DNLM: I. Brain Diseases--physlOpathology. 2. Brain Stem-physiopathology. WI AC8661 v. 40/WL 310 P952]
RC394.B7P74 1987. 616.8. 87-31089
ISSN 0065-1419
ISBN-13 :978-3-7091-8943-6 e-ISBN-13:978-3-7091-8941-2
DOl: 10.1007/978-3-7091-8941-2
Foreword
Lesions of the brain stem and related disorders of autonomous regulation systems have been the
"Leitmotiv" of the scientific work in the Neurosurgical Department of the Giessen University under
the leadership of the late Professor Hans Werner Pia. Some of the results have already been published
in supplement volumes of Acta Neurochirurgica. The first one of these was Vol. 4 with the monograph
written by H. W. Pia on "Die Schadigungen des Hirnstammes bei den raumfordernden Prozessen des
Gehirns". Vol. 19 deals with central disorders of temperature regulation, written by G. Lausberg,
followed by Vol. 20 with R. Lorenz's monograph on the effects of intracranial space-occupying lesions
on blood pressure and heart rate.
Shortly before his death Hans Werner Pia had asked me to combine and publish in this series of
supplement volumes of Acta Neurochirurgica another five papers by his co-workers, also related to
brain stem lesions and also to cerebral blood flow and CSF dynamics. The result is this volume which
contains work dealing with the CT- findings of cerebral mass displacements and their clinical correlations
(Sch6nmayr), with other lesions of the brain stem (Laun), with the blink reflex and acoustic evoked
potentials in brain stem lesions (Klug and Csecsei), with blood flow in brain structures during increased
ICP (Zierski) and with the description of a mathematical model for analysis and simulation of the
haemodynamics of intracranial CSF (Hoffmann).
The papers not only present valuable scientific information but at the same time reflect the scientific
activity of Hans Werner Pia and his team. As a fitting memorial they are dedicated to him.
F. Loew, Homburg/Saar, Federal Republic of Germany
Contents
Listed in Current Contents
Cerebral Mass Displacements. Part I: Cisternal Hernia in Intracranial Tumours in the Computer Tomogram.
By R. Schonmayr .
Introduction ....
Materials and Methods 2
Results. . . . . . . 2
Influence of Tumour Location on Alterations of the Cisterns 2
1. Tumours of the Frontal Lobe 2
1.1. Frontal Tumours . . . 3
1.2. Frontobasal Tumours . 4
1.3. Frontolateral Tumours 4
1.4. Summary . . . . . . 5
2. Tumours of the Temporal Lobe 5
2. I. Temporal Tumours . . 5
2.2. Temporobasal Tumours . 6
3. Tumours of the Parietal Lobe . 6
4. Tumours of the Occipital Lobe 7
5. Tumours of the Basal Ganglia 8
6. Tumours of the Posterior Cranial Fossa 8
6.1. Midline Tumours . . . . . . . . 8
6.2. Tumours of the CerebeIIar Hemispheres 9
6.3. Extracerebral Tumours of the Posterior Cranial Fossa 10
7. Occlusive Hydrocephalus 11
Discussion 12
References 13
Cerebral Mass Displacements. Part II: Clinical Findings in Primary and Secondary Brain Stem Lesions.
By R. Schonmayr . 14
Introduction . . . . 14
Patients and Methods 15
Results. . . . . . . 16
1. Individual Parameters and Their Combinations 16
2. Progress Investigations 20
3. Summary 23
Discussion 24
References 25
Acute Direct and Indirect Lesions of the Brain Stem - CT Findings and Their Clinical Evaluation. By
A. Laun 29
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29
VIII Con ten ts
Material and Methods 30
Results . . . . . . . 30
1. Supratentorial Lesions 31
1.1. Acute Supratentorial Lesions 31
1.2. Decerebration Without Herniation 34
1.3. Discussion of Supratentorial Lesions 35
2. Infratentorial Lesions . . . . . . 37
2.1. Acute Infratentorial Lesions . . . 37
2.2. Subacute Infratentorial Lesions . . 39
2.3. Discussion of Infratentorial Lesions 40
3. Direct Changes in the Brain Stem . . . 41
3.1. Hyperdense Lesion . . . . . . . 41
3.1.1. Traumatic Direct and Indirect Brain Stem Haemorrhage 41
Discussion of Traumatic Brain Stem Haemorrhages . 44
3.1.2. Spontaneous Brain Stem Haemorrhage . . . . . . 45
Discussion of Spontaneous Brain Stem Haemorrhages 46
3.2. Hypodense Brain Stem Lesions . . . . . 46
3.2.1. Brain Stem Infarcts . . . . . . . 46
Discussion of Brain Stem Infarcts. 47
3.2.2. Basilar Artery Occlusion. . . . . 47
Discussion of Basilar Artery Occlusions 48
4. Indirect Secondary Infarcts of the Brain Stem and Other Regions 49
Discussion of the Indirect Secondary Infarcts 52
References . . . . . . . . . . . . . . 53
Electrically Elicited Blink Reflex and Early Acoustic Evoked Potentials in Circumscribed and Diffuse Brain
Stem Lesions. By N. Klug and G. Csecsei . 57
1. Introduction and Objectives 58
2. Historical Review . . . . . 58
2.1. Blink Reflex . . . . . 58
2.2. Early Acoustic Evoked Potentials (BAEP) 58
3. Materials and Methods 59
3.1. Clinical Investigations . . . . . . . . . 59
3.1.1. Blink Reflex . . . . . . . . . . 59
3.1.2. Brain Stem Acoustic Evoked Potentials 59
3.2. Experimental Investigations 60
3.2.1. Blink Reflex . . . . . . . . . . . . 60
3.2.2. Acoustic Evoked Potentials 60
3.2.3. Investigation of the Blood-Brain Barrier 60
4. Results ..... 60
4.1. Normal Findings 60
4.1.1. BR ... 60
4.1.2. BAEP 60
4.2. Circumscribed Processes with Involvement of the Brain Stem 61
4.2.1. Cerebellar Space Occupations 61
4.2.1.1. BR ........ . 63
4.2.1.2. BAEP. . . . . . . . 63
4.2.2. Cerebellopontine Angle Tumours 63
4.2.2.1. BR . 63
4.2.2.2. BAEP. . . . . . . . 65
Contents IX
4.2.3. Space-Occupying Processes of the Brain Stem 65
4.2.3.1. Blink Reflex . . . . . 65
4.2.3.l.l. M Response 65
4.2.3.l.2. R Response 65
J
4.2.3.1.3. R2 Response 66
4.2.3.2. BAEP. . . . . . . . 66
4.2.4. Discussion. . . . . . . . . . 67
4.2.5. The Significance of Pontomesencephalic Structures in the Development of the Late Com-
ponent of BR (R2) . . . . . . . . . . . . . . . 68
4.2.5.l. Discussion . . . . . . . . . . . . . . . 70
4.3. Diffuse Acute Processes with Involvement of the Brain Stem 71
4.3.l. Blink Reflex. . . . . . . . . . . . . . . . . . 71
4.3.1.1. BR Findings in Acute Midbrain Syndrome . 71
4.3.1.2. BR Findings in Apallics, in Bulbar Syndrome and Brain Death 72
4.3.1.3. The Blink Reflex as Prognostic Criterion. 74
4.3.1.4. Discussion. . . . . . . . . . . . 74
4.3.2. BAEP ................. 75
4.3.2.1. BAEP in Acute Midbrain Syndrome. 75
4.3.2.l.1. Interpeak Latencies 75
4.3.2.1.2. Amplitude Ratios . . . . 75
4.3.2.1.3. "Morphological" Structure of Individual Potential Components and
Latency Instability. . . . . . . . . . . . . . . . . . . 77
4.3.2.1.4. BAEP, Lesion Level and Neurological Brain Stem Symptoms 77
4.3.2.1.5. BAEP Findings Differing on the Right and Left Side . 78
4.3.2.1.6. BAEP Findings in Bulbar Syndrome and Brain Death 78
4.3.2.1.7. The Prognostic Significance of BAEP . 79
4.3.2.1.8. Discussion 80
4.4. Experimental Findings. . . 80
4.4.1. Normal Findings . . . . . . 81
4.4.1.1. Blink Reflex . . . . 81
4.4.1.2. Acoustic Evoked Potentials 81
4.4.2. Results During the Elevation of Intracranial Pressure 81
4.4.2.1. Pathophysiological Findings 81
4.4.2.2. Blink Reflex . . . . . . . . . . . . . . 82
4.4.2.3. Acoustic Evoked Potentials 82
4.4.2.4. Pathomorphological and Histopathological Findings . 84
4.4.2.4.1. Macroscopic Findings . . . . . 84
4.4.2.4.2. Fluorescence Microscopy Findings . 85
4.4.2.4.3. Light Microscopic Investigations. . 85
4.4.2.4.4. Electron Microscopic Investigations 86
4.4.3. Discussion. 86
5. Summary 88
References 89
Blood Flow in Brain Structures During Increased ICP. By J. Zierski 95
Summary ..... . 95
Introduction . . . . 95
Material and Methods 96
1. Blood Flow Measurement 96
2. Experimental Protocol . . 96
x Contents
Results .............. . 97
l. Control Values . . . . . . . . . . . . 97
2. Effect of rcp upon Systemic Measurements 97
3. Macroscopic Changes . . . . . . . . . 98
4. rCBF in the Initial Phase of ICP Increase 99
5. Effect of ICP upon Regional CBF. . . . 99
5.1. Comparison of Regional Flows with Total Brain Flow 99
5.2. Comparison of Left and Right Side Flows . . 101
5.3. Brain Stem Flow . . . . . . . . . . . . . 101
5.4. Comparison of Control Flow with Final Flow 104
6. Influence of ABP . . . . . . . . . . . . . . . 106
6.1. Effect of ICP Increase upon Flow in the Spine, Heart and Kidneys 107
6.2. CBF After Cerebral Ischaemia 107
Discussion . . . . 109
Acknowledgements. 113
References 113
Biomathematics of Intracranial CSF and Haemodynamics. Simulation and Analysis with the Aid of a
Mathematical Model. By O. Hoffmann 117
Summary . . . . 117
Introduction 117
Model Equations 118
l. Intracranial System 118
2. Cardiovascular Components 120
3. Baroreceptor Feedback Control 122
4. Disturbance of Central Regulation. 123
5. Space Occupying Lesions. . . . . 124
Stability, Model Validation and Simulation Technique 124
Model Applications . . . . . . . . . . . . . . . 125
l. Intracranial Pulse Pressure Relationship and Haemodynamics 125
2. Volume Pressure Test and Haemodynamics 126
3. Parameter Estimation 127
4. Rhythmic Phenomena 127
Discussion 127
References 129
Acta Neurochirurgica, Suppl. 40, 1-27 (1987)
© by Springer-Verlag 1987
Cerebral Mass Displacements
Part I: Cisternal Hernia in Intracranial Tumours in the Computer Tomogram
Part II: Clinical Findings in Primary and Secondary Brain Stem Lesions
Robert Schonmayr
Department of Neurosurgery, University of Giessen, Federal Republic of Germany
Contents Part I
Cisternal Hernia in Intracranial Tumours in the
Part I:
Cisternal Hernia in Intracranial Twnours in the Computer Tomogram Computer Tomogram
Introduction ........................................................................... . Introduction
Materials and Methods ........................................................... . 2
Results .................................................................................... . 2 Arnold (1894) and Chiari (1896) described the displace
Influence of Tumour Location on Alterations of the Cisterns .. 2 ment of the cerebellar tonsils through the foramen
I. Tumours of the Frontal Lobe ........................................... . 2 magnum into the initial part of the spinal canal.
1.1. Frontal Tumours ...................................................... . 3
However, they related this observation exclusively to
1.2. Frontobasal Tumours .............................................. . 4
the simultaneous occurrence of malformations. Alquier
1.3. Frontolateral Tumours ............................................. . 4
1.4. Summary .................................................................. . 5 (1905) and Henschen (1910) reported such tonsillar
2. Tumours of the Temporal Lobe ....................................... . 5 alterations in intracranial tumours. Cushing (1917 and
2.1. Temporal Tumours .................................................. . 5 1929) recognized the connection with the increase of
2.2. Temporobasal Tumours ........................................... . 6
intracranial pressure and coined the term "cerebellar
3. Tumours of the Parietal Lobe ........................................... . 6
pressure cone".
4. Tumours of the Occipital Lobe ......................................... . 7
5. Tumours of the Basal Ganglia .......................................... . 8 A first more extensive description of alterations in
6. Tumours of the Posterior Cranial Fossa .......................... . 8 the form of the brain at bone and dura projections in
6.1. Midline Tumours ..................................................... . 8 raised intracranial pressure was made by Meyer (1920).
6.2. Tumours of the Cerebellar Hemispheres ................. . 9
Besides the mass displacement taking place under the
6.3. Extracerebral Tumours of the Posterior Cranial
falx, he described above all the protrusion of the medial
Fossa ........................................................................ . 10
7. Occlusive Hydrocephalus .................................................. . 11 parts of the temporal lobe over the tentorial margin,
Discussion ............................................................................... . 12 and chose the expression "hernia" for these processes.
References .............................................................................. . 13
In his studies with Stroescu (1934) and Hasenjager
(1937), Spatz presented his comprehensive concept of
Part II:
mass displacements of the brain in space-occupying
Clinical Findings in Primary and Secondary Brain Stem Lesions
processes. The significance of special anatomical
features of the cisterns and the alterations of the parts of
Introduction ............................................................................ . 14
Patients and Methods ............................................................. . 15 the brain pressed into the cisternal closure due to
Results ..................................................................................... . 16 swelling was emphasized.
I. Individual Parameters and Their Combinations ............... . 16 Vincent, David, Thiebaut and Rappoport (1930,
2. Progress Investigations ...................................................... . 20
1936) had investigated connections between what they
3. Summary .......................................................................... . 23
termed "temporal pressure cone" and specific clinical
Discussion ............................................................................... . 24
References ............................................................................... . 25 states. Temporal herniation and the clinical symptoms
2 Robert Schiinmayr: Cerebral Mass Displacements. Part I
caused by it were also studied by Bailcy (1933), van ten CT were evaluated per patient. The person-related data of the
Gehuchten (1933), Bannwarth (1935), Olivecrona patient. data on the diagnosis. time course and outcome of the disease
were recorded on a survey form. The documentation of the computer
(1936), Jefferson (1937) Cairns (1937), Mansuy (1937),
tomographic findings was made in the form of a description of the
and Le Beau (1938).
alterations which can be discerned in the CT, Much space is taken up
The essential foundations of the view of "alterations
by the documentation of possible signs of mass displacement. Each
in the form of the brain in space-occupying processes" individual rcglOn of the internal and external CSF spaces was
which is still valid today was laid by Riessner and Ziilch appraised with regard to compression or enlargement and displace
ment. After exclusion of inadequately imaged CT or CT which could
(1939) and Tonnis, Riessner and Ziilch (1940) with their
not be evaluated owing to artefacts, each individual cistern was
studies on this topic. They described the passive
appraised with regard to its form. width and the nature of the
displacements of the brain mass owing to increase of
impairment. Since the CT recordings were done by a machine of the
volume and pressure and its principles in relation to the second generation. the cisterns of the cerebcllopontine angle and the
nature, localization and concomitant circumstances of cerebellomedullar cistern could not be visualized in a sufficient
number for evaluation owing to artefacts,
the space-occupying process. Pia (1956) gave a synopsis
The data obtained in this way were transferred onto a marking
of the mass displacements in raised brain pressure and
sheet which could be read by machine for further processing,
in particular in cisternal hernia together with a compre
transferred to punch cards and these were read onto magnetic tape,
hensive description of their clinical effects, above all on For evaluation. the behavior of each individual cistern was now
the brain stem. considered taking into account the location of the tumour. Besides
the cistern width, in the case of the paired cisterns. their symmetry was
All the investigations mentioned are based on an
also evaluated.
extensive autopsy material and were also supported by
CT recordings in which there was a dilatation of the inner CSF
intraoperative biopsy observations. However, a sys spaces with simultaneous narrowing of the external CSF spaces were
tematic investigation of cisternal behavior in space considered separatcly, These recordings were listed separately from
occupying processes intra vitam was only made possi the remaining localizations in the tables under the term
"hydrocephalus" ,
ble by computer tomography. The majority of the
In order to be able to evaluate the behavior of the cisternal spaces
cisterns described in pathological anatomical investi
in space-occupying processes of different sizes. a distinction was
gations and recognized as significant are also to be made between "large" and "small" processes on the basis of the
regularly identified on computer tomographic record degree of displacement of the midline structures, The midline
ings. Difficulties result only in the cisterns of the displacement is the result of all space-occupying components taken
together. i,e, tumour + perifocal oedema. A small tumour with large
posterior cranial fossa so long as they were still imaged
oedema may bring about a more pronounced mass displacement than
with instruments of the first and second generation.
a major tumour with slight perifocal oedema, Since the sum of all
Because of frequent artefacts based on the technique, intracranial space-occupying components is always decisive for the
above all the cerebellomedullary cistern, the median behaviour of cisterns, the degree of midline displacement was taken as
and lateral parts of the pontocerebellar and a yardstick, The term "tumour" is not used in its histopathological
sense, but with its original Latin meaning as "swelling,
pontomedullary cistern can only be appraised in rare
accumulation",
cases. Only the images obtained with instruments of the
The problem of preoperative and postoperative CT recordings is
most recent generation permit unequivocal appraisal of
also solved by the definition of "tumour size" as the extent of the
these cisterns.
midline displacement. In consequence of the postoperative decline of
The objective of my investigation was to observe the mass displacement with accompanying stepwise normalization of
behavior of the cisterns in intracranial space-occupying cisternal findings. the CT in which distinct mass effects are still to be
seen, are to be found amongst the "large tumours". whereas with
processes in intracranial tumours as an example and to
increasing regression of the displacements the corresponding CT are
establish how individual cisterns react to tumours of a
classified under the "small tumours", Complete normal computer
specific size and localization, and to what extent and in tomograms in which no space-occupying process was to be detected
what form they are affected by alterations. were not considered,
Conversely, the question was also to be clarified as
to whether depending on their location, specific se Results
quence or characteristic combinations tumours lead to
Influence of Tumour Location on Alterations of the
an impairment of the cisterns.
Cisterns
1. Tumours of the Frontal Lohe (Figs. 1, 2, 3)
Materials and Methods
Among the tumours of the frontal lobes, three groups
A total of 800 CT recordings were used for evaluation. These were
can be distinguished with regard to cisternal alterations
computer tomograms of 289 patients with intracranial tumours, of
these 59 patients with tumours of the posterior cranial fossa. Up to they induce: