Chih-Lung Lin

Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease.

Study Design Clinical and radiologic study evaluating the outcome after anterior corpectomy with iliac bone fusion compared with discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease. Objectives To investigate the safety and effectiveness of interbody titanium cage with plate fixation in multilevel postdiscectomy fusion. Summary of Background Data The operation for segmental multilevel cervical degenerated disc disease remains controversial. Data on safety and efficacy of titanium cages in multilevel postdiscectomy fusion are rarely available. We investigated the safety and effectiveness of interbody fusion cages with plate fixation and compared the clinical and radiographical results between anterior corpectomy and iliac bone fusion with plate fixation and multilevel discectomy and cage fusion with plate fixation. Methods Sixty-two patients were treated with either a multilevel discectomy and cage fusion with plate fixation (27 patients, group A) or an anterior corpectomy and iliac graft fusion with plate fixation (35 patients, group B). We evaluated the patients for cervical lordosis, fusion status, and stability 24 months postoperatively on the basis of spine radiographs. The patients neurologic outcomes were assessed by the Japanese Orthopedic Association (JOA) scores. Neck pain was graded using a 10-point visual analog scale. Results Both groups A and B demonstrated a significant increase in the JOA scores (preoperatively 11.1±2.1 and 10.4±3.5, postoperatively 14.3±2.4 and 13.9±2.1, respectively) and a significant decrease in the visual analog pain scores (preoperatively 8.5±1.1 and 8.7±1.5, postoperatively 2.9±1.8 and 3.0±2.0, respectively). However, there was no significant difference between groups A and B. Both groups A and B showed a significant increase in the cervical lordosis after operation and reached satisfactory fusion rates (96.3% and 91.4%, respectively). Three patients (two 2-level corpectomies and one 3-level corpectomy) had construct failures that required a second operation. Eight of 35 patients who underwent iliac bone fusion had donor site pain. The hospital stay in group A was significantly shorter than that in group B (P=0.022). Conclusions Either a multilevel discectomy and cage fusion with plating or a corpectomy and iliac bone fusion with plating provides good clinical results and similar fusion rates for cervical degenerative disc disease. However, absence of donor site complications and construct failures and shorter hospital stay make the multilevel discectomy and cage fusion with plate fixation better than corpectomy and strut graft fusion with plate fixation.

Massive cerebral air embolism after cardiopulmonary resuscitation

We report a case of massive intracerebral air embolism after cardiopulmonary resuscitation in a patient with a fatal head injury. There was no pneumothorax or extravascular pneumocephalus, however, air was found in the internal carotid artery. Massive cerebral air embolism may occur after entrance of air into the circulatory system via ruptured pulmonary vessels during cardiopulmonary resuscitation.

Attenuation of subarachnoid hemorrhage-induced apoptotic cell death with 17 beta-estradiol. Laboratory investigation.

OBJECTnApoptosis is implicated in vasospasm and long-term sequelae of subarachnoid hemorrhage (SAH). The authors observed that 17beta-estradiol (E2) can attenuate cerebral vasospasm, lower endothelin-1 production, and preserve normal endothelial nitric oxide synthase expression by reduction of inducible NO synthase expression in experimental SAH. The authors investigated the potential antiapoptotic effects of E2 in an experimental rat model of SAH.nnnMETHODSnThe authors examined the antiapoptotic effects of E2 in a double-hemorrhage SAH model in male Sprague-Dawley rats. The rats underwent subcutaneous implantation of a Silastic tube containing corn oil either with or without E2, and some E2-treated animals also received ICI 182,780 (a nonselective estrogen receptor [ER] antagonist) for 7 days after SAH. The degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after SAH. The expression of apoptotic indicators, including TNF-alpha, caspase 3, Bcl-2, Bax, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL), and cell death assays were used for detection of apoptosis.nnnRESULTSnTreatment with E2 significantly attenuated SAH-induced vasospasm. Seven days after the induction of SAH, positive TUNEL-staining was seen, and DNA fragmentation was increased in the dentate gyrus. Increased TNF-alpha and cleaved caspase-3 protein expression and decreased Bcl-2 protein expression in the dentate gyrus were also observed. These changes were reversed with E2-treatment but not in the presence of ICI 182,780. However, the expression of Bax did not change after SAH either with or without E2 treatment.nnnCONCLUSIONSnThe authors found that E2 appears to confer an antiapoptotic effect that reduces secondary brain injury after SAH via estrogen receptor-dependent mechanisms. This finding provides support for possible future applications of E2 treatment for the reduction of secondary injury after SAH in patients.

Upregulation of estrogen receptor α and mediation of 17β-estradiol vasoprotective effects via estrogen receptor α in basilar arteries in rats after experimental subarachnoid hemorrhage

OBJECTnThe authors previously demonstrated that 17beta-estradiol benzoate (E2) treatment prevents subarachnoid hemorrhage (SAH)-induced cerebral vasospasm and preserves endothelial nitric oxide synthase (eNOS) in male rats. Changes in the expression of estrogen receptor (ER) subtypes ERalpha and -beta and their roles in the E2-mediated preservation of eNOS in SAH remain unknown. In the present study the effects of SAH on the expression of ERalpha and -beta in the cerebral arteries were clarified, and the receptor roles in the E2-mediated preservation of eNOS expression in SAH were differentiated.nnnMETHODSnA 2-hemorrhage SAH model was induced by 2 autologous blood injections into the cisterna magna of adult male rats. The effect of SAH on ERalpha and -beta expression was evaluated. Other rats subcutaneously received implanted Silastic tubes containing corn oil with E2 and daily injections of various doses of an ERalpha- (methyl-piperidinopyrazole [MPP]) or ERbeta-selective antagonist (R,R-tetrahydrochrysene) after the first hemorrhage. The protein levels of ERalpha, ERbeta, eNOS, and inducible nitric oxide synthase (iNOS) from basilar arteries were examined using Western blot analysis, and their mRNAs were evaluated by reverse transcription-polymerase chain reaction.nnnRESULTSnThe ERalpha but not the ERbeta was upregulated in the basilar artery after SAH. Treatment with MPP eliminated E2-mediated effects in SAH, relieved cerebral vasospasm, preserved eNOS expression, and suppressed iNOS expression.nnnCONCLUSIONSnEstrogen receptor alpha is upregulated in the basilar artery after SAH. Note that E2 exerts its protective effects through ERalpha-dependent pathways to relieve cerebral vasospasm and preserve eNOS expression. A selective ERalpha agonist may be the drug of choice for the treatment of patients with SAH.

Purpurogallin, a Natural Phenol, Attenuates High-Mobility Group Box 1 in Subarachnoid Hemorrhage Induced Vasospasm in a Rat Model

High-mobility group box 1 (HMGB1) was shown to be an important extracellular mediator involved in vascular inflammation of animals following subarachnoid hemorrhage (SAH). This study is of interest to examine the efficacy of purpurogallin, a natural phenol, on the alternation of cytokines and HMGB1 in a SAH model. A rodent double hemorrhage SAH model was employed. Basilar arteries (BAs) were harvested to examine HMGB1 mRNA and protein expression (Western blot). CSF samples were to examine IL-1β, IL-6, IL-8, and TNF-α (rt-PCR). Deformed endothelial wall, tortuous elastic lamina, and necrotic smooth muscle were observed in the vessels of SAH groups but were absent in the purpurogallin group. IL-1β, IL-6, and TNF-α in the SAH only and SAH plus vehicle groups were significantly elevated (P < 0.01). Purpurgallin dose-dependently reduced HMGB1 protein expression. Likewise, high dose purpurogallin reduced TNF-α and HMGB1 mRNA levels. In conclusion, purpurogallin exerts its neuroinflammation effect through the dual effect of inhibiting IL-6 and TNF-α mRNA expression and reducing HMGB1 protein and mRNA expression. This study supports purpurogallin could attenuate both proinflammatory cytokines and late-onset inflammasome in SAH induced vasospasm.

Arctigenin, a Potent Ingredient of Arctium lappa L., Induces Endothelial Nitric Oxide Synthase and Attenuates Subarachnoid Hemorrhage-Induced Vasospasm through PI3K/Akt Pathway in a Rat Model

Upregulation of protein kinase B (PKB, also known as Akt) is observed within the cerebral arteries of subarachnoid hemorrhage (SAH) animals. This study is of interest to examine Arctigenin, a potent antioxidant, on endothelial nitric oxide synthase (eNOS) and Akt pathways in a SAH in vitro study. Basilar arteries (BAs) were obtained to examine phosphatidylinositol-3-kinase (PI3K), phospho-PI3K, Akt, phospho-Akt (Western blot) and morphological examination. Endothelins (ETs) and eNOS evaluation (Western blot and immunostaining) were also determined. Arctigenin treatment significantly alleviates disrupted endothelial cells and tortured internal elastic layer observed in the SAH groups (p < 0.01). The reduced eNOS protein and phospho-Akt expression in the SAH groups were relieved by the treatment of Arctigenin (p < 0.01). This result confirmed that Arctigenin might exert dural effects in preventing SAH-induced vasospasm through upregulating eNOS expression via the PI3K/Akt signaling pathway and attenuate endothelins after SAH. Arctigenin shows therapeutic promise in the treatment of cerebral vasospasm following SAH.

Attenuation of cerebral vasospasm and secondary injury by 17β-estradiol following experimental subarachnoid hemorrhage

OBJECTnCerebral vasospasm remains a major complication in patients who have suffered a subarachnoid hemorrhage (SAH). Previous studies have shown that 17beta-estradiol (E2) attenuates experimental SAH-induced cerebral vasospasm. Moreover, E2 has been shown to reduce neuronal apoptosis and secondary injury following cerebral ischemia. Adenosine A1 receptor (AR-A1) expression is increased following ischemia and may represent an endogenous neuroprotective effect. This study was designed to evaluate the efficacy of E2 in preventing cerebral vasospasm and reducing secondary injury, as evidenced by DNA fragmentation and AR-A1 expression, following SAH.nnnMETHODSnA double-hemorrhage model of SAH in rats was used, and the degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after the first SAH. A cell death assay was used to detect apoptosis. Changes in the protein expression of AR-A1 in the cerebral cortex, hippocampus, and dentate gyrus were compared with levels in normal controls and E2-treated groups (subcutaneous E2, 0.3 mg/ml).nnnRESULTSnThe administration of E2 prevented vasospasm (p < 0.05). Seven days after the first SAH, DNA fragmentation and protein levels of AR-A1 were significantly increased in the dentate gyrus. The E2 treatment decreased DNA fragmentation and prevented the increase in AR-A1 expression in the dentate gyrus. There were no significant changes in DNA fragmentation and the expression of AR-A1 after SAH in the cerebral cortex and hippocampus in the animals in the control and E2-treated groups.nnnCONCLUSIONSnThe E2 was effective in attenuating SAH-induced cerebral vasospasm, decreasing apoptosis in the dentate gyrus, and reducing the expression of AR-A1 in the dentate gyrus after SAH. Interestingly, E2 appears to effectively prevent cerebral vasospasm subsequent to SAH as well as attenuate secondary injury by reducing both apoptosis and a compensatory increase in AR-A1 expression in the dentate gyrus.

Clinical Pathway in the Treatment of Nocardial Brain Abscesses following Systemic Infections

Nocardial infections are commonly encountered in patients with immunocompromised states. Cerebral nocardiosis is an uncommon clinical entity, representing only 2% of all cerebral abscesses. It has a higher mortality rate, especially for multiple cerebral lesions in immunocompromised hosts following systemic infections. However, an optimal treatment policy to deal with these immunocompromised patients in Asia is still lacking. We retrospectively reviewed the subjects with nocardial brain abscesses from 2001 to 2011 at our medical center. All of them had multiple brain abscesses, underlying with immunocompromised state following systemic infections. All cases were under steroid control due to their comorbidities for more than six months. The comorbidities and misdiagnosis often lead to poor prognosis. The change in the environments of the microorganisms caused by immunosuppressive agents and multiple antibiotic uses may play an important role in this critical disorder. Aggressive craniotomy should be performed in time to avoid grievous neurological outcomes. Our conclusion is that early diagnosis and appropriate antibiotic uses should be implemented promptly, and aggressive craniotomy should be performed for nocardial brain abscesses in subjects with systemic infections under an immunocompromised status.

Overexpression of Fli-1 in astrocytoma is associated with poor prognosis

Background Astrocytoma, a common and highly malignant type of brain tumor, is associated with poor overall survival despite advances in surgical treatment, radiotherapy, and chemotherapy. The nuclear transcription factor Fli-1 has been shown to increase cellular proliferation and tumorigenesis in many types of cancer; however, previous reports have not described a correlation between clinical outcomes and Fli-1 in astrocytoma patients. The present study aimed to elucidate the clinical role of Fli-1 in astrocytoma. Results High-level of Fli-1 protein expression was significantly association with World Health Organization (WHO) high grade and poor prognosis. A multivariate analysis revealed that the WHO grade and Fli-1 protein expression were independent factor of prognostic factors of patients with astrocytoma. In addition, Fli-1 silencing inhibited proliferation, migration, and invasion and led to the downregulation of Ki-67, VEGF, and cyclin D1 expression in the astrocytoma cells. Materials and methods Fli-1 protein expression in astrocytoma tissue samples were detected via immunohistochemistry, and potential correlations between clinical parameters and Fli-1 expression were assessed in patients with astrocytoma. Additionally, proliferation, invasion, and migration assays of astrocytoma cell lines were conducted to evaluate the effects of short interfering RNA (siRNA) on these processes; in addition, these cells were subjected to western blotting to detect the expression levels of Fli-1, Ki-67, VEGF, and Cyclin D1. Conclusion Fli-1 shows promise as a potential prognostic biomarker and therapeutic molecular target for astrocytoma patients.

Comparison Study of Clinical Presentation and Surgical Outcome between Children and Adults with Craniopharyngioma: A 22-Year Single-Center Experience in Southern Taiwan

Background: The differences in clinical presentation and surgical outcome between children and adults with craniopharyngioma have not been well-described and there are few data available for Asian population. The aim of this study is to investigate the differences between paediatric and adult patients with craniopharyngioma at a single medical centre in southern Taiwan. nMethods: The clinical records of 40 patients with craniopharyngioma who were all surgically treated at Kaohsiung Medical University Hospital from January 1990 to December 2012 were reviewed. The patients were divided into two groups based on age: children (= 20 years) and adults (>20 years). MRI and CT images were obtained pre- and post-operatively. Histopathological examination diagnosed tumors. Statistical analyses were performed to compare the differences in the two groups. nResults: Among the patients, 17 were children and 23 were adults. The children group demonstrated more diagnoses of large or giant tumors (p<0.001), a higher rate of tumors with both solid and cystic composition (p=0.027) as well as adamantinomatous type tumors (p=0.020). The children group also had a higher surgical complication rate of diabetes insipidus (p=0.023). nConclusions: There are significant differences between children and adults with craniopharyngioma with regard to tumor size, histopathology type of tumor and hormone-related surgical complications. These findings are useful for improving the strategies for managing patients with craniopharyngioma.