G. Schwarz

Cerebral oximetry in dead subjects.

Near-infrared spectroscopy is a technique used to monitor cerebral oxygenation. To validate the method, we measured regional oxygen saturation (rSo2) in the brains of 18 dead subjects (mean age, 74.4 ± 14.6 years) 19.8 ± 18.2 h (range, 1–73) after cessation of systemic circulation, and in 15 healthy probands (mean age, 34.2 ± 8.7 years) with an INVOS 3100 cerebral oximeter. The mean (±SD) rSo2 in the dead subjects was 51.0 ± 26.8% [range, 6–88%; left, 48.4 ± 28.0% (n = 21); right, 54.4 ± 25.7% (n = 16)]. The mean rSo, in the control group was 68.4 ± 5.2% (range, 60–76%; left, 68.1 ± 5.0%; right, 68.7 ± 5.6%). After removal of the brain at autopsy in five of the dead subjects, the rSo2 was 73.4 ± 13.3% (15 measurements). Six of 18 of the dead subjects had values above the lowest values found in the healthy adults (≥60%). These findings raise concerns about the validity of cerebral rSo2 data in adults obtained by the INVOS 3100 system.

Fiberoptic Intubation in 327 Neurosurgical Patients With Lesions of the Cervical Spine

In patients with lesions of the cervical spine, direct laryngoscopy for endotracheal intubation entails the risk of injuring the spinal cord. In an attempt to avoid this complication, the authors used flexible fiberoptic nasal intubation in a series of 327 patients with cervical lesions undergoing elective neurosurgical procedures. The nasal route was preferred for laryngeal intubation because it is easier than the oral route and a restraining collar or halo device does not impair the intubating maneuver. Bronchoscopic intubation was possible in all patients. In 12 patients (3.6%), anatomic abnormalities prevented transnasal insertion of the endotracheal tube, and transoral fiberoptic intubation was necessary. Endotracheal intubation was graded as slightly difficult in 85 patients (26%). The minimal peripheral oxygen saturation during intubation exceeded 90% in 289 patients (88%). In the other 38 patients, the mean O2 saturation was 84.2+/-4.3% (range, 72-89%). Intubation was well tolerated by all patients and none had recall of the procedure. Cervical stabilizers did not have to be removed for intubation in any patient. None of the patients had postoperative neurologic deficits attributable to the intubation procedure. The authors consider fiberoptic transnasal intubation to be a useful alternative to direct laryngoscopic tracheal intubation in patients undergoing elective surgical procedures on the cervical spine to avoid potential injury to the cervical spinal cord.

Clinical relevance of long-latency SEPs and VEPs during coma and emergence from coma

Follow-up measurements of long-latency visual (VEP) and somatosensory (SEP) evoked potentials were performed on 30 comatose patients. Twenty-seven of the patients had severe head injury, 2 had encephalitis and 1 was in a posthypoxic state. For the SEP study a mechanical vibration stimulus was used, applied 60 times at intervals of 10 sec. The same rate was used for visual stimulation. The late EP components were classified by a signal-to-noise ratio (SNR), whereby an SNR of less than 2.6 is characteristic of a questionable or unmeasurable EP and an SNR greater than 2.6 is evidence of a clearly existing EP; the clinical state was scored using the Glasgow Coma Scale (GCS); the patient outcome was assessed 6 months after the injury using the Glasgow Outcome Scale. The highest correlation (r = 0.72) was found between the clinical state, represented by the GCS, and the SEP. A similar correlation (r = 0.66) was obtained between the GCS and the vertex VEP. The occipital VEP showed no correlation. Emergence from coma and recovery was accompanied by an increase of the SEP and an increasing spread of the VEP over the whole scalp. Most patients with a clear long-latency SEP in coma had a favourable outcome; a missing or a questionable SEP indicated a poor outcome.

Effects of acupuncture on the oxygenation of cerebral tissue

Monitoring of regional cerebral oxygen saturation (r. cereb. O2 satn.) was carried out continuously in 12 healthy subjects (mean age 35.2 +/- 4.4 years; range 26-41 years; 4 women, 8 men), prior to, during and following acupuncture. Measurements were obtained with the INVOS 3100 cerebral oximeter (Somanetics Corp., Troy, USA). In addition new robotic transcranial Doppler sonography (TCD) probes enabling three-dimensional imaging of the middle cerebral artery by the use of multi-scan techniques were used simultaneously. The results showed small increases in r. cereb. O2 satn. mean values (69.9% before, 70.3% during and 70.2% after acupuncture) and a significant (p < 0.01; ANOVA, Tukey test) increase in mean bloodflow velocity during acupuncture measured simultaneously at different depths within the right middle cerebral artery. There are reports in the literature about the effects of acupuncture on the oxygenation of cerebral tissue in a study with animals. An increase in the cerebral oxygen saturation could be registered with the help of microelectrodes in the cortex. This is parallel evidence to the present results with near infrared spectroscopy and transcranial Doppler sonography. Quantifiable changes in the physiological effects of acupuncture may contribute to improved acceptance of this unconventional complementary medical procedure.

Effects of QiGong on brain function.

Abstract QiGong is an ancient and widely practiced Chinese meditation exercise. We studied the effects of QiGong on brain function with modern neuromonitoring tools in two subjects. In a male QiGong master (extremely trained practitioner), the technique induced reproducible changes in transcranial Doppler sonography, EEG, stimulus-induced 40 Hz oscillations, and near-infrared spectroscopy findings. Similar effects were seen after the application of multimodal stimuli and when the master concentrated on intense imagined stimuli (e.g. 22.2% increase in mean blood flow velocity (vm) in the posterior cerebral artery, and a simultaneous 23.1% decrease of vm in the middle cerebral artery). Similar effects were seen in the female subject. Neuromonitoring during QiGong appears able to objectify accompanied cerebral modulations surrounding this old Chinese meditation exercise. [Neurol Res 2001; 23: 501-505]

The influence of positioning on spectroscopic measurements of brain oxygenation.

This study was designed to evaluate the influence of body position during neurosurgical and cerebrovascular operations on regional cerebral oxygen saturation (rSO2). Awake volunteers (group I; n = 14), anesthetized patients (group II; n = 48) undergoing lumbar discectomy, and 12 patients undergoing carotid endarterectomy (group III) with internal carotid artery (ICA) stenosis were studied. Anesthesia in the patient groups was performed with sevoflurane (1.1 Vol% insp.) in N2O2/O2 mixture (FiO2 0.4) rSO2 was monitored with a INVOS 4100 cerebral oxymeter (Somanetics Corporation, Troy, MI). Measurements were done in all groups in supine position with head turned to the right and left side. Furthermore, in groups I and II, rSO2 was measured in right lateral, left lateral, prone, or sitting position. In each position the parameters were registered at three times (1, 3, and 5 min after taking up the position). In the healthy volunteers, the mean rSO2 values of both hemispheres were 71.3 ± 5.0%. No significant changes of rSO2 were found interhemispherical and upon turning the head to both sides or positioning to the prone and both lateral positions. After assuming the sitting position, the decrease of rSO2 was not significant. In group II, rSO2 decreased significantly in the sitting position. In group III, baseline readings for rSO2 obtained from the side of ICA stenosis were significantly lower, compared to the contralateral side. After turning the head to the ipsilateral side, this difference diminished. In contrast, turning the head toward the contralateral side, the rSO2 difference remained nearly constant, both values decreasing constantly throughout the observation period. In conclusion, after different positioning maneuvers awake and under anesthesia, alterations of rSO2 can be registrated by near-infrared spectroscopy (NIRS).

Ultrasound-monitored effects of acupuncture on brain and eye

A new transcranial Doppler sonography arrangement was used to monitor blood flow profiles in the supratrochlear and middle cerebral arteries simultaneously and continuously. The technique selectively demonstrated the specific effect of acupuncture on the cranial arteries, in a 25-year-old female with pigmentary retinopathy. Stimulation of points Zanzhu and Yuyao led to a marked increase of blood flow velocity in the supratrochlear artery and to a decrease of flow velocity, in the middle cerebral artery. These acupuncture-induced effects were reproducible even though both arteries originate from the same major vessel.

Sitting position for neurosurgery: experience with preoperative contrast echocardiography in 301 patients.

A persisting foramen ovale (PFO) is the most common cause of paradoxical air embolism. To detect right-to-left shunting, transthoracic contrast echocardiography was performed preoperatively in 301 patients scheduled for neurosurgical procedures in the sitting position. Echocardiography yielded evaluable results in 285 patients (94.7%). In 72 of 285 patients (25.2%), a PFO was diagnosed on the basis of contrast echo signals appearing in the left atrium or ventricle within 5 heart cycles after application of contrast medium via a peripheral vein. If echo signals appeared in the left heart after more than 5 heart cycles, an intrapulmonary right-to-left shunt was considered (11 patients, 3.9%). Venous air embolism (VAE) occurred in 27.4% of 226 patients operated on in the sitting position and in none of the 59 patients operated on in a nonsitting position. We conclude that the sitting position during neurosurgery should be avoided in patients with preoperative evidence of a right-to-left shunt at contrast echocardiography to reduce the risk of paradoxical air embolism (PAE).

Computer-controlled acupuncture. Quantification and separation of specific effects.

The effects of acupuncture have been described and handed down empirically for centuries but there are few reports based on objective data. The aim of this study was to provide selective evidence of a specific effect of acupuncture on the brain and the eye using a Doppler ultrasound technique. A transcranial Doppler sonography arrangement was developed to monitor blood flow profiles in the supratrochlear and middle cerebral arteries simultaneously and continuously. Two acupuncture schemas were tested in a randomized cross-over study with 13 patients with ophthalmologic diseases. Applying acupuncture needles to special eye points increased the blood flow velocity in the supratrochlear artery significantly (p < 0.001) compared to the reference interval before acupuncture. In the middle cerebral artery only a minimal, non-significant increase in blood flow velocity was seen. In contrast, acupuncture of points that are held to increase cerebral blood flow velocity increased blood flow velocity in the middle cerebral artery significantly (p < 0.001) while leaving that in the supratrochlear artery unchanged. Specific acupuncture produce specific, reproducible quantifiable effects on blood flow velocity in arteries to the brain and eye.

Laser Doppler Flowmetry in Combined Needle Acupuncture and Moxibustion: A Pilot Study in Healthy Adults

Abstract. Laser Doppler flowmetry (LDF) (DRT 4/Moor Instruments Ltd, Devon, UK) was used in this pilot study for monitoring the effects of an invariable acupuncture pattern on microcirculation of the skin before, during, and after combined needle acupuncture and moxibustion in 12 healthy volunteers (mean age 35.2±4.4 years, range 26–41 years, four female and eight male). According to the standards of traditional Chinese medicine (TCM), this acupuncture pattern is assumed to be unspecific and non-therapeutic. Flux decreased during the treatment period (p<0.05) compared to the control phase before combined needle acupuncture and moxibustion. After the removal of the needles, flux did not return to the initial control value. No significant differences between mean arterial blood pressure, heart rate, skin temperature or gender were detected. A prediction of individual incidences and kinds of acupuncture effects in our healthy volunteers was not possible. Modern monitoring techniques like LDF could be a method to separate responders from non-responders to acupuncture in peripheral microcirculatory disorders. Further studies on patients with peripheral microcirculatory disorders are necessary in order to demonstrate the value of LDF in detecting responders/non-responders in combination with therapeutic acupuncture patterns according to TCM.