James W. Correll

Rupture of a previously documented asymptomatic aneurysm enhances the argument for prophylactic surgical intervention

A case is presented of an incidentally discovered 6-mm aneurysm that was left untreated and subsequently produced a subarachnoid hemorrhage. The patient had no previous history of intracranial hemorrhage from any other source. A case of this type has not been previously documented in the literature. This experience points out the potential for catastrophe in small unruptured aneurysms found in patients without previous subarachnoid hemorrhage. The extremely low operative morbidity for repair of these types of lesions in otherwise healthy individuals would argue strongly for prophylactic surgery in properly selected patients.

Degeneration and Necrosis of Neurones in Eighth Cranial Nuclei Caused by Streptomycin

Toxic effects of streptomycin on the eighth noted, cranial nerve apparatus have been frequently 1 , 8 but the pathogenesis of these dis turbances has not yet been established. 1 , 2 , 4 , 8 This preliminary report is based on the neuropathological findings in 5 human beings who became partially or completely deaf while receiving large amounts of streptomycin, and on the study of the eighth cranial nerve nuclei in 3 dogs given the drug experimentally. Table I provides a summary of the findings in the 5 clinical cases. It is noteworthy that all of the patients died with tuberculosis and all manifested varying degrees of tuberculous involvement of the central nervous system, though there was no clinical evidence that the function of any of the cranial nerves except the eighth had been disturbed in any of the cases. In one case (patient No. 4) there was softening of a part of the basis of the pons immediately below the ventral cochlear nucleus, this change being unilateral whereas the degeneration and necrosis of neurones presumably due to streptomycin was bilateral. To learn whether neuronal changes similar to those encountered in the 5 patients could be produced experimentally, 3 medium sized, adult, mongrel dogs were given 170 mg of-highly purified streptomycin per kg of body weight during 12 hours each day in 4 equal doses intramuscularly, this being roughly equivalent to a 12 g dose for an adult human being. 10 All 3 dogs developed marked ataxia, weaving of the head, tail-chasing, and weakness following administration of the drug, the symptoms being markedly accentuated following the final dose each evening. An accurate appraisal of auditory acuity could not be made, but none of the animals became manifestly deaf. One of the dogs died on the 9th day with advanced, bilateral, necrotizing renal arteriolitis and glomerulitis; the

Computerized Electroencephalogram Monitoring and Carotid Artery Shunting

During carotid artery surgery, ischemic electroencephalogram (EEG) changes were detected by computerized analysis in 27 of 225 carotid clamping intervals. All but 7 of these changes resolved spontaneously before the restoration of blood flow. Restored flow was associated, after variable delay, with an improved EEG pattern in 6 of 7 cases. Of 27 EEG episodes, there were 5 cases in which the EEG event persisted for 10 minutes or longer. All 5 patients developed new neurological deficits; none of the other patients did. It is suggested that all patients undergoing carotid artery surgery be monitored with EEG and that a shunt be placed if a persistent EEG change is noted.

Reassessment of Central Neural Pathways Necessary for Adrenal Catecholamine Output in Response to Hypoglycemia

Summary Insulin-induced hypoglycemia produced a marked increase in adrenal catecholamine output in intact dogs as well as in dogs with midbrain transection at the level of the inferior colliculus. An increase in plasma FFA also occurred in these groups of animals with an increase in ACO. In 10 animals with cervical (C1) spinal cord transection in which the pH remained above 7.35 there was no increase in ACO or FFA following the production of severe hypoglycemia. In an animal with cervical spinal cord transection that developed an acidosis to pH 7.12, a rise in ACO occurred which returned to normal with correction of the acidosis. In a previous similar study pH was not followed and it seems likely that acidosis may have caused increased ACO in dogs with C1 transection. Our findings suggest that the locus at which hypoglycemia acts to initiate an increase in ACO and FFA is within the brainstem, below the level of the inferior colliculus.

Outcome after carotid endarterectomy for asymptomatic carotid stenosis

OBJECTIVEnTo compare the long-term outcome in patients with asymptomatic carotid stenosis (ACS) among those treated with carotid endarterectomy (CE) or medical therapy.nnnBACKGROUNDnUntil randomized trials are completed, treatment of ACS will depend on identification of subgroups likely to benefit from CE.nnnMETHODSnA retrospective cohort study was done on 215 patients with ACS: 107 underwent CE, and 108 were treated medically (MED). A neurologist reviewed medical records and performed a telephone interview to detect outcome (stroke and death). Mean follow-up was 3.8 years; only 4% were lost to follow-up.nnnRESULTSnAmong CE patients, there was a 4.7% risk of postoperative ipsilateral stroke within 30 days. Four of five postoperative strokes occurred among patients with prior contralateral symptoms. There was no significant difference between CE and MED in the cumulative life-table 5-year risk of ipsilateral stroke, any stroke, or survival free of any stroke. Among diabetics, however, there were no ipsilateral strokes at 5 years after CE compared to 20% in MED (p = 0.03). Excluding postoperative complications, the 5-year risk of ipsilateral stroke was reduced among CE patients who ever smoked (CE 1%, MED 8%, p = 0.03) and the 5-year risk of any stroke was reduced among CE patients who had no prior myocardial infarction (CE 6%, MED 16%, p = 0.02). Among those with prior contralateral carotid territory symptoms, the 5-year risk of any stroke was worse in the MED patients (CE 5% MED 32%, p = 0.004). Among CE patients, a Cox proportional hazards model determined that the independent predictors of worse long-term outcome were: a history of myocardial infarction; admission systolic blood pressure greater than 160 mm Hg; and age greater than 65.nnnCONCLUSIONnThe approach to patients with ACS will await completion of large, randomized clinical trials, now in progress. Even if these studies are negative, there may remain specific subgroups of patients who show clear benefit from carotid endarterectomy.

Effect of Polyoxyalkylene Sorbitan Monooleate on Blood Cholesterol and Atherosclerosis in Cholesterol-Fed Rabbits.

Summary Rabbits fed Tween 80 and: cholesterol developed blood cholesterol levels that were 2 to 3 times as high as those obtained by cholesterol feeding alone, and also exhibited an earlier and somewhat rnore severe degree of atherosclerosis.

Interstitial Irradiation of Brain Tumors with Iridium 192

Interstitial irradiation of brain tumors has been attempted in the past with encouraging clinical results (1) but was abandoned because of technical difficulties. Satisfactory distribution of radon seeds is extremely difficult to achieve in the brain. Radium needles have a tendency to migrate in brain tissue because of their weight and require reoperation for removal. Henschke in 1956 (2) described the use of iridium-192 seeds in nylon ribbons for interstitial radiation therapy. This technic has been modified for interstitial irradiation of intracerebral lesions. Special requirements for interstitial sources in the brain are: (a) a simple method for suitable distribution; (b) satisfactory physical factors for proper dose rate; (c) sources and containers light in weight and flexible enough to prevent migration after implantation; (d) possibility of removal without operation. The first two criteria are met by the Henschke ribbons. Modification was necessary to satisfy the other requirements. The greatest ac...

Mediastinal hematoma after carotid endarterectomy

Abstract A patient with bilateral carotid disease presented with hypotension, unexplained fever, and failing hematocrit after the second of two carotid endarterectomies. Chest roentgenogram revealed marked mediastinal widening, which resolved rapidly with an otherwise benign post-operative course. Mediastinal hematoma is an unusual complication of carotid surgery.