Jiang-Chuan Liu

New stereotactic technique for percutaneous thermocoagulation upper thoracic ganglionectomy in cases of palmar hyperhidrosis

To perform unilateral or bilateral upper thoracic ganglionectomy, we established a three-dimensional system of coordinates for T2 and T3 ganglia. For this purpose, the spatial relations were represented by drawings obtained from 50 Chinese cadavers. A simple stereotactic frame was constructed as an aid in performing the procedure. Then, according to the established three-dimensional system of coordinates, percutaneous thermocoagulation of both T2 and T3 ganglia was performed on 10 patients (20 sides) with palmar hyperhidrosis, under local anesthesia and fluoroscopic guidance at the posteroanterior projection. Excellent relief of abnormal sweating in 19 of the 20 hands was achieved. Partial relief was obtained in the remaining hand. No complication was observed in our patients. The technique has been proved to be safe, effective, and simpler than other methods now in use.

Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosis in 1742 cases

OBJECTIVE We sought to determine the long-term outcome of percutaneous stereotactic thermocoagulation for upper thoracic ganglionectomy and sympathectomy in patients with palmar and craniofacial hyperhidrosis with the use of a three-dimensional system of coordinates for the location of the T2 and T3 ganglia on the basis of the findings in a cadaveric study. METHODS From November 1986 to May 1998, upper thoracic ganglionectomy and sympathectomy with the use of percutaneous stereotactic thermocoagulation were performed in 1688 patients with palmar hyperhidrosis and 54 patients with craniofacial hyperhidrosis as outpatient surgical procedures based on a three-dimensional coordinate system for determining the location of the thermocoagulation point, which was developed by the authors in a cadaveric study. The technique requires only local anesthesia. RESULTS After initial thermocoagulation, sweating stopped in 3465 (99.5%) of 3484 sides. Hyperhidrosis recurred within 2 to 59 months of treatment in 268 procedures. All patients in whom hyperhidrosis recurred were retreated successfully, resulting in a final success rate of 99.9%. Complications of treatment included pneumothorax in seven procedures (0.2%) and partial Horner’s syndrome in five procedures (0.15%). Decreased plantar sweating was noted during follow-up in 92% of patients. CONCLUSION The results of this study indicate that upper thoracic ganglionectomy and sympathectomy performed with the use of percutaneous thermocoagulation are a very effective treatment for palmar and craniofacial hyperhidrosis that provides excellent immediate and long-term results as well as a low complication rate. The method is also effective as a retreatment for recurrences. Our data also suggest that performing ganglionectomy and sympathectomy in both T2 and T3 is unnecessary, because the procedure had equal long-term effectiveness when performed in T2 alone.

Retrograde localization of the innervation of the middle cerebral artery with horseradish peroxidase in cats

The innervation of the middle cerebral artery (MCA) of the cat was studied by applying horseradish peroxidase (HRP) to the wall of the right MCA. After a survival period of 48 to 72 hours, the bilateral superior cervical ganglia, middle cervical ganglia, stellate ganglia, T-4 sympathetic paravertebral ganglia, geniculate ganglia, semilunar ganglia, nodose ganglia, and brain stem including midbrain, pons, and medulla oblongata were removed to be processed with tetramethyl benzidine. HRP-labeled neurons were found in the ipsilateral superior cervical ganglion, semilunar ganglion, and dorsal raphe nucleus. The other areas did not have HRP activity. The results suggest that the adrenergic nerves innervating the MCA originate in the ipsilateral superior cervical ganglion, the sensory nerves originate in the ipsilateral semilunar ganglion, and the serotonergic nerves originate in the ipsilateral dorsal raphe nucleus. Cerebral arterial constriction may relate to the intrinsic (intracerebral) neurogenic pathway involving the trigeminal nerve and the dorsal raphe nucleus.

Contralateral temperature changes of the finger surface during video endoscopic sympathectomy for palmar hyperhidrosis

One hundred and eight consecutive patients with primary palmar hyperhidrosis were surgically managed by coagulation of bilateral T2 sympathetic ganglia using video thoracoscopic techniques. Patients were divided into two groups. In the first group (N = 46), finger surface temperature of the ipsilateral index finger was recorded before and after T2 ganglionectomy. The average increase of post-operative temperature was 2.74 +/- 0.27 degrees C (mean +/- SE) on the right side and 2.67 +/- 0.33 degrees C on the left (P < 0.05). The significant rise of temperature resulting from sympatholytic vasodilatation was only noted in cases of exact ablation of the T2 ganglion. In the second group (N = 62), surface temperatures of both index fingers were monitored and recorded simultaneously. These patients were arbitrarily subdivided into Group 2-A (N = 29) when right side ganglionectomy was performed first and Group 2-B (N = 33) when left side ganglionectomy was done initially. After the first ganglionectomy was completed, an ipsilateral increase with a contralateral decrease of temperature was observed; the average increase of temperature was 1.92 +/- 0.35 degrees C and 2.19 +/- 0.30 degrees C, and the average decrease was 1.50 +/- 0.51 degrees C and 1.67 +/- 0.39 degrees C for Group 2-A and 2-B respectively (P < 0.05). The authors postulate that a cross-inhibitory effect by the post-ganglionic neurons innervating blood vessels of the upper extremities may exists in humans and this effect is released after ganglionectomy, resulting in contralateral vasoconstriction and decrease of finger surface temperature.

Horseradish peroxidase localization of the sympathetic postganglionic neurons innervating the cat heart.

The localization of the sympathetic postganglionic neurons innervating the cat heart has been investigated by using retrograde axonal transport of horseradish peroxidase (HRP). HRP was injected into the subepicardial layers of 4 different cardiac regions. The animals were sacrificed 72-96 h later and fixed by perfusion via the left ventricle. The paravertebral sympathetic ganglia from the superior cervical, middle cervical and stellate ganglia to T10 ganglia were removed and processed for HRP identification. Following injections of HRP into the apex of the heart, the sinoatrial (SA) nodal region and the ventral wall of the right ventricle, we observed that HRP-labeled sympathetic neurons were localized predominantly in the right stellate ganglia, and to a lesser extent, in the right superior and middle cervical ganglia, and left stellate ganglia. Fewer labeled cells were found in the right T4-T6. T8 and T9. After HRP injection into the dorsal wall of the left ventricle, HRP-labeled cells were present mainly in the left stellate ganglia.

Sympathetic postganglionic innervation of the cardiac coronary artery in cats.

The localization of the sympathetic postganglionic neurons innervating the cardiac coronary arteries of the cat was investigated using retrograde axonal transport with horseradish peroxidase. We found after the enzyme was applied to the main trunk of the right coronary artery, and to the main trunk and the terminal branch of the ventral descending vessels of the left coronary artery, the peroxidase-labeled sympathetic neurons were localized predominantly in the right stellate ganglia, with a few cells in the left stellate ganglia. There were very few labeled cells in the middle cervical, superior cervical, and T4-7 ganglia on both sides. After peroxidase application to the terminal branch of the dorsal descending vessels of the right coronary artery, labeled cells were mainly in the left stellate ganglia, with only a few cells in the right stellate ganglia.

Pyrogenic responses in the decerebrate monkey (Macaca cyclopis).

Abstract Pyrogenic responses to intravenous injections of typhoid vaccine were studied in intact and acute high- and low-level decerebrate monkeys (Macaca cyclopis). Responses in intact animals were characterized by drowsiness, increasing rectal and decreasing cutaneous temperatures of soles of the feet. Piloerection and shivering occurred after a latency of 30 min. Febrile responses of 2.3 ± 0.5°C peaked at 2 h. Soon after piloerection and shivering decreased and temperature of the soles stabilized. Body temperature returned to normal by 6 h. Side reactions of retching, vomiting, defecation, and urination were frequently noted. High-decerebrate preparations (brain stem truncated in the mesencephalon) showed no pyrogenic responses but urinated and defecated. Low-level preparations (truncated just rostral to the trapezoid body) showed all pyrogenic responses noted in intact animals, except drowsiness. Shivering and all side reactions were more marked than in intact animals. Latencies for onset of febrile response, maximum response, and defervescence were quite similar. Low-decerebrate animals showed a febrile peak of 1.6 to 2.3°C irrespective of “set point” for thermal regulation (animals regulating at 37.9 ± 0.3°C peaked at 1.9 ± 0.3°C; at 35.8 ± 0.2°C peaked at 2.2 ± 0.1°C; at 39.5°C peaked at 2.1°C). Febrile responses to bacterial pyrogens are not dependent on integrity of the hypothalamus and high-decerebrate preparations fail to show febrile responses because thermoregulatory heat gain mechanisms are tonically inhibited by released mesencephalic and rostral pontine tegmental systems. Lowering the decerebration to the level of the trapezoid body abolished released inhibition and restored thermoregulatory responses to cooling and febrile reactions to bacterial pyrogens.

Recovery of cutaneous vasomotor activity in the spinal dog.

Abstract Vasomotor responses of the glabrous skin of the fore and hind feet of six adult female dogs subjected to thermal stress, by cooling or warming the periphery or the spinal cord, were compared in the intact and thoracic spinal animal. In the intact dog the temperature of the forefeet at a neutral ambient temperature (22°C) was higher than the hind feet. After spinal transection the hind feet were warmer than the forefeet for several days, recovering their preoperative temperature by 6.0 ± 0.89 days. The vasomotor response to cooling (13°C) and warming (45°C) one hind limb in the intact animal induced a drop or elevation respectively in the temperature of the contralateral hind foot. This reflex response to peripheral cooling was abolished for several weeks after transection but had recovered by the 29.3 ± 2.94 day. Cooling and warming of the spinal cord below the level of transection by extradurally implanted thermodes failed to induce vasomotor responses in the hind foot pads for several weeks, recovering by the 27.1 ± 3.48 day. It is concluded that whereas thermal regulation by appropriate vasomotor response to peripheral cooling and warming is influenced by supraspinal systems, the vasomotor response recovers and functions appropriately after spinal shock has subsided. This finding contrasts with the failure of spinal animals to regulate body temperature by shivering after peripheral cooling and suggests that vasomotor regulation of body temperature is a primitive thermoregulatory response.