Shelley N. Chou

Cerebral Arterial Spasm – A Controlled Trial of Nimodipine in Patients with Subarachnoid Hemorrhage

We enrolled 125 neurologically normal patients with intracranial aneurysms in a multi-institution, prospective, double-blind, randomized, placebo-controlled trial within 96 hours of their subarachnoid hemorrhage, to determine whether treatment with the calcium blocker nimodipine would prevent or reduce the severity of ischemic neurologic deficits from arterial spasm. A deficit from cerebral arterial spasm that persisted and was severe or caused death by the end of the 21-day treatment period occurred in 8 of 60 patients given placebo and in 1 of 56 given nimodipine (P = 0.03, Fishers exact test). Analysis of the amount of basal subarachnoid blood on pre-entry CAT scans in patients with deficits from spasm showed that an increase in subarachnoid blood was not associated with a worse neurologic outcome among patients who received nimodipine, unlike the situation in patients given a placebo. There were no side effects from nimodipine. We conclude that nimodipine should be given to patients who are neurologically normal after subarachnoid hemorrhage in order to reduce the occurrence of severe neurologic deficits due to cerebral arterial spasm.

Surgical treatment of vascular lesions in the brain stem.

✓ The authors report the total surgical removal of five vascular lesions of the brain stem, three hemangioblastomas and two arteriovenous malformations. One patient died; among the others, the quality of survival is excellent. Factors favoring surgical removal of such lesions are discussed.

Klippel-Feil syndrome in children: clinical features and management

A retrospective analysis of 11 children with the diagnosis of Klippel-Feil syndrome treated at the University of Minnesota Hospital over a period of 20 years is presented. The salient features of the syndrome and its associated anomalies are reviewed. Emphasis is placed on its neurological aspects, particularly the potential risks of injury to the craniocervical junction and cervical spine. Guidelines for the management of these patients are suggested.

A Decade of Experience with Electronic Simulation of the Micturition Reflex

Neurologic dysfunction of the urinary bladder is a frequent and morbid sequel to many diseases of the nervous system including spinal injury. Ten years of research into electronic techniques to return urinary bladder function to the control of the patient have resulted in a multicomponent system which is effective in the laboratory. However, clinical applications of this technique have been frustrated by unknowns regarding smooth muscle function in neurologic disease. We anticipate that a review of our efforts in this field will stimulate other investigators to delineate these unknowns and accelerate the employment of prosthetic devices to aid bladder evacuation.

Combined embolization and operation in the treatment of cervical arteriovenous malformations

The effectiveness of a combined approach of embolization and operation for cervical vascular malformations is stressed. Lesions that seem to be inoperable may have their blood flow sufficiently reduced by preoperative embolization to allow surgical extirpation. Polyvinyl alcohol foam is an ideal embolic agent; not only may it be used preoperatively, but its permanency allows it to be used for primary therapy.

Radionuclide bolus angiography: A technique for verification of brain death in infants and children

Fifteen infants and children, 11 of whom had clinical brain death and four of whom were comatose, were evaluated with the radionuclide bolus study and electroencephalography. Clinical criteria for brain death included: (1) absence of spontaneous respirations, (2) absence of cephalic reflexes, and (3) unresponsiveness. Results demonstrated complete correlation among clinical examination, EEG, and radionuclide study in 79% of cases. An approach to the evaluation of the infant or child with possible brain death is outlined utilizing serial examinations, radionuclide bolus study, and electroencephalography. The radionuclide bolus study appears to be a safe, rapid, portable technique which can be used for this purpose in infants and children.

A Rapid Method for Clinical Total Blood Volume Determination Using Radioactive Iodinated Human Serum Albumin (RIHSA)

Summary (1) A clinical laboratory procedure for directly measuring total circulating blood volume using RIHSA as the tracer agent has been described. (2) A series of 40 cases in whom total circulating blood volume was determined by this technic. (3) The advantages of this technic over the dye method have been discussed.

Neural and vascular tissue reaction to aneurysm-coating adhesive (ethyl 2-cyanoacrylate)

The effect of ethyl 2-cyanoacrylate (Aaron-2-Alpha) obtained from two different manufactures was evaluated in 37 cats divided into two groups. The first group (n = 28) received a 9-year-old preparation. The second group (n = 9) received recently acquired adhesive. Aaron-2-Alpha was applied to the left cruciate cortex and left femoral neurovascular bundle under barbiturate anesthesia. Normal saline was applied on the right side for control. Survival was allowed for 2, 4, 7, and 14 days after application of the adhesive. The 2-day survival was excluded in the second group. Neuropathological examination revealed meningeal necrosis, neuronal and axonal degeneration, vascular wall degeneration, thrombosis, and inflammatory reaction in both groups of cats. The compounds tested are far from satisfying the ideal requirements for their safe use. Chemical degradation may take place in the adhesives stored for prolonged periods of time. Adhesives obtained from two different sources may contain adjuvants of different toxicity. Severe local tissue reaction could produce marked neurological deficits when adhesives are applied in critical areas.

Radioactive iodinated human serum albumin as tracer agent for diagnosing and localizing intracranial lesions.

Various isotopes have been used to diagnose and localize intracranial lesions by the isotope- encephalometric technic described by Moore( 2 , 3 , 4 ). So far, diiodofluorescein has given the most satisfactory results and therefore gained the widest acceptance. However, at this clinic radioactive-iodinated-human-serum albumin has been used and appears to be as satisfactory, if not superior, to diiodofluores-cein. The iodination of human serum albumin (RIHSA‡) is carried out with ele-mental iodine in an essentially neutral buffer. One cc of RISHA contains 5 mg of human serum albumin with a salt concentration of approximately 2 mg( 6 ). Metabolic studies in both animals and humans have shown that RIHSA given intravenously remains in the blood stream for a long period of time. It is apparently gradually metabolised by the body and free iodine liberated. Although most of the radioactive iodine is excreted through the urine, about 5%percnt; of it is taken up by the thyroid gland by the end of 24 hours( 5 ). A small amount of RIHSA, which is not readily metabolized, diffuses out into the tissue and into lymphatics unchanged. About 1-2%percnt; of the tagged albumin can be obtained from the thoracic duct by the end of one hour. The liver, however, apparently does not participate in the excretion of RIHSA. It has been shown in experimental animals that only a neglibgible amount of RIHSA can be recovered in the bile( 5 ).

Acute cerebral revascularization after regional cerebral ischemia in the dog. Part 2: Clinicopathological correlation.

The efficacy of cerebral revascularization by anastomosis of the superficial temporal artery (STA) to the middle cerebral artery (MCA), performed 4 and 24 hours after a regional MCA infarction had been produced by combined occlusion of the MCA and internal carotid artery, was tested in 12 dogs. To control possible intercurrent variables, seven other dogs remained untreated and five had a sham operation. Clinical and pathological changes were recorded and analyzed. An incidence of 85% infarction was obtained in the untreated control group. The severity of the clinical deficits and pathological changes for the anastomosed groups were greater than those seen in the untreated control group. The extent of the infarction was significantly greater (p less than 0.05) in the anastomosed groups than in the sham-operated and control groups. Hemorrhagic infarcts occurred in most of the dogs in the anastomosed groups, but were not present in either control group (p less than 0.05). Two dogs in the 4-hour and one in the 24-hour group improved more than any control dog, but the difference was not statistically significant (p greater than 0.05). In two dogs with occluded anastomosis the clinical deficits and the pathological changes were less than those seen in animals with patent anastomosis. The severity of the pathological and clinical changes correlated well with the reestablishment of flow in the MCA territory. It is proposed that cerebral revascularization at 4 and 24 hours following a regional MCA infarct in the dog is followed by an exacerbation of the microcirculatory obstruction, cerebral edema, and infarction. From improvement noted in three animals the authors suggest that under special conditions the revascularization could benefit some cases following acute cerebral infarction.