Food intolerance, flushing, and diarrhea in a 44-year-old woman.
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Adult↗
Biomedical subjects
Anil Nanda
Publications and source records attributed to Anil Nanda.
Palliation of brain stem metastasis in patients with lung cancer by radiotherapy: how safe?
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Adult↗
Surgical management of intracranial cavernous malformations: the Louisiana State University Health Sciences Center, Shreveport experience.
Intracranial cavernous malformations are vascular anomalies consisting of endothelium-lined caverns filled with blood at various stages of thrombosis and organized and separated by a collagenous stroma devoid of mature vessel wall elements. They represent a clinical challenge both in diagnosis and management due to the variety of presenting symptoms and neuroradiological features. This study analyzes the clinical manifestations and surgical outcomes in 16 patients with cavernous malformations who were treated surgically at the Louisiana State University Health Sciences Center in Shreveport. The most common presenting features were headache, seizure, and focal neurologic deficits. Three patients had deep lesions (two in the brainstem and one in the basal ganglion), and 13 patients had superficial lesions. All patients underwent surgery and had complete excision of the lesion. The overall outcome was satisfactory for all patients with significant symptom relief over a mean follow-up period of 60 months. The optimal management of cavernous malformations should be determined on a case-by-case basis and, when indicated, surgery provides good outcome.
Adolescent↗
Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment.
OBJECTIVE: To characterize admissions related to ventricular shunts in the year 2000 in terms of diagnoses, procedures, socioeconomic status, and other related data. METHODS: The Nationwide Inpatient Sample database (year 2000) was analyzed retrospectively. We reviewed 7.45 million patient admissions for primary International Classification of Diseases, 9th Revision, procedure codes 023 to 0243 (ventricular shunts to peritoneal, atrial, pleural, and urinary systems for initial placement, revision, and removal); admissions listing ventriculostomy placement (code 022) were excluded from analysis. RESULTS: Five thousand five hundred seventy-four admissions were identified. Admission sources primarily were routine (58.8%) and the emergency department (32.4%). Admission types primarily were elective (43.3%), emergent (33.2%), and urgent (21.9%). The top three primary diagnoses treated were shunt malfunction (40.7%), noncommunicating hydrocephalus (16.6%), and communicating hydrocephalus (13.2%). Shunt infection was the primary diagnosis in 7.2% of admissions. Age frequency of admissions was nonparametric, being highest for infants; the average stay was 8.4 +/- 0.2 days (standard error range, 0-243 d). The most common procedures were ventriculoperitoneal shunt placement (43.4%) and ventricular shunt replacement (42.8%); ventricular shunt removal occurred in 7.3% of admissions, whereas ventricle-to-thorax (0.6%), ventricle-to-circulatory system (0.5%), and ventricle-to-urinary system (0.05%) shunts were rare. Average cost was $35,816 +/- $810 (standard error range, $137-$814,748). Primary payers primarily were private insurers (43.8%), Medicare (26.0%), and Medicaid (24.5%). Disposition mainly was routine (78.4%, with home health care in 6.5%), and inpatient mortality was 2.7%. There was no socioeconomic disproportion in treatment with respect to average household income. CONCLUSION: Ventricular shunts as primary procedures constitute a significant medical and economic problem.
Adolescent↗
Exposure of brain to high-dose, focused gamma rays irradiation produces increase in leukocytes-adhesion and pavementing in small intracerebral blood vessels.
OBJECTIVE: Radiosurgery is used to destroy a predetermined target within the brain, with minimal radiation injury to the surrounding tissue. We hereby present our in vivo model to study the effects of single-session, high-dose radiation on the cerebral vessels that are targeted with radiosurgery using the Leksell Gamma Knife. METHODS: The study was conducted in 29 adult male WT C57BL/6J mice weighing 21 to 28 g (6-8 wk old). The animals were exposed to 100 Gy single-session focused gamma ray irradiation using the Leksell Gamma Knife, and subsequently underwent intravital microscopy at different time intervals to study leukocytes and platelets adhesion patterns to the endothelium of the irradiated cerebral micro-vessels. RESULTS: The leukocyte adhesion response showed a bell-shaped curve upon quantitative analysis with a steady increase in the number of adherent cells during the first four hours and a subsequent plateau response that was maintained during the next 24 hours. The platelet adhesion response did not demonstrate any particular pattern similar to the leukocyte response. CONCLUSION: The experiment was able to establish in vivo increased leukocyte adhesion to the cerebral vascular endothelial cells in response to radiation injury and elaborate the time frame within which the leukocyte adhesion response increases, reaches a peak and then starts decreasing.
Animals↗
Idiopathic primary pan intra-ventricular hemorrhage in a child.
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Adult↗
New lumbar method for monitoring cerebrospinal fluid pressure in rats.
OBJECTIVE: Monitoring cerebrospinal fluid pressure or intracranial pressure (ICP) is crucial in the study of neurosurgical disorders. In the present study, we report a new lumbar method for monitoring ICP in rats. METHODS: A PE10 catheter connected to a pressure transducer was placed into the subarachnoid space of L5 through the duramater after laminectomy to record lumbar cerebrospinal fluid pressure (lumbar-ICP). ICP at the cisterna magna (cisterna-ICP) was recorded simultaneously via a catheter in the subarachnoid space at the cisterna magna. Eighteen anesthetized adult male S-D rats were subjected to baseline recording followed by either experimental subarachnoid hemorrhage (SAH) induced by intravascular puncture method or experimental intracerebral hemorrhage (ICH) induced by blood injection with a stereotaxic system. RESULTS: Baseline lumbar-ICP and cisterna-ICP varied between 6 and 8 mmHg, and respiratory variation could be detected. A similar acute response to SAH was recorded in both the lumbar-ICP and cisterna-ICP in all rats. In rats subjected to SAH, the lumbar catheter continuously and accurately monitored lumbar-ICP, and reliable pressure tracings were obtained for up to 24 h after SAH. However, continued cisterna-ICP monitoring was abandoned in two rats in the cisterna magna method due to obstruction of the catheter by blood clots (hematoma). CONCLUSION: This new lumbar-ICP method is simple, safe, easy, and reliable in rats. Continued lumbar-ICP measurements provided monitoring for up to 24 h after experimental manipulation.
Animals↗
Ras protein contributes to cerebral vasospasm in a canine double-hemorrhage model.
BACKGROUND AND PURPOSE: Mitogen-activated protein kinase (MAPK) has been shown to be involved in the pathogenesis of cerebral vasospasm after subarachnoid hemorrhage (SAH). In the present study we examined the role of Ras protein, an upstream regulator of MAPK, and the effects of the inhibitors of Ras farnesyltransferase (FTase), FTI-277 and FTase inhibitor I, on angiographic vasospasm and clinical evaluations. METHODS: Twenty-five dogs were randomly divided into 5 groups: control, SAH, SAH+dimethyl sulfoxide, SAH+FTI-277, and SAH+FTase inhibitor I. An established canine double-hemorrhage model of SAH was used by injecting autologous arterial blood into the cisterna magna on days 0 and 2. Angiography was performed at days 0 and 7. Clinical behavior and the activation of Ras (GTP-Ras) and phosphorylated ERK1/2 of MAPK in the basilar arteries were examined. RESULTS: Severe vasospasm was obtained in the SAH and SAH+dimethyl sulfoxide dogs (42.5+/-2.5% and 38.9+/-2.4%, respectively). Enhanced GTP-Ras and phosphorylated ERK1/2 were observed in the spastic basilar arteries (P<0.05). Inhibitors of Ras FTase decreased GTP-Ras and phosphorylated ERK1/2, attenuated angiographic vasospasm, and improved appetite and activity scores. CONCLUSIONS: Ras contributes to cerebral vasospasm, and inhibitors of Ras FTase may have potential in the management of cerebral vasospasm.
Alkyl and Aryl Transferases↗
Inflammatory responses to ischemia and reperfusion in the cerebral microcirculation.
Ischemia and reperfusion (I/R) has been shown to elicit an inflammatory response that is characterized by an increased production of reactive oxygen species, and the rolling, firm adhesion, and transendothelial migration of leukocytes in postcapillary venules. A rate-determining role for leukocyte-endothelial cell (L/E) adhesion in the initiation and propagation of reperfusion injury is supported by several reports that describe attenuated microvascular dysfunction and tissue injury following I/R in animals receiving neutralizing antibodies directed against certain leukocyte adhesion receptors and in mutant mice that are genetically deficient in these adhesion receptors The technique of intravital videomicroscopy has been applied to several tissues, including the brain, in order to directly observe the microcirculatory alterations and inflammatory responses that are elicited by I/R. The leukocyte- and platelet-endothelial cell adhesion responses to cerebral I/R are addressed and compared to responses observed in other postischemic vascular beds. The limited data available for the brain microcirculation support the potential of anti-leukocyte and anti-platelet strategies for stroke therapy.
Animals↗
Stereotactic radiosurgery using the Leksell Gamma Knife: current trends and future directives.
Stereotactic radiosurgery is the extremely precise administration of a radiation dosage in three-dimensional space to treat an increasingly broad spectrum of intracranial and skull-base lesions. 455 patients with various indications were treated using the 201 Source Co-60 Leksell Model "B" Gamma Knife(r) at Louisiana State University Health Sciences Center in Shreveport, Louisiana. 273 (60.2%) patients received radiosurgery as the first line of treatment for their disease. The mean Karnofsky Performance Score (KPS) of the patients was 70. Cerebral metastases were the main indications for radiosurgery at our center accounting for 27% of the patients, while meningioma, AVM, trigeminal neuralgia, movement disorders, and primary CNS malignant tumors were the other indications. Our institutional experience and results indicate that low incidence of complications coupled with a high tumor control rate makes Gamma Knife stereotactic radiosurgery a viable option for patients who must undergo neurosurgery. As the Gamma Knife continues to prove itself as a first-line treatment of many complex brain disorders, new indications for this technology will continue to emerge, further broadening the scope of patient care.
Forecasting↗
Dose dependence and time course of the immunologic response to administration of standardized cat allergen extract.
BACKGROUND: The immunologic response to allergen immunotherapy with 3 serial 5-fold doses of cat extract has been studied after approximately 5 weeks of immunotherapy. The highest dose containing 15 mug of Fel d 1 produced the most consistent and favorable response. It is unknown whether the comparative response on reaching a maintenance dose is maintained with long-term maintenance therapy. OBJECTIVE: The purpose of this investigation was to evaluate the immunologic responses with these 3 serial doses of cat hair and dander extract at baseline, after reaching the maintenance dose (approximately 5 weeks), and after 1 year of maintenance immunotherapy. METHODS: Twenty-eight patients with cat allergy randomized in a double-blind study were assigned to one of 4 treatment groups: placebo or cat hair and dander extract containing 0.6 mug of Fel d 1, 3 mug of Fel d 1, and 15 mug of Fel d 1 at maintenance. Studies included skin prick tests and late cutaneous reactions with cat hair and dander extract, titrated nasal challenges with the extract, serum cat allergen-specific IgG4 and IgE measurement, and flow cytometric and ELISA analysis of whole blood and intranasal cytokines (TGF-beta, IL-10, IFN-gamma, IL-4, and IL-5). RESULTS: Twenty-six subjects completed the study. After both 5 weeks and 1 year, significant and dose-dependent differences were seen with total symptom scores on nasal challenge ( P < .0001), with titrated skin prick testing with cat dander extract at 5 weeks ( P = .014) and 1 year ( P < .0001), and with cat-specific IgG4 measurement at 5 weeks ( P = .004) and 1 year ( P = .003). At 1 year, neither flow cytometry of whole blood nor ELISA evaluation of nasal cytokines demonstrated any significant differences among the treatment groups. CONCLUSION: The response to titrated nasal allergen challenge, titrated skin prick testing, and allergen-specific IgG4 measurement to cat immunotherapy at 5 weeks is predictive of the response at 1 year.
Allergens↗
Survival trends in elderly patients with glioblastoma multiforme: resective surgery, radiation, and chemotherapy.
BACKGROUND: It is appropriate to investigate and to determine survival trends following glioblastoma multiforme treatment using resective surgery, radiation therapy, and/or chemotherapy in patients aged 59 years and higher. METHODS: We retrospectively reviewed 30 elderly patients (> or =59 years old) who were treated for histopathologically confirmed glioblastoma multiforme at our tertiary care institution from 1990 through 2002. All patients were treated with steroids. In addition, 22 patients underwent resective surgery (RS), 17 patients underwent radiation therapy (RT), and 10 patients underwent chemotherapy (C). Many patients underwent these treatments in various combinations: 6 underwent biopsy only, 7 RS only, 6 RS+RT only, and 9 RS+RT+C. For each case, pre-treatment Karnofsky performance scores (KPS), tumor location, presenting symptoms and signs, associated surgical morbidity, and pre-existing medical conditions were also recorded. Patients were categorized into one of four treatment subgroups: Biopsy only, RS only, RS+RT, and RT+RS+C. For each of these subgroups, pretreatment KPS and post-treatment survival were compared. RESULTS: Post-treatment survival following biopsy only was 3.2 +/- 0.8 months (mean +/- SE); RS 2.2 +/- 0.5; RS+RT 5.5 +/- 1.2; RS+RT+C 13.6 +/- 2.1. A longer survival trend was noted for the RS+RT versus RS group (two-tailed unpaired t test, p = 0.02;), as well as the RS+RT+C group, which showed consistently higher survival in comparison to most of the other groups (p = 0.0021, 0.00039, 0.013 vs. the biopsy only, RS only, and RS+RT groups, respectively). No significant difference was found in KPS, comparing all individual groups versus each other (p > or = 0.06). Remarkably, 6 patients survived over 14 months (range, 14.1-22.7 months), all of which received RS+RT+C. CONCLUSIONS: This study suggests a significant improvement in elderly patients treated with the combination of resective surgery, radiation therapy, and chemotherapy, rather than either treatment alone or other combination. This significant improvement does not appear to be biased by pretreatment KPS, as mean KPS values did not significantly differ between any of these groups. However, a greater number of patients in each group must be considered to achieve the power to make more definitive treatment guidelines.
Age Factors↗
Gamma knife radiosurgery for trigeminal neuralgia: a study of predictors of success, efficacy, safety, and outcome at LSUHSC.
BACKGROUND: Trigeminal neuralgia (TN) is a painful condition of controversial origin; however, vascular compression of the root entry zone of the trigeminal nerve is thought to be responsible in some cases. Recently, stereotactic radiosurgery has been established as an alternative treatment for medically intractable TN. METHODS: Forty patients with medically refractory TN underwent gamma knife surgery for pain control at our institution. Dose planning was based on high-resolution, contrast-enhanced, axial, volume acquisition magnetic resonance images. Images were reviewed to detect vascular compression of the trigeminal nerve at the root entry zone by an observer blinded to the affected side and the outcome. Another observer, blinded to radiologic findings, conducted the patient follow-up. Results were classified as excellent and good (favorable outcomes) and failure (unfavorable) based upon the intensity of pain, frequency of episodes, pain medications, and need for additional interventions after radiosurgery. RESULTS: Pain was left-sided in 22 patients and right-sided in 18 patients. Vascular compression of the affected nerve at the root entry zone was demonstrable in 14 patients. Prescription dose ranged from 70 to 90 Gy. At a median follow-up of 14 months (range, 3-31 months), 16 patients (40%) had excellent pain control, 12 (30%) had good control, while 12 (30%) had failed treatment. The Kaplan-Meier actuarial pain control rate at 15 months was 82.25 +/- 0.8% (95%CI). Magnetic resonance detectable vascular compression did not affect the outcome (p = 0.6). Increasing marginal dose (> or =40Gy) was a significant predictor of favorable outcome (p = 0.015). CONCLUSIONS: gamma knife surgery is an effective and safe treatment for TN. In our study, we found that vascular compression of the nerve at the root entry zone was not a predictor of the outcome of gamma surgery for TN. The outcome improves with marginal prescription dose of 80 Gy or higher.
Adult↗
Adopting 540-degree fusion to correct cervical kyphosis.
BACKGROUND: Two cases of severe cervical spine kyphotic deformity resulting from late effects of infection were successfully corrected by combined anterior and posterior instrumentations in a single operative sitting. CASE DESCRIPTION: Case 1 is a 43-year-old man who developed severe cervical kyphosis from C5-6 discitis over a few months despite long-term antibiotic therapy. He was neurologically intact except for severe neck pain and obvious deformity. Case 2 is a 40-year-old woman who had a previous wound infection five years before presentation. There was gradual worsening of swan neck deformity at the C2-3 and C5-6 levels with some spinal cord compression worsening her baseline myelopathy. The patients were placed and maintained in cervical traction on the Stryker frame for the duration of the procedure. Both cases required anterior approach initially to achieve some release of dense scar tissue using a high-speed drill. The wounds were then closed and patients were rotated to the prone position for further release of fused bony elements, including the facets. Lateral mass screws and plates were placed. In Case 2, additional instrument to the occipital was performed to stabilize the C2 using a U-shaped cervical rod. Once adequate reduction had been achieved, the patients were rotated back to supine position for further corpectomy and fibular construct fusion with plates. CONCLUSION: In cases of severe kyphotic deformity complicating infectious vertebral destruction, the spinal alignment can be achieved safely by a multi-step technique combining the anterior as well as posterior surgical approaches.
Adult↗
Quantification of the advantages of the extended frontal approach to skull base.
This anatomic study evaluated the extent that a fronto-orbital osteotomy (FOO) added to a bilateral frontal craniotomy widened the exposure to the midline compartment of the anterior, middle, and posterior cranial fossae. The goal was to determine if osteotomy would significantly increase angles for two targets: the foramen magnum (FM) and anterior clinoid process (ACP). Stepwise dissections were performed on five cadaveric heads. A bilateral frontal craniotomy was made, followed by FOO. After the ethmoids were removed, the planum sphenoidale was drilled to enter the sphenoid sinus. Further drilling exposed the anterior clivus, which was drilled down to FM. Excellent exposure of the basilar artery, vertebral artery, and brain stem was achieved. With and without FOO, angles of exposure were measured for two targets: the ACP and FM. The angle of exposure after FOO increased markedly with an average gain of 76% for the ACP and of 80% for FM. Compared with a conventional bifrontal craniotomy, the addition of FOO increased the surgical exposure and minimized frontal lobe retraction for accessing lesions of the anterior, middle, and posterior cranial fossae.
Journal Article↗
Caspase inhibitors prevent endothelial apoptosis and cerebral vasospasm in dog model of experimental subarachnoid hemorrhage.
Apoptosis in the endothelium of major cerebral arteries may play a role in the initiation and maintenance of cerebral vasospasm after subarachnoid hemorrhage (SAH). We tested the therapeutic effect of caspase inhibitors on endothelial apoptosis and on cerebral vasospasm in an established dog double-hemorrhage model. Thirty-one mongrel dogs were divided into five groups: control; SAH; SAH treated with vehicle [DMSO]; SAH treated with Ac-DEVD-CHO [a specific caspase-3 inhibitor]; and SAH treated with Z-VAD-FMK [a broad caspase inhibitor]. The inhibitors (100 microM) were injected into the cisterna magna daily from Day 0 through Day 3. Angiography was performed on Day 0 and Day 7. Histology, TUNEL staining, and immunohistochemistry were conducted on basilar arteries collected on Day 7 after SAH. Positive staining of TUNEL, poly(ADP)-ribose polymerase (PARP), caspase-3, and caspase-8 was observed in the endothelial cells of the spastic arteries. Double fluorescence labeling demonstrated co-localization of TUNEL with caspase-3 and TNFalpha receptor-1 (TNFR1). Ac-DEVD-CHO and Z-VAD-FMK prevented endothelial apoptosis and reduced angiographic vasospasm. The mechanism of apoptosis in endothelial cells involves TNFR1 and the caspase-8 and caspase-3 pathways. Caspase inhibitors may have potential in the treatment of cerebral vasospasm.
Animals↗
Survival in relation to radiotherapeutic modality for brain metastasis: whole brain irradiation vs. gamma knife radiosurgery.
The purpose of this report is to evaluate and compare the survival of patients with brain metastasis (BRM) treated by whole brain irradiation (WBI) using linear energy accelerator (LINAC) and by stereotactic radiosurgery using gamma knife. This study consists of a series of 67 patients with BRM treated with WBI between 1998 and 1999 and 53 patients with BRM treated with gamma knife radiosurgery (GKRS) between 2000 and 2001. A retrospective study of the data was performed and the overall survival between these 2 groups was analyzed. The comparability of these 2 groups was tested by chi2 and t test values. Log-rank test was used in the survival comparison. The 1-year survival rate was 26.3% and 22.6%, and corresponding mean survival was 7.8 months and 6.7 months for WBI and GKRS groups, respectively. There was no statistically significant difference between these 2 groups' survival. It was evident from imaging defined lesions that with GKRS the lesions were reduced, stabilized, or disappeared in 89% of cases. Survival of patients with BRM treated with WBI or GKRS was similar in these series. The present study suggests that good tumor response by GKRS does not translate in longer patient survival.
Adult↗
Management strategies for patients with brain metastases: has radiosurgery made a difference?
BACKGROUND: Brain metastases develop in up to 50% of all patients with cancer. The purpose of this retrospective study was to compare the outcomes for brain metastases patients treated with adjuvant whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS). METHODS: Between 1990 and 1995, 86 patients with brain metastases received external beam WBRT with a megavoltage beam at our center. Between January 2000 and July 2001, 48 patients with 84 tumors diagnosed as cerebral metastases were treated with SRS using the Leksell Gamma Knife. A comparative analysis of the outcomes in the two different groups was made to determine a possible statistically significant difference in survival. RESULTS: In the WBRT group, the median follow-up was 11 months. Thirty-nine patients (45.3%) experienced an improvement in neurologic status. The median overall survival was 5 months (range, 1-40 months). In the SRS group, the median follow-up for this group was 9 months. Thirty-four patients experienced an improvement in their neurologic signs and symptoms. The median survival was 12 months (range, 1-16 months). CONCLUSION: SRS appears to be a safe and effective treatment option for those patients with a limited number of brain metastases and in patients with controlled or limited systemic disease.
Adult↗