Biomedical subjects
Publications and source records attributed to H E James.
The experience of the Special Care Nursery of the University of California Medical Center, San Diego, in the management of the high risk newborn with progressive ventricular enlargement is reviewed, and the physiopathological basis of progressive ventricular enlargement is analyzed.
Fifty-three low birth weight high risk newborns who developed progressive hydrocephalus despite a trial period of intermittent lumbar punctures underwent cribside ventriculoperitoneal shunt placement. They all weighed less than 2000 g at the time of shunting (mean, 1308.6 g +/- 398.2 SD). The operative procedures were performed at a mean age of 31.5 days +/- 16.1 (SD). There were no deaths in this series. During the nursery stay, 14 patients required operative revisions for obstruction. The most common problem was infection, which occurred in 13 (24.5%) after the primary intervention and in another 5 of the 14 (35.7%) patients who required revision. The overall infection rate/patient was 26.9%. Shunt removal and intensive antibiotic therapy cured the infection in all but 1 patient. Premature, low birth weight newborns may undergo ventriculoperitoneal shunting, but close follow-up for complications such as infection and shunt obstruction is always required.
Ten patients with ages ranging from 4 weeks to 21 years presented with a subcutaneous lumbosacral mass noted at birth. After spinal high resolution ultrasonography or computed tomography to determine the extent of neural involvement and the length of the tumor mass in the spinal canal, the patients underwent operation. Rectal electromyographic continuous monitoring was used in all for assessment of the S-2 and S-3 function during dissection. Carbon dioxide laser microneurosurgery was used in all operations. Radiating energy was used for the subcutaneous mass removal (40 to 60 W), the intracanalicular dissection (1 to 5 W), and the intraconus dissection (1 to 3 W). A radical removal was obtained in all. Postoperative cerebrospinal fluid fistula occurred in 1 patient and was successfully treated. Wound dehiscence that healed with secondary closure occurred in 2 patients. Would infection that required treatment with systemic antibiotics and topical therapy occurred in 1 patient. Paraplegia occurred in 1 patient. This was the single very significant complication of this series. It was thought to have occurred because of the polymer used to seal the tenuous dura mater at the time of closure. We conclude that, with carbon dioxide laser microneurosurgery, the lipomatous tumors can be removed safely from the neural structures of the conus and cauda.
Craniofacial fibrous dysplasia has rarely been described in the polyostotic form of McCune-Albright disease. The unique ophthalmic features of interest in this patient with McCune-Albright's disease was the presence of an orbital tumor that suddenly increased in size compressing the optic nerve. Prompt excision of the tumor resulted in restoration to normal vision.
Albino rabbits with experimental brain oedema produced by a combined cryogenic left hemisphere and a metabolic 6-aminonicotinamide lesion were given indomethacin (20 mg/kg) fifteen minutes prior to dimethyl sulfoxide (DMSO) treatment (1 g/kg bolus). Intracranial pressure (ICP), systolic arterial pressure (SAP), central venous pressure (CVP), and EEG were continuously measured while the animals were being mechanically ventilated at a constant PaCO2 (38-42 torr). At the end of the run, brain H2O and electrolytes were measured. There was no significant reduction in ICP at 5 minutes and 15 minutes after DMSO. This was strikingly different to what occurred when DMSO alone was administered, when a significant reduction was noted (p less than 0.05). At 30 minutes there was a reduction in ICP in both the DMSO and the DMSO/indomethacin groups, but in the former it was 50% of the pretreatment values while in the latter it was only 24%. Because indomethacin is a proven prostaglandin inhibitor, these results suggest that these substances may play a role in the mechanism of action of DMSO.
Albino rabbits with experimental brain oedema produced by a combined left hemisphere cryogenic injury and a metabolic insult by a 6-aminonicotinamide (6-ANA) were administered intravenous dimethyl sulphoxide (DMSO) in varying concentrations and doses in the following manner: Subgroup A (concentration response) received 1.0 g/kg bolus of a 10, 20, 30, or 40% solution. Subgroup B (dose response) received as a 20% solution a 1.0 g/kg bolus, 1.5 g/kg bolus, or 2.0 g/kg infusion. One hour following administration of the agent, the animals were killed, their brains rapidly removed by craniectomy and brain water, sodium and potassium measured. Significant decreases in brain sodium and water content in the right hemisphere were noted in both subgroups A (p less than 0.05) and B (p less than 0.005) and in the left hemisphere in subgroup B only (p less than 0.005). There is an apparent effect on brain oedema by a DMSO mediated sodium dependent water mobilization.
Explore the source record for details and available documents.
Spinal dysraphism refers to incomplete embryologic development of the dorsal midline. Frequently it is not clinically obvious, and lack of treatment can lead to progressive neurological damage. Early diagnosis of occult defects can allow appropriate surgical intervention and prevent neurological deficits. The authors have used high-resolution real-time ultrasound to screen infants with various cutaneous lumbosacral markers, all of whom were at risk of occult spinal dysraphism. Preliminary results suggest that ultrasound is a reliable screening procedure and could obviate the need for more costly and invasive tests.
An infant with a lumbosacral spinal subcutaneous and intraspinal lipoma involving the conus medullaris was studied with computed tomography and high resolution real time ultrasonography to determine the extent and location of the disease before operation. The high resolution ultrasonogram demonstrated the abnormality with good detail and the added advantage of real time display of the lack of pulsatile mobility of the neural elements, confirming spinal cord tethering. Spinal high resolution ultrasonography is a noninvasive diagnostic tool in infants with spinal abnormalities and should be an important part of a neurosurgeon's diagnostic support system.
Explore the source record for details and available documents.
The purpose of this report is to compare the effect of acute therapy with dimethyl sulphoxide (DMSO) and pentobarbitone on experimental brain oedema produced by a cryogenic lesion over the left hemisphere in albino rabbits. A group of animals received DMSO (1 mg/kg-10% solution) by intravenous bolus, and another group received a pentobarbitone intravenous 30-minute infusion (40 mg/kg). Intracranial pressure (ICP), systolic arterial pressure (SAP), central venous pressure (CVP), and EEG were studied. Brain water and electrolyte content were analyzed at one hour following the initiation of therapy. ICP was promptly reduced with both forms of therapy. A 66% reduction from control values was reached at 50 +/- 12 minutes with pentobarbitone, and a 45% reduction from control values was reached at 30 minutes with DMSO. There was no significant reduction in the water content of the brain with either form of therapy. A significant elevation in brain potassium content was noted following DMSO when compared to untreated controls. CVP was essentially unchanged in both groups. Pentobarbitone produced a reduction of SAP with a mean value of 20.3 torr at 45 minutes from infusion. DMSO produced no reduction of SAP. It is concluded that DMSO and pentobarbitone are just as effective in reducing ICP. DMSO has the capacity to maintain SAP which pentobarbitone does not have, thus assuring a better cerebral perfusion pressure.
Increased intracranial pressure due to brain oedema was produced in albino rabbits by combining a cryogenic lesion in the left hemisphere with the intraperitoneal administration of 6-aminonicotinamide (cytotoxic agent). The following parameters were assessed: intracranial pressure (ICP), systolic arterial pressure (SAP), central venous pressure (CVP), EEG, brain water and electrolyte content, gross pathology, and blood brain barrier integrity. Acute therapy to reduce ICP was performed by administering a bolus of mannitol (1 gm/kg) and 30 minutes later, also in bolus, frusemide (5 mg/kg). Immediately following the administration of mannitol an infusion of pentobarbitone was commenced; this was continued for one hour so that a total of 10 mg/kg was administered. There was a 50% reduction of ICP at one hour from initiation of treatment. The brains of the animals were extracted immediately upon cessation of therapy (pentobarbitone) and they revealed a significant reduction of water content for the right, uninjured, hemisphere only, when compared to controls; a slight but not significant reduction of the brain sodium and potassium was noted in both hemispheres. There was no change noted in the gross pathology and extent of blood brain barrier breakdown. In all animals epinephrine infusion had to be administered for between 20 and 30 minutes to maintain a SAP over 80 torr. There seems to be no advantage in the simultaneous administration of barbiturates and diuretics for the control of ICP due to brain oedema.
Albino rabbits with experimental brain edema produced by a combined cryogenic left hemisphere lesion and metabolic 6-aminonicotinamide lesion were administered a 3-hour intravenous infusion of dimethyl sulfoxide (DMSO). Simultaneous recording of intracranial pressure (ICP), systolic arterial pressure (SAP), and central venous pressure (CVP) and electroencephalography were performed while the animals were being ventilated mechanically to produce a constant Pa CO2 value (38-42 torr). At the end of the infusion, the brain water and electrolyte contents were measured. There was a persistent and progressive reduction of ICP during the infusion, the nadir occurring at 3 hours (p less than 0.005 from zero time), with no change in SAP or CVP. There was a reduction of brain water in both hemispheres when compared to untreated controls, but this was significant for the right hemisphere only (p less than 0.005). There was a significant reduction of the brain sodium content for both hemispheres, but no significant change occurred in brain potassium content. The DMSO infusion was effective not only in reducing ICP, but also in sustaining this reduction for 3 hours.
Albino rabbits with experimental brain edema produced by a combined cryogenic and metabolic 6-aminonicotinamide lesion were administered intravenous dimethyl sulfoxide in varying concentrations and doses in the following manner: Subgroup A (concentration response) received a 1.0-g/kg bolus as a 10%, 20%, 30%, or 40% solution. Subgroup B (dose response) received as a 20% solution a 1.0-g/kg bolus, 1.5-g/kg bolus, or 2.0-g/kg infusion. Simultaneous recording of intracranial pressure (ICP), systolic arterial pressure (SAP), and central venous pressure and electroencephalography were performed while the animals were being mechanically ventilated at a constant PaCO2 (38 to 42 torr). There was significant lowering of ICP when compared to pretreatment values in Subgroup A in the 10% subset at 30 minutes (p less than 0.05) and in the 20% subset at 5 (p less than 0.05) and 30 (p less than 0.05) minutes. ICP was not significantly decreased in the 30% and 40% subsets. All animals of Subgroup B displayed significant reductions of ICP when compared to their pretreatment values. There was no significant change in SAP in either subgroup.
Fourteen children with repeated transient or sustained cerebrospinal fluid shunt dysfunction and with markedly increased intracranial pressure are presented. In all cases, the lateral ventricles had become very small soon after the insertion of a shunt valve that opened at a low pressure, but symptoms of shunt dysfunction did not occur until 6 months to 12 years later. The raised intracranial pressure was treated by subtemporal craniectomy alone (12 patients) or in combination with elevation of the shunt valve opening pressure (2 patients). Subtemporal craniectomy alone was sufficient to alleviate moderately increased intracranial pressure, but both methods were required when the pressure rise was severe. The high intracranial pressure is accompanied by impairment of the drainage of ventricular fluid, which is caused by collapse of the walls of the lateral ventricles around the proximal shunt catheter. But the sequence of events that leads to the severe rises in intracranial pressure characteristic of this syndrome is poorly understood. The possibility that an inflammation-mediated brain swelling arising from mild systemic infections might further compromise already small ventricles and precipitate shunt dysfunction is suggested.
The antibiotic concentration of the fluid from either lateral ventricle was determined 104 times in 37 patients through direct ventricular puncture, external ventricular drainage (EVD), or cerebrospinal fluid shunt sampling. The patients were 1 month to 12 years old. When the patients were receiving maximal intravenous antibiotic therapy alone, the concentrations for the most part were below 5 microgram/ml, whereas patients receiving an antibiotic through direct ventricular puncture, EVD, or a shunt reservoir usually had concentrations over 5 microgram/ml. However, wide variations from patient to patient were found with all forms of treatment despite similar dosages. Clustering of the concentration tended to occur in each individual patient. The authors conclude that, to obtain a high concentration of an antibiotic in the ventricular fluid, one should administer it directly into the ventricle.
Fifty patients with infected cerebrospinal fluid shunts were treated by one of three forms of treatment: a) Twenty-two patients had shunt removal, systemic antibiotic treatment, and either external ventricular drainage or intermittent ventricular taps for decompression and antibiotic administration. b) Seventeen patients had removal and immediate replacement of the shunt with intrashunt and systemic antibiotics. c) Eleven patients received intrashunt and systemic antibiotics without shunt removal. In the first group, antibiotics were given for a period of one week; in the second and third groups, intravenous antibiotics were administered for a minimum period of three weeks, and intraventricular antibiotics twice daily for two weeks. In all patients ventricular CSF was obtained and cultured 48 hours after cessation of antibiotic therapy, and cultures were repeated within four months after completion of therapy. Twenty-one of 22 patients in the first group as well as 11 of 13 of the second group, were successfully treated. In the third group only four of the 11 patients responded to treatment.
Increased intracranial pressure due to brain oedema was produced in albino rabbits by combining a cryogenic lesion in the left hemisphere with the intraperitoneal administration of 6-aminonicotinamide (cytotoxic agent). The most effective reduction in ICP (74%) was achieved when furosemide and mannitol were used in combination. When either mannitol or furosemide was employed alone, the average ICP reduction was approximately 53%. Peak ICP reduction occurred at 45 minutes with furosemide, 30 minutes with mannitol and furosemide combined, and at 60 minutes with a combination of mannitol and acetazolamide. Also studied simultaneously in these animals were investigated elastance (Em), brain water content, hemispheric water volume content, electrolytes, EEG, and gross pathology. Following therapy there was a statistically significance reduction of water content in the left hemisphere (cryogenic lesion) by all therapeutic modalities except with furosemide alone. In the right hemisphere the water content was reduced by furosemide and the furosemide-mannitol combination but not by the association of mannitol with acetazolamide. A significant decrease of brain sodium was noted only for the combination of mannitol and furosemide. This study indicates that effective reduction of cytotoxic-cryogenic brain oedema and intracranial hypertension can be obtained with a variety of diuretic agents. From the standpoint of tissue dehydration, restoration of tissue electrolyte balance, and rate of ICP reduction, the combination of furosemide-mannitol appears to offer advantages over furosemide alone, or acetazolamide-mannitol.