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Biomedical subjects

J Biller

Publications and source records attributed to J Biller.

At least 109 records · Page 6Linked to original sources
PubMed1988

Carotid endarterectomy in symptomatic elderly patients.

Fifty-three of 203 consecutive carotid endarterectomies (26%) performed on the Neurosurgical Service at the University of Iowa were in patients over 70 years of age (mean age, 73.4). This series included 38 men and 15 women. Thirty-three patients (62%) presented with transient ischemic attacks, and the remaining 38% were functional stroke patients. Medical risk factors in this group included hypertension in 70%, previous myocardial infarction in 26%, angina in 17%, peripheral vascular disease in 23%, and diabetes in 13%. Sixty-four per cent of the patients had been previously treated with antihypertensive drugs, 43% with antiplatelet agents, and 4% with anticoagulants. Noninvasive vascular evaluation was performed in 25 of 53 (47%) patients, and all underwent angiography before operation. There were no angiographic complications. All patients were operated on with full-channel electroencephalographic (EEG) monitoring. Indwelling shunts were required in 6 of 53 (11%) cases. Intraoperative heparin was given and not reversed; the mean dose was 5100 units. The mean clamp time was 48 minutes. Patch grafts, fashioned from common facial or saphenous veins, were used in 2 patients. Eight patients had contralateral carotid occlusions, but only 2 (25%) required indwelling shunt placement based on EEG criteria. There were no perioperative deaths in this series. One patient had a postoperative stroke, and 1 patient had a postoperative nonfatal myocardial infarction. Transient surgical complications included 3 wound hematomas, 1 wound abscess, and 2 self-limited cranial nerve palsies (13%).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1988

Dose-escalation study of intravenous nicardipine in patients with aneurysmal subarachnoid hemorrhage.

A dose-escalation study of the calcium ion entry blocking drug nicardipine was performed using large dose infusions in 67 patients with recent aneurysmal subarachnoid hemorrhage (SAH). A safe, potentially therapeutic dose of the drug was determined. Patients admitted within 7 days of SAH from a documented cerebral aneurysm were entered into the study if no spasm was present on the initial angiogram. Nicardipine was administered as a continuous intravenous infusion throughout the 14-day period after SAH, regardless of the timing of surgery. To determine the safest possible dose, nicardipine was administered at seven dose levels from 0.01 to 0.15 mg/kg/hr. The total daily doses ranged from 27.7 mg to 375.0 mg. A follow-up angiogram was carried out on all 67 patients 7 to 10 days after SAH. Computerized tomography and neurological examinations were used to determine the presence of cerebral infarction. No major adverse effects, unexpected reactions, or permanent sequelae could be attributed to nicardipine. A decline in blood pressure was noted following administration of the drug. This occurred more frequently among patients given the largest dose but did not produce clinical problems or require discontinuation of the drug. Favorable outcomes were noted in 52 patients (78%). Vasospasm was found by arteriography in 31 patients (46%). A dose-related trend was noted: only eight (24%) of 33 patients treated at the highest dose level (approximately 10 mg/hr) developed arteriographic evidence of vasospasm. Symptomatic vasospasm was diagnosed in only two (6%) of 33 patients treated with this dose. Of the 34 patients receiving the lower dose levels, angiographic spasm was observed in 68% and symptomatic vasospasm in 27%. No deaths due to vasospasm occurred. Nicardipine appears to prevent both vasospasm and cerebral ischemia after SAH. A multicenter randomized double-blind trial to test this hypothesis is planned.

Adult↗
PubMed1987

Global aphasia without hemiparesis.

Three patients acutely developed global aphasia, but did not manifest the typical accompanying right hemiparesis. Computed tomography and magnetic resonance imaging studies demonstrated that the patients had two discrete left hemisphere lesions, one in the anterior language cortices or language-related subcortical areas, and one in the posterior language cortices. Cerebral angiography showed that two patients had complete occlusion of the left internal carotid artery, and the third had an intraluminal "clot" in the supraclinoid portion of the left internal carotid, findings suggestive of an embolic etiology. Our cases indicate that global aphasia without hemiparesis predicts two discrete lesions and a particularly good recovery of speech and language.

Adult↗
PubMed1987

Nontraumatic intracerebral hemorrhage in young adults.

We reviewed our experience with 72 patients, aged 15 to 45 years, who were hospitalized for nontraumatic intracerebral hemorrhages (ICHs) between 1978 and 1985. Evaluation included arteriography in 61 patients. Computed tomography demonstrated 41 lobar, 11 putaminal, four thalamic, four pontine, four intraventricular, two caudate, two midbrain, two cerebellar, one globus pallidum, and one corpus callosum hemorrhage. Forty-three patients, with either progressive neurologic deterioration, arteriovenous malformations (AVMs), or saccular aneurysms underwent surgery. The overall in-hospital survival, including those patients treated medically, was 87.5%. A presumed cause for the ICH was found in 55 (76.4%) patients. The main causes were ruptured arteriovenous malformations (21), hypertension (11), ruptured saccular aneurysms (seven), and sympathomimetic drug abuse (five). Surgical explorations demonstrated a necrotizing angiitis in one patient and arteriovenous malformations in two patients who had negative arteriograms. Young patients with nontraumatic ICHs represent a heterogeneous group. A cause can be established in most patients. Arteriovenous malformations account for less than one third of the hemorrhages in young adults, and other causes should be sought.

Adolescent↗
PubMed1987

Management of radiation-induced accelerated carotid atherosclerosis.

Patients with long survival following cervical irradiation are at risk for accelerated carotid atherosclerosis. The neurologic presentation in these patients mimics naturally occurring atheromatous disease, but patients often present at younger ages and with less concurrent coronary or systemic vascular disease. Hypercholesterolemia also contributes to this accelerated arteriosclerosis. Angiographic findings in this disorder include disproportionate involvement of the distal common carotid artery and unusually long carotid lesions. Pathologic findings include destruction of the internal elastic lamina and replacement of the normal intima and media with fibrous tissue. This article describes two surgical patients with radiation-induced accelerated carotid atherosclerosis who typify the presentation and characteristics of this disease.

Adult↗
PubMed1987

Further observations on cerebral or retinal ischemia in patients with right-left intracardiac shunts.

Between October 1983 and November 1986, 20 patients suspected of having a paradoxical cerebral or retinal embolism were identified. Cerebral infarction was the most common presentation. Six patients had a patent foramen ovale demonstrated by cardiac catheterization or surgery. Three patients had a newly discovered atrial septal defect, and one had an atrial septal defect that had previously been treated surgically. Results of the cardiac physical examination, chest roentgenography, and electrocardiography were unremarkable in 12 patients. Eighteen patients had a right-to-left shunt demonstrated by contrast echocardiography. Nine of these patients underwent cardiac catheterization; seven had abnormal catheterization study results: four had a patent foramen ovale and three had an atrial septal defect. Sixteen patients received medical therapy only while four underwent surgery. All patients survived the initial insult. There were no deaths or ischemic recurrences on follow-up ranging from one month to three years. We believe that contrast echocardiography can provide important diagnostic information, even in situations in which cardiac involvement is not suspected. Additional studies are needed before the optimal treatment of presumptive paradoxical cerebral embolism can be determined.

Adult↗
PubMed1987

Diagnosis of stroke in young adults.

The cause of stroke in a young adult can usually be ascertained with proper workup. One of the most common causes is atherosclerotic cerebrovascular disease, and cigarette smoking is an important risk factor in young adults. Several types of nonatherosclerotic cerebral vasculopathy can also result in premature cerebral infarction; these include cervicocephalic arterial dissection, nonpenetrating traumatic arterial disease, moyamoya disease, fibromuscular dysplasia, vasculitis, and migraine. Cardiac embolism may play a more important role than was previously thought, and hematologic disorders (eg, sickle cell disease, polycythemia rubra vera, coagulation problems) are known to predispose patients to stroke. A careful history of risk factors and a thorough neurologic and cardiovascular examination followed by adequate testing, including angiography, are essential to diagnosis.

Adult↗
PubMed1987

Nonbacterial thrombotic endocarditis and nondisseminated malignancy associated with osteopetrosis.

Nonbacterial thrombotic endocarditis (NBTE) is a presentation of an occult malignancy. The clinical, laboratory and postmortem findings of a 44-year-old man with osteopetrosis and NBTE are reported. A small apical bronchogenic carcinoma was found on postmortem examination. A thorough search for malignancy should be made in patients with unexplained cerebral emboli, especially if hematologic abnormalities are present. There is presently no evidence that anticoagulation or other treatment is beneficial.

Adult↗
PubMed1987

Spontaneous subarachnoid hemorrhage in young adults.

We evaluated 95 hospitalized patients (50 women and 45 men) aged 15 to 45 who had nontraumatic subarachnoid hemorrhage (SAH). Aneurysmal SAH was identified in 75 patients. Other causes for SAH were ruptured arteriovenous malformations (2 cases), amphetamine arteritis (1 case), and leptomeningeal melanoma (1 case). The cause of SAH was undetermined in 16 (17%) patients. Thirteen patients had histories of hypertension, 5 used oral contraceptives, and 4 had consumed large quantities of alcohol during the day before SAH. Only 1 patient had Type I diabetes mellitus. Diagnosis was delayed in 21 patients. Operation was performed in 71 patients, with only 3 (4.2%) deaths. The overall mortality was 8.4% (8 of 95), with all deaths due to neurological causes. Our data suggest that the overall management and surgical results of treatment of ruptured aneurysms in young adults are excellent, diabetes is rare among young adults with SAH, recent alcohol consumption does not seem to be a major factor predisposing to SAH in young adults, and misinterpretation of the early symptoms of SAH continues to be a serious problem.

Adolescent↗
PubMed1987

Diagnosis and treatment of spontaneous intracerebral hemorrhage.

Although ICH continues to decline as a cause of stroke, ICH must be considered in every patient with acute onset of focal cerebral dysfunction even if headache is absent. A variety of diseases leads to the occurrence of ICH, with hypertension continuing to head the list. The prognosis for recovery depends on the cause of the hemorrhage, the site and size of the lesion, and the patient's neurologic status. Each case must be treated individually. Both medical and surgical therapies are important in the management of these difficult problems. As more information is obtained on the natural history of ICH, treatment strategies will continue to evolve.

Brain↗
PubMed1986

Nonhemorrhagic cerebral infarction in young adults.

We evaluated 144 patients (81 males and 63 females) aged 15 to 45 years who had nonhemorrhagic cerebral infarction. Atherosclerotic cerebral infarction was diagnosed in 38 patients. Potential cardiac causes of cerebral embolism were found in 33 patients. Only three events could be attributed to mitral valve prolapse. Hematologically related disorders were diagnosed in 21 patients, while 38 patients had nonatherosclerotic vasculopathies. Young patients with cerebral infarction are a heterogeneous group. A potential cause can be found in most patients. We found more than 40 possible etiologies among our patients. Mitral valve prolapse apparently is not a common cause of cerebral infarction among young adults. Cerebral infarction should not be ascribed to oral contraceptives or migraine until other possible causes have been eliminated.

Adolescent↗
PubMed1986

Cervicocephalic arterial dissections. A ten-year experience.

Between April 1976 and April 1986, cervicocephalic arterial dissections were diagnosed in 19 of 4531 patients undergoing cerebral arteriography for acute cerebrovascular symptoms. Most dissections were extracranial. Spontaneous cases were as frequent as those following known trauma. Cerebral infarction was the most common presentation. Thirteen patients received only medical therapy, and six had surgery. Most patients survived the initial insult. Many questions remain to be answered regarding the optimal management of this condition, but treatment should be individualized based on clinical status, computed tomography, and angiographic findings.

Adult↗
PubMed1986

Cerebellar infarction: comparison of computed tomography and magnetic resonance imaging.

We correlated clinical, computed tomographic (CT), and magnetic resonance imaging (MRI) findings in 14 patients with cerebellar infarctions. Before MRI, the diagnosis of cerebellar infarction was made in only 7 patients on the basis of clinical and CT evidence. Cerebellar infarction was bilateral in 3 patients and was associated with brainstem infarction in 6. Infarction occurred in the territory of the posterior inferior cerebellar artery (PICA) in 12 patients. The territory of the superior cerebellar artery (SCA) was involved in 1 patient, and 1 infarction encompassed the watershed between the PICA and the SCA. In patients with infarction of the PICA territory, the medial and intermediate hemispheric segments were most frequently involved. Involvement of the lateral hemispheric segment was infrequent and was independent of brainstem involvement. Because of its fine demonstration of anatomical detail, its lack of bony artifact, and its ability to visualize infarctions readily within the first 24 hours, MRI is an excellent method for demonstrating cerebellar infarction.

Adult↗
PubMed1986

Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review.

Between March 1980 and March 1985, intraluminal thrombi of the carotid artery were noted in 9 of 2250 patients undergoing arteriography for symptoms of cerebral ischemia. Five patients had transient ischemic attacks, and four had acute cerebral infarctions. Six patients had surgery, but a thrombus was only found in five. Two patients had new neurological deficits after surgery. Three patients received only medical therapy, and all remained stable. Intraluminal thrombus is an uncommon radiographic finding in patients with cerebral ischemia. Not all clots are confirmed at operation. The optimal treatment of this situation is not known. Both surgical and medical treatments deserve further investigation.

Adult↗
PubMed1986

Interhemispheric subdural hematoma.

A case of interhemispheric subdural hematoma (ISH) following closed head injury is reported. Our patient had seizures and mental status changes. Cranial computed tomography (CT) demonstrated areas of increased density along the right side of the falx cerebri and over the right leaf of the tentorium cerebelli. Conservative treatment was chosen and the patient recovered. Ten other patients with ISH were compared with ours. Head injury is the leading cause of ISH. Most patients display confusion, lethargy, or a "falx syndrome," with a delayed interval of prominent neurological deficits from the time of injury until presentation. Although patients with ISH can be successfully treated by medical management, surgical intervention may be required.

Aged↗
PubMed1986

Lumbar puncture. Technique, indications, and complications.

Lumbar puncture is a safe and simple procedure that can be performed with little risk of major complication if proper technique and indications are followed. As an emergency diagnostic procedure, spinal puncture is indicated when CNS infection is suspected or to establish the diagnosis of subarachnoid hemorrhage when results of cranial computed tomography are normal. The major contraindication is elevated intracranial pressure with evidence of a mass lesion.

Adult↗