[Neurologic emergencies in the physician's office].
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Adult↗
Biomedical subjects
L Regli
Publications and source records attributed to L Regli.
Brain biopsy in patients with acquired immunodeficiency syndrome: diagnostic value, clinical performance, and survival time.
BACKGROUND: Despite extensive discussion in recent years, brain biopsy in patients positive for human immunodeficiency virus who manifest cerebral mass lesions remains an ill-defined step in management. METHODS: Prebiopsy data of 26 human immunodeficiency virus-positive patients with cerebral mass lesions who underwent computed tomography-guided stereotactic brain biopsy (SBB) were reviewed by a specialist in infectious diseases and by a neuroradiologist to establish a clinical diagnosis and a treatment plan for each patient. The postbiopsy diagnosis was compared with the prebiopsy diagnosis. Long-term patient outcome after SBB was recorded by means of a clinical performance scale to estimate its impact on life expectancy and clinical performance. RESULTS: The SBB was diagnostic in 25 patients (96%). Potentially treatable disease was diagnosed in 21 patients (81%), and specific therapy was initiated in 17 patients (65%); 10 patients (39%) were able to complete therapy. The SBB corroborated the clinical diagnosis in 13 (52%) of 25 patients. The group with identical clinical and biopsy-proved diagnoses showed significantly better response to therapy (P = .02), clinical performance (P = .04), and survival after biopsy (P = .01), as compared with the group with different clinical and biopsy-proved diagnosis, although no significant difference was found for the degree of immunosuppression. Only completion of the treatment plan increased life expectancy significantly (P = .008). CONCLUSIONS: These data show that in human immunodeficiency virus-positive patients with brain mass lesions, SBB has a high diagnostic yield. A subgroup of patients will benefit from specific therapy guided by the SBB result. The procedure should, however, be strictly limited to patients able to tolerate specific therapy.
Acquired Immunodeficiency Syndrome↗
Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: a consecutive series.
OBJECT: The goal of this study was to delineate the angioanatomical features that determine whether a patient with an unruptured middle cerebral artery (MCA) aneurysm is treated using endovascular coil placement or surgical clipping. METHODS: Thirty consecutive patients harboring 34 unruptured MCA aneurysms were evaluated. Patients with unruptured aneurysms are managed prospectively according to the following protocol: the primary treatment recommendation is endovascular packing with Guglielmi detachable coils (GDCs). Surgical clipping is recommended after failed attempts at coil placement or in the presence of angioanatomical features that contraindicate that type of endovascular therapy. Of 34 unruptured MCA aneurysms, two (6%) were successfully embolized and 32 (94%) were clipped. Of these 32 surgically treated aneurysms, in 11 (34%) an attempt at GDC embolization had failed, whereas in 21 (66%) primary clipping was performed because of unfavorable angioanatomy. Of the 13 aneurysms treated endovascularly, two (15%) were successfully excluded, whereas GDC treatment failed in 11 (85%). An unfavorable dome/neck ratio (< 2) and an arterial branch originating at the aneurysm base were the reasons for embolization failure. CONCLUSIONS: Careful evaluation of the angioanatomy of unruptured aneurysms allows selection of the most appropriate treatment. However, for unruptured MCA aneurysms, surgical clipping appears to be the most efficient treatment option. Series of unruptured aneurysms are ideal for comparing treatment results.
Adult↗
[Sentinel headache: a premonitory symptom too often unrecognized in intracranial ruptured aneurysm].
Headache is a common complaint in emergency departments, but only a small percentage of patients have a serious disease. Nevertheless, some forms of headache, such as "warning headaches", need special attention. By far the most common symptom associated with aneurysmal minor bleed (warning leak) is a sudden headache that is considered to be a warning symptom of impending aneurysmal rupture. In the presence of sudden severe headache with or without meningeal signs or nausea, subarachnoid hemorrhage should always be considered. Recognition of these warning headaches probably offers the best opportunity of reducing the otherwise serious mortality and morbidity of aneurysmal subarachnoid hemorrhage. This report describes 7 non-consecutive patients presenting warning headaches before major aneurysm rupture. Based on our experience and a review of the literature, we recommend a management algorithm for patients presenting with sudden severe headache.
Adult↗
Phantom face: conscious correlate of neural reorganization after removal of primary sensory neurones.
A patient in whom mandibular and maxillary parts of right trigeminal ganglion were removed experienced referred sensations after stimulation of the right hand and right forehead. She described them either as parallel to the perception at the actual stimulation site or as coming uniquely from a (non-existent) stimulation of denervated territory. The latter occurred in 6-19% of stimulations performed on the right forehead and on digits 1, 3 and 4 of the right hand. Thumb stimulations were localized on the right side of the face, stimulations of right forehead, middle and ring fingers more precisely on right cheek. Referred sensations were present on postoperative day 7 and had a more real-like quality than 5 days later.
Brain Mapping↗
Nitric oxide synthase inhibition by L-NAME prevents brain acidosis during focal cerebral ischemia in rabbits.
This experiment examined the effects of nitric oxide (NO) synthase inhibition on brain intracellular pH, regional cortical blood flow, and NADH fluorescence before and during 3 h of focal cerebral ischemia using in vivo fluorescence imaging. Thirty fasted rabbits under 1% halothane were divided into four treatment groups receiving N omega-nitro-L-arginine methyl ester (L-NAME) intravenously at 20 min prior to ischemia (0.1, 1, and 10 mg/kg and 1 mg/kg + 5 mg/kg L-arginine) and two control groups (nonischemic and ischemic). In ischemic controls, brain pH(i), declined to 6.73 +/- 0.03 at 30 min and remained acidotic through the remainder of the ischemic period. In the 0.1 mg/kg group, brain pH(i) fell after 30 min of ischemia to 6.76 +/- 0.05 (p < 0.05), but then improved progressively despite occlusion. In the 1 mg/kg group, brain pH(i), remained normal despite middle cerebral artery (MCA) occlusion. In the 10 mg/kg group and in the combined L-NAME + L-arginine group, pH(i) fell after 30 min of ischemia to 6.81 +/- 0.03 (p < 0.05) and remained acidotic. During occlusion, regional cortical blood flow dropped in a dose-dependent manner. After 3 h of ischemia, regional cortical blood flow was 33.9 +/- 10.9 and 25.1 +/- 8.9 ml/100 g/min at doses of 0.1 and 10.0 mg/kg, respectively, L-NAME treatment did not significantly alter the increased NADH fluorescence that accompanied occlusion. This study shows that L-NAME can prevent intracellular brain acidosis during focal cerebral ischemia independent from regional cortical blood flow changes. This experiment suggests that NO is involved in pH(i) regulation during focal cerebral ischemia.
Acidosis↗
Effects of intermittent reperfusion on brain pHi, rCBF, and NADH during rabbit focal cerebral ischemia.
BACKGROUND AND PURPOSE: The use of intermittent reperfusion versus straight occlusion during neurovascular procedures is controversial. This experiment studied the effects of intermittent reperfusion and single occlusion on intracellular brain pH (pHi), regional cerebral or cortical blood flow, and nicotinamide adenine dinucleotide (NADH) fluorescence during temporary focal ischemia. METHODS: Twenty fasted rabbits under 1.0% halothane anesthesia were divided into four groups: (1) nonischemic controls, (2) 60 minutes of uninterrupted focal ischemia, (3) 2 x 30-minute periods of focal ischemia separated by a 5-minute reperfusion, and (4) 4 x 15-minute periods of focal ischemia separated by three 5-minute reperfusion periods. Focal ischemia was produced by occlusion of both the middle cerebral and ipsilateral anterior cerebral arteries. After the final occlusion, there was a 3-hour reperfusion period in all groups. Regional cerebral and cortical blood flow, brain pHi, and NADH fluorescence were measured with in vivo panoramic fluorescence imaging. RESULTS: During occlusion, regional cerebral and cortical blood flows and NADH fluorescence values were not different among the groups. Brain pHi was significantly lower in the 4 x 15-minute group compared with the 1 x 60-minute group (6.57 +/- 0.02 versus 6.73 +/- 0.06; P < .03) but not significant when compared with the 2 x 30-minute group. During the short reperfusion periods, all parameters returned to normal except for NADH fluorescence levels, which remained elevated. During the postischemic final reperfusion period, there was a mild brain alkalosis of approximately 7.1 in all groups. There were no significant differences in NADH fluorescence among groups during the final reperfusion. Regional cerebral and cortical blood flow returned to near normal values in all groups. CONCLUSIONS: This study demonstrates that intermittent reperfusion during temporary focal ischemia has different effects on the intracytoplasmic and the intramitochondrial compartments: worsening of brain cytoplasmic pHi but no significant differences in the oxidation/reduction level of mitochondrial NADH.
Animals↗
Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation.
To evaluate the late results and the natural history of long saphenous vein bypass grafts (SVGs) between the extracranial and intracranial circulation, the authors retrospectively analyzed 202 consecutive SVGs performed at the Mayo Clinic from 1979 to 1992. The distal anastomosis was to the vertebrobasilar system in 98 patients and to the carotid artery system in 103 patients. Surgical indications were advanced cerebroocclusive disease in 63% (127 cases), giant aneurysm in 37% (74 cases), and neoplasm in one patient. In 125 patent SVGs follow-up information was obtained for longer than 1 year and in 23 patent SVGs it was over 10 years (maximum 13 years, median 6.5 years). Most of the graft failures (76%) occurred during the 1st year after surgery, with 42% of all graft failures found during the first 24 hours after operation. Late graft attrition occurred in only 10 patients (8%). Cumulative patency at 1 year was 86% +/- 3%, at 5 years 82% +/- 4%, and at 13 years 73% +/- 19%. Neurological worsening at the time of occlusion developed in 72% of patients with early occlusion, whereas 80% of patients with late graft occlusion had no new neurological symptoms. Long-term patency of SVGs for cerebral revascularization appears to be excellent, with an average failure rate of 1% to 1.5% per year following the 1st year after surgery. To minimize early graft thrombosis, meticulous attention must be paid to technical detail.
Adolescent↗
Considerations in the prophylactic treatment of transient ischemic attack or ischemic stroke in the carotid artery territory.
This non-randomized study surveys the prophylactic treatment of 154 patients after transient ischemic attack or ischemic stroke in the carotid artery territory. Clinical presentation and etiologies were compared on the basis of the proposed prophylactic treatment. A surgical intervention or a long-lasting anticoagulation was restricted to only 30 patients (20%) due especially to the gravity of the ischemic cerebral lesions, general deterioration, and the advanced age of most of the patients. The purpose is to emphasize the "down-to-earth" situation in current medical care of non-selected patients as distinguished from the strictly selected patients of randomized studies. More importance should be done to open studies which better reflect the daily medical reality.
Adult↗
Basic fibroblast growth factor increases cortical blood flow in vivo.
Basic FGF has recently been shown to produce systemic and cerebral vasodilation. To test the hypothesis that bFGF increases regional cortical blood flow (rCBF), rCBF and brain pHi were measured while bFGF or vehicle was superperfused onto the cortex of rabbits. The results of this study demonstrate that topical application of bFGF causes an increase in rCBF.
Animals↗
Reconstruction of previously ligated external carotid arteries for cranial base arteriovenous malformation embolization: technical note.
Ligation of the external carotid artery has been used in the past as a treatment for cranial base and facial arteriovenous malformations. By current selective embolization techniques, this prior ligation of the external carotid artery may hinder optimal treatment. Reported here are the indications and surgical techniques used for reconstructing previously ligated external carotid arteries in preparation for endovascular treatment. Direct reconstruction or an interposition graft was useful, depending on the patient's anatomy. There were no complications in this series, despite the presumed increase in blood flow to the arteriovenous malformation after reconstruction. After reconstruction, early embolization is feasible and may be necessary to prevent the engorgement of the arteriovenous malformation.
Adult↗
Magnetic resonance imaging with gadolinium contrast agent in small deep (lacunar) cerebral infarcts.
OBJECTIVE: To assess gadolinium-diethylenetriamine-pentaacetic acid (Gd-DTPA) contrast-enhanced magnetic resonance (MR) imaging as an index of recent symptomatic small deep cerebral infarcts (SDCIs). DESIGN: Prospective case series. SETTINGS: Primary-care center. PATIENTS: Thirty-one consecutive patients presenting with the clinical diagnosis of SDCI in the territory of the perforators of the internal carotid artery or the vertebrobasilar system and confirmed by MR imaging. INTERVENTION: Rapid intravenous infusion of Gd-DTPA 5 to 10 minutes prior to acquisition of T1-weighted images. MAIN OUTCOME MEASURES: Precise clinicotopographic correlation on MR scans. RESULTS: Non-contrast-enhanced MR imaging allowed precise clinicotopographic correlation in five (38%) of 13 patients with SDCI symptoms in the internal carotid artery territory. After Gd-DTPA administration, precise clinicotopographic correlation improved in 11 (85%) of 13 patients. In five patients, precise correlation was possible only after Gd-DTPA enhancement. Nonenhanced MR imaging allowed precise clinicotopographic correlation in 15 (83%) of 18 patients with SDCI symptoms in the vertebrobasilar territory. After Gd-DTPA administration, we could establish precise clinicotopographic correlation in all patients with SDCIs in the vertebrobasilar territory. In three patients, precise correlation was possible only after Gd-DTPA contrast enhancement. In seven (23%) of 31 patients, Gd-DTPA failed to enhance symptomatic lesion: in five patients MR scans were performed early (less than 7 days) and in two patients later in the course (greater than 7 days). CONCLUSIONS: Although Gd-DTPA administration is unlikely to improve the sensitivity of MR images in visualizing SDCIs, it significantly improves the rate of precise clinicoanatomic correlation. All enhancing lesions showed precise clinicotopographic correlation. Enhancement may be absent in the acute phase (less than 7 days).
Aged↗
[Carbon dioxide laser and stereotaxic craniotomy].
This article describes the development and contemporary clinical applications for a computer interactive volumetric stereotactic system in CT and/or MRI-based resection of superficial and deep seated intracranial lesions. The carbon dioxide laser was found to be particularly useful in the resection of deep seated lesions by this volumetric stereotactic method for three reasons: 1) the CO2 laser is a convenient tool for removing tissue from the depths of a deep cavity, 2) it is relatively hemostatic, and 3) the precision provided by the CO2 laser renders it safer than other methods for dissecting tumors from important brain tissue, e.g. the internal capsule. The specific clinical methods of the technique: data acquisition, computer based surgical planning, and interactive stereotactic open surgery are discussed. The clinical experience in 500 consecutive cases in the resection of various lesions from specific anatomical areas is presented. Total overall morbidity was 7% and mortality 1%. We have found the technique of most benefit in the resection of histologically circumscribed intra-axial lesions.
Adolescent↗
Tuberothalamic infarct after division of a hypoplastic posterior communicating artery for clipping of a basilar tip aneurysm: case report.
The authors present a case of a tuberothalamic infarct subsequent to division of the posterior communicating artery for clipping of a high-lying aneurysm of the basilar bifurcation using the pterional approach. In view of this clinical observation and some particular aspects of the microsurgical anatomy of the perforating vessels of the posterior communicating artery, we conclude that interrupting this parent vessel carries a significant risk of infarction.
Aged↗
[Focal cerebral necrosis caused by intraventricular chemotherapy with methotrexate].
A 60 year old white woman progressively developed radicular pain and weakness in both legs. A meningeal carcinomatosis was diagnosed, and an intrathecal chemotherapy with methotrexate (M.T.X.) was begun. A catheter was placed in the frontal horn of the right lateral ventricle. One month later, the patient progressively developed inattentiveness and confusion. The examination showed an abulic-hypokinetic syndrome, and a left hemiparesis. A C.T. scan showed a hypodensity in the frontal-lobe white matter on the right, with contrast enhancement surrounding the region of the catheter. Results of cytologic, bacterial and fungal studies of cerebrospinal fluid were negative. The catheter was removed. The patient was treated with prednisone and she improved. This complication is very rare, and is noticed in only 0.6% of patients who had intraventricular M.T.X. therapy. The cause of this syndrome is a displacement of the catheter into parenchyma. This syndrome is distinct from the other complications (meningoencephalitis, leukoencephalopathy, myelopathy).
Brain↗
Chiasmal apoplexy: haemorrhage from a cavernous malformation in the optic chiasm.
We present a patient who experienced sudden onset of orbital headache, visual loss and bitemporal visual field defect. MRI of the optic chiasm suggested a diagnosis of haemorrhage and hence a vascular malformation. Pterional craniotomy revealed an intrachiasmatic haematoma with a cavernous angioma. The malformation was totally excised and vision improved after surgery. The syndrome of chiasmal apoplexy is discussed.
Adult↗