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Acetazolamide treatment of progressive hydrocephalus secondary to intraventricular hemorrhage in a preterm infant.

Progressive hydrocephalus in the preterm infant requires judicious management. Fortunately, in some infants, short-term treatment may obviate the need for shunting procedures. This case illustrates the successful control of progressive hydrocephalus in a preterm infant managed by acetazolamide, a carbonic anhydrase inhibitor. The drug was discontinued transiently early in the course of treatment. This patient's clinical course, change in head circumference, and cerebral ultrasound provide evidence of the benefit of this drug regimen in treating hydrocephalus.

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Acetazolamide inhibition of basolateral Cl-/HCO3- exchange in rabbit renal proximal tubule S3 segment.

Cell pH (pH(i)) and cell membrane potential (Vb) were measured in isolated S3 segments of rabbit renal proximal tubule with double-barrelled microelectrodes to search for a possible effect of the carbonic anhydrase inhibitor, acetazolamide (ACZ), on Cl-/HCO3- exchange in the basolateral cell membrane. ACZ was found to retard and reduce the pH(i) response to bath Cl- removal reversibly with half-maximal inhibition at 0.42 mmol/l and a rather flat concentration dependence (Hill coefficient approximately 0.36). To determine whether the retardation resulted from inhibition of cytoplasmic carbonic anhydrase, which might have delayed the attainment of HCO3-/CO2 equilibrium, we have measured the response of pH(i) to step changes in PCO2 in the presence and absence of ACZ. ACZ greatly retarded the pH(i) response to CO2 steps; however, the concentration dependence differed (half-maximal inhibition at 18 mumol/l) and even at maximal ACZ concentrations the response to CO2 steps was more than twice as fast as the response to Cl- replacement. Since, in addition, the ACZ inhibition of Cl-/HCO3- exchange could not be overcome by increasing PCO2 we conclude that the ACZ effect on Cl-/HCO3- exchange in rabbit proximal tubule S3 segments does not result from inhibition of cytosolic or membrane-bound carbonic anhydrase, but from a direct interaction with the exchanger molecule.

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Acetazolamide inhibition of basolateral base exit in rabbit renal proximal tubule S2 segment.

The influence of the carbonic anhydrase inhibitor acetazolamide (ACZ) was investigated on HCO3- transport mechanisms in the basolateral cell membrane of rabbit renal proximal tubule. Experiments were performed on isolated S2 segments using double-barrelled microelectrodes to measure cell membrane potential (Vb) and cell pH (pH(i)) during step changes in bath perfusate ion concentrations. Peritubular application of ACZ (1 mmol/l) reduced the initial Vb response to 10:1 reduction of bath HCO3- concentration only slightly, from +53.8 +/- 4.2 mV to +49.1 +/- 0.3 mV (n = 5), but caused an intermittent overshooting repolarization in the secondary Vb response. In conjunction with these effects it left the initial pH(i)) response virtually unchanged but induced a secondary slow acidification. These observation indicate that--under the present experimental conditions--ACZ does not block the Na(+)-HCO3- cotransporter but acts via inhibition of cytosolic carbonic anhydrase. This was confirmed by studying the effect of elevated intracellular HCO3- concentrations under reduced flux conditions and by comparing the concentration dependence of the Vb response with the inhibition kinetics of cytosolic carbonic anhydrase. In contrast, peritubular ACZ inhibited Na(+)-independent Cl-/HCO3- exchange in the basolateral cell membrane of S2 segments directly in a similar way to that described in the preceding publication for S3 segments.

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Effects of the diuretics mannitol or acetazolamide on nephrotoxicity and physiological disposition of cisplatin in rats.

The anticancer drug cisplatin has been known to produce severe renal lesions characterized by high levels of blood urea nitrogen (BUN), toxic nephrosis, and platinum (Pt) retention in the kidney. The effect of IV pretreatment with acetazolamide (ACZ) 30 min before or mannitol (MAN) immediately prior to IP administration of 5 mg/kg cisplatin on Pt excretion, tissue distribution, and nephrotoxicity was investigated in male F344 rats. ACZ pretreatment reduced the cisplatin-induced nephrotoxicity, as indicated by only a slight elevation of BUN, a milder histopathologic lesion, and a more rapid recovery of renal function and structure. Although MAN-pretreated animals exhibited similar changes in BUN to ACZ-pretreated animals, the renal damage was similar to that seen in animals treated with cisplatin alone. A reduction of kidney Pt content was observed with both diuretics, although there was significantly less retention after ACZ pretreatment. The diuretic ACZ was more effective than MAN in reducing the renal lesions induced by cisplatin and it might be clinically useful in preventing cisplatin nephrotoxicity.

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The effect of EC-IC bypass surgery on resting cerebral blood flow and cerebrovascular reserve capacity studied with stable XE-CT and acetazolamide test.

Cerebral blood flow (CBF) and cerebrovascular reserve capacity (CRC) were measured by stable xenon computerized tomography (Xe-CT) and acetazolamide test in 15 patients with cerebrovascular disease before and after extracranial-intracranial (EC-IC) bypass surgery for minor stroke, reversible ischemic neurological deficit or transient ischemic attack. All had angiographically shown occlusive lesions of the major arterial trunk. In the present series, global analysis showed that the bypass did not increase the resting rCBF, but did increase the rCRC. We divided the patients into four groups according to the preoperative resting rCBF and rCRC. All 3 patients with normal resting rCBF and reduced rCRC showed postoperative improvement of rCRC. Of 6 patients with reduced CBF and reduced CRC, three had postoperative increase in resting CBF and four had increased CRC. One of two patients with reduced CBF and normal CRC showed only an increase in CRC. We propose that reduced CRC or reduced CBF with reduced CRC are criteria for selection of candidates for bypass surgery. We conclude that Xe-CT with the Diamox test is a useful and simple method for evaluating cerebral hemodynamics. Preoperative grouping with a combination of preoperative resting rCBF and preoperative rCRC is useful for predicting the effect of EC-IC bypass surgery.

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A study of acetazolamide-induced changes in cerebral blood flow using 99mTc HMPAO SPECT in patients with cerebrovascular disease.

For semiquantification of SPECT studies we tried to calculate cerebral 99mTc-HMPAO uptake related to injected dose and estimated brain volume. The method was applied to SPECT investigations of 27 patients who had at least one ischaemic attack and a confirmed 80-100% stenosis of the corresponding internal carotid artery (ICA). Vascular reactivity was tested by parenteral administration of acetazolamide (AZ). Increase in HMPAO uptake after AZ was evident in both hemispheres, although the increase (AZ effect) was significantly lower in the affected hemisphere (+24% versus +28%). No interhemispheric uptake differences were seen in patients with largely normal SPECT studies, although local asymmetries in HMPAO deposition were visible. Patients with low density lesions on CT and with a well-demarcated lesion in the same location on SPECT revealed interhemispheric uptake differences, with lower uptake on the affected side. This was not due solely to alterations in the lesion, but also to reduced HMPAO uptake and AZ effect in the surrounding area. The AZ effect showed no correlation with angiographic findings, indicating no major haemodynamic influence of the ICA stenosis on cerebral hemisphere perfusion. Calculated cerebral HMPAO uptake changes after AZ administration were in good accordance with absolute cerebral blood flow measurements, and made interindividual comparisons possible. However, as changes in the area around an infarct or local reduction in vascular reserve may not be reproduced adequately by uptake calculations, visual inspection is still necessary.

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Long-term treatment of retinitis pigmentosa with acetazolamide. A pilot study.

The therapeutic effect of long-term treatment with acetazolamide (from 3 weeks to 16 months) of seven patients with retinitis pigmentosa was studied. Improvement in visual acuity was found in almost all the eyes, accompanied by an improvement in the macular threshold in two patients. The therapeutic effect was independent of reduction of macular edema, as judged by fluorescein angiography.

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Acetazolamide inhibits the recovery from triethyl tin intoxication: putative role of carbonic anhydrase in dehydration of central myelin.

The vacuolar degeneration of central myelin was produced in Sprague-Dawley rats by oral administration of triethyl tin. The wet weight of brain stems which seems to reflect the degree of accumulation of water increased during the administration of the toxin, whereas the activity of 2', 3'-cyclic nucleotide 3'-phosphodiesterase altered less remarkably. When TET was withdrawn from the drinking water, the rats showed a dramatic clinical improvement along with reduction in wet weight of brain stems. Treatment with acetazolamide following TET inhibited the clinical improvement and reduction in wet weight of brain stems. The present results indicates that central myelin has plasticity in recovering from the vacuolar degeneration by removing the accumulated fluid and carbonic anhydrase is possibly involved in the dehydration of myelin in such a recovery phase.

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Prediction of cerebral infarction due to vasospasm following aneurysmal subarachnoid haemorrhage using acetazolamide-activated 123I-IMP SPECT.

Prediction of cerebral infarction due to vasospasm (VS) following aneurysmal subarachnoid haemorrhage (SAH) was investigated using acetazolamide-activated (A-A) N-isopropyl-p-[123I]iodoamphetamine (123I-IMP) single photon emission computed tomography (SPECT) in 79 SAH patients. A-A SPECT was undertaken twice or more for one each patient by Day 18. Fifty-six (71%) of the 79 patients presented with reduction of cerebral vasodilatory capacity (CVC) on SPECT due to VS by Day 18. Of the 56 patients, 29 showed CVC by Day 8 (Group A), while the other 27 first showed CVC reduction between Day 9 and 18 (Group B). Cerebral infarction on CT was revealed by Day 18 in 15 patients (52%) of Group A and 3 (11%) of Group B. Of the 56 patients, 20 showed reduced CVC in watershed[s] (Type 1), 12 in a sole territory of the intracranial major arterial trunk (Type 2), and 24 in several territories or in a sole territory with distant watershed[s] (Type 3). Cerebral infarction on CT by Day 18 was revealed in one patient (5%) in Type 1, 3 (25%) in Type 2, and 14 (58%) in Type 3. Twelve (71%) of 17 patients belonging to both Group A and Type 3 resulted in cerebral infarction. These results suggest that early and extensive CVC reduction are significant factors responsible for cerebral infarction due to VS following SAH. Cerebral infarction can be reasonably predicted using A-A SPECT in SAH patients.

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Acetazolamide-induced increase in blood flow to rabbit organs is confirmed using colored microspheres.

Inhibitors of carbonic anhydrase activity have been found to increase blood and organ PCO2 and to increase blood flow (BF) in individual organs. To determine whether carbonic anhydrase inhibition coordinately induces an increase in BF in several organs, we assayed the effect of the carbonic anhydrase inhibitor, acetazolamide (AZ), on BF in rabbit organs using the colored microsphere (CM) assay. Eight female white rabbits were anesthetized with ketamine and urethane, and administered three sequential doses of 4 mg/kg AZ. After each dose, the rabbits were injected with 9 x 10(5) CMs of different colors, and arterial blood was collected. We found that AZ had no effect on blood pressure, body temperature, hemoglobin concentration, or PaCO2. In contrast, 12 mg/kg AZ significantly increased PaO2 and significantly decreased base excess. When we measured organ BF, we observed, in response to 12 mg/kg AZ, an 82% increase in brain BF and a 55% increase in kidney BF, but no change in BF of the liver, stomach wall, or abdominal muscle. These findings suggest that the inhibition of carbonic anhydrase activity by AZ, which decreases the rate of CO2 conversion to HCO3-, causes the retention of CO2 in tissues and organs, and thus increases BF in specific organs. Administration of carbonic anhydrase inhibitors, such as AZ, may increase BF to the brain and kidney without reducing PaO2, thereby increasing the supply of oxygen in conditions involving hypoxia such as ischemia and shock.

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Acetazolamide assisted Tc-99m MAG3 renography to assess renal blood flow reserve.

OBJECTIVE: The present study examines whether or not baseline and acetazolamide (ACZ) Tc-99m MAG3 renography can assess renal blood flow reserve. METHODS: Renography proceeded for 50 min after sequential injections of 370 MBq Tc-99m MAG3 for baseline renography and 10 min after a 1,000 mg injection of ACZ for ACZ renography. Effective renal plasma flow of renal cortex (cERPF) in each kidney and the percentage change in cERPF of those parameters (deltaERPF) were obtained before and after the administration of ACZ in 10 subjects without hypertension or diabetes (normal group), in 10 with essential hypertension (hypertensive group) and in 10 who had Type 2 diabetes with hypertension (diabetic group). A placebo test was performed in the 10 without hypertension or diabetes using distilled water instead of ACZ (placebo group). RESULTS: The placebo test performed in the 10 without hypertension or diabetes using distilled water instead of ACZ indicated that the parameter variance between the two types of renogram was below 3.2%. The cERPF of baseline and ACZ Tc-99m MAG3 renography and deltaERPF in the normal, hypertensive and diabetic groups were 89 +/- 10 and 110 +/- 10 ml/min, 89 +/- 14 and 117 +/- 22 ml/min, 100 +/- 23 and 112 +/- 23 ml/min, respectively, and 24.5 +/- 13.5%, 26.0 +/- 9.7% and 12.3 +/- 11.1%, respectively. The difference in the cERPF value was significant in the normal and hypertensive groups whereas this did not change in the diabetic group before or after ACZ administration. CONCLUSIONS: We suggested that the deltaERPF determined by baseline and ACZ Tc-99m MAG3 renography is a useful parameter for assessing renal blood flow reserve.

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Acetazolamide induced myocardial ischemia in patients with severe coronary artery disease.

UNLABELLED: Acetazolamide (ACZ)-augmented brain SPECT is commonly used for evaluating cerebral vascular reserve in patients with cerebrovascular disease. ACZ may cause myocardial ischemia in patients with coronary artery disease. To evaluate the risk of induction of myocardial ischemia with ACZ-augmented myocardial SPECT, we performed combined ACZ-augmented Tl-201 myocardial SPECT (ACZ-myo SPECT) with Tc-99m HMPAO brain SPECT in patients with severe coronary artery disease. METHODS: Nine patients underwent combined ACZ-myo SPECT with Tc-99m HMPAO brain SPECT. (1) For qualitative analysis, SPECT images were divided into 13 segments to calculate the total defect scores. (2) Six ROIs were placed on the slices in the myocardial SPECT short-axis images and the regional uptake ratio was obtained as the ratio of the mean counts in the myocardium to the maximal count in the slice. The total defect score and regional uptake ratio of ACZ-myo SPECT were compared with those of early and delayed dipyridamole Tl-201 myocardial SPECT (DP-Tl SPECT) images. RESULTS: (1) In the 21 coronary artery territories with coronary stenosis > or = 75%, the total defect score in ACZ-myo SPECT, early and delayed DP-Tl SPECT images were 3.52 +/- 4.14*, 4.19 +/- 4.65* and 2.25 +/- 3.34, respectively (*: p < 0.05 vs. delayed DP-Tl SPECT images). (2) In 44 of 54 ROIs with coronary stenosis > or = 75%, the regional uptake ratio of ACZ-myo SPECT, early and delayed DP-Tl SPECT images were 0.670 +/- 0.166**, 0.677 +/- 0.194**, 0.721 +/- 0.178, respectively (**: p < 0.01 vs. delayed DP-Tl SPECT images). Systolic blood pressure fell at 11 min after ACZ infusion without electrocardiographic ST-T changes or chest pain. CONCLUSION: As ACZ has the potential to cause myocardial ischemia, ACZ-augmented brain SPECT should be performed with caution in patients with severe coronary artery disease associated with cerebrovascular disease.

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Acetazolamide for prevention of contrast-induced nephropathy: a new use for an old drug.

Reactive oxygen species play a major role in the pathogenesis of contrast-induced nephropathy (CN). Hydration with sodium bicarbonate (HCO3-) can reduce the incidence of CN in high-risk patients, suggesting a direct causal relationship between low pH of tubular fluid and enhanced activity of generated reactive oxygen species to damage renal tubular cells. Whether acetazolamide (AZ), a carbonic anhydrase inhibitor, is more effective than HCO3- unknown. Ninety-six children with stable chronic renal insufficiency were randomly assigned to receive either a 154 mEq/L infusion of sodium bicarbonate (HCO3-) (n = 46) or 0.9% sodium chloride plus oral AZ (n = 50) at a rate of 3 ml/kg/hr for 1 hour before and 1 ml/kg/hr for 6 hours after the radiographic procedure. Serum creatinine concentration (Scr) was measured before and 48 hours after the procedure. The primary endpoint was an increase in the Scr concentration of > or = 25% 48 hours after the contrast administration. The baseline clinical and biochemical characteristics of the two groups were similar. The mean Scr concentration after contrast administration was significantly lower in the AZ group (p = 0.02) than in the HCO3- group (p = 0.27). The mean absolute decrease in Scr concentration at 48 hours was significantly greater in the AZ group (p < 0.01). Four of the 46 patients (8.7%) in the HCO3- group had an increase in the Scr concentration of > or = 25% compared with none of the 50 patients (0%) in the AZ group (p = 0.049). Thus, compared to HCO3-, AZ plus saline hydration was more effective for the prevention CN after radiographic procedure.

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Use of technetium-99m hexamethylpropylene amine oxime SPET for the study of cerebral blood flow reactivity after acetazolamide infusion in patients with Behçet's disease.

The purpose of this study was to characterise the nature of the baseline perfusion defects found in patients with Behçet's disease using hexamethylpropylene amine oxime single-photon emission tomography in conjunction with acetazolamide test (Acz SPET). Eleven patients underwent both baseline and Acz SPET. Regions of interest (ROIs) were drawn on the areas with decreased perfusion (D-ROI) and, in the same section, on areas with normal perfusion (N-ROI). The ROIs were then repositioned on the corresponding section on Acz SPET. The mean ROI counts were then transformed into a perfusion index value (PIV) with reference to the global brain counts. In total we found 24 D-ROIs (17 in the cortical and 7 in subcortical grey matter). The influence of Acz infusion was selectively registered in the D-ROIs, where PIVs changed from 1.23+/-0.17 (baseline SPET) to 1.63+/-0.23 (Acz SPET) (P<0.001). No significant difference was seen in the N-ROIs (1.46+/-0.21 and 1.40+/-0.17, respectively, on baseline SPET and Acz SPET). Our results demonstrate that Acz infusion increases the regional cerebral blood flow within baseline grey matter perfusion defects. This finding suggests that baseline perfusion abnormalities could reflect a disconnection rather than local vasculitic involvement.

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Acetazolamide and corticosteroid therapy in complicated arachnoid cyst.

CASE REPORT: We report on the successful conservative treatment of a child harbouring a right-temporal arachnoid cyst associated with bilateral hygroma. TREATMENT: Medical treatment was by corticosteroids for several days and acetazolamide (15 mg/kg/die) for 10 months. OUTCOME: Clinical symptoms and signs disappeared completely with partial resolution of the bilateral hygroma at MRI follow-up.

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The effect of acetazolamide on passive and active transport of fluorescein across the blood-retina barrier in retinitis pigmentosa complicated by macular oedema.

BACKGROUND: The carbonic anhydrase inhibitor acetazolamide (AZM) reduces macular oedema in some patients with retinitis pigmentosa. To better understand the oedema-reducing effect of AZM, the effect of AZM on passive permeability and active transport of fluorescein across the blood-retina barrier was studied in patients with retinitis pigmentosa and varying degrees of macular oedema. METHOD: The selection of patients was based on an introductory examination including vitreous fluorometry for qualitative assessment of the vitreous. Macular oedema was graded by fluorescein angiographic leakage. The effect of AZM on the transport properties of the blood-retina barrier was determined by differential spectrofluorometry, in a randomised, double-masked, cross-over study, comprising 2 weeks' treatment with AZM (500 mg/day) and 2 weeks' treatment with placebo. The penetration ratio, defined as the ratio between vitreous concentration 3 mm in front of the retina and the plasma integral, was determined for fluorescein and its metabolite fluorescein glucuronide at 30-60 min and at 120 min after fluorescein injection. Passive permeability and unidirectional permeability in the direction vitreous to blood, due to outward active transport of fluorescein, were determined in those cases where the curves for vitreous concentration of fluorescein could be fitted to a mathematical model. Visual acuity was tested by use of ETDRS standard logarithmic charts. RESULTS: Twenty-two patients volunteered to participate in the study. Signs of significant vitreous detachment/liquefaction caused the exclusion of ten patients after the introductory examination. Nine patients with approximately intact vitreous and varying degrees of oedema completed the cross-over study. AZM treatment was related to a decrease in the penetration ratio of 21% for fluorescein (P=0.01) and of 22% for fluorescein glucuronide (P=0.004). Passive permeability and unidirectional permeability were determined in seven patients. AZM caused a decrease of 27% in the passive permeability of fluorescein (from 1.1 x 10(1) nm/s, P=0.031), and a 95% increase in unidirectional permeability of fluorescein (from 1.2 x 10(2) nm/s, P=0.047). AZM led to a reduction in the grade of macular oedema as determined by fluorescein angiography in three out of seven patients. Only small improvements (< or =5 letters) in visual acuity were noted. CONCLUSION: The present study indicates that the oedema-reducing effect of AZM is due to decreased leakage and stimulated active transport across the blood-retina barrier.

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Partial recovery of in vivo function by improved incubation conditions of isolated renal proximal tubule. II. Change of Na-HCO3 cotransport stoichiometry and of response to acetazolamide.

In the preceding publication we reported that some transport properties of proximal tubules perfused in vitro differ from those of tubules perfused in vivo, and that the in vivo function can be largely recuperated by improved metabolic substrate supply and stimulation with norepinephrine (NE). Since we have previously observed that the basolateral Na-HCO3-cotransporter operates with an overall stoichiometric ratio of q approximately 3 HCO3- :1 Na+ in vivo, but with q approximately 2 HCO3- :1 Na+ in vitro and that it responds differently in both cases to acetazolamide (ACZ), we have now tested whether the cotransporter can regain its in vivo function in vitro if the incubation conditions are improved. Cell membrane potentials (Vb) and cell pH (pHi) were measured with microelectrodes and microfluorimetric techniques on isolated S2 segments of rabbit proximal tubule and the instantaneous Vb response to a 2:1 reduction of bath HCO3- or Na+ concentration was determined. (DeltaVb)HCO3 and (deltaVb)Na averaged 13.1 +/- 0.9 mV (SEM) and 6.9 +/- 0.5 mV in D-glucose-containing control HCO3-Ringer solution and decreased respectively to 10.1 +/- 0.5 mV and 3.8 +/- 0.2 mV (n = 8) after incubation in tissue culture medium and NE (10(-5) mmol/l). These data imply that q increased from 1.9 to 2.7. Concomitantly the tubules became susceptible to ACZ (1 mmol/l), which reduced (deltaVb)HCO3 in control conditions only to 94.6 +/- 1.2% but under improved incubation conditions to 64.5 +/- 2.4%. As verified in voltage divider measurements the latter reduction was not caused by activation of a basolateral K+ conductance. The results indicate that improved incubation conditions can at least partially revert cotransport function towards that of the in vivo state. The effect of ACZ may be explained if in the improved state 1 CO32- + 1 HCO3- + 1 Na+ are cotransported, in which case inhibition of carbonic anhydrase (CA) may cause a CO32-/pH disequilibrium to develop in the basal labyrinth which impedes the cotransport. Under conventional incubation conditions, however, when only 2 HCO3- + 1 Na+ are cotransported no such disequilibrium should develop irrespective of whether CA is active or inhibited.

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Therapeutic effectiveness of acetazolamide in hindbrain hernia headache.

A 43-year-old man had been suffering from exertional headache for 10 years. Sagittal sections on magnetic resonance imaging showed a Chiari type 1 malformation and a cerebellar arachnoid cyst. This syndrome, named hindbrain hernia headache, disappeared with oral acetazolamide. This treatment should be tried in patients with hindbrain hernia headache prior to considering surgical decompression of the foramen magnum.

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