Stroke patients, what to do and what to avoid.

In Italy (130,000 new strokes in the general population per year) ischemic stroke is the third cause of death, after cardiovascular disease and neoplastic disease with a prevalence of 6.5%. Different physicians are involved in the emergent evaluation and treatment of the acute ischemic stroke. As other acute events, the initial evaluation must be addressed to assess the patient's airway and breath-ing and cardiocirculatory conditions. The neurological examination must not be exhaustive and it should be completed in 5-10 minutes and a particular attention should be given to clinical findings leading to the suspect of an intracranial hemorrhages. A plain CT scan of the brain is the most important initial diagnostic study. Emergency therapy must be mainly directed to the correction of hypovolemia, hypoxia and the treatment of severe hypertension, hypoglycemia, intracranial hypertension and seizures. The goal is to achieve and to maintain an adequate cerebral perfusion by lowering the intracranial pressure (treating the cerebral oedema) and by increasing the mean arterial pressure, with an appropriate volemic expansion and/or with inotropic or vasopressor drugs. The thrombolytic therapy with intravenous recombinant tessutal plasminogen activator (r-TPA) when not specifically contraindicated, is recommended within 3 hours of onset of ischemic stroke. The benefit of intravenous r-TPA for acute ischemic stroke beyond 3 hours from the onset has never been proved.

Regional variation in brain capillary density and vascular response to ischemia.

Differences in brain neuroarchitecture have been extensively studied and recent results demonstrated that regional differences in the physiological properties of glial cells are equally common. Relatively little is known on the topographic differences in vascular supply, distribution and density of brain capillaries in different CNS regions. We developed a simple method consisting of intravascular injection of fluorescent dyes coupled to immunocytochemical techniques that allows for simultaneous observation of glia-neuronal-vascular interactions in immersion-fixed brain specimens from small rodents. This technique permits quantitative evaluation of regional differences in glial/neuronal distribution and the study of their relationship to vascular densities. Variations of this technique also allow the detection of abnormal microvasculature (i.e. 'leaky' vessels), a useful feature for studies of blood-brain barrier function in health and disease. By use of quantitative confocal microscopy, the three-dimensional geometry of cortical and hippocampal structures revealed remarkable differences in vascularization between cortical gray/white matter junction, and hippocampal formation (CA1 and CA3 regions). Significant differences were also observed within the same investigative region: CA1 was characterized by low capillary density compared to neighboring CA3. Following an ischemic insult, CA1 vessels had more extensive blood-brain barrier leakage than CA3 vessels. We conclude that in addition to neuronal and glial heterogeneity, cortical structures are also endowed with region-specific vascular patterns characterized by distinct pathophysiological responses.

Do peritoneal catheters remove pro-inflammatory cytokines after cardiopulmonary bypass in neonates?

BACKGROUND: Cardiopulmonary bypass (CPB) in neonates induces a cytokine-mediated capillary leak syndrome that can cause organ dysfunction. Removing harmful cytokines after CPB may attenuate this response. This study measured the concentrations of serum and peritoneal fluid (PF) cytokines after CPB to determine if harmful cytokines can be removed with peritoneal catheters. METHODS: Neonates (n = 18) had cardiac surgery using CPB with circulatory arrest. Peritoneal catheters were placed at the end of surgery to drain excess fluid. Serum samples were obtained before and after CPB, and PF after CPB. Cytokines were measured by enzyme-linked immunosorbent assay. RESULTS: Tumor necrosis factor-alpha and interleukin-1beta (IL-1beta) were not detected in any serum or PF sample. Serum concentrations of IL-6, IL-8, and IL-10 increased significantly after CPB. PF concentrations of IL-6 and IL-8 exceeded serum concentrations, whereas IL-10 concentrations were higher in the serum. There was a significant negative correlation between serum and PF concentrations of IL-6 after CPB (r = -0.63; p<0.05). CONCLUSIONS: PF has very high concentrations of the proinflammatory cytokines, IL-6 and IL-8, after CPB but not the antiinflammatory cytokine IL-10. The PF may be a depot for the harmful inflammatory cytokines after CPB, and removing the PF could lower serum concentrations.

Patent ductus arteriosus. Follow-up of 677 operated cases 40 years later.

BACKGROUND: This review is about the patency of ductus arteriosus (PDA), with particular care concerning diagnosis, surgical techniques, survival and postoperative pregnancy in operated females. METHODS: a) Sperimental study: the research has been conducted retrospectively and the follow-up is 40 years. b) ENVIRONMENT: all the patients were operated on in the Division of Cardiac Surgery, University of Turin (public structure) and in the Italian Institution of Cardiac Surgery (private structure). c) PATIENTS: from 1958 to 1987, 677 patients were operated on: mean age was 11.5 +/- 8.7 years. A complete follow-up was made on 487 patients (72%). d) Technique of operation: left lateral thoracotomy was often performed; in younger children, however, the tying of PDA was frequently made within the pericardium by left anterior thoracotomy in the third intercostal space. In uncomplicated situations, PDA was tied more frequently than divided, by two purse string stitches and one or two transfixed ligatures. e) SURVEY: overall early and late mortality, the clinical conditions of all patients, pregnancies and preor postoperative miscarriages of operated women were examined. RESULTS: From 1958 to 1967 overall early mortality was 5%; during the following years, there was no hospital mortality. The recurrence of PDA occurred only in 4 patients. 72% of the operated females became pregnant. CONCLUSION: Life expectancy is normal after surgical closure of an uncomplicated PDA in infancy or in childhood but premature death may not always be avoided operating on adults with long-standing chronic congestive heart failure. At least, postoperative pregnancy is not a risk factor for the mother and PDA seems not to be correlated to foetal transmission.

Rapid two-stage repair of S,L,L, ventricular septal defect, pulmonary atresia, Ebstein anomaly of the tricuspid valve, and stenotic pulmonary arteries.

The repair of a corrected transposition of the great arteries, ventricular septal defect, and pulmonary atresia is presented. An Ebstein anomaly of the tricuspid valve, dextrocardia, and severe distortion of the pulmonary arteries complicated the surgical procedure, which was performed in two stages. Reconstruction of the pulmonary arteries and a bidirectional cavopulmonary anastomosis were performed first; Rastelli and hemi-Mustard procedures completed the correction. The rationale and the possible indications of this "one and a half ventricle" repair are discussed.

The seagull wing self retaining prosthesis in the surgical treatment of pectus excavatum.

BACKGROUND: Between June 1958 and June 1996 we operated many patients affected by pectus excavatum with an original surgical technique. In this study we evaluated the durability of the results. EXPERIMENTAL DESIGN: Retrospective study with a mean follow-up time of 15.8 years/pt, and 60% complete. SETTING: private and institutional practice. PATIENTS OR PARTICIPANTS: 357 patients (253 males and 104 females, mean age = 18.2+/-5.1 years) affected by pectus excavatum. The grade of PE (Chin classification) was I in 76 patients, II in 165 and III in the remaining 116. Most of the patients required operation for aesthetic reasons only (339 patients; 95%). INTERVENTION: the surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using an original stainless steel strut prosthesis moulded into a seagull wing. The strut was removed 12 months postimplantation. RESULTS: There were no operative deaths. Four patients (1.2%) had sternal wound infection, which was successfully treated. From the aesthetic point of view, the postoperative results were excellent in 262 patients (73.4%), good in 82 (22.9%) and poor in 13 (3.6%). All subjective symptoms, when present, disappeared after surgery. CONCLUSIONS: The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.

Atrial septal defect and pregnancy: a retrospective analysis of obstetrical outcome before and after surgical correction.

STUDY OBJECTIVES: To describe the obstetrical outcome and long-term cardiac follow-up of a group of patients who had surgery for atrial septal defect repair before pregnancy and a group who underwent pregnancy before surgical correction. DESIGN: Retrospective. SETTING: Public Institution. PATIENTS: Eighty women (mean age 20.15 +/- 4.5 years) complaining of atrial septal defect, 60 of which had surgical correction before pregnancy and subsequently had 115 pregnancies, and 20 of which underwent pregnancy before the correction of cardiac defect and subsequently had 48 pregnancies. INTERVENTIONS: Surgical correction of atrial septal defect: 49 by open heart technique (13 with cardiopulmonary bypass, 36 with light hypothermic circulatory arrest), 11 by closed heart techniques. RESULTS: Patients who underwent pregnancy before surgery had an increased incidence of miscarriage, pre-term delivery and cardiac symptoms during pregnancy. Patients operated before pregnancy required more frequently cesarean section and pharmacological therapy. The frequency of stillbirths, malformations in the offspring and long-term cardiac complications were similar in both groups. CONCLUSIONS: Surgical correction of atrial septal defect before pregnancy is recommended even in case of apparently well compensated hemodinamic situation for the low rate of surgical complications in spite of the higher incidence of obstetrical problems in case of medical therapy alone.