Transcranial Motor-Evoked Potentials Are More Readily Acquired Than Somatosensory-Evoked Potentials in Children Younger Than 6 Years.

BACKGROUND: There is a general belief that somatosensory-evoked potentials (SSEPs) are more easily obtained than transcranial motor-evoked potentials (TcMEPs) in children younger than 6 years. We tested this assumption and the assumption that motor-evoked potentials are rarely obtained in children younger than 2 years. METHODS: The records of all patients who were monitored during surgical procedures between April 1, 2010, and June 30, 2013, were reviewed and those who were younger than 72 months at the time of surgery were identified and analyzed for the rate of obtaining clinically useful SSEPs and motor-evoked potentials. Subgroup analysis was performed by age. RESULTS: A total of 146 patients were identified, 9 had SSEPs without TcMEPs monitored, 117 had both TcMEPs and SSEPs monitored, and the remainder had only electromyographic monitoring. All patients who were to have TcMEPs recorded received a total IV anesthetic. Among the 117 patients who had both SSEPs and TcMEPs monitored, clinically relevant TcMEPs were obtained more frequently than SSEPs (110/117 vs 89/117; χ = 14.82; P = 0.00012). There were significant differences between the rates of obtaining SSEPs and TcMEPs in the 0- to 23-month (P = 0.0038) and 24- to 47-month (P = 0.0056) age groups. Utilization of a double-train stimulation technique facilitated obtaining TcMEPs in the youngest patients. CONCLUSIONS: TcMEPs can be obtained more easily than SSEPs in patients younger than 72 months if a permissive anesthetic technique is used. The success rate for obtaining TcMEPs can be further enhanced by the use of a temporal facilitation (double-train) stimulation technique.

Lactate flux during carotid endarterectomy under general anesthesia: correlation with various point-of-care monitors.

PURPOSE: The ability to assess the brain-at-risk during carotid endarterectomy (CEA) under general anesthesia remains a major clinical problem. Point-of-care monitoring can potentially dictate changes to management intraoperatively. In this observational study, we examined the correlation between a series of point-of-care monitors and lactate flux during CEA. METHODS: Both neurosurgeons and vascular surgeons participated in the study. The patients underwent arterial-jugular venous blood sampling for oxygen, carbon dioxide, glucose, and lactate, n = 26; bispectral index (BIS) monitoring ipsilateral to side of surgery, n = 26; raw and processed electroencephalogram (EEG), n = 22; and bi-frontal cerebral oximetry using the Fore-Sight monitor, n = 20. RESULTS: One patient experienced a new neurological deficit when assessed at 24 hr following surgery. Lactate flux into the brain was correlated with the greatest decrease in cerebral oximetry with carotid cross-clamping; lactate efflux was correlated with the least. The most noticeable changes in processed EEG (density spectral analysis) were also seen with lactate influx, but at a slower time resolution than cerebral oximetry. Loss of autoregulatory behaviour was demonstrated with lactate influx; however, no correlation was seen between lactate flux and BIS monitoring. CONCLUSION: There was a correlation between cerebral oximetry and lactate flux during carotid cross-clamping. The Fore-Sight monitor may be of value as a point-of-care monitor during CEA under general anesthesia. A novel finding of this study is lactate flux into the brain in the presence of a large difference in cerebral oxygenation during cross-clamping of the carotid artery. Registered at clinicaltrials.gov: NCT000737334.

Does thrombin play a role in the pathogenesis of brain damage after periventricular hemorrhage?

Neonatal periventricular hemorrhage (PVH) is a devastating complication of prematurity in the human infant. Based upon observations made primarily in adult rodents and the fact that the immature brain uses proteolytic systems for cell migration and growth, we hypothesized that thrombin and plasmin enzyme activities contribute to the brain damage after PVH. The viability of mixed brain cells derived from newborn rat periventricular region was suppressed by whole blood and thrombin, but not plasmin. Following injection of autologous blood into the periventricular region of newborn rat brain, proteolytic activity was detected in a halo around the hematoma using membrane overlays impregnated with thrombin and plasmin fluorogenic substrates. Two-day old rats received periventricular injection of blood, thrombin, and plasminogen. After 2 days, thrombin and blood were associated with significantly greater damage than saline or plasminogen. Two-day old mice received intracerebral injections of blood in combination with saline or the proteolytic inhibitors hirudin, alpha2macroglobulin, or plasminogen activator inhibitor-1. After 2 days, hirudin significantly reduced brain cell death and inflammation. Two-day-old mice then received low and high doses of hirudin mixed with blood after which behavioral testing was conducted repeatedly. At 10 weeks there was no statistically significant evidence for behavioral or structural brain protection. These results indicate that thrombin likely plays a role in neonatal periventricular brain damage following PVH. However, additional factors are likely important in the recovery from this result.

Body oxygen stores, aerobic dive limits and diving behaviour of the star-nosed mole (Condylura cristata) and comparisons with non-aquatic talpids.

The dive performance, oxygen storage capacity and partitioning of body oxygen reserves of one of the world's smallest mammalian divers, the star-nosed mole Condylura cristata, were investigated. On the basis of 722 voluntary dives recorded from 18 captive star-nosed moles, the mean dive duration (9.2+/-0.2 s; mean +/- S.E.M.) and maximum recorded dive time (47 s) of this insectivore were comparable with those of several substantially larger semi-aquatic endotherms. Total body O(2) stores of adult star-nosed moles (34.0 ml kg(-1)) were 16.4 % higher than for similarly sized, strictly fossorial coast moles Scapanus orarius (29.2 ml kg(-1)), with the greatest differences observed in lung and muscle O(2) storage capacity. The mean lung volume of C. cristata (8.09 ml 100 g(-1)) was 1.81 times the predicted allometric value and exceeded that of coast moles by 65.4 % (P=0.0001). The overall mean myoglobin (Mb) concentration of skeletal muscles of adult star-nosed moles (13.57+/-0.40 mg g(-1) wet tissue, N=7) was 19.5 % higher than for coast moles (11.36+/-0.34 mg g(-1) wet tissue, N=10; P=0.0008) and 54.2 % higher than for American shrew-moles Neurotrichus gibbsii (8.8 mg g(-1) wet tissue; N=2). The mean skeletal muscle Mb content of adult star-nosed moles was 91.1 % higher than for juveniles of this species (P<0.0001). On the basis of an average diving metabolic rate of 5.38+/-0.35 ml O(2) g(-1) h(-1) (N=11), the calculated aerobic dive limit (ADL) of star-nosed moles was 22.8 s for adults and 20.7 s for juveniles. Only 2.9 % of voluntary dives by adult and juvenile star-nosed moles exceeded their respective calculated ADLs, suggesting that star-nosed moles rarely exploit anaerobic metabolism while diving, a conclusion supported by the low buffering capacity of their skeletal muscles. We suggest that a high mass-specific O(2) storage capacity and relatively low metabolic cost of submergence are key contributors to the impressive dive performance of these diminutive insectivores.