EEG changes during open heart surgery on infants aged 6 months or less: relationship to early neurologic morbidity.

In a prospective study, we analyzed the intraoperative electroencephalographic (EEG) changes during open heart surgery with deep hypothermia in 66 infants aged 6 months or younger, 70% of whom were neonates. Suppression of amplitude and continuity at the nadir of temperature reduction and following rewarming, and the appearance of periodic paroxysmal activity, was compared with neurologic abnormalities before and following operation, patient characteristics, and operation variables. EEG changes disclosed no relationship to abnormal neurologic findings, age at operation, type of anesthetic, duration of cardiopulmonary bypass (CPB), duration of low-flow CPB or cooling, temperature at circulatory arrest (HCA) or low flow, or nasopharyngeal-venous return temperature differences. EEG suppression following rewarming was associated with the use of thiopentone and duration of HCA. Use of thiopentone was also related to decreased levels of alertness at the end of the first postoperative week. We could not demonstrate any association between operation variables, including duration of HCA, and postoperative neurologic findings which include abnormalities of tone, alertness, seizures, generalized pyramidal signs, choreoathetosis, and hemiparesis. Severe hypotonia before operation was associated with continuing severe hypotonia during the postoperative period. EEG changes during cooling for open heart surgery on infants appear to be physiologic, and these plus EEG suppression following HCA or low-flow CPB are not useful predictors of early neurologic morbidity.

Delayed postoperative nonembolic neurologic deficit after left internal carotid endarterectomy in presence of known contralateral carotid artery occlusion.

Neurologic sequelae are known complications of carotid endarterectomy. The current overall perioperative stroke rate is 2-5% (1,2). The incidence of perioperative morbidity and mortality is increased in certain patient subgroups, including neurologically unstable patients and patients who have known contralateral common or internal carotid artery occlusion (3-9). We present the case of a patient who had known total right carotid artery occlusion and a known previous right cerebrovascular accident who sustained a contralateral deficit after a left internal carotid thromboendarterectomy with vein patch angioplasty.

A case of barbiturate poisoning with a readily-accessible laboratory reagent.

We report a patient with barbiturate intoxication due to surreptitious ingestion of barbital buffer from a clinical laboratory. Although detected in the urine toxicology screening test using an immunologic technique, this agent was not recognized in the more specific serum analysis done by gas-liquid chromatography. Barbital buffer is an effective long-acting sedative-hypnotic and is widely available from the laboratory shelf. It may not be reported by very specific analytical methods.

Early detection and treatment of spinal epidural metastases: the role of myelography.

Spinal epidural metastases were detected in 75 of 140 cancer patients with back pain who were evaluated prospectively by clinical criteria, spine roentgenography, and bone scan. Fifty-five of the 75 patients with epidural metastases had no evidence of myelopathy when diagnosed. Of the patients diagnosed and treated while still ambulatory, more than 90% remained so. Myelograms were performed in 127 patients to diagnose the 75 with epidural disease. To try to reduce the number of myelograms needed, we attempted to design radiotherapy ports based on clinical symptoms and the plain spine films alone. A port could not be designed for 64 of the 127 patients, either because of diffuse vertebral metastases or a normal plain roentgenogram. A port could be designed for 63 patients, and all epidural disease would have been encompassed in 50 of the 54 patients who had spinal epidural metastases (93%). Most patients with cancer and back pain require myelography for accurate treatment planning. There are, however, situations in which treatment can be determined based on symptoms and plain films alone, with a low risk of missing epidural cancer.

Muscle pathology in Bassen-Kornzweig syndrome and vitamin E deficiency.

A constellation of histologic abnormalities was demonstrated in the quadriceps femoris muscle of a 29-year-old man with Bassen-Kornzweig syndrome. The abnormalities consisted of fibers containing dense lipid inclusions ceroid and lipofuscin, a spectrum of fiber size, architectural changes, and an increase in central nuclei. A dramatic shift of fiber type predominance, from type I to type II, was demonstrated in the myosin ATPase reactions one year after vitamin E therapy. Despite an apparent reduction in the number of fibers containing lipid and ceroid granules in the second biopsy, neuromyopathic changes worsened. The relationship of these findings to vitamin E therapy is discussed.

Glucose utilization is unchanged in red nucleus after axotomy.

Separate series of adult rats were subjected to unilateral high cervical and low thoracic section of the rubrospinal tract and sacrificed 1-30 (cervical series) and 3-100 days (thoracic series) later. Local cerebral glucose utilization ([14C]2-DG method of Sokoloff et al.) was determined in the red nucleus and in the inferior colliculus, nucleus interpositus and sensorimotor cortex of both sides in operates and controls. Although severe atrophy of rubral neurons follows cervical tractotomy while reversible chromatolytic alterations occur after thoracic lesions, glucose utilization did not differ in the red nucleus of operated and control rats. However, glucose utilization increased slightly in the inferior colliculus of all operated animals, a finding of indeterminate significance. The failure of axotomized intrinsic neurons of red nucleus and their surround to show altered glucose utilization stands in sharp contrast to the marked increase which occurs in cranial nerve nuclei after axotomy of their contained extrinsic neurons. The data are held to constitute another indication that there is a fundamental difference in the metabolic responses of extrinsic and intrinsic mammalian neurons to axotomy and may support the contention that, in mammals, the axon reaction of intrinsic neurons is fundamentally different from that of extrinsic nerve cells. This difference may have significance for failure of axon regeneration in mammalian CNS.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonpharmacologic treatment of chronic headache: prediction of outcome.

We studied the ability of headache history, a 4-week headache diary, standard psychological tests, and laboratory measures of psychophysiologic responses to stress to predict the outcome of relaxation therapy and biofeedback for three types of chronic headache. Using canonical discriminant function analyses, each potential predictor set was tested separately, and all four were tested together. Information from the headache history alone correctly classified 89 to 95% of patients as improved or unimproved. No other single predictor set was consistently better than headache history. When all four predictor sets were combined, prediction improved; 93 to 100% of patients were correctly classified.

Psychological functioning in headache sufferers.

The present study examined the psychological test responses of 99 headache sufferers and 30 matched nonheadache controls. Headache subjects were of four types: migraine (n = 26), muscle contraction (n = 39), combined migraine-muscle contract ion (n = 22), and cluster (n = 12). Measures consisted of the Minnesota Multiphasic Personality Inventory, a modified hostility scale derived from the MMPI, Back Depression Inventory, State-Trait Anxiety Inventory, Autonomic Perception Questionnaire, Rathus Assertiveness Schedule, Social Readjustment Rating Scale, Psychosomatic Symptom Checklist, Schalling-Sifneos Scale, Need for Achievement, and Hostile Press. Significant differences were found on five clinical scales of the MMPI--1, 2, 3, 6, and 7. Of the non-MMPI scales, only the Psychosomatic Symptom Checklist and Trait Anxiety Inventory were significant. Control subjects revealed no significant findings on any tests. The headache groups fell along a continuum, beginning with cluster subjects, who showed only minimal distress, continuing through migraine and combined migraine-muscle contraction, and ending with muscle contraction subjects, who revealed the greatest degree of psychological disturbance. However, none of the headache groups could be characterized by marked elevations on any of the psychological tests, which contrasts with past research findings. It is suggested that the present results may be more representative of the "typical" headache sufferer.

Cross-validation of the Kudrow-Sutkus MMPI classification system for diagnosing headache type.

In order to determine the generality of the Kudrow-Sutkus (1979) MMPI classification system for diagnosing headache type, a cross-validation analysis was performed on 99 headache subjects. Results indicated a high level of support for Kudrow-Sutkus' Group A (migraine and cluster) classification criteria (65.4% and 75.0% correct assignments for female and male subjects, respectively) but a low level of support for Kudrow-Sutkus' Group B (combined and chronic scalp muscle tension) classification criteria (5.9% and 25.2% correct assignments for female and male subjects, respectively). Possible reasons accounting for these differences are discussed.

Early diagnosis of spinal epidural metastases.

Early signs of spinal cord injury on neurologic examination have been the primary indication to proceed with myelography in patients with possible spinal epidural metastases. With this approach, loss of ambulation occurs in more than one half of the patients. In an attempt to diagnose epidural metastases before the onset of myelopathy, we designed a prospective study based on the development of back pain, a precursor of spinal cord injury in nearly all cancer patients. Eighty-seven patients were studied. A high incidence of epidural metastases was found in patients with myelopathy (78 percent). In addition, patients with radiculopathy alone frequently had epidural tumor (61 percent). In 36 percent of the patients who presented with back pain but who had normal neurologic findings, there was evidence of epidural metastases on myelography; all of those patients had vertebral metastases on plain roentgenogram. Over-all, the plain roentgenogram of the spine correctly predicted the presence or absence of epidural tumor in 83 percent of the patients. Whereas 93 percent of the patients with myelopathy had more than 75 percent myelographic block, this occurred in 53 percent of those with radiculopathy and in only 33 percent of those with back pain and normal neurologic findings. In most cancer patients, spinal epidural metastases are both detectable and significantly less extensive before the onset of spinal cord injury.