The use of ultrasound in intracranial tumor surgery.

BACKGROUND: As an intraoperative imaging modality, ultrasound is a user-friendly and cost-effective real-time imaging technique. Despite this, it is still not routinely employed for brain tumor surgery. This may be due to the poor image quality in inexperienced hands, and the well-documented learning curve. However, with regular use, the operator issues are addressed, and intraoperative ultrasound can provide valuable real-time information. The aim of this review is to provide an understanding for neurosurgeons of the development and use of ultrasound in intracranial tumor surgery, and possible future advances. METHODS: A systematic search of the electronic databases Embase, Medline OvidSP, PubMed, Cochrane, and Google Scholar regarding the use of ultrasound in intracranial tumor surgery was undertaken. RESULTS AND DISCUSSION: Intraoperative ultrasound has been shown to be able to accurately account for brain shift and has potential for regular use in brain tumor surgery. Further developments in probe size, resolution, and image reconstruction techniques will ensure that intraoperative ultrasound is more accessible and attractive to the neuro-oncological surgeon. CONCLUSIONS: This review has summarized the development of ultrasound and its uses with particular reference to brain tumor surgery, detailing the ongoing challenges in this area.

Injuries to the spinal accessory nerve: a lesson to surgeons.

The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its anatomical course and function, and documented the results of repair. From examination of our records, 111 patients with lesions of the spinal accessory nerve were treated between 1984 and 2007. In 89 patients (80.2%) the damage was iatropathic. Recognition and referral were seldom made by the surgeon responsible for the injury, leading to a marked delay in instituting treatment. Most referrals were made for painful loss of shoulder function. The clinical diagnosis is straightforward. There is a characteristic downward and lateral displacement of the scapula, with narrowing of the inferior scapulohumeral angle and loss of function, with pain commonly present. In all, 80 nerves were explored and 65 were repaired. The course of the spinal accessory nerve in relation to the sternocleidomastoid muscle was constant, with branches from the cervical plexus rarely conveying motor fibres. Damage to the nerve was predominantly posterior to this muscle. Despite the delay, the results of repair were surprising, with early relief of pain, implying a neuropathic source, which preceded generally good recovery of muscle function.

The lateral approach to intraspinal reimplantation of the brachial plexus: a technical note.

Intraspinal re-implantation after traumatic avulsion of the brachial plexus is a relatively new technique. Three different approaches to the spinal cord have been described to date, namely the posterior scapular, anterolateral interscalenic multilevel oblique corpectomy and the pure lateral. We describe an anatomical study of the pure lateral approach, based on our clinical experience and studies on cadavers.

Intractable neurostenalgia of the ulnar nerve abolished by neurolysis 18 years after injury.

A 39 year-old farmer sustained a closed rupture of the left brachial artery, which was successfully managed by emergency vein graft repair of the artery. Adjacent nerve trunks were seen to be intact, but stretched. Burning pain in the distribution of the ulnar nerve started at day seven postoperatively, and worsened over the ensuing years. There was no response to membrane stabilising drugs, amitryptiline, nor to regional sympatholytic or local anaesthetic blocks. Neurolysis of the ulnar nerve, which was densely adherent to the dilated vein graft, abolished his pain.

A longitudinal study of cognition in primary progressive multiple sclerosis.

There are few longitudinal studies of cognition in patients with multiple sclerosis, and the results of these studies remain inconclusive. No serial neuropsychological data of an exclusively primary progressive series are available. Cross-sectional analyses have revealed significant correlations between cognition and magnetic resonance imaging (MRI) parameters in primary progressive multiple sclerosis (PPMS). This study investigated cognitive and MRI change in 99 PPMS patients from five European centres for 2 years. They were assessed at 12 month intervals using the Brief Repeatable Battery, a reasoning test, and a measure of depression. The MRI parameters of T1 hypointensity load, T2 lesion load, and partial brain volume were also calculated at each time point. There were no significant differences between the mean cognitive scores of the patients at year 0 and year 2. However, one-third of the patients demonstrated absolute cognitive decline on individual test scores. Results indicated that initial cognitive status on entry into the study was a good predictor of cognitive ability at 2 years. There was only a small number of significant correlations between changes in cognition and changes on MRI, notably T1 hypointensity load with the two attentional tasks (r = -0.266, P = 0.017; r = -0.303, P = 0.012). It is probable that multiple factors underlie this weak relation between the cognitive and MRI measures.

A new test of memory for multiple sclerosis I: format development and stimuli design.

Memory tests were often developed for healthy populations. The accuracy of these measures is reduced when administered to patients with neurological diseases, who may experience physical and/or cognitive symptoms. Also, methodological factors, for example, spanning the ability spectrum, and content/format artefacts, may contribute to a decline in test precision. The aim of this study was to develop a new test of memory, which addresses these issues. The new memory test comprises assessments of recall, paired association, and recognition, at a Task Familiarisation stage and two difficulty levels, for both the verbal and spatial modalities. It was administered to 85 healthy individuals and 100 patients with multiple sclerosis (MS). All patients were able to attempt each task of the new assessment and there was no influence of visual integrity or manual dexterity on memory test performance, supporting the applicability of the tasks to patients with multiple sclerosis. Both the standardisation and validation samples demonstrated a wide range of scores on each section of the new test suggesting that the measure spanned an acceptably broad range of abilities. It seems probable, therefore, that the new assessment offers a more exact measure of verbal and spatial recall, paired association, and recognition memory.

Cognitive function in primary progressive and transitional progressive multiple sclerosis: a controlled study with MRI correlates.

The relative rarity of primary progressive (PP) and transitional progressive (TP) multiple sclerosis has meant that little documentation of cognitive function in such patients is currently available. The aim of this study was to investigate the cognitive skills of patients with PP and TP multiple sclerosis relative to matched healthy controls, and to examine the relationship of this impairment to MRI parameters. Sixty-three patients (43 PP, 20 TP) were individually matched with healthy controls, who undertook the same cognitive tasks as the patient group. The neuropsychological assessment comprised Rao's brief repeatable battery, a reasoning test, and a measure of depression. Patients also underwent T1- and T2-weighted brain MRI. These patients were taken from a larger cohort (158 PP, 33 TP) in whom it had been demonstrated that the re were no significant differences between the mean scores of the PP and TP groups on any of the cognitive variables. The 63 patients were therefore taken as one group for comparison with the healthy controls. These patients performed significantly worse than the controls in tests of verbal memory, attention, verbal fluency and spatial reasoning. An impairment index was constructed and applied to the patient data. This correlated modestly with T2-lesion load (r = 0.45, P = 0.01), T1-hypointensity load (r = 0.45, P = 0.01) and cerebral volume (r = -0.35, P = 0.01). Thus, PP and TP multiple sclerosis patients demonstrate significant cognitive dysfunction when compared with matched healthy controls. The relationship between this impairment and MRI parameters is moderate, suggesting that cognitive dysfunction in PP and TP multiple sclerosis has a complex and multifactorial aetiology, which is not adequately explained by pathology as demonstrated on conventional MRI.

Kinetics and disposition of picumeterol in animals.

1. The pharmacokinetics and disposition of picumeterol, a novel beta 2 receptor agonist agent, have been studied in the rat and dog following administration by inhalation, intravenous and oral routes at various dose levels. 2. Picumeterol was found to be transferred across the lung of the rat and dog following inhalation dosage. After i.v. dosage picumeterol was eliminated from plasma with a half-life of about 1 h in the rat and about 2 h in the dog. Plasma clearance in the rat was about twice liver blood flow and the plasma levels of picumeterol were low after oral administration. 3. Following instillation of 14C-picumeterol to the trachea of isolated respiring rat lung preparations radioactivity was transferred from the airways to perfusion media as unchanged drug within 2 min. After 2 h perfusion, no metabolites were detected in the recirculation perfusate or lung. 4. Picumeterol was extensively metabolized in vivo in the rat (about 95%) and dog (about 90%) and in vitro in microsomal preparations of rat, dog and human liver. O-dealkylation and beta-oxidation are important as routes of metabolism. 5. Radioactivity was largely excreted in the urine of the rat and dog (> 50% of dose), as metabolites, following i.v. administration. There was some excretion of radioactivity in dog bile. Extensive first-pass metabolism was found after oral administration in the rat.

Salivary amylase in crevicular fluid.

Extrasulcular substances such as saliva, supragingival plaque and salivary sediment may be contaminants in gingival crevicular fluid (GCF) collected with Periopaper. This report provides data obtained with salivary amylase as a marker for these substances in GCF. Amylase was a common constituent of GCF collected from sites with clinical health and with clinical signs of periodontitis. Rinsing the mouth with water reduced, but did not eliminate amylase in GCF. More frequent (p < 0.01) and greater (p < 0.001) contamination of GCF with amylase occurred in samples from periodontitis than from healthy subjects. The volume of saliva required to give the amylase in the GCF was calculated. This volume exceeded the GCF volume in 21% of samples collected without a water rinse. Thus, oral constituents other than saliva likely contribute to GCF amylase. Small quantities of plaque and salivary sediment (9.6 +/- 5.9, 3.4 +/- 2.0 micrograms protein) provided amylase from a saliva volume equal to the GCF volume in health (0.23 microliters). The above and other data presented here show that extrasulcular substances likely are frequent constituents of GCF collected with Periopaper. Reporting GCF constituents as quantities/sample appears least subject to error from the contamination by extrasulcular substances.