Heparin treatment of atrial thrombus in ventriculo-atrial shunts.

This short report details the management of two cases of atrial thrombus on ventriculoatrial shunts, treated non-surgically by simple anticoagulation. While this is extremely simple it appears not to have been reported before.

Occipital condyle fracture with peripheral neurological deficit.

A 24-year-old woman sustained a type III Anderson and Montesano fracture in a road traffic accident. Acute respiratory stridor, multiple cranial nerve palsies and right upper limb neurological deficits associated with a C1 to T2 extradural haematoma were unique features of this case. The patient made a full and uncomplicated recovery with conservative management.

Primary non-Hodgkin's lymphoma of the CNS treated with BVAM or CHOD/BVAM chemotherapy before radiotherapy.

PURPOSE: To assess whether chemotherapy that includes drugs that cross the blood-brain barrier improves survival in primary CNS non-Hodgkin's lymphoma (PCNSL) when combined with radiotherapy. PATIENTS AND METHODS: Thirty-four patients, with no evidence of human immunodeficiency virus type 1 (HIV-1) infection, were treated with the related chemotherapy regimens of carmustine (BCNU), vincristine, cytarabine, and methotrexate (BVAM; 12 patients), cyclophosphamide, doxorubicin, vincristine, and dexamethasone (CHOD)/BVAM (17 patients) and intensified CHOD/BVAM (five patients) between 1986 and 1994. The median age was 60 years (range, 16 to 73) and 47% had a performance status of 3 or 4 (Eastern Cooperative Oncology Group [ECOG]/World Health Organization [WHO]). Ten patients were treated with BVAM chemotherapy between 1986 and 1989, and subsequently 17 patients were treated with CHOD/BVAM (cytarabine 3 g/m2). Twenty of these 27 patients received whole-brain radiotherapy (craniospinal in four). RESULTS: The complete response (CR) rate at the completion of chemotherapy was 63% for BVAM and 67% for CHOD/BVAM; more neutropenia occurred with CHOD/BVAM. The 5-year actuarial probability of survival of all 34 patients was 33% (95% confidence interval [CI], 14% to 52%), with so far only one recurrence after 2 years. Using multivariate analysis, age (P = .0005) and number of tumors at diagnosis (P = .0358) were prognostic factors. All five patients aged > or = 70 years died during or shortly after chemotherapy. Performance status was not an independent variable. CONCLUSION: The BVAM or CHOD/BVAM regimens can be delivered despite neutropenia without significant treatment delay or dose reduction in patients less than 70 years of age. Further intensification of this type of chemotherapy is probably not possible with patients of this age, many of whom have a poor performance status.

Anterior spinal hernia: an increasingly recognised cause of thoracic cord dysfunction.

Two cases of anterior spinal hernia are presented. The medical literature is reviewed, the syndrome characterised, and its cause and treatment discussed. The patient is typically middle aged with a history of stepwise slowly progressive mid-thoracic anterior hemicord syndrome manifesting as hemianalgesia below the affected segment, followed by contralateral lower limb spasticity that develops into an asymmetric paraparesis with sparing of dorsal column sensation. Radiological investigation demonstrates an enlarged dorsal arachnoid space in association with an apparently focally narrowed thoracic cord, kinked towards the anterior dura. At operation the cord is found to be prolapsed into an anterolateral dural diverticulum. The most likely cause of this syndrome is anterior spinal artery segmental branch ischaemia, in a cord chronically incarcerated in a congenital anterior meningocele. This readily treatable condition should be considered in all cases of thoracic cord dysfunction and surgical repair effected early to prevent stepwise progression to paraplegia.

The effects of brace position on injuries sustained in the M1 Boeing 737/400 disaster, January 1989. NLDB Study Group.

Of the initial 87 survivors of the East Midlands Boeing 737/400 aircraft, 77 sustained head and facial trauma during the crash, 45 of whom were rendered unconscious. There were 21 who received injuries to the back of their head, including 5 of the 6 severely head-injured adults. Those passengers who adopted the fully flexed "brace" position for crash-landing achieved significant protection against head injury, concussion, and injuries from behind irrespective of local aircraft structural damage. A computer graphics simulation developed by a commercial firm (H. W. Structures, Ltd.) using the predicted crash pulse of the accident has validated these clinical findings and allows theoretical biomechanical modeling for the design of occupant protection systems in the future. Although the major role of structural failure should not be forgotten, bracing maximizes the chance of uninjured survival in the current generation of aircraft and should be demonstrated and practiced as a pre-flight routine.

The effects of structural failure on injuries sustained in the M1 Boeing 737 disaster, January 1989. NLDB Study Group.

Only 10 occupants escaped uninjured from the wreckage of the East Midlands Boeing 737/400 aircraft accident. The remaining 116 suffered injuries similar in pattern, but ranging in severity from simple bruising to fatal crushing trauma. Overall, the individual's degree of injury and likelihood of death was proportional to the local structural damage of the aircraft. Limb injuries were particularly severe in the forward section of the wreckage where the floor failed. In areas where structural damage appeared to be survivable, a number of passengers suffered disproportionately severe head injuries. Many of these had trauma to the posterior aspect of their head, some of whom died as a result. It is likely that these injuries were caused by falling overhead lockers or unrestrained cabin furniture. The significance of these injuries and their future prevention is discussed.

Direct and indirect stimulations of cyclic AMP formation in human brain.

1. Adenosine 3':5'-cyclic monophosphate (cyclic AMP) formation, by use of an [3H]-adenine prelabelling assay, was measured in fragments of human cerebral cortex, taken in the course of various neurosurgical procedures. 2. Large accumulations of [3H]-cyclic AMP due to isoprenaline, noradrenaline and adenosine and small effects due to forskolin were observed. Histamine, 5-hydroxytryptamine (5-HT) and the excitatory amino acids glutamate and quisqualate were ineffective. 3. The response to noradrenaline consisted of two components; a direct beta-adrenoceptor response and an enhancement mediated by an alpha-adrenoceptor which appears to be similar to that in rat cerebral cortex. 4. The response to isoprenaline was also potentiated by histamine H1 receptor stimulation but the direct effect of 2-chloroadenosine was not altered by histamine, 5-HT or quisqualate. 5. It is concluded that some, but not all, of the indirect modulations of cyclic AMP formation previously observed in experimental animal brain exist in human cerebral cortex.

Clinical experience with contrast enhanced echo-planar imaging of the brain.

The overall effects of intravenous Gd-DTPA on tissue signal in intracranial tumors are complex depending on dose, time of administration, pulse sequence, and tissue structure. Ultrahigh speed EPI permits the kinetics of tissue enhancement in intracranial tumors to be studied during the "wash-in" equilibrium and "wash-out" phases. Ongoing studies employing dynamic scanning have shown it to be a valuable adjunct to a morphological study of tumors, providing an assessment of vascularity which is important in planning resection; and demonstrating areas with maximal breakdown of the blood-brain barrier which are most suitable for stereotactic biopsy. There are grounds for anticipating that the analysis of the temporal profile of enhancement may allow discrimination between different tumor types and provide information on factors which relate to the malignant potential of a single type.

Dynamic imaging of contrast enhancement in brain tumors.

Gadolinium-DTPA has been shown to be a good probe for demonstrating defects in the blood-brain barrier, but it has a rapid rate of elimination so that peak circulating levels are short-lived. In this study ultrafast echo-planar imaging has been used in combination with a bolus injection of gadolinium-DTPA to evaluate perfusion within brain tumors and to assess the degree of disruption of the blood-brain barrier. The temporal profile of enhancement may allow discrimination between different tumor types.

Observation of cerebrospinal fluid flow with echo-planar magnetic resonance imaging.

Using echo-planar (EP) magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) flow patterns have been demonstrated in the normal subject and patients with pathological conditions including communicating hydrocephalus, aqueduct stenosis and syringohydromyelia. Snap-shot imaging times of 128 ms allow detailed demonstration of transient intraventricular CSF flow patterns, which is not possible with conventional MRI. The potential of EPI as a method for qualitative and quantitative assessment of CSF dynamics is illustrated.

Inositol phospholipid hydrolysis in human brain; adenosine inhibition of the response to histamine.

1. Inositol phospholipid hydrolysis was examined in human cerebral cortex slices by a [3H]-inositol prelabelling assay. 2. Enhancement of [3H]-inositol phosphates accumulation was observed in the presence of carbachol, noradrenaline, histamine, 5-hydroxytryptamine (5-HT) and depolarizing concentrations of KCl. 3. Despite having no effect alone, adenosine (and its analogue 2-chloroadenosine) selectively inhibited the direct response to histamine. 4. The inhibition due to adenosine was antagonized by theophylline, but not by 8-cyclopropyltheophylline.

A clinical survey of head injuries sustained in the M1 Boeing 737 disaster: recommendations to improve aircrash survival.

On 8 January 1989 at 20:25 h, a British Midland Boeing 737/400 on approach to East Midlands Airport crashed across the M1 motorway with the immediate loss of 39 lives from the 126 people on board. In the aftermath of the accident a clinical review was commenced to determine the mechanisms of injury in the 87 initial survivors and hopefully provide data to improve commercial aircraft safety in the future. Seventy-seven survivors sustained head and facial trauma in the crash, 45 of whom had periods of amnesia surrounding the event. Twenty-one received injuries from behind, including five of the six severely head-injured adults. Loss of consciousness and duration of amnesia were directly related to the degree of superficial head trauma. Adoption of the fully flexed brace position for crash-landing offered significant protection from head injury and concussion, and possibly reduced injuries from behind. Suggestions are made for potentially improving the survivability of aircraft accidents.

Brain abscess in the 1980s.

Brain abscess was reviewed in 24 patients admitted to University Hospital, Nottingham over a period of 3 years. Chronic ear infection was the most common predisposing factor, but in 11 patients the focus of infection remained unknown. CT scanning, carried out in all patients, was negative in one patient with clinical signs of meningitis. Polymicrobial and anaerobic infections were common. Actinomyces species were isolated in mixed culture from seven patients; in five the abscess was located in the cerebellum. Therapy was most often a combination of surgical drainage and antimicrobial therapy with beta-lactam agents and metronidazole. Evidence suggests that cefotaxime may offer a suitable alternative to chloramphenicol and benzylpenicillin in the treatment of brain abscess.

Rhodotorula rubra ventriculitis.

We describe a case of post-operative ventriculitis in an immunocompetent patient caused by an unusual organism, namely Rhodotorula rubra. The patient was treated successfully with antifungal agents.

Benign intracranial hypertension: visual loss and optic nerve sheath fenestration.

Five patients with serious ocular complications of benign intracranial hypertension are described. Optic nerve sheath fenestration resulted in resolution of papilloedema with, in three instances, improvement in vision. Benign intracranial hypertension may not always be benign for vision and fenestration operations may prevent or reverse visual deterioration by an effect on the optic nerve rather than by reducing intra-cranial pressure.

Return to flying after head injuries: a review.

The pathology of head injury is discussed in relation to severity and to the chance of recovery. Return to flying status, then, depends mainly on the hazard of subsequent post-traumatic epilepsy (PTEP). Assessment of the threat of PTEP is based on the incidence of onset of PTEP within 1 year (75%) and 2 years (85%) of head injury in those who will develop the complication. Clear risk markers which increase the chances of later PTEP include past history of febrile convulsions, family history of epilepsy, "early" PTEP, intracranial haematoma, and depressed skull fracture. The persisting risk in depressed skull fracture is itself adversely affected by early epilepsy, dural laceration, focal neurological signs, and post-traumatic amnesia longer than 24 h. Permanent prohibition on grounds of initial severity can rarely be warranted. A cautious open-minded assessment of each individual by AMEs with specialist referral where indicated is recommended.

Subcutaneous cerebrospinal fluid reservoirs in patients with acute leukaemia.

Subcutaneous cerebrospinal fluid (Ommaya) reservoirs were inserted in 23 patients wich acute leukaemia and 2 patients with malignant lymphoma. In 9 leukaemia patients reservoirs were used for the prophylaxis of central nervous system leukaemia: only 1 patient developed meningeal leukaemia but less invasive therapy has now been shown to achieve effective prophylaxis and prophylactic use of Ommaya reservoirs has been discontinued. In 16 patients, reservoirs were inserted as aids to the treatment of meningeal leukaemia or lymphoma. Intracranial disease was successfully controlled and recurrences were prevented but patients eventually died from relapse of their systemic disease. The principal complications of the subcutaneous reservoirs were obstruction, misplacement, and one case of infection. Leucoencephalopathy in several patients was attributable to irradiation and cytotoxic drugs and not to the reservoirs. Problems due to misplacement of the reservoir occurred in 3 out of 13 reservoirs inserted by the occipital route and in only 1 of 12 reservoirs inserted by a frontal approach. With adequate supervision, the reservoirs are valuable aids to intrathecal therapy in patients with established meningeal leukaemia or lymphoma.