Accuracy of transcranial Doppler ultrasonography and single-photon emission computed tomography in the diagnosis of angiographically demonstrated cerebral vasospasm.

OBJECT: The goal of this study was to assess the accuracy of the routine clinical use of transcranial Doppler (TCD) ultrasonography and SPECT in predicting angiographically demonstrated vasospasm. METHODS: Following receipt of institutional review board approval, the authors reviewed the records of patients with subarachnoid hemorrhage who had been admitted between 2004 and 2005 and underwent TCD ultrasonography and SPECT evaluations within 24 hours of cerebral angiography. Patients were categorized based on the presence or absence of vasospasm and/or hypoperfusion in the anterior cerebral arteries (ACAs), middle cerebral arteries (MCAs), and basilar arteries (BAs) or posterior cerebral arteries (PCAs) according to each imaging modality. Logistic regression was used to estimate the odds ratio (OR) of an angiographically demonstrated vasospasm also detected on TCD ultrasonography and SPECT. RESULTS: One hundred fifty-two patients (101 women) with a mean age (+/- standard deviation) of 53 +/- 13 years were included in the study. In the ACA, the OR of a vasospasm on TCD ultrasonography was 27 (95% confidence interval [CI] 3-243) and on SPECT 0.97 (95% CI 0.36-2.6); in the MCA, 17 (95% CI 5.4-55) and 2.0 (95% CI 0.71-5.5), respectively; in the BA, 4.4 (95% CI 0.72-27) and 5.6 (95% CI 0.89-36), respectively. There was no substantial change in the relative odds of a vasospasm when the findings on TCD ultrasonography and SPECT were considered jointly. CONCLUSIONS: Transcranial Doppler ultrasonography appears to be highly predictive of an angiographically demonstrated vasospasm in the MCA and ACA; however, its diagnostic accuracy was lower with regard to vasospasm in the BA. Single-photon emission computed tomography was not predictive of a vasospasm in any of the vascular territories assessed.

Transcranial Doppler ultrasonography: a diagnostic tool of increasing utility.

PURPOSE OF REVIEW: Since its introduction in 1982, transcranial Doppler ultrasonography has become an important diagnostic and monitoring tool in patients with surgical disease. It has applications in the perioperative period, as well as in the intensive care unit. It is therefore appropriate for the anesthesiologist to maintain an understanding of its current utility. RECENT FINDINGS: Transcranial Doppler has an established role in diagnosing cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage and for guiding transfusion therapy in children with sickle cell disease. It has application in the preoperative evaluation of patients with cerebrovascular disease, as well as that of an intraoperative monitor in carotid endarterectomy and carotid stenting. It is useful for detecting right-to-left shunts in settings in which transesophageal echocardiography is not desirable. Its value in settings such as traumatic brain injury, hepatic failure, and migraine headache has yet to be fully clarified. SUMMARY: Although there are several settings in which transcranial Doppler has well established usefulness, there are many more in which it is likely valuable, such as traumatic brain injury, ischemic stroke, and fulminant hepatic failure. Further research is needed in these fields to elucidate the exact role for transcranial Doppler.

Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance.

BACKGROUND: The purpose of the study was to compare the effect of equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation and electrolyte balance. METHODS: After institutional review board approval and informed consent, patients with American Society of Anesthesiologists physical status II-IV, scheduled to undergo craniotomy for various brain pathologies, were enrolled into this prospective, randomized, double-blind study. Patients received 5 ml/kg 20% mannitol (n = 20) or 3% HS (n = 20). Partial pressure of carbon dioxide in arterial blood was maintained at 35-40 mmHg, and central venous pressure was maintained at 5 mmHg or greater. Hemodynamic variables, fluid balance, blood gases, electrolytes, lactate, and osmolality (blood, cerebrospinal fluid, urine) were measured at 0, 15, 30, and 60 min and 6 h after infusion; arteriovenous difference of oxygen, glucose, and lactate were calculated. The surgeon assessed brain relaxation on a four-point scale (1 = relaxed, 2 = satisfactory, 3 = firm, 4 = bulging). Appropriate statistical tests were used for comparison; P < 0.05 was considered significant. RESULTS: There was no difference in brain relaxation (mannitol = 2, HS = 2 points; P = 0.8) or cerebral arteriovenous oxygen and lactate difference between HS and mannitol groups. Urine output with mannitol was higher than with HS (P < 0.03) and was associated with higher blood lactate over time (P < 0.001, compared with HS). Cerebrospinal fluid osmolality increased at 6 h in both groups (P < 0.05, compared with baseline). HS caused an increase in sodium in cerebrospinal fluid over time (P < 0.001, compared with mannitol). CONCLUSION: Mannitol and HS cause an increase in cerebrospinal fluid osmolality, and are associated with similar brain relaxation scores and arteriovenous oxygen and lactate difference during craniotomy.

Gender differences in cerebral blood flow velocity and autoregulation between the anterior and posterior circulations in healthy children.

There is little information on gender differences in cerebral autoregulation. The purpose of this study was to compare autoregulation of the anterior and posterior circulations using the tilt test method in healthy boys and girls who were 10-16 y of age. Transcranial Doppler was used to measure middle cerebral artery and basilar artery flow velocities (Vmca and Vbas). Cerebral autoregulation (ARI) of the middle cerebral (ARImca) and basilar arteries (ARIbas) was examined using the tilt test method. An ARI <0.4 indicates impaired autoregulation. Among the 13 boys and 13 girls, Vmca and Vbas were higher in girls. All children demonstrated intact autoregulation, but boys had higher ARImca than girls, whereas girls had higher ARIbas than boys. Girls demonstrated greater autoregulation in the basilar artery, whereas boys demonstrated greater autoregulation in the middle cerebral artery. Girls had higher flow velocities in both vessels. This study provides normative data on cerebral autoregulation of the posterior circulation in healthy, awake boys and girls.

Feeding intolerance as a result of small-intestine intussusception in a child with major burns.

Feeding intolerance is common in critically ill children. We present an unusual case of jejunojejunal intussusception causing feeding intolerance in a child with major burns. An 18-month-old female was admitted to the intensive care unit after sustaining a 65% TBSA burn. Following a decompressive laparotomy for abdominal compartment syndrome, nasojejunal feeds were started immediately after surgery, which she did not tolerate. A plain abdominal radiograph revealed a collection of intraluminal air and an abdominal CT revealed a proximal jejunojejunal intussusception. The patient underwent laparotomy and an uncomplicated reduction of the small-bowel intussusception (SBI). Successful enteral feedings were commenced on hospital day 24, and the patient was discharged to home after approximately a 4.5-month hospitalization. The major learning point is that SBI can cause feeding intolerance in the child with major burns. Despite the low incidence of SBI in critically ill children, arriving at a timely diagnosis is essential because the consequences of a missed or delayed diagnosis include intestinal ischemia, necrosis, or perforation. Because SBI defies diagnosis by techniques traditionally used to diagnose intussusception involving the colon, clinical suspicion for intussusception is needed to facilitate the urgent diagnosis and correction of feeding intolerance caused by mechanical obstruction.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE: To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS: The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS: Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS: Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

Ultrasonographic evidence of a mushroom-shaped choroidal metastasis.

PURPOSE: To describe the evolution of a "collar-button" or mushroom-shaped choroidal metastasis. METHODS: Case report. RESULTS: A 52-year-old woman with known primary colon cancer and widespread extraocular metastases developed bilateral choroidal masses with neurosensory retinal detachments. Clinical and ultrasound evaluation demonstrated evolution of a choroidal metastasis with a "collar-button" configuration in the right eye. CONCLUSION: A choroidal metastasis may develop a mushroom-shaped configuration. This "collar-button" configuration is not pathognomonic for choroidal melanoma.

Choroidal neovascularization with granulomatous inflammation in ocular histoplasmosis syndrome.

PURPOSE: To report pathologic examination of an excised choroidal neovascular membrane in a patient with ocular histoplasmosis syndrome that demonstrated granulomatous inflammation. METHOD: Case report. A 50-year-old woman with sudden vision loss in her left eye demonstrated clinical and fluorescein angiographic findings characteristic of choroidal neovascularization secondary to ocular histoplasmosis syndrome. RESULTS: Histopathologic examination of the surgically excised choroidal neovascular membrane disclosed granulomatous inflammation. CONCLUSIONS: This case suggests an important role of mononuclear phagocytic cells as primary mediators of angiogenesis or modifiers of choroidal neovascularization. This association of choroidal neovascularization with granulomatous inflammation did not respond to treatment with systemic corticosteroids.

The Arabidopsis sugar-insensitive mutants sis4 and sis5 are defective in abscisic acid synthesis and response.

Although soluble sugar levels affect many aspects of plant development and physiology, little is known about the mechanisms by which plants respond to sugar. Here we report the isolation of 13 sugar-insensitive (sis) mutants of Arabidopsis that, unlike wild-type plants, are able to form expanded cotyledons and true leaves when germinated on media containing high concentrations of glucose or sucrose. The sis4 and sis5 mutants are allelic to the ABA-biosynthesis mutant aba2 and the ABA-insensitive mutant abi4, respectively. In addition to being insensitive to glucose and sucrose, the sis4/aba2 and sis5/abi4 mutants also display decreased sensitivity to the inhibitory effects of mannose on early seedling development. Mutations in the ABI5 gene, but not mutations in the ABI1, ABI2 or ABI3 genes, also lead to weak glucose- and mannose-insensitive phenotypes. Wild-type and mutant plants show similar responses to the effects of exogenous sugar on chlorophyll and anthocyanin accumulation, indicating that the mutants are not defective in all sugar responses. These results indicate that defects in ABA metabolism and some, but not all, defects in ABA response can also alter response to exogenous sugar.

Localized neurofibroma of the orbit: a radiographic and histopathologic study.

PURPOSE: To demonstrate the clinical, radiographic, intraoperative and histopathologic presentation of a localized neurofibroma of the orbit. METHODS: Clinicopathologic case report. RESULTS: A 25-year-old man was examined for inferior displacement of the right globe. Physical examination and neuro-imaging identified a localized solid tissue mass of the superior orbit. Histopathologic evaluation after complete surgical resection proved the lesion to be a localized neurofibroma. CONCLUSIONS: The patient's history, clinical presentation, and imaging studies were strongly characteristic for this infrequently encountered orbital lesion. Several imaging features, including multilobulation, multiplicity, ring-configured contrast enhancement, and magnetic resonance imaging (MRI) signal intensity heterogeneity, when present in combination, may be reasonably diagnostic of this tumor.

Ocular disease in the diabetic elderly.

Diabetic retinopathy is a significant complication for the older diabetic patient. Visual loss often can be prevented, ameliorated, or delayed, but timely referral is key. Even those who cannot be helped medically or surgically can be assisted in making use of remaining visual function and other remaining senses. Many patients are not screened or referred according to American College of Physicians/American Academy of Ophthalmology guidelines and thus are not receiving the best possible care.

Cutaneous malignant melanoma metastatic to the eyelid.

Cutaneous malignant melanoma metastatic to the choroid, orbit, or vitreous is rare. Metastatic lesions to the eyelid are rare as well. The authors report a case of malignant melanoma metastatic to the eyelid. This was the first sign of tumor recurrence in a patient who was thought to have been successfully treated for a melanoma of the back 3 years previously. The patient died 6 weeks after diagnosis of the eyelid lesion. In the presence of known malignancy, metastasis must be suspected in new eyelid lesions.

Transconjunctival mitomycin C as an adjunct to conventional glaucoma filtration surgery in rabbits.

PURPOSE: Subconjunctival mitomycin C has been used in glaucoma filtration surgery with success. A prospective, randomized, masked, placebo-controlled study was performed to evaluate whether single transconjunctival mitomycin C applied either preoperatively or postoperatively would enhance the success of filtration surgery in rabbits. METHODS: Two groups of 5 rabbits were studied. In Group I, a Weck-Cel sponge soaked in 0.5 mg/ml mitomycin C was applied transconjunctively for 7 minutes immediately before a full thickness filtering procedure. The other eye was treated similarly with a sponge soaked in balanced salt solution. Group II first underwent filtration surgery followed by treatment with either mitomycin-c or balanced salt solution 3 days later. Postoperative intraocular pressure, bleb status, and complications were evaluated. Treatment failure was defined as postoperative pressure within 4 mmHg of that determined preoperatively or the absence of bleb formation. RESULTS: In Group I, mean time to failure (+/- SD) was significantly longer (p = 0.03) in experimental eyes (30 +/- 15.1 days) than control eyes (8.6 +/- 0.8 days). In Group II, the time to failure was 12.4 (+/- 2.6) days versus 9.6 (+/- 2.5) days in the experimental and control eyes respectively, but this was not statistically significant (p = 0.10). Transient limbal vascularization and corneal haze were seen in all experimental eyes. Serious complications included late bleb rupture in eyes pretreated with mitomycin C (all eyes in Group I) and corneal decompensation (one mitomycin-c eye). CONCLUSIONS: This study demonstrates that a single preoperative tranconjunctival application of mitomycin-c is more effective at the time of surgery than an application applied in the intermediate postoperative period. Additional studies are needed, however, to further refine both the dose and timing of mitomycin-c application during filtration surgery.

Effects of serotonin reuptake inhibitors on aggressive behavior in psychiatrically hospitalized adolescents: results of an open trial.

Low concentrations of the neurotransmitter serotonin and its 5-hydroxyindoleacetic acid metabolite in the central nervous system have been associated with increased aggressive behavior in animals and humans. Controlled clinical trials of serotonin agonists in depressed adults have suggested that aggressive behavior is less likely during treatment with these medications than with placebo, but there have been no previous studies of selective serotonin reuptake inhibitors (SSRIs) and aggression in children. We prospectively followed the course of aggressive behavior in 19 psychiatrically hospitalized adolescents (not selected for aggressiveness) who received open clinical trials of fluoxetine, paroxetine, or sertraline. The patients received standard doses (equivalent to fluoxetine 10-40 mg daily) for a minimum of 5 weeks. The starting dose was 15 +/- 5 mg, and dosages were raised at a mean rate of 5 mg every 4 days up to a mean dose of 25 +/- 10 mg daily. Results from trials of the three SSRIs were clustered because the sample sizes were not sufficient for separate analyses. Overall, there were no statistically meaningful improvements in the level of aggressive behavior, as measured on a modified version of the Overt Aggression Scale, over the course of these patients' SSRI trials. Symptoms of physical aggression toward others or self were manifest in 12 of the 19 patients while on SSRIs. Of the 19 patients, 13 were assessed both on and off SSRIs: verbal aggression (p = 0.04), physical aggression toward objects (p = 0.05), and physical aggression toward self (p < 0.02) occurred significantly more frequently on SSRIs than off; no increase was observed in physical aggression toward others. Patients with the highest baseline aggressivity scores did not show greater improvement during SSRI treatment. Further research is warranted, particularly to explore whether SSRIs may have therapeutic effects on aggression at higher (or lower) doses than were administered in this open trial.

Osteogenin-enhanced bone-specific differentiation in hydroxyapatite orbital implants.

Hydroxyapatite orbital implants undergo early ingrowth of fibrovascular tissue after enucleation. This animal study determined whether control and osteogenin-impregnated hydroxyapatite orbital implants vary in their osteogenic response at 6 and 52 weeks. Rabbits underwent enucleation with implantation of control or osteogenin-impregnated hydroxyapatite spheres. Light microscopy determined fibrovascular ingrowth, and histomorphometry quantitated the amount of bone produced. Osteogenin implants vascularized at a faster rate and contained bony foci by 6 weeks that became confluent at 1 year. Spontaneous osteogenesis was not seen in control animals at 6 weeks. After 1 year they contained bone, although less than in the osteogenin implants. Mixed cell inflammation was observed at the hydroxyapatite-tissue interface in both groups. No inflammation was noted at the interface of hydroxyapatite and bone. These are the first controlled observations that bone-specific differentiation occurs in the pores of spherical hydroxyapatite implants within the soft tissues of the socket. This vascularized process can be enhanced with osteogenin to occur earlier and more uniformly in the implants at one year.

Aminoglycoside levels in the rabbit vitreous cavity after intravenous administration.

PURPOSE: To determine the penetration of gentamicin and amikacin into the rabbit vitreous cavity after their intravenous administration. METHODS: Gentamicin (1.6 mg/kg every 8 hours) and amikacin (6 mg/kg every 12 hours) were administered intravenously to 25 rabbits that had previously had the lens and vitreous removed from 43 eyes. For each drug, ocular inflammation was induced in one group of eyes by injection of heat-killed Staphylococcus epidermidis, while the other group was maintained as a control. Samples from the vitreous cavity were taken at regular intervals for 72 hours after beginning the intravenous medications and were analyzed for drug concentrations. RESULTS: The maximum intravitreal concentration +/- SD achieved for gentamicin was 1.8 +/- 0.5 microgram/ml. The maximum intravitreal concentration for amikacin was 8.5 +/- 3.2 micrograms/ml. Inflamed eyes demonstrated higher concentrations than did those without inflammation. CONCLUSIONS: In a rabbit model with conditions optimized to enhance penetration of antimicrobials into the vitreous cavity after intravenous administration, neither gentamicin nor amikacin penetrated sufficiently to reach potentially therapeutic concentrations consistently for either Pseudomonas or S epidermidis organisms.

Characterization of a central corneal cloudiness sharing features of posterior crocodile shagreen and central cloud dystrophy of François.

A 56-year-old black woman with full-thickness mosaic pattern central corneal cloudiness, similar in appearance to central cloudy dystrophy and posterior crocodile shagreen, underwent corneal transplantation. Atypical features included decreased vision, photophobia, and epithelial involvement, with occasional foreign body sensation. Numerous 0.5-2.0-micron-diameter lacunae were present in the corneal stroma and Bowman's layer, and a saw-toothed lamellar pattern was often evident in the corneal stroma. Soybean agglutinin (SBA), a lectin that binds N-acetyl-galactosamine residues, bound diffusely to stromal foci exhibiting similar size and distribution to the lacunae observed by electron microscopy. An absence of histochemically detectable lipid associated with these lacunae suggests that SBA reacted with glycoconjugates other than glycolipids. Biochemical analyses revealed similar contents of keratan sulfate, chondroitin/dermatan sulfate, and collagen as in normal controls, suggesting that the SBA binding moieties are associated with a glycoprotein or proteoglycan that is structurally or compositionally different from those found in normal cornea. This patient may represent an extreme variant of Vogt's or François central corneal clouding or a previously undescribed corneal dystrophy.

Demographics, family history, premorbid functioning, developmental characteristics, and course of patients with deteriorated affective disorder.

OBJECTIVE: This exploratory study examined the characteristics of a group of unusual and previously undescribed patients with major affective disorder who not only had been continuously symptomatic for prolonged periods of time but were also so functionally impaired that they required years of continuous care in psychiatric facilities or by family members. METHOD: Twenty-seven inpatients with major mood disorders and 29 inpatients with schizophrenia were recruited from a large state hospital; 27 outpatients with major mood disorders were recruited from an affiliated outpatient facility. The research battery included the Structured Clinical Interview for DSM-III-R--Patient Version, the Premorbid Adjustment Scale, and a semistructured interview designed to assess demographic, family history, developmental, and course information. RESULTS: Inpatients with deteriorated affective disorder differed from outpatients with nondeteriorated affective disorder along several important dimensions, including family history of mental illness, birth-related problems, physical disorders in infancy, premorbid functioning, presence of mixed episodes and rapid cycling, and medication non-compliance between hospitalizations. Inpatients with deteriorated affective disorder differed from inpatients with schizophrenia on the Premorbid Adjustment Scale. Patients with bipolar affective disorder differed from those with unipolar disorder on many of the variables associated with deterioration of functioning. CONCLUSIONS: Birth-related problems, physical disorders in infancy, and poor premorbid adjustment in childhood and adolescence appear to play an important role in deterioration of functioning among patients with unipolar depression. Disruption in treatment because of medication noncompliance and the appearance of mixed episodes and rapid cycling are associated with functional decline in bipolar affective disorder. Several characteristics previously considered specific to deterioration of functioning in schizophrenia, such as a high rate of birth complications and poor premorbid adjustment, appear to be associated with functional deterioration among patients with major depression as well.