A comparative study between a calcium channel blocker (Nicardipine) and a combined alpha-beta-blocker (Labetalol) for the control of emergence hypertension during craniotomy for tumor surgery.

We compared the efficacy of the combination of enalaprilat/labetalol with that of enalaprilat/nicardipine to prevent emergence postcraniotomy hypertension. A prospective, randomized open labeled clinical trial was designed to compare the incidence of breakthrough hypertension (systolic blood pressure [SBP] > 140 mm Hg) and adverse effects (hypotension, tachycardia, and bradycardia) between the two drug combinations. Secondarily, the effects of the drugs on SBP, mean blood pressure, and diastolic blood pressure were evaluated over the course of the study. Forty-two patients received enalaprilat 1.25 mg IV at dural closure followed by either multidose nicardipine 2 mg IV or labetalol 5 mg IV to maintain the SBP below 140 mm Hg. SBP was similarly controlled in both groups. There was a marginally smaller incidence of failures and adverse effects with labetalol. Blood pressure profiles were similar for both groups.

Rapid decline of cerebral microemboli of arterial origin after intravenous acetylsalicylic acid.

BACKGROUND AND PURPOSE: The present study investigated the influence of the antiplatelet agent acetylsalicylic acid (ASA) on cerebral microembolism as detected by transcranial Doppler sonography (TCD). METHODS: Nine patients with recent transient ischemic attack or minor stroke of arterial origin were investigated. Eight had not received an antiplatelet or anticoagulant medication before TCD, and in 1 patient a preexisting ASA medication (100 mg/d) had not been changed since the onset of stroke symptoms. An initial 1-hour TCD monitoring was extended for an additional 2.5 hours after an intravenous bolus injection of 500 mg ASA and was repeated for 1 hour on the following day. RESULTS: Microembolic signals (MES) were detected in all patients only on the symptomatic side. After the ASA bolus injection, a significant drop of the MES rate was found in 7 patients, all without previous medication, starting 30 minutes after the application (mean per hour=25.1 [range, 6 to 66] versus mean per hour=6.4 [range, 0 to 14]). In 3 of these patients, platelet aggregation tests were performed that demonstrated normal aggregation before bolus injection and inhibited aggregability as early as 30 minutes after bolus injection. The rate of MES remained unchanged in 1 patient without antiplatelet medication. The ninth patient, who had suffered an ischemic event on ASA, showed only a transient decrease of MES frequency. CONCLUSIONS: In patients with recent stroke of arterial origin, intravenous ASA can rapidly reduce cerebral microemboli as detected by TCD. Microemboli might be a useful parameter to monitor early effects of antiplatelet therapy.

Diagnostic impact and prognostic relevance of early contrast-enhanced transcranial color-coded duplex sonography in acute stroke.

BACKGROUND AND PURPOSE: We sought to evaluate the diagnostic value of echo-enhanced transcranial color-coded duplex sonography (TCCD) and the clinical relevance of vascular pathology assessed by sonography for early clinical outcome in acute ischemic stroke. METHODS: We present 23 consecutive patients with an anterior circulation stroke in whom clinical examination, CT, and ultrasonography were performed within 5 hours after the onset of symptoms. Transcranial Doppler sonography (TCD) and unenhanced and contrast-enhanced TCCD (Levovist, 4 g, 300 mg/mL) were compared for their ability to detect middle cerebral artery (MCA) occlusion and flow velocity reduction suggesting hemodynamic impairment in the MCA distribution pathway. Sonographic examination times were registered. Baseline clinical characteristics and CT findings were assessed. Neurological deficit was quantified according to the National Institutes of Health Stroke Scale score, with an early clinical improvement defined as decrease of the score by 4 or more points or a complete resolution of the deficit on day 4. RESULTS: Contrast-enhanced TCCD enabled diagnosis of intracranial vascular pathology in 20 affected hemispheres, whereas unenhanced TCCD and TCD were conclusive in 7 and 14 hemispheres, respectively (P=0.0001). Contrast-enhanced TCCD was superior in evaluating distal carotid (carotid-T) occlusion and differentiating major vessel occlusions from patent arteries with flow velocity diminution. Mean examination time for enhanced TCCD ranged from 5 to 7 minutes, depending on the number of investigated vessels (without or with MCA branches). Logistic regression selected a patent MCA without reduced blood flow velocity as the only independent predictor for an early clinical improvement (P<0.01). CONCLUSIONS: Contrast-enhanced TCCD is a promising tool for early prognosis in anterior circulation stroke. It is considered superior to unenhanced TCCD and TCD.

Improved detection of hypotension by automated noninvasive blood pressure monitoring.

This study was undertaken to determine whether the use of automated noninvasive blood pressure monitoring altered the frequency of detection of intraoperative hypotension. We retrospectively reviewed 1,861 anesthetic records from a period in 1987, when blood pressure was obtained manually by auscultation. We compared the records from 1987 with 1,716 anesthetic records from 1989, when automated blood pressure monitors were used universally. The incidences of hypotension requiring vasopressor therapy were determined during the two periods and compared using Student's two-tailed t test. The data revealed that the incidence of detected hypotension increased from 2.4 to 5.2% with the use of automated blood pressure monitors (P less than 0.00002). We conclude that at our hospital the use of automated noninvasive blood pressure monitors increases the incidence of detection of intraoperative hypotension as compared with the use of manual blood pressure measurement.

[Effect of heading in soccer on the head--a quantifying EEG study of soccer players]. / Balleinwirkung auf den Kopf--eine quantifizierende EEG-Untersuchung bei Fussballern.

We observed a patient with epileptic seizures as a consequence of an occipital contre coup injury, due to heading in football. We decided to investigate the EEGs of ten healthy football players by computerized EEG analysis during their "header training". One player's EEG showed focal slowing, there were no clinical symptoms. The EEG of the other players showed only signs of relaxation after training. These results lead us to the following conclusions: - Cerebral damage due to heading in football cannot be assumed in general. - In predisposed persons, however, the microtrauma caused by heading can lead to clinical manifestation. - Subclinical cerebral disfunction due to heading is possible. However, long term studies should be performed to prove that there might be a risk of permanent cerebral damage in football players, as has already been established in boxing.

["Typical" and "less typical" sports injuries in the field of neurology]. / "Typische" und "weniger typische" Sportschäden im neurologischen Bereich.

In times of increasing "sparetime pathology" sequels of sports are getting a new meaning in medicine. Surgeons are mainly involved in this issue but it also contacts neurologists. We differentiate between direct sequels of sports and concomitant incidents of sports. Besides the typical head injuries we saw a number of atypical traumatic damages such as a hit by a golf ball, fall on the buttocks and the header in football. Discprotrusions are mainly understood as concomitant incidents at sports because in most cases one has to consider preexisting disc lesions. Though there are typical motions in sports which rather lead to discprotrusions such as strong torsions of the body in football, serving in tennis, heavy lifting in wrestling or an unexpected fall into a hollow in skiing. In cerebrovascular events, sports is usually only one additive etiological component. Nevertheless the lack of adequate acclimatisation and the brisk beginning of stressing sports in high mountain areas (which is enabled through modern technic) can contribute a great deal to decompensation of cerebrovascular disorders. In this respect doping can have a serious influence since protecting physiological mechanisms are eliminated. Diving accidents are able to give rise to spinal, cerebral and cerebellar gasembolisation. Warning early symptoms of great value are TIA, vertigo and fits. Sport practice can figure as an unspecific test situation in order to provoke these events. Diagnostic investigation of the cardiovascular system and the CNS has to be performed in those cases. Particular regard should be paid to expert situations which tend to distort the clinical pictures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Headache and EEG changes caused by acetate and bicarbonate dialysis]. / Kopfschmerzen und EEG-Veränderungen unter Azetat- und Bikarbonatdialyse.

10 patients suffering from severe headache during Acetatedialysis were subsequently treated with Acetatedialysis (AD) and Bicarbonatedialysis (BD). During AD the headaches occurred more frequently and more intensely. After AD a deterioration of EEG-results was also seen more frequently than after BD. Urea, osmolarity and sodium in the blood as well as heart frequency and blood pressure showed no different variation. An essential difference was found in correction of the metabolic acidosis. After AD there could be seen a negative base excess and a fall in PaCO2, after BD the PaCO2 rose and the base excess was positive. Headaches and EEG-changes as signs of a cerebral dysfunction (disequilibrium syndrome) may perhaps be caused by a decrease of the cerebral blood flow. From our experience we recommend a change to BD for patients suffering from headaches during AD.

[The role of cardiac disease in the causation of cerebrovascular syndromes (author's transl)]. / Zur Frage der kardialen Verursachung von zerebrovaskulären Syndromen.

To obtain a clearer definition of the influence of cardiac disease on the development of cerebrovascular disease (CVD), we carried out a comparative study of two groups of patients, matched for age and sex, one with and one without CVD. These were compared with regard to the incidence of cardiac disease, hypertension and diabetes mellitus. On comparing the groups as a whole a significant preponderance of hypertension is shown in patients with CVD, but no significant difference in the frequency of cardiac disease. With regard to the site of the lesion in CVD there is a clear preponderance of cardiac arrhythmias when the territory of the carotid artery is affected. This seems to favour an embolic, rather than a haemodynamic mechanism in the aetiology of cardiogenic CVD. Hence, it follows for therapeutic purposes that in the case of arrhythmias, prophylaxis with aggregation-inhibiting drugs to prevent recurrence of embolism and adequate treatment of hypertension are useful measures, whereas administration of digitalis should be determined only by the presence of cardiac insufficiency.