The role of the centrifugal pump in hemolysis during neonatal extracorporeal support.

While the use of the centrifugal vortex ECMO pump as an alternative to a roller-occlusion pump offers distinct advantages, unacceptable hemolysis may occur during its use in newborn infants. The authors studied 87 consecutive neonatal patients with respiratory failure supported with venoarterial ECMO using a centrifugal vortex pump. Baseline mean plasma free hemoglobin level for all patients during the first 48 hours of bypass was 31.3 +/- 3.1 md/dl. In 51 patients, an abrupt rise in the plasma free hemoglobin occurred. In 48 of 51 patients, the pump head alone was changed at 91.9 +/- 6.6 hours after initiation of bypass. Mean plasma free hemoglobin decreased to baseline values following pump head change. The authors could not determine any factors that distinguish the infants who developed hemolysis from those who did not. Changing only the pump head provides a simple approach to hemolysis during use of the centrifugal vortex pump on newborn infants.

Late solitary cerebral metastases from renal cell carcinoma: report of two cases.

We report two cases of solitary cerebral metastases from renal cell carcinoma 15 and 18 years after nephrectomy. In a review of the literature, only two cases of solitary brain metastasis from renal cell carcinoma with latency periods greater than 10 years have been documented. Our two cases represent the longest latency periods reported between nephrectomy and detection of a solitary cerebral metastasis. Histologic examination and immunohistochemical profile of the primary renal tumors and metastatic cranial tumors showed identical morphology and immunophenotype.

Disk-caused nerve compression in patients with acute low-back pain: diagnosis with MR, CT myelography, and plain CT.

Ninety-five patients with acute low-back and radicular pain underwent magnetic resonance (MR) imaging and either plain computed tomography (CT) (n = 32) or CT myelography (n = 63) for diagnosis of herniated nucleus pulposus-caused nerve compression (HNPNC). Patients were followed up for at least 6-12 months. Fifty-six patients underwent surgery, and 39 received conservative treatment. Receiver operating characteristic (ROC) analysis was performed on correlation of results of blinded image reading with "true" diagnoses determined by an expert panel [corrected]. Results in subgroup analysis for ROC curve areas were MR, 0.84, versus plain CT, 0.86; MR, 0.81, versus CT myelography, 0.83; and MR, 0.82, versus findings with both CT techniques, 0.85. Results indicate no statistically significant difference in diagnostic accuracy of HNPNC among the three modalities. Thus, factors of cost, radiation dose, and invasiveness influence selection of modality. On the basis of accuracy findings, the authors suggest that MR should replace CT myelography because of the invasiveness of myelography but that MR should not replace plain CT because plain CT is equally accurate and much less costly.

Hydrocephalus following spinal cord schwannoma resection.

We describe a patient who developed signs and symptoms of intracranial hypertension immediately after complete excision of a benign spinal cord schwannoma located at C3-4. We also present a brief review of the literature on the association of hydrocephalus with spinal cord tumors.

The catecholamine response to multisystem trauma.

We studied the catecholamine response in two groups of patients with multisystem injuries according to the presence (group 1, N = 124) or absence (group 2, N = 82) of head injury. Markers of injury severity included the injury Severity Score, the Glasgow Coma Scale, the need for intubation, admission hypotension, the amount of blood products and fluid expanders administered during the first 24 hours, and patient outcome. In group 1, higher norepinephrine levels always and epinephrine concentrations usually were associated with worsening indexes of injury severity. The best correlations were between the Injury Severity Score and the Glasgow Coma Scale and norepinephrine concentrations. In group 2, despite elevated catecholamine levels, such associations were seldom present. Thus, circulating catecholamine levels, especially norepinephrine levels, significantly correlated with the severity of injury in patients who had suffered multisystem injury, but only if the injury included the brain.

Acute monocular blindness secondary to fibrous dysplasia of the skull: a case report.

An unusual case of acute monocular visual loss secondary to fibrous dysplasia is presented. Orbital and optic canal decompression restored vision completely. A review of the pertinent literature revealed that operative intervention may be curative in patients with acute monocular visual loss. This finding contrasts with the chronic visual decline found secondary to fibrous dysplasia of the skull.

Meningeal hemangiopericytoma of the posterior fossa and thoracic spinal epidural space: case report.

The rare combination of spinal and intracranial meningeal hemangiopericytomas in the same patient is reported. The coexistence of cerebral and spinal meningiomas of all histological subtypes is distinctly uncommon with only nine cases found in the literature.

A prospective, multicenter, randomized study of high versus low positive end-expiratory pressure during extracorporeal membrane oxygenation.

To test the hypothesis that increased positive end-expiratory pressure (PEEP) could prevent deterioration of pulmonary function and lead to more rapid recovery of lung function, we randomly assigned 74 patients undergoing extracorporeal membrane oxygenation (ECMO) at four centers to receive either high (12 to 14 cm H2O) or low (3 to 5 cm H2O) PEEP. The two groups were similar in terms of weight, gestational age, diagnosis, and pre-ECMO course. All other aspects of care were identical. Dynamic lung compliance was measured at baseline and every 12 hours. Radiographs of the chest were obtained daily. Survival rates were similar in the two groups: 36 of 40 for low PEEP and 34 of 34 for high PEEP. The duration of ECMO therapy was 97.4 +/- 36.3 hours in the high-PEEP group and 131.8 +/- 54.5 hours in the low-PEEP group (p less than 0.01). Dynamic lung compliance throughout the first 72 hours of ECMO was significantly higher in patients receiving high PEEP. Radiographic appearance of the lungs correlated well with lung compliance: patients receiving high PEEP had significant deterioration of the radiographic score less frequently than those receiving low PEEP. High PEEP also was associated with significantly fewer complications. We conclude that PEEP of 12 to 14 cm H2O safely prevents deterioration of pulmonary function during ECMO and results in more rapid lung recovery than traditional lung management with low PEEP.

Effects of intoxication on the catecholamine response to multisystem injury.

In patients suffering isolated head trauma, we have previously shown that levels of circulating catecholamines obtained within 48 hours of trauma correlate with the severity of brain injury and predict outcome and that intoxication blunts this response. The effects of alcohol on the increase in catecholamines in systematically injured patients, however, have not been well defined. From 1983 to 1990, 78 patients (74% male; median age 30 years) with blunt head and multisystem injury, who also had alcohol levels measured within 5 hours of injury, were studied. Norepinephrine and epinephrine levels were assayed by a radioenzymatic technique. Injury severity was assessed by the admission Glasgow Coma Scale (GCS) score (4-15; median, 12), the Injury Severity Score (ISS) (13-50; median, 25) and the volume of blood products administered within the first 24 hours (0-14.4 L; median, 0.5 L). The impact of alcohol on the norepinephrine response to injury was analyzed using multiple linear regression models, including polynomial interaction terms. Norepinephrine levels significantly (p less than 0.0001) correlated with the GCS score and ISS. However, alcohol significantly lowered the norepinephrine response to decreasing GCS score (R = 0.49, p less than 0.002) and to increasing ISS (R = 0.51, p less than 0.0006). The blunting of the catecholamine response was most marked in those severely injured. The rise in norepinephrine concentrations seen with increasing volume of blood replacement was not affected by intoxication. An association between injury severity and epinephrine levels was also present, but not as consistently. Epinephrine concentrations rose with falling GCS score and with increasing ISS values, but unlike norepinephrine, there were no apparent effects of alcohol on changes in epinephrine levels. Thus, in patients suffering head and multisystem injury, catecholamine changes reflect the severity of injury using three different scalers. Furthermore, intoxication blunts only the norepinephrine component of this important biologic response.

The adrenocortical response to brain injury: correlation with the severity of neurologic dysfunction, effects of intoxication, and patient outcome.

To test the hypothesis that cortisol levels reflect the extent of neurologic dysfunction and predict patient outcome, neurologic function and cortisol levels were determined in 120 traumatically brain injured patients who never received glucocorticoid treatment. Their mean age was 29 years and 78% were men. The impact of intoxication was examined in 59 patients who had ethanol levels measured. Ethanol was detectable in 40 patients and greater than or equal to 100 mg/dl in 31. There were significant correlations between the extent of neurologic dysfunction, determined by the Glasgow Coma Score and plasma cortisol concentrations 1 and 4 days postaccident. Cortisol levels were universally elevated on admission and approached normal 7 days later. Multiple linear regression analysis revealed significant effects of circulating ethanol levels on the association between cortisol concentrations and progressively worsening neurologic function, i.e., ethanol reduced the magnitude of the cortisol elevations in a dose dependent manner, abolishing this relationship at levels above 100 mg/dl. Analysis of the relationships between circulating cortisol levels and patient outcome provided a second method for ascertaining the association between injury severity and the magnitude of adrenocortical activation. Admission and day 1 cortisol concentrations were 25 to 40% lower in patients having good recoveries or moderate disabilities than those who remained severely disabled, persistently vegetative or died; serum cortisol values of less than 20 micrograms/dl one day after the accident were more likely to be associated with a good outcome than a poor one (55 vs. 25%, p less than 0.001). The worsening prognosis of patients having higher cortisol values is further reflected in the duration of acute hospitalization of these individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramedullary melanotic schwannoma of the cervical spinal cord: report of a case.

We present a case report of a patient with an intramedullary tumor of the midcervical cord. At surgery, the lesion was found to be highly pigmented, and pathological analysis revealed a melanotic schwannoma. Intramedullary schwannomas and melanotic schwannomas are exceedingly rare. This is the second reported case of an intramedullary melanotic schwannoma of the central nervous system.

Alcohol intoxication blunts sympatho-adrenal activation following brain injury.

In 46 patients experiencing traumatic brain injury, we studied the interactions of alcohol intoxication and severity of neurologic dysfunction on the resulting sympathetic nervous system activation. Sixty percent of the variation in norepinephrine (p less than 0.0001) and more than 50% of the variation in epinephrine (p less than 0.0001) were due to the initial ethanol concentrations and extent of brain injury assessed by the admission Glasgow Coma Score (GCS). As brain function deteriorated plasma cathecholamines rose (p less than 0.0001), but ethanol qualitatively and quantitatively modified this observation. The magnitude of the sympathetic response to worsening neurologic function was progressively diminished in association with increasing ethanol levels, i.e., the inverse relationship of GCS values with both norepinephrine and epinephrine was flattened. In comatose patients (GCS less than 8) increasing ethanol levels was associated with progressively decreasing norepinephrine and epinephrine responses (p less than 0.04), such that catecholamines were reduced by 80 to 90% at ethanol concentrations approaching 400 mg/dl (87.0 mmol/l). However, the impact of ethanol on the degree of sympathetic nervous system activation depended upon the degree of injury; the apparent ethanol suppression was greatest in patients with the most severe neurologic dysfunction (GCS 3 or 4), but it diminished as neurologic function improved. We conclude that the presence of alcohol appears to modify the rise in catecholamine levels following traumatic brain injury in a dose-dependent manner and alters the relationship between neurologic dysfunction and SNS activation. These alterations may have profound effects on patient morbidity in the immediate post-accident period.

Use of Vicryl (polyglactin 910) mesh to limit epidural scar formation after laminectomy.

A variety of substances have been used at laminectomy sites to prevent postoperative epidural scarring. Free grafts of autologous subcutaneous fat are commonly used both clinically and experimentally. The free fat grafts usually survive, but decrease in size by about 50%. Postoperatively, subcutaneous seroma has been observed with the use of fat grafts, as well as recurrent symptoms of neural compression by the graft that required additional operations. When compared to the use of free grafts after laminectomy in dogs, Vicryl mesh produced slightly more scarring, but consistently less than that observed in control animals. The Vicryl mesh was resorbed by a minimal chronic inflammatory response over about 45 days. Seven of 11 fat-grafted zones showed signs of necrosis, at times with a greater collection of inflammatory cells than that associated with the Vicryl mesh. Of the 4 fat-grafted zones that showed good survival, 2 had gross evidence of neural compression. No surgical zone treated with Vicryl mesh exhibited evidence of neural compression. In view of these results, the use of Vicryl mesh at laminectomy sites may be a safer method of limiting postoperative epidural scar formation.

Chondroma of the lumbar spine, a rare cause of sciatica: case report.

A case of chondroma of the lumbar spine causing nerve root compression is presented. This benign tumor was completely removed, resulting in relief of all radicular symptoms.

Basilar artery migraine. Case report.

The case of a 40-year-old woman with a 24-year history of basilar artery migraine is described. She was admitted to the hospital after suffering a large cerebellar infarction causing hydrocephalus and deep stupor during an attack of migraine. She recovered after ventricular shunting and removal of the infarct.

Vicryl (polyglactin 910) mesh as a dural substitute in the presence of pia arachnoid injury.

Previously presented data showed that Vicryl mesh was a potentially effective dural grafting material. It is easily handled, relatively inexpensive, absorbed over time, and elicits a minimal inflammatory response. The present experimental project was conducted to investigate the effectiveness of a tightly woven version of the material as a watertight seal and to evaluate its performance in the presence of pia arachnoid injury. The mesh formed a seal promptly and adhesion formation was slight. Tightly woven Vicryl mesh appears to have a significant potential as an absorbable dural substitute.

Immunocytochemical localization of pro-opiomelanocortin neurons in human brain areas subserving stimulation analgesia.

The distribution of pro-opiomelanocortin (beta-endorphin, adrenocorticotropic hormone, and 16-K) neurons and fiber projections was evaluated immunocytochemically in 50-mu thick cryostat sections of human diencephalon and midbrain. Specific attention was focused upon regions in which deep brain stimulation has been most effective in the relief of selected chronic pain syndromes. This study revealed a remarkable, nearly point-to-point correlation between clinically effective stimulation sites and the distribution of pro-opiomelanocortin fibers in the human brain. Of particular interest was the dense innervation of the periventricular stratum along the third ventricle, the parafascicular centromedian region of the thalamus, and the periaqueductal gray matter of the midbrain. This study provides anatomical support for the hypothesis that beta-endorphin-containing neuronal systems may contribute to stimulation analgesia in the human.