Dysesthesia perceived as painful spasticity: A report of 3 cases.

Lesions of the central nervous system often involve the pyramidal tracts and the sensory pathways to produce spasticity, paresthesias, and dysesthesia. Three patients with intractable spasticity were treated with intrathecal baclofen. Two had an implanted Medtronic SynchroMed pump for long-term delivery of the muscle relaxant. The third patient had undergone a screening trial in which the baclofen was delivered into the intrathecal space through a lumbar catheter. All had excellent relief of spasms on clinical examination, but they reported painful spasms particularly at night. Two of the patients were successfully treated for dysesthesia.

Brain pH monitoring during ischemia.

BACKGROUND: Brain tissue acidosis can result from ischemia when cerebral blood flow reduction reaches a critical value. The portable, battery-operated Khuri pH monitor has been used previously in a large number of patients undergoing cardiopulmonary bypass surgery to monitor the intramyocardial pH during aortic clamping. It was found to be easy to use, reliable, and a strong predictor of myocardial preservation. The goal of this study was to evaluate the applicability of this monitor in the measurement of brain pH. METHODS: Fifteen New Zealand white rabbits underwent general endotracheal anesthesia. A right frontal craniotomy was performed and a pH/temperature glass electrode was inserted in the frontal lobe. Both common carotid arteries were exposed in the neck and prepared for occlusion. Three rabbits were used as control; their brain pH was recorded over 60 minutes. Twelve rabbits underwent bilateral common carotid artery occlusion of varying duration and their brain pH measurements were recorded. RESULTS: There was no significant difference in pH levels at baseline in the two groups (p = 0.604). There were significant differences in pH over time between the control and occlusion group (p = 0.016). The pH dropped steadily and significantly in the occlusion group (p = 0.008), whereas little change in pH was noted over time in the control group (p = 0.366). CONCLUSION: The portable Khuri pH monitor has been used by cardiothoracic surgeons to monitor the myocardium during bypass procedures. Our experimental pilot study found it to be reliable in measuring the brain pH and to be relatively simple to use. It is approved by the Food and Drug Administration (FDA). We believe it may be of benefit to neurosurgeons.

Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity.

The aim of this study was to determine the efficacy, safety, and cost-effectiveness of intrathecal baclofen delivered by a programmable pump for the chronic treatment of severe spasticity. Sixty-six patients with severe spasticity of spinal cord origin that was refractory to oral baclofen or who experienced intolerable side effects with this form of the drug were screened. The first nine participated in a double-blinded, randomized, placebo (normal saline)-controlled trial to determine response to a bolus dose of intrathecal baclofen. Subsequent patients were enrolled in an open-label treatment protocol without a placebo trial. All passed the screening, and the pump was implanted in 59 patients. Spasticity scores and medical costs before and after surgery were analyzed. In all patients, the mean Ashworth score for rigidity decreased from 4.3 preoperatively to 1.4 (p < 0.0005) with use of intrathecal baclofen. The spasm frequency score decreased from a mean of 3.6 to 0.5 (p < 0.0005). Activities of daily living, sleep, and skin integrity improved, and pain was eradicated in some. Constipation occurred in six patients. A reduction in dosage was necessitated by muscular hypotonia in three ambulatory patients, areflexic bladder and urinary retention in three others, and nausea, dizziness, and drowsiness in one. Catheter-related problems occurred 19 times in 15 patients. One pump was explanted because of infection in the pump pocket, and one was removed after it eroded through the skin. There were no pump failures. The use of intrathecal baclofen resulted in a decrease in the average length of subsequent hospitalizations. It is concluded that intrathecal baclofen delivered by an implanted programmable pump is a safe, effective, and cost-efficient method for treatment of severe intractable spinal spasticity.

A synthetic dural prosthesis constructed from hydroxyethylmethacrylate hydrogels.

Hydroxyethylmethacrylate (HEMA) hydrogels were investigated for their suitability as a dural prosthesis. Poly-HEMA has many characteristics required for an artificial dural substitute: it is durable, flexible, easily prepared, inexpensive, easily sterilized and handled, easily shaped, and known to be chemically inert and nontoxic. Sheets made of plain HEMA were evaluated as dural substitutes in rats and rabbits after either craniotomy or laminectomy with durectomy. Histological evaluations of the prostheses and the underlying tissues were undertaken at various time points from 2 to 9 weeks postoperatively. There was minimal tissue response to the implanted HEMA gel in contrast to marked thickening of the overlying leptomeninges and cortical herniation in the control animals. It is concluded that HEMA gels fulfill the essential criteria for an effective dural substitute.

Audible cerebrospinal fluid flow through a ventriculoperitoneal shunt. Report of two cases.

An audible, noisy cerebrospinal fluid flow is an uncommon sequela of ventriculoperitoneal shunting. Two cases presenting this phenomenon are described.

Intracerebral hemorrhage and phenylpropanolamine use.

Two patients developed intracerebral hemorrhage within hours from first-time ingestion of phenylpropanolamine-containing medications. One patient had marked hypertension, presented with three intracerebral hematomas, and developed a fourth hemorrhage 10 days later. Angiogram in one patient revealed "beading" of intracranial arteries, an abnormality also detected in a third patient who developed severe headache, vomiting, and acute hypertension following a single dose of phenylpropanolamine. These cases and others reported in the literature strongly suggest an association between phenylpropanolamine ingestion and hemorrhagic stroke. Direct questioning of use of this medication in cases of unexplained intracranial hemorrhage in previously healthy young individuals may reveal an unsuspected high frequency of this association.

Inefficacy of routine laboratory analysis of CSF obtained during myelography for suspected disc disease.

The routine laboratory analysis of cerebrospinal fluid (CSF) obtained during myelography is performed in many institutions. The records of 100 consecutive patients who had myelography for suspected disc disease were reviewed retrospectively. The laboratory analysis of the CSF obtained during myelography did not benefit patient management in any instance. In one case, the CSF results adversely affected patient management. The CSF analysis did not add any information to the myelogram result. The CSF protein level did not correlate in a statistically significant way with the degree of disc protrusion seen myelographically.

Effect of high-frequency ventilation versus conventional mechanical ventilation on ICP in head-injured dogs.

Changes in intrathoracic pressure may influence intracranial pressure (ICP), presumably by affecting venous return. High-frequency ventilation (HFV) has been associated with lower intrapleural and airway pressures and has the potential to lower ICP. To evaluate the effects of HFV compared to conventional ventilation on ICP, normocarbia was maintained in nine dogs while alternating between conventional ventilation and HFV at 200 breaths/min. The mean ICP was raised from 6.3 +/- 6.1 to 24.7 +/- 1.04 mm Hg by inflation of Fogarty balloons implanted in the epidural space. The ICP peaks associated with positive inflation pressures were eliminated with HFV, but mean ICP was not significantly different between the two ventilatory modes (23.4 +/- 9.7 mm Hg for the conventional system versus 26.0 +/- 10.0 mm Hg for HFV). Four dogs exhibited neurogenic pulmonary edema: they developed elevated pulmonary artery and intrathoracic pressures and required increased inspiratory flow with HFV to maintain normocarbia. The authors conclude that, in this head-injury model, there did not seem to be an advantage of HFV over conventional ventilation.

Carotid--cavernous fistula--iatrogenic carotid--cavernous fistula due to thrombectomy with a Fogarty catheter.

Removal of thrombus from a totally occluded internal carotid artery with a patent siphon by means of a balloon-tipped Fogarty catheter has been an acceptable technique. There have, however, been five reported cases of carotid-cavernous fistula following this procedure (Barker et al., 1968; Davie and Richardson, 1967; Motarjeme and Keifer, 1973; Newton and Potts, 1974). The purpose of this report is to add a sixth case to the literature and to suggest that this surgical method be abandoned.

The neuroradiologic evaluation of "optic neuritis".

Optic neuritis, even when clinically typical, cannot be diagnosed with certainty because mass lesions compressing the anterior visual pathways may mimic it. The radiologist is in a position to assist in identifying such lesions or in ruling them out and thus preventing surgical exploration. While every patient in whom the diagnosis of optic neuritis is entertained should have plain roentgenograms of skull, orbits and optic canals, we have developed a schema for detailed neuroradiologic investigation based on clinical and plain roentgenographic findings. A classification of such lesions by location is illustrated.