Acute intraoperative brain herniation during elective neurosurgery: pathophysiology and management considerations

OBJECTIVES

To describe operative procedures, pathophysiological events, management strategies, and clinical outcomes after acute intraoperative brain herniation during elective neurosurgery.

METHODS

Review of clinical diagnoses, operative events, postoperative CT findings, intracranial pressure, and arterial blood pressure changes and outcomes in a series of patients in whom elective neurosurgery had to be abandoned because of severe brain herniation.

RESULTS

Acute intraoperative brain herniation occurred in seven patients. In each patient subarachnoid or intraventricular haemorrhage preceded the brain herniation. The haemorrhage occurred after intraoperative aneurysm rupture either before arachnoidal dissection (three) or during clip placement (one); after resection of 70% of a recurrent hemispheric astroblastoma; after resection of a pineal tumour; and after a stereotactic biopsy of an AIDS lesion. In all patients the procedure was abandoned because of loss of access to the intracranial operating site, medical measures to control intracranial pressure undertaken (intravenous thiopentone), an intraventricular catheter or Camino intracranial pressure monitor inserted, and CT performed immediately after scalp closure. The patients were transferred to an intensive care unit for elective ventilation and multimodality physiological monitoring. Using this strategy all patients recovered from the acute ictus and no patient had intracranial pressure > 35 mm Hg. Although one patient with an aneurysm rebled and died three days later the other six patients did well considering the dramatic and apparently catastrophic nature of the open brain herniation.

CONCLUSIONS

There are fundamental differences in the pathophysiological mechanisms, neuroradiological findings, and outcomes between open brain herniation occurring in post-traumatic and elective neurosurgical patients. The surprisingly good outcomes in this series may have occurred because the intraoperative brain herniation was secondary to extra-axial subarachnoid or intraventricular haemorrhage rather than intraparenchymal haemorrhage or acute brain oedema. Expeditious abandonment of the procedure and closure of the cranium may also have contributed to the often very satisfactory clinical outcome.

Death anxiety, locus of control, and purpose in life of physicians. Their relationship to patient death notification

This study explored gender and specialty differences in death anxiety, locus of control, and purpose in life of physicians, and if these variables might influence the clinical behavior of physicians regarding death notification. The subjects were 155 attending and house staff physicians who responded to mailed questionnaires. The female physicians scored higher in death anxiety than the male physicians. The psychiatrists scored higher in death anxiety than surgeons. There was a trend for the internists to have scores indicating a more external locus of control. Purpose in life was inversely correlated with death anxiety and external locus of control. Death anxiety was related to the physicians' preferred mode of conveying the news of an unexpected patient death to the next of kin.

Detection of sugarcane bacilliform virus in sugarcane germplasm

Sugarcane bacilliform virus (SCBV), a badnavirus was found in sugarcane genotypes of Saccharum officinarum L., S. barberi Jesw., S. sinense Roxb., S. robustum Brand and Jesw., and Saccharum hybrids. In most of the suspected genotypes the virus was found associated with clear foliar symptoms. However, certain symptom-free clones carried the virus too. The virus was detected by immuno-electron microscopy (IEM) and enzyme-linked immunosorbent assay (ELISA) in suspected clones. The virions measured about 108-118 x 20-21 nm in size. The virus was serologically closely related to another badnavirus, banana streak virus (BSV). Virus titer was low in most of the genotypes. However, a close correlation between symptoms expression and virus titer existed in some genotypes.

CO2 production in three earthworm species exposed to terbuthylazine and carbofuran in food

Studies were conducted in the laboratory to determine the influence of sublethal doses of pesticides on the respiration of earthworms. Three different lumbricids were exposed to different concentrations of terbuthylazine and carbofuran for up to 12 weeks by allowing them to feed on contaminated plant material. After different exposure periods the CO2 output of the worms was determined by gas chromatography. High terbuthylazine concentrations generally increased CO2 production, whereas the low concentration tended to decrease it, especially in two of the three species studied. Low carbofuran concentration increased the CO2 expired in all the species; the high dose negatively affected the respiration in Lumbricus terrestris and L. rubellus after 3 weeks and in Eisenia andrei after 4 weeks of exposure.

Liquid to hexatic to crystalline order in Langmuir-Blodgett films

Atomic force microscope images of zinc arachidate (ZnA2) Langmuir-Blodgett films show that three- and five-layer films are "hexatic," with long-range bond-orientational order and short-range positional correlations of three to five lattice repeats. The monolayer in contact with the substrate is disordered. Films of seven or more layers of ZnA2 are crystalline. A population of dislocations, most likely originating at the substrate, disrupts the positional but not the orientational order of the lattice, leading to hexatic layers intermediate between crystal and liquid. The influence of the substrate propagates farther into ZnA2 films than into cadmium arachidate films because the molecular cohesion is much weaker in ZnA2 than in cadmium arachidate, as evidenced by a less dense molecular packing.

The structure and stability of phospholipid bilayers by atomic force microscopy

Atomic force microscopy (AFM) was used to investigate the structure, stability, and defects of the hydrophilic surfaces of Langmuir-Blodgett bilayer films of distearoylphosphatidylcholine (DSPC) and dipalmitoylphosphatidylethanolamine (DPPE) in the solid phase, and dilinoleoylphosphatidylethanolamine (DLPE) in the fluid phase. Their relative resilience to external mechanical stress by the scanning tip and by fluid exchange were also investigated. DPPE monolayers showed parallel ridges at the surface with a period of 0.49 nm, corresponding to the rows of aligned headgroups consistent with the known crystallographic structure. DSPC and DLPE monolayers did not show any periodic order. The solid DSPC and DPPE monolayers were stable to continued rastering by the AFM tip; however, the stability of DLPE monolayers depended on the pH of the aqueous environment. Structural defects in the form of monolayer gaps and holes were observed after fluid exchange, but the defects in DLPE monolayer at pH 11 were stable during consecutive scanning. At pH 9 and below, the defects induced by fluid exchange over DLPE monolayers were more extensive and were deformed easily by consecutive scanning of the AFM tip at a force of 10 nN. The pH dependence of resilience was explained by the increasing bending energy or frustration due to the high spontaneous curvature of DLPE monolayers at low pH. The tangential stress exerted by the AFM tip on the deformable monolayers eventually produced a ripple pattern, which could be described as a periodic buckling known as Shallamach waves.

Nail gun injury to the brain: an unusual case of suicide

An unusual case of fatal suicidal craniocerebral penetrating injury due to a nail gun is described. The victim, a 52 year old joiner experienced in the use of nail drivers, shot himself just above the forehead in the midline, driving the nail through his hypothalamus and midbrain. Death was delayed by nearly 24 hours.

Langmuir-Blodgett films

The controlled transfer of organized monolayers of amphiphilic molecules from the airwater interface to a solid substrate was the first molecular-scale technology for the creation of new materials. However, the potential benefits of the technology envisioned by Langmuir and Blodgett in the 1930s have yet to be fully realized. Problems of reproducibility and defects and the lack of basic understanding of the packing of complex molecules in thin films have continued to thwart practical applications of Langmuir-Blodgett films and devices made from such films. However, modern high-resolution x-ray diffraction and scanning probe microscopy have proven to be ideal tools to resolve many of the basic questions involving thin organic films. Here, studies are presented of molecular order and organization in thin films of fatty acid salts, the prototypical system of Katharine Blodgett. Even these relatively simple systems present liquid, hexatic, and crystalline order; van der Waals and strained layer epitaxy on various substrates; wide variations in crystal symmetry and interfacial area with counterions; modulated superstructures; and coexisting lattice structures. The wide variety of possible structures presents both a challenge and an opportunity for future molecular design of organic thin-film devices.

Stereotaxic brain biopsy in AIDS patients: does it contribute to patient management?

The authors analysed all cases of brain biopsy done in AIDS or HIV+patients at the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, during the period 1989-92 to determine the clinical utility of the procedure. Thirteen lesions were biopsied revealing toxoplasmosis in five, lymphoma in four, progressive multifocal leucoencephalopathy in three, HIV encephalitis in two and encephalitis of unknown aetiology in one. One biopsy specimen contained abnormal tissue but was non-diagnostic. The median survival after biopsy was only 7 weeks, but preoperative immunological (median CD4 count 45) and clinical status of the patients were poor. Although the impact of tissue diagnosis on patient survival was minimal it did enable modification of drug therapy. The authors preliminary experience with biopsy in AIDS patients suggests that the diagnostic information obtained is of limited value in prolonging the lives of patients in poor immunological status, but may be useful in refining medical therapies for toxoplasmosis and progressive multifocal leucoencephalopathy. Whether biopsy should be performed earlier in the course of cerebral disease in an effort to prolong survival time remains unclear.

Strained-layer van der Waals epitaxy in a Langmuir-Blodgett film

Atomic force microscope images of Langmuir-Blodgett films of lead and manganese fatty acid salts show that these monolayers have long-range order and are oriented with respect to the mica substrate, although the lattice symmetries of the monolayers and substrate are dramatically different. The surface lattice of sequentially thicker films evolves toward the bulk structure while retaining the substrate alignment. This behavior is in distinct contrast to films of cadmium fatty acid salts on mica, or all films on amorphous silicon oxide, in which the monolayer structure is disordered and a three-layer-thick film displays the bulk structure.

Parasellar chondromyxofibroma with ipsilateral total internal carotid artery occlusion

A case of parasellar chondromyxofibroma with ipsilateral total internal carotid artery occlusion is presented. Its radiological appearance and its pathological characteristics are discussed and compared with previously published reports. The rare association with total internal carotid artery occlusion is reviewed.

Physicians' and the public's attitudes on communication about death

We studied the preferences of physicians and the public as to how physicians should inform a family of a patient's unexpected death. When the family had to be reached by telephone, 72% of our 150 physician-respondents preferred telling the family that the patient was critically ill and asking the family to come to the hospital immediately (critical notification [CN]); 25% of the physicians preferred announcing the death over the telephone (death notification [DN]). When the news had to be announced in person, 58% of physicians preferred immediately announcing it (IA), and 33% preferred gradual announcement (GA). A Gallup poll commissioned by us showed that 64% of the adult population in the United States preferred CN, 26% DN, 79% IA, and 17% GA; CN and IA were preferred in all the demographic subgroups examined. We discuss our findings, the reasons for them, and their ethical and practical implications.

Development of agoraphobia after surviving cancer

We present a case conference on a 32-year-old accountant who developed embryonal carcinoma of the testis, two months after the birth of a son with a missing leg. His cancer was successfully treated with surgery and chemotherapy. After 5 years, when he was told that he need not be closely followed by his physicians anymore because he had been cured of cancer, he developed agoraphobia with panic attacks. This interfered with his occupational and social adjustment. His phobia was treated successfully with pharmacotherapy, behavior therapy, and psychotherapy. We explore the psychologic impact of cancer, the activation of separation anxiety and aggressive impulses after its successful treatment, the crippling nature of his agoraphobia, and the ingredients of his successful response to treatment.

Alzheimer's disease in a patient on long-term hemodialysis: a case report

This case report describes a progressive dementia in a 49-year-old black male on long-term hemodialysis. The initial presentation simulated depression. The dementia persisted after an unsuccessful cadaver homograft transplant. The character of the dementia was nonspecific but typical features of dialysis dementia were lacking. Autopsy revealed a ruptured cerebral aneurysm, polycystic kidneys, moderately severe atherosclerosis, miliary tuberculosis, and neurofibrillary degeneration of the hippocampus. The significance of a possible relationship between end-stage renal disease (ESRD), hemodialysis, and Alzheimer's disease in this case is discussed.