Hemorrhagic cerebral dissecting aneurysms: surgical treatments and results

INTRODUCTION

Cerebral dissecting aneurysms are an increasingly recognized etiology of subarachnoid hemorrhage SAH and cerebral stroke. Hemorrhagic dissecting aneurysms of the anterior circulation have been considered to be somewhat different to those of the posterior circulation not only in terms of their pathophysiology, but also in terms of their management. Herewith our series of hemorrhagic dissecting aneurysms of the internal carotid artery ICA, vertebral artery VA, basilar artery BA and some of those of distal cerebral arteries is presented and compared to the series reported in the literature. Therapeutic consideration in the light of our experiences emphasizing the significance of aneurysm entrapment in combination with bypass surgery is presented.

MATERIAL AND METHODS

During the last 13 years over 1000 patients with cerebral aneurysms were treated surgically in our department. Hemorrhagic dissecting aneurysms were diagnosed in 26 patients. Diagnosis was based on neuroradiological findings as well as intraoperative findings. All patients underwent surgical intervention. Clinical findings of these patients were analysed retrospectively. Follow-up outcomes were evaluated according to the Glasgow Outcome Scale GOS at 3 months after treatments.

RESULTS

Location of 26 dissecting aneurysms was: ICA 11 cases (42%), VA 9 cases (35%), BA 3 cases, MCA 2 cases and PCA (P1 segment) one case. Primary surgical treatments were performed on day 3.7 of SAH on average. Clinical manifestation of dissecting aneurysms of the ICA and their outcome was more severe compared with those of the VA (p < 0.01): WNFS grade 3.1 vs 2.4 and GOS score 3.4 vs 4.3. As a conventional neck clipping procedure was problematic or impossible (aneurysm recurrence after clipping, premature rupture at the time of exposure or clipping), entrapment (or proximal ligation) plus EC-IC bypass procedure was the most frequent final definitive method of surgical treatment (9/26 35%: ICA 6/11, VA 1/9 and MCA 2/2) followed by proximal ligation or trapping only 7/26, neck clipping 7/26 and coating 4/26.

CONCLUSIONS

Hemorrhagic dissecting aneurysms still remain problematic in their diagnosis and treatment. One has to be aware of the diagnostic possibility of dissecting aneurysms as an etiology of SAH. Neurosurgeons have to be prepared to be able to manage complex surgical situations also by the use of EC-IC bypass, as its combination with entrapment procedure can be the final treatment of choice. Less invasive endovascular technique is in evolution but its availability and superiority are still to be settled.

Bonnet bypass in multiple cerebrovascular occlusive disease

The rationale and technique of the bonnet bypass procedure is discussed in two cases of multiple cerebrovascular occlusive disease.

METHOD

Cerebral revascularization was achieved using respectively a radial artery interposition graft and a brachiocephalic vein interposition graft to connect the contralateral STA with a cortical branch of the ipsilateral MCA.

FINDINGS

This alternate bypass technique proved to be an effective means of cerebral revascularization in selected cases where ipsilateral extracranial donor vessels were unavailable for classic STA-MCA bypass surgery.

CONCLUSION

Clinical and hemodynamic improvement can be achieved by a bonnet bypass in selected cases of multiple cerebrovascular occlusive disease. In addition to its previously described role in skull base tumor surgery, the procedure should therefore earn consideration in the treatment of cerebral ischemia and stroke prevention.

Impact of graft size and resuspension level of the commissures on aortic insufficiency after reimplantation of the aortic valve

BACKGROUND

In addition to the size of the graft, the resuspension of the commissures has been described as important for valve function in valve-sparing aortic root replacement procedures. This study describes the influence of a stepwise reduction of the fixation level of the commissures within the graft as well as a stepwise reduction of graft size on valve insufficiency.

METHOD

Porcine aortic valves were reimplanted into a tubular graft and the height of the commissures was reduced in a stepwise manner. In a second series of experiments, the diameter of the grafts was reduced by 30 % and 50 %.

RESULTS

A reduction of the commissure heights by 10 % and 20 % caused a significant increase in reflux water. Using the criteria of homograft preparation, a 10 %, but not a 20 %, reduction was tolerated. The coaptation level of the valve became increasingly lower, indicating a higher risk for late valve incompetence. A reduction of the prosthesis diameter by 30 % and 50 % did not result in insufficiency of the valve but it lowered the coaptation level.

CONCLUSION

Resuspension of the commissures within the graft has a more important impact on early failure rates than the choice of graft size.

Large-scale, saturating insertional mutagenesis of the mouse genome

We describe the construction of a large-scale, orderly assembly of mutant ES cells, generated with retroviral insertions and having mutational coverage in >90% of mouse genes. We also describe a method for isolating ES cell clones with mutations in specific genes of interest from this library. This approach, which combines saturating random mutagenesis with targeted selection of mutations in the genes of interest, was successfully applied to the gene families of G protein-coupled receptors (GPCRs) and nuclear receptors. Mutant mouse strains in 60 different GPCRs were generated. Applicability of the technique for the GPCR genes, which on average represent fairly small targets for insertional mutagenesis, indicates the general utility of our approach for the rest of the genome. The method also allows for increased scale and automation for the large-scale production of mutant mice, which could substantially expedite the functional characterization of the mouse genome.

Measurements of daily urinary uranium excretion in German peacekeeping personnel and residents of the Kosovo region to assess potential intakes of depleted uranium (DU)

Following the end of the Kosovo conflict, in June 1999, a study was instigated to evaluate whether there was a cause for concern of health risk from depleted uranium (DU) to German peacekeeping personnel serving in the Balkans. In addition, the investigations were extended to residents of Kosovo and southern Serbia, who lived in areas where DU ammunitions were deployed. In order to assess a possible DU intake, both the urinary uranium excretion of volunteer residents and water samples were collected and analysed using inductively coupled plasma-mass spectrometry (ICP-MS). More than 1300 urine samples from peacekeeping personnel and unexposed controls of different genders and age were analysed to determine uranium excretion parameters. The urine measurements for 113 unexposed subjects revealed a daily uranium excretion rate with a geometric mean of 13.9 ng/d (geometric standard deviation (GSD)=2.17). The analysis of 1228 urine samples from the peacekeeping personnel resulted in a geometric mean of 12.8 ng/d (GSD=2.60). It follows that both unexposed controls and peacekeeping personnel excreted similar amounts of uranium. Inter-subject variation in uranium excretion was high and no significant age-specific differences were found. The second part of the study monitored 24 h urine samples provided by selected residents of Kosovo and adjacent regions of Serbia compared to controls from Munich, Germany. Total uranium and isotope ratios were measured in order to determine DU content. (235)U/(238)U ratios were within +/-0.3% of the natural value, and (236)U/(238)U was less than 2 x 10(-7), indicating no significant DU in any of the urine samples provided, despite total uranium excretion being relatively high in some cases. Measurements of ground and tap water samples from regions where DU munitions were deployed did not show any contamination with DU, except in one sample. It is concluded that both peacekeeping personnel and residents serving or living in the Balkans, respectively, were not exposed to significant amounts of DU.

Serum S100B levels in patients after cardiac surgery: possible sources of contamination

BACKGROUND

S100B protein is considered to be a potential marker of brain damage. The aim of our study was to determine the contamination effect of retransfused blood on the serum S100B concentrations in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to differentiate between this simple contamination effect and its possible enhancement by haemolysis.

METHODS

The first part of the study was performed in a group of 10 patients scheduled for coronary artery bypass grafting. Baseline S100B level was determined in a blood sample drawn from the radial artery before skin incision. After performing the distal anastomosis, additional blood samples were drawn from 1) the radial artery, 2) the aortic root catheter, 3) the pericardial space, and 4) CPB suction. To study the possible haemolytic effect on serum S100B levels, a second group of 23 patients was studied. S100B concentrations were determined in samples drawn simultaneously from the radial artery and bypass circuit after the end of CPB. Further samples from the retransfusion blood bag were analysed after one, two and three hours.

RESULTS

Blood samples from the pericardial space and CPB suction exhibited significantly higher levels of S100B than the samples drawn from the peripheral artery and aortic root catheter in the first group of patients. No significant differences between the S100B levels in the peripheral blood and aortic root catheter were detected. In the second group, S100B was significantly elevated in the samples taken from the retransfusion blood bag in comparison with peripheral blood. S100B levels remained stable during the whole follow-up period.

CONCLUSION

The results of our study show increased serum S100B levels caused by contamination originating in the mediastinal tissues. Storage of blood in the retransfusion bag and haemolysis can be excluded as sources of contamination. The role of S100B in perioperative monitoring of patients undergoing cardiac surgery remains to be established and should be confirmed by further studies using neuropsychological tests and imaging techniques.

Biokinetic modelling of natural thorium in humans by ingestion

The retention of naturally occurring thorium (228Th, 230Th, 232Th) in model compartments and its daily urinary and faecal excretion after acute and chronic injections and ingestions were calculated for male and female subjects of six age groups based on the current age-dependent biokinetic model for thorium (Th) recommended by the International Commission on Radiological Protection (ICRP). The results are tabulated in a database. The calculated contents of 228,230,232Th in organs or tissues using their reference concentrations in foodstuffs for the European population are compared with autopsy data. The model prediction of 232Th in whole body for a 50-year-old unexposed person is 22 mBq, 86% of that in skeleton, 9.7% in other soft tissues, 3.4% in liver, 0.7% in kidneys and 0.01% in blood. The modelling predicts lower contents of the natural Th isotopes in whole body, especially in blood compared with measured data for the unexposed public. Modelled 232Th daily urinary excretions are 5 to 10 times less than bio-assay data from the authors' own laboratory.

Practical implications of procedures developed in IDEA project--comparison with traditional methods

The idea of the IDEA project aimed to improve assessment of incorporated radionuclides through developments of more reliable and possibly faster in vivo and bioassay monitoring techniques and making use of such enhancements for improvements in routine monitoring. In direct in vivo monitoring technique the optimum choice of the detectors to be applied for different monitoring tasks has been investigated in terms of material, size and background in order to improve conditions namely to increase counting efficiency and reduce background. Detailed studies have been performed to investigate the manifold advantageous applications and capabilities of numerical simulation method for the calibration and optimisation of in vivo counting systems. This calibration method can be advantageously applied especially in the measurement of low-energy photon emitting radionuclides, where individual variability is a significant source of uncertainty. In bioassay measurements the use of inductively coupled plasma mass spectrometry (ICP-MS) can improve considerably both the measurement speed and the lower limit of detection currently achievable with alpha spectrometry for long-lived radionuclides. The work carried out in this project provided detailed guidelines for optimum performance of the technique of ICP-MS applied mainly for the determination of uranium and thorium nuclides in the urine including sampling procedure, operational parameters of the instruments and interpretation of the measured data. The paper demonstrates the main advantages of investigated techniques in comparison with the performances of methods commonly applied in routine monitoring practice.

Daily uranium excretion in German peacekeeping personnel serving on the Balkans compared to ICRP model prediction

An investigation was performed to assess a possible health risk of depleted uranium (DU) for residents and German peacekeeping personnel serving on the Balkans. In order to evaluate a possible DU intake, the urinary uranium excretions of volunteers were collected and analysed using inductively coupled plasma mass spectrometry (ICP-MS). In total, more than 1300 urine samples from soldiers, civil servants and unexposed controls of different genders and ages were analysed to determine uranium excretion parameters. All participating volunteers, aged 3-92 y, were grouped according to their gender and age for evaluation. The results of the investigation revealed no significant difference between the unexposed controls and the peacekeeping personnel. In addition, the geometric means of the daily urinary excretion in peacekeeping personnel, ranging from 3 to 23 ng d(-1) for different age groups, fall toward the lower end of renal uranium excretion values published for unexposed populations in literature. The measured data were compared with the International Commission on Radiological Protection prediction for the intake of natural uranium by unexposed members of the public. The two data sets are in good agreement, indicating that no relevant intake of additional uranium, either natural or DU, has appeared for German peacekeeping personnel serving on the Balkans.

Observation of changes in urinary excretion of thorium in humans following ingestion of a therapeutic soil

The study investigated the changes in urinary thorium excretion by humans following ingestion of a therapeutic soil, which contains about 10 ppm of thorium. This well-known healing earth in Germany has been considered as an alternative medicine for diarrhoea and gastric hyper-acidity. Six adult volunteers ingested this therapeutic soil in varying quantities for 1-15 days at levels approximating those described in the package insert of the medicine (10-60 g of soil per day). The subjects ingested about 0.1-0.6 mg of thorium daily, which is 100-600 times higher than the normal daily intake of about 1 microg thorium in Germany. All 24-h urine samples collected from the subjects during pre-ingestion, ingestion and post-ingestion periods of the soil were analyzed for (232)Th using inductively coupled plasma mass spectrometry (ICP-MS). The measured excretion values varied in a wide range. Apparently, the high thorium amounts administered did not increase the (232)Th excretion in urine as expected, suggesting that this soil ingestion will not result in a considerably higher and harmful uptake of thorium into the human body.

Improvements in routine internal monitoring--an overview of the IDEA project

The IDEA project aimed to improve the assessment of incorporated radionuclides through developments of advanced in vivo and bioassay monitoring techniques and making use of such enhancements for improvements in routine monitoring. Many of these findings are not new in the sense that they are being already employed in advanced laboratories or for specialised applications. The primary goal was to categorise those new developments regarding their potential and eligibility for the routine monitoring community. Attention has been given to in vivo monitoring techniques with respect to detector characteristics and measurement geometry to improve measurement efficiency with special attention to low energy gamma emitters. Calibration-specifically supported by or through methods of numerical simulation-have been carefully analysed to reduce overall measurement uncertainties and explore ways to accommodate the individual variability based on characteristic features of a given person. For bioassay measurements at low detection limits, inductively coupled plasma mass spectroscopy offers significant advantages both in accuracy, speed, and sample preparation. Specifically, the determination of U and Th in urine and the associated models have been investigated. Finally, the scientific achievements have been analysed regarding their potential to offer benefits for routine monitoring. These findings will be presented in greater detail in other papers at this conference, whereas this paper intends to give an overview and put both the scientific achievements as well as the derived benefits into perspective.

Implementation of bioassay methods to improve assessment of incorporated radionuclides

The present work which was carried out in the framework of an EU project (IDEA: Internal Dosimetry-Enhancements in Application; Contract Number: FIKR CT2001 00164) shall provide commonly acceptable guidelines for optimum performance of ICP-MS measurements with focus on urinary measurements of uranium, thorium and actinides. From the results of this work it is recommended that, whenever feasible, 24 h urine sampling should be conducted to avoid large uncertainties in the quantitation of daily urinary excretion values. For storage, urine samples should be acidified and kept frozen before analysis. Measurement of total uranium in urine by ICP-MS at physiological levels (<10 ng.l(-1)) requires no sample preparation besides UV photolysis and/or dilution. For the measurement of thorium in urine by ICP-MS, it can be concluded, that salt removal from the urine samples is not recommended. For the measurement of actinides in urine it is shown that ICP-MS is well-suited and a good alternative to alpha-spectrometry for isotopes with T1/2>5x10(4) years. In general, ICP-MS measurements are an easy, fast and cost-saving methodology. New improved measuring techniques (HR-SF-ICP-MS) with detection limits in urine of 150 pg.l(-1) (1.9 microBq.l(-1)) for 238U, 30 pg.l(-1) (2.4 microBq.l(-1)) for 235U and 100 pg.l(-1) (0.4 microBq.l(-1)) for (232)Th, respectively, meet all necessary requirements. This method should therefore become the routine technique for incorporation monitoring of workers and of members of the general public, in particular for uranium contamination.

Limits on the high-energy gamma and neutrino fluxes from the SGR 1806-20 giant flare of 27 December 2004 with the AMANDA-II detector

On 27 December 2004, a giant gamma flare from the Soft Gamma-Ray Repeater 1806-20 saturated many satellite gamma-ray detectors, being the brightest transient event ever observed in the Galaxy. AMANDA-II was used to search for down-going muons indicative of high-energy gammas and/or neutrinos from this object. The data revealed no significant signal, so upper limits (at 90% C.L.) on the normalization constant were set: 0.05(0.5) TeV-1 m;{-2} s;{-1} for gamma=-1.47 (-2) in the gamma flux and 0.4(6.1) TeV-1 m;{-2} s;{-1} for gamma=-1.47 (-2) in the high-energy neutrino flux.

Long-lasting decrease in viremia in macaques chronically infected with simian immunodeficiency virus SIVmac251 after therapeutic DNA immunization

Rhesus macaques chronically infected with highly pathogenic simian immunodeficiency virus (SIV) SIVmac251 were treated with antiretroviral drugs and vaccinated with combinations of DNA vectors expressing SIV antigens. Vaccination during therapy increased cellular immune responses. After the animals were released from therapy, the virus levels of 12 immunized animals were significantly lower (P = 0.001) compared to those of 11 animals treated with only antiretroviral drugs. Vaccinated animals showed a persistent increase in immune responses, thus indicating both a virological and an immunological benefit following DNA therapeutic vaccination. Several animals show a long-lasting decrease in viremia, suggesting that therapeutic vaccination may provide an additional benefit to antiretroviral therapy.

The role of intraoperative monitoring of oculomotor and trochlear nuclei -safe entry zone to tegmental lesions

OBJECTIVE

A safe entry zone to tegmental lesions was identified based on intraoperative electrophysiological findings, the compound muscle action potentials (CMAP) from the extraocular muscles, and anatomic considerations. This entry zone is bordered caudally by the intramesencephalic path of the trochlear, laterally by the spinothalamic tract, and rostrally by the caudal margin of the brachium of the superior colliculus.

METHODS

Four intrinsic midbrain lesions were operated upon via the safe entry zone using the infratentorial paramedian supracerebellar approach. All lesions involved the tegmentum and included an anaplastic astrocytoma, a metastatic brain tumor, a radiation necrosis, and a cavernous angioma. CMAP were bilaterally monitored from the inferior recti (for oculomotor function) and superior oblique (for trochlear nerve function) muscles.

RESULTS

In three of four cases, CMAP related to the oculomotor nerve were obtained upon stimulation at the cavity wall after removal of the tumor. Stimulation at the surface of the quadrigeminal plate, however, did not cause any CMAP response. Using this monitoring as an indicator, the lesions were totally removed.

CONCLUSIONS

In the surgery of tegmental lesions, CMAP monitoring from extraocular muscles is particularly helpful to prevent damage to crucial neural structures during removal of intrinsic lesions, but less so to select the site of the medullary incision. The approach via the lateral part of the colliculi is considered to be a safe route to approach the tegmental lesions.

Diagnostic prénatal et prise en charge d’un cas d’hémangiome congénital du cuir chevelu

Rapidly involuting congenital hemangioma (RICH) is a rare vascular lesion, identified in 1996, of elective localization in the dermal-hypodermic tissue. Its name comes from its particular natural course: it is fully developed at birth and then completely involutes, usually in the first year. We present a case of a RICH of the scalp discovered with a screening ultrasonography in the 31st week of gestation. We list the differential diagnoses. After birth, positive diagnosis lies preferably on pathology examination of a biopsy specimen in order to eliminate the hypothesis of a less favorable vascular lesion, teratoma or malignant tumor.