Impairment of vertebral artery flow caused by extrinsic lesions

In a consecutive series of 71 cases of extrinsic lesions involving the vertebral artery (VA), 51 patients presented with external compression of this vessel. The compressive agents included 34 tumors, 4 osteophytes, 5 fibrous bands, 4 traumatic lesions, 2 neural elements, and 2 infectious processes. The main site was the second portion of the VA (C2-C6) (30 of 51 patients). Compression always induced at least significant stenosis, and in 8 patients caused complete occlusion. The compression was either permanent (44 patients) or intermittent (7 patients). Symptoms were observed in 11 patients, including 2 with permanent deficits. Surgical release of compression was performed each time symptoms could be explained by a reduction in VA flow and also when the compressing agent needed to be removed, as in the cases involving tumors. VA decompression was achieved by direct approach in 37 patients, by reduction and fixation of a traumatic dislocation in 2 patients, and by distal revascularization in 4 patients. Medical treatment or roentgenotherapy was used in the other patients. Results were excellent in all but 2 patients, who died from traumatic and ischemic lesions, respectively. Therefore, it seems important to identify external causes of compression of the VA for two reasons: 1) to suppress symptoms of vertebrobasilar insufficiency when their relation to VA compression is clearly established, and 2) to remove compressive agents like tumors safely while preserving the VA.

Madreporic coral: a new bone graft substitute for cranial surgery

Since 1985, the authors have been using madreporic coral fragments (genera Porites) as a bone graft substitute. Of the 167 coral grafts implanted, 150 were coral "corks" used to obliterate burr holes (diameter 10 mm), five were large implants (length 20 to 40 mm) to repair skull defects, and 12 were coral blocks to reconstruct the floor of the anterior cranial fossa. Previous experimental studies suggested that coral grafts would be well tolerated and become partially reossified as the calcific skeleton was resorbed. The authors describe their experience and detail the main biological properties of these materials, which appear to be very promising for use in cranial reconstructive surgery.

Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note

In surgery, better access to the anterior part of the foramen magnum with less risk to the lower brainstem can be obtained by lateral enlargement of the usual posterior opening. This requires exposure and control of the vertebral artery (VA) and the sigmoid sinus (SS) and, for further enlargement, medial transposition of the VA and section of the SS with inferior petrosal resection. This technique has been applied fully or partially in 14 cases of anteriorly located tumors of the foramen magnum. It widens exposure on the anterior aspect of the neural axis and allows work in a nearly frontal plane.

Coarctation repair without cardiac catheterization in infants

Of 35 infants who underwent an operation for coarctation of the aorta, 15 did not undergo cardiac catheterization before surgery. The diagnoses in all uncatheterized patients were made by clinical examination, chest radiography, ECG, and two-dimensional echocardiography combined with pulsed Doppler echocardiography. Associated anomalies diagnosed by two-dimensional/Doppler echocardiography included a patent ductus arteriosus in all patients, bicuspid aortic valve in six, small ventricular septal defect in four, and complete common atrioventricular canal in one. In no instance was the diagnosis of coarctation in error. In addition, the clinical significance of the ventricular septal defect was judged correctly by two-dimensional echocardiography, and no patient required an early reoperation because of significant left-to-right shunt. Two significant lesions were missed in one patient each: mitral stenosis and aortic stenosis. These diagnoses were missed in patients who were first seen with either profound congestive heart failure or shock. Coarctation of the aorta and associated lesions can be diagnosed accurately by two-dimensional echocardiography. This permits proper patient management without the added risk of cardiac catheterization. Although mitral and aortic lesions may be missed because of low cardiac output, this does not result in management errors.

Congenital abnormalities of the aortic arch: MR imaging

Thirty-four patients, 1 month to 63 years old, with known or suspected congenital abnormalities of the aortic arch underwent magnetic resonance (MR) imaging. Sixteen patients were studied retrospectively, 18 prospectively. In all retrospective studies, the aortic arch abnormality was seen with MR imaging. In the prospective studies, MR imaging enabled diagnosis in 15 of 18 (83%) patients. Twenty-nine of 34 patients underwent two-dimensional echocardiography; nine were studied retrospectively, 20 prospectively. In the prospective studies, echocardiography enabled diagnosis in 13 of 20 (65%) patients. Although two-dimensional echocardiography has a high sensitivity in the detection of aortic arch abnormalities in the neonate, arch abnormalities in the neonate, its sensitivity is lower in older children, adults, and postoperative patients. The authors' experience shows that MR imaging is an important, noninvasive modality in the evaluation of older children, adults, and postoperative patients with congenital aortic arch abnormalities.

Hygromycin A, an antitreponemal substance. II. Therapeutic effect for swine dysentery

This study was conducted to evaluate hygromycin A fed to growing swine at 1, 5, 10 or 20 g/ton feed for the control of Treponema hyodysenteriae-caused dysentery. Pigs provided carbadox at 50 g/ton feed served as an infected treatment control group. All pigs were orally, via stomach intubation, administered 100 ml of a T. hyodysenteriae broth culture. During the in vivo test, rectal swabs were taken for T. hyodysenteriae isolation, body weights of all pigs and the feed consumption was determined. All pigs were euthanized and necropsied at study end; the large intestine was cultured for T. hyodysenteriae and gross intestinal lesions were noted. T. hyodysenteriae-caused swine dysentery was successfully controlled by feeding hygromycin A at 5 g/ton. Hygromycin A medicated pigs performed as well as or better than carbadox-medicated pigs.

Use of in situ pericardium for surgical relief of pulmonary venous obstruction following Mustard's operation

A technique is described for relief of pulmonary venous obstruction following the Mustard procedure. The functional left atrium is enlarged by using the pericardium in situ. This is expected to allow for growth of the pericardial patch and to avoid recurrent obstructions. This technique has also been used in reoperations for systemic venous obstruction after enlargement of the systemic baffle with a patch.

Stimulation of muscle protein degradation by murine and human epidermal cytokines: relationship to thermal injury

Accelerated muscle proteolysis is a characteristic of systemic reaction following trauma, sepsis, or extensive thermal injury. The factors involved in this accelerated muscle breakdown have not been fully described. However, recently leukocytic pyrogen or interleukin 1 (IL-1) have been implicated in the induction of muscle protein degradation in septicemia or trauma. The epidermal cytokine epidermal cell-derived thymocyte activating factor (ETAF) is biochemically and functionally similar to IL-1. Injury to skin can augment ETAF activity. Using a murine model, we found that thermal injury can significantly enhance ETAF/IL-1 activity in a dose-dependent fashion. In addition, ETAF can cause net muscle protein breakdown in vitro. Thus, increased amounts of ETAF produced by thermally injured skin may contribute to the accelerated muscle breakdown in extensive thermal injury.

Use of a venous assist device after repair of complex lesions of the right heart

Sixteen patients underwent hemodynamic evaluation of a venous assist device after complex operations on the right side of the heart. The device consists of an inflatable abdominal binder attached to a Jobst extremity pump causing intermittent external compression of the abdomen. In addition, six of these patients were evaluated using total lower body compression for comparison. Modifications of the Fontan procedure were performed in 14 patients, mitral valve anuloplasty and tricuspid valve replacement in 1 patient and reconstruction of the right ventricular outflow tract for treatment of pulmonary atresia with intact septum in 1 patient. The patients' ages ranged from 23 months to 31 years (mean 10.7 +/- 1.8 years). Systemic blood pressure, right and left atrial pressures, heart rate and arterial-mixed venous oxygen saturation difference were recorded in each patient with and without the device in place. With the venous assist device, mean systolic pressure increased from 95 +/- 4 to 122 +/- 3 mm Hg (p less than 0.05) and diastolic pressure rose from 57 +/- 3 to 70 +/- 3 mm Hg (p less than 0.05). Left atrial pressure increased from 7 +/- 1 to 15 +/- 1 mm Hg and right atrial pressure from 15 +/- 1 to 23 +/- 1 mm Hg (both p less than 0.05). In addition, arterial-mixed venous oxygen saturation difference decreased from 29% without the device to 23% with the device in place (p less than 0.05). Total lower body compression gave similar results to intermittent abdominal compression alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Actinomycotic osteomyelitis of the skull and atlas with late dissemination. A case of transient neurosurgical syndrome

Actinomycosis of the skull and/or the vertebral column is extremely rare in previously healthy children and its diagnosis is difficult. A case is reported here involving the occipital bone and the atlas. The disease had started 4 years before diagnosis and presented as a neurosurgical affection in a 13-year-old-girl. The disease spread towards the retropharyngeal space and probably disseminated to the liver and the lung. Actinomyces israeli grew from cultures. Antibiotic treatment was successful.

Endovascular treatment of vertebral arteriovenous fistulas in twenty-two patients

Twenty-two cases of vertebral arteriovenous fistulas treated by embolization are reported. Although such fistulas are usually asymptomatic they may be occasionally responsible for tinnitus. Neurologic complications are exceptional. Spontaneous fistulas have been found predominantly in the C1-C2 region (9 of 13 cases), while post-traumatic fistulas were located in the C5-C6 region and were often iatrogenic in origin (7 of 9 cases). In 17 cases embolization caused definitive closure of the fistula, while the vertebral artery remained patent. In three patients it was also necessary to close the vertebral artery in order to occlude the fistula. In two instances, endovascular management failed to obliterate the fistula. At present, endovascular treatment is the simplest and one of the least aggressive therapeutic approaches to vertebral arteriovenous fistulas.

Twelve months' follow-up by night sleep EEG after recovery from severe head trauma

Night sleep EEG recordings were obtained in patients, 1, 6, and 12 months after recovery from severe head trauma with signs of brain stem dysfunction. Modifications of intra-sleep wakefulness (W.) and REM sleep were observed but none of slow wave sleep (SWS). At one month after regaining consciousness, the lower the initial level of brain stem dysfunction, the greater the sleep disturbances were. At six months, improvement was observed. At one year, sleep disturbances increased again mainly in patients between 35 and 45 years old. These results are best compared to those observed in normal but elderly people, over 70 years.

Early and late results in the treatment of patients with pulmonary atresia and intact ventricular septum

The courses of 22 consecutive patients with pulmonary atresia and intact ventricular septum who underwent surgery between 1977 and 1984 were reviewed. This included 18 patients undergoing an initial surgical palliation, and four patients referred for a definitive procedure. A surgically oriented classification based on the degree of right ventricular hypoplasia was developed and applied. Three groups were identified and were termed the mild, moderate, and severe hypoplasia groups. Those in the mild and moderate groups had mild or moderate right ventricular and tricuspid hypoplasia with well-developed right ventricular outflow tracts and were therefore acceptable candidates for procedures to create an opening between the right ventricle and pulmonary artery. Those in the severe hypoplasia group and severe hypoplasia of the tricuspid valve, the right ventricle, and the right ventricle outflow tract so that attempts at establishing continuity with the pulmonary artery were thought to be unlikely to succeed. There were three patients with mild, 11 with moderate, and eight with severe hypoplasia. In the mild hypoplasia group, all three patients initially underwent valvotomy alone, but two required a shunt in the early postoperative period. In the moderate hypoplasia group, all patients underwent a valvotomy and received a central shunt with a snare, which allowed subsequent adjustment of pulmonary flow without thoracotomy in four patients. In the severe hypoplasia group, five patients received a shunt alone and one underwent valvotomy with atrial septectomy. This last patient represents the only early (less than 30 days) death in the series (6% mortality).(ABSTRACT TRUNCATED AT 250 WORDS)

Extradural and hourglass cervical neurinomas: the vertebral artery problem

Eleven cases of cervical neurinomas with an extradural component were operated on with control of the vertebral artery as the first step of the surgical procedure. The lateral anterior approach was used first in each case with excellent results. In the case of hourglass tumors (seven cases), a complementary posterior approach was performed to remove the intradural portion. Primary control of the vertebral artery in cases of extradural or hourglass neurinoma is a logical and safe procedure in the attempt to achieve complete and bloodless tumor removal.

Lateral sinus reconstructive surgery: treatment of intracranial hypertension by venous anastomosis

Ten cases of venous by-pass for revascularization of the lateral sinus have been performed to treat intracranial hypertension following hindrance of cerebral venous drainage. Principles and indications of this technique are discussed. In correctly selected cases this technique proved to be efficient in normalizing hypertension of venous origin.

Management of pulmonary arteriovenous fistulas after superior vena cava-right pulmonary artery (Glenn) anastomosis

Pulmonary arteriovenous fistulas developed following a superior vena cava-right pulmonary artery shunt in a patient with cyanotic heart disease. An axillary arteriovenous fistula was created to improve oxygenation, but its effectiveness was compromised by the pulmonary fistulas. Transcatheter coil embolization of the pulmonary fistulas was performed with clinical improvement.

Vertebro-basilar ischaemia. Its relation to stenosis and occlusion of the vertebral artery

Bilateral vertebral angiography has been performed on 44 cases of vertebrobasilar ischaemia (VB I), excluding transient ischaemic attacks, and on 20 cases of carotid ischaemia with lesions of the vertebral artery (VA). Significant lesions (stenosis of more than 50% of the lumen and occlusion) of the VA were found in 72% of VB I and 70% of carotid ischaemia cases. In the VB I group, occlusions are as frequent as stenosis (17 occlusions and 15 stenosis); on the contrary, occlusions are half as frequent as stenosis in the carotid ischaemia group. Bilateral lesions are also more often discovered after VB I than after carotid ischaemia. Topographically, the lesions are mainly at the ostium and in the third portion of the VA. The possibility that vertebro-basilar strokes are related to significant lesions of the VA in its cervical part is emphasized. Haemodynamic disorder can explain infarcts related to bilateral lesions and some of those reported after unilateral lesions. Embolism may be suggested in cases of significant stenosis and of certain unilateral occlusions.

[Lumbosciatica and nerve root anomalies]

The authors report 3 cases of lumbar pain and sciatica where operation revealed the existence of abnormalities in the distribution of L5 and S1 roots. In one case, the L5 root was not recognised within fibrous tissue also surrounding S1 and S2 and histological examination of this "fibrosis" led to the identification of nerve structures. Development of postoperative L5 paralysis showed that the L5 root was contained within the tissue non-individualised, consisting of multiple rootlets. In the other two cases the L5 and S1 roots arose from a common trunk. There was an associated herniated disc in all three cases. A review of the literature revealed the rarity of such abnormalities, as well as the fact that they were not recognised before surgery. They are difficult to recognise, even at the time of operation. The prognosis is less good than in typical lumbar pain and sciatica, essentially because of surgical difficulties of the disc curettage.

Vertebro-basilar ischaemia with thrombosis of the vertebral artery: report of two cases with embolism

Two cases with vertebro-basilar infarcts associated with severe stenosis of the vertebral artery in its cervical part is reported. Complete thrombosis of the vertebral artery was observed after a short delay in both cases. As the carotid arteries were normal and the controlateral vertebral artery was dominant, an embolic mechanism was suspected. No new event occurred in the following one and three years respectively after the stroke. These two cases demonstrate the possibility of embolism from severe stenosis of the cervical vertebral artery. This mechanism could explain some of the infarcts related to vertebral artery occlusion.

[Polygraphic study of nocturnal waking in patients with traumatic brain stem injuries (author's transl)]

The waking periods during sleep of 16 patients, having been in post-traumatic coma for 5-40 days (aged 15-28 years), were studied electroencephalographically 1 month (T1) and 6 months (T6) after regaining consciousness and were compared with control subjects. The amount of waking (frequency and duration) increased appreciably at 1 month (20% of total sleep time and 21 awakenings per night) and was augmented even more in those cases in which the initial damage was more severe caudally and the duration of coma longer. At 6 months, the duration of waking was reduced somewhat (12% vs. 3% controls), but the frequency of awakening had not changed. By this stage the level of initial damage did not seem to produce any effect. These results show that the disturbance in the sleep-waking cycle regresses more rapidly the less severe the degree of initial damage was.

Frequency of primary brain stem lesions after head injuries. A CT scan analysis from 186 cases of severe head trauma

Analysis of level of brain stem dysfunction, evolution, and CT scan profile was made on 76 cases of head injuries with prolonged unconsciousness and without hemispheric focal lesion and midline shift on CT scan. Eleven cases were considered normal on CT scan. The CT scan aspect of primary brain stem lesion was identified in 31.5% of these series, and in 14.5% of all severe head traumas (186 cases), from which this series is taken. Primary and secondary CT scan profiles were observed whatever the clinical level of dysfunction and its evolution. Pontine lesions were mainly associated with haemorrhage in the brain stem and diffuse brain swelling; but minimal signs (cortical level) and benign outcome can also be related to axial haemorrhage. These results emphasize the frequency of primary brain stem lesions and the value of CT scan in head injuries.

Neurophysiological effects of experimental intracranial hypertension on three different structures of the brain stem in the cat. Rostrocaudal deterioration

Modifications if multi-unit activity are analyzed during experimental intracranial hypertension in the cat at three levels of the brain stem red nucleus (NR), nucleus giganto-cellularis (Gc), and lateral geniculate body (GO). An initial increase of activity is observed in NR and Gc, which is followed by a fall of activity. This fall is sooner and more important for the rostral structures than for the caudal ones. In GO, activity decreases as soon as intracranial hypertension starts. These results are similar to those already recorded in the mesencephalic and bulbar reticular formation. They are discussed on the basis of monoamine levels and local CBF variations studied in the brain stem, following the same protocol. The higher sensitivity of rostral brain stem structures to intracranial hypertension is correlated to the clinical concept of rostro-caudal deterioration.

Surgical approach to the whole length of the vertebral artery with special reference to the third portion

A lateral route between the SCM and the lateral border of the internal jugular vein is defined from an anatomical study for exposure of the VA. It offers the simplest route for controlling any part or the whole length of the VA, including its intracranial portion. Surgical indications are discussed on the basis of our experience in eight cases with, in all cases, control of the VA in its third segment between C2 and the foramen magnum. Arteriovenous malformations are the most frequent indications; two cases were treated by direct approach and one by exclusion and anastomosis between the internal carotid artery and the vertebral artery at C1-C2. TUmours of the lateral cervical space (one haemangiopericytoma and one jugular glomus tumour) or of the posterior fossa extruding out of the foramen magnum or the jugular foramen (one meningioma) may require control of the VA. Traumatic lesions (one case) or compression by an osteophytic spur are also indications for this approach. Wall lesions of the VA (aneurysm or stenosis) are best treated by exclusion and anastomosis between either the carotid or the subclavian artery and the vertebral artery at C1-C2 level. One case of aneurysmal dysplasia was cured by anastomosis between the subclavian artery and the vertebral artery at C1-C2 with a saphenous vein graft and clipping of the VA proximal to the by-pass. Radiological examinations are fundamental for diagnosis, treatment when embolization is necessary, and choice of surgical treatment, according to the importance of the contralateral VA and the medullary branches.

[Significance and prognostic value of Parinaud's syndrome in hydrocephalus (author's transl)]

Eleven out of 260 cases of chronic hydrocephalus in adults were associated with mesencephalic symptoms, in particular Parinaud's ophthalmoplegia. Investigations aimed at detecting intracranial growth consistently gave negative results. In most cases, the midbrain symptoms were accompanied by intracranial hypertension and therefore reflected an aggravation of the hydrocephalus. They regressed when manoeuvres tending to reduce intracranial pressure were applied on time. On three occasions, they were followed by pontobulbar symptoms and treatment was ineffective. When brain stem symptoms (especially Parinaud's syndrome) occur in the course of hydrocephalus, one should always look for tumoral lesions, but they may also point to deterioration of the disease, which should be treated before it becomes irreversible. The mechanism of brain stem involvement in hydrocephalus is discussed in the light of electrophysiological recordings during experimentally-induced intracranial hypertension in the cat.