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Vuong NB, Quang HV, Linh Trang BN, Duong DH, Toan NL, Tong HV. Association of PKLR gene copy number, expression levels and enzyme activity with 2,3,7,8-TCDD exposure in individuals exposed to Agent Orange/Dioxin in Vietnam. Chemosphere 2023; 329:138677. [PMID: 37060958 DOI: 10.1016/j.chemosphere.2023.138677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3,7,8-TCDD) is the most toxic congener of dioxin and has serious long-term effects on the environment and human health. Pyruvate Kinase L/R (PKLR) gene expression levels and gene variants are associated with pyruvate kinase enzyme deficiency, which has been identified as the cause of several diseases linked to dioxin exposure. In this study, we estimated PKLR gene copy number and gene expression levels using real-time quantitative PCR (RT-qPCR) assays, genotyped PKLR SNP rs3020781 by Sanger sequencing, and quantified plasma pyruvate kinase enzyme activity in 100 individuals exposed to Agent Orange/Dioxin near Bien Hoa and Da Nang airfields in Vietnam and 100 healthy controls. The means of PKLR copy numbers and PKLR gene expression levels were significantly higher, while pyruvate kinase enzyme activity was significantly decreased in Agent Orange/Dioxin-exposed individuals compared to healthy controls (P < 0.0001). Positive correlations of PKLR gene copy number and gene expression with 2,3,7,8-TCDD concentrations were observed (r = 0.2, P = 0.045 and r = 0.54, P < 0.0001, respectively). In contrast, pyruvate kinase enzyme activity was inversely correlated with 2,3,7,8-TCDD concentrations (r = -0.52, P < 0.0001). PKLR gene copy number and gene expression levels were also inversely correlated with pyruvate kinase enzyme activity. Additionally, PKLR SNP rs3020781 was found to be associated with 2,3,7,8-TCDD concentrations and PKLR gene expression. In conclusion, PKLR copy number, gene expression levels, and pyruvate kinase enzyme activity are associated with 2,3,7,8-TCDD exposure in individuals living in Agent Orange/Dioxin-contaminated areas.
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Affiliation(s)
- Nguyen Ba Vuong
- Department of Haematology, Toxicology, Radiation, and Occupation, 103 Military Hospital, Vietnam Military Medical University, Hanoi, Viet Nam
| | - Ha Van Quang
- The Center of Toxicological and Radiological Training and Research, Vietnam Military Medical University, Viet Nam
| | - Bui Ngoc Linh Trang
- Institute of Biomedicine and Pharmacy, Vietnam Military Medical University, Hanoi, Viet Nam
| | - Dao Hong Duong
- Institute of Biomedicine and Pharmacy, Vietnam Military Medical University, Hanoi, Viet Nam
| | - Nguyen Linh Toan
- Department of Pathophysiology, Vietnam Military Medical University, Hanoi, Viet Nam
| | - Hoang Van Tong
- Institute of Biomedicine and Pharmacy, Vietnam Military Medical University, Hanoi, Viet Nam; Department of Pathophysiology, Vietnam Military Medical University, Hanoi, Viet Nam.
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Abstract
The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.
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Marshall RS, Lazar RM, Pile-Spellman J, Young WL, Duong DH, Joshi S, Ostapkovich N. Recovery of brain function during induced cerebral hypoperfusion. ACTA ACUST UNITED AC 2001; 124:1208-17. [PMID: 11353736 DOI: 10.1093/brain/124.6.1208] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
We used the setting of clinically indicated internal carotid artery balloon test occlusions in 44 patients with inoperable carotid cavernous aneurysms or head and neck tumours to examine real-time changes in higher cerebral function that correlate with specific levels of cerebral blood flow. By making detailed haemodynamic and neurobehavioural measurements during the 30 min the carotid artery was occluded, we were able to quantify higher cerebral function patterns in relation to absolute cerebral blood flow (CBF) levels. We found that once the carotid artery was occluded, patients whose CBF averaged 47 ml/100 g/min (no different from baseline) maintained consistent performance on a sustained attention task; those whose CBF dropped to an average 37 ml/100 g/min had a reversible deterioration of sustained attention, and those whose CBF fell to 27 ml/100 g/min had impaired sustained attention that persisted until the carotid occlusion was reversed. The relevance of these results to the pathological state of clinical stroke is discussed with respect to the haemodynamic and physiological mechanisms that may determine how brain function is lost and regained in the setting of acute cerebral hypoperfusion.
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Affiliation(s)
- R S Marshall
- Department of Neurology, New York-Presbyterian Medical Center, Columbia University, 710 W. 168th Street, New York, NY 10032, USA.
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Joshi S, Hashimoto T, Ostapkovich N, Pile-Spellman J, Duong DH, Hacein-Bey L, Hacien-Bey L, Marshall RS, James DJ, Young WL. Effect of intracarotid papaverine on human cerebral blood flow and vascular resistance during acute hemispheric arterial hypotension. J Neurosurg Anesthesiol 2001; 13:146-51. [PMID: 11294457 DOI: 10.1097/00008506-200104000-00013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study assessed the feasibility of augmenting cerebral blood flow (CBF) and decreasing hemispheric cerebrovascular resistance (CVR) by intracarotid papaverine during acute cerebral hypotension. Awake patients (n = 10) undergoing transfemoral balloon occlusion of an internal carotid artery (ICA) with nitroprusside (SNP)-induced systemic hypotension (10% reduction of mean arterial pressure) were studied. We measured mean femoral artery pressure (MAP), mean distal ICA pressure (P(ica)), and CBF (intracarotid 133Xe) at two time points: before and after intracarotid papaverine infusion (1 or 7 mg/min). Two patients became symptomatic immediately after ICA occlusion and were excluded. One patient developed a focal seizure during papaverine infusion. In another, the occlusion balloon deflated prematurely. Of the remaining six patients, two of the three patients who received high-dose papaverine (7 mg/min) developed transient obtundation. The remaining three patients, who received low-dose papaverine (1 mg/min), did not develop any neurologic symptoms. There was a trend for intracarotid papaverine to increase hemispheric CBF by 36% (33 +/- 10 versus 45 +/- 22 ml x 100 g(-1) x min(-1), P = .084, n = 6); papaverine decreased CVR from 1.3 +/- 0.4 to 1.0 +/- 0.3 mm Hg x ml(-1) x 100 g(-1) x min(-1) (P = .049). There was no significant change in heart rate, MAP, or P(ica) during experimental protocol. Manipulation of CVR by intracarotid papaverine during acute hemispheric arterial hypotension appears to be feasible. Further studies are needed to establish safety and efficacy.
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Affiliation(s)
- S Joshi
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Abstract
BACKGROUND A case is described in which an intraorbital hematoma was found to complicate recovery from attempted aneurysm clipping 5 days into the postoperative period. The etiology, management, and complication avoidance are discussed. CASE DESCRIPTION Five days after attempted surgical clipping of an internal carotid artery aneurysm via a frontotemporal craniotomy with orbital osteotomy, a patient underwent coiling of the aneurysm. Shortly after the endovascular procedure, the patient developed exophthalmos and ophthalmoplegia involving the right side followed by decline in her level of consciousness. An emergency computed tomography (CT) scan revealed an epidural hematoma with intraorbital extension. After evacuation of the hematoma, the patient recovered extraocular function and returned to her baseline mental status. CONCLUSION Exophthalmos and ophthalmoplegia in a patient recovering from cranial surgery using skull base techniques warrants immediate attention, especially after endovascular procedures. Delay in intervention may result in loss of neurologic function or life. The authors discuss the relevant literature and management of this uncommon complication.
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Affiliation(s)
- C A Spence
- Department of Neurological Surgery, The George Washington University Medical Center, Washington, DC 20037, USA
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Joshi S, Young WL, Duong DH, Ostapkovich ND, Aagaard BD, Hashimoto T, Pile-Spellman J. Intracarotid infusion of the nitric oxide synthase inhibitor, L-NMMA, modestly decreases cerebral blood flow in human subjects. Anesthesiology 2000; 93:699-707. [PMID: 10969303 DOI: 10.1097/00000542-200009000-00019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors hypothesized that if nitric oxide (NO) was a determinant of background cerebrovascular tone, intracarotid infusion of NG-monomethyl-L-arginine (L-NMMA), a NO synthase (NOS) inhibitor, would decrease cerebral blood flow (CBF) and intracarotid L-arginine would reverse its effect. METHODS In angiographically normal cerebral hemispheres, after the initial dose-escalation studies (protocol 1), the authors determined the effect of intracarotid L-NMMA (50 mg/min for 5 min) on CBF and mean arterial pressure (MAP) over time (protocol 2). Changes in CBF and MAP were then determined at baseline, during L-NMMA infusion, and after L-NMMA during L-arginine infusion (protocol 3). To investigate effects of higher arterial blood concentrations of L-NMMA, changes in CBF and MAP were assessed at baseline and after a bolus dose of L-NMMA (250 mg/1 min), and vascular reactivity was tested by intracarotid verapamil (1 mg/min, protocol 4). CBF changes were also assessed during induced hypertension with intravenous phenylephrine (protocol 5). RESULTS Infusion of L-NMMA (50 mg/min for 5 min, n = 7, protocol 2) increased MAP by 17% (86 +/- 8 to 100 +/- 11 mmHg; P < 0.0001) and decreased CBF by 20% (45 +/- 8 to 36 +/- 6 ml. 100 g-1. min-1; P < 0.005) for 10 min. Intracarotid l-arginine infusion after L-NMMA (protocol 3) reversed the effect of L-NMMA. Bolus L-NMMA (protocol 4) increased MAP by 20% (80 +/- 11 to 96+/-13 mmHg; P< 0.005), but there was no significant decrease in CBF. Intracarotid verapamil increased CBF by 41% (44+/- 8 to 62 +/- 9 ml. 100 g-1. min-1; P< 0.005). Phenylephrine-induced hypertension increased MAP by 20% (79 +/- 9 to 95 +/- 6 mmHg; P = 0.001) but did not affect CBF. CONCLUSIONS The results suggest that intracarotid L-NMMA modestly decreases CBF, and the background tone of cerebral resistance vessels may be relatively insensitive to NOS inhibition by the intraarterial route.
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Affiliation(s)
- S Joshi
- Departments of Anesthesiology, Neurological Surgery, and Radiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Abstract
Delayed neurologic deficits secondary to vasospasm remain a vexing problem. Current treatments include: hypertensive hypervolemic hemodilution (Triple-H) therapy, angioplasty, and intra-arterial papaverine administration. Significant morbidity and mortality still result from vasospasm despite these therapies. We present two patients with symptomatic vasospasm who received intra-aortic balloon pump counterpulsation (IABP) to improve cerebral blood flow when they were unable to tolerate Triple-H therapy. One patient (L.T.) developed vasospasm after resection of a meningioma that encased the carotid and middle cerebral artery. The other patient (D.F.) suffered a subarachnoid hemorrhage (Fisher Grade III, Hunt/Hess Grade III) from a basilar tip aneurysm. Postoperatively, both patients developed vasospasm. Treatment with Triple-H therapy, angioplasty, and papaverine yielded modest results. When they experienced cardiac ischemia, Triple-H therapy was stopped, but their neurologic condition deteriorated markedly. Because of this, IABP was started. Both patients had an immediate improvement in cardiac function. IABP was able to reverse some of the neurologic deficits, and was weaned off after several days of support. Both patients had a substantial improvement in function, and are now capable of caring for themselves. We conclude that IABP may play an important role for improving cerebral blood flow in patients with vasospasm. It may be particularly useful in those patients with limited cardiac reserve.
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Affiliation(s)
- C L Rosen
- Department of Neurological Surgery, The George Washington University Medical Center, Washington D.C, USA
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Abstract
A 49-year-old woman presenting with recurrent, reversible brainstem symptoms and a distal basilar artery aneurysm underwent balloon test occlusion. Five minutes after balloon inflation she developed a reversible isolated dysarthria. Despite failing the test occlusion (and after an additional brainstem event), the patient underwent surgery with placement of a clip across the basilar artery. The operation was tolerated without complication. The authors conclude that 1) pure dysarthria may be a symptom of temporary basilar artery occlusion and 2) balloon testing may overestimate the risk of basilar artery clipping.
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Affiliation(s)
- A Hartmann
- The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY 10032, USA
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Marshall RS, Lazar RM, Mohr JP, Pile-Spellman J, Hacein-Bey L, Duong DH, Joshi S, Chen X, Levin B, Young WL. Higher cerebral function and hemispheric blood flow during awake carotid artery balloon test occlusions. J Neurol Neurosurg Psychiatry 1999; 66:734-8. [PMID: 10329746 PMCID: PMC1736397 DOI: 10.1136/jnnp.66.6.734] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Measures capable of detecting early alterations of brain function during acute cerebral ischaemia have not been adequately defined. Internal carotid artery (ICA) test occlusions provide a well controlled environment to investigate the effects of reversible acute hemispheric hypoperfusion on brain function. A continuous time estimation task was developed that reliably demonstrated alterations in higher cerebral function before development of any deficits in elementary neurological function during ICA balloon catheter test occlusions. In the present study, we hypothesised that alterations in our behavioural task would correlate significantly with absolute level of ipsilateral CBF. METHODS Twenty five patients underwent awake ICA test occlusions during which sustained attention and ipsilateral CBF were measured simultaneously using our time estimation task and the intracarotid 133Xe washout method. Alteration in sustained attention was correlated with CBF after occlusion using Fisher's exact test. RESULTS Deterioration in sustained attention was significantly associated with ipsilateral CBF below 30 ml/g/min (Fisher's exact test, p=0.047). Changes in individual patients' performance on the behavioural task correlated in real time with changes occurring either at the point of occlusion or at a specific threshold of induced hypotension. Sensitivity for our behavioural test in predicting CBF was 75%; specificity 70%. CONCLUSIONS Monitoring sustained attention during carotid balloon test occlusions seems to be a sensitive means to detect decreases in CBF as measured by 133Xe washout. Correlation between higher cerebral function and CBF can allow more detailed investigations of physiological relations between cerebral haemodynamics and brain function in human conditions of cerebral ischaemia.
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Affiliation(s)
- R S Marshall
- Department of Neurology, Columbia-Presbyterian Medical Center, New York, USA
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Sullivan BJ, Sekhar LN, Duong DH, Mergner G, Alyano D. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms. Acta Neurochir (Wien) 1999; 141:1-11; discussion 11-2. [PMID: 10071680 DOI: 10.1007/s007010050259] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass with profound hypothermia and circulatory arrest has seen a resurgence as an adjunct technique in neurological surgery. We report our experience with this technique in treating seven complex vertebro-basilar aneurysms. METHODS Skull base approaches were used in all cases, providing excellent exposure and minimizing brain retraction. There were six basilar artery aneurysms and one giant fusiform vertebro-basilar artery aneurysm. All aneurysms but one had an apparent neck, which could be clipped. The fusiform vertebro-basilar artery aneurysm was trapped, partially resected, and the circulation was reestablished with a saphenous vein graft from the cervical internal carotid artery to the mid-basilar artery. RESULTS Five patients had an excellent outcome and two had a good outcome at one year or at latest follow up. Two of the patients showed improvement of neurological deficits which were present before the surgical intervention. CONCLUSION Applying very strict selection criteria in this small series of patients with posterior circulation aneurysms, excellent or good results were achieved using the profound hypothermic circulatory arrest technique.
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Affiliation(s)
- B J Sullivan
- Department of Neurological Surgery, George Washington University Medical Center, Washington DC, USA
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Joshi S, Young WL, Pile-Spellman J, Duong DH, Vang MC, Hacein-Bey L, Lee HT, Ostapkovich N. The feasibility of intracarotid adenosine for the manipulation of human cerebrovascular resistance. Anesth Analg 1998; 87:1291-8. [PMID: 9842815 DOI: 10.1097/00000539-199812000-00015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED To assess the feasibility of manipulating human cerebrovascular resistance with adenosine, we measured cerebral blood flow (CBF) by determining the initial slope (IS) of tracer washout 20-80 s after intracarotid 133Xe injection (standard IS) during sequential 3-min intracarotid infusions of (a) saline; (b) adenosine 1.2-mg bolus followed by an infusion of 1 mg/min (bolus + infusion); (c) saline; and (d) nicardipine (0.1 mg/min). During 133Xe washout, adenosine caused a rapidly clearing compartment. Therefore, tracer washout was also analyzed 5-25 s after injection (early IS). Nicardipine (n = 8) increased both standard IS (from 39+/-12 to 53+/-16 mL 100g.min(-1); P < 0.005) and early IS (from 40+/-9 to 55+/-20 arbitrary units; P < 0.02) to a similar degree. Adenosine bolus + infusion increased early IS (from 33+/-6 to 82+/-43 arbitrary units; P < 0.02) but did not increase standard IS (from 41+/-12 to 43 +/-16 mL 100g(-1) min(-1)). Standard and early IS values were then determined before and after adenosine delivered either by infusion alone (2 mg/min for 3 min, n = 5) or bolus alone (2 mg in 1 s, n = 3). Neither standard nor early IS changed after adenosine infusion alone. Early IS increased after adenosine bolus alone. Increase in early IS, but not standard IS, suggests a transient (<30 s) increase in CBF. IMPLICATIONS Intracarotid adenosine, in the 1- to 2-mg dose range, may cause a transient, but not a sustained, increase in cerebral blood flow. Intracarotid adenosine in such a dose range does not seem to be an appropriate drug for sustained manipulation of cerebrovascular resistance.
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Affiliation(s)
- S Joshi
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA
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Abstract
The effects of pulsed direct current (dc) electric fields on the frequency of spontaneous bursting in a model epileptic focus were studied. The high potassium hippocampal slice model was used to generate spontaneous burst firing activity similar to interictal spikes in the pyramidal cell layer of CA3. Electric fields were generated from platinum subdural electrodes placed in the perfusion bath. Three hundred and seventy-eight experimental trials were performed on 10 hippocampal slices from 10 rats and the effects of field polarity, field strength and duration of stimuli on firing frequency was examined. Hippocampal slices were oriented horizontally with the CA3 layer towards the positive electrode, the average interburst interval did not correlate significantly with polarity of the delivering pulses (one-way ANOVA, p = 0.96). Average interburst interval showed a significant correlation with pulse duration of 200 and 400 msec (p = 0.030 and p = 0.004, respectively). As a function of field strength, there were significant average interval changes for fields of 33, 46, and 73 mV/mm (p = 0.024, p = 0.001 and p = 0.001, respectively). In conclusion, CA3 burst firing activity in high potassium concentration can therefore be altered by electric fields.
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Affiliation(s)
- D H Duong
- Department of Neuroscience and Epilepsy Center, King/Drew Medical Center, Los Angeles, CA 90059, USA
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Bejjani GK, Duong DH, Kalamarides M, Ziyal I, Sullivan BJ. Cerebral vasospasm after tumor resection. A case report. Neurochirurgie 1998; 43:164-8. [PMID: 9696892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE AND IMPORTANCE Symptomatic cerebral vasospasm can occur after resection of tumors in or adjacent to the basal cisterns, causing delayed neurological deterioration. This potentially treatable condition may go unrecognized. Delay in its recognition will adversely affect the outcome of the patients. There has been a few cases of vasospasm after tumoral resection reported in the literature, mostly in adults. We report a case of vasospasm after resection of a third nerve schwannoma in a pediatric patient. This is the youngest patient reported to date with vasospasm after resection of a brain tumor. CLINICAL PRESENTATION A six years old girl presented with sudden onset diplopia. Radiological work-up revealed a third nerve mass. She underwent a craniotomy for resection of her mass. Pathological findings were consistent with a third nerve schwannoma. One week postoperatively, her mental status deteriorated. A CT scan revealed a diffuse hypodense area involving the right frontal and temporal lobes in the middle cerebral artery distribution as well as the midbrain. The absence of these findings on the MRI imaging performed on the first postoperative day made us evoke a vascular etiology. A cerebral angiogram was performed and revealed vasospasm in the right internal carotid artery and in the right middle and posterior cerebral arteries. Hyperdynamic hypervolemic hemodilutional therapy was instituted. CONCLUSION Delayed clinical deterioration from vasospasm is a potentially reversible condition, if recognized early. A high index of suspicion should be maintained in case delayed clinical deterioration occurs after surgery of tumors in the basal cisterns. Cerebral angiography will confirm the diagnosis. Early institution of hyperdynamic hypervolemic hemodilutional therapy and angioplasty may reverse the deficit and improve outcome.
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Affiliation(s)
- G K Bejjani
- Department of Neurosurgery, George Washington University, Washington, DC 20037, USA
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Duong DH, Young WL, Vang MC, Sciacca RR, Mast H, Koennecke HC, Hartmann A, Joshi S, Mohr JP, Pile-Spellman J. Feeding artery pressure and venous drainage pattern are primary determinants of hemorrhage from cerebral arteriovenous malformations. Stroke 1998; 29:1167-76. [PMID: 9626290 DOI: 10.1161/01.str.29.6.1167] [Citation(s) in RCA: 174] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to define the influence of feeding mean arterial pressure (FMAP) in conjunction with other morphological or clinical risk factors in determining the probability of hemorrhagic presentation in patients with cerebral arteriovenous malformations (AVMs). METHODS Clinical and angiographic data from 340 patients with cerebral AVMs from a prospective database were reviewed. Patients were identified in whom FMAP was measured during superselective angiography. Additional variables analyzed included AVM size, location, nidus border, presence of aneurysms, and arterial supply and venous drainage patterns. The presence of arterial aneurysms was also correlated with site of bleeding on imaging studies. RESULTS By univariate analysis, exclusively deep venous drainage, periventricular venous drainage, posterior fossa location, and FMAP predicted hemorrhagic presentation. When we used stepwise multiple logistic regression analysis in the cohort that had FMAP measurements (n = 129), only exclusively deep venous drainage (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.4 to 9.8) and FMAP (OR, 1.4 per 10 mm Hg increase; 95% CI, 1.1 to 1.8) were independent predictors (P < 0.01) of hemorrhagic presentation; size, location, and the presence of aneurysms were not independent predictors. There was also no association (P = 0.23) between the presence of arterial aneurysms and subarachnoid hemorrhage. CONCLUSIONS High arterial input pressure (FMAP) and venous outflow restriction (exclusively deep venous drainage) were the most powerful risk predictors for hemorrhagic AVM presentation. Our findings suggest that high intranidal pressure is more important than factors such as size, location, and the presence of arterial aneurysms in the pathophysiology of AVM hemorrhage.
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Affiliation(s)
- D H Duong
- Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Hartmann A, Mast H, Mohr JP, Koennecke HC, Osipov A, Pile-Spellman J, Duong DH, Young WL. Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation. Stroke 1998; 29:931-4. [PMID: 9596237 DOI: 10.1161/01.str.29.5.931] [Citation(s) in RCA: 207] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Decisions on invasive arteriovenous malformation (AVM) treatment are currently based on natural-course risk estimates of AVM bleeding and assumptions on morbidity from cerebral hemorrhage in general. However, morbidity of AVM hemorrhage has rarely been reported. We sought to assess the morbidity of intracranial hemorrhage in patients with cerebral AVMs. METHODS From a prospective AVM database, 119 patients were analyzed: 115 had a hemorrhage as the diagnostic event, and 27 of them suffered a second hemorrhage during follow-up; an additional 4 patients had other diagnostic symptoms but bled during follow-up. The type (parenchymal, subarachnoid, intraventricular) and location of AVM hemorrhage were determined by CT/MR brain imaging. Disability and neurological impairment were assessed with the Barthel Index, the Rankin Scale, and the National Institutes of Health Stroke Scale, with a mean follow-up time of 16.2 months. RESULTS Of the 115 incident hemorrhages, 34 (30%) were subarachnoid, 27 (23%) parenchymal, 18 (16%) intraventricular, and 36 (31%) in combined locations. In 54 patients (47%; 95% confidence interval [CI], 38% to 56%) the incident hemorrhage resulted in no neurological deficit, and an additional 43 patients (37%; 95% CI, 28% to 46%) were independent in their daily activities (Rankin 1). Fifteen patients (13%; 95% CI, 7% to 19%) were moderately disabled (Rankin 2 or 3), and 3 (3%; 95% CI, 0% to 6%) were severely disabled (Rankin > or =4). Parenchymal hemorrhages were most likely to result in a neurological deficit (52%). Type and morbidity of hemorrhage during follow-up were similar to incident events. Twenty (74%) of 27 patients with both incident and follow-up hemorrhages were normal or independent (Rankin 0 or 1). None of the patients with a hemorrhage during follow-up died during the observation period. CONCLUSIONS Hemorrhage from cerebral AVMs appears to have a lower morbidity than currently assumed. This finding encourages a reevaluation of the risks and benefits of invasive AVM treatment.
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Affiliation(s)
- A Hartmann
- Stroke Unit, The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY 10032, USA.
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Duong DH, Kolluri VR, Spittaler PJ, Sengupta RP. Risk Score Estimation: a new method to determine optimal timing of aneurysm clipping for improved management outcome. Neurol Res 1998; 20:218-24. [PMID: 9583582 DOI: 10.1080/01616412.1998.11740509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The outcome of 703 patients who underwent surgery following aneurysmal subarachnoid hemorrhage were analyzed with regards to age, associated medical conditions, vasospasm and clinical status at the time of operation. Patients with Hunt and Hess grade I, II, and III had a 96%, 90% and 93% favorable (good and fair) outcome respectively. In contrast only 58% of patients with grade IV had the same result. The outcome was unfavorable in 13% of the patients who were older than 60 years of age and only in 9% of the patients between 30-59 years of age. All the patients younger than 30 years old had a good outcome. Associated medical condition increased the incidences of poor outcome (7% vs. 12%). Patients harboring vertebro basilar aneurysms had a poorer outcome, as opposed to those with aneurysms located in the anterior circulation (20% vs. 8%). The presence of angiographic vasospasm alone did not influence outcome. A proposed point value was given for each of the adverse factors and from this the optimal surgical time was determined for each individual patient. This concept of Risk Score Estimation approach may improve the management outcome of patients with ruptured intracranial aneurysms.
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Affiliation(s)
- D H Duong
- Department of Neuroscience and Epilepsy Center, King-Drew Medical Center, Los Angeles, CA 90059, USA
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Abstract
Intravascular papillary endothelial hyperplasia (IPEH) is a rare benign reactive lesion usually found in thrombosed subcutaneous blood vessels. It uncommonly occurs in the central nervous system and may be mistaken for a more malignant type of tumour such as angiosarcoma. We present a first case of multiple IPEH occurring intracranially in a 51-year-old woman. She developed neurological compromises secondary to the mass affect of the haematoma arising from one of the lesions. Prompt surgical evacuation of the haematoma stabilized her condition. Surgical treatment, pathological findings, radiographic characteristics, and a review of the literature are presented.
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Affiliation(s)
- D H Duong
- Department of Neurological Surgery, George Washington University Medical Center, Washington, DC, USA
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Joshi S, Young WL, Pile-Spellman J, Duong DH, Hacein-Bey L, Vang MC, Marshall RS, Ostapkovich N, Jackson T. Manipulation of cerebrovascular resistance during internal carotid artery occlusion by intraarterial verapamil. Anesth Analg 1997; 85:753-9. [PMID: 9322451 DOI: 10.1097/00000539-199710000-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED Occlusion of the internal carotid artery (ICA) results in acute cerebral hypotension. We hypothesized that during acute cerebral hypotension, in addition to physiological autoregulation, further arteriolar relaxation is possible by pharmacological means. We tested the feasibility of using intracarotid verapamil, a calcium channel blocker, to decrease the cerebrovascular resistance (CVR) and augment cerebral blood flow (CBF) at low postocclusion distal ICA pressures (PICA). Eleven patients undergoing trial occlusion of ICA were enrolled. Distal ICA or stump pressure, hemispheric CBF, and CVR were determined before and after carotid occlusion. During ICA occlusion, CBF and other physiological variables were determined before and after intracarotid verapamil. Two patients were excluded from the study. Carotid occlusion (n = 9) significantly decreased PICA (mean +/- SD, from 82 +/- 22 to 46 +/- 11 mm Hg, P = 0.001) and CBF (from 42 +/- 11 to 33 +/- 11 mL.100 g-1.min-1, P < 0.05). During occlusion, after intracarotid verapamil (3.9 +/- 1.6 mg), hemispheric CBF tended to increase from 31 +/- 11 to 35 +/- 14 mL.100 g-1.min-1 (P = 0.067). However, the percent increase in CBF after verapamil was a linear function of PICA (y = 1.01 x -32, n = 9, r2 = 0.84, P = 0.006). The decrease in CBF during carotid occlusion suggests that near maximal cerebral autoregulatory vasodilation had occurred, although our results indicate that it may be feasible to further augment CBF by pharmacological means during acute cerebral hypotension. IMPLICATIONS When the internal carotid artery is occluded during neurosurgical procedures, there may be a significant reduction in cerebral perfusion. The authors have demonstrated that the intraarterial administration of verapamil increases cerebral blood flow as a linear function of cerebral artery pressure. Intracarotid injection of vasodilators may augment cerebral blood flow during acute cerebral hypotension.
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Affiliation(s)
- S Joshi
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA
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Bejjani GK, Caputy AJ, Kurtzke RN, Duong DH, Sekhar LN. Remote hemorrhage of a pontine cavernous angioma fifty-two years after cerebral irradiation. Acta Neurochir (Wien) 1997; 139:583-4. [PMID: 9248595 DOI: 10.1007/bf02751004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- G K Bejjani
- Department of Neurological Surgery, George Washington University, DC, USA
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Abstract
Cerebellar hemorrhage is a devastating condition with morbidity and mortality related not only to the etiology of the hemorrhage, but also to the timing of the intervention. Sixteen consecutive pediatric patients with acute cerebellar hemorrhages are presented: 6 had vascular abnormalities, 3 had tumors, and 2 had hemorrhages of unknown etiology. Thirteen of the 16 patients survived with only 1 of the 13 having persistent vegetative state as a neurologic outcome. Six of 8 patients presenting in a moribund condition had good outcomes, and 3 of 4 patients presenting with fixed and dilated pupils also had good outcomes. Thus, in contrast to adults, rapid evaluation by CT scanning, followed by the judicious use of ventricular drainage and prompt surgical treatment, have resulted in favorable outcomes in pediatric patients despite their poor clinical presentations. None of the neonates having cerebellar hemorrhages required surgical intervention; their courses could be followed clinically and with transfontanel ultrasound.
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Affiliation(s)
- W M Chadduck
- Department of Neurosurgery, Children's National Medical Center, Washington, DC 20010, USA
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Duong DH, Chadduck WM. Reconstruction of the hypoplastic posterior arch of the atlas with calvarial bone grafts for posterior atlantoaxial fusion: technical report. Neurosurgery 1994; 35:1168-70. [PMID: 7885567 DOI: 10.1227/00006123-199412000-00025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Posterior atlantoaxial fusion is a common procedure performed for instability at C1-C2. This operation requires intact posterior elements of both the atlas and the axis. When this is not the case, the incorporation of the occiput and the lower spinal segments is usually required for adequate posterior fusion, but such a procedure limits the mobility of the upper cervical spine. A technique for the reconstruction of the posterior arch of the atlas with calvarial bone is described in this report. This technique allowed the successful fusion of the C1 and C2 vertebrae in a patient with traumatic atlantoaxial subluxation who also had a congenital absence of the posterior arch of the atlas.
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Affiliation(s)
- D H Duong
- Department of Neurological Surgery, George Washington University Medical Center, Washington, D.C
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Abstract
In a spontaneously bursting neuronal network in vitro, chaos can be demonstrated by the presence of unstable fixed-point behaviour. Chaos control techniques can increase the periodicity of such neuronal population bursting behaviour. Periodic pacing is also effective in entraining such systems, although in a qualitatively different fashion. Using a strategy of anticontrol such systems can be made less periodic. These techniques may be applicable to in vivo epileptic foci.
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Affiliation(s)
- S J Schiff
- Department of Neurosurgery, Children's National Medical Center, Washington, DC
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Abstract
The authors describe a method for quantitation of the area and volume of the resection cavity in patients who have undergone surgery for brain tumors. Using a slide scanner and Image 1.27, a public domain program for the Apple Macintosh II computer, computerized tomography scans and magnetic resonance images can be digitized and analyzed for a particular region of interest, such as the area and volume of tumor on preoperative and postresection scans. Phantom scans were used to analyze the accuracy of the program and the program users. User error was estimated at 2%, program error was 4.5%. This methodology is proposed as a means of retrospectively calculating the extent of tumor resection.
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Affiliation(s)
- D H Duong
- Department of Neurological Surgery, University of Washington Medical Center, Seattle
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