Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration

BACKGROUND AND OBJECTIVES

Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES.

METHODS

A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES).

RESULTS

In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected.

CONCLUSION

The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.

Complications of the Superior Eyelid Endoscopic Transorbital Approach to the Skull Base: Preliminary Experience With Specific Focus on Orbital Outcome

BACKGROUND

The endoscopic superior eyelid approach is a relatively novel mini-invasive technique that is currently investigating for skull base cancers. However, questions remain regarding specific approach-related complications when treating different skull base tumors. This study aims to analyze any surgical complications that occurred in our preliminary consecutive experience, with specific focus on orbital outcome.

METHODS

A retrospective and consecutive cohort of patients treated via a superior eyelid endoscopic transorbital approach at the Division of Neurosurgery of the Hospital Clinic in Barcelona was analyzed. Patients features were described in detail. Complications were divided into 2 groups to analyze separately the approach-related complications, and those resulting from tumor removal. The ocular complications were subdivided into early ocular status (<3 weeks), late ocular status (3-8 weeks), and persistent ocular complications. The "Park questionnaire" was used to determine patient's satisfaction related to the transorbital approach.

RESULTS

A total of 20 patients (5 spheno-orbital meningiomas, 1 intradiploic Meningioma, 2 intraconal lesions, 1 temporal pole lesion, 2 trigeminal schwannoma, 3 cavernous sinus lesions, and 6 petroclival lesions) were included in the period 2017-2022. Regarding early ocular status, upper eyelid edema was detected in all cases (100%) associated with diplopia in the lateral gaze in 30% of cases, and periorbital edema in 15% of cases. These aspects tend to resolve at late ocular follow-up (3-8 weeks) in most cases. Regarding persistent ocular complications, in one case of intraconal lesion, a limitation of eye abduction was detected (5%). In another patient with intraconal lesion, an ocular neuropathic pain was reported (5%). In 2 cases of petroclival menigioma, who were also treated with a ventriculo-peritoneal shunt, slight enophthalmus was observed as a persistent complication (10%). According to the Park questionnaire, no cosmetic complaints, no head pain, no palpable cranial irregularities, and no limited mouth opening were reported, and an average of 89% of general satisfaction was encountered.

CONCLUSIONS

The superior eyelid endoscopic transorbital approach is a safe and satisfactory technique for a diversity of skull base tumors. At late follow-up, upper eyelid edema, diplopia, and periorbital edema tend to resolve. Persistent ocular complications are more frequent after treating intraconal lesions. Enophthalmus may occur in patients with associated ventriculo-peritoneal shunt. According to patient's satisfaction, fairly acceptable results are attained.

Deep brain stimulation and digital monitoring for patients with treatment-resistant schizophrenia and bipolar disorder: A case series

AIM

The use of deep brain stimulation (DBS) has been recently extended for treating resistant psychiatric disorders, but the experience in patients with schizophrenia-related disorders and bipolar disorder (BD) is scarce.

METHOD

We conducted an observational, one-year longitudinal study to evaluate the effects of DBS in four treatment-resistant patients with schizophrenia, schizoaffective, and BD, included in a pilot, last-resource protocol. Patients were digitally monitored for objective assessment of behavioral changes.

RESULTS

After one year of its initiation, DBS of the nucleus accumbens (in subjects N2, N3, and N4) and subgenual anterior cingulate cortex (in N1) produced a significant clinical improvement, associated with decreases in the Clinical Global Impression (from 5.25±0.5 to 3.5±1, p=0.035) and in the Hamilton Depression Rating Scale (HADRS scores, from 14.5±6.56 to 1.5±1.29, p=0.020). We observed a notable, durable therapeutic response in two patients from this cohort (N1 and N3), a clinically relevant relief in a third (N2), and a lack of a significant response in the last one (N4). Maintenance electroconvulsive therapy sessions could be discontinued in the three patients that responded to DBS (N1-3). There were no side effects or relevant changes in cognitive functioning. There were relevant differences between physical activity and sleep time among the four participants.

CONCLUSIONS

These results suggest initial evidence that DBS may be an effective and safe alternative for treating complex and resistant forms of schizophrenia-related disorders and BD. Digital monitoring may help to capture objective measures of behavioral changes after the intervention.

Assessment of cerebral blood flow velocities, brain midline shift and optic nerve sheath diameter by ultrasound in patients undergoing elective craniotomy: A prospective observational feasibility study

BACKGROUND

Brain ultrasound allows measuring the cerebral flow velocity, brain midline shift and optic nerve sheath diameter. Literature is scarce in determining the feasibility to perioperatively perform these measurements altogether and the cerebrovascular behavior in patients scheduled for elective craniotomy.

METHODS

We assessed bilateral cerebral flow velocities, composite index, brain midline shift and optic nerve sheath diameter by cerebral ultrasound in patients scheduled for elective craniotomy before anesthetic induction, at extubation, and at 6 and 24 h after. The aim was to assess the feasibility of brain ultrasound in patients for elective craniotomy and to describe the changes in cerebral flow velocities, brain midline shift and optic nerve sheath diameter from baseline values at different times in the postoperative period.

RESULTS

Sixteen patients were included, of these two were excluded from analysis due to an inadequate sonographic window. There were no changes throughout the study regarding cerebral flow velocity, brain midline shift nor optic nerve sheath diameter assessments. All parameters were maintained in the physiological range without significant variations during the procedure. No perioperative complications were detected.

CONCLUSIONS

The results of our study show the feasibility to perform a perioperative assessment of cerebral flow velocity, brain midline shift or optic nerve sheath diameter jointly and successfully to obtain additional information of baseline cerebral hemodynamics in patients scheduled for elective craniotomy and their postoperative changes during the first 24 h. Future studies with lager samples are needed to address the efficacy of cerebral ultrasound as a monitoring tool.

Hemodynamic Response, Coughing and Incidence of Cerebrospinal Fluid Leakage on Awakening with an Endotracheal Tube or Laryngeal Mask Airway in Place after Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial

We aimed to compare systemic and cerebral hemodynamics and coughing during emergence after pituitary surgery after endotracheal tube (ETT) extubation or after replacing ETT with a laryngeal mask airway (LMA). Patients were randomized to awaken with an ETT in place or after replacing it with an LMA. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, plasma norepinephrine, need for vasoactive drugs, coughing during emergence, and postoperative cerebrospinal fluid (CSF) leakage. The primary endpoint was postoperative MAP; secondary endpoints were SrO2 and coughing incidence. Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. There were no significant between-group differences in blood pressure, nor in the number of patients that required antihypertensive drugs during emergence (ETT: 8 patients (34.8%) vs. LMA: 3 patients (14.3%); p = 0.116). MCA flow velocity was higher in the ETT group (e.g., mean (95% CI) at 15 min, 103.2 (96.3-110.1) vs. 89.6 (82.6-96.5) cm·s-1; p = 0.003). SrO2, cardiac index, and norepinephrine levels were similar. Coughing was more frequent in the ETT group (81% vs. 15%; p < 0.001). CSF leakage occurred in three patients (13%) in the ETT group. Placing an LMA before removing an ETT during emergence after pituitary surgery favors a safer cerebral hemodynamic profile and reduces coughing. This strategy may lower the risk for CSF leakage.

Association between pre-operative serum lactate concentrate with tumour cell proliferative index in primary brain tumour

BACKGROUND

Elevated preoperative lactate levels have been reported in patients admitted for resection of brain tumors. As histologic type and tumor grade have also been linked to lactate concentration, we hypothesized that preoperative lactate concentration in patients with brain tumors may be associated with tumor proliferation. We describe the relationship between preoperative plasma lactate levels, and the cell proliferation marker Ki-67 in brain tumor surgery.

METHODS

In this cross-sectional study, records of patients who underwent craniotomy between June 2017 and February 2018 at our Hospital were reviewed to select glioma and meningioma cases in which lactate concentrations in plasma and degree of cell proliferation were registered. Bivariable and linear regression analyses were used to assess the association between lactate concentrations and the Ki-67 index.

RESULTS

Lactate concentrations in plasma and Ki-67 index were available in 55 patients. Meningioma cases had a mean concentration of 1.2 (0.1) mmol/L compared to diffuse astrocytic and oligodendroglial tumours cases with 1.7 (0.1) mmol/L (p<.01). Both variables had a low positive correlation in meningiomas (Spearman's r, 0.29; 95% CI, -0.10-0.61; p=.13) and a high correlation in gliomas (Spearman's r, 0.64; 95% CI, 0.33-0.82; p<.01). The pooled analysis showed a high correlation index (Spearman's r, 0.61; 95% CI, 0.40-0.76; p<.01). A linear regression model showed that the Ki-67 index explained 43% of the variation in lactate (p<.01).

CONCLUSIONS

Brain tumors with higher rates of cell proliferation have higher plasma lactate levels. In this scenario, lactate concentrations may not only reflect systemic perfusion.

Safety and Feasibility Assessment of the O-Arm as an Intraoperative Angiography Device in Aneurysm Surgery

OBJECTIVE

To describe the technique and initial experience of using a rotational 3-dimensional (3D) fluoroscopy system (O-arm; Medtronic) as intraoperative angiography (IA) in the surgery of cerebral aneurysms.

METHODS

The 3D IA with O-arm (IAWOA) was performed in a consecutive cohort of patients with unruptured intracranial aneurysms. Conventional microsurgical clipping was performed with the assistance of indocyanine green videoangiography. Then the O-arm chassis was brought in, the ipsilateral internal carotid artery was catheterized, and contrasted images were acquired. Resulting datasets were exported in Digital Imaging and Communications in Medicine and processed using the Osirix software in an accessory computer. The 3D image reconstruction was evaluated intraoperatively to confirm aneurysm occlusion and parent vessel patency. Afterward, agreement among IAWOA, indocyanine green videoangiography, and standard postoperative angiography was analyzed.

RESULTS

The initial pilot study was performed in 6 patients with 7 unruptured aneurysms. The aneurysm occlusion rate was 100%. The concordance of the IAWOA and the standard postoperative angiography was complete, both in terms of occlusion and parent vessel patency. No complications derived from the IAWOA were observed except in 1 patient, who presented a retroperitoneal hematoma without clinical consequences.

CONCLUSIONS

The 3D rotational fluoroscopy (O-arm) device could be safely and effectively used as an IA system in selected patients. To the best of our knowledge, this is the first study reporting its use as an IA device. This technique seems to offer excellent image quality that could be compared with that of the gold standard 3D digital subtraction angiography but with a lower cost and versatility of use for other subspecialties.

Abstract P1-09-01: Impact of MAF gene amplification on disease recurrence and effects of adjuvant zoledronic acid in early breast cancer

Background: Meta-analysis of clinical trials has shown that adjuvant bisphosphonates reduce bone metastases and improve survival in postmenopausal (PM) pts1. However, we are unable to select pts most likely to benefit. To address this, the recently identified early breast cancer bone relapse biomarker, 16q23(MAF) gain (MAF+)2, was tested retrospectively in the large prospectively randomized AZURE trial3 of standard adjuvant therapy +/- zoledronic acid (ZOL) to determine the prognostic value of MAF and its potential to predict the effects of ZOL on disease outcomes.

Materials and methods: All analyses were performed with ethics approval and consent. The biomarker analysis was completed on TMAs from primary tumors. Quadruplicate cores of breast tumor tissue were arrayed across replicate TMAs. MAF+ was detected using a validated (MAF/D16Z3) FISH test (Inbiomotion SL, Barcelona, Spain). A central laboratory (Targos, Kassel, Germany) validated the assay for analytic and diagnostic performance, established acceptance criteria, included appropriate quality controls for each assay, and performed the analyses in a blinded fashion. A copy number cut-off ≥2.5 was preset for MAF+. Invasive disease free (IDFS), overall (OS) survival and time to bone metastases multivariate analyses were performed in control and ZOL pts separately. Subsequently, interactions between MAF+ and effects of ZOL on disease outcomes by menopausal status were evaluated.

Results: 1769 of the 3360 AZURE pts donated primary tumor samples. Median follow-up was 84 months. 865 pts (49%) had 2 FISH evaluable cores and were included in the analysis of which 184 (21%) had MAF+ tumors. Tumors that were MAF+ were more likely to be of higher grade, ER-ve and Her2+.

In control pts, MAF was not prognostic for IDFS or OS although there were differences in IDFS by menopause (HR for MAF-/MAF+ in PM=0.47 [95%CI 0.25-0.88]; HR in non-PM=1.58 [0.82-3.03], test for interaction (TFI) by menopause P=0.007). In ZOL pts, MAF was prognostic for IDFS (HR=0.52 [0.36-0.75] and OS (HR=0.48 [0.31-0.75]). There were insufficient bone events (19 MAF+, 73 MAF-) in this sample set to reliably assess the impact of MAF+ on relapse in bone.

In pts with MAF- tumors, ZOL was associated with improved IDFS (HR=0.74 [0.56-0.98]) and OS (HR=0.78 [0.55-1.10]). However, the effects of ZOL in MAF+ were profoundly influenced by menopausal status with possibly better outcomes in PM women (HR for IDFS=0.74 [0.35-1.58]) but clearly worse IDFS and OS outcomes in ZOL treated MAF+ pts who were non-PM (HR for IDFS 2.46 [1.23-4.92], TFI by treatment P=0.002 and HR for OS=2.27 [1.04-4.93], TFI by treatment P=0.032). The interactions between disease outcomes, ZOL use and menopause were driven largely by an association between MAF+ and an increased risk of extra-skeletal recurrence with the use of ZOL in women who were not PM.

Conclusions: Absence of MAF amplification is associated with improved disease outcomes with adjuvant ZOL. However, the use of adjuvant ZOL in women with MAF+ tumors who are not PM at the start of treatment is associated with extraskeletal spread and worse DFS and OS.

1EBCTCG Lancet 2015;386:1353–1361; 2Pavlovic M et al JNCI 2015;107(12):djv256; 3Coleman RE et al Lancet Oncol 2014;15:997-1006.

Citation Format: Coleman R, Hall A, Bell R, Cameron D, Marshall H, Jean-Mairet J, Tercero J, Rojo F, Albanell J, Gomis R. Impact of MAF gene amplification on disease recurrence and effects of adjuvant zoledronic acid in early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-01.

[Experience with the proseal laryngeal mask in ventriculoperitoneal shunting]

OBJECTIVE

To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitonea shunting.

PATIENTS AND METHODS

We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded.

RESULTS

Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateral-cervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases.

CONCLUSIONS

The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand.

[Importance of monitoring neuroendoscopic intracranial pressure during anesthesia for neuroendoscopic surgery: review of 101 cases]

OBJECTIVE

The aim of this study was to describe monitoring, anesthetic management, and risk factors for complications in neuroendoscopic surgery.

PATIENTS AND METHODS

Patients who underwent neuroendoscopy between 1994 and 2003 under general anesthesia, with monitoring of intracranial pressure from inside the neuroendoscope, were studied retrospectively. In some patients, the blood flow rate in the middle cerebral artery was monitored using transcranial Doppler ultrasound. Information was collected related to surgical procedure and the development of complications.

RESULTS

Of 101 patients included in the study, transcranial Doppler ultrasound images were available for 20. In 75 patients neuroendoscopic intracranial pressure exceeded 20 mm Hg. Forty-five percent of the patients with available transcranial Doppler ultrasound images showed episodes of reduced diastolic flow rate in the middle cerebral artery during ventricular irrigation. Hemodynamic instability was associated with higher neuroendoscopic intracranial pressures (P < .05). An increase of more than 30 mm Hg in neuroendoscopic intracranial pressure was associated with more postoperative complications, the most common of which was delayed awakening. Procedures that were more complicated than a simple ventriculostomy were performed in 58% of the cases. Mean (SD) neuroendoscopic intracranial pressures in such cases were higher (50.5 [30.9] mm Hg vs 31.8 [25.1 mm Hg] in the simpler procedures) and the postoperative complication rate was higher (P = .003).

CONCLUSIONS

Neuroendoscopic surgery can causes increases in neuroendoscopic intracranial pressure that are associated with disturbances in cerebral blood flow and complications. This situation demonstrates the importance of monitoring intracranial pressure and cerebral blood flow.

Magnetic structure of the large-spin Mn10 and Mn19 complexes: a theoretical complement to an experimental milestone

High-spin molecules have been proposed as candidates for the storage of information at the molecular level. The electronic structure of two complex magnetic molecular systems, Mn 10 and Mn 19, is characterized by means of a computational study based on density functional theory. All the exchange interactions in the recently reported Mn 19 complex with the highest known spin value of 83/2, and in its highly symmetric Mn 10 parent compound, are ferromagnetic. In these complexes, there are two kinds of ferromagnetic coupling: the first one corresponds to Mn (II)-Mn (III) interactions through a double mu 2-alkoxo-mu 4-oxo bridge where the high coordination number of the Mn (II) cations results in long Mn (II)-O bond distances, while the second one involves Mn (III)-Mn (III) interactions through mu 2-alkoxo-mu 3-eta (1):eta (1):eta (1) azido bridging ligands with long Mn (III)-N distances due to a Jahn-Teller effect.

[Frequency of bacterial contamination of epidural and plexus catheters in postoperative analgesia]

OBJECTIVE

There is little available information regarding contamination of perineural catheters. Incidence ranges from 5% to 57%, depending on the location of the catheter. The objective of this prospective study was to evaluate the incidence and predisposing factors of bacterial contamination of these catheters.

PATIENTS AND METHODS

The study included 47 patients who had an epidural (24 patients) or perineural (23 patients) catheter inserted for a minimum of 48 hours. We recorded details of the patients' characteristics, difficulty of insertion and duration of placement of the catheter, antibiotic treatment received, and signs of local or systemic infection immediately after surgery. When the catheters were removed, cultures were prepared using the Maki method. A descriptive analysis was performed and the frequency of contamination was determined using various parameters.

RESULTS

The incidence of contamination was 28% (13 patients): 5/24 (21%) in epidural catheters, 6/17 (35%) in femoral catheters, and 2/6 (33%) in brachial and sciatic plexus catheters. Colonization was not influenced by the patients' characteristics, technical difficulties in placing the catheter, prophylactic antibiotic treatment, or the characteristics of the infusion administered. None of the patients presented clinical signs of infection. The most commonly isolated microorganism was Staphylococcus epidermidis, found in 10 patients (69% of the colonized catheters).

CONCLUSIONS

Although infection of perineural catheters is exceptional when they are placed for 2 or more days, contamination is very common. Epidemiological studies are required to evaluate the variables involved.

An orthogonal ferromagnetically coupled tetracopper(ii) 2 × 2 homoleptic grid supported by µ-O4bridges and its DFT study

A pyrazole based ditopic ligand (PzOAP), prepared by the reaction between 5-methylpyrazole-3-carbohydrazide and methyl ester of imino picolinic acid, reacts with Cu(NO3)2.6H2O to form a self-assembled, ferromagnetically coupled, alkoxide bridged tetranuclear homoleptic Cu(II) square grid-complex [Cu4(PzOAP)4(NO3)2] (NO3)2.4H2O (1) with a central Cu4[micro-O4] core, involving four ligand molecules. In the Cu4[micro-O4] core, out of four copper centers, two copper centers are penta-coordinated and the remaining two are hexa-coordinated. In each case of hexa-coordination, the sixth position is occupied by the nitrate ion. The complex 1 has been characterized structurally and magnetically. Although Cu-O-Cu bridge angles are too large (138-141 degrees) and Cu-Cu distances are short (4.043-4.131 A), suitable for propagation of expected antiferromagnetic exchange interactions within the grid, yet intramolecular ferromagnetic exchange (J = 5.38 cm(-1)) is present with S = 4/2 magnetic ground state. This ferromagnetic interaction is quite obvious from the bridging connections (d(x2-y2)) lying almost orthogonally between the metal centers. The exchange pathways parameters have been evaluated from density functional calculations.

Unexpected ferromagnetic interaction in a new tetranuclear copper(II) complex: synthesis, crystal structure, magnetic properties, and theoretical studies

The new tetranuclear carbonate complex [Cu2L)2(CO3)] x 8H2O (1 x 8H2O) (H3L = (2-(2-hydroxyphenyl)-1,3-bis[4-(2-hydroxyphenyl)-3-azabut-3-enyl]-1,3-imidazolidine) has been obtained by two different synthetic routes and fully characterized. Recrystallization of 1 x 8H2O in methanol yields single crystals of {[(Cu2L)2(CO3)]}2 x 12H2O (1 x 6H2O), suitable for X-ray diffraction studies. The crystal structure of 1 x 6H2O shows two crystallographically different tetranuclear molecules in the asymmetric unit, 1a and 1b. Both molecules can be understood as self-assembled from two dinuclear [Cu2L]+ cations, joined by a mu4-eta(2):eta(1):eta(1) carbonate ligand. The copper atoms of each crystallographically different [(Cu2L)2(CO3)] molecule present miscellaneous coordination polyhedra: in both 1a and 1b, two metal centers are in square pyramidal environments, one displays a square planar chromophore and the other one has a geometry that can be considered as an intermediate between square pyramid and trigonal bipyramid. Magnetic studies reveal net intramolecular ferromagnetic coupling between the metal atoms. Density functional calculations allow the assignment of the different magnetic coupling constants and explain the unexpected ferromagnetic behavior, because of the presence of an unusual NCN bridging moiety and countercomplementarity of the phenoxo (or carbonate) and NCN bridges.

Exchange coupling in transition-metal complexes via density-functional theory: Comparison and reliability of different basis set approaches

Theoretical methods based on density-functional theory with Gaussian, plane waves, and numerical basis sets were employed to evaluate the exchange coupling constants in transition-metal complexes. In the case of the numerical basis set, the effect of different computational parameters was tested. We analyzed whether and how the use of pseudopotentials affects the calculation of the exchange coupling constants. For the three different basis sets, a comparison of the exchange coupling constants and spin distributions shows that both the plane-wave and the numerical basis set approaches are accurate and reliable alternatives to the more established Gaussian basis functions.

Anesthetic management of a patient in prone position with a drill bit penetrating the spinal canal at C1-C2, using a laryngeal mask

Airway management in patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. A 19-yr-old patient was brought to the emergency room in prone position with a drill bit protruding from the posterolateral aspect of his neck. The bit had entered the spinal canal below the first cervical vertebra, and placed near the odontoid peg. He was referred for surgical removal of the drill. The use of an inhaled induction of anesthesia, avoiding muscle relaxants, and ventilation through a laryngeal mask airway inserted in the prone position seemed to offer a satisfactory approach.

IMPLICATIONS

Management of patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. Anesthesia may be induced and the airway can be managed with the patient already in the prone position for surgery.

Oxamato-bridged trinuclear NiIICuIINiII complexes: a new (NiIICuIINiII)2 hexanuclear complex and supramolecular structures. Characterization and magnetic properties

Eight oxamato-bridged heterotrinuclear Ni(II)Cu(II)Ni(II) complexes of formula ([Ni(H(2)O)(dpt)](2)(mu-Cu(H(2)O)(opba)))(ClO(4))2 (1), ([Ni(H(2)O)(dien)](2)(mu-Cu(pba)))(ClO(4))(2).6H(2)O (2), ([Ni(H(2)O)(Medpt)](2)(mu-Cu(OHpba)))(ClO(4))(2).4H(2)O (3), ([Ni(H(2)O)(dien)](2)(mu-Cu(Me(2)pba)))(ClO(4))(2).2.5H(2)O (4), ([Ni(H(2)O)(dpt)](2)(mu-Cu(Me(2)pba)))(ClO(4))(2).2H(2)O (5), ([Ni(H(2)O)(dien)](2)(mu-Cu(OHpba)))(ClO(4))(2).4H(2)O (6), ([Ni(2)(dpt)(2)(mu-Cu(H(2)O)(pba))](2)(mu-N(3))(2))Na(2)(ClO(4))(4).6H(2)O (7), and ([Cu(H(2)O)(2)(dpt)Ni(2)(H(2)O)(dpt)(2)](mu-H(2)Me(2)pba(2-)))(ClO(4))(4).3H(2)O (8) in which opba = o-phenylenbis(oxamato), pba = 1,3-propylenebis(oxamato), OHpba = 2-hydroxy-1,3-propylenebis(oxamato), Me(2)pba = 2,2-dimethyl-1,3-propylenbis(oxamato), dpt = 3,3'-diaminodipropylamine, dien = 2,2'-diaminodiethylamine, and Medpt = 3,3'-diamino-N-methyldipropylamine were synthesized and characterized. The crystal structures of 1, 7, and 8 were solved. For complex 1, the trinuclear entities are linked by hydrogen bonds forming a one-dimensional system, and for complex 8, the presence of van der Waals interactions gives a one-dimensional system, too. For complex 7, the trinuclear entities are self-assembled by azido ligands, given a hexanuclear system; each of these hexanuclear entities are self-assembled through two [Na(O)(3)(H(2)O)(3)] octahedral-sharing one-edge entities, given a one-dimensional system. The magnetic behavior of complexes 2-7 was investigated by variable-temperature magnetic susceptibility measurements. Complexes 2-6 exhibit the minimum characteristic of this kind of polymetallic species with an irregular spin state structure. The Jvalue through the oxamato bridge varied between -88 cm(-1) (for 6) and -111.2 cm(-1) (for 5). For complex 7, the values obtained were J(1) = -101.7 cm(-1) (through the oxamato ligand) and J(2) = -3.2 cm(-1) (through the azido ligand).

Postoperative pain relief after hepatic resection in cirrhotic patients: the efficacy of a single small dose of ketamine plus morphine epidurally

In cirrhotic patients undergoing hepatic surgery, postoperative analgesia remains a challenge. In this study, we evaluated the efficacy of a single dose of morphine combined with small-dose ketamine given epidurally for postoperative pain relief. One-hundred-four classification "Child A" cirrhotic patients were randomly assigned to two groups: 1) (MKG, n = 54): epidural morphine (3.5-5 mg) plus ketamine (20/30 mg); and 2) epidural morphine (3.5/5 mg) (MG, n = 50). The level of analgesia, side effects, psychomimetic and neurological disorders, additional analgesic needs, and overall quality of the analgesia were recorded. The mean duration of analgesia was longer in the MKG group (27.2 +/- 8 h versus 16.4 +/- 10 h; P < 0.05). In the MKG group, the visual analog scale (VAS) score began to be significantly lower from 14 h at rest and 12 h on coughing until the end of the study. The need for additional analgesia was also smaller in the MKG group (P < 0.05): at 24 h, only 10% of patients in the MKG group needed complementary analgesia, whereas in the MG group it was 100% (P = 0.003). Side effects were similar in both groups. Psychomimetic side effects and neurological disorders were not detected. These results suggest that postoperative analgesia provided by a single dose of epidural morphine with small-dose ketamine is effective in cirrhotic Child's A patients having major upper abdominal surgery.

New oxamidato-bridged Cu(II)-Ni(II) complexes: supramolecular structures with thiocyanate ligands and hydrogen bonds. Magnetostructural studies: DFT calculations

Four new supramolecular compounds of Cu(II)-Ni(II) have been synthesized and characterized: [Cu(Me(2)oxpn)Ni(mu-NCS)(H(2)O)(tmen)](2)(ClO(4))(2) (1), [Cu(Me(2)oxpn)Ni(mu-NCS)(H(2)O)(tmen)](2)(PF(6))(2) (2), [Cu(oxpn)Ni(mu-NCS)(NCS) (tmen)](n) (3), and [Cu(Me(2)oxpn)Ni(mu-NCS)(NCS)(tmen)](n) (4), where oxpn = N,N'-bis(3-aminopropyl)oxamidate, Me(2)oxpn = N,N'-bis(3-amino-2,2'-dimethylpropyl)oxamidate, and tmen = N,N,N',N'-tetramethylethylenediamine. Their crystal structures were solved. Complexes 1 and 2 have the same tetranuclear cationic part but a different counteranion. The cationic part consists of two [Cu(Me(2)oxpn)Ni] moieties linked by SCN(-) bridged ligands and intra-tetranuclear hydrogen bonds. In the case of complex 3, a two-dimensional system was built, the thiocyanate ligand linking the dinuclear units gives a chain, and the chains are linked together by hydrogen bonds; intrachain hydrogen bonds are also present. For complex 4, the thiocyanate ligands produce intermolecular linkages between the dinuclear entities, giving a one-dimensional system; intrachain hydrogen bonds are also present. The magnetic properties of the four complexes were studied by susceptibility measurements vs temperature. DFT calculations were made to study the contribution of the SCN(-) and hydrogen bond bridges in the magnetic coupling.

New oxamato-bridged trinuclear Cu(II)-Cu(II)-Cu(II) complexes with hydrogen-bond supramolecular structures: synthesis and magneto-structural studies

Three oxamato-bridged copper(II) complexes of formula [(Cu(H(2)O)(tmen)Cu(tmen))(mu-Cu(H(2)O)(Me(2)pba))](n)((PF(6))(2))(n).2nH(2)O (1), [(Cu(H(2)O)(tmen)Cu(NCS)(tmen))(mu-Cu(H(2)O)(Me(2)pba))](2)(ClO(4))(2).4H(2)O (2), and [(Cu(H(2)O)(tmen)Cu(NCS)(tmen))(mu-Cu(H(2)O)(Me(2)pba))](2)(PF(6))(2).4H(2)O (3), where Me(2)pba = 2,2-dimethyl-1,3-propylenebis(oxamato) and tmen = N,N,N',N'-tetramethylethylenediamine, have been synthesized and characterized. Their crystal structures were solved. Complex 1 crystallizes in the monoclinic system, space group P2(1), with a = 15.8364(3) A, b =8.4592(2) A, c = 15.952 A, beta = 101.9070(10) degrees, and Z = 2. Complex 2 crystallizes in the monoclinic system, space group P2(1)/c, with a = 6.69530(10) A, b = 18.2441(3) A, c = 31.6127(5) A, beta = 90.1230(10) degrees, and Z = 4. Complex 3 crystallizes in the monoclinic system, space group P2(1)/c, with a = 6.68970(10) A, b = 18.150 A, c = 32.1949(4) A, beta = 90.0820(10) degrees, and Z = 4. The three complexes have a central core in common: a trinuclear Cu(II) complex with the two terminal Cu(II) ions blocked by N,N,N',N'-tetramethylethylenediamine. The structure of complex 1 consists of trinuclear cationic entities connected by hydrogen bonds to produce a supramolecular one-dimensional array. The structure of complexes 2 and 3 consist of trinuclear cationic entities linked by pairs by hydrogen bonds between the water molecule of the central Cu(II) and one oxygen atom of the oxamato ligand of the neighboring entity, forming a hexanuclear complex. The magnetic properties of the three complexes were studied by susceptibility vs temperature measurement. For complexes 1-3 the fit was made by the irreducible tensor operator (ITO). The values obtained were J(1) = -386.48 cm(-1) and J(2) = 1.94 cm(-1) for 1, J(1) = -125.77 cm(-1) and J(2) = 0.85 cm(-1) for 2, and J(1) = -135.50 cm(-1) and J(2) = 0.94 cm(-1) for 3. In complex 1, the coordination polyhedron of the terminal Cu(II) atoms can be considered as square pyramidal; the apical positions are filled by the oxygen atom from a water molecule in the former and a F atom of the hexafluorophosphate anion in the latter showing a quasi-planar [Cu(CuMe(2)pba)Cu] network. For complexes 2 and 3, the square pyramidal environment of the terminal Cu(II) ions was strongly modified. To our knowledge, this is the first time that the longest distance (apical) in complexes with oxamato derivatives and bidentate amines as blocking ligands has been reported in one of the oxamato arms. The great difference in J(1) values between 1 and the other two complexes is interpreted as an orbital reversal of the magnetic orbitals of the terminal Cu(II) ions in 2 and 3.

Synthesis and characterization of [Cu(Me2oxpn)Ni(NO2)(tmen)](ClO4): a single ferrimagnetic dinuclear CuII-NiII complex acting as weak molecule-based magnet

The new heterodinuclear complex [Cu(Me2oxpn)Ni(NO2)(tmen)](ClO4), that exhibits strong antiferromagnetic intramolecular coupling between CuII and NiII ions (ferrimagnetic behavior), shows ferromagnetic ordering at low temperature, due likely to a small canting phenomenon; it is one of the very few compounds made from isolated molecules that lead to cooperative magnetic behavior.

Synthesis, characterization, and magnetic properties of self-assembled compounds based on discrete homotrinuclear complexes of Cu(II)

Three new supramolecular entities of Cu(II) were synthesized and characterized: [(Cu(H(2)O)(tmen))(2)(mu-Cu(H(2)O)(opba))](2)[(ClO(4))(2)](2).2H(2)O (1), [(Cu(H(2)O)(tmen))(2) (mu-Cu(H(2)O) (Me(2)pba))](2)[(ClO(4))(2)](2) (2), and [(Cu(H(2)O)(tmen))(Cu(tmen))(mu-Cu(OHpba))](n)() ((ClO(4))(2))(n)().nH(2)O (3), where opba = o-phenylenbis(oxamato), Me(2)pba = 2,2-dimethyl-1,3-propylenbis(oxamato), OHpba = 2-hydroxy-1,3-propylenbis(oxamato), and tmen = N,N,N'N'-tetramethylethylenediamine. The crystal structures of 1, 2, and 3 were solved. Complex 1 crystallizes in the monoclinic system, space group C2/c with a = 20.572(4) A, b = 17.279(6) A, c = 22.023(19) A, beta = 103.13(4) degrees, and Z = 8. Complex 2 crystallizes in the monoclinic system, space group P2(1)/c, with a = 16.7555(7) A, b = 13.5173(5) A, c = 17.1240(7) A, beta = 104.9840(10) degrees, and Z = 4. Complex 3 crystallizes in the orthorhombic system, space group Pca2(1) with a = 21.2859(4) A, b = 12.8286(10) A, c = 12.6456(2) A, and Z = 4. The three complexes are very similar in structure: a trinuclear Cu(II) complex with the two terminal Cu(II) ions blocked by N,N,N',N'-tetramethylethylenediamine, but with a different environment in the Cu(II) central ion. In the case of complex 1, two of these trinuclear entities are packed with a short distance between the central Cu(II) ions of two separate entities forming a hexanuclear-type compound. In the case of 2, two of these trinuclear entities are linked by a hydrogen bond between a water molecule of one terminal Cu(II) and one oxygen atom of the oxamato ligand of the neighboring entity, also forming a hexanuclear complex. In the case of complex 3, the intermolecular linkages give a one-dimensional system where the OH groups of the OHpba entities are linked to the terminal Cu(II) of the neighboring entities. The magnetic properties of the three complexes were studied by susceptibility measurements vs temperature. For complex 1, an intramolecular J value of -312.1 cm(-)(1) and a contact dipolar interaction of -0.44K were found. For complex 2 and 3 the fit was made by the irreducible tensor operator formalism (ITO). The values obtained were as follows: J(1) = -333.9 cm(-)(1) and J(2) = 0.67 cm(-)(1) for 2 and J(1) = -335.9 cm(-)(1) and J(2) = 3.5 cm(-)(1) for 3.

Episodic high irrigation pressure during surgical neuroendoscopy may cause intermittent intracranial circulatory insufficiency

Intermittent high peak pressure values inside the endoscope during neuroendoscopic surgical procedures are associated with postoperative morbidity. Unexpected delay in awakening is the complication most frequently observed by the anesthesiologist as a result of high peak pressure values inside the endoscope. During eight neuroendoscopic procedures the authors continuously monitored cerebral hemodynamic function, using a transcranial doppler (TCD) probe fixed on patients' temporal window. We observed that episodes of high peak pressure values inside the endoscope during neuroendoscopic navigation rinsing periods resulted in changes in the TCD wave profile consistent with "near intracranial circulatory arrestlike" wave. No systemic hemodynamic warning signs accompanied these intermittent episodes of severe decrease in cerebral perfusion pressure. When the rinsing liquid was allowed to escape, the pressure inside the endoscope decreased and the TCD wave immediately returned to its previous value. Neuroendoscopic procedures, although classified as minimally invasive surgery, warrant special monitoring that could alert us to a decrease in cerebral perfusion pressure. Middle cerebral artery TCD recording is a reliable and accurate tool for this purpose.