Neuronal VEGF expression correlates with angiogenesis in postnatal developing rat brain

When exposed to chronic sublethal hypoxia the developing brain responds with increases in permeability and angiogenesis. Vascular endothelial growth factor (VEGF) may mediate this response. Here, we present data on the localization of VEGF in the rat brain cortex during postnatal development and its correlation to vascularization. We reared newborn rats under normoxic conditions and in hypoxic chambers (FiO(2) 9.5%), removed them at postnatal days (P) 3, 8, 13, 24, and 33 and prepared the cortical brain tissue for immunohistochemistry, in situ hybridization (ISH), Western blot analyses and vessel density counting. When compared to age-matched controls, hypoxic-reared animals displayed a significant increase in platelet endothelial cell adhesion molecule 1 (PECAM-1) protein levels, cerebral microvascular lumen diameter and number and density of vessels (number of capillaries per area). In control animals, ISH and immunohistochemistry revealed that localization of VEGF is restricted almost exclusively to cortical neurons at early stages of development. As the vascular bed begins to stabilize, predominant VEGF expression switches to maturing glial cells which invest vessels while neuronal expression is reduced to a basal level. In hypoxic animals, early localization of VEGF is also restricted to cortical neurons, however, during later developmental stages, glial cells express elevated levels of VEGF protein and high neuronal expression also persists. Thus chronic sublethal hypoxia disrupts the temporal-spatial expression of VEGF, which correlates with continuing hypoxia-driven angiogenesis.

Diffuse nodular eyelid lipogranuloma following sutureless transconjunctival blepharoplasty dressed with topical ointment

PURPOSE

Transconjunctival blepharoplasty is becoming the approach of choice for many cosmetic surgeons. The authors describe a case of a diffuse, multinodular eyelid lipogranuloma following transconjunctival blepharoplasty, after which the unsutured wound was dressed with a topical ointment.

METHODS

Report of clinical course and histopathologic findings.

RESULTS

A patient developed multiple firm, nontender masses of the left lower eyelid that enlarged despite topical and systemic medical therapy. Prior to referral, the progressive lesions had recurred despite three successive attempts at surgical eradication. Histopathologic examination of excised tissue demonstrated a multifocal lipogranulomatous inflammation consistent with reaction to retained ointment.

CONCLUSIONS

Sclerosing lipogranulomas are a known complication of intradermal lipid injection, as well as a late complication of sinus surgery after postoperative nasal packing with ointment-saturated gauze. The application of a topical ointment should be avoided until after transconjunctival lower blepharoplasty unless wound closure is secure or until conjunctival epithelialization is complete.

Correction of lower eyelid retraction by transconjunctival retractor excision and lateral eyelid suspension

PURPOSE

To investigate the effectiveness of a procedure that addresses both the lower eyelid retractors and the lateral canthus in the treatment of patients with lower eyelid retraction.

METHODS

Through a combined lateral canthotomy and full-length transconjunctival incision, the lower eyelid retractors were disinserted across the horizontal length of the eyelid, recessed to the inferior fornix, and excised. A lateral canthopexy elevated the mobilized eyelid, and horizontal length disparity was corrected.

RESULTS

Forty lower eyelid operations in 23 patients yielded good results; all patients attained significant improvement in both eyelid position and function. No reoperations were required during a mean follow-up period of 28 months.

CONCLUSION

Although not ideal for severe cases requiring posterior lamellar spacers or anterior lamellar (skin) grafts, this union of techniques successfully treats many types of lower eyelid retraction.

Centurion syndrome and its surgical management

PURPOSE

To describe the clinical features and treatment outcomes in patients with the centurion syndrome.

METHODS

Review of medical records.

RESULTS

Forty patients, 38 of whom were male, were examined. Epiphora commenced during the second decade of life in all patients. Fluorescein dye pooled near the medial canthus because of anterior displacement of the medial lower eyelid and inferior punctum. Probing of the canaliculi and irrigation of the lacrimal drainage system confirmed anatomic patency in all patients. Disinsertion of the anterior limb of the medial canthal tendon relieved epiphora by restoring normal apposition between the lower eyelid and the globe in all 22 patients who underwent surgery.

CONCLUSION

Centurion syndrome is a unique clinical entity that may manifest as epiphora during puberty. Outcomes of surgical correction are favorable.

Association of chronic sublethal hypoxia with ventriculomegaly in the developing rat brain

Bronchopulmonary dysplasia remains a major cause of neurodevelopmental handicap in preterm infants. Because bronchopulmonary dysplasia may be associated with prolonged hypoxemia without obvious changes in systemic blood pressure, we developed an animal model of chronic sublethal hypoxia to test the hypothesis that this insult results in significant alterations in corticogenesis in the developing brain. Three groups of newborn rats were placed in a chamber with FIO2 9.5% on postnatal day 3 (P3). One group was sacrificed at P13; a second group was sacrificed at P33, and the third group was removed at P33 and reared in normoxia until sacrifice at P63. Control rats were those raised in room air for the corresponding periods of time. Rats were transcardially perfused and the brains were embedded in celloidin and prepared for morphometric analysis using standard stereology methods. Although experimental rat pups in the third group demonstrated 'catch-up' of body weight following return to normoxia, these studies demonstrated both failure of brain growth (p<0.01) and progressive cerebral ventriculomegaly (p<0.01). Decreased subcortical white matter (p<0. 05) and corpus callosum size (p<0.01) were noted at P63 in pups reared under conditions of chronic hypoxia. Decreases in cortical volume (p<0.05) were noted at all three experimental time points for hypoxic-reared pups when compared to control animals. These data suggest that chronic sublethal hypoxia may lead to severe impairments in corticogenesis in an animal model of developing brain.

Sino-orbital giant cell reparative granuloma

An otherwise healthy, 9-year-old boy had gradual onset of a mass deformity in the region of the left medial canthus with resulting superior and lateral globe displacement. Radiographic evaluation demonstrated an osteolytic, expansile lesion involving the bones of the ethmoid and maxillary sinuses. Combined anterior orbitotomy and nasal endoscopic surgical resection revealed additional involvement of the nasolacrimal sac wall. Histopathology was consistent with a giant cell reparative granuloma. The authors know of 15 case reports of sino-orbital giant cell reparative granulomas with ophthalmic manifestations; only 3 of these appeared in the ophthalmology literature. This case appears unique in that extension of the abnormal tissue into the nasolacrimal sac wall was demonstrated.

An in vitro three-dimensional coculture model of cerebral microvascular angiogenesis and differentiation

The microvasculature of the developing brain is plastic and responds differently to the many insults associated with preterm birth. We developed three-dimensional in vitro culture models for the study of the responses of the developing cerebral microvasculature. Beagle brain microvascular endothelial cells (BBMEC) were isolated by differential centrifugation from newborn beagle pups on postnatal Day 1 and placed in three-dimensional culture dispersed in a collagen gel. Alternatively, BBMEC were placed in a three-dimensional coculture with neonatal rat forebrain astrocytes. Cultures were analyzed for extracellular matrix components at 1 and 6 d, and total RNA was extracted for Northern analyses. Urokinase plasminogen activator activity was assayed in both mono- and cocultures of the two cell types. Studies of three-dimensional BBMEC/astrocyte cocultures demonstrated progressive tube formation with only low levels of endothelial proliferation. By 6 d in three-dimensional coculture, the BBMEC formed capillarylike tubes with a wrapping of glial processes, and basement membrane protein synthesis was noted. Urokinase plasminogen zymography suggested intercellular signaling by the two cell types. These data suggest that the three-dimensional beagle brain germinal matrix microvascular endothelial cell/neonatal rat astrocyte coculture provides a good model for the investigation of microvascular responses in the developing brain.

Chronic postnatal hypoxia increases the numbers of cortical neurons

Premature infants have been shown to undergo prolonged periods of sublethal hypoxia. There is considerable evidence to link these hypoxic events with neurodevelopmental disorders. As an animal model for this clinical problem, rats were raised from the third day of life in a chamber where the O2 level was 9.5%. After 30 days of hypoxia the rats were sacrificed and their brains processed for determination of the number of cortical neurons. This work was performed to test the hypothesis that chronic hypoxia would result in increased cortical cell death. The hypoxic rats had lower body and brain weights as well as decreased cortical volumes. However, hypoxic rats had increased neuronal density and significantly more cortical neurons than controls (P < 0.05). The results of this study suggest that chronic sublethal hypoxia may lead to reduction in the amount of programmed cell death in the developing neocortex.

Vascular endothelial growth factor mediates reactive angiogenesis in the postnatal developing brain

Although chronic sublethal hypoxia has been shown to promote angiogenesis in the developing brain, the pathogenesis of this response is unknown. We hypothesized that this response may be mediated in part by vascular endothelial growth factor (VEGF). We reared newborn rats (P3) in a chamber with FIO2 of 9.5 +/- 1% (exposed, E). At P33, the animals were removed from the chamber and the brains prepared for immunohistochemistry, mRNA extraction, or horseradish peroxidase (HRP) permeability studies. We also isolated beagle brain germinal matrix endothelial cells from PND 1 beagle pups and placed them in three-dimensional (3-D) coculture with PND 1 rat forebrain astrocytes. Cultures were grown for 6 days in 11% O2 and compared to control 3-D cocultures. When compared to age-matched controls, the experimental rats had significantly increased cortical vascular density (vessels/mm2: 518 +/- 18 vs. 400 +/- 15, P = 0.025). HRP studies demonstrated significantly increased permeability in all cortical vessels examined in experimental rats compared to controls. Compared to controls, VEGF mRNA from hypoxic pups was increased 2.4 times, and immunohistochemical studies of VEGF protein confirmed this finding. Similarly, when compared to controls, hypoxic cocultures of brain microvascular endothelial cells and astrocytes demonstrated significant increase in tubelike structures representing in vitro angiogenesis. Additionally, astrocyte VEGF protein levels increased 4.4-fold in hypoxic compared to control astrocyte cultures and VEGF protein levels increased 1.7-fold in hypoxic compared to control cocultures. Finally, addition of VEGF (10 ng/ml culture medium) to BBMEC alone in 3-D culture elicited not only significant proliferation (P = 0.001) but also increased tube formation. These data demonstrate that the developing brain responds to chronic sublethal hypoxia with increases in permeability and angiogenesis and suggest that VEGF mediates this response.

The individual versus the statistical patient: relationships between treatment of malignant eyelid neoplasms and their "Hosts"

The essence of the doctor-patient interaction is that of a caring relationship. Too often, our reliance upon data, statistical analysis, and out-come percentages obscure the need for subjective interpretation of each healing interaction in which we are engaged. Awareness and responsiveness, on personal and professional levels, to the intuitive and sacred aspects of the doctor-patient relationship need to be recognized as being as important as the rational and scientific aspects of treatment and management if we are to be healers in the fullest sense.

Lotus lectin labels subpopulation of olfactory receptor cells

Experiments were performed to test the hypothesis that subsets of olfactory receptor cells could be recognized based on their lectin binding and that mapping of their projections onto the olfactory bulb would reveal details of anatomic organization of the olfactory nerve projection to the olfactory bulb. The results from one lectin, Lotus, were examined in detail. Olfactory receptor cells in the lateral part of the main epithelium were labeled, as well as scattered cells in the remainder of the epithelium. Glomeruli labeled by Lotus were concentrated primarily in the region of the olfactory bulb that receives its input from the lateral epithelium, although scattered glomeruli could be identified in other regions. Within the terminal field of these axons there was a mosaic pattern, with some glomeruli densely labeled, some lightly labeled and others unlabeled. These findings support the notion that there are biochemically distinct populations of olfactory receptor cells having localized distributions in the epithelium, with axons that coalesce to terminate in specific glomeruli, rather than diffusely over their projection field.

Germinal matrix microvascular maturation correlates inversely with the risk period for neonatal intraventricular hemorrhage

The risk period for intraventricular hemorrhage (IVH) of the preterm neonate is the first 3-4 postnatal days. For infants of < 34 weeks' gestation, this risk period is independent of gestational age. We hypothesized that this risk period is attributable to the perinatal induction of maturation of the germinal matrix microvasculature and tested this hypothesis by examining changes in the classical ultrastructural features of the blood-brain barrier over the first ten postnatal days in the newborn beagle model for neonatal IVH. Newborn beagle pups (n = 6) were anesthetized and systemically perfused and the brains were removed and prepared for electron microscopic examination. Examination of electron micrographs from the germinal matrix of animals on the first, fourth and tenth postnatal days demonstrated no difference in perimeter lengths and capillary and endothelial cell areas; in contrast, luminal areas significantly decreased across postnatal age (P = 0.04). Significant increases were found in basement membrane area between days 1 and 4 (P = 0.01) and tight junction length (day 1 vs. day 10, P = 0.02). In addition, on day 1, 19% of germinal matrix capillary perimeter was determined not to be covered by supporting cell processes, while by day 10, only 5% was bare. In contrast, the microvessels of the white matter exhibited no changes in these parameters during these three time points. These studies are consistent with the concept that basal lamina deposition and organization precede increases in endothelial cell tight junction formation and coverage by supporting cells.

Indomethacin promotes germinal matrix microvessel maturation in the newborn beagle pup

BACKGROUND AND PURPOSE

Although indomethacin has been demonstrated to prevent germinal matrix and intraventricular hemorrhage in clinical and animal studies, the mechanism of action of this agent to prevent hemorrhage remains unclear. Previous studies have demonstrated both that the microvessels in the germinal matrix of newborn beagle pups undergo basement membrane maturation during the first 4 postnatal days and that indomethacin may promote laminin deposition in tumor cell culture systems.

METHODS

We employed the newborn beagle pup model to test the hypothesis that indomethacin may stimulate laminin deposition in germinal matrix microvessels. Newborn pups were randomized to receive either 0.1 mg/kg/dose i.p. indomethacin or an equal volume of saline diluent. Pups received doses of study medication once a day for 1, 2, or 3 days and were studied on postnatal days 1, 2, 3, or 4. Pups were anesthetized and systemically perfused with buffered formalin; the brains were removed and prepared for immunohistochemical study.

RESULTS

Sections stained with Bandeiraea lectin demonstrated that there was no difference in germinal matrix vessel density among the postnatal ages studied; similarly, there were no differences in vessel density between saline- and indomethacin-treated animals at any postnatal age. Quantification of germinal matrix stained intensity by confocal microscopy demonstrated significant increases in indomethacin-treated pups for both laminin staining at postnatal days 2 (p = 0.05) and 3 (p = 0.0009) and type V collagen staining at postnatal day 2 (p = 0.011). Although staining for beta 1 integrins increased across postnatal ages, there were no differences between saline- and indomethacin-treated animals.

CONCLUSIONS

These data suggest that indomethacin may stimulate basement membrane deposition in the germinal matrix microvessels of newborn beagle pups to prevent germinal matrix and/or intraventricular hemorrhage.

Temporoparietal fascial flap for orbital and eyelid reconstruction

The temporoparietal fascial flap is a recognized technique for the transfer of vascularized tissue in the craniofacial region. The flap has a predictable axial vessel, provides thin vascularized tissue, and can be harvested with minimal donor-site morbidity. The temporoparietal fascial flap is well suited for orbital or eyelid reconstruction because of its proximity to the orbit. The flap is useful for reconstruction of anatomic barriers between the orbit, intracranial cavity, and paranasal sinus spaces. We present four patients in whom the temporoparietal fascial flap was used for orbital reconstruction following extirpative surgery for orbital neoplasm and two patients in whom the flap was used for lower eyelid and malar reconstruction.

Orbital exenteration. The reconstructive ladder

Following orbital exenteration, there is a spectrum of immediate and delayed options for orbital reconstruction. Goals of reconstruction after exenteration include detection of recurrent disease, restoration of boundaries between the orbit and surrounding structures, and optimal aesthetics. Local solutions to problems of the exenterated orbit, such as healing by granulation or application of split-thickness skin grafts, are advantageous for detecting recurrent disease. Regional solutions, involving transfer of periorbital tissue into the orbit, may mask recurrent disease and create adjacent deformity; however, these solutions can be used to restore orbital boundaries and shallow the orbital cavity. Distant solutions, such as skin-muscle flaps and free tissue grafts, allow for facial reconstruction in patients with extensive orbital and periorbital defects.

A micro system for rigid bony fixation in orbital surgery

Plates and screws are effective for rigid internal fixation of bone fractures and osteotomies in the midface, orbit, and cranium. We describe our experience with the Luhr Micro System. This is the newest generation of Luhr Systems and is the smallest system available for rigid internal fixation. The self-tapping screws are 0.8 mm in diameter, with lengths of 2-8 mm. The plates have an extremely flat profile. We have used the Micro System for closure of elective osteotomies following resection of orbital neoplasm, bony orbital reconstruction, and repair of congenital craniofacial deformities. Because the orbital bones have minimal functional stress, the Micro System provides adequate support. The plates are not apparent through the thin periorbital skin. For bony fixation in the periorbital region, the Micro System appears superior to larger systems and to wire or nonabsorbable sutures.

Beagle pup germinal matrix maturation studies

Intraventricular hemorrhage, or hemorrhage into the germinal matrix tissues of the developing brain, remains a common problem of preterm infants. The "risk period" for this insult is the first 3-4 postnatal days. We hypothesized that this risk period for hemorrhage is related to rapid perinatal maturation of the germinal matrix vasculature and employed the newborn beagle pup model for the study of this maturation. Newborn beagle pups (n = 30) were anesthetized and systemically perfused with buffered formalin; the brains were removed and prepared for immunohistochemical study. Sections stained with Bandeiraea lectin demonstrated that there was no difference in germinal matrix vessel density between postnatal days 1 and 4. Germinal matrix sections were also stained for antibodies to alpha-smooth muscle actin, collagen IV, collagen V, desmin, factor VIII-related antigen, fibronectin, glial fibrillary acidic protein, laminin, transferrin, and vimentin. Vasculature staining by alpha-smooth muscle actin was not noted until postnatal day 10, and differential staining was detected for antibodies to laminin and collagen V. Quantification of staining intensity by confocal microscopy demonstrated a significant increase in both extracellular matrix components at postnatal day 4 compared with day 1 (p less than 0.05 for both). These basement membrane proteins may add sufficient structural integrity to germinal matrix vessels to prevent capillary rupture and thus intraventricular hemorrhage.

Computer-assisted three-dimensional reconstructions of [14C]-2-deoxy-D-glucose metabolism in cat lumbosacral spinal cord following cutaneous stimulation of the hindfoot

We report on computer-assisted three-dimensional reconstruction of spinal cord activity associated with stimulation of the plantar cushion (PC) as revealed by [14C]-2-deoxy-D-glucose (2-DG) serial autoradiographs. Moderate PC stimulation in cats elicits a reflex phasic plantar flexion of the toes. Four cats were chronically spinalized at about T6 under barbiturate anesthesia. Four to 11 days later, the cats were injected (i.v.) with 2-DG (100 microCi/kg) and the PC was electrically stimulated with needle electrodes at 2-5 times threshold for eliciting a reflex. Following stimulation, the spinal cord was processed for autoradiography. Subsequently, autoradiographs, representing approximately 8-18 mm from spinal segments L6-S1, were digitized for computer analysis and 3-D reconstruction. Several strategies of analysis were employed: 1) Three-dimensional volume images were color-coded to represent different levels of functional activity. 2) On the reconstructed volumes, "virtual" sections were made in the horizontal, sagittal, and transverse planes to view regions of 2-DG activity. 3) In addition, we were able to sample different regions within the grey and white matter semi-quantitatively (i.e., pixel intensity) from section to section to reveal differences between ipsi- and contralateral activity, as well as possible variation between sections. These analyses revealed 2-DG activity associated with moderate PC stimulation, not only in the ipsilateral dorsal horn as we had previously demonstrated, but also in both the ipsilateral and contralateral ventral horns, as well as in the intermediate grey matter. The use of novel computer analysis techniques--combined with an unanesthetized preparation--enabled us to demonstrate that the increased metabolic activity in the lumbosacral spinal cord associated with PC stimulation was much more extensive than had heretofore been observed.

Beagle puppy model of perinatal asphyxia: blockade of excitatory neurotransmitters

The N-methyl-D-aspartate receptor antagonist MK801 has been reported to prevent neuronal change in models of ischemia in adult animal systems. We studied the hypothesis that blockade of the N-methyl-D-aspartate receptor would prevent the depression of cerebral high-energy phosphates found in perinatal asphyxia without producing alterations in cerebral blood flow, and thus prevent neuropathologic damage. Newborn beagle puppies were anesthetized, tracheotomized, ventilated, and randomized to asphyxial insult (I = discontinuation of ventilatory support for 5 min) or no insult (NI) and drug treatment with MK801 (10 mg/kg intravenously) or an equal volume of saline (S). Puppies received MK801 or saline 15 min prior to I/NI. In S/I pups during insult, blood flow increased to brainstem structures but decreased elsewhere. MK801 had no effect on cerebral blood flow in either control or insulted puppies. 1H NMR studies demonstrated no effect of the MK801 on NI brains. Phosphocreatine levels were 1.7 +/- 0.1, 0.6 +/- 0.1, and 0.9 +/- 0.1 mmole/kg (mean: +/- S.D.) for the S/NI, S/I, and MK801/I pups, respectively. Cerebral lactate was 1.3 +/- 0.2, 3.0 +/- 0.7, and 2.0 +/- 0.4, respectively. The pH fell 0.8 units in the S/I puppies, compared to 0.4 units in the MK801/I puppies. We conclude that pretreatment with the N-methyl-D-aspartate receptor antagonist MK801 in part protects the developing brain against severe metabolic insult.

Thromboxane synthesis inhibitor in a beagle pup model of perinatal asphyxia

During perinatal asphyxia, cerebral blood flow is markedly reduced in the gray and white matter of the telencephalon. Since previous work has implicated prostaglandins in the control of blood flow, we tested the hypothesis that a thromboxane synthesis inhibitor would improve cerebral blood flow and blunt the metabolic alterations that accompany asphyxia. Forty-three newborn beagles 2-7 days old were anesthetized, ventilated, and randomized to insult (5 minutes of asphyxia) or no insult and received treatment with either the thromboxane synthesis inhibitor CGS 13080 (CIBA-GEIGY Corp.) (0.06 mg/kg/hr i.v. infusion) or saline. Cerebral blood flow was measured in 25 pups. Pups received treatment 30 minutes before insult or no insult. In pups randomized to insult and receiving saline, cerebral blood flow increased during insult in the medulla but decreased elsewhere. Pups randomized to insult and treated with thromboxane synthesis inhibitor had increased cerebral blood flow during insult in all cerebral regions studied. In addition, these pups experienced a significantly higher incidence of intraventricular hemorrhage than did pups randomized to insult and receiving saline. In other experiments with 18 pups, brain extracts were prepared for proton nuclear magnetic resonance spectral analysis of high-energy phosphorylated compounds and lactate levels. In pups exposed to insult and receiving saline, mean +/- SD phosphocreatine concentration fell from 1.9 +/- 0.1 to 0.4 +/- 0.1 mmol/kg, lactate concentration increased from 2.0 +/- 0.5 to 3.3 +/- 0.4 mmol/kg, and the calculated pH fell 0.8 units. There were no differences between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Orbital surgery. The technique of coronal scalp flap approach to the qateral orbitotomy

Lateral orbitotomy may be performed using a coronal scalp flap to provide exposure of the lateral orbital wall and rim. A coronal incision is made across the scalp. The scalp flap is developed anteriorly to expose the orbital margin from the superior orbital rim to the zygomatic arch. The temporalis muscle is dissected from its bony attachments and bluntly retracted, providing maximal exposure of the lateral orbital wall. The orbitotomy proceeds as required. The case concludes with a layered closure. In selected patients, the coronal scalp flap provides improved exposure and postoperative aesthetics compared with approaches in which the skin and muscle layer are incised directly over the lateral orbit. Complications are infrequent.

Multidisciplinary approach to the management of complex bony and soft tissue orbitocranial disorders

Orbital reconstructive surgery is entering a new age as progress in surgical techniques and diagnostic imaging are applied to the patient with severe acquired orbital and periorbital deformities. The authors present a series of six patients with orbitocranial neoplasms and congenital and traumatic deformities whose management involved a multidisciplinary approach. Particular emphasis is placed on the use of reformatting two-dimensional orbital scans into three-dimensional images and surgical techniques using composite flaps and periorbital microsurgical vascular anastomoses. Advancements in technology and sophisticated reconstructive surgical techniques have exciting potential. Ophthalmologists can play an important role in this expanding field since they frequently serve as the entry point or provide long-term follow-up to patients with these complex problems.

A multidisciplinary approach to orbital neoplasm

The patient with orbital and periorbital neoplasia requires careful assessment of the extent and biologic activity as well as histopathologic categorization. Treatment is optimal through a multidisciplinary approach involving the ophthalmic surgeon, plastic surgeon, neurosurgeon, head and neck surgeon, and oral surgeon.

Computer-designed prostheses for orbitocranial reconstruction

Three-dimensional imaging is an adjunct to preoperative evaluation and surgical management in some patients with complex anatomic defects of various etiologies. Deformities defined by conventional computerized tomography can be viewed as accurate three-dimensional images calculated from the original scan. The images are viewed on a high-resolution video monitor and can be photographed for a permanent record. A computer-controlled milling device can use these data to fabricate prostheses. The prostheses aid reconstructive surgery through use as an alloplastic implant, as a template to fashion autogenous bone grafts, or as a model for tissue removal. We have utilized three-dimensional imaging in combination with computer-assisted prosthesis manufacture in six patients with complex orbitocranial deformities. Four patients have undergone reconstructive surgery with satisfactory results and no complications thus far. The use of computer-designed prostheses adds a new aspect to orbitocranial reconstructive surgery that facilitates increased accuracy in the correction of anatomic defects.

Beagle puppy model of perinatal asphyxia: alterations in cerebral blood flow and metabolism

Perinatal asphyxia remains a major cause of neurodevelopmental handicap. The neuropathologic and clinical sequelae of perinatal asphyxia are likely attributable to alterations in cerebral blood flow (CBF) to the developing brain with uncoupling of CBF and metabolism. The newborn beagle puppy model was used to study the control of CBF in physiologic and pathologic conditions in the developing brain. Pups, 2-10 days of age, were randomized to asphyxial insult (i.e., ventilator lines clamped for 5 min) or no insult. In the first series, pups underwent radioactive microsphere determinations of CBF immediately prior to insult (t = 0), at the end of insult (t = 5), and after 60 min of observation (t = 65). In the second series, utilizing a 2.0 tesla superconducting magnet, pups underwent continuous serial in vivo 31P nuclear magnetic resonance spectral analysis of cerebral hemispheric metabolic state. Animals exposed to insult had significant alterations in PO2, PCO2, pH, and mean arterial pressure at the end of insult compared to control pups (all pups: p less than 0.001). Serial CBF data demonstrated decreases in flow in cortical gray and white matter regions during insult and return to baseline 1 hour later; brainstem structures were hyperemic during insult. Analysis of phosphorylated metabolites inorganic phosphorus (Pi), phosphocreatine (PCr), and ATP demonstrated that during insult both the PCr/Pi and ATP/Pi ratios were depressed but by 20-30 min following insult, these ratios of cerebral phosphorylated metabolites had almost returned to baseline values. These data demonstrate that even after a severe asphyxial episode which results in electrocerebral silence, CBF and metabolism may return to normal.

Beagle pup model of brain injury: regional cerebral blood flow and cerebral prostaglandins

Asphyxia is the most common cause of severe brain injury in very young children, and frequently results in lesions of the periventricular white matter in addition to other neuropathological changes. This study examines the effects of asphyxia on regional cerebral blood flow (rCBF) and the role of prostaglandins (PG's) in its control in the newborn beagle pup. Pups were anesthetized, tracheotomized, paralyzed, artificially ventilated, and randomly assigned to two groups: asphyxial insult produced by discontinuing ventilatory support, and no insult. Experiments for carbon-14-iodoantipyrine autoradiographic determination of rCBF and regional cerebral PG determination were performed on separate groups of pups. These studies demonstrated a significant increase in cortical gray PGE2 levels at a time when rCBF was significantly impaired in response to severe asphyxial insult. No such increase was noted in the periventricular white matter zones.

The spatial organization of olfactory nerve projections

The spatial organization of olfactory nerve projections was examined in the rat. The pathway was traced by orthograde transport of HRP following nasal lavage and by retrograde transport of HRP following injections into the olfactory bulb. The results indicated that there was a broad relationship between the epithelium and the olfactory bulb. Specific regions of the olfactory bulb received input from a large region of the epithelium. However, there was evidence that olfactory nerve terminations were not uniformly dense across their terminal fields. The results suggest that there may be finer sorting of olfactory nerves based on functional specificity.

Beagle pup model of perinatal asphyxia: nimodipine studies

Calcium antagonists may be of significant benefit in the pharmacotherapy of cerebral ischemia, possibly by improving postischemic cerebral blood flow (CBF). This study evaluated the effects of the calcium antagonist nimodipine on CBF in a newborn beagle pup model of perinatal asphyxia lasting 5 minutes. Immediately after the asphyxial episode, nimodipine (2 micrograms/kg/min) or saline was infused for 10 minutes, following which [14C]iodoantipyrine determinations of CBF were performed. In noninsulted pups, nimodipine caused both significant decreases in CBF to cortical and deep gray structures as well as a decrease in mean arterial blood pressure (MABP) (p less than 0.05). In insulted pups, nimodipine similarly decreased MABP (p less than 0.001) and CBF to cortical and deep gray matter regions. Nimodipine appeared to have no effect on arterial blood gases and EEG tracings in either insulted or noninsulted pups. Although nimodipine may be shown to improve neurologic outcome in asphyxiated newborn infants, the limits of this study do not show the mechanism to be that of improving CBF.

Temporal relationship between neurotransmitter release and ion flux during spreading depression and anoxia

Brain ion homeostasis is severely perturbed during spreading depression of Leao and during anoxia. The ionic composition of the extracellular space changes abruptly and approaches the intracellular concentrations owing to an increase in cell permeability. In spreading depression, synchronous transmitter efflux caused by a depolarization of the presynaptic terminals has been implicated as a possible mechanism that would explain the concomitant movement of ions. Anoxia, having many features in common with spreading depression, may follow the same mechanism. We have measured the concentrations of extracellular potassium with ion-selective microelectrodes and dopamine by in vivo voltammetry with carbon fiber microelectrodes during spreading depression and anoxia to compare the temporal relationship between the release of dopamine and ion movements in the striatum. There is a pronounced release of dopamine during both spreading depression and anoxia. In spreading depression, the sharp increase of potassium concentration that follows an initial smaller and slower increase of potassium is accompanied by the release of dopamine. In anoxia, the dopamine release clearly precedes the fast rise of extracellular potassium concentration. We conclude that in striatum, there is a pronounced dopamine release during spreading depression and anoxia, but that the relationships between ionic changes and transmitter release for these two phenomena are different and probably reflect different mechanisms.

Blood flow and metabolism in the developing brain

The newborn brain has mechanisms that act to preserve the blood flow to the brain stem. When challenged with an asphyxial episode, there is a redistribution of blood flow in the brain. The brain stem structures have increased blood flow, and telencephalic structures, particularly white matter, have decreased flow. These changes are made possible in part because the newborn brain stem vascular appears to be much more sensitive to pCO2 than the telencephalic vasculature. In fact, several brain stem regions exhibit a higher sensitivity to CO2 than the adult cortex. Consequently, vessels in this region are able to vasodilate more effectively. In addition, the sympathetic vascular innervation in the newborn brain appears more profuse in the forebrain. So this system could produce a widespread vasoconstruction and participate in the shift of blood flow from the cerebral hemispheres to the brain stem. This capacity to preserve blood flow to the critical brain stem regions may explain, in part, the ability of the neonatal animal to survive long periods of asphyxia. This phenomena might also explain the clinical findings of white matter loss and stroke in the cerebral hemispheres, since these regions seem to be selectively deprived of blood flow during insult. This relationship is summarized in Fig 1.

The technique of cranial bone grafts in the correction of posttraumatic orbital deformities

The technique of split-thickness cranial bone graft for reconstructive orbital surgery, is reported in five patients who sustained extensive orbital trauma. This technique involves exposing the skull via a coronal scalp incision, after which the cranial bone is split in situ along the diploe. The outer table of the cranial bone is then used as a graft to correct orbital defects and other associated bony deformities. Cranial bone grafts have several advantages over other graft sites in orbital reconstruction, including more rapid postoperative recovery, close proximity of donor site to recipient site, and improved survival of cranial bone grafts in experimental studies. Cranial bone grafts are an important source of autogenous tissue for the reconstructive surgeon.

Beagle puppy model of perinatal cerebral infarction. Regional cerebral prostaglandin changes during acute hypoxemia

Perinatal cerebral infarction, or stroke, is a not uncommon finding in newborns who survive after intensive care. Asphyxia, with its component parts hypoxemia and hypotension, represents the most common cause of perinatal cerebral infarction and may result in neuropathological changes in the periventricular white matter. Previous studies have demonstrated regional alterations in cerebral blood flow (CBF) in response to hypoxemic insult. This work examines the effects of hypoxemia on regional cerebral prostaglandin levels in the developing brain, since some observers believe that local CBF is controlled in part by prostaglandins. In this study, newborn beagle pups were anesthetized, subjected to tracheotomy and artificially ventilated to maintain normoxemia and normocarbia. Mean arterial blood pressure (MABP) was continuously monitored by means of an indwelling catheter and transducer, and craniectomies were performed. When the pups were physiologically stabilized, they were randomly assigned to receive acute hypoxemic insult (pO2 14.0 +/- 1.55 mm Hg, mean +/- standard deviation) accomplished by altering the oxygen concentration in the inspired air) or to receive no insult (mean pO2 84.3 +/- 13.0 mm Hg). Fifteen minutes following stable hypoxemic or normoxic conditions, all pups underwent in vivo freezing of the intracranial contents under anesthesia followed by rapid sacrifice. No significant differences were noted between the MABP, pH, or pCO2 values for the control and hypoxemic pups during the experimental period. Regional cerebral prostaglandin data demonstrated a significant increase in prostaglandin (PG)E2 in the gray matter of hypoxemic pups when compared to the normoxic controls (p less than 0.02). No significant differences were noted for 6-keto-PGE1 alpha, the stable metabolite of prostacyclin, or thromboxane (TX)B2, the stable metabolite of TXA2, in the gray matter. In addition, although 6-keto-PGE1 alpha was significantly lower in the periventricular white matter of the hypoxemic pups (p less than 0.05), there were no changes in the white matter in either PGE2 or TXA2. This regional differential synthesis of PGE2 in response to hypoxemic insult may explain the relative failure of CBF to the periventricular white matter and thus the neuropathological alterations attributed to it.

Beagle puppy model of perinatal cerebral insults. Cerebral blood flow changes and intraventricular hemorrhage evoked by hypoxemia

Asphyxia, with its attendant hypoxemia, is by far the most common cause of neonatal cerebral infarction, and frequently results in lesions of the parieto-occipital white matter in addition to other neuropathological changes. This study examines the effects of hypoxemia on regional cerebral blood flow (CBF) in the newborn beagle pup. The animals were anesthetized, underwent a tracheotomy, and were paralyzed. Pups were randomly divided into two groups: one group was subjected to hypoxemia produced by altering the oxygen concentration in the inspired air, and the other received no insult. In the hypoxemic pups, the pO2 was 13.1 +/- 2.1 mm Hg (mean +/- standard deviation). Autoradiographic determinations of CBF were performed by the carbon-14-iodoantipyrine technique 15 minutes after randomization. Significant increases in CBF were found throughout the brains of the hypoxemic pups. The CBF was increased to cortical and central gray regions and to frontal and temporal white matter but was unchanged in the parietal white matter, one of the classic sites of radiological and neuropathological injury in neonates with perinatal asphyxia. An unexpected finding was the increased incidence of germinal matrix and/or intraventricular hemorrhages in the hypoxemic pups.

Mapping of an olfactory receptor population that projects to a specific region in the rat olfactory bulb

An anatomically distinct group of glomeruli, termed the modified glomerular complex (MGC), is present in the posterior dorsomedial portion of the main olfactory bulb. This region has been strongly implicated as part of the pathway that processes odor cues for suckling in neonatal rat pups. We studied the distribution pattern of olfactory receptor neurons that project to the MGC region after ionophoretic injections of WGA-HRP into the olfactory bulbs of 12-day-old rat pups. HRP label was confined to an identifiable localized region in the MGC of the main olfactory bulb. Label extended over 2-7% of the glomerular sheet of the main olfactory bulb, including the MGC. Olfactory receptor neurons within the olfactory epithelium of the nasal cavity were labeled with HRP ipsilateral to the injected side. Maps constructed of the olfactory epithelium revealed that the labeled neurons occurred within topographically defined regions. Anteriorly, labeled olfactory neurons were confined to a narrow strip medial to the dorsal recess, and, more posteriorly, this strip widened medially along the septal wall and laterally onto a limited area on the nasal turbinates. Only a portion of the receptor population within a region was labeled. The boundaries between labeled and unlabeled regions were sharp. These findings support the concept that the olfactory epithelium is an anatomical mosaic in which receptors with different glomerular projections sites are intermingled. In conjunction with previous evidence on the functional specificity of the MGC, and staining of receptor neuron subgroups with monoclonal antibodies, these findings further suggest that olfactory receptor neurons form a functional mosaic within the olfactory epithelium.

Beagle puppy model of perinatal cerebral infarction. Acute changes in regional cerebral prostaglandins during hemorrhagic hypotension

Perinatal cerebral infarction is a not uncommon finding in newborn babies surviving intensive care. Asphyxia, with its attendant hypotension, is the most common cause of this problem and may result in neuropathological changes in the periventricular white matter. Previous studies have demonstrated uncoupling of cerebral blood flow and metabolism in the periventricular white matter regions of newborn beagle pups exposed to hemorrhagic hypotension. This work examines the effects of hypotension on serum and regional cerebral prostaglandin levels in the newborn beagle pup. The animals were anesthetized, tracheostomized, and paralyzed. Pups were randomly assigned to two groups: one was subjected to hemorrhagic hypotension and the other received no insult. Hypotension was induced by slow venous hemorrhage calculated to maintain a mean arterial blood pressure at 20 to 30 mm Hg. Serum prostaglandin determinations were made immediately before and 15 minutes after random assignment to hypotension or control groups. In addition, regional cerebral prostaglandin determinations were performed 15 minutes after randomization. Analysis of the serum prostaglandin data revealed that there were no significant differences in the values for thromboxane B2 or 6-keto-prostaglandin (PG) F1 alpha, which are the stable breakdown products of thromboxane A2 and prostacyclin, respectively. Prostaglandin E2 levels increased in response to hemorrhagic hypotension insult. Regional cerebral prostaglandin determinations demonstrated decreases in thromboxane B2 and 6-keto-PGF1 alpha in both gray and white matter. Although gray matter PGE2 was increased in pups exposed to hemorrhagic hypotension, this increase was not found in the periventricular white matter of injured pups. This regional difference in PGE2 synthesis in response to insult may explain the periventricular white matter neuropathological changes attributed to it.

Randomized indomethacin trial for prevention of intraventricular hemorrhage in very low birth weight infants

We admitted 48 preterm neonates (600 to 1250 gm birth weight, normal 6-hour echoencephalograms) to a randomized prospective indomethacin or placebo trial for the prevention of neonatal intraventricular hemorrhage. Beginning at 6 postnatal hours, indomethacin or placebo was administered intravenously every 12 hours for a total of five doses. Cardiac ultrasound studies to assess the status of the ductus arteriosus were performed at 6 postnatal hours and on day 5. Urinary output, serum electrolytes, and renal and clotting functions were monitored. No differences in birth weight, gestational age, Apgar scores, or ventilatory needs were noted between the two groups. Six infants given indomethacin had intraventricular hemorrhage, compared to 14 control infants (P = 0.02). The indomethacin-treated group had significant decreases in serum prostaglandin values 30 hours after the initiation of therapy. The overall incidence of patent ductus arteriosus was 82% at 6 postnatal hours; 84% of the indomethacin-treated infants experienced closure of the ductus, compared to 60% of the placebo-treated patients. Closure of the ductus was not related to incidence of intraventricular hemorrhage. We speculate that indomethacin may provide some protection against neonatal intraventricular hemorrhage by acting on the cerebral microvasculature.

Labelling of olfactory bulb glomeruli following horseradish peroxidase lavage of the nasal cavity

The transport of horseradish peroxidase (HRP) from the nasal cavity to the olfactory bulb was examined in rat. HRP was present primarily in the olfactory nerve and glomerular layer. In some animals the glomeruli were densely filled with product while in others there was considerable interglomerular variation in density. Examination of the decalcified noses revealed a restricted distribution of HRP in those rats with partially labelled olfactory bulbs. The presence of small groups of densely labelled glomeruli was also noted using the 2-deoxyglucose method to examine odor-induced metabolic activity.

Beagle puppy model of perinatal cerebral infarction. Acute changes in cerebral blood flow and metabolism during hemorrhagic hypotension

Asphyxia, with its attendant hypotension, is by far the most common cause of neonatal cerebral infarction and frequently results in lesions of the parieto-occipital white matter. This study examines the effects of hypotension on regional cerebral blood flow (CBF), local cerebral glucose utilization (LCGU), and serum prostaglandin levels in newborn beagle pups. The animals (24 to 96 hours old) were anesthetized, tracheotomized, and paralyzed. Pups were randomly divided into two groups: one was subjected to hemorrhagic hypotension and the other received no insult. Hypotension was induced by slow venous hemorrhage to maintain a mean arterial blood pressure of 20 to 30 mm Hg. Autoradiographic determinations of LCGU using carbon-14 (14C)-2-deoxyglucose were performed 45 minutes after randomization to groups. Autoradiographic determinations of CBF were performed using 14C-iodoantipyrine on a second group of pups 15 minutes after randomization. Prostaglandins were measured immediately before and 15 minutes after insult or control manipulation. There were no significant differences in the values for thromboxane B2 or 6-keto-prostaglandin F1 alpha, the stable breakdown products of thromboxane A2, and prostacyclin. Prostaglandin E2 levels significantly increased in response to hemorrhagic hypotensive insult. In addition, although regional CBF was maintained in cortical and central gray matter structures during hypotension, CBF to the periventricular temporal and parietal white matter zones significantly decreased, and LCGU was increased in these same regions during hypotensive insult. The uncoupling of CBF and metabolism in these periventricular white matter regions may be responsible for the neuropathological sequelae of perinatal asphyxia.

Beagle puppy model of intraventricular hemorrhage. Effect of superoxide dismutase on cerebral blood flow and prostaglandins

Intraventricular hemorrhage (IVH) represents a major problem for preterm neonates and is thought to occur secondary to alterations in cerebral blood flow (CBF) to damaged germinal matrix tissues. Many investigators believe that both local CBF and changes in capillary morphology and permeability may be partially controlled by prostaglandins. To evaluate this hypothesis, the authors have studied the effects of superoxide dismutase (SOD), a known free-radical scavenger, on newborn beagle pups that were randomly assigned by computer to four groups consisting of either SOD- or saline-pretreated animals that underwent either insult by hemorrhagic hypotension/volume reexpansion or no insult. Prostaglandin levels were determined prior to and 60 minutes following the administration of the solutions, and carbon-14 iodoantipyrine autoradiography was performed for determination of CBF. It was demonstrated that, although SOD significantly decreased the incidence of IVH in this model (p less than 0.05), it caused no alterations in baseline CBF or prostaglandin levels. In addition, SOD did not prevent either the systemic blood pressure changes or the alterations in CBF found in response to a hemorrhagic hypotensive insult. The authors propose that neonatal IVH results from a combination of factors, one of which is prostaglandin-mediated alterations in CBF to a damaged capillary matrix.

Calcifications in lesions of the fossa of the lacrimal gland

It is frequently reported that calcification in the fossa of the lacrimal gland is a reliable sign of malignancy. We present a small, previously unreported series of lacrimal gland fossa calcifications, in which in three out of five cases the lesion was benign. Calcification can be a misleading radiographic sign and should not, in and of itself, be considered diagnostic of malignancy. This is important because proper preoperative diagnosis of lacrimal fossa tumors is essential as management differs.

Bimanual endoscopic orbital biopsy. An emerging technique

Diagnostic biopsy specimens from six posterior orbital lesions have been obtained under direct endoscopic view with either a fine needle aspiration or an intracannular microbiopsy forcep. This method is comparable to earlier fine needle aspiration techniques, but has the decided advantage of providing a specimen from visually indentified abnormal tissue. In those cases where inadequate specimens are obtained by fine needle aspiration, a microforcep is used to obtain a substantial specimen. The microinvasive endoscopic biopsy technique of the Orbital Unit at Pacific Medical Center is described with an analysis of six cases. The emerging technology of fiberoptic illumination, minified color video cameras, sophisticated imaging, efficient microsurgical instruments and laser delivery methods make the potential for deep orbital endoscopic microinvasive surgery exciting.

Perinatal cerebral insults: hemorrhage and ischemia

The incidence of major neurodevelopmental handicaps in the survivors of newborn special care has remained essentially unchanged over the past decade despite the development of sophisticated perinatal care. Preterm infants with parenchymal involvement of intraventricular hemorrhage and neonates of all gestational ages with cerebral infarction are believed to be at higher risk for both neurologic and developmental abnormalities than infants without these problems. Both lesions are thought secondary to alterations in cerebral blood flow to the developing brain, and many infants demonstrate evidence for both hemorrhage and ischemic insult.