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Neal F. Kassell

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Thomas W. Langfitt and Neal F. Kassell

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Introduction

Focused ultrasound surgery

W. Jeffrey Elias and Neal F. Kassell

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David W. Beck, Neal F. Kassell and Charles G. Drake

✓ The authors report a case of glomus jugulare tumor presenting with papilledema and visual loss. The tumor was extremely vascular with significant shunting of arterial blood into venous sinuses. There was no intracranial extension of tumor, and papilledema resolved after removal of the lesion.

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David J. Boarini, Neal F. Kassell and Hans C. Coester

✓ High-dose sodium thiopental is frequently used in neuroanesthesia. The authors performed a study to compare a shorter-acting barbiturate, methohexital, to sodium thiopental in producing high-dose barbiturate anesthesia. In two groups of five mongrel dogs each, regional cerebral blood flow (CBF) was determined using the radioactive-microsphere technique, and cardiovascular parameters were measured before, during, and 1 hour after a 1½hour period of deep barbiturate anesthesia with either sodium thiopental or methohexital. Doses of the barbiturates were adjusted to produce electroencephalogram burst suppression of greater than 30 seconds.

Both agents produced a similar degree of cardiac depression, reduction in CBF, and decrease in cerebral metabolic rate of oxygen (CMRO2). Changes in cerebral and peripheral vascular resistance indicated that methohexital caused less vasoconstriction than sodium thiopental. When the barbiturate infusions were discontinued, CMRO2 and CBF returned more rapidly toward control values in the methohexital group than in the thiopental group. The more rapid recovery time and decrease in cerebral vascular resistance with methohexital suggest that it may have some advantage over sodium thiopental during certain neurosurgical procedures.

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Editorial

Unruptured aneurysms

Aaron S. Dumont, Giuseppe Lanzino and Neal F. Kassell

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Tomikatsu Toyoda, Neal F. Kassell and Kevin S. Lee

Object. Inflammatory responses and oxygen free radicals have increasingly been implicated in the development of ischemic brain injury. In some cases, an attenuation of inflammation or free-radical injury can provide tissue protection. Diphosphoryl lipid A (DPL) is a detoxified derivative of a lipopolysaccharide (endotoxin) of Salmonella minnesota strain R595, which is capable of stimulating the immune system without eliciting direct toxic effects. In this study the authors examined the influence of preconditioning with DPL on ischemia/reperfusion injury in rats.

Methods. Sprague—Dawley rats were injected intravenously with either DPL or vehicle. Twenty-four hours later, some animals were tested for superoxide dismutase (SOD) activity. Others were subjected to a 3-hour period of focal cerebral ischemia and, after a reperfusion period of 24 hours, were killed. Infarction volume, SOD activity, and myeloperoxidase (MPO) activity were assayed in the postischemic animals.

Pretreatment with DPL produced significant reductions in cerebral infarction and MPO activity in the ischemic penumbra. A significant enhancement of basal SOD activity was observed 24 hours after DPL treatment (that is, before ischemia), and a further enhancement of SOD activity was seen in the ischemic penumbra 24 hours after reperfusion.

Conclusions. These data provide the first evidence of a neuroprotective effect of preconditioning with DPL in an in vivo model of cerebral ischemia. Although the precise mechanisms through which DPL exerts its neuroprotective influence remain to be established, an inhibition of the complex inflammatory response to ischemia and an enhancement of endogenous antioxidant activity are leading candidates.

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Satoshi Suzuki, Neal F. Kassell and Kevin S. Lee

✓ Hemin is a prominent breakdown product of hemoglobin, and high levels of hemin are found in the cerebrospinal fluid during subarachnoid hemorrhage—induced vasospasm. The possible role of hemin in modifying vascular function was examined in the present study by testing its effects on nitric oxide synthase (NOS) activity in cultured rat aortic smooth-muscle cells. Nitric oxide synthase activity was estimated from the amounts of accumulated nitrite and nitrate, which are oxidative products of nitric oxide (NO). Hemin (1–100 µM) increased the levels of nitrite and nitrate in culture medium in a dose- and time-dependent manner. The hemin-induced elevation of nitrite and nitrate was inhibited significantly by the NOS inhibitor, Nω-nitro-l-arginine (300 µM), and by the protein synthesis inhibitor, cycloheximide (5 µg/ml). These results indicate that hemin is capable of stimulating the expression of an inducible isoform of NOS (iNOS) in vascular smooth muscle. Transcriptional expression of iNOS is known to cause injurious effects on the maintenance of cellular homeostasis by generating extremely high levels of NO. The generation of hemin from methemoglobin during hemolysis of a subarachnoid blood clot could therefore stimulate an excessive production of NO in vascular smooth-muscle cells. It is postulated that this series of events contributes to the development of vascular injury associated with cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

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Nader Pouratian, Neal F. Kassell and Aaron S. Dumont

Intracerebral hemorrhage (ICH) is a lingering cause of significant mortality and morbidity rates in contemporary society. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical (both craniotomy and minimally invasive) and medical management of patients with ICH. No consistently efficacious strategies have been identified through such investigations. Limitations in study design and execution have universally impaired the interpretation and impact of available data. Management of ICH unfortunately remains heterogeneous across institutions, and it continues to suffer from the lack of proven medical and surgical effectiveness. Urgently needed are further prospective randomized controlled trials in which investigators consider the shortcomings of previous endeavors in the management of ICH. In the present article the authors review the current management practices of ICH, discuss the controlled trials, and highlight recent trials and future avenues of further study.

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Marc N. Pilipuf, John C. Goble and Neal F. Kassell

✓ The authors have developed a noninvasive head immobilization system for use in neuroimaging (magnetic resonance imaging, computerized tomography, single photon emission computerized tomography, and projection angiography), neurosurgical planning, and neurosurgery. These diagnostic and surgical procedures require patient immobilization, reproducible patient positioning, and anatomical localization. The thermoplastic system described in this technical note addresses each of these requirements with a high degree of accuracy and with no bone fixation. The reproducibility of positioning and effectiveness of immobilization were evaluated using nine healthy volunteers during repeated sessions of magnetic resonance imaging. The mean axial displacement for repeated positioning was 0.6 mm (variance 0.1 mm); the mean displacement during robust patient motion in the axial direction was 1.8 mm (variance 0.9 mm).