✓ The authors report a case of progressive foramen magnum syndrome due to deposits of calcium pyrophosphate dihydrate crystals, which caused reactive hypertrophy in the posterior longitudinal ligament at C-1 and in the transverse ligament of the atlas in an 84-year-old woman. This is the first reported case of symptomatic pseudogout in this anatomic location. Rapid neurological recovery followed transoral decompression of the cervicomedullary junction.
Samuel F. Ciricillo and Philip R. Weinstein
Reizo Shirane and Philip R. Weinstein
✓ The effects of pretreatment with mannitol on local cerebral blood flow (CBF) after permanent or temporary global cerebral ischemia were evaluated with 14C-iodoantipyrine autoradiography in rats under halothane-N2O endotracheal anesthesia. Blood pressure, pulse rate, arterial blood gas levels, and electroencephalographic (EEG) tracings were monitored throughout the experiments. After permanent occlusion of the basilar artery and both external carotid and pterygopalatine arteries, severe global ischemia was induced by permanent occlusion of the common carotid arteries (CCA's) or by a 30-minute temporary CCA occlusion followed by 5 minutes of reperfusion. Intravenous mannitol (25%, 1 gm/kg) or saline solution was administered 5 minutes before occlusion of the CCA's. Cerebral blood flow was measured in 24 anatomical regions.
The EEG tracings flattened within 2 to 3 minutes after the onset of ischemia, and no recovery was observed during reperfusion. In the mannitol-treated rats and the saline-treated controls, autoradiographic studies after permanent occlusion showed no CBF in the forebrain or cerebellum, although brain-stem and spinal cord CBF values were normal. After 5 minutes of reperfusion, CBF in the cortex, basal ganglia, and white matter was 100% to 200% higher in mannitol-treated rats and 50% to 100% higher in saline-injected rats than in the nonischemic anesthetized control group. Heterogeneously distributed areas of no-reflow were seen in all saline-injected rats but were observed in none of the mannitol-treated rats. Pretreatment with mannitol prevented postischemic obstruction of the microcirculation during 5 minutes of recirculation after 30 minutes of severe temporary ischemia, but the EEG signals did not recover. Further studies of the functional and morphological responses to longer periods of postischemic recirculation are needed to verify the extent to which these mannitol-induced effects are protective.
Joseph R. Thompson, Philip R. Weinstein, and Charles R. Simmons
✓ Cerebral angiography, performed after a seizure in a patient with a life-long history of typical hemiplegic migraine, disclosed markedly dolichoectatic anterior and middle cerebral arteries. No abnormality of the adjacent capillary or venous structures was present. A positive brain scan was attributed to ischemia induced by vasospasm rather than to the corresponding large tortuous anterior and middle cerebral arteries. There were no permanent sequelae and the patient has been free of seizures on Dilantin and phenobarbital over a 3-year follow-up period. Angiographic demonstration or description of a similar ectatic set of anterior and middle cerebral arteries could not be found in the literature. The concurrence of seizures and hemiplegic migraine adds to the peculiarity of this case.
Kenneth R. Feingold, Ira D. Goldfine, and Philip R. Weinstein
✓ In rare cases, acromegalic patients have normal basal concentrations of growth hormone, and their acromegaly results from abnormal growth-hormone secretory patterns. A patient is reported with the clinical features of acromegaly, who had elevated somatomedin levels and an enlarged sella turcica, but whose serum growth-hormone levels on continuous monitoring were in the normal range, with levels of 2.8 to 8.9 ng/ml. Dynamic studies of growth hormone revealed normal responses to hypo- and hyperglycemia, but abnormal responses to L-dopa and thyroid-releasing hormone. At surgery, neither a pituitary adenoma nor eosinophilic hyperplasia was present. It is likely that this patient's acromegaly resulted from the presence of chronically high normal levels of growth hormone.
Report of two cases
Alex R. MacKay, Hoi Sang U, and Philip R. Weinstein
✓ The association of myopathy with epsilon-aminocaproic acid (EACA) treatment after subarachnoid hemorrhage in two cases is reported. Clinical and laboratory findings and possible mechanisms are discussed in light of the known pharmacology of the drug. Recovery ensues if EACA treatment is terminated as soon as myopathy appears.
Hiroshi Karibe, Gregory J. Zarow, and Philip R. Weinstein
✓ To determine which of two treatments for reducing ischemic injury after temporal focal ischemia is more effective, the effects of mild (33°C) intraischemic hypothermia were compared with those of mannitol, the most commonly used neuroprotective agent. Four groups of Sprague-Dawley rats underwent 1 hour of endovascular middle cerebral artery occlusion followed by 23 hours of normothermic reperfusion. The four experimental groups were as follows: Group A, saline control; Group B, mannitol (25%, 1 g/kg); Group C, hypothermia; and Group D, hypothermia plus man-nitol.
Laser-Doppler estimates of cortical blood flow showed that hypothermia did not affect blood flow during ischemia or reperfusion. Mannitol increased cortical blood flow during ischemia and reperfusion under both normothermic and hypothermic conditions (p < 0.05). Neurological deficit was significantly less severe in treated rats (Group B, p < 0.05; Group C or D, p < 0.01) than in controls (Group A). Infarct volume, measured on semiserial Nissl-stained sections, was significantly smaller in treated rats (p < 0.01) than in controls. Infarct volume was also significantly smaller in rats treated with hypothermia than in those treated with mannitol (Group C vs. Group B, p < 0.05); there was no difference between rats treated with mannitol and those treated with mannitol and hypothermia. All three treatments reduced infarct area in the ischemic penumbra; hypothermia with or without mannitol also reduced infarct area in the ischemic core.
These results demonstrate that both mild intraischemic hypothermia and mannitol reduce infarct size and neurological deficit: hypothermia reduces infarct size more effectively than mannitol, and mannitol adds no significant protection to hypothermia, whereas hypothermia adds significant protection beyond that afforded by mannitol after brief focal ischemia followed by reperfusion in rats. The results suggest that mild intraischemic hypothermia alone, or in combination with mannitol, may be useful in avoiding ischemic injury from temporary vessel occlusion during cerebrovascular surgery.
Yoshio Hosobuchi, John E. Adams, and Philip R. Weinstein
✓ Percutaneous dorsal column stimulation was done as a screening procedure in 34 candidates before implantation of a permanent dorsal column stimulator for the treatment of intractable pain. This procedure was useful in forecasting the tolerance of the patient to the “vibratory sensation” produced by a dorsal column stimulator, and the efficacy of the device in relieving pain. Eight patients termed the “vibratory sensation” intolerable. Sixteen found it unpleasant but preferable to the pain, and two found it actually pleasant.
Jun Chen, Philip R. Weinstein, and Steven H. Graham
✓ Arachidonic acid metabolites are believed to be important mediators of tissue injury during reperfusion after cerebral ischemia. To determine whether inhibiting the oxygen-dependent metabolism of arachidonic acid would reduce reperfusion injury, we administered the mixed cyclooxygenase—lipoxygenase inhibitor BW755C (3-amino-1-[m(trifluoromethyl) phenyl]-2-pyrazoline) near the time of reperfusion in a rat model of temporary focal ischemia. The duration of ischemia + reperfusion was 2 hours + 22 hours, 3 hours + 3 hours, or 3 hours + 21 hours. The effects of drug or saline treatment on infarct volume, blood-brain barrier permeability, and blood flow were determined. Cortical blood flow was monitored with laser Doppler flowmetry and blood-brain barrier permeability was evaluated by the Evans blue dye method. Infarct volume was determined in all groups by computerized image analysis of Nissl-stained sections. We found that BW755C treatment significantly attenuated delayed postischemic hypoperfusion in the 3 + 3 group (p < 0.05) and reduced the volume of Evans blue dye staining in the cortex (p < 0.01) and basal ganglia (p < 0.05). Hemispheric swelling was reduced in all treatment groups (p < 0.01), as was total infarct volume in the ischemic hemisphere (p < 0.05). These results support the hypothesis that arachidonic acid metabolites contribute to acute postischemic reperfusion injury and suggest that using a mixed cyclooxygenase—lipoxygenase inhibitor as an adjunct to thrombolytic or revascularization therapy could lengthen the ischemia time after which reperfusion is beneficial.
Operative results in 65 cases
Brian T. Andrews, Norman L. Chater, and Philip R. Weinstein
✓ Forty-seven patients with middle cerebral artery (MCA) stenosis and 18 patients with MCA occlusion underwent extracranial-intracranial arterial bypass procedures. Patients presented with a history of transient ischemic attacks (TIA's), reversible ischemic neurological deficits, TIA's after initial stroke, stroke-in-evolution, or completed stroke. Angiography revealed that the MCA stenosis ranged from 70% to over 95%. Two patients (4.3%) in the stenosis group had a perioperative stroke (within 30 days of operation). There was no perioperative mortality. In the occlusion group, no patient had a perioperative stroke, and one patient (5.5%) died from a non-neurological disease. The TIA's resolved completely in 90% of the patients with stenosis and in 91.6% of those with occlusion. No patient with MCA stenosis had a late ipsilateral stroke, although five had a contralateral or vertebrobasilar stroke. One patient with MCA occlusion had a late ipsilateral stroke. The bypass patency rate at late follow-up review was 100%.
The results of intracranial-extracranial arterial bypass procedures appear to be similar for patients with either stenosis or occlusion of the MCA. Symptomatic relief of TIA's was excellent and, in two patients with progressive stroke-in-evolution, the deficit was stabilized. The incidence of postoperative ipsilateral stroke was low in patients with TIA's alone or with TIA's after an initial stroke, but among patients with completed stroke, improvement was confined to slight reduction in the neurological deficit.