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James Rodney Feild, Ling Lee and Robert F. McBurney

✓ Of 1000 patients who had 1202 brachial and 1099 carotid arteriograms between 1966–1970, 52 had mild and 15 severe complications. Cerebrovascular disease was most frequently encountered. There were 11 patients undergoing simultaneous carotid and brachial arteriography in whom complications could not be localized to an individual artery. Including this group the complication rate for brachial arteriograms was 3.99% and excluding this group the complication rate was 3.08%. There were 3.32% mild and 0.60% severe complications of brachial arteriography and a mortality rate of 0.21%. A serious complication occurred at a rate of one per 152 brachial arteriograms. The complication rate of brachial arteriography with carotid vascular disease was 2.70% and 6.41% with basilar artery disease. The total complication rate of brachial arteriography in cerebrovascular disease was 12.17%. The most common local complication was a transient loss of the radial pulse. The most common cerebral complication was a transient motor deficit.

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Method for measuring brain tissue pressure

Response to alteration in pCO2, systemic blood pressure, and middle cerebral artery occlusion

Robert M. Clark, Norman F. Capra and James H. Halsey Jr.

✓ The authors report a method for measuring total local brain tissue pressure (BTP) using a miniature catheter transducer stereotaxically introduced into the white matter of the cat's cerebrum. Quantitative rapid phasic pressure changes were satisfactorily demonstrated. Due to some drift of baseline of the transducers and inability to perform in vivo calibration, reliable long-term quantitative pressure measurements sometimes could not be studied. The BTP from each cerebral hemisphere and the cisternal pressure (CP) were monitored during alterations of pCO2 and systemic blood pressure, and distilled H2O injection prior to and after right middle cerebral artery (MCA) ligation. The catheter transducers functioned well on chronic implantation for up to 6 weeks. Compared to the chronically implanted catheters, acutely implanted catheters responded identically except for drift. The response of intracranial pressure and CP to MCA occlusion, alterations in pCO2, and systemic blood pressure were similar. No BTP gradients appeared in response to MCA ligation, hypercapnia, hypertension, or progressive swelling of the resulting infarction.

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Robert A. Crawford, Ian R. Griffiths and James McCulloch

✓ The effect of intra-arterially administered norepinephrine (NE) upon spinal cord blood flow (SCBF), before and after disruption of the blood-cord barrier was studied in dogs. Barrier disruption was accomplished with an intra-arterial bolus injection of 2.5 M urea. Multiple ligations of branches of the posterior aorta and cannula placements ensured that the urea was directed to the lumbar and sacral segments of the cord. The SCBF was measured by the hydrogen clearance method. Intra-arterial urea by itself had no significant effect on SCBF.

The intra-arterial infusion of NE (12 µg/min and 30 µg/min) was without overall effect on SCBF. However, if the blood-cord barrier had been previously disrupted with hypertonic urea, both concentrations of NE resulted in large reductions in SCBF. No such reductions in SCBF were seen with blood-cord barrier disruption and NE if the animals had been pre-treated with the α-blocker, phenoxybenzamine (1.5 mg/kg). Some aspects of the possible involvement of NE in the pathophysiology of acute spinal injury are discussed.

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Ian R. Griffiths, James G. Trench and Robert A. Crawford

✓ Spinal cord blood flow (SCBF) and dorsal column conduction, as assessed by the dorsal column evoked potential (DCEP), were measured during subacute cord compression in dogs. Ventral, midline balloons were used to produce compression and a dorsally situated strain gauge transducer measured the cord pressure. In normotensive animals there was autoregulation of SCBF to perfusion pressures (PP) of 65 to 70 mm Hg, and up to cord pressures of 55 to 60 mm Hg. The DCEP amplitude was significantly decreased even during this autoregulatory period. Conduction failure occurred at PP of 20 to 30 mm Hg. Chemically produced hypotension (74 mm Hg) did not affect either SCBF or DCEP. Minimal compression superimposed on hypotension decreased both flow and DCEP amplitude. The results indicate that ischemia is probably not the cause of the impaired conduction although, as the degree of compression increases, the cord will become ischemic once the autoregulatory limit is passed.

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Harvey S. Levin, Robert G. Grossman, James E. Rose and Graham Teasdale

✓ Long-term recovery from severe closed head injury was investigated in predominantly young adults whose Glasgow Coma score was 8 or less at the time of admission. Of the 27 patients studied (median follow-up interval of 1 year), 10 attained a good recovery, 12 were moderately disabled, and five were severely disabled. In contrast to previous studies suggesting that intellectual ability after severe closed head injury eventually recovers to a normal level, our findings showed that residual intellectual level, memory storage and retrieval, linguistic deficit, and personal social adjustment corresponded to overall outcome. All severely disabled patients and several moderately disabled patients exhibited unequivocal cognitive and emotional sequelae after long follow-up intervals. Analysis of persistent neuropsychological deficit in relation to neurological indices of acute injury severity demonstrated the prognostic significance of oculovestibular deficit.

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Donald F. Huelke, James O'Day and Robert A. Mendelsohn

✓ The National Crash Severity Study data in which occupants sustained severe, serious, critical-to-life, or fatal cervical injuries were reviewed. Of passenger cars damaged severely enough to be towed from the scene, it is estimated that one in 300 occupants sustained a neck injury of a severe nature. The neck-injury rate rose to one in 14 occupants for those ejected from their cars, although many of these injuries resulted from contacts within the car before or during the process of ejection. Severe neck injuries were rather rare in cars struck in the rear, but were more common in frontal and side impacts. Occupants between 16 and 25 years of age had such injuries more than twice as often as those in any other age group. Most of the neck injuries of a more severe nature involved the cervical spine or spinal cord. Injuries of the anterior aspect of the neck were relatively infrequent, and usually resulted from direct blunt impacts. National projections of the number of fatalities related to cervical injuries indicates that 5940 deaths, or approximately 20% of all in-car deaths, include fatal cervical spine injuries, and that about 500 cases of quadriplegia per year result from automobile accidents.

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Richard F. Bulger, James E. Rejowski and Robert A. Beatty

✓ In a series of 375 patients with anterior cervical fusions, long-term follow-up results complete with laryngeal examination were obtained in 102 patients. One patient was found to have an inferior laryngeal nerve palsy, and one had a superior laryngeal nerve palsy. Both deficits were thought to be the result of surgical trauma. Measures to minimize the incidence of vocal cord paralysis include careful surgical technique and knowledge of the surgical anatomy of the laryngeal nerves. Suggestions are given for the assessment of postoperative hoarseness, and for the management of vocal cord paralysis.

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DNA in meningioma tissues and explant cell cultures

A flow cytometric study with clinicopathological correlates

James W. Ironside, Robert D. E. Battersby, John Lawry, Reginald S. Loomes, Christopher A. Day and Walter R. Timperley

✓ Flow cytometry was performed on stored frozen tissues and explant cell cultures from 39 meningiomas using ethidium bromide and mithramycin in a selective staining technique for deoxyribonucleic acid (DNA). The ploidy index and percentage of cells in the G0/G1, S, and G2/M phases were calculated for each specimen. The results were compared with the age and sex of the patients; the site, the histological subtype, and mitotic rate of the neoplasms; and the estrogen and progesterone-receptor levels assayed in cytosol-enriched supernatants from cryostat-cut sections. Sixteen neoplasms (41%) were aneuploid. These included two recurrent neoplasms, seven of the eight neoplasms from patients with multiple meningiomas, and three clinically aggressive neoplasms (one hemangiopericytic and two anaplastic meningiomas). Significant correlations were found between values for the ploidy index (r =0.75, p < 0.01), the percentage of S-phase cells (r = 0.82, p < 0.01), and the percentage of G2/M-phase cells (r = 0.69, p < 0.05) in vivo and in vitro. The results support the suggestion that flow cytometry for DNA in meningiomas may be of value in predicting the behavior of these neoplasms, and indicate that under controlled conditions explant cell cultures may provide a useful model for the proliferative characteristics of meningiomas in vivo.

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Vertebrobasilar insufficiency

Part 1: Microsurgical treatment of extracranial vertebrobasilar disease

Robert F. Spetzler, Mark N. Hadley, Neil A. Martin, Leo N. Hopkins, L. Philip Carter and James Budny

✓ Extracranial vertebrobasilar artery thrombo-occlusive disease may cause repetitive transient ischemic episodes and, less frequently, brain-stem or cerebellar infarction. This report describes 40 patients who experienced repetitive vertebrobasilar ischemic symptoms despite maximal medical therapy. The natural history, pathogenesis, and treatment options for each causative lesion are reviewed. The operative approaches to symptomatic disease of the proximal vertebral arteries, arterial compression by cervical osteophytes, traumatic lesions of the vertebral arteries, and thrombo-occlusive pathology of the distal extracranial vertebral arteries are outlined. Specific anesthetic and surgical techniques that have proved successful while achieving zero operative mortality and low perioperative morbidity rates are reported.

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Vertebrobasilar insufficiency

Part 2: Microsurgical treatment of intracranial vertebrobasilar disease

Leo N. Hopkins, Neil A. Martin, Mark N. Hadley, Robert F. Spetzler, James Budny and L. Philip Carter

✓ Posterior circulation transient ischemic attacks have an associated risk of subsequent infarction of approximately 5% per year. Intracranial vertebrobasilar thrombo-occlusive lesions appear particularly likely to result in repetitive ischemic symptoms and in infarction due to hemodynamic insufficiency. The authors present their experience with 45 patients with symptomatic intracranial vertebrobasilar vascular disease despite maximal medical therapy. The specific operative approaches for intracranial vertebral artery endarterectomy and extracranial to intracranial posterior circulation revascularization procedures are outlined.