Increasing evidence in animal models and clinical trials for stroke, hypoxic encephalopathy for children, and traumatic brain injury have shown that mild hypothermia may attenuate ischemic damage and improve neurological outcome. However, it is less clear if mild intraoperative hypothermia during vascular neurosurgical procedures results in improved outcomes for patients. This review examines the scientific evidence behind hypothermia as a treatment and discusses factors that may be important for the use of this adjuvant technique, including cooling temperature, duration of hypothermia, and rate of rewarming.
Raymond Choi, Robert H. Andres, Gary K. Steinberg and Raphael Guzman
Robert H. Andres, Arjun V. Pendharkar, Dominique Kuhlen and Luigi Mariani
Patients requiring CSF shunts frequently have comorbidities that can influence water and electrolyte balances. The authors report on a case involving a ventriculoperitoneal shunt in a patient who underwent intravenous hyperhydration and withdrawal of vasopressin substitution prior to scheduled high-dose chemotherapy regimen for a metastatic suprasellar germinoma. After acute neurological deterioration, the patient underwent CT scanning that demonstrated ventriculomegaly. A shunt tap revealed no flow and negative opening pressure. Due to suspicion of proximal shunt malfunction, the comatose patient underwent immediate surgical exploration of the ventricle catheter, which was found to be patent. However, acute severe hypernatremia was diagnosed during the procedure. After correction of the electrolyte disturbances, the patient regained consciousness and made a good recovery. Although rare, the effects of acute severe hypernatremia on brain volume and ventricular size should be considered in the differential diagnosis of ventriculoperitoneal shunt failure.
Raphael Guzman, Raymond Choi, Atul Gera, Alejandro De Los Angeles, Robert H. Andres and Gary K. Steinberg
✓ The use of stem cell transplantation to restore neurological function after stroke is being recognized as a potential novel therapy. Before stem cell transplantation can become widely applicable, however, questions remain about the optimal site of delivery and timing of transplantation. In particular, there seems to be increasing evidence that intravascular cell delivery after stroke is a viable alternative to intracerebral transplantation. In this review, the authors focus on the intravascular delivery of stem cells for stroke treatment with an emphasis on timing, transendothelial migration and possible mechanisms leading to neuroprotection, angiogenesis, immunomodulation, and neural plasticity. They also review current concepts of in vivo imaging and tracking of stem cells after stroke.
Robert H. Andres, Thilo Graupner, Christian B. Bärlocher, Arthur Augsburger and Javier Fandino
The authors describe a modification of the medial branch kryorhizotomy technique for the treatment of lumbar facet joint syndrome using a fluoroscopy-based laser-guided method. A total of 32 patients suffering from lumbar facet joint syndrome confirmed by positive medial nerve block underwent conventional or laser-guided kryorhizotomy. The procedural time (20.6 ± 1.0 vs 16.3 ± 0.9 minutes, p < 0.01), fluoroscopy time (54.1 ± 3.5 vs 28.2 ± 2.4 seconds, p < 0.01), radiation dose (407.5 ± 32.0 vs 224.1 ± 20.3 cGy/cm2, p < 0.01), and patient discomfort during the procedure (7.1 ± 0.4 vs 5.2 ± 0.4 on the visual analog scale, p < 0.01) were significantly reduced in the laser-guided group. There was a tendency for a better positioning accuracy when the laser guidance method was used (3.0 ± 0.3 vs 2.2 ± 0.3 mm of deviation from the target points, p > 0.05). No difference in the outcome was observed between the 2 groups of patients (visual analog scale score 3.5 ± 0.2 vs 3.3 ± 0.3, p > 0.05). This improved minimally invasive surgical technique offers advantages to conventional fluoroscopy-based kryorhizotomy.
Tejas Sankar and Andres M. Lozano
Lukas Andereggen, Sepideh Amin-Hanjani, Marwan El-Koussy, Rajeev K. Verma, Kenya Yuki, Daniel Schoeni, Kety Hsieh, Jan Gralla, Gerhard Schroth, Juergen Beck, Andreas Raabe, Marcel Arnold, Michael Reinert and Robert H. Andres
Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.
In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.
Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.
Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.
Robert H. Andres, Raphael Guzman, Angélique D. Ducray, Pasquale Mordasini, Atul Gera, Alain Barth, Hans R. Widmer and Gary K. Steinberg
✓ Intracerebral hemorrhage (ICH), for which no effective treatment strategy is currently available, constitutes one of the most devastating forms of stroke. As a result, developing therapeutic options for ICH is of great interest to the medical community. The 3 potential therapies that have the most promise are cell replacement therapy, enhancing endogenous repair mechanisms, and utilizing various neuroprotective drugs. Replacement of damaged cells and restoration of function can be accomplished by transplantation of cells derived from different sources, such as embryonic or somatic stem cells, umbilical cord blood, and genetically modified cell lines. Early experimental data showing the benefits of cell transplantation on functional recovery after ICH have been promising. Nevertheless, several studies have focused on another therapeutic avenue, investigating novel ways to activate and direct endogenous repair mechanisms in the central nervous system, through exposure to specific neuronal growth factors or by inactivating inhibitory molecules. Lastly, neuroprotective drugs may offer an additional tool for improving neuronal survival in the perihematomal area. However, a number of scientific issues must be addressed before these experimental techniques can be translated into clinical therapy. In this review, the authors outline the recent advances in the basic science of treatment strategies for ICH.