Ischemic toe after surgery for lesser toe deformities: An algorithm

Ischemia after correction of lesser toe deformities is usually due to temporary vasospasm and can rarely cause gangrene. The published literature on dealing with the issue and been reviewed and used to suggest an algorithm for a logical step by step approach to a pale or white toe when encountered in the postoperative period.     

Combined endovascular therapy of ruptured aneurysms and cerebral vasospasm

We describe two patients with subarachnoid haemorrhage due to a ruptured intracranial aneurysm and severe symptomatic vasospasm. The aneurysm was occluded with detachable coils followed by intra-arterial infusion of papaverine to treat vasospasm as an one-stage procedure. There was significant resolution of the vasospasm. The long-term clinical outcome in one patient was excellent, the other still has minor deficits. Combined endovascular aneurysm therapy followed by intra-arterial spasmolysis with papaverine is a technically feasable therapeutic alternative in patients with symptomatic vasospasm. Received: 5 November 1999/Accepted: 12 July 2000     

Selective Cerebrospinal Fluid Hypothermia: Bioengineering Development and In Vivo Study of an Intraventricular Cooling Device (V-COOL)

Hypothermia is a promising therapeutic strategy for severe vasospasm and other types of non-thrombotic cerebral ischemia, but its clinical application is limited by significant systemic side effects. We aimed to develop an intraventricular device for the controlled cooling of the cerebrospinal fluid, to produce a targeted hypothermia in the affected cerebral hemisphere with a minimal effect on systemic temperature. An intraventricular cooling device (acronym: V-COOL) was developed by in silico modelling, in vitro testing, and in vivo proof-of-concept application in healthy Wistar rats (n = 42). Cerebral cortical temperature, rectal temperature, and intracranial pressure were monitored at increasing flow rate (0.2 to 0.8 mL/min) and duration of application (10 to 60 min). Survival, neurological outcome, and MRI volumetric analysis of the ventricular system were assessed during the first 24 h. The V-COOL prototyping was designed to minimize extra-cranial heat transfer and intra-cranial pressure load. In vivo application of the V-COOL device produced a flow rate-dependent decrease in cerebral cortical temperature, without affecting systemic temperature. The target degree of cerebral cooling (− 3.0 °C) was obtained in 4.48 min at the flow rate of 0.4 mL/min, without significant changes in intracranial pressure. Survival and neurological outcome at 24 h showed no significant difference compared to sham-treated rats. MRI study showed a transient dilation of the ventricular system (+ 38%) in a subset of animals. The V-COOL technology provides an effective, rapid, selective, and safe cerebral cooling to a clinically relevant degree of − 3.0 °C.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13311-022-01302-y.     

前列地尔联合尼莫地平治疗动脉瘤性蛛网膜下腔出血脑血管痉挛的效果分析

目的 探讨前列地尔联合尼莫地平治疗动脉瘤性蛛网膜下腔出血脑血管痉挛的效果.方法 选取2017年6月—2019年12月沈阳市第五人民医院收治的76例动脉瘤性蛛网膜下腔出血脑血管痉挛患者,依据治疗方式的不同将患者分为对照组和观察组各38例.对照组在常规治疗方案基础上加用尼莫地平治疗,观察组在对照组治疗方案基础上联合应用前列...     

Ergotism and factitious hypotension associated with interaction of ergotamine with CYP3A4 inhibitors

Background. Although uncommon, severe ergotism continues to occur. The purpose of this study is to describe causes and clinical effects of ergotism in recent years. Methods. This is an observational case series with data obtained retrospectively from all patients with ergotism referred to Ramathibodi Poison Center in Bangkok, Thailand from January 2006 to August 2013. Result. Twelve cases of ergotism were identified. All cases involved ergotamine 1 mg/caffeine 100 mg combination tablets. Nine cases (75%) were precipitated by drug–drug interactions with CYP3A4 inhibitors. The other cases involved suicidal attempt (2 cases) and pediatric unsupervised ingestion (1 case). Ten patients (83%) had signs of peripheral vascular insufficiency. Five of these patients initially had factitiously low or unmeasurable blood pressure using non-invasive technique and had paradoxical increase following intravenous vasodilator administration. Two patients required partial foot amputations due to gangrene. Two patients, including a 15-month-old boy with an unsupervised ingestion, died. Discussion. In this series, most cases of severe ergotism were associated with interaction with CYP3A4 inhibitors, which increase ergotamine bioavailability. Factitious low blood pressure in these cases was likely caused by severe vasospasm. Conclusion. Critical ergotism continues to occur in Thailand, most commonly associated with the drug–drug interactions.     

Perfil clínico y evolución de pacientes con hemorragia subaracnoidea durante 11 años

IntroductionSpontaneous subarachnoid haemorrhage is a rare cause of stroke, but it causes great socioeconomic impact and high morbidity and mortality.The aim of this study is to describe the clinical profile and evolution of a series of patients with SAH admitted to a tertiary hospital, as well as the diagnostic and therapeutic management.Material and methodsRetrospective study of 536 patients diagnosed with SAH admitted to the ICU of the Hospital Universitario de A Coruña between 2003 and 2013 (Age: 56.9 ± 14.1 years, female/male ratio: 1.5:1). Demographic characteristics, risk factors, aetiologies and clinical signs, prognostic scales, diagnostic tests and treatment were collected. A comparative analysis was made between the general series and subgroups of patients with aneurysmal (SAH-A) and idiopathic (SAH-I) subarachnoid haemorrhage.ResultsThere were 49.0 ± 15.1 patients/year (2013 incidence: 4.3/100,000 inhabitants). 60.3% presented Glasgow Coma Scale 14-15, with scarce symptomatology (Hunt-Hess I-II 61.9%, World Federation Neurosurgeons Scale I-II 60.4%). 50.7% presented Fisher IV.SAH-A was diagnosed in 78.3% (n = 396); perimesencephalic subarachnoid haemorrhage (SAH-PM) in 3.2%; and SAH-I in 17.9%. During the study period there was an increase in the prevalence of aneurysms, causing an increased number of surgeries in recent years. Both SAH-A and SAH-I presented greater severity upon admission. Patients with SAH-A had higher percentage of complications and mortality, with lesser degree of independence at 6 and 12 months.ConclusionsThe incidence of SAH appears to have decreased in recent years, with SAH-I comprising 17.9% of the cases. Patients with SAH-I have better prognosis and lower risk of complications, highlighting the benignity of SAH-PM.     

CT评价腰大池引流减少蛛网膜下腔出血的研究

目的 探讨腰大池引流对蛛网膜下腔出血患者的有效性和安全性.方法 选择蛛网膜下腔出血患者44例,19例行腰大池引流设为引流组,25例未行脑脊液引流或仅行单独的脑室外引流设为对照组.分析2组患者新发脑梗塞的发生率及引流组的并发症.结果 CT影像比较表明,引流组新发脑梗塞的发生率(5％)少于对照组(32％),其差异具有统计学意义(P＜0.05);脑积水的发生率2组无区别,腰大池引流组并发症很少且可进行良好的控制.结论 严格掌握适应症和正确操作,腰大池引流具有较少的并发症和良好的安全性,可有效减少蛛网膜下腔出血患者脑血管痉挛及其相关梗塞.     

Prevention of symptomatic vasospasm after SAH by constant venous infusion of nimodipine

Sixty-one patients with SAH due to rupture of a cerebral aneurysm, classified in Grades I to IV according to Hunt and Hess, received a constant venous infusion of Nimodipine in a dose of 2mg/h for at least 14 days, followed by an oral administration of 60 mg/6 h for at least 4 days. Patients admitted after the 6th day of SAH, patients with SAH but without aneurysm on the angiogram and patients in Grade V were excluded. Mortality in 30 patients of Grades I-II was 3.3%, in 31 patients of Grades III-IV 42%. In the latter group 1 patient died due to cerebral vasospasm. Transient vasospasm occurred in 2 patients of Grades I-II. Recovery was complete in both cases. Thus, incidence of cerebral vasospasm was 4.9%, the incidence of poor-outcome-vasospasm even only 1.6%. The syndrome of cerebral vasospasm seems to be more than only constriction of cerebral vessels. The deleterious effects of Ca²⁺ shift into vascular cells and into neural cells which causes irreversible damage are discussed. Early administration of a specific 'cerebral' calcium antagonist like Nimodipine after SAH will prevent the intracellular Ca²⁺ overloading, thus protecting the neural cells and preventing Ca²⁺-induced smooth-muscle contraction of cerebral vessels, which encourages ischaemic deficits after SAH. The preventive use of Nimodipine has markedly reduced the incidence of symptomatic vasospasm in our clinic.     

Image guidance to improve reliability and data integrity of transcranial Doppler sonography

Background

Principles and accuracy of image-guided transcranial Doppler (IG TCD) sonography have been published recently. However, it remains open whether combination of image guidance and TCD offers an additional clinical advantage. This study scores the accuracy of conventional TCD examinations and investigates the potential improvement of TCD data integrity and reliability regarding the additional use of IG.

Methods

Conventional TCD was performed by a group of experienced investigators, who were blinded to images of a navigation system tracking the Doppler probe, whereas an independent observer documented the TCD findings, acquired by the investigators, due to saving spatial data of the TCD sample volume using IG for subsequent analysis. In a second set of experiments, image guidance was available to investigators without any previous TCD experience.

Results

The analysis of 3D data of vessels (n = 173) labeled by experienced investigators in conventional TCD, revealed a rate of 37% misinterpreted Doppler signals regarding the target vessel. Correctness of labeling was comparable between the different vascular segments. The rate of correct labeling was higher for right- (69%) than for left-sided vessels (57%). In comparison, by using IG, TCD investigators without any previous TCD experience achieved a significantly lower rate of 10% (n = 39) mislabeled vessels.

Conclusions

Our data suggest, that misinterpretation of the vascular source of the Doppler signal is a common source of errors in conventional TCD. Visualization of the vascular anatomy by image guidance offers improved accuracy and reliability of TCD results and may positively influence the learning curve for inexperienced investigators.