Diffusion of ketoprofen into the cerebrospinal fluid of young children

BACKGROUND: The objective was to examine whether or not ketoprofen enters the cerebrospinal fluid after a single oral dose of 1 mg.kg-1 syrup, and to find out what is the lowest plasma concentration that will achieve a measurable level in the cerebrospinal fluid. METHODS: We measured ketoprofen concentrations both in plasma and cerebrospinal fluid of 10 young and healthy children (aged 9-86 months) after surgery with spinal anaesthesia. Samples of cerebrospinal fluid were collected 30 min after drug administration, at the same time as venous blood samples. A validated high-performance liquid chromatography method with a lower limit of 0.02 microg x ml(-1) was used to detect ketoprofen concentrations in cerebrospinal fluid and plasma. RESULTS: Ketoprofen was detectable in the cerebrospinal fluid only in the child who had the highest plasma concentration, 7.4 microg x ml(-1), while at plasma concentrations 6.5 microg x ml(-1) or less, cerebrospinal fluid (CSF) concentrations remained unmeasurable. The detected CSF/plasma ratio was 0.008. CONCLUSIONS: These results indicate that ketoprofen at a dose of 1 mg x kg(-1) is too low to produce measurable CSF levels within 30 min of oral administration.     

Penetration of fusidic acid into human brain tissue and cerebrospinal fluid

Summary Penetration of fusidic acid into brain tissue in six patients and cerebrospinal fluid in seven patients was determined. Tissue samples, taken during surgery revealed drug levels at about 7% of simultaneous serum concentrations. In contrast, cerebrospinal fluid concentrations were below 1% of serum levels. Since serum- and tissue levels of fusidic acid were far above the minimal inhibitory concentration (MICs) of staphylococci and streptococci, and since it has a long serum half-life of about 10 hours, it is a promising candidate for prophylaxis in neurosurgery.     

持续腰穿引流治疗脊柱手术后脑脊液漏

目的:探讨脊柱外科手术后脑脊液漏的有效治疗措施。方法:对1994年5月~2003年11月我院脊柱外科手术后64例脑脊液漏患者的治疗进行回顾性分析,根据治疗方法分为两组:A组以俯卧位和伤口加压为主,辅以甘露醇脱水;B组以持续腰穿引流为主,辅以甘露醇脱水,平卧位或侧卧位。结果:A组治愈率81.5%,5例仍有脑脊液漏,其中4例经持续腰穿引流后痊愈,1例再次手术冲洗引流痊愈;B组32例经持续腰穿引流3～7d后痊愈,治愈率100%。结论:持续腰穿引流是治疗脊柱手术后脑脊液漏安全有效的方法。     

Management of overdrainage in cerebrospinal fluid shunting

Objective : To reveal the effectiveness and safety of adding a single slit valve serially to the ventriculoperitoneal shunt system in order to reverse overdrainage. Materials and Methods : The study is a retrospective review of clinical experience in a regional hospital (Tuen Mun Hospital, Hong Kong). A series of 10 cases are reported. All cases showed evidence of cerebrospinal fluid overdrainage after a ventriculoperitoneal shunt procedure. The advantages and disadvantages of other treatment options are also reviewed. Results : The symptoms of all six patients who presented symptomatically subsided or improved after the procedure. Nine of the 10 patients had radiological improvement in their postoperative computed tomography scan. No procedure‐related complication occurred. Conclusion : The early results of such a treatment option appeared safe and rewarding. However, longer term follow up and more experience is needed before the treatment’s efficacy can be proved definitely.      

Different release of cytokines into the cerebrospinal fluid following surgery for intra- and extra-axial brain tumours

Summary To elucidate the role of cytokines in brain repair processes and in local inflammation after neurosurgical procedures, cerebrospinal fluid (CSF) samples from 8 patients with intra-axial tumours and 8 patients with extra-axial tumours were analysed for interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1ra), IL-6, IL-8, IL-10, and tumour necrosis factor (TNF)-alpha at the beginning and after surgery. Levels of IL-6 and IL-8 increased dramatically in all patients just hours after surgery and fell during subsequent days. IL-1beta was found only in low amounts in the CSF of both patient groups. Other cytokines demonstrated different courses. In patients with intra-axial tumours IL-1ra peaked two to four hours after surgery with a subsequent decrease. In patients with extra-axial tumours there was a continuous low-level IL-1ra release into the CSF without a peak. TNF-alpha was not present in detectable levels in the CSF after surgery for extra-axial tumours but was found to peak two to four hours after surgery for intra-axial tumours. IL-10 was detected in the CSF of both patient groups, but a higher peak was seen after surgery for extra-axial tumours. These results suggest different requirements for the cytokine response and an involvement of different cell types in cytokine release. However, the analysis of the CSF from both patient groups showed no differences in cell counts and populations, with a mild pleocytosis being present in both patient groups after surgery. Therefore, we conclude that after surgery for extra-axial tumours cytokines were predominately produced by non-immune cells stimulated through hypoxia or mechanical irritation. After surgery for intra-axial tumours with a significant brain injury immune cells — activated by necrotic material —seem to be involved in the process of cytokine synthesis. In these cases an additional IL-1ra and TNF-alpha peak was found and these cytokines may be markers for cerebral injury.     

腰椎术后脑脊液漏的处理

1993年7月～2007年5月,我科共行腰椎手术429例,其中18例术后发生脑脊液漏,发生率4．2％,经积极处理后均治愈。     

Subdural hematoma induced by cerebrospinal fluid drainage

A 50-year-old man underwent replacement of the descending thoracic aorta for a DeBakey type III-b chronic dissecting aortic aneurysm. During the surgery, lumbar cerebrospinal fluid (CSF) drainage with a 10 cm H₂O pop-off pressure was used to protect against spinal cord ischemia. During cardiopuhnonary bypass, the patient’s pupils were isocoric, but anisocoric at end of the operation. As computed tomography of the brain showed right subdural hematoma, neurosurgical drainage was instituted emergently. Although some neurological deficit remained, the patient recovered well and was discharged. This case provides a strong reminder that CSF drainage for spinal cord protection against ischemia might induce subdural hematoma, which can be catastrophic during an operation for thoracoabdominal aortic aneurysm.     

脊柱术后脑脊液漏的早期观察和护理体会

目的：探讨脊柱手术后脑脊液漏的早期观察及护理,并观察其疗效。方法回顾性分析2010年1月～2012年12月我科行脊柱手术后发生脑脊液漏45例患者的临床资料,总结早期观察的要点及护理体会。结果本组107例患者中,45例术后发生脑脊液漏,13例采取蛛网膜下腔置管术治愈,32例采取局部加压,按期拔管后治愈。1例发生感染,1例出现假性硬脊膜囊肿,均经2次手术治愈。结论对于脊柱术后脑脊液漏的患者进行早期观察和护理干预,可有效地减轻患者痛苦,缩短住院天数,提高护理质量,促进患者的康复。     

The role of cerebrospinal fluid shunting in tuberculous meningitis

Twenty-three patients with severe tuberculous meningitis who underwent cerebrospinal fluid shunting within the first month of illness were reviewed nine months later. The criteria for and results of the use of cerebrospinal fluid shunts in tuberculous meningitis are reviewed.     

Nasoseptal flap closure of traumatic cerebrospinal fluid leaks

The vascularized nasoseptal flap has become a principal reconstructive technique for the closure of endonasal skull base surgery defects. Despite its potential utility, there has been no report describing the use of the modern nasoseptal flap to repair traumatic cerebrospinal fluid (CSF) leaks and documenting the outcomes of this application. Specific concerns in skull base trauma include septal trauma with disruption of the flap pedicle, multiple leak sites, and issues surrounding persistent leaks after traumatic craniotomy. We performed a retrospective case series review of 14 patients who underwent nasoseptal flap closure of traumatic CSF leaks in a tertiary academic hospital. Main outcome measures include analysis of clinical outcome data. Defect etiology was motor vehicle collision in eight patients (57%), prior sinus surgery in four (29%), and assault in two (14%). At the time of nasoseptal flap repair, four patients had failed prior avascular grafts and two had previously undergone craniotomies for repair. Follow-up data were available for all patients (mean, 10 months). The overall success rate was 100% (no leaks), with 100% defect coverage. The nasoseptal flap is a versatile and reliable local reconstructive technique for ventral base traumatic defects, with a 100% CSF leak repair rate in this series.     

Site of origin of spinal cerebrospinal fluid pulse wave

Since vascular pulsation in the cerebrospinal fluid causes the cerebrospinal fluid pulse wave (CSFPW), spinal CSFPW may serve as a monitor of spinal cord blood flow. However, there are two possible sources of spinal CSFPW: brain and spinal cord pulsation, and it is unclear for which region spinal CSFPW provides blood flow information. To resolve this question, we analyzed changes in CSFPW caused by occlusion of the large vessels in mongrel dogs. The thoracic and abdominal aorta (TA group, n = 13; AA, n = 6), bilateral internal carotid arteries (ICA, n = 7), and superior and inferior vena cava (SVC, n = 6; IVC, n = 8) were occluded. The CSFPW was measured at the second cervical and sixth lumbar spine level. To eliminate the influence of hemodynamic changes caused by the occlusion, CSFPWs were decomposed into component frequencies, harmonic waves (HWs), and analyzed using the system analysis method. After occlusion, cervical CSFPW was decreased in groups ICA (change in the first HW, 38%; P < 0.05 by Wilcoxon signed-ranks test), TA (40%; P < 0.05), and SVC (53%; P < 0.05), while lumbar CSFPW was decreased in groups TA (71%; P < 0.01), AA (78%; P < 0.05), and IVC (48%; P < 0.05). These results show that spinal CSFPW provides information on the blood flow of a relatively localized region, and could be used to monitor spinal cord blood flow. Received for publication on May 28, 1997; accepted on Aug. 11, 1997     

Determination of the glial fibrillary acidic protein in human cerebrospinal fluid and in cyst fluid of brain tumors

Summary The glial fibrillary acidic protein (GFAP) have been quantitatively determinated in over 200 samples of liquid content of brain tumours and in cerebrospinal fluid (CSF) of cases with various tumours of the cerebral nervous system. For establishing the GFAP value, the rocket radioimmunoelectrophoresis was used. The studies were performed in three series of patients. The GFAP value of fluids from 26 cysts of both neoplastic and non-neoplastic type had a wide range of 0,6 g/ml to 40 g/ml. Significant elevation of GFAP was usually recorded in fluid from cysts of anaplastic tumour with astroglial differentiation. In this series of 24 cases with various brain tumours, the GFAP value of the CSF ranged from 0,2 g/ml to 50 g/ml. In gliomas, as in astrocytoma and glioblastoma, these values were on a higher level, of over 4 g/ml. In other tumours and in cerebral lesions of other aetiology, the GFAP values were lower, below 3 g/ml and 0,3 g/ml respectively.In another series of 32 patients with brain tumour treated surgically, a significant increase of GFAP (to 30 g/ml) was noted in the CSF during the first week after operation, and that was always associated with an increase of the total protein of the CSF. During the second and third week after operation, when the total protein of the CSF was reduced to a normal level, the values of GFAP were still elevated, first of all in those cases of astrocytoma and glioblastoma which were not radically excised. These findings suggest that investigation of GFAP in the CSF of patients with brain tumour may be helpfull in diagnosis and prognosis.Presented at the XV Congress of the Polish Society of Neurosurgeons Szczecin/Poland, September 27–29, 1985.     

颈椎手术并发脑脊液漏的处理

目的 探讨颈椎手术并发脑脊液漏（CSFL）的处理方法及其疗效。方法 对11例颈椎手术并发CSFL的患者,后路手术采用自体筋膜修补2例,前路手术采用自体筋膜明胶海绵堵塞9例,手术后仍存在CSFL患者采取去枕头高足低位、延长脱水剂应用时间、行腰穿蛛网膜下腔引流。结果 2例后路手术CSFL患者修补成功。9例前路行硬膜堵塞患者4例仍有CSFL,行腰穿蛛网膜下腔引流,切口引流或漏出0—3d停止．切口在引流后7d拆线均愈合。结论 CSFL术中采用修补或堵塞硬膜破口术后采用头高足低位、延长脱水剂应用时间可减少手术后CSFL的发生;术后持续腰穿蛛网膜下腔引流,能有效终止切口内CSFL,有利于切口愈合,避免感染发生。     

预防性应用头孢曲松钠治疗外伤性脑脊液漏的临床分析

目的探讨预防性应用头孢曲松钠治疗外伤性脑脊液漏、防治并发感染的疗效分析。方法回顾性分析我院2001年2月～2009年2月期间137例外伤性脑脊液漏患者的临床资料,根据是否使用头孢曲松钠治疗,这些患者分为头孢曲松钠治疗组和对照组。结果预防性使用头孢曲松钠组患者70例,脑膜炎发生3例;患者住院时间9～35天,平均13.2天。对照组66例,7例患者发生脑膜炎。住院时间12～43天,平均16.3天。结论治疗外伤性脑脊液漏中应用头孢曲松钠防治继发性脑膜炎,对于降低脑膜炎发生率、促进漏口愈合、缩短住院时间等方面,能够改善疗效,具有积极的作用。     

Ketorolac or fentanyl to supplement local anesthesia?

Study Objective: To evaluate the usefulness of ketorolac in the treatment of intraoperative pain refractory to the administration of local anesthetic alone.

Design: Intraoperative acute-pain treatment model consisting of awake, nonsedated patients who randomly received either an opioid or a study drug in a double-blind fashion.

Setting: University medical center.

Patients: Eighty patients who underwent breast biopsy, lumpectomy, or central venous catheter placement.

Interventions: Patients received either ketorolac 1 mg/kg intravenously (IV) up to a total dose of 60 mg or fentanyl 3 μg/kg IV up to a total dose of 250 μg to supplement the local anesthetic.

Measurements and Main Results: Verbal pain evaluation and the visual analog scale (VAS) were used for perioperative measurement of pain. Heart rate (HR), blood pressure, and respiratory rate (RR) were recorded before and after analgesic drug injections at 10-minute intervals, both intraoperatively and while the patient was in the postanesthesia care unit (PACU). Speed of recovery was quantified by p-deletion and digit substitution tests on admission to the PACU and at 30-minute intervals until discharge. The frequency of nausea, vomiting, and pruritus were recorded. There were no differences between the groups in perioperative verbal pain evaluation, VAS scores, HR, systolic blood pressure, diastolic blood pressure, or RR. Patients who received ketorolac exhibited a significantly lower frequency of intraoperative and postoperative medication administration intraoperatively, than those who received fentanyl. No additional pain medication was required by patients in the PACU in either group.

Conclusions: Ketorolac is a useful alternative to fentanyl for the treatment of intraoperative pain refractory to the administration of local anesthetic alone during monitored anesthesia care. A decided advantage of ketorolac over fentanyl is the absence of nausea and vomiting in the intraoperative and postoperative periods.     

颈椎前路手术并发脑脊液漏的处理

目的 探讨颈前路手术中脑脊液漏并发症的防治措施.方法 通过回顾性的方法 对2000-01-2009-08所发生6例颈椎前路手术后脑脊液漏患者的临床资料进行分析总结.结果 术中采用硬脊膜破损口缝合或修补和明胶海绵封堵填塞法处理,术后采用俯卧头低腰高体位,引流管拔除时管口皮肤全层缝合,或经腰椎蛛网膜下腔持续引流及对症处理,...     

颈椎手术后并发脑脊液漏的原因和处理

目的：分析颈椎手术后并发脑脊液漏（CSFL）的原因，探讨其处理方法及疗效。方法：1999年12月～2004年12月共行颈椎减压手术562例，术后发生CSFL5例，其中4例为前路减压时切除后纵韧带骨化块或椎体后方骨赘时直接损伤硬膜所致，1例为后路颈椎管双开门扩大成形后发生CSFL。但术中未见明确硬膜撕裂：4例在术后1～3d发现，1例于术后第9d发现。发现CSFL后均拔除伤口引流、缝合封闭皮肤裂口、常规应用抗生素，并采取头高脚低位和经腰椎蛛网膜下腔持续引流治疗。结果：5例漏口均在1～3d内停止渗出．4～8d内伤口愈合。引流时间11～16d，引流量每天150～410ml，平均320ml。引流过程中4例出现头痛、恶心、呕吐：1例有嗜睡、神志淡漠，检查发现有低钠血症，予补液、对症处理后症状缓解。术后随访10～38个月（平均20个月），无切口感染及脑脊液囊肿形成。结论：密闭伤口、头高脚低位并经腰椎蛛网膜下腔持续引流治疗颈椎术后CSFL，有利于漏口闭合，操作简单易行，是值得应用的非手术治疗措施。     

扩大额下硬膜外入路治疗外伤性脑脊液鼻漏

目的 探讨外伤性脑脊液鼻漏的手术方法。方法 对14例创伤性脑脊液鼻漏采用扩大额下硬膜外入路修补治疗。用CT、MRI、CT脑池造影进行术前瘘口定位。结果 本组14例随访3个月—3年。除8例嗅觉丧失或减退外，无严重并发症，无手术死亡。结论 扩大额下硬膜外入路适用于脑脊液鼻漏的修补，手术安全，并发症少，疗效满意。