Neurophysiologic monitoring and pharmacologic provocative testing for embolization of spinal cord arteriovenous malformations

BACKGROUND AND PURPOSE: Embolization of a spinal cord arteriovenous malformation (SCAVM) is still considered risky. We evaluated the efficacy and reliability of pharmacologic provocative testing with neurophysiologic monitoring in the embolization of SCAVMs. METHODS: We retrospectively analyzed results of 60 provocative tests during 84 angiographic procedures (in 52 patients) with intended endovascular embolization. Tests included 47 sodium amytal and 56 lidocaine injections. All procedures were performed with general anesthesia and monitoring of cortical somatosensory evoked potentials (SEPs) and transcranial motor evoked potentials (MEPs). For provocative testing, 50 mg of amytal and 40 mg of lidocaine were consecutively injected through a microcatheter placed at the position of intended embolization. If SEPs and MEPs did not change, embolization was performed with N-butyl-cyanoacrylate (NBCA). If SEPs or MEPs changed, NBCA embolization was not performed from that catheter position. RESULTS: One false-negative result occurred, with an increase in spasticity after embolization. Nineteen positive results occurred: four after amytal injection and 15 after lidocaine injections. Seven injections in a posterior spinal artery feeder resulted in loss of SEPs or MEPs. Eleven injections in the anterior spinal artery feeder and one in the posterior inferior cerebellar artery feeder resulted in loss of MEPs. CONCLUSION: Provocative testing with amytal and lidocaine combined with neurophysiologic monitoring had a high negative predictive value and was a useful adjunct for SCAVM embolization. Both amytal and lidocaine should be used as provocative agents, and both SEPs and MEPs should be monitored.     

蛛网膜下腔注射利多卡因和舒芬太尼对肛肠术后恢复的影响

 目的 比较联合应用小剂量利多卡因和舒芬太尼同单纯应用利多卡因进行腰麻对门诊患者肛肠手术后恢复时间的影响.方法 选择49例ASAⅠ～Ⅲ级,20～69岁,准备在腰麻下行门诊肛肠手术的患者,随机分为两组:A组(n=28)蛛网膜下腔给予小剂量利多卡因15 mg,舒芬太尼10 μg;B组(n=21)单纯给予利多卡因50 mg.记录恢复运动的时间,瘙痒发生率和其他变化.结果 蛛网膜下腔联合注射小剂量利多卡因和舒芬太尼明显较单纯注射利多卡因恢复运动快(P<0.01).A组50%出现瘙痒.结论 蛛网膜下腔联合注射利多卡因和舒芬太尼比单纯注射利多卡因的运动恢复时间明显缩短.除了瘙痒不良反应外,A组麻醉效果较好.     

Stanford B型主动脉夹层动脉瘤腔内隔绝术后截瘫的预防对策

目的 探讨Stanford B型胸主动脉夹层动脉瘤(TAD)腔内隔绝术(EVE)后截瘫或轻瘫的综合防治措施。方法 回顾在1998年至2001年实施的116例TAD EVE。对于可能发生截瘫的高危患者，术后常规给予地塞米松。结果 包括接受脊髓动脉造影者在内，成功释放并固定移植物的115例中，均无截瘫或轻瘫发生。结论 EVE虽避免了长时间主动脉阻断，但仍可因封闭肋间动脉造成脊髓的严重缺血，包括选择性脊髓动脉造影、糖皮质激素在内的综合性预防措施能减小发生截瘫／轻瘫的危险，而选择适当长度的移植物是其关键。     

多层螺旋CT血管成像对脊髓Adamkiewicz动脉的显示研究

目的:探讨多层螺旋CT血管成像(MDCTA)技术判定脊髓Adamkiewicz动脉的异常起源,指导临床实施主动脉病变手术,从而预防截瘫发生。方法:回顾性分析我院2008年10月～2009年8月对37例主动脉动脉瘤、主动脉夹层修补术及支架植入的术前影像评估,采用多平面立体成像技术,以清晰显示脊髓Adamkiewicz动脉解剖细节。结果:此技术可以清楚显示脊髓damkiewicz动脉异常起源及其与周围动脉之间的微细解剖关系。脊髓Adamkiewicz动脉成功显示率为75.68%,67.65%起源于左侧肋间动脉或腰动脉。结论:该技术(MDCTA)无创是评价Adamkiewicz动脉的有效影像学方法,对合理选择手术方案、减少脊髓缺血性损害,降低术后脊髓截瘫并发症的发生,具有重要的临床指导意义。     

Extensive spinal epidural hematoma: a rare complication of aortic coarctation

Development of collateral circulation belongs among the typical signs of aortic coarctation. Cerebral or spinal artery aneurysm formation with increased risk of subarachnoid hemorrhage represent the most common neurovascular complication of this disease. We report a case of a 20-year-old sportsman who developed acute non-traumatic paraplegia as a result of extensive spinal epidural hemorrhage from collateral vessels accompanying aortic coarctation which was unrecognized up to that time. To the best of our knowledge, acute spinal epidural hematoma as a complication of aortic coarctation has not been previously reported.     

Lidocaine pharmacokinetics during hyperbaric hyperoxia in humans.

METHODS: The disposition of drugs may be influenced by hyperbaric conditions, in particular by changes of liver perfusion. The effect of hyperbaric hyperoxia on the pharmacokinetics of lidocaine, a drug eliminated in the liver with a perfusion-limited clearance, was investigated in human volunteers in a crossover trial. METHODS: A single dose lidocaine i.v. bolus (0.69 or 0.75 mg x kg(-1)) was administered to two volunteers under normobaric conditions (NB: 1 bar or 0.1 MPa, air) and under hyperbaric/hyperoxic conditions (HBO: 2.5 bar or 0.25 MPa, alternating 100% O2-breathing for 20 min and air breathing for 5 min). Blood samples were serially collected for 5 h (NB) or 75 min (HBO), and lidocaine concentration in serum was measured by immunoassay. Data were analyzed assuming linear kinetics and an open two-compartment model. RESULTS: At 1 bar or 0.1 MPa, lidocaine injection caused only slight dizziness and buzzing in the ear. Heart rate and blood pressure were not influenced. Under HBO, lidocaine injection caused marked dizziness and buzzing in the ears, sweating, tremor and coordination-disturbances, even though maximal lidocaine concentrations (0.63 mg x L(-1) and 0.70 mg x L(-1)) were far below therapeutic serum concentrations (1.5-5.0 mg x L(-1)). Pharmacokinetic parameters of lidocaine were similar to those published earlier (T1/2beta: 110+/-16 min; CI: 12.6+/-2.9 ml x min(-1) x kg(-1); Vss: 1.73+/-0.18 L x kg(-1)). There was no indication for effects of HBO on the disposition of lidocaine (p > 0.05). CONCLUSION: The pharmacokinetics of lidocaine do not seem to be influenced in a clinically relevant way in humans by a single HBO-exposure under usual therapeutic conditions. Side effects of lidocaine at 2.5 bar or 0.25 MPa may be caused by pharmacodynamic interactions between lidocaine and hyperbaric/hyperoxic conditions.     

Intraarterial administration of lidocaine for analgesia in hepatic chemoembolization

Hepatic chemoembolization (HCE) routinely results in severe pain requiring massive doses of intravenously administered narcotics. This study examines the efficacy and safety of lidocaine administered intraarterially for analgesia in HCE. In 45 HCE procedures, lidocaine was injected into hepatic arterial branches just prior to and during chemoembolization. Adjunctive analgesic doses given during the procedure and the need for a morphine sulfate drip infusion for postprocedural pain control were recorded and compared with those in 20 procedures performed previously without lidocaine. In procedures with lidocaine, an average of 0.13 mg of morphine sulfate and 1.3 mg of midazolam were required. This is significantly lower than the 11.7 mg of morphine sulfate and 3.7 mg of midazolam used during procedures without lidocaine. A postprocedural morphine drip infusion was required for control of severe pain in 16 of 20 (80%) procedures performed without lidocaine compared with nine of 45 (20%) of those performed with lidocaine. Peripheral blood levels of lidocaine were well below the toxic level, and no complications referable to lidocaine toxicity occurred. Marked reductions in the amount of narcotic analgesia in HCE procedures may be safely achieved with the administration of intraarterial lidocaine.     

支气管动脉内灌注化疗药物并发脊髓损伤的初步探讨

作者对３７例肺癌患者进行了１２５次支气管动脉造影和动脉内灌注化疗药物（顺铂、丝裂霉素、５－氟脲嘧啶），其中１例在灌注的同时加用５ｍｌ碘苯酯经乳化后进行支气管动脉栓塞。共发生３例脊髓损伤，１例在支气管动脉栓塞后即出现截瘫，另两例为术后第３～４ｄ出现右下肢麻木无力及小便困难，继而出现两下肢瘫痪及大小便失禁。症状出现后用激素、神经营养药及对症处理后均有好转。作者对并发脊髓损伤的原因、预防措施及治疗作了初步探讨。     

多层螺旋CT血管成像对脊髓Adamkiewicz动脉的显示

Adamkiewicz动脉是脊髓胸腰段重要的供血血管,术前对其解剖结构的了解,有助于术前设计周密的手术方案,能有效降低脊髓缺血性损伤及术后截瘫或下肢瘫的发生。以往利用选择性动脉造影来了解脊髓的血液供应,但属于有创检查,且技术要求高。随着现代医学影像的发展,多层螺旋CT血管成像技术凭借其较高的空间分辨率和时间分辨率,可以在注入对比剂后一次扫描即可完成全部数据的采集,再通过强大的后处理功能可以获得Adamldewicz动脉及起源的节段性动脉的清晰影像。它在显示脊髓Adamkiewicz动脉方面的优势日益突出。本文综述多层螺旋CT血管成像对脊髓Adamkiewicz动脉显示的临床应用价值。     

Digital subtraction spinal cord angiography in patients undergoing thoracic aneurysm surgery

Thoraco-abdominal aortic replacement can be associated with a high incidence of paraplegia. Because the major source of blood supply to the thoraco-abdominal spinal cord is through the anterior spinal artery of Adamkiewicz, reimplantation of intercostal and lumbar arteries could reduce the risk of this operation. We used intraarterial digital subtraction angiography (DSA) for preoperative localization of the anterior spinal artery in 12 patients. This vessel was successfully located in 9 patients, with DSA providing good quality images in all patients. Preoperative knowledge of the origin of this vessel was helpful in the planning of the operation in all patients, but its efficacy as a routine procedure was not established.     

超选择性支气管动脉栓塞化疗治疗肺癌

目的　探讨超选择性支气管动脉栓塞化疗治疗肺癌的安全性和疗效。方法　回顾分析32 9例经病理学诊断的肺癌作单纯支气管动脉灌注化疗和超选择性支气管动脉栓塞化疗的资料。(1)单纯支气管动脉灌注化疗组 (2 2 1例 ) :普通导管插至支气管动脉主干或肋间 支气管动脉干造影后 ,经导管注入顺铂 4 0～ 6 0mg或卡铂 2 0 0～ 30 0mg ,联合用丝裂霉素 10～ 2 0mg或鬼臼乙叉甙 10 0～ 2 0 0mg。间隔 2～ 4周再次灌注化疗 ,2 2 1例共行 5 4 9次。 (2 )超选择性支气管动脉栓塞化疗组(10 8例 ) :普通导管插管造影后 ,在路图成像指引下 ,将微导管超选择性插至供瘤动脉近瘤处 ,经微导管注入抗癌药 (同单纯支气管动脉灌注化疗组 )和栓塞剂。栓塞剂选用 0 5～ 1 5mm3 明胶海绵颗粒30～ 5 0颗和 (或 )超液态碘油 3～ 8ml。间隔 6～ 9周再次作栓塞化疗 ,10 8例共行 2 6 6次。结果　 2组均未出现脊髓损伤等严重并发症。 2 2 1例单纯支气管动脉灌注化疗中 ,完全缓解 (CR) 2 8例 ,部分缓解 (PR) 79例 ,稳定 (S) 88例 ,进展 (P) 2 6例 ,有效率 (CR +PR)为 4 8 4 % ,1年生存率为 5 3 8% ,2年生存率为 4 4 8% ;10 8例超选择性支气管动脉栓塞化疗中 ,CR 16例 ,PR 5 3例 ,S 32例 ,P 7例 ,有效率为 6 3 9% ,1年生存率为 77 8% ,2年     

Prostate brachytherapy under local anesthesia; lessons from the first 600 patients

PURPOSE: Local anesthesia for prostate brachytherapy was instituted at the Puget Sound Veterans Hospital in 1999, peforming the procedure in our own department without anesthesia personnel in attendance. MATERIALS AND METHODS: The patient is brought into the simulator suite in the radiation oncology department, an i.v. line is started, a cardiac monitor attached, and a urinary catheter is inserted. He is then placed in the lithotomy position, using stirrups attached to the simulator table. A 6-8 cm patch of perineal skin and subcutaneous tissue is anesthetized by local infiltration of 1% lidocaine. The transrectal ultrasound (TRUS) probe is then inserted and positioned to reproduce the planning images. A 3.0 inch 22-gauge spinal needle is used to inject lidocaine up to the prostatic apex, in a pattern around the periphery of the prostate. Once the pelvic floor and prostatic apex are anesthetized, a 7.0-inch, 22-gauge spinal needle is inserted through an 18-gauge 3 inch spinal needle into the peripheral planned needle tracks, monitored by TRUS. As the needles are advanced to the prostatic base, about 1.0 cc of lidocaine solution is injected in the intraprostatic track. A total of 200 to 500 mg of lidocaine is used. RESULTS: As of December 2000, more than 600 patients have received implants under local anesthesia at Seattle, WA. Patients tolerate brachytherapy under local anesthesia surprisingly well. Post-implant CT-defined target coverage has ranged from 80% to 95%, well within published criteria for technical adequacy. Patients' typical implant pain score is 3, on a scale of 0-10. After a series of patient acceptance quality studies, we have abandoned the routine use of sedation, and relied instead on local lidocaine infiltration alone. CONCLUSION: In addition to a high degree of patient satisfaction, performing implants under local anesthesia allows for phenomenal logistical efficiencies and cost advantages.     

Preoperative mapping of arterial spinal supply using 3.0-T MR angiography with an intravasal contrast medium and high-spatial-resolution steady-state

Introduction

Preoperative mapping of the arterial spinal supply prior to thoracoabdominal aortic aneurysm repair is highly relevant because of high risk for postoperative ischemic spinal cord injuries such as paraparesis or paraplegia.

Methods

Twenty-four consecutive patients prior to surgical thoracoabdominal aortic aneurysm repair were investigated. All patients underwent steady-state MR angiography (MRA) of the spinal vasculature with 3-T MRI. The sequence used was a steady-state coronary 3D FLASH with 0.7-mm isotropic voxels. MRA was performed using an intravasal contrast agent. Studies were evaluated by three readers including delineation of arterial spinal supply including both aortic origin and spinal canal entry by three readers.

Results

Identification and localization of the Adamkiewicz artery and its spinal canal entry was successful in all patients. Overall depiction of the vascular anatomy was graded as very good in 3 (12.5%), good in 14 (58.4%), sufficient in 5 (20.8%), and poor in 2 (8.3%) patients. Depiction of segmental artery aortic exit level was graded as good in 6 (25.0%), sufficient in 10 (41.7%), poor in 4 (16.7%) and not identifiable in 4 (16.7%) patients. Delineation of segmental artery entry level into the spinal canal was graded as very good in 4 (16.7%), good in 11 (45.8%), sufficient in 6 (25.0%), and poor in 3 (12.5%) patients.

Conclusions

The use of 3-T MRA with an intravascular contrast agent and steady-state enables AKA localization including its segmental arteries with regard to the level of aortic origin and spinal canal entry in most patients.     

芬太尼复合艾司洛尔或利多卡因对高血压患者气管插管时心血管反应影响的比较

目的比较芬太尼复合艾司洛尔或利多卡因对原发性高血压患者气管插管时心血管反应的影响。方法择期上腹部手术合并原发性高血压患者60例,年龄40~65岁,体重48~78kg,ASAI或Ⅱ级,随机分为3组(n=20):芬太尼3μg/kg组(I组)、芬太尼3μg/kg+艾司洛尔1mg/kg组(Ⅱ组)和芬太尼3μg/kg+利多卡因1mg/kg组(Ⅲ组)。3组均静脉注射咪达唑仑0.05mg/kg、丙泊酚1.5mg/kg和罗库溴铵0.8mg/kg麻醉诱导后气管插管,机械通气。分别于麻醉诱导前(T0)、麻醉诱导后1min(T1)、气管插管后即刻(T2)、气管插管后1min(T3)、3min(T4)及10min(T5)记录心率(HR)、收缩压(SP)、舒张压(DP),并于T0、T1、T3时采集桡动脉血7ml,测定肾上腺素(Ad)和去甲肾上腺素(NA)的浓度。结果与T0比较,Ⅰ组在T2、T3时的HR、SP、DP明显升高(P<0.05);而Ⅱ组、Ⅲ组在T2、T3时的HR、SP、DP变化没有统计学意义(P>0.05);Ⅱ组与Ⅲ组的HR、SP、DP在T1~T5差异无统计学意义(P>0.05)。Ⅰ组T3时血浆Ad和NA的浓度变化没有统计学意义(P>0.05),而Ⅱ、Ⅲ组血浆中Ad、NA浓度低于Ⅰ组(P<0.05)。结论芬太尼3μg/kg复合艾司洛尔1mg/kg或利多卡因1mg/kg均可减轻高血压患者气管插管时的心血管反应。     

Intracranial dural arteriovenous fistula with spinal medullary venous drainage

We report on a 46-year-old patient in whom an intracranial dural arteriovenous (AV) fistula, supplied by a branch of the ascending pharyngeal artery, drained into spinal veins and produced rapidly progressive symptoms of myelopathy and brainstem dysfunction including respiratory insufficiency. Magnetic resonance imaging studies demonstrated brainstem oedema and dilated veins of the brainstem and spinal cord. Endovascular embolization of the fistula led to good neurological recovery, although the patient had been paraplegic for 24 h prior to embolization. This case demonstrates the MRI characteristics of an intracranial dural AV fistula with spinal drainage and illustrates the importance of early diagnosis and treatment. Even paraplegia may be reversible, if angiography is performed and the fistula treated before ischaemic and gliotic changes become irreversible. Received: 25 May 1999; Revised: 25 January 2000; Accepted: 15 February 2000     

前路减压固定植骨融合治疗胸腰椎骨折合并脊髓损伤前路减压固定植骨融合治疗胸腰椎骨折合并脊髓损伤

目的 探讨经前路椎体切除减压固定植骨融合治疗胸腰椎骨折合并脊髓损伤的疗效。方法 通过对自1985年1月至2002年6月采用前路减压固定植骨融合治疗537例胸腰椎骨折合并脊髓损伤患者临床资料分析，以及248例患者的随访结果比较，观察其神经功能恢复和局部脊柱的稳定性。结果 573例患者术后均无神经功能损害加重。出院时神经功能改善情况：93例无神经损伤者，术后功能良好；新鲜骨折合并不全瘫患者275例中，240例有1～3级恢复；107例陈旧性骨折患者术后神经功能均有不同程度改善；62例全瘫患者，仅5例感觉有部分恢复。248例随访中，26例全瘫患者仅4例部分浅感觉恢复，204例不全瘫患者均有不同程度的神经功能改善。全部患者X线片显示植骨均已融合，有4例出现断钉，但无临床症状。结论对来自椎管前方压迫的胸腰椎骨折合并脊髓损伤，前路减压手术具有减压彻底、神经功能改善率高、Ⅰ期固定融合成功率高、脊柱稳定性好等优点，是治疗胸腰椎骨折合并脊髓损伤的有效方法。     

前路减压固定植骨融合治疗胸腰椎骨折合并脊髓损伤

目的探讨经前路椎体切除减压固定植骨融合治疗胸腰椎骨折合并脊髓损伤的疗效。方法通过对自1985年1月至2002年6月采用前路减压固定植骨融合治疗537例胸腰椎骨折合并脊髓损伤患者临床资料分析,以及248例患者的随访结果比较,观察其神经功能恢复和局部脊柱的稳定性。结果573例患者术后均无神经功能损害加重。出院时神经功能改善情况:93例无神经损伤者,术后功能良好;新鲜骨折合并不全瘫患者275例中,240例有1～3级恢复;107例陈旧性骨折患者术后神经功能均有不同程度改善;62例全瘫患者,仅5例感觉有部分恢复。248例随访中,26例全瘫患者仅4例部分浅感觉恢复,204例不全瘫患者均有不同程度的神经功能改善。全部患者X线片显示植骨均已融合,有4例出现断钉,但无临床症状。结论对来自椎管前方压迫的胸腰椎骨折合并脊髓损伤,前路减压手术具有减压彻底、神经功能改善率高、Ⅰ期固定融合成功率高、脊柱稳定性好等优点,是治疗胸腰椎骨折合并脊髓损伤的有效方法。     

选择性椎体供血动脉栓塞的动物实验研究

目的 通过对实验犬进行选择性椎体供血动脉栓塞的研究，旨在建立椎体急性缺血模型以及探讨影响栓塞结果的因素，为临床更好地实施脊柱肿瘤术前动脉栓塞提供理论依据。方法 用明胶海绵对12只实验犬分别行单节段和多节段选择性腰动脉造影和栓塞，栓塞后1－7d内观察后肢功能情况、靶节段椎体、脊髓MRI表现和病理改变。结果 栓塞单节段（双侧）或多节段腰动脉者均引起椎体不同程度的缺血、坏死改变。栓塞单根腰动脉者，不管靶动脉是否发出根髓动脉其靶椎体未见明显变化和未发生瘫痪；栓塞多节段腰动脉者有1只犬发生不全。在栓塞单节段以上腰动脉的脊柱节段水平可背部肌肉发生不同程度的缺血坏死表现。结论 （1）选择性动脉栓塞可用于椎体急性缺血模型的制作，为椎体缺血性病变的实验性诊断和治疗研究提供可能。（2）单节段动脉栓塞难于使整个椎体缺血坏死。（3）多节段动脉栓塞时有可能引起并发症，特别是栓塞范围内存在根髓动脉时。（4）在作选择性脊柱动脉检塞时，必要时应行保护性栓塞。     

兔不完全性截瘫损伤脊髓神经生长因子免疫组化阳性表达的动态变化

目的：探讨兔不完全性截瘫后损伤脊髓神经生长因子（NGF）阳性表达的动态变化,探讨NGF在脊髓损伤过程中的作用。方法：采用压迫法造成不完全截瘫兔模型,于伤后6h、7、15d取损伤脊髓组织3．0mm长,用免疫组织化学S—P法染色,并用关国产Optimas6．51彩色图像分析系统进行图像分析。结果：脊髓损伤后NGF表达升高,主要体现在白质部位,可见峰值为伤后7、15d时灰质降至正常水平以下（P〈0．01）。结论：脊髓损伤不能完全自身修复的原因与NGF缺乏有关（NGF水平15d后低于正常值）,NGF水平可为脊髓损伤和损伤修复的时间提供诊断和治疗依据。     

椎体动脉栓塞治疗椎体血管瘤的临床应用与研究(附5例报告)

目的:探讨椎体动脉栓塞法治疗椎体血管瘤的优越性及其临床应用价值。材料与方法:使用两种栓塞材料——真丝线段0.5cm长的1号医用缝合丝线,可吸收明胶海棉块1mm~3,对5例椎体血管瘤患者进行了栓塞治疗,5例均为女性,年龄29～62岁,其中胸,_(12)2例,胸_(10)腰_3及胸_8人工椎体置换术后复发各1例,5例患者均有不同程度的脊髓、神经根压迫症状,2例出现痉挛性截瘫。结果:5例患者经栓塞治疗后,除1例于1年后死于肝癌,但其症状有明显改善;4例均在一段时间后,临床症状和体征基本消失或完全恢复正常,生活完全自理,随访6～10年无复发,取得显著疗效。结论:椎体动脉栓塞治疗椎体血管瘤是一种安全、有效的治疗方法,与手术及放射疗法比较有明显的优越性。