Biomedical subjects
Publications and source records attributed to R F Heimburger.
Many able investigators have shown electronic conduction across the transected spinal cords of a variety of animals. LW Freeman reported return of function in paralyzed extremities after spinal cord section and transection in rats, cats and dogs before Medline searches could be performed online. This summary of Freeman's reports will lead today's investigators to his publications methods and successes.
High intensity focused ultrasound was employed to modify the permeability of the normal feline and canine blood-brain barrier (BBB) to a circulating vital dye--Evans blue (EB). The threshold doses (W sec/cm2) for focally increasing the permeability of the BBB in white matter (WM) and gray matter (GM) were as follows: internal capsule (WM)--340 to 680; thalamus (GM)--approximately 1326; and caudate nucleus (GM)--2284 to 2952. In the presence of supralesioning doses of ultrasound, the cross sectional area occupied by the EB was consistently greater than that of the attendant nonhemorrhagic lesion--thus suggesting that BBB changes may be inducible at sublesioning doses. These findings, in conjunction with those of others, suggest that high intensity focused ultrasound may have a role in the treatment of brain tumors based on cell destruction by two mechanisms: (a) direct, by the ultrasound and (b) indirect, by an antineoplastic agent which is delivered via an ultrasonically modified BBB.
Certain features of head-injured patients admitted to the Chang Gung Memorial Hospital in Taiwan during the period 1977 to 1987 were reviewed. The most common causes of injury were motorcycle accidents (56.3%) and street accidents with pedestrian injury (29.47%). The age groups with the greatest incidence of injury were aged 16-20 years, 21-25 years, and 25-30 years. The pedestrian group involving the highest incidence of injury was less than 10 years of age. Overall mortality was 17.26%. The injured pedestrian group had the highest mortality (19.1%). Initial clinical assessment was recorded using the Glasgow Coma Scale. Head-injured patients with a GCS less than 8 had a mortality in the injured pedestrian group of 46%, whereas the mortality rate in the motorcycle accident group was 41%. Additional features studied were time of occurrence of injury and pattern of injury. Information gathered from this study would suggest the need to establish a Head Injury Prevention Program in Taiwan. This of course implies major cooperation among the providers of health care delivery, the medical profession, legislators, and the government at all levels.
Health care personnel (HCP) from developing nations are seeking to increase their knowledge and skills in other countries. Improved health care in developing parts of the world makes long periods of training abroad less necessary. HCP who train abroad for a year or even less return to their homes and practice new skills. Eighty percent of those who stay abroad three years or more do not return to their native country. Specialists from developed nations teaching for months or years improve health care in developing areas more quickly than individual HCP training abroad.
Phenytoin (15 mg/kg) was administered intravenously to 189 patients shortly before their intracranial, supratentorial surgery was completed. Intravenous phenytoin of 5-6 mg/kg/day in three divided doses was administered daily for the first 3 postoperative days. Therapeutic serum levels (10-20 micrograms/mL) were achieved in 113 (59.8%) patients. An equally constituted, randomized control group of 185 patients received a placebo under identical conditions. The group receiving phenytoin had only one immediate and two early postoperative seizures. The 185 controls had four immediate and nine early postoperative seizures. None of the follow-up computed tomography scans of the patients with seizures showed postoperative hematoma. One patient had a significant tension pneumocranium, a possible cause of postoperative seizures. To avoid a decrease in the serum anticonvulsant level due to intraoperative blood loss, it is suggested that for patients who need an urgent or emergent craniotomy, prophylatic anticonvulsant medication should be given at least 20 minutes before completion of wound closure.
Paired unipolar electrodes were introduced into the pulvinar and ventrolateral thalamic nuclei in 3 patients. Stimulation was applied in 1 patient in an attempt to alter the vegetative state after a closed head injury, and increased alertness and ability to comply resulted with stimulation. Auditory evoked responses improved from almost flat to a recognizable pattern. In the 2nd patient, bilateral disabling intention tremor was relieved for several days after a few hours of stimulation. In the 3rd, brachial plexus avulsion pain was improved by stimulation from the contralateral pulvinar to the ventroposterior lateral thalamic nucleus.
Pituitary apoplexy presenting with intracerebral hemorrhage into the left frontal lobe and lateral ventricle, simulating an anterior cerebral artery aneurysm rupture, is reported. No other cases of intracerebral hemorrhage caused by pituitary apoplexy have been found in a review of the English literature.
A young woman with a cystic glioma in the region of the posterior third ventricle is presented. Each time she turned to the supine position she developed immediate, forceful, conjugate upward gaze (oculogyric crises) and an inability to talk. If she turned to either side, she was alert and oriented, and could talk and lie comfortably. After stereotaxic removal of the cystic fluid, this phenomenon disappeared and did not return, even when the cyst refilled.
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Alternating Horner's sign and hyperhidrosis appeared in this patient 8 years after a spinal cord injury at C6-7. An intramedullary cyst was suspected but was not found at operation. There was a striking improvement in both symptoms after adhesions between the spinal cord and the dura mater were freed.
It has been said that late manifestation of transient alternating Horner's signs in cases of spinal cord injury is caused by intramedullary cavity formation in which some movement of fluid stimulates the sympathetic system corresponding to their positioning. We had a patient complaining of alternating Horner's signs which became manifest 8 years after the injury. We could not find any intramedullary cavity formation, in spite of a spinal puncture at operation, but the symptoms made a striking improvement after the operation simply by making free the spinal cord from the dura mater at operation. So we suppose that late manifestation of transient alternating Horner's signs will be manifested not only in cases of intramedullary cavity, but also in cases of dense adhesion between the spinal cord and the dura mater. In addition to this, we propose the new term "Poromyelia" for the intramedullary cavity because of its resemblance to "Porencephalia" in the cerebrum, and because of the confusing usage of the word "Syringomyelia" for this condition of "Poromyelia". It has been said that "Syringomyelia" in the spinal cord is similar to "Hydrocephalia" in the cerebrum.
58 patients, whose convulsions and behavioral disorders did not respond to nonsurgical therapy, were treated with stereotactic amygdalotomy between 1963 and 1973. A retrospective study was carried out by a psychiatric research team 1--11 years postoperatively. Using reliable objective methods of assessment they found that 50% operated primarily for seizures, 33% for uncontrolled conduct disorders and 50% with both conditions seemed improved after surgery.
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Stereotaxic amygdalotomy for the control of unmanageable behavior and/or intractable seizures is a controversial treatment approach with unknown risk-to-benefit ratios. Information about this subject was obtained from a retrospective follow-up study of 58 patients who received this form of treatment 1 to 11 years earlier (average 6 years). Assessments of the patients were made by invesgators external to the surgical treatment system, using structured psychiatric interviews, neuropsychological tests, and EEGs. In addition, global assessments were made, comparing pre- versus postoperative status. The objective data revealed no indication of worsening or damage with similar pre- and postoperative test scores and EEG features. Computer-scored interviews revealed considerable psychopathology in the ambulatory patients. Overall judgments of behavior, seizures, and functional levels indicated that more than a third of the group was probably improved, although the relationship of outcome to the surgery was indeterminate.
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