Biomedical subjects
Publications and source records attributed to W E Hunt.
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Magnetic resonance imaging was used to evaluate 24 patients with injuries to the thoracic, thoracolumbar (T12-L1), or lumbar spine. Correlation of the magnetic resonance imaging findings to surgical therapy and outcome was evaluated, with particular attention to the longitudinal ligaments. The ability of the magnetic resonance imaging to detect the extent of trauma to the spinal cord parenchyma and to the anterior and posterior longitudinal ligaments was found to be important in guiding the surgical approach to these spine fractures.
The authors give a review on the Tolosa-Hunt Syndrome. They discuss its differential diagnosis, appropriate diagnostic and therapeutic measures for the evaluation of this painful ophthalmoplegia which may be combined with neurological deficit referrable to the anterior cavernous sinus.
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Thirty-two patients with aneurysmal subarachnoid hemorrhage (SAH) were managed according to a protocol based on pain control and hemodynamic manipulation, monitored by an arterial line and Swan-Ganz catheter. Hemodynamic parameters were adjusted to four clinical situations. 1) For the unoperated patient with no neurological deficit, the regimen aims to maintain pulmonary wedge pressure (PWP) at 10 to 12 mm Hg, and the cardiac index (CI) and blood pressure (BP) at normal levels. 2) For the unoperated patient presenting with or developing neurological deficit, the PWP is increased until the deficit is reversed or the CI falls; the CI is high, and the BP normal. 3) For the postoperative patient with no neurological deficit, the PWP is maintained at 12 to 14 mm Hg, the CI is a high normal, and the BP is normal. 4) For the postoperative patient developing neurological deficit but showing no surgical complication on the computerized tomography scan, the PWP is increased until the deficit is reversed or the CI falls; the CI is high and the BP is increased with vasopressors if necessary. Fourteen patients developed neurological deficits either preoperatively, postoperatively, or both. Neurological deficits were repeatedly reversed by increasing the PWP, as measured hourly. In several patients an optimal wedge pressure was determined, below which deficits would reappear. In one patient whose neurological deficit was reversed on several occasions by increasing the PWP, the optimal PWP rose after each episode until it reached 22 mm Hg. Detailed event-related analysis of these patients' course illustrates these phenomena well. The optimal PWP varied from patient to patient, but ranged most frequently from 14 to 16 mm Hg. Meticulous monitoring of the patients' neurological status coupled with prompt correction of low PWP (assuming an adequate CI) has proven to be an effective way to prevent and reverse neurological deficits following aneurysmal SAH.
Cervical monoradiculopathy occurs most commonly at C5-6 and C6-7. It is due mostly to acute herniation of nuclear material. The syndrome often responds to conservative prescription but when surgery is indicated, the results are good. The neurologic examination is the most specific and sensitive clinical test. Acute radiculopathies due to herniated nucleus are, in our hands, best approached via a posterior muscle-splitting incision. Chronic radiculopathies due to osteophyte formation may be approached either anteriorly or posteriorly. Reflex discogenic pain requiring anterior fusion exist but are less common. These patients must be carefully screened because of the functional factors involved.
The authors present seven cases drawn from 620 consecutive cases over 30 years, in which previously undemonstrated (hence "de novo") intracranial aneurysms formed and ruptured at intervals of 3-20 years, after clipping of an initial aneurysm. Six patients were treated for rupture of a second aneurysm. All six had undergone successful treatment of a previous aneurysm; pre- and postoperative angiography showed not only successful clipping of the first aneurysm but also no incidence of multiple aneurysms. In no case was a major artery occluded at the time of the initial surgery. The implications as to natural history and the advisability of repeated arteriography in some patients with aneurysms are discussed.
A multicenter double-blind randomized trial was conducted to examine the efficacy of a high dose of methylprednisolone (1,000-mg bolus and daily thereafter for ten days) compared with a standard dose (100-mg bolus and daily thereafter for ten days) in 330 patients with acute spinal cord injury. No difference in neurological recovery of motor function or pinprick and light touch sensation was observed between the two treatment groups six weeks and six months after injury. The lack of a treatment effect was independent of the severity of the initial lesion or the time from injury to starting treatment. Although not statistically significant, early case fatality was greater in the high-dose protocol (relative risk of 3.1 and 1.9, less than or equal to 14 and 15 to 28 days after injury, respectively) but not from 29 to 210 days after injury. Wound infections of both trauma and operative sites were more prevalent in the high-dose regimen (relative risk of 3.6).
This review of pediatric neck injuries includes patients admitted to Children's Hospital of Columbus, Ohio, during the period 1969 to 1979. The 122 patients with neck injuries constituted 1.4% of the total neurosurgical admissions during this time. Forty-eight patients had cervical strains; 74 had involvement of the spinal column; and 27 had neurological deficits. The injuries reached their peak incidence during the summer months, with motor-vehicle accidents accounting for 31%, diving injuries and falls from a height 20% each, football injuries 8%, other sports 11%, and miscellaneous 10%. There is a clear division of patients into a group aged 8 years or less with exclusively upper cervical injuries, and an older group with pancervical injuries. In the younger children, the injuries involved soft tissue (subluxation was seen more frequently than fracture), and tended to occur through subchondral growth plates, with a more reliable union than similar bone injuries. In the older children, the pattern and etiology of injury are the same as in adults. The entire cervical axis is at risk, and there is a tendency to fracture bone rather than cartilaginous structures.
Within 3 weeks of definitive surgery, 609 patients with histologically demonstrated, supratentorial malignant glioma were randomized to receive, in addition to 6000 rads of radiotherapy, one of four treatment regimens: carmustine (BCNU), high-dose methylprednisolone, procarbazine, or BCNU plus high-dose methylprednisolone. We analyzed the data for the total randomized population and for the 527 patients (87% with glioblastoma multiforme) in whom the initial protocol specifications were met (the valid study group). Significantly longer survival was experienced by patients receiving procarbazine or BCNU alone compared to those receiving only high-dose methylprednisolone. No other pairwise comparisons demonstrated differences significant at the 0.05 level. However, the combination of BCNU plus high-dose methylprednisolone tended to be less effective than BCNU alone in patients with poor prognosis. This study indicates that BCNU and procarbazine are moderately useful agents in conjunction with radiotherapy for patients with malignant glioma. In addition, future protocols may allow use of corticosteroids in conventional dosages for treating cerebral edema and controlling symptoms; conclusions based on survival as the endpoint are unlikely to be affected by administering steroids at somewhat greater than the usual dose. More effective regimens for the treatment of malignant glioma should be sought.
A case of aneurysm at the junction of the vertebrospinal and anterior spinal arteries at the level of C-1 is presented. There was severe intracranial subarachnoid hemorrhage with subsequent right hemiplegia and 6th nerve palsies. Angiograms showed an anomalous arrangement of the arteries, but no arteriovenous malformation was seen. The lesion was repaired via a posterior approach. Anatomical and technical considerations of this approach are discussed. A review of the pertinent literature is presented.
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Hyperthyroidism due to thyrotrophin (TSH)-secreting pituitary tumors is rare. Four cases are described, with the features that allow preoperative diagnosis. In all the patients, thyroid hormone production was consistently elevated despite antithyroid therapy, and TSH levels were inappropriately elevated. All patients were treated with both surgery and irradiation. Each patient had recurrent tumor with suprasellar, intrasphenoidal, or intraorbital spread. The combination of a recurrent, aggressive tumor complicated by thyrotoxicosis makes this a complex and difficult surgical problem.
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Within three weeks of definitive surgical intervention, 467 patients with histologically proved malignant glioma were randomized to receive one of four treatment regimens: semustine (MeCCNU), radiotherapy, carmustine (BCNU) plus radiotherapy, or semustine plus radiotherapy. We analyzed the data for the total randomized population and for the 358 patients in whom the initial protocol specifications were met (the valid study group). Observed toxicity included acceptable skin reactions secondary to radiotherapy and reversible leukopenia and thrombocytopenia due to chemotherapy. Radiotherapy used alone or in combination with a nitrosourea significantly improved survival in comparison with semustine alone. The group receiving carmustine plus radiotherapy had the best survival, but the difference in survival between the groups receiving carmustine plus radiotherapy and semustine plus radiotherapy was not statistically significant. The combination of carmustine plus radiotherapy produced a modest benefit in long-term (18-month) survival as compared with radiotherapy alone, although the difference between survival curves was not significiant at the 0.05 level. This study suggests that it is best to use radiotherapy in the post-surgical treatment of malignant glioma and to continue the search for an effective chemotherapeutic regimen to use in addition to radiotherapy.
In the common dihydrofolate reductase inhibitors an amino substituent replaces the pteridine carbonyl oxygen atom of folates, with altered hydrogen-bonding properties and size. Flexibility in the amino groups could facilitate enzyme binding. Studies of cycloguanil hydrochloride by neutron diffraction show both in-plane and out-of-plane deformation of amino groups. Molecular-orbital calculations ab initio on 2,4-diamino-5-methylpyrimidinium cation confirm that the 4-amino group is readily deformable. The 2,4-diaminoquinazoline structure is reported. Atomic co-ordinates, thermal parameters, bond distances and bond angles for cycloguanil and 2,4-diaminoquinazoline have been deposited as Supplementary Publication SUP 50108 (13 pages) at the British Library Lending Division, Boston Spa. Wetherby, West Yorkshire LS23, 7BQ, U.K., from whom copies can be obtained on the terms indicated in Biochem. J. (1978) 169, 5.
Degenerative disc disease may be considered a normal process of aging which occurs in virtually the entire population that reaches middle age. Pain problems associated with it should be approached with the greatest reluctance by the surgeon since intermittent flare-ups with subsidence and ultimate overall improvement can be expected in most cases. The clearest indications for surgery have to do with neurologic deficit. The simplest and most obvious example is herniated nucleus pulposus with acute monoradicular or myelopathic symptoms. This situation requires an aggressive approach. More chronic neurologic changes must be approached more cautiously. When unequivocal progression is identified, surgical decompression is in order. Finally, narrowing of the canal from either congenital or acquired processes may in some instances justify prophylactic surgical decompression, but requires the greatest caution. The radiologic findings often do not correlate with the signs and symptoms. The patient's input and his or her full awareness of the possibilities of serious complication is an essential part of good surgical management.