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Neurosurgery. 2000 Nov;47(5):1243-6; discussion 1246-7.
Nimodipine-induced acute hypoxemia: case report.
Devlin JW, Coplin WM, Murry KR, Rengachary SS, Wilson RF.
Department of Pharmacy, Wayne State University, Detroit Receiving Hospital, Michigan 48201, USA. jdevlimc.org
OBJECTIVE AND IMPORTANCE: Nimodipine is commonly used to improve neurological outcomes after subarachnoid hemorrhage. Although nimodipine reportedly has high specificity for the cerebral vasculature, adverse systemic effects such as hypotension have been described. This case report describes a patient with traumatic subarachnoid hemorrhage who experienced two episodes of previously undescribed, life-threatening hypoxemia that was directly related to nimodipine therapy. CLINICAL PRESENTATION: The patient experienced acute hypoxemia (partial pressures of oxygen of 32.9 and 58.7 mm Hg), on two separate occasions (3 d apart), that was temporally related to single doses of nimodipine therapy for traumatic subarachnoid hemorrhage. Other disease- and medication-related causes did not explain these episodes. INTERVENTION: After the inspired oxygen concentration was increased to 100% (both episodes) and the positive end expiratory pressure was increased to 7.5 mm Hg (first episode), the arterial oxygen saturation of the patient returned to baseline levels (>99%) within 40 minutes in each instance. Nimodipine therapy was discontinued after each episode. CONCLUSION: It is hypothesized that, in the presence of concomitant adult respiratory distress syndrome, nimodipine increased ventilation/perfusion ratio mismatch, through its direct vasodilatory effects on the pulmonary artery, and possibly interfered with the reflex hypoxic pulmonary vasoconstriction necessary to maintain adequate oxygenation for this patient. Clinicians should carefully monitor the oxygenation status of patients when nimodipine therapy is initiated.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11063120&dopt=Abstract hemorrhage
Neurosurgery. 2000 Nov;47(5):1106-15; discussion 1115-6.
Multiple interstitial substances measured by microdialysis in patients with subarachnoid hemorrhage.
Staub F, Graf R, Gabel P, Kochling M, Klug N, Heiss WD.
Department of Neurosurgery, University of Cologne, Germany. Frank.Stauni-koeln.de
OBJECTIVE: Intracerebral microdialysis is a tool to monitor metabolic disturbances in the brains of patients with severe head injuries or subarachnoid hemorrhage (SAH). In the search for putative indicators of primary and secondary brain damage, we measured multiple metabolites in the dialysates of patients with SAH, to elucidate their significance for the outcomes of the patients as well as their temporal profiles of liberation after the insult. METHODS: Microdialysis probes were placed, with a ventriculostomy catheter for drainage of cerebrospinal fluid, into a frontal lobe of 10 patients with aneurysmal SAH, for 4.6 +/- 0.5 days. Amino acids, metabolites of glycolysis, purines, catecholamines, and nitric oxide oxidation byproducts were measured by high-performance liquid chromatography. Spearman's correlation coefficient and Student's t test were used to compare the levels of the metabolites with the outcomes of the patients, as assessed using the Glasgow Outcome Scale, 3 months after the ictus. RESULTS: For patients with unfavorable outcomes (Glasgow Outcome Scale scores of 1-3), which were primarily associated with the development of large infarctions, dialysate levels of excitatory amino acids increased up to 30-fold, those of lactate up to 10-fold, and those of nitrite up to 5-fold, compared with normal levels observed for patients with favorable outcomes (Glasgow Outcome Scale scores of 4 or 5). When average peak concentrations in the dialysates of patients with favorable and unfavorable outcomes were compared, significantly higher levels of excitatory amino acids, taurine, lactate, and nitrite, but not of purines and catecholamines, were observed for those with poor outcomes (P < 0.05). With respect to the temporal profiles of the average metabolite concentrations, the significantly increased levels of amino acids observed for patients with poor outcomes followed a biphasic course, with maximal concentrations on the first and second days or the seventh day after the insult (P < 0.01). CONCLUSION: These data confirm the usefulness of excitatory amino acids and lactate as major parameters for neurochemical monitoring for patients threatened by acute cerebral disorders. Other substances, such as taurine and nitrite, were also demonstrated to be potentially predictive. Release of these substances into the extracellular fluid of the brain might be particularly relevant for the development of secondary brain damage after SAH, e.g., infarction or brain swelling.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11063103&dopt=Abstract hemorrhage
Int J Gynaecol Obstet. 2000 Nov;71(2):127-33.
Maternal mortality in a tertiary center after introduction of free antenatal care.
Daponte A, Guidozzi F, Marineanu A.
Department of Obstetrics and Gynecology, Johannesburg Hospital and University of the Witwatersrand Medical School, Parktown, South Africa.
OBJECTIVE: Determination of maternal mortality rate (MMR) and the main causes of maternal death after the implementation of free antenatal care in a tertiary center in South Africa. METHODS: Retrospective case study on maternal deaths from 1 January 1993 to 31 July 1997. RESULTS: The maternal mortality rate was 128/100000 births. Hypertension disorders (18%), hemorrhage (18%) and sepsis (13%) were the most important causes of death; 44% of all deaths were considered preventable. CONCLUSIONS: The high percentage (44%) of preventable deaths is a cause of concern and is the result of increased workload, decreased staff numbers and late referrals with low socio-economic class of the patient. The discrepancy in the mortality rate between patients booked at the tertiary institution (29.8/100000) and patients booked elsewhere (304.7/100000) or not booked at all (348.5/100000) indicates the need for improving antenatal care in the periphery.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11064009&dopt=Abstract hemorrhage
Neurosurgery. 2000 Nov;47(5):1147-52; discussion 1152-3.
Endovascular treatment of distally located giant aneurysms.
Ross IB, Weill A, Piotin M, Moret J.
Service de Neuro-Radiologie Interventionnelle, Fondation Ophtalmologique Rothschild, Paris, France. iroseurosurgery.umsmed.edu
OBJECTIVE: Because giant aneurysms (GAs) can be technically difficult to clip, the endovascular approach is becoming increasingly popular. Endovascular treatment of distally located GAs, which often requires parent vessel occlusion, is particularly challenging because limited pathways are available for collateral flow. We aimed to determine the outcomes of endovascular attempts to treat GAs downstream from the circle of Willis. METHODS: Between 1991 and 1998, 27 patients with 27 distally located very large aneurysms or GAs were evaluated for possible endovascular treatment. Ten underwent selective embolization and 9 were treated with primary parent vessel occlusion, with or without distal bypass. Eight patients could not be treated endovascularly. RESULTS: Selective embolization resulted in only one cure. Two patients died as a result of subarachnoid hemorrhage during the follow-up period. One coil-treated patient, who underwent subsequent spontaneous parent vessel occlusion, and all nine patients treated primarily with parent vessel occlusion were considered cured after their treatments. Only two patients treated with parent vessel occlusion experienced periprocedural ischemia, which did not result in a major deficit in either case. Of the eight patients who could not be treated endovascularly, one succumbed to surgery, four died while being treated conservatively, and three were lost to follow-up monitoring. CONCLUSION: Selective aneurysm embolization is usually not curative in these situations. For selected patients, however, endovascular parent vessel occlusion is usually safe and effective in preventing the progression of symptoms and bleeding.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11063108&dopt=Abstract hemorrhage
Intern Med. 2000 Nov;39(11):956-60.
Slowly progressive dystonia following central pontine and extrapontine myelinolysis.
Yoshida Y, Akanuma J, Tochikubo S, Hoshi A, Matsuura Y, Homma M, Yamamoto T.
Department of Neurology, Fukushima Medical University.
A 28-year-old woman was hospitalized with dysarthria and oro-mandibular and upper limb dystonia. Approximately 8 years prior to the current admission, the woman became severely hyponatremic due to traumatic subarachnoid hemorrhage-related SIADH. Brain MRIs showed a signal increase in the central pons, thalamus and striatum on T2 weighted images compatible with central pontine and extrapontine myelinolysis. From a few months after that event, dystonia progressed slowly over the subsequent 8 years. We speculate that the particular damage chiefly to the myelin structures by myelinolytic process may have caused an extremely slow plastic reorganization of the neural structures, giving rise to progressive dystonia.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11065251&dopt=Abstract hemorrhage
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