Complex coil assisted single coil embolization for small intracranial aneurysm.

The purpose of the technical note is to introduce the complex coil assisted coil embolization method in the treatment of intracranial small aneurysm, in order to enhance the safety of the procedure. The first microcatheter was navigated into the aneurysm sac and the ultrasoft coil was used as the embolization coil. If the embolizations coil could not stay within the aneurysm sac smoothly, such as coil herniation into parent artery during the delivery process. The second microcatheter would be navigated to the aneurysm level in the parent artery. Another complex coil was delivered within the parent artery via the second microcatheter to provide the neck bridge effect in order to enhance the stability of embolization coil. Besides, the protection coil will not disturb the parent artery flow. While the embolization coil was put into the aneurysm sac smoothly under the help of complex protective coil, the protective coil was then withdrawn gently. We use the most magnified view, dual-plane approach simultaneously to observe the stability of embolization coil. The embolization coil would be detached without any evidence of coil motion or vibration. The new method could provide the physiological protective method, without leaving any protective device such as stent within the parent artery.

Mutagenicity and genotoxicity effects of Lignosus rhinocerotis mushroom mycelium.

ETHNOPHARMACOLOGICAL RELEVANCE: Lignosus rhinocerotis mushroom is widely used as traditional medicine and as soup ingredient in Malaysia and Hong Kong. Its sclerotium is the part of edibility and is traditionally used for the treatment of fever, cough, asthma and cancer. In view of its safety profile, very little information is found in scientific literature. MATERIALS AND METHODS: We evaluated the potential genotoxic and mutagenic effects of Lr in the Ames test using Salmonella typhimurium strains TA98, TA100, TA102, TA1535 and TA1537, an in vitro chromosome aberration test in Chinese Hamster Ovary (CHO-K1) cells and an in vivo erythrocyte micronucleus test in ICR mice. RESULTS: In all tested concentrations, no mutagenicity was observed in either testing strain under both presence and absence of S9 metabolic mixture when tested up to the highest dose of 100mg/ml. No significant increases in chromosome aberration numbers or micronucleated polychromatic erythrocytes were observed. Erythropoiesis was not affected in animals gavaged up to 2000 mg/kg of Lr. CONCLUSIONS: Results from this study conclude that Lignosus rhinocerotis mycelium does not provoke mutagenicity and genotoxicity in these applied systems.

Developmental toxicity assessment of medicinal mushroom Antrodia cinnamomea T.T. Chang et W.N. Chou (higher Basidiomycetes) submerged culture mycelium in rats.

Antrodia cinnamomea is a Taiwanese medicinal mushroom with high antioxidant and polysaccharide content. The objective of this study is to investigate developmental toxicity of A. cinnamomea in pregnant Sprague-Dawley rats. Animals were daily gavaged with A. cinnamomea mycelium at dosage levels of 0 (reverse osmosis water), 50, 150, and 500 mg/kg from gestation day (GD) 6 to 15. All dams were sacrificed on GD 20 and were subjected to cesarean section. Fetuses were examined for external, visceral, and skeletal abnormalities. All copulated females survived until the end of the study. No significant differences were recorded in body weight change, food consumption, and maternal gestational parameters. Only two fetal malformations were noted in 970 fetuses from the treatment groups. Some variations, such as enlarged fontanel, split sternebrae, absent sacral, absent caudal vertebral centra, absent thoracic centra, absent 13th-14th ribs, and fused ribs, were found during the skeletal examination, but no treatment-induced abnormalities occurred. No dose dependency was observed in any of the developmental variations. Overall observation of foetal malformations from rats given A. cinnamomea mycelium during pregnancy demonstrates that this material is not teratogenic at doses up to 500 mg/kg. It is concluded that A. cinnamomea BCRC 35398 mycelium has no teratogenic effects in female rats and is safe to be used as a functional food ingredient.

Iatrogenic and fatal arterial air embolism during the CT scan.

Systemic and fatal arterial air embolism during the computed tomography (CT) scan is rarely reported in English-based literature. Iatrogenic air embolism happening during the CT scan is often related to the injector, usually venous air embolism and asymptomatic. We report one fatal and extensive systemic arterial air embolism because of one error that happened during a brain CT scan. The mechanism is different from the reported cases in the literature. The possible mechanism and pathogenesis are well discussed to alert clinicians and prevent the recurrence of such complication.

A 90-day subchronic toxicological assessment of Antrodia cinnamomea in Sprague-Dawley rats.

Antrodia cinnamomea (Ac) is a medicinal mushroom widely used for the treatment of abdominal pain, hypertension and hepatocellular carcinoma, but subchronic toxicity of this material has not yet been investigated. This present study was conducted to assess the 90-day oral toxicity of A. cinnamomea from submerged culture in male and female Sprague-Dawley (SD) rats. Eighty rats were divided into four groups, each consisting of ten male and ten female rats. Test articles were administered by oral gavage to rats at 3000, 2200 and 1500 mg/kg BW/day for 90 consecutive days and reverse osmosis water was used as control. All animals survived to the end of the study. During the experiment period, no abnormal changes were observed in clinical signs, body weight and ophthalmological examinations. No significant differences were found in urinalysis, hematology and serum biochemistry parameters between the treatment and control groups. Necropsy and histopathological examination indicated no treatment-related changes. According to the above results, the no-observed-adverse-effect level (NOAEL) of Antrodia cinnamomea is identified to be greater than 3000 mg/kg BW/day in Sprague-Dawley rats.

Perioperative airway management in a child with Treacher Collins syndrome.

We report the perioperative airway management in a 12-year-old boy suffering from Treacher Collins syndrome (TCS) and severe mental retardation who was scheduled for elective dental treatment under general anesthesia. TSC is also known as mandibulofacial dysostosis or Franceschetti syndrome, usually with a potentially difficult airway presentation. It is a major challenge for the anesthesiologist to manage an uncooperative child with such a congenital airway anomaly. A difficult airway was encountered during induction of general anesthesia, and both oral intubation by direct laryngoscopy and classic laryngeal mask airway (LMA) insertion were unsuccessful. In an expedient critical trial, with the cooperation of two anesthesiologists, one performing nasal fiberoptic intubation and the other maintaining oral mask ventilation, a nasal endotracheal tube was successfully placed at the first attempt, although at the expense of prolonged respiratory depression in the patient. Therefore, fiberoptic nasal intubation simultaneously with mask ventilation for placement of the endotracheal tube is a practical substitute for a difficult airway usually managed by LMA with inadequate ventilation. After extubation, tracheostomy may be indicated if the TCS patient suffers from persistent difficult upper airway in consequence of a traumatic intubation.

Ultrasound examination for the optimal head position for interscalene brachial plexus block.

BACKGROUND: Surface anatomic landmarks have traditionally been used to locate the brachial plexus in the interscalene groove. Head rotation can affect the orientation of neck vessels and may possibly affect the brachial plexus. The optimal degree of head rotation has been specified for better internal jugular vein cannulation but not for interscalene brachial plexus block. The purpose of this study was to evaluate the influence of head rotation on interscalene brachial plexus block. METHODS: We simulated the needle insertion in interscalene approach to brachial plexus with the ultrasound probe to mimic the needle in the manner of actual block in 53 volunteers. Ultrasound-derived measurements were recorded to evaluate the influence of head rotation on the approach including deviation from the imitative needle path to plexus center, depth of brachial plexus and vessel intersection. RESULTS: Medial deviation of the imitative needle path to the center of brachial plexus was found from all angles of head rotation. Increased head rotation angle of 0 degree, 15 degrees, 30 degrees, 45 degrees and 60 degrees from the midline was associated with increasing medial deviation. The brachial plexus became more superficial if head rotation was over 30 degrees than within the realm of 15 degrees. The likelihood of the stimulated needle path intersecting the internal jugular vein was lower than 5% for head rotation within 30 degrees and would become significantly higher for head rotation over 45 degrees. CONCLUSIONS: Whenever we perform interscalene brachial plexus block, the head rotation angle should not exceed 30 degrees. The measured medial deviation of surface landmark should be considered when it is used to approach interscalene brachial plexus.

Clinical experience of pain treatment for postherpetic neuralgia in elderly patients.

BACKGROUND: Postherpetic neuralgia (PHN) is a neuropathic pain syndrome that occurs following acute herpes zoster infection. The main clinical problem is intractable pain which interferes with activity of daily life and reduces the quality of life in the elderly patients. This retrospective study was to evaluate the outcome of pain treatment for the elderly patients with PHN at the Pain Clinic of Kaohsiung Medical University Hospital. METHODS: Fifty-eight elderly outpatients with PHN were studied from January 2004 to June 2006. The pain intensity before and after treatment were assessed by patients themselves with numeric pain scale (NPS). The pain treatment included (1) medication with anticonvulsants, opioids and nonsteroidal anti-inflammatory drugs (NSAIDs); (2) nerve block with 0.25% bupivacaine or 1% lidocaine twice a week at the beginning of the treatment. The therapeutic outcome was expressed by pain relief. The reduction of pain and residual pain intensity were evaluated subjectively by the patients themselves with patients' global impression and NPS, respectively, after treatment for one and three months (or last visit). The adverse events throughout the treatment course were analyzed. RESULTS: (1) The mean age of the patients was 75.1 yr. The number of female PHN sufferers was higher than that of male in all aged groups and the highest incidence was found in the age group of 70-79 (65.5%). The most commonly involved dermatomes were in the thoracic region (82.7%). (2) All patients suffered from severe pain (NPS 8-10) before treatment. (3) The pain management was a combination of medication and nerve block at the beginning of the treatment. Among the medications, gabapentin was prescribed to all the patients and almost all of them (98.3%) required opioids simultaneously and some of them needed additional NSAIDs at the beginning of the treatment. (4) The most common adverse event was somnolence (24.1%). (5) Among the sympathetic blocks, the intercostal nerve block was performed commonly (84.5%). (6) The therapeutic outcome was expressed by pain relief. As to the reduction of pain, 46 cases (79.3%) and 57 cases (98.3%) felt moderate and much improvement after treatment for one and three months (or last visit), respectively. As to residual pain intensity, although none of them got complete pain relief, however, there were 12 cases (20.7%) and 45 cases (77.6%) felt the pain intensity was mild (NPS 1-3) after treatment for one and three months respectively. (7) There was a statistically significant decrease in the pain intensity between before treatment and after treatment for one month and three months. CONCLUSIONS: Our study results showed that the concurrent combination therapy with proper medications and appropriate nerve blocks could offer satisfactory pain relief in the majority of elderly patients with PHN.

Functional neuroprotective effect of CGS 26303, a dual ECE inhibitor, on ischemic-reperfusion spinal cord injury in rats.

Endothelin-1 (ET-1) has been implicated in many neurological diseases, including subarachnoid hemorrhage (SAH) and cerebral ischemia. ET-1 is also proved to deteriorate the ischemia-reperfusion injury in many organs. Our previous studies demonstrated that the endothelin-converting enzyme (ECE) inhibitor, CGS 26303, possessed beneficial effects for the treatment of SAH and transient middle cerebral artery occlusion. In this study, we investigated the neuroprotective effect of CGS 26303 on the locomotor function and mRNA expression of heme-oxygenase-1 (HO-1) in rats subjected to a 15-min spinal cord ischemia. The results showed that pretreatment with CGS 26303 significantly preserved the locomotor function and decreased the paraplegia rate at Days 1 and 3 as compared with a saline-treated group. Furthermore, rats pretreated with CGS 26303 had a significant increase in the levels of HO-1 mRNA expression at Day 3 when compared with animals pretreated with saline after spinal cord ischemia and the sham operation group. These results suggest that CGS 26303 may have a promising neuroprotective effect in the spinal cord after ischemia-reperfusion injury, and beneficial result may be due to an adaptive mechanism involved by HO-1 overexpression.

Delayed resolution of negative pressure pulmonary edema associated with low-molecular-weight dextran after microsurgery--a case report.

Negative pressure pulmonary edema (NPPE) is an uncommon perioperative complication after total or partial upper airway obstruction during anesthesia or respiratory distress. The cardinal event causative of the pathophysiology is believed to be the generation of a sudden and marked negative intrapleural pressure against a closed glottis, resulting in a disruption of the normal intravascular Starling mechanism. Ultimately, excessive intravascular fluid which transudes into the interstitial space eventuates in pulmonary edema. In most reports, patients suffering from NPPE could recover within 24 h after appropriate treatment. Here, we report a case of highly suspected NPPE with delayed resolution associated with the perioperative use of dextran, following microsurgery for digital anastomosis of the nearly amputated right thumb. We have reviewed the possible pathomechanisms of NPPE, and discuss herein the possible relationship between the delayed resolution of NPPE and perioperative use of dextran.

Sudden onset of paraplegia after total hip replacement surgery in a patient with hepatocellular carcinoma--a case report.

Postoperative paraplegia is a major complication, of which the pathogenesis is usually multifactorial. This report is to discuss the case of a 36-year-old male patient who, after total hip replacement (THR), right, sustained a sudden-onset postoperative paraplegia. On subsequent examination, it was discovered that the patient had multiple vertebral metastases from hepatocellular carcinoma (HCC) resulting in thecal sac compression at L1 and S1 levels. This instance of distal spinal metastasis from HCC, with initial presentation of a sudden onset of paraplegia immediately after THR surgery, is worth reporting because of its being a rare occurrence and traumatizing effects on the patient, family members, and the surgical team. More importantly, we bring forth this case in order to advance an opinion concerning prevention of this devastating complication. Hence, we discuss the contributory factors and the appropriate perioperative survey and management relevant to cancer patients who are to undergo a non-cancer surgery.