Innervation of the urinary bladder in higher primates.

Stimulating electrodes were placed on the terminal branches of the pelvic nerves to the urinary bladder and the pudendal nerve to the sphincters in seven Rhesus monkeys and two chimpanzees. The proximity of the electrodes to these structures assured organ specificity. Evoked responses produced by stimulation of these terminal nerve branches were recorded in the fascicles and rootlets of the lower thoracic, lumbar, and sacral nerve roots. During identical stimulating and recording conditions, the amplitude as well as presence or absence of the evoked responses recorded was variable within the various roots. The amplitude of the evoked responses or their absence depended on the number of fibers within a particular fascicle which conducted impulses to the urinary bladder or the urethral and anal sphincters. By this method, it was determined that there was segregation or compartmentalization of the nervous innervation to the urinary bladder and sphincters within the spinal roots. In addition, the segmental spinal cord origin of the innervation of the urinary bladder was determined for the Rhesus monkey and chimpanzee. In the Rhesus monkey, the pelvic nerves to the urinary bladder arose from the first and second sacral segments and to a much lesser extent from the seventh lumbar segment. In the chimpanzee, the sacral segments one to four gave rise to innervation of the urinary bladder.

Innervation of the external urethral and external anal sphincters in higher primates.

Stimulating electrodes were placed on the terminal branches of the pudendal nerve to the external urethral and external anal sphincters. The proximity of the electrodes to the sphincters assured organ specificity. Evoked responses produced by stimulation of these terminal nerve branches were recorded in the fascicles and rootlets of the lower thoracic, lumbar, and sacral nerve roots. By this method, the segmental spinal cord origin of the innervation of the external urethral and anal sphincters was determined for the Rhesus monkey and chimpanzee. The data indicated that the pudendal nerves to the urethral and anal sphincters in the Rhesus monkey arose from the sixth and seventh lumbar spinal segments and the first and second sacral spinal segments which are homologous to the S-1 and S-4 segments found to give innervation to these structures in the chimpanzee. The primate experiments thus indicate that the spinal origin of the pudendal nerve was more rostrally located by one segment or more than was the origin of the pelvic nerves to the urinary bladder.

Superficial temporal to middle cerebral artery anastomosis. Clinical outcome in patients with ischemia of infarction in internal carotid artery distribution.

The clinical outcome of our first 40 patients (six with transient ischemic attacks, 22 with mild ischemic infarctions, and 12 with moderate ischemic infarctions) treated with a superficial temporal artery-middle cerebral artery anastomosis was analyzed. All cerebral ischemias or infarctions occurred in the internal carotid artery distribution. An independent neurologist observer recorded the patients preoperative and postoperative medical and neurological histories and objective neurological findings. There was no operative mortality. During the period of observation (up to 36 months), four patients died of probable myocardial infarction. No patient suffered from recurrent cerebral infarction. Three patients experienced a single ischemic event postoperatively. Neurological deficits were either unchanged (21 patients) or improved (19 patients). Postoperative angiograms showed patency in 97% of the anastomoses.

Cervical lymphangiomatosis with progressive craniospinal deformity.

A case of lymphangiomatosis of the cervical spine with progressive instability of the cervical spine despite anterior and posterior fusion is presented and discussed.

Neural and vascular tissue reaction of cyanoacrylate adhesives: a further report.

The effect of a new tissue adhesive, carbohexoxymethyl 2-cyanoacrylate monomer (Ethicon CHC), was evaluated in six cats divided into two groups. With the cats under barbiturate anesthesia. Ethicon CHC was applied to the left cruciate cortex and the left femoral neurovascular bundle. Normal saline was applied to the right side for control. The first group (n = 4) and the second group (n = 2) were killed 4 and 7 days, respectively, after application of the adhesive. Neuropathological examination revealed meningeal astrocytosis, vascular wall degeneration, hemorrhage, and inflammatory reaction in both groups. This adhesive does not display the ideal property of inertness, which would permit its safe use. Focal tissue reactions caused by the adhesives in sensitive areas of the cortex can result in significant neurological deficit.

Neural and vascular tissue reaction to aneurysm-coating adhesive (ethyl 2-cyanoacrylate).

The effect of ethyl 2-cyanoacrylate (Aaron-2-Alpha) obtained from two different manufactures was evaluated in 37 cats divided into two groups. The first group (n = 28) received a 9-year-old preparation. The second group (n = 9) received recently acquired adhesive. Aaron-2-Alpha was applied to the left cruciate cortex and left femoral neurovascular bundle under barbiturate anesthesia. Normal saline was applied on the right side for control. Survival was allowed for 2, 4, 7, and 14 days after application of the adhesive. The 2-day survival was excluded in the second group. Neuropathological examination revealed meningeal necrosis, neuronal and axonal degeneration, vascular wall degeneration, thrombosis, and inflammatory reaction in both groups of cats. The compounds tested are far from satisfying the ideal requirements for their safe use. Chemical degradation may take place in the adhesives stored for prolonged periods of time. Adhesives obtained from two different sources may contain adjuvants of different toxicity. Severe local tissue reaction could produce marked neurological deficits when adhesives are applied in critical areas.

Radiation-induced meningiomas in pediatric patients.

Radiation-induced meningiomas rarely have latency periods short enough from the time of irradiation to the clinical presentation of the tumor to present in the pediatric patient. Three cases of radiation-induced intracranial meningiomas in pediatric patients are presented. The first involved a meningioma of the right frontal region in a 10-year-old boy 6 years after the resection and irradiation of a 4th ventricular medulloblastoma. Review of our pediatric tumor cases produced a second case of a left temporal fossa meningioma presenting in a 15-year-old boy with a history of irradiation for retinoblastoma at age 3 years and a third case of a right frontoparietal meningioma in a 15-year-old girl after irradiation for acute lymphoblastic leukemia. Only three cases of meningiomas presenting in the pediatric age group after radiation therapy to the head were detected in our review of the literature.

Neuroschisis of the cervical spinal cord in a patient with Klippel-Feil syndrome.

During the neurological work-up of a young patient with Klippel-Feil syndrome, the presence of a neuroschisis of the cervical spinal cord was detected. The patient presented with a transient and acute hemisensory loss and a Horner's syndrome of the opposite side. The unusual presentation and radiological findings in a patient with Klippel-Feil syndrome prompted this report.

Hypogammaglobulinemia and Nocardia brain abscesses.

The host defense responses to Nocardia asteroides are not known. We have investigated a patient with common variable adult onset hypogammaglobulinemia who developed fatal disseminated nocardiosis. The patient had low levels of serum immunoglobulins; the total lymphocyte count was normal as were the percentages of circulating T and B cells. Transmission electron microscopic studies demonstrated typical N. asteroides within the brain parenchyma and nonspecific inflammatory changes in the central nervous system. The findings suggest that humoral immunity may play a major role in the host defense of patients with this disease.

Combined embolization and operation in the treatment of cervical arteriovenous malformations.

The effectiveness of a combined approach of embolization and operation for cervical vascular malformations is stressed. Lesions that seem to be inoperable may have their blood flow sufficiently reduced by preoperative embolization to allow surgical extirpation. Polyvinyl alcohol foam is an ideal embolic agent; not only may it be used preoperatively, but its permanency allows it to be used for primary therapy.

Can academic medical centers compete in a managed care system?

The authors review characteristics of successful group practices, health maintenance organizations, and integrated service networks and then identify the critical actions that academic medical centers must take in order to compete with such service-oriented community providers. Centers must (1) form the clinical faculty into a competitive medical group that offers more price-competitive and user-friendly services; (2) restructure clinical training to be more relevant to the emerging practice situation; and (3) clearly delineate funding streams and identify the cross-subsidies taking place in the teaching, research, and patient care enterprises. These changes have the potential to strengthen clinical training and improve the financial positions of both the faculty and the university hospitals. The authors maintain that centers can make these and other necessary changes while still providing high-quality care and maintaining their educational and research functions; they cite organizations that have succeeded in these ways. However, as with all complex, large-scale organizations, public and private alike, the major factor limiting centers' ability to make the organizational changes required to successfully compete in the new health care environment is the lack of political will. It will be very difficult for academic medical centers to unite their powerful internal interest groups and take action without first experiencing a rather severe external jolt. The challenge for the leaders of academic medical centers is to prepare for the managed care jolt so that they can then guide their institutions to a new, more competitive position.

Spectrum of the hangman's fracture.

The authors review their experience in managing 26 cases of "hangman's fracture." The basic mechanism of injury was hyperextension of the upper cervical spine. Radiographic studies revealed a spectrum of injury beginning with the classical hangman's fracture and progressing to the simple C-2 laminar-pedicle fracture. Appreciation of the fracture instability will dictate the method and duration of fracture treatment. Management by a closed, nonoperative means resulted in solid union of the bone in all fully treated cases, with a minimum of morbidity.

Aneurysmal tumors of the basifrontal region.

The authors report the cases of three men who presented for evaluation of a rapidly progressing dementia. All were found to have a giant aneurysmal mass in the basifrontal region, and all were successfully treated by surgical excision of the mass. The presenting syndrome included rapidly progressive and severe loss of recent memory associated with confusion, chronic headache, wide-based staggering gait disturbance, urinary urgency, frequency, and incontinence, and a fine tremor of the hands exacerbated by purposeful movements. The clinical presentation, radiological assessment, and surgical treatment are discussed.

Radiation therapy of a choroid plexus papilloma of the cerebellopontine angle with bone involvement. Case report.

A case is reported of cerebellopontine angle choroid plexus papilloma with overlying bone destruction. Its favourable response to radiation therapy following subtotal excision is described.

Prognosis of seventh nerve palsy following removal of a large acoustic tumors.

Before the advent of microsurgery for acoustic tumors, it was accepted that the majority of seventh nerves would be lost during the removal of large tumors. It is now possible to preserve these attenuated seventh nerves, even with very large tumors. Postoperative facial palsy may be present even with an anatomically intact seventh nerve, but our experience has demonstrated that recovery will ultimately occur. Eight of our nin patients with this situation have regained facial function, although in some the first clinical evidence of recovery did not occur for 1 year.

Effect of delayed local cooling on experimental spinal cord injury.

The authors report studies indicating that delayed local cooling is effective in minimizing the neurological deficits of experimental spinal cord injury in cats. Cortical evoked responses were useful in predicting the neurological outcome; untreated animals whose evoked response disappeared for 6 hours failed to recover whereas all treated animals in the same group recovered dramatically. Decompression by laminectomy alone proved ineffective. Possible explanations for the therapeutic effects of cooling and the significance of the delay are briefly discussed.

Identification and management of high-risk patients with Klippel-Feil syndrome.

Patients with Klippel-Feil syndrome are often at high risk for neurological injury. The cervicomedullary junction and cervical spinal cord are especially vulnerable. Twenty-one patients examined and treated over a 20-year period are reviewed. The salient features of the syndrome are identified, and an approach to management is proposed.

Re-evaluation of differential sacral rhizotomy for neurological bladder disease.

The authors describe long-term follow-up results (4 to 6 years) in 13 patients who underwent differential sacral rhizotomy for urgency incontinence. Six patients were originally presented in a preliminary report in 1973. In the last seven patients, a highly selective rhizotomy of sacral fascicles innervating only the urinary bladder was performed. Results in the original six patients appear to be superior to those in patients who underwent a more refined rhizotomy. Possible explanations for this as well as alternative approaches to the treatment of urgency incontinence are briefly discussed.

Immunoproteins in human brain tumor cyst fluids.

Quantitation of the concentration of immunoproteins in serum, and cystic fluids from six patients (three with cerebral astrocytoma and three with cerebellar hemangioblastoma) has been determined. The values for total protein, albumin, immunoproteins IgG, IgA, and IgM, and C3C (complement) in cyst fluid more closely correspond to serum than to cerebrospinal fluid values. Values for cyst fluid, cerebrospinal fluid, and serum were determined using albumin ratios in order to compare relative differences between fluids from these three compartments. Our data suggests that: 1) the major protein content of brain tumor cyst fluid is consequential to a transudative process from serum, and 2) that immunoglobulins IgG and IgA are present in higher concentrations in human brain tumor cyst fluids in comparison to IgM concentrations. These studies further question the concept of the brain as an "immunological privileged site", and may be of direct relevance to the investigation of the use of immunotherapeutic modalities as an adjunct after surgical tumor removal.

Cerebral arterial spasm. Part 4: in vitro effects of temperature, serotonin analogues, large nonphysiological concentrations of serotonin, and extracellular calcium and magnesium on serotonin-induced contractions of the canine basilar artery.

In vitro experiments were performed using a small volume chamber to study serotonin-induced contractions of the canine basilar artery. Temperature was found to have a profound effect on the artery's response to serotonin. Raising the temperature to 40 degrees C (104 degrees F) increased the maximum response by 20% and lowering the temperature by 10 degrees C caused a 40% reduction in the maximum contraction. Cumulative log-dose response curves for analogues of serotonin demonstrated a high degree of specificity for the serotonin receptor and large nonphysiological concentrations of serotonin caused relaxation of the contracted artery. Extracellular calcium was shown to be an absolute requirement for serotonin-induced contractions. Extracellular magnesium, in contrast, was shown to inhibit serotonin-induced contractions.