Dural venous sinus thrombosis in anaplastic astrocytoma following concurrent temozolomide and focal brain radiotherapy plus bevacizumab.

Malignant gliomas have long been a therapeutic dilemma in neuro-oncology, with a poor overall prognosis. Standard treatment, consisting of primary resection, followed by radiation therapy and temozolomide, has improved prognosis. Recently, studies have looked at the addition of bevacizumab (Avastin), a humanized murine IgG1 monoclonal antibody against vascular endothelial growth factor-A, to conventional regiments. Bevacizumab gained US FDA approval for single agent use in recurrent glioblastoma in 2009. Known side effects of bevacizumab include increased risk of arterial and venous thromboembolism, as well as hemorrhage. With emerging data for the use of bevacizumab in malignant gliomas, the extent of risks such as bleeding and thrombosis in patients with primary brain tumors treated with bevacizumab remains unknown. Here, we present only the second reported case of dural venous sinus thrombosis during treatment with bevacizumab and the first reported case for a primary glioma treated with temozolomide, radiation, and bevacizumab.

[The comparative effectiveness of different infusion and blood warming methods]. / Experimentelle Untersuchung zur Effektivität verschiedener Infusions- und Blutwärme-verfahren.

UNLABELLED: Heat loses during surgery occur mainly to the environment and due to infusions and irrigations. Infusions given at room temperature account for a great deal of the total heat deficit during major operations, e.g., the infusion of 53 ml/kg 20 degrees C fluid leads to a loss of 1 degree C in mean body temperature. Hence, heating i.v. fluids will add to the effect of other measures aimed at reducing heat loss to the environment. We investigated the efficacy of different warming methods for i.v. fluids in an experimental model by measuring the temperature at the end of the delivery line. METHODS: The following in-line warmers were studied: Hotline HL-90 and System H-250/heat exchanger D-50 (Level 1 Technologies, Marshfield, USA), Astotherm IFT 260 (Stihler Elektronic GmbH, Stuttgart, Germany), RSLB 30 H Gamida (Productions Hospitalieres Francaises, Eaubonne, France), Bair Hugger 241/Modell 500 Prototype (Augustine Medical, Eden Prairie, USA). They were compared with pre-warming infusions (39 degrees C) only using the Clinitherm S (Labor Technik Barkey GmbH, Bielefeld, Germany) and pre-warming with "active insulation" of the delivery line using the Autotherm/Autoline system (Labor Technik Barkey GmbH, Bielefeld, Germany). We investigated the influence of four variables on the efficacy of warming: (1) flow rate (50-15,000 ml/h); (2) ambient temperature (20 degrees C and 25 degrees C); (3) infusion bag temperature (6 degrees C, 20 degrees C, and 39 degrees C); and (4) length of infusion system downstream from the heat exchanger. Fluid temperatures were measured using thermistors of 1 mm diameter (Modell YSI 520, Yellow Springs Instruments Co., Yellow Springs, USA) incorporated into 3-way stopcocks. Temperatures were recorded using Hellige temperature monitors (Hellige GmbH, Freiburg im Breisgau, Germany) and the signals were collected at 10 Hz through an AD converter and averaged over 1 min. Flows were calculated by timed collection into calibrated cylinders; 10 to 12 different flow rates were taken to define one temperature/ flow plot. Effective warming was defined as a temperature > 33 degrees C at the end of the infusion line. RESULTS: At high flow rates (> 2,500 ml/h) using 20 degrees C fluids at 20 degrees C ambient temperature, the H-250/D-50 system gave the highest temperatures throughout the range and showed effective warming from 1,300 ml/h on over the entire range tested (35 degrees C at 17,000 ml/h) compared to the RSLB 30 H Gamida system (3,000-18,000 ml/h) (Fig. 2). This difference in performance was almost abolished with fluids at 6 degrees C (Fig. 4). Similar efficacy could be reached by using prewarmed infusions that gave effective warming at > 2,000 ml/h and reached 39 degrees C at 13,000 ml/h. Prewarmed infusions could be used effectively down to > 80 ml/h applying "active insulation" (Autotherm/Autoline) to the whole infusion system. The Hotline HL-90 (50-4, 700 ml/h) appeared to be the most effective in-line warmer in the low (< 250 ml/h) and middle (250-2,500 ml/h) flow range, followed by the Astotherm IFT 260 (400-4,000 ml/h), but only if used with a length of 40 cm down-stream from the heat exchanger (Fig. 1). Increasing this distance to 145 cm markedly reduced its efficacy below the range of 2,000 ml/min (1,200- 3,000 ml/h) (Fig. 5). The Bair Hugger 241 Prototype showed a narrow effective range (700-1,300 ml/h) that could be extended beyond 1,300 ml/h by the use of prewarmed infusions (Figs. 1 and 3). The performance for 6 degrees C solutions and ambient temperatures of 25 degrees C are given in Fig. 4 and Table 1. CONCLUSIONS: The importance of infusion warming increases with the amount of fluid given.(ABSTRACT TRUNCATED)

Congenital cystic supratentorial hemangioblastoma. Case report.

The first documented case of congenital supratentorial hemangioblastoma is presented, occurring in a 3-week-old infant. Extensive review of the literature revealed approximately 83 cases of supratentorial hemangioblastoma; however, only one of these occurred in the first year of life, and that case was not presented in detail.

Neurologic deficits restored after elective posterior fossa decompression.

Arnold Chiari malformation is a condition in which the contents of the posterior fossa are herniated below the level of the foramen magnum, and it occurs in three basic forms. Patients with this condition frequently have obstructive hydrocephalus which requires a ventriculo-peritoneal shunt. This article describes the case of a infant female patient with Arnold Chiari Type I, who suffered an episode of acute hydrocephalus and neurologic deterioration after ventriculo-peritoneal shunt malformation. A shunt revision did not reverse her neurologic deficits, so a posterior fossa decompression was performed which did improve her condition.

Intraoperative use of rtPA for subarachnoid hemorrhage.

Intraoperative thrombolysis with recombinant tissue plasminogen activator (rtPA) was performed in 15 patients with aneurysmal subarachnoid hemorrhage. All patients had significant basal cistern blood accumulation seen on CT scans preoperatively. The patients underwent surgery within four days of subarachnoid hemorrhage with aneurysm clipping in all patients. Postoperatively, transcranial doppler examinations demonstrated reduction in the development of vasospasm to a greater degree in patients treated with rtPA than a similar group of patients managed without the rtPA treatment. Eighty percent of patients receiving intracisternal rtPA had fair to good results compared with 78% of a similar group of patients who underwent surgery shortly after subarachnoid hemorrhage and were not given rtPA. Intracisternal rtPA remains an adjunctive treatment of questionable benefit in the management of patients with aneurysmal subarachnoid hemorrhage.

The efficacy of methylprednisolone in reducing flap edema.

It has been suggested that systemic steroids reduce postoperative flap edema. This has been poorly documented by several reports based on subjective clinical observations. In an effort to provide quantitative data on methylprednisolone and edema, a flap edema model in the rat was developed based on the inferior epigastric vessels. Significant edema developed after 48 hours. Differing intraoperative doses of methylprednisolone were studied, producing a dose-response curve. A single low dose of intraoperative steroid is effective in reducing flap edema; previously recommended doses are probably excessive.

The case for prophylactic cholecystectomy concomitant with gastric restriction for morbid obesity.

The pre and postoperative incidence of cholelithiasis were investigated in patients undergoing bariatric surgery at the University of Florida. The first part of the study was retrospective and revealed a pre and 24-month postoperative incidence of cholelithiasis of 30 and 40 percent respectively. Age and postoperative interval were not predictive of cholelithiasis. Patients with cholelithiasis had a significantly greater weight loss (130 +/- 61.0 lbs) than those without stones (109 +/- 59.9 lbs) P = 0.04. Men had a significantly greater weight loss than women (160 +/- 15 lbs SEM versus 99 +/- 7 lbs SEM) as well as a higher incidence of cholelithiasis (53 and 24%, respectively). In the second, prospective part of the study, cholecystectomy was performed in 73 consecutive patients concomitant with their bariatric procedure. Ninety six per cent of removed gallbladders had gross or histologic abnormalities including cholelithiasis in 27 per cent and cholesterolosis/cholecystitis in 69 per cent. The incidence of cholelithiasis was higher than that found in the retrospective series by preoperative ultrasound. The bariatric surgical patient is clearly at risk for the development of postoperative cholelithiasis and cholecystitis. The risk appears to be related to the amount of weight loss. In addition, some gallstones may remain undetected at the time of surgery. We therefore recommend prophylactic cholecystectomy at the time of bariatric surgery.

Preoperative saphenous and cephalic vein mapping as an adjunct to reconstructive arterial surgery.

B-mode ultrasound was prospectively evaluated for its ability to preoperatively assess the adequacy of venous conduit for arterial reconstruction. Fifty-one patients who had lower extremity revascularization had real-time imaging of the saphenous and cephalic veins. Veins were judged adequate based on size, compressibility, and absence of sclerosis or intraluminal echoes. All mapped veins were explored and assessed by the standard criteria for suitability. Vein size was determined from completion angiograms, and wound complications recorded and compared with patients who had similar procedures in the 12 months before the use of vein mapping. Preoperative mapping was found to be accurate in 50 to 51 patients (98%). Vein size as determined by B-mode ultrasound correlated well with angiograms, R = 0.8539 overall with R greater than 0.9 in the last 7 months of the study. Wound complications occurred in 2% of the patients who had preoperative mapping and in 17% of the historic controls. Preoperative vein mapping using B-mode ultrasound is an accurate method of determining vein suitability for use in arterial reconstruction. It improves operative planning and can contribute to a reduction in wound complications. Veins determined to be unusable by preoperative scanning need not be explored.

Total lung lavage for pulmonary alveolar proteinosis in an infant without the use of cardiopulmonary bypass.

Pulmonary alveolar proteinosis is a rare disease that usually affects the adult patient, but is now being recognized as a possible cause of neonatal respiratory distress. In the adult patient, whole lung lavage, as described by Ramirez-R in 1965, is considered the most effective therapy for management of this condition. The lavage can be accomplished safely and with relative ease by using a Carlens or Robertshaw tube to isolate and lavage one lung while ventilating the other. The unavailability of a small double-lumen tube makes this procedure impossible in the pediatric age group. Therefore, whole lung lavage has been possible in only a few children in the past with the help of cardiopulmonary bypass to allow simultaneous oxygenation during the pulmonary lavage. Due to the hazards and technical difficulties of cardiopulmonary bypass, total pulmonary lavage can not be considered a practical option in the very small infant. A 15-week-old infant is reported, weighing 2 kg with a diagnosis of pulmonary alveolar proteinosis, who underwent total pulmonary lavage safely on three different occasions without employing cardiopulmonary bypass. A double-lumen Swan-Ganz catheter, introduced transbronchoscopically through the side-arm of a rigid, 3.5-mm Storz bronchoscope was used to isolate and lavage one lung while ventilation to the other lung was maintained through the bronchoscope. A Nellcor oximeter, utilized for transcutaneous monitoring, revealed satisfactory oxygen saturation during the entire pulmonary lavage. The transbronchoscopic lavage was monitored under direct vision with a video monitor, ensuring correct position of the bronchoscope and the catheter at all times.(ABSTRACT TRUNCATED AT 250 WORDS)