Single-use device endoscopy for the diagnosis of acute bacterial rhinosinusitis in primary care: A pilot and feasibility study.

OBJECTIVE: Antibiotics are largely overprescribed for acute rhinosinusitis in primary care, mainly due to the lack of diagnostic tests to confirm or rule out bacterial infection. The study objective was to assess the on-site applicability and safety of the newly developed JGG endoscope® for the diagnosis of acute bacterial rhinosinusitis in primary care. DESIGN: Five Swiss primary care centres and one university-affiliated ENT unit participated in this single-arm pilot study. PARTICIPANTS: Adults with acute suspected bacterial rhinosinusitis. The newly developed JGG endoscope® , which is attached to a pocket otoscope, was used to inspect after local anaesthesia the nasal cavity and middle meatus and to gain material for bacterial culture from paranasal sinuses draining ostium. MAIN OUTCOME MEASURES: Applicability and safety. RESULTS: The visualisation of the middle meatus was successful in 16 of 21 patients (13 in both sides and three in one side), and unclear or unsuccessful in five patients. Sample collection from the middle meatus was successful in 10 patients (six on both and four on one side) and unclear or unsuccessful in the remaining patients. Only one culture-confirmed bacterial rhinosinusitis and 11 PCR-confirmed viral infections were identified from collected samples. After a 2-week follow-up, no serious adverse events were observed. CONCLUSIONS: The on-site use of the JGG endoscope® in daily primary care routine is feasible and safe and was well accepted by the trial physicians and patients (assessed with structured questionnaires). The JGG endoscope® may support general practitioners to differentiate between bacterial and viral rhinosinusitis.

Perioperative considerations for neurosurgical procedures in the gravid patient: Continuing Professional Development.

PURPOSE: The complexity of neurosurgical procedures and their interactions with maternal and fetal physiologies are key factors in determining the overall maternal and fetal outcome. The literature and guidelines provide only partial information regarding the standard of care in these cases. The purpose of this Continuing Professional Development module is to review the issues related to common neurosurgical conditions and their optimal anesthetic management. PRINCIPAL FINDINGS: The most common neurosurgical conditions found in pregnancy include brain tumours, cerebrovascular diseases, spinal pathologies, and neurotrauma. Though rare, these conditions and related procedures may affect maternal and fetal outcome. Maternal considerations should be given priority in cases of emergent surgeries irrespective of trimester. In the early first trimester, risk of fetal loss and congenital malformation are substantial; hence, proper counselling should be given to the mother with special emphasis on therapeutic abortion. When indicated, anticonvulsants should be started as early as possible and continued throughout pregnancy. Surgical procedures can be performed with relative safety during the second trimester and early third trimester. After 34 weeks, delivery seems to be the first choice, and the role of regional anesthesia in this situation should be carefully planned after proper review of neurosurgical pathology and maternal condition. During acute neurological deterioration, however, Cesarean delivery under general anesthesia should be anticipated. CONCLUSION: A multidisciplinary approach with good communication amongst all team members certainly plays a crucial role for successful management of such cases.

Perioperative variables contributing to the rupture of intracranial aneurysm: an update.

BACKGROUND: Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. METHOD: We have performed a PubMed search (1 January 1991-31 December 2012) using search terms including "cerebral aneurysm," "intracranial aneurysm," and "intraoperative/perioperative rupture." RESULTS: Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. CONCLUSION: We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.

Role of colloids in traumatic brain injury: Use or not to be used?

Trauma is a leading cause of death worldwide and traumatic brain injury is one of the commonest injuries associated with it. The need for urgent resuscitation is warranted for prevention of secondary insult to brain. However, the choice of fluid in such cases is still a matter of conflict. The literature does not provide enough data pertaining to role of colloids in head injury patients. In this article, we have tried to explore the present role of colloid resuscitation in patient with head injury.

Molecular imaging for stem cell transplantation in neuroregenerative medicine.

Stem cell transplantation is a promising new therapeutic option in different neurological diseases. However, it was not yet possible to translate its potential from animal models to clinical application. One of the main problems of applying stem cell transplantation in clinical medium is the difficulty of detection, localization, and examination of the stem cells in vivo at both cellular and molecular levels. State-of-the-art molecular imaging techniques provide new and better means for noninvasive, repeated, and quantitative tracking of stem cell implant or transplant. From initial deposition to the survival, migration, and differentiation of the transplant/implanted stem cells, current molecular imaging methods allow monitoring of the infused cells in the same live recipient over time. The present review briefly summarizes and compares these molecular imaging methods for cell labeling and imaging in animal models as well as in clinical application and sheds light on consecutive new therapeutic options if appropriate.

Postcraniotomy function of the temporal muscle in skull base surgery: technical note based on a preliminary study.

PURPOSE: Patients undergoing craniotomies necessitating preparation of the temporal muscle (TM) may experience postoperative functional impairment of the temporomandibular joint. This topic has not been thoroughly discussed in the literature so far. In the present study, the authors propose a questionnaire as an evaluation tool to assess to what degree different TM preparation techniques correlate with postoperative temporomandibular joint dysfunction. MATERIALS AND METHODS: Between 2004 and 2006, 286 patients underwent either pterional or temporal craniotomies in the department of craniotomies at the University of Münster in Germany. Intraoperatively the TM was prepared either interfascial, submuscular, or subfascial. A patient-based questionnaire was designed and validated (Kendalls-τ = +1) in order to evaluate the patients' postoperative temporomandibular functional outcome. Based on strict inclusion/exclusion criteria, 69 patients were eligible for the application of the questionnaire in this preliminary study. RESULTS: Seventeen percent of the patients complained of either temporomandibular joint pain (3%) or restricted mouth opening (13%) postoperatively in a follow-up period between 3 and 12 months. In 92% postoperative complaints were reported within the first 3 months and in 58% of the patients with complaints the pain eased off. In 34% a therapy was required for the pain to be controlled. In one patient (8%) a postoperative arthroscopy has been necessary. Of the patients who experienced postoperative complaints, 67% had undergone temporal and 33% pterional craniotomy. In the group where postoperatively there were issues of temporomandibular pain/dysfunction, 42% had had the TM dissected, in 25% incised, and in 8% transected. For 25% of the patients, the type of intraoperative manipulation remained unknown. CONCLUSION: For postoperative quality control, the questionnaire showed to be a suitable evaluation tool. Concerning the different preparation techniques, subfascial preparation of the TM tends to result in less postoperative complaints and is thus recommended.

Atypical trigeminocardiac reflex during intranasal dexmedetomidine sedation of a 6-month-old premature baby.

The trigeminocardiac reflex (TCR) is an established brainstem reflex leading to parasympathetic dysrhythmias-including haemodynamic irregularities, apnoea and gastric hypermotility-during stimulation of any sensory branches of the trigeminal nerve. Most of the clinical knowledge about TCR was gathered from general anaesthesia observations, not from procedural sedation.We present a case of a 6-month-old premature baby experiencing the reflex twice under dexmedetomidine-propofol-sedation while undergoing ophthalmic and ear examination. This was interpreted as cross-over sensitisation between the facial and trigeminal cranial nerve (N V and N VII).The present case demonstrates that different TCR subtypes can occur during the same anaesthetic procedure. Triggering TCR seems to be based on several factors and not just on a single stimulus as often presumed. Therefore, for premature babies, there is a risk for TCR under procedural sedation, and we recommend using glycopyrrolate as preventive treatment.

Perioperative Complications and Anesthesia Practices in Managing Patients With Quadriplegia Undergoing Surgery: A Systematic Review.

Quadriplegia is associated with a multitude of health complications affecting numerous organ systems. Complications during the perioperative periods are not uncommon in this patient population due to abnormal responses to surgical stressors. Such complications include autonomic dysreflexia, cardiac ischemia, and respiratory compromise. Currently, there is no clear consensus on the ideal technique for perioperative anesthesia management in this population. In addition, the relationship between the perioperative complications and anesthesia practices have not been explored in-depth. Therefore, we aimed to investigate perioperative complications in the context of anesthesia that are associated with patients with quadriplegia undergoing various surgical procedures. Our PRISMA compliant systematic review included 12 articles covering the literature from inception to January 12, 2021. The review showed complications being pulmonary, cerebral, but most importantly and commonly cardiac in nature, with many patients suffering hypertension, and many others hypotension. In addition, our review showed that autonomic dysreflexia is common and in majority of patients, it was managed successfully with good recovery. Based on our findings, the use of anesthesia, either general or spinal, can be considered. Future studies are needed to elucidate the exact mechanisms involved in perioperative complications and anesthetic management that are associated with patients with quadriplegia. This review will aid in developing general recommendations based on the information available in the literature to guide perioperative management of this vulnerable patient population.

Reappearance of Neurological Deficits in Pathologic Brain: Are Sedatives and Opioids Culprits? A Systematic Review.

Following a brain insult, focal neurological deficits may develop. Despite resolution of these deficits with time, the subsequent administration of sedative medications and opioids may lead to recrudescence of previous neurological deficits. Therefore, the present systematic review aims to explore the role of different sedatives and opioid analgesics at reproducing focal neurological deficits in patients with previous brain insults undergoing surgery. Our PRISMA compliant systematic review covering the literature from 1990 to 2020 showed a consistent reoccurrence of neurological deficits following administration of benzodiazepines and opioids across 12 studies. It appears that in all studies, the manifestations were transient and affected mostly middle-aged patients (45 to 67 y of age). In addition, benzodiazepines and opioid antagonism by naloxone and flumazenil reverses the unmasking of prior neurological deficits. In contrast, it is not clear based on our study whether the unmasking or worsening of neurological deficits occurs following recent injuries or an older brain insult, although for most patients it appears to be the former. Future studies are needed to elucidate the mechanisms involved in unmasking prior deficits and/or extension of prior injuries by sedative and opioid analgesics. This review will aid in developing prospective studies on individual sedative medications and their effects on unmasking neurological deficits in patients with multiple brain pathologies.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review.

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

A Step Further-The Role of Trigeminocardiac Reflex in Therapeutic Implications: Hypothesis, Evidence, and Experimental Models.

The trigeminocardiac reflex (TCR) is a well-recognized brainstem reflex that represents a unique interaction between the brain and the heart through the Vth and Xth cranial nerves and brainstem nuclei. The TCR has mainly been reported as an intraoperative phenomenon causing cardiovascular changes during skull-base surgeries. However, it is now appreciated that the TCR is implicated during non-neurosurgical procedures and in nonsurgical conditions, and its complex reflex pathways have been explored as potential therapeutic options in various neurological and cardiovascular diseases. This narrative review presents an in-depth overview of hypothetical and experimental models of the TCR phenomenon in relation to the Vth and Xth cranial nerves. In addition, primitive interactions between these 2 cranial nerves and their significance are highlighted. Finally, therapeutic models of the complex interactions of the TCR and areas for further research will be considered.

Current molecular imaging of spinal tumors in clinical practice.

Energy metabolism measurements in spinal cord tumors, as well as in osseous spinal tumors/metastasis in vivo, are rarely performed only with molecular imaging (MI) by positron emission tomography (PET). This imaging modality developed from a small number of basic clinical science investigations followed by subsequent work that influenced and enhanced the research of others. Apart from precise anatomical localization by coregistration of morphological imaging and quantification, the most intriguing advantage of this imaging is the opportunity to investigate the time course (dynamics) of disease-specific molecular events in the intact organism. Most importantly, MI represents one of the key technologies in translational molecular neuroscience research, helping to develop experimental protocols that may later be applied to human patients. PET may help monitor a patient at the vertebral level after surgery and during adjuvant treatment for recurrent or progressive disease. Common clinical indications for MI of primary or secondary CNS spinal tumors are: (i) tumor diagnosis, (ii) identification of the metabolically active tumor compartments (differentiation of viable tumor tissue from necrosis) and (iii) prediction of treatment response by measurement of tumor perfusion or ischemia. While spinal PET has been used under specific circumstances, a question remains as to whether the magnitude of biochemical alterations observed by MI in CNS tumors in general (specifically spinal tumors) can reveal any prognostic value with respect to survival. MI may be able to better identify early disease and to differentiate benign from malignant lesions than more traditional methods. Moreover, an adequate identification of treatment effectiveness may influence patient management. MI probes could be developed to image the function of targets without disturbing them or as treatment to modify the target's function. MI therefore closes the gap between in vitro and in vivo integrative biology of disease. At the spinal level, MI may help to detect progression or recurrence of metastatic disease after surgical treatment. In cases of nonsurgical treatments such as chemo-, hormone- or radiotherapy, it may better assess biological efficiency than conventional imaging modalities coupled with blood tumor markers. In fact, PET provides a unique possibility to correlate topography and specific metabolic activity, but it requires additional clinical and experimental experience and research to find new indications for primary or secondary spinal tumors.

Trigeminocardiac reflex, bilateral sagittal split ramus osteotomy, Gow-Gates block: a randomized controlled clinical trial.

PURPOSE: The behavior of trigeminocardiac reflex (TCR) during maxillofacial surgeries has not yet been sufficiently studied and knowledge of its behavior is limited to some case reports. The present study aimed to assess the occurrence of TCR in bilateral sagittal split ramus osteotomy and to determine the possible effect of Gow-Gates block on its incidence. MATERIALS AND METHODS: Twenty candidates for bilateral sagittal split ramus osteotomy (included were American Society of Anesthesiologists I Class III patients with a prognathism of 3 to 5 mm) were given routine general anesthesia after at least 12 hours of fasting. All patients received Gow-Gates mandibular nerve block on 1 random side (case ramus; the other side was used as the control) after induction of general anesthesia before surgery. Pulse rate was recorded at baseline, soft tissue cutting, bone cutting, sagittal splitting, setback manipulation, and recovery. Mean pulse rate values were compared statistically using t test for the 2 sides in patients. RESULTS: No statistically significant differences were found between the blocked and control sides except during ramus sagittal splitting and setback manipulation (P < .0001), when a significantly decreased pulse rate was recorded for the control ramus compared with the blocked ramus. CONCLUSIONS: The present study provides further evidence for the complex neurophysiologic mechanism and probable prevention of peripheral TCR. The results of the present study should be further validated through future studies but already provide strong evidence that peripheral and central TCR may act differently based on slightly different pathways.

Stem cell transplantation in brain tumors: a new field for molecular imaging?

Neural stem cells have been proposed as a new and promising treatment modality in various pathologies of the central nervous system, including malignant brain tumors. However, the underlying mechanism by which neural stem cells target tumor areas remains elusive. Monitoring of these cells is currently done by use of various modes of molecular imaging, such as optical imaging, magnetic resonance imaging and positron emission tomography, which is a novel technology for visualizing metabolism and signal transduction to gene expression. In this new context, the microenvironment of (malignant) brain tumors and the blood-brain barrier gains increased interest. The authors of this review give a unique overview of the current molecular-imaging techniques used in different therapeutic experimental brain tumor models in relation to neural stem cells. Such methods for molecular imaging of gene-engineered neural stem/progenitor cells are currently used to trace the location and temporal level of expression of therapeutic and endogenous genes in malignant brain tumors, closing the gap between in vitro and in vivo integrative biology of disease in neural stem cell transplantation.

Molecular Imaging and Tracking Stem Cells in Neurosciences.

Stem cell transplantation is a promising new therapeutic option in different neurological diseases. However, it is not yet possible to translate its potential from animal models to clinical application. One of the main problems of applying stem cell transplantation in clinical medium is the difficulty of detection, localization, and examination of the stem cells in vivo at both cellular and molecular levels. State-of-the-art molecular imaging techniques provide new and better means for noninvasive, repeated, and quantitative tracking of stem cell implant or transplant. From initial deposition to the survival, migration, and differentiation of the transplant/implanted stem cells, current molecular imaging methods allow monitoring of the infused cells in the same live recipient over time. The present review briefly summarizes and compares these molecular imaging methods for cell labeling and imaging in animal models as well as in clinical application and sheds light on consecutive new therapeutic options if appropriate.

Therapeutic implications of osteoprotegerin.

Osteoprotegerin (OPG), a member of the tumor necrosis factor (TNF) receptor superfamily, contributes determinatively to the bone remodeling as well as to the pathogenetic mechanism of bone malignancies and disorders of mineral metabolism. There is additional evidence that OPG can promote cell survival by inhibiting TNF-related apoptosis-inducing ligand (TRAIL)-induced apoptosis. A number of recent in vitro, in vivo and clinical studies have defined the role of the RANK/RANKL/OPG pathway in skeletal and vascular diseases. These works were the milestone of the deep understanding of the mechanism of OPG. This review provides an overview of the potential innovative therapeutic strategies of OPG in metastatic breast and prostate carcinoma, multiple myeloma, postmenopausal osteoporosis, glucocorticoid-induced osteoporosis and rheumatoid arthritis. Special reference is given to the increasing evidence that RANKL and OPG may link the skeletal with the vascular system.

Molecular imaging of brain tumors personal experience and review of the literature.

Non-invasive energy metabolism measurements in brain tumors in vivo are now performed widely as molecular imaging by positron emission tomography. This capability has developed from a large number of basic and clinical science investigations that have cross fertilized one another. Apart from precise anatomical localization and quantification, the most intriguing advantage of such imaging is the opportunity to investigate the time course (dynamics) of disease-specific molecular events in the intact organism. Most importantly, molecular imaging represents a key-technology in translational research, helping to develop experimental protocols that may later be applied to human patients. Common clinical indications for molecular imaging of primary brain tumors therefore contain (i) primary brain tumor diagnosis, (ii) identification of the metabolically most active brain tumor reactions (differentiation of viable tumor tissue from necrosis), and (iii) prediction of treatment response by measurement of tumor perfusion, or ischemia. The key-question remains whether the magnitude of biochemical alterations demonstrated by molecular imaging reveals prognostic value with respect to survival. Molecular imaging may identify early disease and differentiate benign from malignant lesions. Moreover, an early identification of treatment effectiveness could influence patient management by providing objective criteria for evaluation of therapeutic strategies for primary brain tumors. Specially, its novel potential to visualize metabolism and signal transduction to gene expression is used in reporter gene assays to trace the location and temporal level of expression of therapeutic and endogenous genes. The authors present here illustrative data of PET imaging: the thymidine kinase gene expression in experimentally transplanted F98 gliomas in cat brain indicates, that [(18)F]FHBG visualizes cells expressing TK-GFP gene in transduced gliomas as well as quantities and localizes transduced HSV-1-TK expression if the blood brain barrier is disrupted. The higher uptake of [(18)F]FLT in the wild-type compared to the transduced type may demonstrate the different doubling time of both tumor tissues suggesting different cytosolic thymidine kinase activity. Molecular imaging probes are developed to image the function of targets without disturbing them or as drug in oder to modify the target's function. This is transfer of gene therapy's experimental knowledge into clinical applications. Molecular imaging closes the gap between in vitro to in vivo integrative biology of disease.

Management of the trigeminocardiac reflex: facts and own experience.

The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is--the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta-blockers; and calcium channel blockers. Because of the lack of full understanding of the TCR physiology, the current treatment options for patients with TCR include: (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) administration of vagolytic agents or sympathomimetics.

Extracranial-intracranial bypass to reduce the risk of ischemic stroke in intracranial aneurysms of the anterior cerebral circulation: a systematic review.

BACKGROUND AND PURPOSE: If clip application or coil placement for treatment of intracranial (IC) aneurysms is not feasible, the parent vessel can be occluded to induce thrombosis of the aneurysm. In the case that such an occlusion cannot be tolerated without subsequent sequel, the additional construction of an extracranial (EC)-IC bypass is needed for sufficient ipsilateral revascularization. Hitherto, the effectiveness of this combined treatment option was not investigated in a controlled randomized trial or in a review. The aim of the current report was to analyze clinical effectiveness of EC-IC bypass for cerebral revascularization in patients with Hunterian ligation in case of otherwise untreatable aneurysm of the anterior cerebral circulation. Special reference was given to different hemodynamic subgroups. METHODS: A computerized database search was conducted from November 1985 to November 2002 using MEDLINE, relevant Internet sources, and full-text journal articles using appropriate indexed terms. Journal of Neurosurgery, Neurosurgery, Acta Neurochirurgica, and Stroke were manually searched for the period November 1985 to November 2002 and checked reference lists of all relevant articles for additional eligible studies. Language restriction was done for English, French, and German. Reports dealing with EC-IC bypass surgery for cerebral revascularization in case of aneurysm of the anterior cerebral circulation were reviewed when appropriate. Studies were included that contained evaluable data on clinical state, preoperative and postoperative hemodynamic state, surgical outcome, and follow-up. A statistical analysis was performed for different outcome parameters and clinical effectiveness in the included studies. RESULTS: Overall, 20 studies were included, each with a study quality of 0-1. The postoperative outcome related to death or stroke depended mainly on preoperative hemodynamic subgroups (cerebral blood flow [CBF]/cerebral blood volume [CBV]; oxygen extraction fraction [OEF]). The final functional status was worse the more CBF/CBV ratio and OEF increased. Perioperative risk for death (0.8%) or stroke (1.5%) during the first month after operation was similar to the death or stroke rate during the following 2 to 12 months after operation. Neurologic function was improved over the preoperative state in 74% of the patients and was unchanged in 9%. The modified Rankin scale score was postoperatively 0 to 1 in 81% and 2 in 6% of the patients. Long-term patency was excellent, with 2.3% failure rate per year after the first year after surgery. There was no de novo aneurysm formation in the follow-up. CONCLUSION: Neurologic function and subsequent stroke attributable to hemodynamic insufficiency in patients with otherwise untreatable IC aneurysm improves significantly by EC-IC bypass surgery if the brain area corresponding to the impaired neurologic function remains viable. The hemodynamic parameters observed for patients who experience improved neurologic function or diminished stroke risk profile after EC-IC bypass surgery contain both significantly elevated OEF and CBF/CBV. Therefore, hemodynamic state represents an important indicator for EC-IC bypass surgery. The large amount of data leads to narrow stroke with no significant heterogeneity, and the overall results are, therefore, likely to be statistically robust.