Intraoperative ultrasound-assisted peripheral nerve surgery.

Historically, peripheral nerve surgery has relied on landmarks and fairly extensive dissection for localization of both normal and pathological anatomy. High-resolution ultrasonography is a radiation-free imaging modality that can be used to directly visualize peripheral nerves and their associated pathologies prior to making an incision. It therefore helps in localization of normal and pathological anatomy, which can minimize the need for extensive exposures. The authors found intraoperative ultrasound (US) to be most useful in the management of peripheral nerve tumors and neuromas of nerve branches that are particularly small or have a deep location. This study presents the use of intraoperative US in 5 cases in an effort to illustrate some of the applications of this useful surgical adjunct.

Estimating subglottal pressure via airflow redirection.

Subglottal pressure (SGP) is a valuable parameter in the research and clinical assessment of laryngeal function. The lungs serve as a constant pressure source during sustained phonation, and that pressure, SGP, can be used to determine the efficiency with which the larynx converts aerodynamic power to acoustic power. As the larynx serves as an aerodynamic transducer, the vocal efficiency (Ve) coefficient, defined as acoustic power (dB) divided by aerodynamic power (SGP x glottal airflow) has been shown to reliably reflect vocal health. However, current SGP measurement techniques are hesitantly used because of either an invasive nature or the requirement of intensive patient training. This study tests a novel device that has been designed to noninvasively estimate SGP through mechanical airflow redirection, producing a numeric output on completion of the trial, which lasts only a few seconds. The novelty of this design lies in the ease of use for both the patient and the clinician. Multiple mechanical airflow redirections occlude the airway for only 135 ms, which is predicted to limit the effect of confounding laryngeal reflexes that may occur during the trials. Additionally, the airflow redirection into a retention device allows for the pneumatic in-trial comparison of the estimated SGP with the pressure achieved by the patient, providing a numeric output to the clinician on completion.

Cerebral vasospasm.

Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.

Demographic, circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage.

BACKGROUND: Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before. OBJECTIVE: For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH. METHODS: We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n=338) or naSAH (n=46) on clinical and radiological criteria. PMH (n=32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared. RESULTS: Aneurysmal SAH occurred most often from 6am to 12pm (p<0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p=0.008) and smoking (p=0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p=0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p<0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p=0.0159). CONCLUSION: Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.

Reliable time to estimate subglottal pressure.

Measuring subglottal pressure (P(s)) with complete interruption can be problematic due to unsteady plateaus in supraglottal pressure data traces during balloon valve interruption. Subjectively determining when the graph plateaus neglect the effects of laryngeal, auditory, and other physical reflexes may alter patient effort and glottal configuration. If the P(s) estimation was made at a consistent time before the onset of reflexes, the recorded pressure would not be dependent on subjective analysis by a clinician, and intrasubject data would be more precise. Previously collected data using the airflow interruption system have shown consistency at approximately 150 milliseconds after balloon valve inflation. To evaluate the validity of estimating P(s) at this point, a theoretical and a physical model were applied. A theoretical ideal gas model of capacitance calculated the time necessary for supraglottal pressure to equilibrate with P(s). Using a mechanical pseudolung which served as a constant pressure source, known subresistor pressures were compared to the pressure measured by the interruption device. Both models confirmed the validity of measuring P(s) consistently at 150 milliseconds into the 500-millisecond interruption. In human trials testing 25 subjects, mean intrasubject standard deviation using this optimal time constant was 0.66+/-0.37cm H(2)O, and 1.11+/-0.48cm H(2)O when performing plateau analysis (P<0.0005). This novel modification to the clinically feasible interruption model for P(s) estimation demonstrates a marked improvement in the reliability of balloon valve interruption while maintaining the validity demonstrated in previous studies.