Airway management for patients with ossification of the anterior longitudinal ligament of the cervical spine.

Ossification of the anterior longitudinal ligament (OALL), also called Forestier's disease or diffuse idiopathic skeletal hyperostosis, is characterized by anterior bridging osteophytes of unknown etiology. OALL may cause dysphagia, dyspnea, dysphonia, and acute airway obstruction. We report difficulty in tracheal intubation during anesthesia induction in two OALL patients. In an 82-year-old man, anterior bridging osteophytes (of the cervical region) were observed on preoperative lateral radiograph after several attempts of tracheal intubation for the operation of the anterior fusion of cervical spine. During the same procedure in another 69-year-old man, fiberoptic-assisted awake intubation was extremely difficult because of posterior hypopharyngeal wall protuberance by osteophytes of cervical spine; although tracheal intubation for anesthesia was uneventful on two previous occasions over the months. OALL is usually asymptomatic, but it has been found in 12 % of autopsies and may exaggerate with age. Dysphagia, difficulties with tracheal and/or gastric intubation, acute respiratory compromise, and sleep apnea result from the presence of cervical osteophytes. Anesthesiologists should be aware that tracheal intubation for such patients may be difficult, and thus the preoperative evaluation and airway management need careful consideration.

Different effects of local anesthetics on extracellular signal-regulated kinase phosphorylation in rat dorsal horn neurons.

Local anesthetics, which are widely known to be neuronal voltage-gated Na(+) channel blockers, also affect a variety of other ion channels, N-methyl-d-asparate (NMDA) receptors and α-amino-3-hydroxy-5-methyl-4-izoxazolepropionic acid (AMPA) receptors. Glutamate, which is released from presynaptic fibers, activates extracellular signal-regulated kinase (ERK) through NMDA and AMPA receptors in spinal dorsal horn neurons. ERK plays a key role in central sensitization, which contributes to the chronicity of pain. We investigated the effects of four representative local anesthetics, lidocaine, tetracaine, levobupivacaine, and ropivacaine on ERK phosphorylation induced by capsaicin, which releases glutamate from presynaptic neurons, NMDA, AMPA, or ionomycin, a calcium ionophore, in dorsal neurons. We observed capsaicin-induced phosphorylation of ERK, which was suppressed by lidocaine, tetracaine, or ropivacaine, but not by levobupivacaine. NMDA-induced phosphorylation of ERK was suppressed by lidocaine, tetracaine, or levobupivacaine, but not by ropivacaine. AMPA-induced phosphorylation of ERK was suppressed by lidocaine or tetracaine, but not by levobupivacaine or ropivacaine. Finally, ionomycin-induced ERK phosphorylation was suppressed by lidocaine, tetracaine, or ropivacaine, but not by levobupivacaine. Our results suggest that local anesthetics contribute to the prevention of the incidence of persistent postsurgical pain with varying intensities and through different mechanisms of action.

Intrathecal endothelin-1 has antinociceptive effects in rat model of postoperative pain.

Endothelin-1 is known to be a potent vasoconstrictor. Administration of endothelin-1 to the central nervous system (CNS) induces antinociceptive effects. Nociceptive stimuli affect dorsal root ganglion (DRG) neurons and neurons/astrocytes/microglia in the dorsal horn of the spinal cord. Surgical incision in the plantar aspect of the rat hindpaw is a model for postoperative pain, and withdrawal thresholds reportedly decrease around the incision. We hypothesized that intrathecal endothelin-1 would have antinociceptive effects in this model, and affect DRG neurons and microglia/neurons in the dorsal horn. Intrathecal endothelin-1 partially restored the withdrawal threshold (which was decreased by plantar incision). BQ-123, and BQ-788 (specific endothelin ET(A)- and ET(B)-receptor antagonists, respectively) attenuated the increase in withdrawal threshold induced by endothelin-1. Phosphorylation of extracellular signal-regulated kinase (ERK) in DRG neurons and microglial activation/ERK phosphorylation in the dorsal horn were observed following the incision. Endothelin-1 decreased the incision-induced increase in the numbers of phosphorylated ERK-positive neurons in DRG and activated microglia in the dorsal horn, without affecting the numbers of phosphorylated ERK-positive neurons in the dorsal horn. BQ-123 or BQ-788 partially suppressed these endothelin-1-induced alterations. Our results show that the pain threshold, which is decreased by surgical stimuli, is partially restored by intrathecal endothelin-1 through both endothelin ET(A)- and ET(B)- receptors in DRG neurons and microglia in the spinal cord. Endothelin-1 administration to the CNS may be worth considering as a new candidate for the treatment of postoperative pain and to mitigate prolonged periods of pain.

The antinociceptive activity of intrathecally administered amiloride and its interactions with morphine and clonidine in rats.

UNLABELLED: In this study, we aimed to evaluate the antinociceptive interaction between intrathecally administered amiloride and morphine or clonidine. Using rats chronically implanted with lumbar intrathecal catheters, we examined the ability of intrathecal amiloride, morphine, clonidine, and mixtures of amiloride-morphine and amiloride-clonidine to alter tail-flick latency. To characterize any interactions, isobolographic analysis was performed. The effects of pretreatment with intrathecally administered naloxone or yohimbine were tested. Intrathecal administration of amiloride (25-150 µg), morphine (.25-10 µg), or clonidine (.5-10 µg) alone produced significant dose-dependent antinociception in the tail-flick test. The median effective dose (ED(50)) values for intrathecally administered amiloride, morphine, and clonidine were 120.5 µg, 5.0 µg, and 4.4 µg, respectively. Isobolographic analysis exhibited a synergistic interaction after coadministration of amiloride-morphine and amiloride-clonidine. Intrathecal pretreatment with naloxone (10 µg) completely blocked the antinociceptive effects of morphine and the amiloride-morphine mixture. Intrathecal pretreatment with yohimbine (20 µg) completely blocked the antinociceptive effect of clonidine and antagonized the effect of the amiloride-clonidine mixture. There was no motor dysfunction or significant change in blood pressure or heart rate after the intrathecal administration of amiloride, amiloride-morphine, and amiloride-clonidine. The synergistic effect observed after the coadministration of amiloride and morphine or clonidine suggests a functional interaction among calcium channels, µ-receptors and α(2)-receptors at the spinal cord level of the nociceptive processing system. PERSPECTIVE: Although intrathecal morphine and clonidine produces pronounced analgesia, antinociceptive doses of intrathecal morphine and clonidine produce several side effects, including hypotension, bradycardia, sedation, and tolerance. This article presents antinociceptive synergistic interaction between amiloride and morphine, amiloride, and clonidine on thermal nociceptive tests in the rat.

Continuous cardiac output measurement with a Doppler-equipped pulmonary artery catheter.

BACKGROUND: We developed a Doppler-equipped pulmonary artery catheter that provides continuous measurement of the true main pulmonary blood flow velocity independent of the angle of incidence formed by the pulmonary artery catheter and the main pulmonary artery blood flow. This device uses 2 orthogonally positioned Doppler transducers that allow trigonometric correction for differences in the angle of blood flow between each transducer. We tested the accuracy of the Doppler-equipped pulmonary artery catheter by comparing its cardiac output measurements with those done by conventional techniques in animals. METHODS: The Doppler-equipped pulmonary artery catheter was evaluated in dogs. A pair of ultrasound Doppler transducers positioned at a fixed angle (90°) was mounted on the distal part of the thermodilution pulmonary artery catheter. The Doppler shifts (Δf1, Δf2) were detected by the 2 transducers sampling at 2 closely spaced points in the main pulmonary artery. The values of Δf1 and Δf2 were used to compute 2 velocity measurements. The true flow velocity of the main pulmonary artery was calculated with the following equation: V(pulm) = {(V(transducer1))(2) + (V(transducer2))(2)}(1/2) (V(pulm) = true main pulmonary artery velocity; V(transducer1) and V(transducer2) = velocity detected by transducers 1 and 2, respectively). The flow velocities were calculated by using a phase differential technique. Cardiac output was calculated as V(pulm) multiplied by a coefficient value. The coefficient value was calculated by dividing cardiac output, derived from conventional techniques, by V(pulm) at the beginning of each experiment. After thoracotomy, an electromagnetic flowprobe was placed around the main pulmonary artery in dogs. Cardiac output was simultaneously measured by the Doppler-equipped pulmonary artery catheter (CO-Doppler), and the electromagnetic flowmeter (CO-EMF) or the thermodilution technique (CO-Thermo). Cardiac output was manipulated by dobutamine and propranolol. RESULTS: CO-Doppler was highly correlated with CO-EMF (y = 1.16 × -0.26, r(2) = 0.99, P < 0.001) and CO-Thermo (y = 1.24 × -0.90, r(2) = 0.85, n = 48, P < 0.001). The bias between CO-EMF and CO-Doppler was -0.02 L/min; 95% limits of agreement were -0.32 to 0.28 L/min. The percentage error was 16%. The bias between CO-Thermo and CO-Doppler was 0.18 L/min; 95% limits of agreement were -0.62 to 0.98 L/min. CONCLUSIONS: The newly developed Doppler-equipped pulmonary artery catheter with 2 orthogonally positioned Doppler transducers allowed accurate and continuous measurements of cardiac output independent of the angle of incidence formed by the pulmonary artery catheter and the main pulmonary artery blood flow.

[Evaluation of urine specific gravity as an index of hypotension after spinal anesthesia for cesarean section].

BACKGROUND: Although most cesarean sections are done under spinal anesthesia, we often experience severe hypotension. Fluid resuscitation is usually carried out for prevention of hypotension, but it is difficult to assess the suitable infusion volume. We examined whether the urine specific gravity can predict hypotension after spinal anesthesia for cesarean section. METHODS: Ninety nine patients (ASA 1 or 2) undergoing elective cesarean section were recruited. After dural puncture, we collected the cerebrospinal fluid and injected 2 ml of hyperbaric 0.5% bupivacaine. Thereafter urethral catheters were inserted, and then we collected the urine sample. The specific gravity of each sample was measured by using refractometer after the operation. RESULTS: There was a good correlation between the urinary output and the urine specific gravity. The minimum systolic blood pressure until delivery, the total dose of ephedrine, and the maximum sensory block level showed a significant, but not particularly strong correlation with the urine specific gravity. CONCLUSIONS: We concluded that it was difficult to predict hypotension by using urine specific gravity because the correlation was too weak.

Mechanisms of tumor necrosis factor-alpha-induced interleukin-6 synthesis in glioma cells.

BACKGROUND: Interleukin (IL)-6 plays a pivotal role in a variety of CNS functions such as the induction and modulation of reactive astrogliosis, pathological inflammatory responses and neuroprotection. Tumor necrosis factor (TNF)-alpha induces IL-6 release from rat C6 glioma cells through the inhibitory kappa B (IkappaB)-nuclear factor kappa B (NFkappaB) pathway, p38 mitogen-activated protein (MAP) kinase and stress-activated protein kinase (SAPK)/c-Jun N-terminal kinase (JNK). The present study investigated the mechanism of TNF-alpha-induced IL-6 release in more detail than has previously been reported. METHODS: Cultured C6 cells were stimulated by TNF-alpha. IL-6 release from the cells was measured by an enzyme-linked immunosorbent assay, and the phosphorylation of IkappaB, NFkappaB, the MAP kinase superfamily, and signal transducer and activator of transcription (STAT)3 was analyzed by Western blotting. Levels of IL-6 mRNA in cells were evaluated by real-time reverse transcription-polymerase chain reaction. RESULTS: TNF-alpha significantly induced phosphorylation of NFkappaB at Ser 536 and Ser 468, but not at Ser 529 or Ser 276. Wedelolactone, an inhibitor of IkappaB kinase, suppressed both TNF-alpha-induced IkappaB phosphorylation and NFkappaB phosphorylation at Ser 536 and Ser 468. TNF-alpha-stimulated increases in IL-6 levels were suppressed by wedelolactone. TNF-alpha induced phosphorylation of STAT3. The Janus family of tyrosine kinase (JAK) inhibitor I, an inhibitor of JAK 1, 2 and 3, attenuated TNF-alpha-induced phosphorylation of STAT3 and significantly reduced TNF-alpha-stimulated IL-6 release. Apocynin, an inhibitor of NADPH oxidase that suppresses intracellular reactive oxygen species, significantly suppressed TNF-alpha-induced IL-6 release and mRNA expression. However, apocynin failed to affect the phosphorylation of IkappaB, NFkappaB, p38 MAP kinase, SAPK/JNK or STAT3. CONCLUSION: These results strongly suggest that TNF-alpha induces IL-6 synthesis through the JAK/STAT3 pathway in addition to p38 MAP kinase and SAPK/JNK in C6 glioma cells, and that phosphorylation of NFkappaB at Ser 536 and Ser 468, and NADPH oxidase are involved in TNF-alpha-stimulated IL-6 synthesis.

Comparative effects of cilostazol and aspirin on the impairment of endothelium-dependent cerebral vasodilation caused by acute cigarette smoking in rats.

We previously reported that acute cigarette smoking can cause a dysfunction of endothelium-dependent vasodilation in cerebral vessels, and that a reduction of oxidative stress by agents such as valsartan, fasudil, or apocynin prevented this impairment. Here, our aim was to investigate the comparative effects of two antiplatelet drugs used for stroke-prevention [a phosphodiesterase-3 inhibitor (cilostazol) and a cyclooxygenase inhibitor (aspirin)] on smoking-induced endothelial dysfunction in cerebral arterioles. In Sprague-Dawley rats, we used a closed cranial window preparation to measure the changes in pial vessel diameters induced by topical application of acetylcholine (ACh) following intraperitoneal injection of 0.5% carboxymethyl cellulose sodium salt (CMC; vehicle control for the antiplatelet drugs). After 1-min smoking (1 mg-nicotine cigarette), the arteriolar responses to ACh were reexamined. Finally, after intraperitoneal cilostazol or aspirin (each in 0.5% CMC) pretreatment, we reexamined the vasodilator responses to topical ACh (before and after cigarette smoking). Under control conditions, cerebral arterioles were dose-relatedly dilated by topical ACh (10(-6) and 10(-5 )M). One hour after 1-min smoking, 10(-5 )M ACh (a) constricted cerebral pial arterioles in the control group and in the aspirin-pretreatment group (responses not significantly different from each other), but (b) dilated cerebral pial arteries in the cilostazol pretreatment groups (responses significantly different from those obtained without cilostazol pretreatment). Thus, cilostazol (but not aspirin) may prevent the smoking-induced impairment of endothelium-dependent vasodilation in cerebral pial arterioles.

The association between the initial end-tidal carbon dioxide difference and the lowest arterial oxygen tension value obtained during one-lung anesthesia with propofol or sevoflurane.

OBJECTIVE: The purpose of this study was to examine the correlation between the lowest PaO(2) value recorded during the first 45 minutes of one-lung ventilation (OLV) and the end-tidal CO(2) (ETCO(2)) difference between two-lung ventilation (TLV) and the early phase of OLV. DESIGN: A prospective, randomized study. SETTING: A university hospital. PARTICIPANTS: Thirty-six patients scheduled for elective thoracic surgery. INTERVENTIONS: Thoracic surgery patients were randomly assigned to 1 of 2 groups (group P [n = 18], maintained with propofol; group S [n = 18], maintained with sevoflurane). After setting up, the authors measured arterial blood gases at F(I)O(2) = 1.0 as follows: during TLV and at 5 minutes, 15 minutes, 30 minutes, and 45 minutes after the start of OLV. ETCO(2) was recorded just before and at 3 minutes after the start of OLV. The authors examined the relationship between the initial ETCO(2) difference and the lowest PaO(2) value recorded during the first 45 minutes of OLV. MEASUREMENTS AND MAIN RESULTS: There was a significant negative correlation between the lowest PaO(2) (x) value and the initial ETCO(2) difference (y) during OLV in each group (group P: y = -0.0203x + 7.2571, r(2) = 0.5351; group S: y = -0.0257x + 7.3158, r(2) = 0.6129). This correlation was not significantly different between the groups. CONCLUSION: The present study indicates that the ETCO(2) difference between TLV and early OLV has an association with impaired oxygenation later during OLV. This would be a simple and clinically convenient predictor of the lowest PaO(2) value likely to be reached during one-lung anesthesia with either propofol or sevoflurane.

Involvement of Rho-kinase in tumor necrosis factor-alpha-induced interleukin-6 release from C6 glioma cells.

Tumor necrosis factor (TNF)-alpha stimulated interleukin (IL)-6 release and induced the phosphorylation of myosin phosphatase targeting subunit (MYPT)-1, a Rho-kinase substrate. The IL-6 release was significantly suppressed by Y-27632 and fasudil, Rho-kinase inhibitors. Although IkappaB inhibitor suppressed the TNF-alpha-induced IL-6 release, the Rho-kinase inhibitors did not affect the TNF-alpha-induced IkappaB phosphorylation. TNF-alpha induced the phosphorylation of p38 mitogen-activated protein (MAP) kinase, stress-activated protein kinase (SAPK)/c-Jun N-terminal kinase (JNK), and p44/p42 MAP kinase. The TNF-alpha-induced IL-6 release was suppressed by SB203580, a p38 MAPK inhibitor, or SP600125, a SAPK/JNK inhibitor, but not by PD98059, a MAP kinase/extracellular signal-regulated kinase kinase inhibitor. The Rho-kinase inhibitors attenuated the TNF-alpha-induced phosphorylation of both p38 MAP kinase and SAPK/JNK. Rho-kinase, which has been used for the clinical treatment of cerebral vasospasms, may be involved in other central nervous system (CNS) disorders such as traumatic injury, stroke, neurodegenerative disease and neuropathic pain. TNF-alpha, a proinflammatory cytokine that affects the CNS through cytokines, such as IL-6, release from neurons, astrocytes and microglia. Therefore, we investigated the involvement of Rho-kinase in the TNF-alpha-induced IL-6 release from rat C6 glioma cells. These results strongly suggest that Rho-kinase regulates the TNF-alpha-induced IL-6 release at a point upstream from p38 MAPK and SAPK/JNK in C6 glioma cells. Therefore, Rho-kinase inhibitor may be considered to be a new clinical candidate for the treatment of CNS disorders in addition to cerebral vasospasms.

Mechanisms of interleukin-1beta-induced GDNF release from rat glioma cells.

Glial cell line-derived neurotrophic factor (GDNF) is highly expressed both in neurons and astrocytes in injured tissues. Astrocytes support neurons by releasing neurotrophic factors including GDNF. It has been reported that various agents including cytokines such as interleukin (IL)-1beta induce GDNF mRNA expression and the release in astrocytes. However, the mechanism behind the GDNF synthesis and release remains unclear. Herein, we investigated the mechanisms of the IL-1beta-induced GDNF release from rat C6 glioma cells. IL-1beta time dependently stimulated GDNF release from C6 cells. IL-1beta induced the phosphorylation of inhibitor kappa B (IkappaB), p38 mitogen-activated protein (MAP) kinase, p44/p42 MAP kinase, stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) and signal transducer and activator of transcription (STAT) 3. The IL-1beta-stimulated levels of GDNF were suppressed by wedelolactone, an inhibitor of IkappaB kinase, SB203580, an inhibitor of p38 MAP kinase, PD98059, an inhibitor of MAP kinase kinase 1/2 or Janus family of tyrosine kinase (JAK) inhibitor I, an inhibitor of upstream kinase of STAT3. On the contrary, SP600125, an inhibitor of SAPK/JNK, failed to reduce the IL-1beta-effect. These results strongly suggest that IL-1beta stimulates GDNF release through the pathways of IkappaB-nuclear factor kappa B, p38 MAP kinase, p44/p42 MAP kinase and JAK-STAT3, but not through the SAPK/JNK pathway in glioma cells.

Comparative effects of ultra-short-acting beta1-blockers on voltage-gated tetrodotoxin-resistant Na+ channels in rat sensory neurons.

BACKGROUND AND OBJECTIVE: To examine a possible mechanism for their antinociceptive actions, we compared the effects of two clinically used ultra-short-acting beta1-blockers, landiolol and esmolol, on tetrodotoxin-resistant sodium (TTX-r Na) channels in rat dorsal root ganglion neurons, which are important for nociception. METHODS: In small (<30 microm) dorsal root ganglion neurons from Sprague-Dawley rats, recordings of whole-cell membrane currents were made using the patch-clamp technique. To examine the effects of landiolol and esmolol on TTX-r Na currents, whole-cell membrane Na currents were evoked every 10 s by stepping for 50 ms from a holding potential of -70 to -10 mV. Each drug was applied at stepwise-increased concentrations every 2 min. The voltage dependence of the steady-state inactivation of the TTX-r Na current was investigated by using a conventional double-pulse protocol. To test for use-dependent blockade of TTX-r Na channels by beta-blockers, trains of depolarizing pulses (to -10 from a holding potential of -70 mV) were applied at one of three frequencies (0.2, 5 or 20 Hz) in the absence or presence of drug (landiolol 8 mmol l, esmolol 140 micromol l). RESULTS: Esmolol blocked TTX-r Na currents in a dose-dependent and use-dependent manner, but a very high concentration of landiolol was required to block TTX-r Na channel activities. The half-maximal inhibitory concentrations (IC50) for the TTX-r Na current were (holding potential, -70 mV) landiolol 7.66 +/- 0.62 mmol l (n = 6) and esmolol 145 +/- 7.5 micromol l (n = 6), and the Hill coefficients were landiolol 1.06 +/- 0.09 (n = 6) and esmolol 0.96 +/- 0.05 (n = 6). CONCLUSION: Esmolol, but not landiolol, may have useful effects against pain related to TTX-r Na channel activity.

[Case of pulmonary edema and transient heart failure during difficult airway management].

Many kinds of side effects are likely to occur while managing difficult airway. This article describes a case of a man who fell into pulmonary edema and heart failure during the difficult airway management. He was to undergo arthroscopic surgery on his knee. At first, we planed spinal anesthesia but he took an antiplatelet drug (aspirin). Since we wanted to avoid the epidural hematoma, we chose general anesthesia. After induction of general anesthesia, positive pressure ventilation via face mask was possible, but laryngeal mask ventilation was impossible. Although tracheal intubation was attempted, we recognized that he had difficult airway. After some intubation trials, we decided to quit the operation and awoke the patients. Spontaneous breathing appeared soon, but the oxygenation was getting worse. We performed fiberoptic nasal intubation under spontaneous breathing. Although his blood pressure was quite high during intubation, after intubation the vasopressor was needed to maintain blood pressure. Ventilation with 100% O2 could not maintain the oxygenation well. Chest X-ray revealed the pulmonary edema. We presumed that hypertension associated with airway stimulation had caused acute pulmonary edema and heart failure resulting from diastolic dysfunction induced by increased catecholamine.

Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, inhibits muscarinic acetylcholine receptor-mediated activation of extracellular signal-regulated kinases in PC12 cells.

BACKGROUND: Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, is reported to have an antinociceptive effect by hyperpolarization through the K(+) channel. The activation of extracellular signal-regulated kinase (ERK), a family of mitogen-activated protein kinases, plays an important role in synaptic plasticity and noxious stimulation in the dorsal root ganglion, and spinal neurons have been reported to induce its activation. To understand the biological mechanisms of nicorandil, we examined the effects of nicorandil on muscarinic acetylcholine (ACh) receptor-mediated activation of ERK in a neuronal model cell, rat pheochromocytoma PC12 cells. METHODS: PC12 cells were stimulated with ACh in the presence or absence of nicorandil, and phosphorylation of ERK was examined by a Western blot analysis. We also examined the effects of nicorandil on the ERK activation induced by 4beta-phorbol 12-myristate 13-acetate, an activator of protein kinase C, or ionomycin, a calcium ionophore. Intracellular Ca(2+) increase was visualized in fluo-3-loaded PC12 cells using fluorescence microscopy. RESULTS: Nicorandil inhibited ACh-induced ERK activation in a concentration-dependent manner. The inhibition was abolished by glibenclamide, an adenosine triphosphate-sensitive potassium channel blocker. Nicorandil suppressed the ERK activation induced by ionomycin but not 4beta-phorbol 12-myristate 13-acetate. Pretreatment of PC12 cells with nicorandil reduced the intracellular Ca(2+) concentration stimulated by ACh. CONCLUSIONS: Nicorandil inhibits muscarinic activation of the ERK signaling pathway by reducing the intracellular Ca(2+) concentration.

[Postoperative epidural hematoma remote from the site of craniotomy for STA-MCA anastomosis].

We experienced a case in which the cause of acute brain swelling following resection of dura matter could not be recognized until the postoperative CT scan. A 30-year-old woman presented with a 4-year history of Moyamoya disease. Right hemiplegia developed a month before operation, so that the anti-platelet therapy was continued. At the end of dural resection the brain started to bulge and the brain swelling increased progressively. The patient was immediately placed on a head up position and received a rapid administration of mannitol for the treatment. The operator performed the echo examination for clarifying the cause of the brain swelling, but they could not find it. As the brain swelling slightly improved by the treatment, the surgery was performed continuously At the end of the operation the patient was moved for a CT scan and it showed mass effect caused by epidural hematoma over the left temporal region distant from the site of craniotomy. Evacuation of the hematoma was carried out urgently. At discharge, she was conscious and had no focal neurological deficits. The occurrence of the epidural hematoma is one of the reasons for unknown brain swelling during surgery. We strongly recommend that any sudden deterioration during the operation should be treated with emergency CT scan.

Rho-kinase inhibitor and nicotinamide adenine dinucleotide phosphate oxidase inhibitor prevent impairment of endothelium-dependent cerebral vasodilation by acute cigarette smoking in rats.

INTRODUCTION: We previously reported that acute cigarette smoking can cause a dysfunction of endothelium-dependent vasodilation in cerebral vessels, and that blocking the angiotensin II (Ang II) type 1 (AT1) receptor with valsartan prevented this impairment. Our aim was to investigate the effects of a Rho-kinase inhibitor (fasudil) and a Nicotinamide Adenine Dinucleotide PHosphate (NADPH) oxidase inhibitor (apocynin) on smoking-induced endothelial dysfunction in cerebral arterioles. METHOD: In Sprague-Dawley rats, we used a closed cranial window preparation to measure changes in pial vessel diameters following topical acetylcholine (ACh) before smoking. After one-minute smoking, we again examined the arteriolar responses to ACh. Finally, after intravenous fasudil or apocynin pre-treatment we re-examined the vasodilator responses to topical ACh (before and after cigarette smoking). RESULTS: Under control conditions, cerebral arterioles were dose-dependently dilated by topical ACh (10(-6) M and 10(-5) M). One hour after a one-minute smoking (1 mg-nicotine cigarette), 10(-5) M ACh constricted cerebral arterioles. However, one hour after a one-minute smoking, 10(-5) M ACh dilated cerebral pial arteries both in the fasudil pre-treatment and the apocynin pre-treatment groups, responses that were significantly different from those obtained without fasudil or apocynin pre-treatment. CONCLUSION: Thus, inhibition of Rho-kinase and NADPH oxidase activities may prevent the above smoking-induced impairment of endothelium-dependent vasodilation.

Alpha2 adrenoreceptor agonist regulates protein kinase C-induced heat shock protein 27 phosphorylation in C6 glioma cells.

Dexmedetomidine (Dexmd), a potent and highly specific alpha(2) adrenoreceptor agonist, is an efficient therapeutic agent for sedation. Dexmd has been recently reported to have a neuroprotective effect. Heat shock protein (HSP) 27, a low-molecular weight HSP has been shown to be expressed following cerebral ischemia in astrocytes but not in neurons. HSP27 expression is involved in ischemic tolerance of the brain. This study investigated the effect of Dexmd on HSP27 in rat C6 glioma cells. 12-O-tetradecanoylphorbol-13-actate (TPA), a direct activator of protein kinase C (PKC), stimulated the phosphorylation of HSP27 at Ser82, but not Ser15 in a time-dependent manner. Prostaglandin (PG) E(1) or PGE(2) which activates the adenylyl cyclase-cAMP system as well as forskolin and dibutyryl-cAMP, suppressed the TPA-induced phosphorylation of HSP27. Dexmd reversed the suppression of HSP27 phosphorylation by the adenylyl cyclase-cAMP system. Therefore, these results strongly suggest that Dexmd reverses the suppression of HSP27 phosphorylation by the adenylyl cyclase-cAMP system activation through the inhibition of its system in C6 cells. alpha(2) Adrenoreceptor agonists may therefore show a neuroprotective effect through the modification of HSP27 phosphorylation induced by PKC activation.