Protection against ischemia: a physiological function of the renin-angiotensin system.

The renin-angiotensin system (RAS) is involved in a complex mechanism that serves to preserve the blood supply to organs so that they can maintain cellular function. Angiotensin II exerts this effect, independently of the blood pressure generated, through two time-related events: a fast opening of the reserve collateral circulation and a much slower response of new vessel formation or angiogenesis. This effect is observed in rats with ligation of the abdominal aorta and in gerbils with abrupt or progressive unilateral carotid artery ligation. Inhibition of the angiotensin-converting enzyme (ACE) or the angiotensin II receptor represses this effect, and it appears that it is mediated through a non-AT1 receptor site of angiotensin II. Many tumors, both benign and malignant, express renin and angiotensin. It seems that the stimulating action of angiotensin II on angiogenesis could also be involved in preserving the blood supply to tumor cells. Administration of converting enzyme inhibitors increases survival and decreases tumor size in tumor-bearing rats. These observations support the hypothesis that the RAS, directly or indirectly, is involved in situations in which the restoration of blood supply is critical for the viability of cells and that it is present not only in normal but also in pathological conditions such as tumors. In view of the ubiquitous presence of renins and angiotensins, it is also likely to be involved in other conditions, such as inflammation, arthritis, diabetic retinopathy, and retrolental fibroplasia, among others in which angiogenesis is prominent. In addition, angiotensin II could be involved, through the counterbalance of the AT1 and AT2 receptors, in the rarefaction of blood vessels as an etiologic component of essential hypertension.

Synergistic action of genistein and cisplatin on growth inhibition and cytotoxicity of human medulloblastoma cells.

OBJECTIVE: Recent experimental data have shown that dietary soy isoflavones such as genistein can significantly suppress invasiveness and growth of a number of human malignancies. In this study we examined whether genistein, at a concentration typical of plasma levels following soy formula intake, in combination with cisplatin or vincristine exhibited an additive or synergistic inhibitory effect on the growth of medulloblastoma cells. METHODS: Three human medulloblastomas cell lines (HTB-186, CRL-8805 and MED-1) were treated with genistein at 6 microM, the maximum reported dietary plasma level in children, combined with cisplatin (0-10 microM) or vincristine (0-1 microM). Monolayer cell growth and cytotoxicity, as measured by colonigenic survival in soft agarose, were then compared in control and drug-treated cultures. Presence of apoptosis, using the DNA ladder assay and laser scanning cytometry, was investigated in all cell lines at those concentrations at which an enhancement of antiproliferative effect of cisplatin and vincristine in presence of genistein was observed. RESULTS: Genistein at 6 microM led to a 2.8-fold increase in the monolayer growth inhibitory effect of cisplatin (0.05 microM) in HTB-186 cells (p = 4.5 x 10(-4) by one-tailed t test). Genistein increased colonigenic survival inhibition of HTB-186 2.6-fold at the same cisplatin concentration (p = 1.5 x 10(-4)). Genistein caused a 1. 3-fold increase in antiproliferative effect of cisplatin (0.5 microM) in CRL-8805 cells (p = 3.1 x 10(-4)). Similarly the inhibition of colonigenic survival was enhanced 2.0-fold in CRL-8805 (p = 1.22 x 10(-5)). The addition of genistein to 0.5 microM cisplatin led to a 1.7-fold increase in monolayer growth inhibition and 2.4-fold increase in colonigenic survival inhibition of MED-1 cells (p = 8.3 x 10(-4) and p = 1.1 x 10(-4) respectively). These effects were primarily synergistic but also additive in nature. The combination of genistein and vincristine, as compared to vincristine alone, caused a minimal-to-modest increase in antiproliferative effect on medulloblastoma cells studied here. We were unable to detect apoptosis by two methodologies in any of the medulloblastoma lines when genistein was combined with cisplatin or vincristine. CONCLUSION: These results indicate that genistein at typical dietary plasma levels can significantly enhance the antiproliferative and cytotoxic action of cisplatin and, to a lesser extent, vincristine. The implication for treatment of medulloblastomas of early childhood may be a reduction in the chemotherapeutic dose recommendations of these agents and subsequently a decrease in the risk of treatment sequelae for these patients.

Inhibition of phospholipase C-gamma1 activation blocks glioma cell motility and invasion of fetal rat brain aggregates.

OBJECTIVE: Phospholipase C (PLC)-gamma is a cytosolic enzyme activated by several growth factor (GF) receptors (epidermal GF receptor [EGFR], platelet-derived GF receptor, and insulin-like GF 1 receptor), and its activation is associated with increased cell motility (but not cell proliferation) in nonglioma cell lines. Because up-regulated activation of EGFR has been consistently linked to poor patient survival in patients with glioblastoma multiforme (GBM) and because inhibition of EGFR activation by tyrosine kinase inhibitors prevents glioma infiltration in vitro, we hypothesized that inhibition of PLC-gamma activation would inhibit glioma cell invasiveness. METHODS: Our experimental model assesses tumor spheroid invasion of fetal rat brain spheroids by confocal microscopy. We treated U87 GBM spheroids, and those derived from a single patient, with the PLC inhibitor U73122. We also transfected rat C6 glioma cells with the PLCz complementary deoxyribonucleic acid coding for a dominant negative PLC-gamma1 src-homology-2/src-homology-3 peptide fragment, which blocks binding and activation of PLC-gamma1 by GF receptors. Two clones (C6F and C6E) were grown into spheroids and were tested for invasiveness in the spheroid model and for responsiveness to GFs in a standard in vitro motility assay. RESULTS: The infiltration rate of the patient GBM cell line overexpressing wild-type EGFR was reduced by 2 micromol/L U73122 from a slope (percent invasion/h) of 0.74+/-0.08 (with the inactive congener U73343) to 0.04+/-0.053 (P = 8 x 10(-7) by two-tailed t test, 92% reduction); the integral rate, another measure of invasion, was reduced from 49.7+/-13 percent-hours per hour to 13.6+/-12 (P = 0.002, 72% reduction). The U87 spheroid invasion rate was reduced by 0.5 micromol/L U73122 from 46.7+/-8.5 percent-hours per hour to 11.2+/-4.6 (P = 3 x 10(-5)); the slope decreased from 1.7+/-0.41 percent per hour to 0.35+/-0.14 (P = 0.0001). The C6F and C6E clones demonstrated attachment to and "surrounding" of the fetal rat brain aggregate but no true invasion by confocal or light microscopy. PLCz blocked the motility response to epidermal GF, platelet-derived GF, and insulin-like GF. There was a significant decrease in PLC-gamma1-associated tyrosine phosphorylation. CONCLUSION: These results support a key role for PLC-gamma activation as a common postreceptor pathway for GF-induced tumor infiltration and further identify PLC-gamma1 as a possible target for anti-invasive therapy for GBMs.

Brain tumor invasion rate measured in vitro does not correlate with Ki-67 expression.

The need for more accurate prediction of the biological behavior of brain tumors has lead to the use of immunohistochemical methods for assessment of proliferating cell nuclear antigens such as Ki-67. There is a variable association of glioma Ki-67 labeling index with patient survival. Brain invasion by individual tumor cells also defines biological aggressiveness, and can be assessed in vitro. Further, proliferation and migration seem to be mutually exclusive behaviors for a given cell at a point in time. We studied the relationship between Ki-67 labeling index and invasion rate in a group of 10 gliomas, and 2 meningiomas. Human tumor spheroids obtained from operative specimen were co-cultured with fetal rat brain aggregates, and invasion rate was measured by confocal microscopic observation. There was no correlation between two measures of invasion and Ki-67 labeling. This finding supports the dichotomous nature of glioma proliferation and invasion, and may in part explain the limited usefulness of proliferation marker labeling.

Percutaneous access to the anterior spinal canal through a cervical disk.

We describe a CT-guided percutaneous technique for aspiration of an anterior intraspinal fluid collection through a cervical disk. The approach is identical to that of cervical diskography or percutaneous cervical diskectomy, with intentional placement of the needle tip in the spinal canal. This procedure had no adverse effects and avoided an open operation to exclude spinal cord compression.

Inhibition of glioma invasion of fetal brain aggregates.

Glioblastoma multiforme is a malignant primary brain tumor associated with short patient survival in part because of the ability of individual cells to migrate significant distances into brain tissue. Invasion is a difficult process to model, because many such human tumors do not invade immunologically competent animal tissue, tumors grown in animals do not invade human tissue, and relevant human tissue substrates are not easily reproduced. We discuss models for examining invasion in vitro, and in particular review work using the tumor spheroid--fetal rat brain aggregate co-culture model, assessed with confocal microscopy and four-dimensional imaging. Quantitation of invasion in this model is discussed, as well as the invasion-inhibitory properties of tyrosine kinase (TK) inhibitors. The effects of receptor-specific tyrphostins strongly support a dominant role for Epidermal Growth Factor Receptor activation in this process and show that invasion can be effectively inhibited at much lower concentrations of TK inhibitors than is necessary for growth suppression. Inhibition of activation of the purported growth factor receptor second messenger phospholipase C- gamma 1, by pharmacological means and gene transfection, also profoundly inhibits the invasive properties of human glioblastoma and rat C6 glioma cells. We have assessed invasiveness in several human tumor specimens, which may provide information relative to prognosis and recurrence risk. Our data supports the concept of differential control of invasion and proliferation, and points to possible strategies for anti-invasive therapy for glioblastoma multiforme.

Four-dimensional analysis of human brain tumor spheroid invasion into fetal rat brain aggregates using confocal scanning laser microscopy.

The advent of confocal microscopy and fluorescence probes has made possible the routine visualization of the complex three-dimensional structures of thick fixed or live specimens. Four-dimensional (4-D) imaging of biological specimens (three-dimensional image reconstruction of the same living sample at different time points), remains a seldom-used application of confocal microscopy. In the present study we used 4-D imaging techniques to quantitate the invasion of human brain tumor spheroids into fetal rat brain aggregates (FRBAs), using the vital fluorescence membrane dyes, 3, 3'-Dioctadecyloxacarbocyanine perchlorate (DiO) and 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI) as visualization probes. We found invasion patterns similar to the in vivo behavior of these tumors in the brain. Glioblastoma spheroids showed diffuse and circumscribed infiltration accompanied by cystic degeneration or necrosis of FRBAs. Spheroids from cerebral metastasis, however, showed a sharp delimitation of the invasive margin, and did not penetrate the FRBA beyond a depth of 55 microns. Measured rates of glioblastoma invasion varied with the tumor specimens examined. The slopes of the mid-portions of plots of % infiltration vs. time (hours) for four glioblastoma cell lines were 1.7 +/- 0.21 (SD), 0.67 +/- 0.11, 1.4 +/- 0.22 and 1.3 +/- 0.18. We conclude that confocal microscopy with vital fluorescence probes is a practical method that allows for close monitoring and quantitation of the process of invasion in live tissue preparations, and may be used for assessing the in vitro effects of various tumor treatments.

Weakness of sympathetic neural control of human pial compared with superficial temporal arteries reflects low innervation density and poor sympathetic responsiveness.

BACKGROUND AND PURPOSE: The primary goal of these studies was to understand and investigate the capacity of perivascular nerves to influence the tone of human pial arteries and to compare them with other human cephalic arteries, the superficial temporal and middle meningeal. METHODS: Responses to electrical activation of intramural nerves and related features of fresh segments of human cephalic arteries-the pial (PA; 478+/-34 microm ID), middle meningeal (MMA; 540+/-41 microm ID), and superficial temporal (STA; 639+/-49 microm ID)-obtained from patients aged 15 to 82 years during surgical procedures were studied on a resistance artery myograph. RESULTS: The PA segment responses to electrical nerve activation and to norepinephrine (NE; 10[-5] mol/L) were 1% and 21% of tissue maximum, respectively, compared with 6% and 34% for the MMA and 14% and 90% for the STA. Tissue maximum was defined as the force increase to 127 mmol/L KCl plus arginine vasopressin (1 microm). All arteries dilated well to acetylcholine. Possible explanations for the PA marginal neurogenic responses were assessed. NE ED50 was 5.4+/-2.2 X 10(-7) mol/L and did not vary with age or diameter. NE responsiveness did not increase in vessels with spontaneous or raised potassium-induced tone. Relaxation to isoproterenol was variable and propranolol did not increase the neurogenic response. Neither N(G)-monomethyl-L-arginine, N(G)-nitro-L-arginine methyl ester, endothelium removal, nor indomethacin consistently influenced the contractions to NE or neurogenic reactivity. The weak PA neurogenic response is in keeping with its poor innervation. As determined by catecholamine histofluorescence, innervation in the PA is sparse, with density increasing in the order PA, MMA, and STA. The incidence of nerve structures in the PA adventitio-medial junction was only 3% of those in the STA, and these were situated more than 3 microm from the closest smooth muscle cell. CONCLUSIONS: We conclude that the weak neurogenic response of adult human pial artery reflects its poor innervation and responsiveness to NE, implying that these features are not important in the regulation of its diameter.

Diameter dependence of myogenic tone of human pial arteries. Possible relation to distensibility.

BACKGROUND AND PURPOSE: Responses to changes in intraluminal pressure of isolated human pial arteries (200 to 1200 microns i.d.) obtained from patients undergoing neurosurgery were measured. METHODS: The vessels were cannulated and pressurized (60 mm Hg); vascular diameter and intraluminal pressure were recorded simultaneously. After spontaneous development of steady state tone, intraluminal pressure was changed to both higher and lower levels in random sequence. RESULTS: Human pial arteries exhibited myogenic responses and maintained their diameter over the pressure range of 20 to 100 mm Hg. The level of myogenic tone observed at 30 mm Hg did not vary significantly with artery diameter. In contrast, at 60 and 90 mm Hg, the extent of myogenic tone increased as the diameter decreased (up to 70% to 80% of maximum in 200-microns i.d. arteries). The arteries contracted to KCl 30 mmol/L, norepinephrine 1 mumol/L, and vasopressin 0.1 mumol/L and relaxed to acetylcholine 3 mumol/L. The extent of these responses did not vary with the diameter of the artery. Arterial distensibility, represented by the slope of the tangent of the passive pressure-diameter curve at lower pressures (5 to 50 mm Hg), increased as arteries became smaller. This is consistent with the possibility that the level of myogenic tone is related to vessel distensibility. Human omental arteries of comparable size did not develop myogenic tone but contracted to KCl and norepinephrine and relaxed to acetylcholine to an extent similar to pial arteries. CONCLUSIONS: There is a specific gradient of myogenic responsiveness in human pial arteries that varies inversely with their diameter. This tone does not develop in all vascular beds. These levels of tone in the pial circulation would be expected to be of profound functional significance by allowing blood flow to vary widely.

Localization of CD44 at the invasive margin of glioblastomas by immunoelectron microscopy.

Glioblastoma multiforme is a highly invasive primary brain tumor, which is known to strongly express the CD44 cell adhesion receptor. A number of experimental studies suggest that the interaction of this receptor with extracellular matrix (ECM) proteins such as hyaluronic acid may in part mediate human glioma cell adhesion and invasion of brain tissue. Although the expression of CD44 and its spliced variants in brain tumors have been extensively studied, there have been no reports localizing its expression to the invasive margin of the tumor. The authors used immunoelectron microscopy to investigate the expression patterns of CD44 in an in vitro organotypic invasion assay. Tumor spheroids initiated from the U373 MG human glioblastoma line were confronted with fetal rat brain aggregates in a spheroid coculture system. The CD44 expression appeared at the interface between glioblastoma tumor spheroids and brain tissue, as well as in the spheroid itself. CD44 immunoreactivity was not detectable in mature 21-day fetal brain aggregates. The findings provide direct evidence that CD44 is expressed at the confrontational invasive border between glioblastomas and brain tissue, further supporting its role in glioma cell-ECM recognition and attachment.

A mathematical model of the intracranial system including autoregulation.

Cerebral autoregulation plays an important role in the dynamic processes of intracranial physiology. This work develops a four-compartment, lumped-parameter model for the interactions of intracranial pressures, volumes, and flows as a test bed for examining the consistent inclusion of explicit autoregulation in mathematical models of the intracranial system. It is hypothesized that autoregulation of the blood supply from the arterioles to the capillary bed can be modeled by allowing the flow resistance at the interface of the artery and capillary compartments in the model to be a function of pressure rather than a constant. The functional dependence on pressure of this resistance parameter is not specified in advance, but emerges naturally from the assumed relationship between pressure differences and flows. Results show that a constant flow from the artery to the capillary compartment can be maintained by a flow resistance which is resistance which is directly proportional to the pressure difference between these two compartments. Oscillatory flow is reestablished in the model at the capillary-cerebrospinal fluid and capillary-venous interfaces.

Inhibition of epidermal growth factor receptor-associated tyrosine kinase blocks glioblastoma invasion of the brain.

OBJECTIVE: Glioblastoma multiforme is a malignant primary brain tumor associated with short patient survival despite aggressive treatment, in part because of its propensity to aggressively infiltrate into brain tissue. Glioblastoma multiforme is also unique because it is the only nonepithelial human tumor for which excessive activation of epidermal growth factor receptor (EGFR) has been consistently linked to tumor growth and patient survival, and EGFR activation promotes glioblastoma multiforme infiltration in vitro. METHODS: Cocultures of human glioblastoma spheroids (derived from three separate patients) and fetal rat brain aggregates were examined for infiltration using confocal microscopy, in the presence of 0 to 100 mumol/L genistein, a tyrosine kinase (TK) inhibitor, and 3 mumol/L tyrphostin A25, a specific EGFR-TK inhibitor. RESULTS: Infiltration (not attachment) was completely inhibited by genistein at 10 mumol/L, the IC20 for monolayer growth inhibition in two cell lines. Tyrphostin A25 at 3 mumol/L (the IC20 for monolayers) reduced invasion in a third cell line from 38.8 +/- 6.1% invasion-hour per hour (n = 5) to 2.9 +/- 1.2% invasion-hour per hour (n = 6) (P = 0.0002, two-tailed t test, 93% inhibition), and from 0.54 +/- 0.065% per hour (slope) to 0.028 +/- 0.018% per hour (P = 0.00001, 95% inhibition). Maximal percent invasion was reduced from 100 +/- 0 to 7.4 +/- 5.6% of the fetal rat brain aggregate. No change was detected in EGFR-associated tyrosine phosphorylation at those doses in monolayers by 32P immunolabeling, consistent with the known effects of low concentrations of TK inhibitors. An increase in expression of wild-type and truncated EGFR was demonstrated by Western blotting. Invasion was equally well inhibited by a monoclonal antibody to the high-affinity ligand binding domain of EGFR and not by antibody to an inactive domain. CONCLUSION: Our observations support the role of EGFR activation as a determinant by which glioblastoma invades normal brain tissue, and we show that invasion can be effectively inhibited at much lower concentrations of TK inhibitors than are necessary for growth suppression.

Role of Ca(2+)-activated K+ channels in the regulation of membrane potential and tone of smooth muscle in human pial arteries.

Smooth muscle cells (SMCs) in 58% of human pial arteries obtained during surgery showed no spontaneous contractions and displayed a stable resting membrane potential (MP) of -54.7 +/- 1.5 mV. Those that exhibited periodic spontaneous contractions associated with periodic depolarization and generation of spontaneous action potentials (APs) had a less negative MP of -43.1 +/- 0.5 mV (42%). Inhibition of calcium-activated potassium (KCa) channels in the silent arteries by charybdotoxin (CTX) and tetraethylammonium ions (TEA) induced dose-dependent depolarization, AP generation, and contraction. TEA and CTX enhanced the spontaneous depolarization and force in arteries that exhibited spontaneous activity. They also prolonged the spontaneous APs up to several times and increased their upstroke amplitude. Both TEA and CTX failed to produce significant depolarization in arteries treated with nifedipine. It is concluded that KCa channels are important regulators of human pial artery SMC resting MP and tone. They are also involved in the control of AP amplitude and duration and the associated contractions. These data suggest that alterations in the activity of SMC KCa channels could be responsible for the appearance of spontaneous activity in human pial arteries in vitro and that impaired function of these channels might be related to vasospastic phenomena in human cerebral circulation.

Suppression of plasminogen activator inhibitor-1 release from human cerebral endothelium by plasminogen activators. A factor potentially predisposing to intracranial bleeding.

BACKGROUND: Intracranial bleeding is the most catastrophic potential complication of treatment with thrombolytic agents. To identify potential factors that may contribute to this problem, we characterized elaboration by human brain endothelial cells of plasminogen activator inhibitor-1 (PAI-1) and measured PAI-1 mRNA levels. METHODS AND RESULTS: When human cerebral microvascular endothelial cells (HCMEC), pial arterial endothelial cells, and middle meningeal arterial endothelial cells were exposed to 10 to 1000 ng/mL recombinant tissue-type plasminogen activator (RTPA), urokinase-type plasminogen activator (UPA), or streptokinase/ plasminogen (37 U streptokinase plus 2 mumol/L plasminogen) for 24 hours, they exhibited concentration-dependent decreases in elaboration of PAI-1 of 65 +/- 3%, 48 +/- 3%, and 59 +/- 8%. UPA and streptokinase/plasminogen elicited decreases of 33 +/- 8% and 35 +/- 4%, respectively, that were specific with respect to the protease agonists as to total protein synthesis and cell type; ie, neither human umbilical vein endothelial cells nor cerebral pericytes exhibited inhibition of PAI-1 elaboration. No decrease in HCMEC PAI-1 elaboration was induced by coagulation factor XB (10 nmol/L). A 2.7 +/- 0.5-fold increase was induced by alpha-thrombin (10 nmol/L). PAI-1 secretion from HCMEC decreased within 4 hours of exposure to 100 ng/mL RTPA. In HCMEC exposed to RTPA for 8 hours, PAI-1 mRNA decreased from 176 +/- 20 to 43 +/- 2.2 pg/microgram RNA. CONCLUSIONS: These results indicate that brain endothelial cells exposed to RTPA exhibit paradoxically diminished elaboration of PAI-1. This property may render brain vasculature vulnerable to attack by serine proteases, thereby predisposing to injury and initiating an underlying subsequent intracerebral hemorrhage in patients given plasminogen activators for treatment of coronary thrombosis.

Cost and outcome analysis.

The analysis of cost issues has become increasingly important in all fields of medicine. Understanding these economic analyses can make providers more cognizant of the ultimate health, economic, and social outcomes of their treatment decisions. The methodology of cost studies and the surgical costs of treatment of intracranial metastatic tumors warrant review. Costs of surgical and radiosurgical treatment are in the range of that for the care of other serious illnesses, but comparison of the available options is still sensitive to assumptions, and open to varied interpretations.

Alpha-thrombin stimulates urokinase production and DNA synthesis in cultured human cerebral microvascular endothelial cells.

alpha-Thrombin regulation of endothelial cell (EC) fibrinolysis has been documented by using endothelia derived from a number of anatomic locations but not with those derived from the human cerebral vasculature. In the present study, the fibrinolytic properties of human cerebral microvascular ECs and their regulation by alpha-thrombin are delineated and contrasted with those of human umbilical vein and foreskin microvascular ECs. In cerebral ECs, alpha-thrombin elicited a unique dose-dependent increase in urokinase production and DNA synthesis. Maximal stimulation, observed with 10 nmol/L alpha-thrombin, resulted in a 30- to 50-fold increase in urokinase production and a concomitant fourfold increase in DNA synthesis; the increase in urokinase was reflected in higher steady-state levels of urokinase mRNA. The major urokinase product secreted is the single-chain form of the enzyme. No effect was observed with the addition of other proteases or catalytically inactive variants of alpha-thrombin. A thrombin receptor agonist peptide upregulated urokinase production but had no effect on DNA synthesis, suggesting that fibrinolysis is mediated by the thrombin receptor but that proliferation is regulated by a different pathway. These findings suggest the possibility that the cerebral microvasculature may be a specialized region of the vascular system in which urokinase-type plasminogen activator, not tissue-type plasminogen activator, is the key catalyst of fibrin lysis when the brain responds to thrombotic events and that alpha-thrombin may regulate repair of the cerebral microvascular system.

Normal pressure hydrocephalus: an analysis of aetiology and response to shunting based on mathematical modeling.

The dynamics which maintain the state of enlarged cerebral ventricles and normal intracranial pressures (normal pressure hydrocephalus) are not completely understood, making the response to cerebrospinal fluid diversion difficult to predict. Using our previously described mathematical model of intracranial physiology which allows nonlinear relationships of pressure, volume, and flow in 7 distinct compartments, we desired to determine factors which could be responsible for the development and maintenance of the steady state of normal pressure hydrocephalus. Using typical starting values for CSF volume, pressure, and flow, the model indicates that this condition cannot be sustained, in spite of high CSF outflow resistance, unless capillary flow resistance is elevated. This condition can be the result of arterial hypertension. The additional modeling of a CSF diversion device demonstrates predicted time courses for ventricular size reduction which are consistent with clinical observations. We conclude that certain vascular conditions may allow for the maintenance of an enlarged ventricular size, and that mathematical modeling can assist in identifying factors for clinical study that may maintain normal pressure hydrocephalus even after treatment by CSF diversion.

Sublethal percussion trauma in vitro causes a persisting derangement in the nonthrombogenic properties of brain endothelial cells.

The delivery of a blow to the head represents a transfer of energy, part of which manifests itself as a short-lived pressure change within the skull. An in vitro model was developed to test whether cerebral endothelial cell hemostatic function is altered with exposure to this type of pressure event. Human cerebral microvascular endothelium (HCME) cells were subjected to rapid (2-5 msec) changes in pressure (delta atmosphere = 1.2-10), the sublethal range defined (delta atmosphere < or = 6.5), and the nonthrombogenic status of sublethally percussed HCME cells assessed using the adherence of alpha-thrombin activated platelets as an indicator. The HCME cells had lost their normal capacity to suppress adherence of activated platelets when evaluated 1 hour or 24 hours after percussion. Adherence of activated platelets to percussed HCME cells was blocked by the addition of PGI2, an inhibitor of platelet adherence, when evaluated at 1 hour but not 24 hours after percussion, indicating that percussed HCME cells were undergoing further derangement of their nonthrombogenic mechanisms. Percussed HCME cells cultured for 24 hours in medium containing scavengers of oxygen free radicals recovered their capacity to block platelet adherence. We conclude that sublethal percussion immediately compromises the nonthrombogenic character of HCME cells and initiates the development of a persisting prothrombotic state in HCME cells. This derangement appears linked to increased production of reactive oxygen species by percussed HCME cells.

Cost and survival analysis of metastatic cerebral tumors treated by resection and radiation.

The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)