Cultivation and qPCR Detection of Pathogenic and Antibiotic-Resistant Bacterial Establishment in Naive Broiler Houses.

Conventional commercial broiler production involves the rearing of more than 20,000 broilers in a single confined space for approximately 6.5 wk. This environment is known for harboring pathogens and antibiotic-resistant bacteria, but studies have focused on previously established houses with mature litter microbial populations. In the current study, a set of three naive houses were followed from inception through 11 broiler flocks and monitored for ambient climatic conditions, bacterial pathogens, and antibiotic resistance. Within the first 3 wk of the first flock cycle, 100% of litter samples were positive for and , whereas was cultivation negative but PCR positive. Antibiotic resistance genes were ubiquitously distributed throughout the litter within the first flock, approaching 10 to 10 genomic units g. Preflock litter levels were approximately 10 CFU g for heterotrophic plate count bacteria, whereas midflock levels were >10 colony forming units (CFU) g; other indicators demonstrated similar increases. The influence of intrahouse sample location was minor. In all likelihood, given that preflock levels were negative for pathogens and antibiotic resistance genes and 4 to 5 Log lower than flock levels for indicators, incoming birds most likely provided the colonizing microbiome, although other sources were not ruled out. Most bacterial groups experienced a cyclical pattern of litter contamination seen in other studies, whereas microbial stabilization required approximately four flocks. This study represents a first-of-its-kind view into the time required for bacterial pathogens and antibiotic resistance to colonize and establish in naive broiler houses.

A new sampler for stratified lagoon chemical and microbiological assessments.

A sampler was needed for a spatial and temporal study of microbial and chemical stratification in a large swine manure lagoon that was known to contain zoonotic bacteria. Conventional samplers were limited to collections of surface water samples near the bank or required a manned boat. A new sampler was developed to allow simultaneous collection of multiple samples at different depths, up to 2.3 m, without a manned boat. The sampler was tethered for stability, used remote control (RC) for sample collection, and accommodated rapid replacement of sterile tubing modules and sample containers. The sampler comprised a PVC pontoon with acrylic deck and watertight enclosures, for a 12 VDC gearmotor, to operate the collection module, and vacuum system, to draw samples into reusable autoclavable tubing and 250-mL bottles. Although designed primarily for water samples, the sampler was easily modified to collect sludge. The sampler held a stable position during deployment, created minimal disturbance in the water column, and was readily cleaned and sanitized for transport. The sampler was field tested initially in a shallow fresh water lake and subsequently in a swine manure treatment lagoon. Analyses of water samples from the lagoon tests showed that chemical and bacterial levels, pH, and EC did not differ between 0.04, 0.47, and 1.0 m depths, but some chemical and bacterial levels differed between winter and spring collections. These results demonstrated the utility of the sampler and suggested that future manure lagoon studies employ fewer or different depths and more sampling dates.

Runoff quality from no-till cotton fertilized with broiler litter in subsurface bands.

Surface broadcast of broiler litter to no-till row crops exposes the litter and its nutrients to risks of loss in runoff water and volatilization and may limit the potential benefit of litter to the crops. Subsurface banding of litter could alleviate these risks. A field study was conducted in 2008 and 2009 on an upland Falkner silt loam soil to determine the effect of broiler litter placement on runoff nutrient losses from no-till cotton ( L.). Treatments included surface broadcast broiler litter applied manually, subsurface-banded litter applied by tractor-drawn equipment, and no broiler litter, all in combination with or without winter wheat ( L.) cover crop residue. Broiler litter rate was 5.6 Mg ha. The experimental design was a randomized complete block with a split-plot arrangement of treatments replicated three times. In 2008, simulated rainfall was used to generate runoff 27 d after litter application. Subsurface-banded litter reduced runoff total C, N, P, NH, NO, Cu, Zn and water-soluble P (WP) concentrations by 72, 64, 51, 49, 70, 36, 65, and 77%, respectively, compared with surface broadcast. The reductions were greater in 2009 where runoff occurred 1 d after litter application. Bacterial runoff was decreased by one log with subsurface-banded litter compared to surface broadcast. Except for C, NH, N, and WP, the presence of winter cover crop residue did not affect the load or runoff nutrient concentrations in either year. The results indicate that subsurface banding litter to no-till cotton substantially reduces nutrient and bacterial losses in runoff compared with surface broadcasting.

Broiler litter ammonia emissions near sidewalls, feeders, and waterers.

Ammonia (NH3) volatilized from broiler litter diminishes indoor air quality, which can potentially decrease bird productivity. Emissions of NH3 exhausted from broiler houses pose environmental concerns for ecosystem biodiversity, aquatic nutrient enrichment, and particulate formation in the atmosphere. Research was conducted sampling litter (rice hull base) in 3 tunnel-ventilated commercial broiler houses during wk 3 (mid-growout) of 6 flocks. The purpose was to assess NH3 generated near the sidewalls, waterers, and feeders. Litter samples (100 g) were placed in chambers receiving constant air flow. Boric acid (H3BO3) titration each 24 h for 4 d was used to determine NH3 volatilized from the samples. Litter located near waterers emitted the most cumulative NH3 (approximately 12.3 mg of N•kg of litter(-1)•h(-1)) with less NH3 associated with feeders and sidewalls (2.9 to 7.6 mg of N•kg of litter(-1)•h(-1)). Moisture content of litter samples was greatest at waterers (45%) followed by sidewalls (26%) and feeders (20%). In addition, litter pH at the sidewalls and feeders could be predicted by linear equations associated with the number of flocks on the litter. At the waterers, litter pH was differentiated based on the half of house where higher litter pH existed in the nonbrood half (8.55 vs. 8.13). The results indicate that controlling NH3 near watering lines to a level consistent with feeding lines and near the house wall could reduce NH3 generated by 38 to 77%. These findings support efforts for NH3 control at mid-growout, especially considering zone litter treatments near waterers and appropriate attention to waterer management.

The effect of poultry manure application rate and AlCl(3) treatment on bacterial fecal indicators in runoff.

Increasing costs associated with inorganic fertilizer have led to widespread use of broiler litter. Proper land application, typically limiting nutrient loss, is essential to protect surface water. This study was designed to evaluate litter-borne microbial runoff (heterotrophic plate count bacteria, staphylococci, Escherichia coli, enterococci, and Clostridium perfringens) while applying typical nutrient-control methods. Field studies were conducted in which plots with high and low litter rates, inorganic fertilizer, AlCl(3)-treated litter, and controls were rained on five times using a rain generator. Overall, microbial runoff from poultry litter applied plots was consistently greater (2-5 log(10) plot(-1)) than controls. No appreciable effect on microbial runoff was noted from variable litter application rate or AlCl(3) treatments, though rain event, not time, significantly affected runoff load. C. perfringens and staphylococci runoff were consistently associated with poultry litter application, during early rain events, while other indicators were unreliable. Large microbial runoff pulses were observed, ranging from 10(2) to 10(10) CFU plot(-1); however, only a small fraction of litter-borne microbes were recoverable in runoff. This study indicated that microbial runoff from litter-applied plots can be substantial, and that methods intended to reduce nutrient losses do not necessarily reduce microbial runoff.

Effect of surface incorporation of broiler litter applied to no-till cotton on runoff quality.

Surface application of broiler litter to no-till cotton could lead to degradation of water quality. Incorporation of broiler litter into the top surface soil (0.05 m) could alleviate this risk. A 2-yr field study was conducted on a silt loam upland soil to determine the effect of incorporation of broiler litter into the soil surface on nutrient and bacterial transport in runoff. The experimental design was a randomized complete block with four treatments and three replications. Treatments were (i) unfertilized control; (ii) surface-appliedbroiler litter at 7.8 Mg ha(-1) without incorporation; (iii) surface-applied broiler litter at 7.8 Mg ha(-1) with immediate incorporation; and (iv) inorganic fertilizer N (urea ammonium nitrate, 32% N) and inorganic fertilizer P (triple superphosphate) at the recommended rate. Phosphorus was surface appliedat 25 kg ha(-1) and N was injected at 101 kg ha(-1) into the soil using a commercial liquid fertilizer applicator. Runoff was collected from small runoff plots (2.4 m by 1.6 m) established at the bottom side of main plots (13.7 m by 6.0 m). Incorporation of broiler litter reduced total N (TN), NO3-N, water soluble P (WSP), and total P (TP) concentrations in runoffby 35, 25, 61, and 64%, respectively, and litter-associated bacteria by two to three orders of magnitude compared with unincorporated treatment. No significant difference in total suspended solids (TSS) in runoffwas obtained between incorporated and unincorporated treatments. Incorporation of broiler litter into the surface soil in the no-till system immediately after application minimized the potential risk for surface nutrient losses and bacteria transport in runoff.

Antibiotic resistant bacterial profiles of anaerobic swine lagoon effluent.

Although land application of swine (Sus scrofa) manure lagoon effluent is a common and effective method of disposal, the presence of antibiotic-resistant bacteria, both pathogenic and commensal can complicate already understood issues associated with its safe disposal. The aim of this study was to assess antibiotic resistance in swine lagoon bacteria from sow, nursery, and finisher farms in the southeastern United States. Effluents from 37 lagoons were assayed for the presence of Escherichia coli, Campylobacter, Listeria, and Salmonella. Antibiotic resistance profiles were determined by the Kirby-Bauer swab method for 12 antibiotics comprising eight classes. Statistical analyses indicated that farm type influenced the amount and type of resistance, with nurseries and sow farms ranking as most influential, perhaps due to use of more antibiotic treatments. Finisher farms tended to have the least amount of antibiotic class resistance, signaling an overall healthier market pig, and less therapeutic or prophylactic antibiotic use. Many bacterial isolates were resistant to penicillin, cephalosporin, and tetracycline class antibiotics, while nearly all were susceptible to quinolone antibiotics. It appeared that swine farm type had a significant association with the amount of resistance associated with bacterial genera sampled from the lagoons; nurseries contributed the largest amount of bacterial resistance.

Simple colorimetric microplate test of phage lysis in Salmonella enterica.

A simple microplate method, based on conversion of tetrazolium to formazan, was devised for rapidly assessing Salmonella survival after phage treatment. Results were easily interpretable. Monitoring with a microplate reader was useful, but not required. The method was used in defining phage-Salmonella interactions for selection of phage biocontrol cocktails.

Factors affecting iron sulfide-enhanced bacteriophage plaque assays in Salmonella.

Reaction of ferric ions with hydrogen sulfide (H(2)S) enhances contrast of phage plaques in H(2)S+ Salmonella, but contrast diminishes in weak H(2)S+ strains. H(2)S was affected by concentrations of peptones, glucose, ferric ammonium citrate (FAC) and sodium thiosulfate (ST), and by FAC:ST ratio, temperature, pH, air, and host strain. Increasing peptone levels was most important for improving contrast in weak H(2)S+ strains.

Enhanced contrast of bacteriophage plaques in Salmonella with ferric ammonium citrate and sodium thiosulfate (FACST) and tetrazolium red (TZR).

Visualization of bacteriophage plaques may be enhanced by addition of ferric ammonium citrate and sodium thiosulfate (FACST) or 2,3,5-triphenyltetrazolium chloride (tetrazolium red, TZR) to the soft agar layer of a traditional bacteriophage plaque assay. Background color from these reagents improved contrast between clear plaques and turbid host lawns in trypticase soy agar (TSA) plates. Enhancement by FACST is based on reaction with hydrogen sulfide gas (H2S) produced by some strains of bacteria and was tested here using H2S+ and H2S- strains of Salmonella enterica subsp. enterica with a bacteriophage (Podoviridae) isolated from swine lagoon effluent. Only the H2S+ strain produced dark brown-black color in FACST-amended agar. Both strains showed bright pinkish-red color in TZR-amended agar. Color intensity for both reagents decreased with decreasing concentrations of the reagents. Contrast in FACST-amended plates appeared greater than that with TZR, but diminished after 12 h, while contrast in TZR-amended plates remained constant. At the concentrations tested, neither reagent affected plaque counts in the H2S+ strain. The FACST should be useful in bacteriophage plaque assays with H2S+ strains of Salmonella and other H2S+ bacteria.

Isolation of salmonella bacteriophages from swine effluent lagoons.

Bacteriophages (phages) associated with Salmonella were collected from nine swine manure lagoons in Mississippi. Phages were isolated by an enrichment protocol or directly from effluent. For enrichment, chloroform-treated samples were filtered (0.22 mum) and selectively enriched by adding a cocktail of Salmonella strains in trypticase soy broth. After overnight incubation at 35 degrees C, chloroform was added and samples stored at 5 degrees C. Enriched samples were tested by double agar layer (DAL) plaque assay against individual Salmonella isolates. Phage titers of 2.9 x 10(8) to 2.1 x 10(9) plaque forming units (pfu) per mL were produced, but estimation of phage titers in lagoons was not possible. For direct isolation, effluent was clarified by centrifugation, filtered (0.22 microm), and used in DAL plaque assays to select single-plaque isolates for 15 Salmonella strains. Plaque counts varied among Salmonella strains and lagoons. The most sensitive strain for direct phage recovery was ATCC 13311. Phage titers estimated by direct isolation with ATCC 13311 ranged among lagoons from 12 to 148 pfu per mL. In limited host range tests, 66 isolates recovered by the enrichment protocol produced plaques only on Enteritidis and Typhimurium strains of Salmonella and none produced plaques on lagoon isolates of Citrobacter, Escherichia, Proteus, Providencia, or Serratia. Electron microscopy (EM) showed purified enrichment isolates had Podoviridae morphology (tailless 50-nm icosahedral heads with tail spikes). Electron microscopy of clarified concentrated effluent showed 5.5:1 tailless to tailed phages. The isolated phages have potential as typing reagents, specific indicators, and biocontrol agents of Salmonella.

Decay rates of zoonotic pathogens and viral surrogates in soils amended with biosolids and manures and comparison of qPCR and culture derived rates.

AIMS: The purpose of this study was to establish inactivation decay constants of foodborne pathogens and coliphage in clay and sandy soils for future "downstream" analyses such as quantitative microbial risk analysis and to compare cultivation-dependent and -independent (e.g. qPCR) methods. METHODS AND RESULTS: Salmonella enterica, Campylobacter jejuni, Listeria monocytogenes, Escherichia coli O157:H7, and Clostridium perfringens, were seeded together with MS2 and ØX174 phages, into three waste matrices (Class B biosolids, swine lagoon effluent, cattle manure), and phosphate buffered saline (PBS) as a control, and applied to two soil types (sandy loam, clay loam) using two management practices (incorporated, surface applied). S. enterica and L. monocytogenes inactivation rates were positively affected (e.g. slower rate) by solid wastes, while C. jejuni was quickly inactivated by day 7 regardless of waste type. The use of qPCR provided more conservative inactivation rates, with qPCR-based rates typically twice as slow as cultivation-based. The effect of soil type and management were less apparent as rates were variably affected. For instance, incorporation of waste negatively impacted (e.g. faster rate) inactivation of Salmonella when measured by qPCR, while the opposite was true when measured by cultivation. Inactivation rates were organism∗waste∗soil∗management dependent since the interactions of these main effects significantly affected most combinations. CONCLUSIONS: Class B biosolids and cattle manure most often slowed inactivation when measured by cultivation, but the complex interactions between variables and organism made sweeping conclusions difficult. On the contrary cultivation-independent inactivation rates were negatively affected by solid wastes. Inactivation rates developed by cultivation-dependent and -independent assays needs further scrutiny as interprerations can vary by orders of magnitude depending on the organism∗environment combination. SIGNIFICANCE AND IMPACT OF THE STUDY: This study compares decay rate data based on waste, soil, management and assay type which can be further used in risk assessments.

Using broiler litter and swine manure lagoon effluent in sawdust-based swine mortality composts: Effects on nutrients, bacteria, and gaseous emissions.

Disposition of mortalities challenges confined animal feeding operations (CAFOs), especially sow (farrowing) farms, which experience mortalities daily. Regulations and transportation costs may preclude incineration, landfill burial, and rendering; therefore, swine CAFOs in Mississippi in the Mid-South U.S. often compost mortalities. In this study, a farm-standard composting mix of sawdust (S) and water (W) was compared with mixes where N was supplied by broiler litter (L) and water was replaced with swine lagoon effluent (E). The objective was to assess the effects of these manure byproducts: 1) on nutrients and bacteria in composts destined for land application; and 2) on emissions of ammonia and greenhouse gases. Three replications of four mixes (SW, SLW, SE, SLE) were compared in microcosms comprising modified plastic recycling bins. The experiment was repeated three times in different seasons in one year. Mixes were compared for differences in temperature, water content, nutrients (C, N, P, K, Ca, Mg, Na, Mn, Fe, Cu, Zn), bacteria (Gram-, Gram+, Clostridium perfringens, Salmonella, Listeria, Escherichia coli), and emissions (NH3, CO2, CH4, N2O). Litter addition increased composting temperatures initially and after aerations; increased nutrient concentrations, except C, in start mixes and all except C and N, in finish mixes; increased Gram+ bacteria, Salmonella, and E. coli in start mixes, but only Gram+s in finish mixes; and increased emissions. Effluent addition increased early composting temperatures; had no effect on nutrients or bacteria, except increased C. perfringens in start, but not finish mixes; and had no effect on emissions. Nutrients in finish composts did not differ among mixes for N (average 3.3%), but litter composts had more P and K, and lower N:P than composts without litter. Improving mortality composting is of global importance as increasing livestock populations and intensive animal production systems require practical, safe, environmentally sound disposal of carcasses.

The use of antibodies targeted against the neurofilament subunits for the detection of diffuse axonal injury in humans.

Axonal injury is a common feature of human traumatic brain injury. Typically, damaged axons cannot be recognized unless a patient survives the injury by at least 10-12 hours (h). Limitations associated with the use of the traditional silver methods have been linked with this inability to recognize early posttraumatic reactive axonal change. Recently, we reported that antibodies targeting the neurofilament subunits proved useful in recognizing early traumatically induced axonal change in traumatically brain-injured animals. Accordingly, in the present communication, we employed antibodies to detect at the light microscopic level the 68 kD Nf-L and 170-200 kD Nf-H neurofilament subunits in head-injured patients who survived the traumatic event for periods ranging from 6 h to 59 days. Antibodies targeting all of the above-described subunits revealed a progression of reactive axonal change. Antibodies to the 68 kD subunit proved most useful, as they were not complicated by concomitant immunoreactivity in surrounding nuclei and/or dendritic and somatic elements. These immunocytochemical strategies revealed, at 6 h postinjury, focally swollen axons which appeared intact. By 12 h, this focal swelling had progressed to disconnection, with the immunoreactive swelling undergoing further expansion over 1 week postinjury. These findings demonstrate the utility of the previously described immunocytochemical strategies for detecting reactive axonal change in brain-injured humans, particularly in the early posttraumatic course. More importantly, these methods also demonstrate in humans that reactive axonal change is not necessarily caused by traumatically induced tearing.

Beneficial effects of the radioprotectant 21-aminosteroid U-74389G in a radiosurgery rat malignant glioma model.

PURPOSE: To evaluate the radioprotectant effects of the 21-aminosteroid U-74389G on the rat C6 glioma model after stereotactic radiosurgery. Because radiosurgery causes both tumor cytotoxicity, as well as regional brain edema, we hypothesized that this drug might exhibit advantageous or deleterious effects on healthy and neoplastic tissue. METHODS: Rats were implanted with 10(6) C6 glioma cells into the right frontal brain and randomized to a Control Group (n = 18), radiosurgery on Day 14 (50% isodose = 35 Gy) (n = 15), or radiosurgery preceded by a single 15 mg/kg intravenous dose of 21-aminosteroid (n = 27). All animals were killed by 90 days and evaluated for survival, tumor size, the presence or absence of regional parenchymal edema, or radiation-induced vasculopathy. RESULTS: After tumor implantation, median survival in the Control Group was 23 days. Significant improvements in median survival were noted after RS alone (median, 31 days; p = 0.02), and RS plus 21-aminosteroid (median, 59 days; p < 0.0001). In the Control Group, mean tumor diameter was 5.4 mm. After RS alone, the mean diameter was 3.2 mm (p = 0.002), and after RS plus 21-aminosteroid, 2.9 mm (p = 0.0002). In the Control Group, the tumor grew as a hypercellular, compact mass. Only 3 of 18 animals had peritumoral edema. In contrast, 7 of 15 animals in the RS group had evidence of edema (p = 0.006), but rats that received 21-aminosteroid showed no increase compared to controls (p = 0.38). Similarly, 6 of 15 animals that had radiosurgery alone showed evidence of vasculopathy (p = 0.005) compared to no animals in the control group and only 2 of 27 aminosteroid-treated animals. CONCLUSIONS: The 21-aminosteroid U-74389G exhibits a radioprotectant effect on normal brain tissue, but does not appear to protect the tumor in an in vivo rat radiosurgery model. We believe that the observed beneficial effects on healthy brain led to significant prolongation of animal survival; perhaps, by limiting the adverse effects of high-dose radiosurgery. This radioprotectant should now be evaluated in randomized clinical trials in patients with malignant brain tumors.

Improved ELISA conditions for detection of plant viruses.

Clover yellow vein virus (CYVV) and homologous antisera were used to test effects of time and temperature on enzyme-linked immunosorbent assay (ELISA) in polystyrene substrate plates. Replicated lattice square and Youden square experimental designs were used to measure and account for variation in absorption values associated with sample position within polystyrene plates. Adsorption of coating antibody to polystyrene was relatively rapid, reaching optimum assay efficiency in 1 h at 5 degrees C when applied at 2.5 microgram/ml. Binding of antigen and enzyme-linked antibody (conjugate) in their respective steps during ELISA was also rapid. Incubation of antigen and conjugate for 2 h each was adequate to enable detection of 20 ng CYVV in a 100 microliter sample, but longer incubation of either reactant improved results. At this virus concentration, reduction in antigen incubation time by one-half could be compensated by doubling the conjugate incubation time and vice versa. Incubation of conjugates at 5 degrees C rather than 30 degrees C increased final ELISA readings (A400nm) more than two-fold. Substrate hydrolysis followed classic first order kinetics at room temperature. Greater efficiency of late antisera in ELISA was demonstrated by comparison of antisera produced relatively early and late during a rabbit's immune response. Alfalfa mosaic virus and peanut stunt virus with their homologous antisera were used to test the effects of antigen and conjugate incubation times for optimum assay efficiency. The results of these time course experiments with both viruses were similar to those obtained with CYVV. These time and temperature effects on ELISA should be applicable to most rabbit serum-virus combinations.

Use of experimental designs with quantitative ELISA.

Precise use of enzyme-linked immunosorbent assay (ELISA) as a quantitative technique depends on repeatability of color development and its measurement. Variation in measured response among wells, within and among microtiter plates, often precludes such precision. For example, plates with all wells treated uniformly exhibited unacceptable optical density differences in excess of 0.35 and 0.25 O.D. U among row and column averages, respectively. Arrangement of samples on plates according to classical experimental designs, with compact blocking features and two-dimensional control over spatial patterns, provides a possible remedy. Analysis of variations over uniformly treated plates demonstrated the potential for increased precision when such designs are used instead of random arrangements. Retrospective analysis of more than 100 tests performed with various experimental designs confirmed that this potential was realized when using Youden square and lattice square designs. Several designs appropriate for microtiter plates are presented and their conduct described.

Simple risk predictions for arteriovenous malformation hemorrhage.

We present a simple risk prediction formula for arteriovenous malformation hemorrhage. Natural history studies have shown an annual risk of hemorrhage of 2 to 4% for patients with brain arteriovenous malformations. Although decision analysis programs and biostatistical models are available to predict long-term risks of hemorrhage, we hypothesized that there was varying knowledge regarding the use of such programs within the general neurosurgical community. To obtain information on the current use of risk data, we performed a survey of neurosurgeons at national meetings in 1988 and 1994. Neurosurgeons were asked to define the risk for arteriovenous malformation hemorrhage in the young adult patient over a 20- to 30-year period, given a 3 or 4% annual risk of hemorrhage. A wide range of answers was obtained (1-100% risk), and many different methods of calculation were used. The use of the multiplicative law of probability formula requires only knowledge of patient age and annual hemorrhage risk. Risk of hemorrhage = 1 - (risk of no hemorrhage) expected years of remaining life. The assumptions pertaining to this multiplicative formula include a constant yearly risk of hemorrhage and the independent behavior of all years of observation. We calculated the predictions of risk of hemorrhage across all age groups, as modified by published survival data. We think the use of this formula is justified by published natural history data across different ages and populations and that it is a simple and reasonable alternative to other methods of calculation.

Acute subdural hematoma caused by a ruptured giant intracavernous aneurysm: case report.

A case of a giant intracavernous carotid artery aneurysm that presented as an acute subdural hematoma is reported. The patient was initially treated unsuccessfully with endovascular aneurysmal embolization and subsequently underwent attempted microsurgical clipping with preservation of the parent artery. At operation, an angiogram showed occlusion of the parent vessel, and the aneurysm was trapped by occlusion of the internal carotid artery. The patient did well for 2 days postoperatively but then developed contralateral progressive hemiplegia and aphasia. Emergent subsequent exploration and middle cerebral artery embolectomy were performed, and the hemiplegia and aphasia resolved rapidly. At 2-year follow-up, the patient continues to do well. To our knowledge, this is the first reported case of a patient who survived an acute subdural hematoma caused by an intracavernous carotid artery aneurysm.

Microvascular decompression of the left lateral medulla oblongata for severe refractory neurogenic hypertension.

OBJECTIVE: To demonstrate that microvascular decompression of the left medulla oblongata is a safe and effective modality for treating elevated blood pressure in patients with severe medically refractory "essential" hypertension (HTN). METHODS: Twelve patients with medically intractable HTN with or without autonomic dysreflexia underwent microvascular decompression of the left rostral ventrolateral medulla oblongata. Causes such as pheochromocytoma, carcinoid syndrome, and renal disease were ruled out before surgery. Indications for surgery included systolic blood pressures greater than 180 mm Hg refractory to three or more medications, severe blood pressure lability, or medically resistant HTN at systolic pressures greater than 160 mm Hg associated with autonomic dysreflexia and/or magnetic resonance images demonstrating left medullary compression. The median age and follow-up duration were 51 years and 4.1 years, respectively. RESULTS: Ten of 12 patients experienced reductions in systolic blood pressure greater than 20 mm Hg. Of these 10 patients, pressure reductions were temporary (6 mo) in two. Seven of eight patients experienced improvement in blood pressure lability and/or autonomic dysreflexia, with five patients showing sustained improvements. CONCLUSION: Microvascular decompression of the left rostral ventrolateral medulla oblongata may be an effective treatment modality for patients suffering from severe HTN and/or autonomic dysreflexia refractory to medical management.