Malignant Edema Research Articles

Ultrasonic evaluation of pathological brain perfusion in acute stroke using second harmonic imaging

OBJECTIVETo evaluate the use of transient response second harmonic imaging (HI) by means of ultrasound to assess abnormalities of cerebral echo contrast agent enhancement in patients with acute stroke.METHODSThe study...

Detection and characterization of Clostridium species in soil of Zambia

In the retrospective study of soil-borne diseases of cattle in Zambia, malignant edema and blackquarter were widespread. One hundred and sixty-five cases with malignant edema and 103 cases with blackquarter were reported between 1985 and 1997. It was found that specific soil-conditions associate the emergence of the soil-borne diseases. Soil samples from five areas in Zambia were examined for the presence of genus Clostridium. Direct immuno-fluorescent assay (IFA) examination showed that C. septicum, C. novyi and C. chauvoei were detected in the soil of specific areas in Zambia, respectively. Causal organisms such as C. perfringens were isolated from the soil samples. The information of area-specific distribution of Clositridium species may give an efficient program in protecting cattle and man.

Is decompressive craniectomy for acute cerebral infarction of any benefit?

BACKGROUND Acute occlusion of the major cerebral arteries results in ischaemic changes to the brain, without time for reperfusion by the collateral circulation. The subsequent cellular events lead to a breakdown of the blood-brain barrier, causing malignant cerebral edema manifested clinically by a rapid neurological deterioration. The aim of this study was to determine the value of surgical decompression in patients who present with acute cerebral infarction. METHODS Retrospective review of patients with deteriorating consciousness level from massive cerebral ischemia and secondary edema, treated by decompressive craniectomy. RESULTS There were 10 patients over a 2-year period from 1997–99, consisting of seven male and three female patients (mean age 47.56 years) with a mean preoperative Glasgow Coma Scale (GCS) score of 6/15. Three patients had dominant middle cerebral artery (MCA) infarction, four had nondominant MCA infarction, one had posterior cerebral artery infarction, and the remaining two had cerebellar infarction. At a mean follow-up period of 7 months, two patients had died (20% mortality), four patients (40%) were vegetative or severely disabled, and the remaining four patients (40%) had mild disability or good outcome. Favorable prognostic factors were younger age (less than 50 years) and good initial GCS score (14 or better). CONCLUSION Decompressive craniectomy in the setting of acute brain swelling from cerebral infarction is a life-saving procedure and should be considered in younger patients who have a rapidly deteriorating neurologic status.

Loss of Recent Memory After Bilateral Hippocampal Lesions

Loss of Recent Memory After Bilateral Hippocampal Lesions

Rapid and direct detection of clostridium chauvoei by PCR of the 16S-23S rDNA spacer region and partial 23S rDNA sequences.

Clostridium chauvoei causes blackleg, which is difficult to distinguish from the causative clostridia of malignant edema. Therefore, a single-step PCR system was developed for specific detection of C. chauvoei DNA using primers derived from the 16S-23S rDNA spacer region and partial 23S rDNA sequences. The specificity of the single-step PCR system was demonstrated by testing 37 strains of clostridia and 3 strains of other genera. A 509 bp PCR product, which is a C. choauvoei-specific PCR product, could be amplified from all of the C. chauvoei strains tested, but not from the other strains. Moreover, this single-step PCR system specifically detected C. chauvoei DNA in samples of muscle from mice 24 hr after inoculation with 100 spores of C. chauvoei, and in clinical materials from a cow affected with blackleg. These results suggest that our single-step PCR system may be useful for direct detection of C. chauvoei in culture and in clinical materials from animals affected with blackleg.

Intraoperative radiotherapy (IORT) for high grade glioma of the brain — Treatment planning, dose verification, and results

Introduction: Since May 1992, feasibility, perioperative morbidity, early and long term sequelae as well as survival times following intraoperative radiotherapy are being examined. From our experience, the determination of the correct beam angle and electron energy is difficult by clinical means alone. Therefore, we devised a method for exact pretreatment planning and post-treatment dose verification. Materials and Methods: From May 1992 to October 1998, 50 patients with malignant gliomas of the brain were treated with IORT at our institution, 47 of which were evaluable at the time of analysis. 31 patients had a primary brain tumor, and 16 patients had recurrent tumors. The histological tumor types were distributed as fol-lows: glioma grade Ill (n = 22), and glioblastoma (n = 25). Treatment was carried out as 20 or 25 Gy electron-beam IORT (14 or 18 MeV), followed by 60 Gy postoperative radiation in not previously irradiated patients. The craniotomy was measured in all three dimensions, and the optimal beam angle and the depth of the tumour bed were determined using a neuronavigation system. Afterwards, computerized quality control was carried out by reconstruction of the beam angle and the use of a standard treatment planning system (CadPlan). Results: Perioperative complications were not increased (2 infections, 1 lethal haemorrhage and 1 malignant edema). 21/22 patients with increased brain pressure showed an improvement. Aphasia, hemiparesis, hemianopsia, psychosyndrom, gyrus angularis syndrom and convulsions were markedly reduced. i-year sutvival for all patients was 54%, 2-year survival 14%. Median survival was 12.5 months (glioma Ill: 13.5 months, glioblastoma IV: 11 months). Median time to progression was 7 months. The only prognostic factor was tumour grade (p = 0.04). Extent of resection, tumour size, age, KPI, and treatment had no significant influence. Conclusion: By using X-ray verification films, computerized quality control can be carried out after electron IORT. This way we could show that the neuronavigation method of pretreatment planning yields useful results. Side effects were not increased. Most tumour-associated symptoms could be alleviated. Compared to literature, median survival could be slightly improved.

Detection of neutralizing antibodies against alpha-toxin of different Clostridium septicum strains in cell culture.

Clostridium septicum, a ubiquitious organism, is the pathogen which causes the classical malignant edema after injuries. Because of its strong cytotoxic alpha-toxin, infections are often lethal. To prevent losses in animals, vaccination with alpha-toxoid vaccines is carried out. Quality control of the vaccines is done by a neutralization test in mice. A cytotoxin test and as an alternative method to detect neutralizing antibodies, a cytotoxin inhibition test was standardized. In the studies, alpha-toxin of the C. septicum reference strain (NC 547) from the National Collection of Type Cultures was compared with alpha-toxin of a field strain from an outbreak in Germany. Sera from five heterologous polyvalent and three monovalent vaccines from eight rabbit groups were available. Each vaccination had been carried out according to the procedure of the German Pharmacopoeia. In three out of the five sera of the groups vaccinated with the heterologous polyvalent vaccine, cytotoxin neutralizing antibodies were detected. High antibody titers were observed in sera of rabbits vaccinated with a vaccine of strain NC 547, lower titers in the sera of rabbits vaccinated with a vaccine of the field strain. No cytotoxin neutralizing antibodies could be found in the sera of rabbits vaccinated with the monovalent C. chauvoei vaccine. The toxins of all strains showed the same ranking of the vaccines. Vaccines which caused high antibody titers in the animals were detected by all toxins as such, as well as vaccines which had medium or low antibody inducing capacity. The results were independent of the C. septicum strain used for the production of alpha-toxin.

Detection of neutralizing antibodies against α-toxin of different Clostridium septicum strains in cell culture

Clostridium septicum, a ubiquitious organism, is the pathogen which causes the classical malignant edema after injuries. Because of its strong cytotoxic α-toxin, infections are often lethal. To prevent losses in animals, vaccination with α-toxoid vaccines is carried out. Quality control of the vaccines is done by a neutralization test in mice. A cytotoxin test and as an alternative method to detect neutralizing antibodies, a cytotoxin inhibition test was standardized. In the studies, α-toxin of the C. septicum reference strain (NC 547) from the National Collection of Type Cultures was compared with α-toxin of a field strain from an outbreak in Germany. Sera from five heterologous polyvalent and three monovalent vaccines from eight rabbit groups were available. Each vaccination had been carried out according to the procedure of the German Pharmacopoeia. In three out of the five sera of the groups vaccinated with the heterologous polyvalent vaccine, cytotoxin neutralizing antibodies were detected. High antibody titers were observed in sera of rabbits vaccinated with a vaccine of strain NC 547, lower titers in the sera of rabbits vaccinated with a vaccine of the field strain. No cytotoxin neutralizing antibodies could be found in the sera of rabbits vaccinated with the monovalent C. chauvoei vaccine. The toxins of all strains showed the same ranking of the vaccines. Vaccines which caused high antibody titers in the animals were detected by all toxins as such, as well as vaccines which had medium or low antibody inducing capacity. The results were independent of the C. septicum strain used for the production of α-toxin.

Aspects of clostridial disease in sheep

THE clostridial diseases recognised in sheep may be divided into the enterotoxaemias (caused by Clostridium perfringens B, C and D), tetanus (C tetani), braxy and malignant oedema (C septicum), black...

HEAD INJURY - FOOTBALL

480 HISTORY - A 16 year-old center, during the varsity football game, was struck in the back of the head while lying face down on the ground. He appeared to be momentarily unconscious, but is awake when the trainer evaluates him. Athlete complained of a headache the remainder of the game. He was also noted to have some post-traumatic amnesia. The parents became increasingly concerned when the athlete developed dizziness and unsteady gait. In the ER the athlete was noted to have an ataxic gait, left-sided headache and post-traumatic amnesia. The parents found the athlete to be more lethargic the next day and a half, following which examination by the neurologist was negative. Further the parents state that the athlete had sustained a mild head injury 3 days prior. The initial head injury occurred while blocking. At that time the athlete complained of headache, dizziness, and feeling“funny.” PHYSICAL EXAMINATION - Athlete appeared pleasant, cooperative and in good hygiene. Mini-Mental Status Exam was 30 out of 30. Vital signs, heart and lungs were within normal limits. Neck and back were supple, non-tender, and without deformity. Cranial nerves were intact. Negative Romberg's and heel to shin bilaterally. Gait without abnormality. Deep tendon reflexes were 2+ and equal bilaterally at the knees. 1+ and equal at the elbow and ankles. Babinski's were negative. Strength was 5 out of 5 and equal bilaterally upper and lower extremity. Muscle tone and range of motion normal through out. DIFFERENTIAL DIAGNOSIS: Recurrent Mild Brain Injury. Second Impact Syndrome. Epidural Hematoma. Subdural Hematoma. Post-concussion Syndrome. Malignant Brain Edema Syndrome. Rule out associated neck sprain. TESTS AND RESULTS: CT Scan of the Head without Contrast: No evidence of acute or old bleed. No evidence of edema. Neck X-rays: No evidence of fractures or dislocations. FINAL WORKING DIAGNOSIS: Recurrent Mild Brain Injury: Initial mild head injury followed by a moderate. MANAGEMENT: Athlete was held out of participation for 1 month. He was symptom free for at least 3 weeks. School performance returned to base line after the rest period.

Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema.

The management of malignant posttraumatic cerebral edema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high despite refinements in medical and pharmacological means of controlling elevated intracranial pressure; therefore, a comparison of medical management versus decompressive craniectomy in the management of malignant posttraumatic cerebral edema was undertaken. At the University of Virginia Health Sciences Center, 35 bifrontal decompressive craniectomies were performed on patients suffering from malignant posttraumatic cerebral edema. A control population was formed of patients whose data was accrued in the Traumatic Coma Data Bank. Patients who had undergone surgery were matched with one to four control patients based on sex, age, preoperative Glasgow Coma Scale scores, and maximum preoperative intracranial pressure (ICP). The overall rate of good recovery and moderate disability for the patients who underwent craniectomies was 37% (13 of 35 patients), whereas the mortality rate was 23% (8 of 35 patients). Pediatric patients had a higher rate of favorable outcome (44%, 8 of 18 patients) than did adult patients. Postoperative ICP was lower than preoperative ICP in patients who underwent decompression (P = 0.0003). Postoperative ICP was lower in patients who underwent surgery than late measurements of ICP in the matched control population. A statistically significant increased rate of favorable outcomes was seen in the patients who underwent surgery compared to the matched control patients (15.4%) (P = 0.014). All patients who exhibited sustained ICP values above 40 torr and those who underwent surgery more than 48 hours after the time of injury did poorly. Evaluation of the 20 patients who did not fit into either of those categories revealed a 60% rate of favorable outcome and a statistical advantage over control patients (P = 0.0001). Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.

Alpha-Toxin Production byClostridium septicumat Different Culture Conditions

Clostridium septicumis responsible for a number of diseases, the most serious of which are a frequently fatal non-traumatic gas gangrene in man and braxy malignant oedema and blackquarter in farm animals. Immunity to these diseases is mediated mainly by antitoxin raised againstC. septicumalpha toxin, which has hemolytic, lethal and necrotizing activities.Clostridium septicumproduces lethal antigen only in low titre and in a variable way. In addition, the immunogenicity of native toxic filtrates is weak, which results in poor antibody response in animals.The aim of this work was to determine the best culture conditions for obtention of the protective antigen. To do this, the presence of the alpha toxin was identified in culture filtrates by means of SDS-polyacrylamide gel electrophoresis (SDS-PAGE) under different culture conditions. The strain used wasC. septicum3606. The cultures were performed in anaerobic conditions at 37°C. Two systems were employed: (a) batch (0·5% initial glucose concentration); and (b) batch with partial feeding of the carbon source (0·1% glucose concentration) at controlled pH. The hemolytic activity of supernatants was determined using human erythrocytes, and the final biomass concentration was estimated by dry weight determination. The proteins present in supernatants were concentrated by ultrafiltration and identified in 10% SDS-polyacrylamide gels. With partial feeding of the carbon source the final biomass (2·22 g/L) was three times higher than the amount reached in batch system (0·70 g/L), however, no difference was found in the hemolytic activity (16 HU50/mL) showing no correlations between cell growth and hemolytic activity of the supernatants.Electrophoresis of filtrate cultures obtained with partial feeding of the carbon source allowed us to identify several bands, two of them corresponded to non-active alpha-protoxin (46 kDa) and the active toxin (42 kDa) and the aggregate of the active toxin at the seeding line. On the other hand, the ultrafiltrate from batch system showed less number of bands and the 46 kDa band was much weaker, suggesting a lower toxin production in this system. It becomes important to determine culture conditions and correlate with extracellular protein presence to optimizeC. septicumantigen protector production.

Detection of Clostridium septicum hemolysin gene by polymerase chain reaction.

A polymerase chain reaction (PCR) was developed for the detection of the hemolysin (alpha toxin) gene of Clostridium septicum. The PCR primers were designed from the sequence of the hemolysin gene and synthesized. A DNA fragment of 270 bp was amplified from 10 strains of C. septicum, but was not from strains of C. chauvoei, C. perfringens, C. novyi, or C. haemolyticum. When the PCR product was digested with Sau3AI, two DNA fragments of the expected 148 bp and 122 bp were recognized. The lowest detectable threshold of PCR for the hemolysin gene was 3.8 x 10(3) cells/ml. The PCR technique may be useful for rapid detection or identification of C. septicum associated with malignant edema.

Einsatz von Gamma-Hydroxybuttersäure in der Therapie des erhöhten Hirndrucks und des Vasospasmus

Gamma-hydroxybutyrate (GHB), a suspected neurotransmitter, has sedative properties, reducing brain metabolism and body temperature and thus inducing effects resembling hibernation. Introduced as a narcotic 25 years ago, it has been employed in recent years for basic sedation of intensive-care patients in need of long-term respiratory support. In this study we analysed the effects of continuous GHB application in 19 patients suffering from increased intracranial pressure (ICP) subarachnoid haemorrhage (SAH), or both. GHB, which is only available as a sodium salt, frequently causes hypernatremia and metabolic alcalosis when given continually in dosages higher than 12 mg/kg body weight per hour. GHB is, therefore, often limited to preserve the potential usefulness of controlled hyperventilation or osmotherapy, respectively, when ICP increases. In 7 out of 8 patients with total infarctions in the territory of the middle cerebral artery GHB could not prevent the development of a malignant brain edema. The survivors with territorial infarctions or SAH in whom ICP was monitored showed no critical decreases in cerebral perfusion pressure during GHB application. Early GHB administration seemed beneficial in the prevention of vasospasm subsequent to severe SAH. The intracranial blood flow velocities did not exceed 90 cm/s in all three cases treated with GHB within the first three days after SAH, whereas three out of four cases without GHB showed marked acceleration with values over 90 cm/s. In two patients, the administration of GHB after the development of severe vasospasm was followed by a continuous decrease of flow velocities in the cerebral arteries.

繁殖豚における<I>Clostridium novyi</I> A型感染症の集団発生

繁殖豚における<I>Clostridium novyi</I> A型感染症の集団発生

Neuron-specific enolase concentrations in blood as a prognostic parameter in cerebrovascular diseases.

To investigate the clinical relevance of plasma concentrations of neuron-specific enolase (NSE) in patients with severe cerebrovascular diseases, serial analyses were performed during the first 10 days after the acute event. Plasma samples taken from 61 patients (30 with brain infarction, 13 with intracerebral hemorrhage, 11 with cardiogenic hypoxia-ischemia, and 7 with myocardial infarction [as control group]) were analyzed for NSE concentration using an enzyme immunoassay. The time course of plasma NSE was correlated with clinical findings, clinical outcome, cranial computed tomography, intracranial pressure, and other laboratory data. In cases of hypoxia-ischemia there was close correlation between plasma NSE values during the first 72 hours and the clinical outcome. In brain infarction and intracerebral hemorrhage, high plasma NSE mostly indicated an unfavorable outcome, but low values did not permit a reliable prognostic estimation. In cases of cerebral infarction and intracerebral hemorrhage with secondary neuronal destruction (for example, due to malignant edema), increasing NSE concentrations in plasma preceded the change of clinical or other diagnostic parameters. The course of plasma NSE levels is seen as a relevant parameter for assessing the prognosis of cerebral hypoxia-ischemia. Additionally, it may prove to be a useful tool for monitoring space-occupying brain infarctions and intracerebral hemorrhages and therefore may contribute to improved therapeutic management of severe cerebrovascular diseases.

Cerebral concussion in sport. Management and prevention.

This article explains the various stresses (tensile, compressive, and shearing) that can affect the brain, and how they may produce the different types of brain injury. The biomechanical forces and dynamics that produce coup versus contra coup injury are covered, as are the common intracranial athletic head injuries, i.e. concussion and the various intracranial haematomas (epidural, subdural, subarachnoid and intracerebral). Though less common in occurrence, because their outcome is so catastrophic, space is also devoted to the recognition, the treatment and (especially in the latter case) the prevention of the malignant brain oedema syndrome of the adolescent and the second impact syndrome of the adult. A major emphasis of this paper is the recognition of the 3 grades of cerebral concussion and the delineation of clear guidelines as to when it is safe to return to collision sports after sustaining such injuries, for the first, second or third time during a given season. Clear guidelines are also presented as to when to discontinue collision sport competition for the remainder of the season after multiple concussions. Because of the concern for the second impact syndrome, the requirement to never allow an athlete with postconcussion syndrome symptoms to return to competition is emphasised. Also covered is the prevention of head injuries, which sports are at greatest risk, and the need for additional research on the cumulative effects of concussion.

Pathogenic anaerobic bacteria and the environment

The distribution of pathogenic anaerobes in the environment and the relationship with diseases in animals are discussed. A distinction between the spore-bearing anaerobes (clostridia) and the Gram-negative non-spore-forming anaerobes is necessary. The main habitat of clostridia is the soil but they are also found in dust, sewage, rivers, lakes, sea water, milk, vegetables, fresh meat, fish, insects and the intestinal tract. The Gram-negative non-spore-forming anaerobic bacteria are also widely distributed among animals, principally on mucous membranes of the alimentary tract. After a general introduction and a section on the isolation of anaerobes, the various diseases caused by clostridia (botulism, tetanus, blackleg, malignant oedema, infectious necrotic hepatitis, enterotoxaemia and gas gangrene) and Gram-negative anaerobes (infections due to Fusobacterium and Bacteroides spp., such as diphtheria, footrot, etc.) are discussed. In particular, information concerning the reservoir of the causative agent and the mode of transmission is presented.

Characteristics and Prognosis of Extradural Hematomas in Children

This is a report on 31 children with operated extradural hematoma. The aim of the study was to elucidate the characteristics of extradural hematoma in childhood and the different clinical pattern and outcome compared to adults. For that reason the charts of the patients seen at the Department of Surgery of the Children's University Hospital Zurich between 1972 and 1990 have been revised. Follow-up criteria were recorded according to the Glasgow Outcome Scale. Most hematomas have been provoked by minor injuries and almost all children presented with at least one typical clinical sign. Associated intracranial injuries have been found in four patients, while two were polytraumatised. 30 of the 31 patients survived. One patient died of malignant brain edema. The mean range of follow-up was seven years. 28 patients had a "good recovery", "moderate disability" and "severe disability" was found in a patient one each. Our results demonstrate that the long-term outcome in children with extradural hematoma is far better than in adults regarding survival as well as quality of life. The causes may be minor traumas with fewer associated lesions and presentation with typical clinical findings and therefore early diagnosis and treatment.

Continuous regional cerebral blood flow monitoring in acute craniocerebral trauma

Regional cortical cerebral blood flow (rCBF) and intracranial pressure (ICP) were monitored continuously with a combined thermal diffusion probe/ICP monitor in 12 patients (8 men and 4 women; mean age, 31 years; range, 7-65 years) with acute head injuries. The mean Glasgow Coma Scale score at admission was 6 (range, 4-12). The rCBF/ICP probes were placed during surgical procedures (n = 11) or in an intensive care unit (n = 1) for subdural hematomas (n = 7), cerebral contusions (n = 4), and an epidural hematoma (n = 1). No probe-related complications occurred. Reduced CBF often occurred and was often inversely proportional to elevations in ICP. Posttraumatic cerebral arterial vasospasm in one patient was detected by rCBF monitoring and confirmed by angiography. In 6 patients who progressed to brain death, rCBF patterns disappeared, which correlated with their clinical and electroencephalographic examinations. Several patients with severe, diffuse brain injuries and high ICP had hyperemic rCBF patterns. In 2 of these patients, increases in rCBF preceded rises in ICP, which implied loss of autoregulation as a mechanism in the development of malignant cerebral edema. This method of CBF monitoring has not yet been established for clinical decision making. The early detection of ischemic or hyperemic responses by continuous CBF monitoring could hasten intervention aimed at restoring adequate tissue perfusion. The technique could also serve as an index of the efficacy of therapeutic interventions and is suitable to gain more insight into the pathophysiology of head injury, especially the relationship of CBF to ICP.