Life-threatening reactions to propofol

Journal ArticleTo the Editor: Propofol (2,6-diisopropyl phenol; Diprivan; Stuart Pharmaceuticals, Wilmington, DE) has been advocated as a titratable continuous infusion anesthetic agent associated with fast and smooth recovery (2, 7). The anesthetic properties of a smooth induction, short half-life, and rapid emergence from anesthesia after prolonged operations, with a low incidence of nausea and vomiting and little "hangover' sedation, suggest that this agent may be ideally suited for use in intracranial neurosurgery (6). It also may be given in combination with analgesics, such as sufentanyl and inhalational agents. Accordingly, we have adopted propofol for use in all cranial base, vascular, and functional neurosurgical procedures. We are currently using propofol (50-100 /ig/kg/min infusion, with a burst suppression dosage of approximately 250 jiig/kg/min used during periods of vascular interruption) in a balanced protocol with narcotic (sufentanyl) and low dosage inhalational (isoflurane) anesthesia

Intracranial fusarium fungal abscess in an immunocompetent patient: case report and review of the literature.

Introduction Fusarium spp is an omnipresent fungal species that may lead to fatal infections in immunocompromised populations. Spontaneous intracranial infection by Fusarium spp in immunocompetent individuals is exceedingly rare. Case Report An immunocompetent 33-year-old Hispanic woman presented with persistent headaches and was found to have a contrast-enhancing mass in the left petrous apex and prepontine cistern. She underwent a subsequent craniotomy for biopsy and partial resection that revealed a Fusarium abscess. She had a left transient partial oculomotor palsy following the operation that resolved over the next few weeks. She was treated with long-term intravenous antifungal therapy and remained at her neurologic baseline 18 months following the intervention. Discussion To our knowledge, this is the first reported case of Fusarium spp brain abscess in an immunocompetent patient. Treatment options include surgical intervention and various antifungal medications. Conclusion This case demonstrates the rare potential of intracranial Fusarium infection in the immunocompetent host, as well as its successful treatment with surgical aspiration and antifungal therapy

The effects of primary elevation of cerebral venous pressure on cerebral hemodynamics and intracranial pressure

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/23634/1/0000598.pd

The treatment of complex dural arteriovenous fistulae through cranial base techniques

Introduction: The endovascular modality of treatment is the preferred treatment modality for DAVF. In some circumstances, successful obliteration may not be possible by endovascular means, and such cases may require a direct surgical treatment. The authors report on their experience with the use of cranial base approaches in the treatment of deep and complex DAVF. Materials and Methods: Nine patients were treated between 1992 and 2003. There were six females and three males. Four patients presented with intracerebral hemorrhage, two with progressive myelopathy, two with tinnitus, and one with incapacitating chronic seizures. Four DAVF were tentorial, two transverse sigmoid, one craniocervical, one straight sinus, and one sphenoparietal. Endovascular embolization was attempted and unsuccessful in four cases, and was successful only as an adjunct to surgery in four others. All patients required the use of cranial base approaches to disconnect the fistula or resect the nidus. Results: Complete obliteration of the fistula was possible in all cases. Six-month follow-up results were obtained on seven patients where there was no evidence of recurrence. One postoperative temporal-lobe hematoma required surgical evacuation. One patient died two years postoperatively from an unrelated cause. Conclusion: This retrospective study demonstrates that complex DAVF can be successfully treated with the assistance of cranial base techniques

The effect of temperature on cerebrovascular resistance and cerebral metabolism in the primate

Using a primate single carotid perfusion model we studied CVR and A-VO2 differences through a wide range of cerebral temperatures. By keeping cerebral blood flow constant and systemic temperature normal, the influence of systemic blood pressure and low cerebral blood flow was avoided. Our data suggest a direct relationship between temperature and CVR as well as oxygen extraction. A-VO2 differences became less marked below 15[deg]C and are probably negligible when considering hypothermia for most clinical uses.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/22554/1/0000099.pd

Thrombospondin-1 Modulates the Angiogenic Phenotype of Human Cerebral Arteriovenous Malformation Endothelial Cells

Background: The management of cerebral arteriovenous malformation (AVM) is challenging, and invasive therapies place vital intracranial structures at risk of injury. The development of noninvasive, pharmacologic approaches relies on identifying factors that mediate key angiogenic processes. Previous studies indicate that endothelial cells (ECs) derived from cerebral AVM (AVM-ECs) are distinct from control brain ECs with regard to important angiogenic characteristics. Objective: To determine whether thrombospondin-1 (TSP-1), a potent angiostatic factor, regulates critical angiogenic features of AVM-ECs and to identify factors that modulate TSP-1 production in AVM-ECs. Methods: EC proliferation, migration, and tubule formation were evaluated with bromodeoxyuridine incorporation, Boyden chamber, and Matrigel studies, respectively. TSP-1 and inhibitor of DNA binding/differentiation 1 (Id1) mRNA levels were quantified with microarray and quantitative real-time polymerase chain reaction analyses. TSP-1 protein expression was measured using Western blotting, immunohistochemical, and enzyme-linked immunosorbent assay techniques. The mechanistic link between Id1 and TSP-1 was established through small interfering RNA-mediated knockdown of Id1 in AVM-ECs followed by Western blot and enzyme-linked immunosorbent assay experiments assessing TSP-1 production. Results: AVM-ECs proliferate faster, migrate more quickly, and form disorganized tubules compared with brain ECs. TSP-1 is significantly down-regulated in AVM-ECs. The addition of TSP-1 to AVM-EC cultures normalizes the rate of proliferation and migration and the efficiency of tubule formation, whereas brain ECs are unaffected. Id1 negatively regulates TSP-1 expression in AVM-ECs. Conclusion: These data highlight a novel role for TSP-1 in the pathobiology of AVM angiogenesis and provide a context for its use in the clinical management of brain AVMs