No abstract

An understanding of normal cerebral autoregulation and its response to pathological derangements is helpful in the diagnosis, monitoring, management, and prognosis of severe traumatic brain injury (TBI). Pressure autoregulation is the most common approach in testing the effects of mean arterial blood pressure on cerebral blood flow. A gold standard for measuring cerebral pressure autoregulation is not available, and the literature shows considerable disparity in methods. This fact is not surprising given that cerebral autoregulation is more a concept than a physically measurable entity. Alterations in cerebral autoregulation can vary from patient to patient and over time and are critical during the first 4–5 days after injury. An assessment of cerebral autoregulation as part of bedside neuromonitoring in the neurointensive care unit can allow the individualized treatment of secondary injury in a patient with severe TBI. The assessment of cerebral autoregulation is best achieved with dynamic autoregulation methods. Hyperventilation, hyperoxia, nitric oxide and its derivates, and erythropoietin are some of the therapies that can be helpful in managing cerebral autoregulation. In this review the authors summarize the most important points related to cerebral pressure autoregulation in TBI as applied in clinical practice, based on the literature as well as their own experience.

The efferent projections of the subthalamic nucleus were studied with the autoradiographic tracing technique in Rhesus monkey and cat. From the data it appears that the major efferent projections of the nucleus are to the pallidal complex and the substantia nigra. In both monkey and cat, the projection to the pallidal complex is truly massive and is directed at both pallidal segments. The projection field includes an infracommissural part of the pallidal complex bordering on the substantia innominata. In the monkey the termination in the pallidal complex is organized in several characteristic bands oriented parallel to the medullary laminae. The subthalamo-pallidal projection in monkey further appears to be topographically organized. The projections to the substantia nigra is prominent in both cat and monkey though not as massive as that to the pallidal complex. The distribution of termination in the substantia nigra favors the more ventral strata near the cerebral peduncle. In the monkey the terminal distribution appears to avoid regions of the substantia nigra containing pigmented neurons and it is suggested that the subthalamo-nigral pathway may prefer non-dopaminergic neurons. In addition to the above major projections, sparse projections were noted to the thalamic nuclei ventralis lateralis and ventralis anterior, to the putamen, and to the mesencephalic nucleus tegmenti pedunculopontinus, pars compacta. The findings are discussed.

A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.