Cerebral air embolism occurred in a patient undergoing trigeminal rhizotomy in the sitting position. During the acute episode, a murmur was detected by the Doppler probe and foam was aspirated from the central venous catheter. The patient did not regain consciousness postoperatively, and computerized tomography demonstrated diffuse cerebral infarction. Subsequently, the patient died, and neuropathological examination revealed multifocal discrete infarcts in the gray and white matter with normal intervening brain. No intracardiac septal defects were present. This is the first fully documented case of cerebral air embolism of venous origin in the absence of intracardiac septal defects, and reemphasizes the hazards of operative procedures in the sitting position.
Six patients with myelomeningocele and the Arnold-Chiari malformation developed cricopharyngeal achalasia and lower cranial nerve deficits. Diagnosis is established by cine-esophagram. Distortion of the brain stem or cranial nerves secondary to the Arnold-Chiari malformation may produce the autonomic imbalance necessary for cricopharyngeal achalasia. Treatment is supportive and includes verification of cerebral spinal fluid shunt function. Suboccipital craniectomy may reverse progressive lower cranial nerve deficits and reduce cricopharyngeus spasm. Cricopharyngeal myotomy may be considered when the cranial nerve deficits and cricopharyngeal achalasia are fixed, irreversible, and continue to cause disability.
IntroductionMost homeostatically regulated functions of the mammalian body, including the circulatory system, are controlled by the central nervous system. Different brain areas are known to exert important modulatory influences on cardiovascular function,1 and central nervous system participation in the pathogenesis of such conditions as cardiac arrythmias,2~ myocardial infarction,' and arterial hypertension5-9 has been postulated. Our clinical experience in the management of glossopharyngeal neuralgia from compression of the entry zone of the cranial nerve to the ventrolateral medulla has elicited interest in associated cardiovascular changes.1O-12 An acute experimental model was therefore developed to demonstrate the correlation between pulsatile pressure applied on this specific area of the brain and the regulation of heart function. Materials and MethodsEighteen cats weighing between 2-4.5 kg were selected and divided into 2 groups, 6 control and 12 experimental animals. The cats were anesthetized with IP pentobarbital (35 mg/kg), SC atropine (0.04 mg/kg), IV slow-drip pentobarbital (2.6 mg/kg/hour), and gallamine triethiodide (4.1 mg/kg/ hour).A catheter was inserted in a forelimb vein, and IV injection of 0.45% NaCI and 5% dextrose (125 cc/kg/day) was given with a Harvard infusion pump at Karolinska Institutets Universitetsbibliotek on May 26, 2015 ang.sagepub.com Downloaded from 162 (Harvard Apparatus, Millis, MA). Bilateral femoral artery and vein cutdowns were performed and PE 190 polyethylene tubings were inserted for central venous pressures, arterial pressure, and cardiac output determinations. Arterial pressure and ECG were recorded on a polygraph (Grass Instruments, Quincy, MA). An endotracheal tube was inserted, and the respirator (Harvard Apparatus) and 02 flow were adjusted to maintain arterial blood gases and pH within physiologic limits. Rectal temperature was monitored by a thermoprobe (Yellow Springs Instruments Co., Yellow Springs, OH). The peak of the arterial pulse triggered a cardiotachometer which continuously displayed the heart rate. Cardiac output was determined by the dye (indocyanine green) dilution technique using a COR-100A cardiac output recorder (Waters' Instrument Inc., Rochester, MN). Periodic arterial blood samples were taken and analyzed for hematocrit, pH, and blood gases. Urinary output was measured every hour.With the animal in the stereotaxic frame (David Kopf Instruments, Tujunga, CA) with the neck slightly flexed and turned to the left, a midline posterior fossa incision was made exposing the occiput, the posterior arch of Cl, and the posterior atlanto-occipital ligament. A left retromastoid occipital craniectomy was performed extending 2 cm superiorly and just laterally to the jugular foramen. Microsurgically, the arachnoid was then dissected between the floor of the posterior fossa and the spinal accessory nerve after cutting the first dentate ligament. The dissection was extended superiorly to permit easy insertion of a 1 mm in diameter cylindrical latex pulsatile ...
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