Cerebrovascular Insufficiencies

Kennedy, Anderson and Sokoloff, Neurology (1958),1216 studied cerebral blood flow in four epileptic children, before and after PHT for one week, using a modified nitrous oxide test. Although the group was small, the authors found the increase in mean blood flow to be statistically significant (from 85 to 102 cc per 100 gram per minute).

1216. Kennedy, C., Anderson, W., and Sokoloff, L., Cerebral blood flow in epileptic children during the interseizure period, Neurology, 8: 100-105, 1958.

Slosberg, Mount Sinai Medical Journal (1970),1560 reports on his eight years of experience with medical therapy for cerebrovascular insufficiencies in a series of sixty-one elderly patients. Among these were patients with occlusive disease of the neck arteries; occlusive disease of the intracranial arteries; hypoplastic arteries; vascular anomalies of the circle of Willis; patients with reaction to compression of the common carotid arteries or of the carotid sinus areas; and patients with postural hypotension. The author found a simple and effective method for treating cerebrovascular insufficiencies of diverse origins. This method consists of the use of PHT in conjunction with carotid sinus therapy and support stockings. The author found that this method was both applicable and safe in this heterogeneous group of patients with cerebrovascular insufficiency, and has been well tolerated in the acute stages and on long-term follow-up.

1560. Slosberg, P. S., Medical therapy for the cerebrovascular insufficiencies; eight yearsí experience, Mt. Sinai Med. J., 37: 692698, 1970.

Daniel, Geriatrics (1970),938 says that symptoms of confusion which are so common in the aged often are caused by underlying physical illness, frequently cardiac and respiratory disorders resulting in cerebral hypoxia or ischemia. He states that PHT is therapeutically useful in this group, yet it is often overlooked.

938. Daniel, R., Psychiatric drug use and abuse in the aged, Geriatrics, 144-156, January, 1970.

Aldrete, Romo-Salas, Mazzia and Tan, Critical Care Medicine (1981), 2142 studied the cerebral protective effects of PHT in ten patients who suffered cardiac arrest during or after anesthesia. PHT was given after spontaneous heartbeat and systolic blood pressure greater than 100 mm Hg had been restored and the diagnosis of neurological deficit had been established on the basis of unconsciousness, dilated and areflexic pupils and rigid and/or decerebrate posture. With PHT (7 mg/kg) nine of the ten patients recovered nearly complete neurological function; the other patient had partial recovery but succumbed to other complications. The authors note that laboratory studies of anti-anoxic protective effects of PHT support their clinical endings that PHT may have a reversing effect on post-ischemic brain injury. (See also Refs. 1718, 1719.)

2142. Aldrete, J.A., Romo-Salas, F., Mazzia, V.D.B. and Tan, S.L., Phenytoin for brain resuscitation after cardiac arrest, Critical Care Medicine, 9(6): 474-7, 1981.
1718. Aldrete, J. A., Romo-Salas, F., Jankovsky, L. and Franatovic, Y., Effect of pretreatment with thiopental and phenytoin on postischemic brain damage in rabbits, Critical Care Medicine, 7(10): 466-70, 1979.
1719. Aldrete, J. A., Romo-Salas, F., Mazzia, V. D. B. and Tan, S., Diphenylhydantoin for reversal of neurological injury after cardiac arrest, Rev. Bias. Anest., 30(4): 263-7, 1980.

Massei, De Silva, Grosso, Robbiati, Infuso, Ravagnati and Altamura, Journal of Neurological Science (1983), 2768 report twelve patients treated with intravenous PHT prior to clamping during carotid thromboendarterectomy. During and after surgery no neurological complications or alterations in cardiac function were observed. Prompt awakening, absence of neurologic deficits, and absence of side effects supported their hypothesis that PHT provides cerebral protection during carotid surgery.

2768. Massei, R., DeSilva, E., Grosso, P., Robbiati, B. R., Infuso, L., Ravagnati, L., Altamura, C. A., Cerebral protection with diphenylhydantoin during disobliterating surgery of the sovra-aortic branches, J. Neurosurg. Sci., 27(2): 107-10, 1983.

Betremieux, Lefrancois, Oriot, Rind, Dabadie and Journel, La Revue de Pediatrie (1986), 3176 in a review of the management of anoxic and ischemic phenomena in term neonates, discuss many possible therapeutic approaches. In the description of treatments, the authors state that phenytoin is of great interest because of its membrane action, and its effect on Na-K-ATPase. They note that PHT greatly increases the level of intracerebral GABA and state that they use it at an initial dose of 10 mg/kg and then 5 mg/kg bid.

3176. Betremieux, P., Lefrancois, C., Oriot, D., Rind, M.C., Dabadie, A., and Journal, H., Ischemic anoxia and status epilepticus in term neonates: Therapeutic approaches, Rev. Pediatr., 22: 243-252, 1986.

See also: Surgery

Ogawa, Yoshimoto, Mizoi, Sugawara, Sakurai and Sato, Acta Neurochirurgica (Wien) (1991), 3177 reported performing acute stage vascular reconstruction in 28 patients with progressing stroke. The vascular lesion was on the internal carotid artery in 8 patients and on the middle cerebral artery in 20. Following admission, brain protective substances (500 ml mannitol, 500 mg vitamin E, 500 mg phenytoin) are administered to all the patients. Hypervolaemia is induced with Dextran and hypertension to 20 - 30 mmHg is induced with Angiotensin II. Changes in symptoms are then observed, and vascular reconstruction is performed on patients whose symptoms have progressed. Neurological symptoms completely disappeared in 12 cases. Although mild neurological symptoms remained in 11 other patients, they were able to return to normal social life. Symptoms remained in three cases and there were two fatalities. In a long-term follow-up study, there were no cases of aggravation of symptoms due to ischaemic stroke. Moreover, the reconstruction was judged effective on the basis of cerebral blood flow and metabolism.

The authors believe that the relatively good results obtained in their series are due not only to the fact that the progression of symptoms was gradual, but also due to the administration of brain protective substances (manitol, vitamin E and phenytoin) in an early period following onset of stroke.

3177. Ogawa, A., Yoshimoto, T., Mizoi, K., Sugawara, T., Sakurai, Y., and Sato, H., Acute revascularization for progressing stroke, Acta. Neurochir. (Wien), 112: 100-105, 1991.

See also: Surgery

Li and Dong, National Workshop of Clinical Use of Phenytoin, Chengdu, China (1995), 3178 examined the clinical efficacy of phenytoin and its effect on cerebral hemodynamics in 52 patients with acute cerebral infarction, as verified by cerebral computer tomography. Twenty-seven patients (control group) received conventional therapy and phenytoin, and twenty-five patients (treatment group) received conventional therapy and phenytoin (250 - 500 mg/day, iv) for three days. Treatment was started at or less than 72 hours after the onset of symptoms. Quantitative neurologic deficits were assessed before treatment and at 3, 7, 14 and 28 days after treatment. Cerebral hemodynamics were measured before and after the first phenytoin intravenous administration. The author's tabulated results of both treatments show that phenytoin had a significant (p < 0.05) effect on the neurologic deficits of the patients. The changes of cerebral hemodynamic parameters were significantly improved in patients receiving the 500 mg dosage, but not those given 250 mg. No side effects occurred during treatment. The authors state that their results suggest that there is a certain protective effect of phenytoin on ischemic brain tissue in patients with acute cerebral infarction.

3178. Li, C. and Dong, W., Clinical efficacy of phenytoin and its effect on cerebral hemodynamics in patients with acute cerebral infarction, Presented at the National Workshop of Clinical Use of Phenytoin, Chengdu, China, 1995.

See also: Surgery