Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects. In view of these findings in asymptomatic subjects, we concluded that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.

Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation

Background The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain. Methods We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also d...

Magnetic resonance imaging of the lumbar spine in people without back pain.

Objective. —Neurofibromatosis 1 and neurofibromatosis 2 are autosomal dominant genetic disorders in which affected individuals develop both benign and malignant tumors at an increased frequency. Since the original National Institutes of Health Consensus Development Conference in 1987, there has been significant progress toward a more complete understanding of the molecular bases for neurofibromatosis 1 and neurofibromatosis 2. Our objective was to determine the diagnostic criteria for neurofibromatosis 1 and neurofibromatosis 2, recommendations for the care of patients and their families at diagnosis and during routine follow-up, and the role of DNA diagnostic testing in the evaluation of these disorders. Data Sources. —Published reports from 1966 through 1996 obtained by MEDLINE search and studies presented at national and international meetings. Study Selection. —All studies were reviewed and analyzed by consensus from multiple authors. Data Extraction. —Peer-reviewed published data were critically evaluated by independent extraction by multiple authors. Data Synthesis. —The main results of the review were qualitative and were reviewed by neurofibromatosis clinical directors worldwide through an Internet Web site. Conclusions. —On the basis of the information presented in this review, we propose a comprehensive approach to the diagnosis and treatment of individuals with neurofibromatosis 1 and neurofibromatosis 2.

https://jamanetwork.com/journals/jama/articlepdf/417288/jama_278_1_042.pdf

The diagnostic evaluation and multidisciplinary management of neurofibromatosis 1 and neurofibromatosis 2.

LOW back pain is usually a self-limiting symptom, but it costs at least $16 billion each year1 , 2 and disables 5.4 million Americans.3 The fact that a benign physical condition has such an importa...

Back pain and sciatica.

Several surgical approaches to the cerebellopontine angle and internal auditory canal have been developed for the removal of acoustic neuromas. The choice of an approach may be influenced by hearing levels and tumor size. We reviewed the records of the primary translabyrinthine removal of 167 large (> or = 4 cm) acoustic neuromas performed between 1982 and 1990. Patients ranged in age from 15 to 83 years, with a mean of 43 years (male, 49%; female, 51%). Total removal was achieved in 95%. The facial nerve was preserved anatomically intact in 91%. At follow-up (mean, 2.1 yr), facial nerve function was acceptable (Grades I-IV) in 75% and good (Grades I-II) in 42%. Vascular complications occurred in 4.8%; however, there were no deaths. A cerebrospinal fluid leak occurred in 9.6% of cases, and meningitis occurred in 8.3%. In patients with large tumors where there is little chance to preserve preoperative hearing, we have successfully used the translabyrinthine approach for total tumor removal. The advantages and disadvantages of both the translabyrinthine and suboccipital approaches are discussed.

Translabyrinthine removal of large acoustic neuromas.

Recently, five cases of quadriplegia following surgery for removal of an acoustic tumor have come to our attention. Although complete details of each case are not available, all of these patients had in common being operated on in the sitting position, and awakening from anesthesia with midcervical quadriplegia. To our knowledge, this complication of acoustic tumor surgery has not previously been reported. This surgical disaster apparently is the result of direct prolonged focal pressure on the cervical spinal cord. In one case, postmortem examination showed acute diffuse infarction of the midcervical cord, possibly related to a preexisting asymptomatic spondylitic bar at the level of the infarction. There are several features of suboccipital craniectomies carried out in the sitting position that can potentiate the effects of pressure on the cervical cord. After the induction of general anesthesia and placement of the patient in the sitting position, the patient's head is

A warning regarding the sitting position for acoustic tumor surgery.

A completely new surgical approach is presented that allows selective section of the preganglionic fibers of the fifth nerve for tic douloureux with preservation of sensation as suggested by Dandy. The procedure is done by the retrolabyrinthine approach and carries only the morbidity of a simple mastoidectomy. This operation may be preferable to the long-term medical management of patients with trigeminal neuralgia.

Trigeminal nerve (posterior root) retrolabyrinthine selective section. Operative procedure for intractable pain.

Objective To evaluate the indications for, techniques used in, and patient outcomes after surgery with the transcochlear approach in the treatment of petroclival tumors. Methods Retrospective review of 24 cases between 1985 and 1995 at the House Ear Clinic (Los Angeles, CA, U.S.A.). Results Meningioma was the most common tumor. Complete removal was achieved in 82% of tumors after one-or two-stage surgeries (average follow-up time, 36 months). The second-stage surgery was a middle fossa transpetrous approach. Most patients had some degree of facial nerve dysfunction immediately after surgery, and 12 of 20 patients subsequently improved to House-Brackmann Grade III or better. Fifty-nine percent of patients had permanent neurologic sequelae because of either the surgery or their disease. Conclusion The transcochlear approach is best suited to treating petroclival intradural tumors that extend ventrally to the brainstem in patients without serviceable hearing. Temporary facial weakness is expected as a result of posterior facial nerve transposition.

The transcochlear approach revisited.

Patients with large acoustic neuromas may have secondary obstructive hydrocephalus and occasionally significant neurologic deficit develops. At the House Ear Clinic, we have managed patients with hydrocephalus by translabyrinthine tumor removal without preoperative ventriculoperitoneal shunting. Forty-three patients with documented hydrocephalus who underwent acoustic neuroma removal have been reviewed. Six patients had neurologic deficit resulting from raised intracranial pressure before surgery. In each of these six cases, the deficit resolved after tumor removed without requiring shunting. Two patients had had ventriculoperitoneal shunts inserted because of neurologic deficit before referral for tumor removal. Two other patients underwent postoperative shunting for neurologic deficit --one at 2 weeks and one at 2 years. Cerebral or cerebellar herniation was not noted in any case. Cerebrospinal fluid leak occurred in five patients (11.6%) and culture-positive meningitis in two patients (4.6%). We conclude that decompression by translabyrinthine tumor removal is a safe method of management for patients with hydrocephalus resulting from large acoustic tumors.

William E. Hitselberger

Papers

Translabyrinthine removal of large acoustic neuromas.

A warning regarding the sitting position for acoustic tumor surgery.

Trigeminal nerve (posterior root) retrolabyrinthine selective section. Operative procedure for intractable pain.

The transcochlear approach revisited.

Management of hydrocephalus resulting from acoustic neuromas