Showing papers in "Journal of Neurosurgery in 1973"
TL;DR: Cerebral blood flow, intracranial pressure, brain metabolism, and arterial blood gases were measured in comatose patients, most of whom had suffered a head injury, and there was no correlation between the status of autoregulation on the one hand and CBF or survival on the other.
Abstract: ✓ Cerebral blood flow (CBF), intracranial pressure (ICP), brain metabolism (CMRO2), systemic arterial pressure (SAP), and arterial blood gases were measured in comatose patients, most of whom had suffered a head injury. The patients were divided into two groups according to whether a mass lesion was or was not demonstrated by bilateral carotid angiography. In the majority of patients a control run measuring regional cerebral blood flow (rCBF) was followed by a test of cerebral autoregulation; hypertonic mannitol was then administered. During the control period there was marked and unpredictable variability in all of the parameters recorded. There was no correlation between ICP or CBF and neurological status or CMRO2 except at very high levels of ICP. Autoregulation was intact in some patients and defective in others, and there was no correlation between the status of autoregulation on the one hand and CBF or survival on the other. Mannitol increased CBF in nearly all patients, to twice the control value i...
307 citations
TL;DR: Intracranial epidural pressure (EDP) was recorded in 29 patients admitted with ruptured saccular aneurysms, but unfit for immediate surgery, indicating an increasing risk of rebleeding as the epidural Pressure decreases toward normal pressure.
Abstract: ✓ Intracranial epidural pressure (EDP) was recorded in 29 patients admitted with ruptured saccular aneurysms, but unfit for immediate surgery. In 10 patients a total of 13 recurrent hemorrhages were recorded; the average time before rerupture was 7.7 days after the last hemorrhage. Ten of the rebleedings started from intracranial pressure levels at or below 400 mm H2O whereas three started from higher prerupture levels. The observations indicate an increasing risk of rebleeding as the epidural pressure decreases toward normal pressure. Most repeat hemorrhages are arrested at EDP levels about that of the diastolic blood pressure. The resulting reduced pressure gradient across the aneurysm wall is important in the arrest of hemorrhage and the maintenance of hemostasis. Measurement of internal carotid artery blood flow during the acute stage of recurrent hemorrhage shows marked changes in blood flow pattern. Arrest of blood flow occurred only at the end of diastole; forward flow occurred only during systole....
277 citations
TL;DR: An anti-siphoning valve for use in hydrocephalic shunt systems reduces the hazard of negative intraventricular pressure when the patient is sitting or standing and prevents the formation of post-shunt subdural hematomas.
Abstract: ✓ An anti-siphoning valve for use in hydrocephalic shunt systems is described. The addition of this valve to the system effectively reduces the hazard of negative intraventricular pressure when the patient is sitting or standing. The formation of post-shunt subdural hematomas was prevented by temporary postoperative occlusion of the shunt using a percutaneously reversible occlusion valve, which is also described.
249 citations
TL;DR: Two points emphasized are that it is possible to operate within the cavernous sinus and still be outside both the venous and arterial components of the fistula, and that, by one means or another, the carotid should be preserved.
Abstract: ✓ The techniques and advantages of the direct approach to carotid cavernous fistulas with repair of the fistula and preservation of the carotid artery are discussed with illustrative case reports. The surgical significance of the anatomy of the parasellar venous structures and their relationship to the carotid artery are discussed. Two points emphasized are that it is possible to operate within the cavernous sinus and still be outside both the venous and arterial components of the fistula, and that, by one means or another, the carotid should be preserved.
202 citations
TL;DR: The most frequent findings were alteration of consciousness, headache, and elevated peripheral white blood cell count; fever, hemiparesis, seizures, neck stiffness, nausea and vomiting, and papilledema were less common.
Abstract: ✓ The records of 88 patients with intraparenchymal brain abscess treated during 1946–1971 were reviewed The incidence of brain abscess did not decline significantly during this period The overall mortality rate was 364%, and the operative mortality rate 291% The most frequent findings were alteration of consciousness, headache, and elevated peripheral white blood cell count; fever, hemiparesis, seizures, neck stiffness, nausea and vomiting, and papilledema were less common Lumbar puncture was a definite threat to the patient with a brain abscess Ventriculography appeared slightly superior to angiography in accurately localizing the site of the abscess There was a close correlation between the preoperative level of consciousness and the operative mortality rate With the aid of Thorotrast, simple aspiration or drainage was superior to excision; when Thorotrast was not used, excision produced better results The rate of postoperative seizure disorder was similar regardless of the type of treatment
189 citations
TL;DR: Warning signs prior to major hemorrhage were analyzed in 112 cases of single intracranial aneurysm, and results of treatment clearly suggested the group with warn...
Abstract: ✓ Warning signs prior to major hemorrhage were analyzed in 112 cases of single intracranial aneurysm. Fifty-four of 112 patients (48.2%) showed such signs, and the incidence for women was slightly higher (49.2%) than that for men (46.6%). Incidence decreased as patient age advanced, more steeply for men than women. Incidence and characteristics of warning signs varied according to location of aneurysm. Nineteen different signs occurred in 97 instances for 54 patients (average 1.76), and were placed into three groups according to possible etiologies: Group 1, vascular origin due to expansion of aneurysm and adjacent artery; Group 2, minor bleeding; and Group 3, ischemic lesion, arterial spasm, or occlusion. The average time interval from onset of warning sign to major hemorrhage was 20.7 days: 110.5 days for Group 1, 10.4 days for Group 2, and 21.0 days for Group 3. Therefore, signs in Group 2 suggest the necessity of most urgent medical attention. Results of treatment clearly suggested the group with warn...
173 citations
TL;DR: After intracranial surgery for an aneurysm, postoperative angiography may demonstrate lesions such as arterial spasm and hematoma, and may also show, sometimes quite unexpectedly, that the sac has not been completely obliterated.
Abstract: ✓ After intracranial surgery for an aneurysm, postoperative angiography should be routine. This may demonstrate lesions such as arterial spasm and hematoma, and may also show, sometimes quite unexpectedly, that the sac has not been completely obliterated. A clip or ligature may be merely misplaced, not be closed tightly enough, slip, or include the parent artery. In our series of 329 patients who underwent postoperative angiography, contrast filling of a significant part of the sac still occurred in 43 (13%); at least 12 of these rebled. Further intracranial surgery was carried out in 18, with satisfactory obliteration of the sac in 16. An incompletely obliterated aneurysm should be reoperated on as soon as possible. The risk involved at this time is minimal and far less than the possibility of another catastrophic hemorrhage.
167 citations
TL;DR: The technique, results, advantages, and complications of a combined translabyrinthine-transtentorial approach to the cerebellopontine angle are discussed.
Abstract: ✓ The technique, results, advantages, and complications of a combined translabyrinthine-transtentorial approach to the cerebellopontine angle are discussed. The method has been associated with a low morbidity and no operative mortality in 23 cases of acoustic nerve tumor and six with miscellaneous lesions.
164 citations
TL;DR: A current review of the development, techniques, and applications of angiographic studies of the spinal cord, with special emphasis on selective arteriography, is presented.
Abstract: ✓ The authors present a current review of the development, techniques, and applications of angiographic studies of the spinal cord, with special emphasis on selective arteriography.
156 citations
TL;DR: A new technique for monitoring intracranial pressure is presented based on a hollow screw in the skull whose tip projects through the dura into the subarachnoid space and has been successfully used in 56 patients during a 6-month period.
Abstract: ✓ A new technique for monitoring intracranial pressure is presented. It is based on a hollow screw in the skull whose tip projects through the dura into the subarachnoid space. The screw can be easily inserted under local anesthesia. Pressure is monitored isovolumetrically by connecting the screw to a transducer. The system can be calibrated in situ and has been successfully used in 56 patients during a 6-month period.
150 citations
TL;DR: Treatment consisted of suboccipital craniectomy and complete removal of cysts in the posterior fossa, and there were four operative deaths.
Abstract: ✓ A series of 20 cases of arachnoid cysts in the posterior fossa is reported. Classification was made according to the location of the cysts. Accurate clinical localization was only possible with cysts in the cerebellopontine angle. Ventriculography and pneumoencephalography were the most helpful investigations for making the diagnosis. Treatment consisted of suboccipital craniectomy and complete removal. There were four operative deaths. The remaining 16 patients had essentially complete recoveries.
TL;DR: Fifty-three cases of pineal and posterior-third ventricular tumors seen at the Massachusetts General Hospital from 1920 to 1972 are reviewed and a plan of management is proposed based on a correlation between the clinical and pathological features and the response of each type of tumor to the currently available modes of therapy.
Abstract: ✓ Fifty-three cases of pineal and posterior-third ventricular tumors seen at the Massachusetts General Hospital from 1920 to 1972 are reviewed. This series includes 35 pathologically verified tumors and 18 cases accepted as pineal neoplasms on clinical and radiographic grounds. A plan of management is proposed based on a correlation between the clinical and pathological features and the response of each type of tumor to the currently available modes of therapy.
TL;DR: A new ventriculofiberscope useful in both diagnosing and operating on lesions of the ventricular system is reported, and its advantages are illustrated in representative cases.
Abstract: ✓ The authors report a new ventriculofiberscope useful in both diagnosing and operating on lesions of the ventricular system. The technique and its advantages are illustrated in representative cases.
TL;DR: The authors report 16 consecutive cases of ulnar nerve palsy at the elbow successfully relieved by simple division of the tendinous insertions of the flexor carpi ulnaris, which form the roof of the “cubital tunnel.”
Abstract: ✓ The authors report 16 consecutive cases of ulnar nerve palsy at the elbow successfully relieved by simple division of the tendinous insertions of the flexor carpi ulnaris, which form the roof of the “cubital tunnel.” They believe the more complex procedures of anterior transposition of the nerve or resection of the medial epicondyle are unnecessary, and even undesirable.
TL;DR: Four clinical categories are described, based on the time of onset of symptoms, and the diagnostic studies and surgical techniques discussed, and four-vessel angiography and ligation of the feeding vessels at the point of entry into the vein of Galen are recommended.
Abstract: ✓ The authors review 37 cases of primary aneurysms of the vein of Galen reported in the literature and present five new ones. The magnitude of the shunt from arterial feeders to the primary aneurysm indicates the age at which the patient's symptoms first appeared as well as the nature and severity of those symptoms. Newborn infants have intractable heart failure, older infants have hydrocephalus, and adolescents have headache and syncope. Four clinical categories, based on the time of onset of symptoms, are described, and the diagnostic studies and surgical techniques discussed. Four-vessel angiography and ligation of the feeding vessels at the point of entry into the vein of Galen are recommended.
TL;DR: In six consecutive patients treated with systemic antibiotics for brain abscess, chloramphenicol, methicillin, and penicillin were found capable of penetrating the abscess in therapeutic concentration, and organisms were sensitive, in vitro, to the antibiotics used.
Abstract: ✓ In six consecutive patients treated with systemic antibiotics for brain abscess, chloramphenicol, methicillin, and penicillin were found capable of penetrating the abscess in therapeutic concentration. Nafcillin, a fourth antibiotic tested, failed to penetrate. While on antibiotics, all six patients continued to deteriorate neurologically until needle aspiration of the abscess was carried out, after which recovery began promptly. Organisms were found in the pus despite the presence of therapeutically effective antibiotic levels, and despite the fact that the organisms were sensitive, in vitro, to the antibiotics used. These observations confirm that antibiotics alone are insufficient and that surgical evacuation of the abscess is essential. The need for local instillation of antibiotics directly into abscesses is questionable since penetration following systemic administration of three antibiotics tested was adequate when blood levels were high. It is suggested that the instillation of penicillin or its...
TL;DR: The data emphasize the deleterious effects of hydrocephalus in the acute period following a subarachnoid hemorrhage and suggest that it may be treated effectively by external ventriculostomy.
Abstract: ✓ The role of ventriculostomy in the treatment of acute hydrocephalus following subarachnoid hemorrhage from intracranial aneurysms is evaluated. Eleven patients treated with an external ventricular drain are compared to a matched control series of untreated patients. Improvement occurred in eight of the 11 treated patients and in only one of the nine patients in the control group. Seven of the patients in the ventriculostomy series improved sufficiently to justify definitive surgery. There were no infections. In 50% of the surviving ventriculostomy patients, permanent shunts were unnecessary. Our data emphasize the deleterious effects of hydrocephalus in the acute period following a subarachnoid hemorrhage and suggest that it may be treated effectively by external ventriculostomy.
TL;DR: A case of disseminated intravascular coagulation in a patient with massive brain trauma is reported and it is suggested that the condition was caused by the liberation of thromboplastin.
Abstract: ✓ The authors report a case of disseminated intravascular coagulation in a patient with massive brain trauma. It is suggested that the condition was caused by the liberation of thromboplastin. The detailed diagnostic studies and related theories are discussed.
TL;DR: Analysis of a personal series of 274 cases of brain abscess indicates that excision gives better results than aspiration, even in most of the so-called acute abscesses.
Abstract: ✓ Analysis of a personal series of 274 cases of brain abscess indicates that excision gives better results than aspiration, even in most of the so-called acute abscesses. The general outlines of the neurosurgical treatment are given, with emphasis on emergency procedures. A similar method is advised in cases of acute subdural empyema.
TL;DR: The effect of brain compression on cerebral blood flow was measured in 13 anesthetized, ventilated dogs by inflation of extradural balloons and the effects of the raised intracranial pressure were correlated with the presence or absence of autoregulation of cerebralBlood flow to induced changes of arterial pressure.
Abstract: ✓ The effect of brain compression on cerebral blood flow was measured in 13 anesthetized, ventilated dogs by inflation of extradural balloons The effects of the raised intracranial pressure, so produced, were correlated with the presence or absence of autoregulation of cerebral blood flow to induced changes of arterial pressure, which was tested immediately prior to each episode of inflation of the balloon Cerebral blood flow was measured by a venous outflow method and monitored continuously, together with arterial and supratentorial intracranial pressure; arterial pCO2 and body temperature were held constant Three stages were identified When autoregulation to a change of arterial pressure was intact, initial inflation of the balloon did not reduce cerebral blood flow until the difference between arterial and intracranial pressure (which was taken to represent cerebral perfusion pressure) was less than 40 mm Hg When autoregulation was impaired, which occurred after the first inflation of the balloon
TL;DR: Cases of communicating hydrocephalus after subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms are reported and the availability and value of echoencephalography in treating such patients is emphasized.
Abstract: ✓ Twenty-eight cases of communicating hydrocephalus after subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms are reported. The relationship between the incidence of this complication and the various clinical features of SAH is discussed. The findings of RISA cisternography have little relationship to the findings of pneumoencephalography or the results of shunting procedures. The availability and value of echoencephalography in treating such patients is emphasized.
TL;DR: From the analysis of 648 patients operated on for ruptured cervical discs between 1939 and March of 1972 and a follow-up study of 380 of these patients, the following conclusions seem justified.
Abstract: ✓ From the analysis of 648 patients operated on for ruptured cervical discs between 1939 and March of 1972 and a follow-up study of 380 of these patients, the following conclusions seem justified. Osteophytes or hypertrophic spurs rarely produced the classical clinical picture or deficits. Ninety per cent of the patients awakened in the morning with pain in the neck and rhomboid region. Ten per cent had a history of injury, but there was no characteristic pattern as in lumbar discs. Only one patient had a typical hyperextension injury. Anterior chest pain occurred in one-fifth of the cases. Pain in the neck, rhomboid region, and anterior chest was referred from the discs, while the arm pain was usually the result of nerve root compression; however, in a few cases the degenerating disc caused referred pain to the arm without any nerve root pressure. Since accurate diagnosis can be made on clinical grounds, myelography is not necessary in most cases. In our experience conservative treatment was usually unsu...
TL;DR: The authors report their experience with 124 cases of intracranial hemorrhage in children and adolescents; the study includes 25 cases first reported in 1958.
Abstract: ✓ The authors report their experience with 124 cases of intracranial hemorrhage in children and adolescents; the study includes 25 cases first reported in 1958. Fifty aneurysms with a mortality rate of 28% and 33 arteriovenous malformations with a mortality rate of 21% are included; 32 cases had no angiographically demonstrable lesion, six had miscellaneous lesions, and three primary cerebral hemorrhage. Specific programs for therapeutic management based on this experience are discussed.
TL;DR: A case in which vaginal perforation complicated a ventriculoperitoneal shunt is reported.
Abstract: ✓ A case in which vaginal perforation complicated a ventriculoperitoneal shunt is reported.
TL;DR: A 20-year series of 531 patients with cervical spine fractures or dislocations is reviewed, and the records of 54 quadriplegic patients are analyzed in detail.
Abstract: ✓ A 20-year series of 531 patients with cervical spine fractures or dislocations is reviewed, and the records of 54 quadriplegic patients are analyzed in detail. Tracheostomy, surgery, overhydration, advanced age, severity of neurological injury, and corticosteroid therapy are discussed as factors in pulmonary complications.
TL;DR: The results suggest that an appropriate combination of tricyclic antidepressant and substituted phenothiazine medication may decrease the necessity for surgical intervention in postherpetic neuralgia.
Abstract: ✓ Five patients with postherpetic neuralgia experienced almost complete relief of pain within 1 to 2 weeks after the institution of therapy with amitriptyline and a substituted phenothiazine. Three of the group had shown no response to amitriptyline or nortriptyline alone; one had had symptoms exacerbated by surgical denervation. In three, discontinuance or diminution of the dose of the phenothiazine was followed by return of pain, which was then relieved with reinstitution. The results suggest that an appropriate combination of tricyclic antidepressant and substituted phenothiazine medication may decrease the necessity for surgical intervention in postherpetic neuralgia.
TL;DR: Operative or autopsy findings confirm that the solid lesions are more likely to involve the brain stem, hence explaining the difficulty in operative treatment and the extremely high mortality and morbidity of these tumors.
Abstract: ✓ In this report six cases of solid hemangioblastoma were encountered out of 19 cases operated on, and carried a 50% mortality rate compared to 15% for the remaining 13 cases of cystic tumors. The solid tumor cases have more brain-stem signs than those with the cystic tumor. Angiographically the solid lesion often shows diffuse involvement of the brain stem. Operative or autopsy findings confirm that the solid lesions are more likely to involve the brain stem, hence explaining the difficulty in operative treatment and the extremely high mortality and morbidity. Decompressive operation is thought to be the better method of handling these tumors.
TL;DR: Ventriculography in seven infants who had developed hydrocephalus after surviving neonatal meningitis and ventriculitis disclosed intraventricular septations or veils that compartmentalized the ventricular system, interfering with attempted shunting procedures.
Abstract: ✓ Ventriculography in seven infants who had developed hydrocephalus after surviving neonatal meningitis and ventriculitis disclosed intraventricular septations or veils. These post-inflammatory septations compartmentalized the ventricular system, interfering with attempted shunting procedures. Pathogenesis and treatment are discussed.
TL;DR: Oral 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), a lipid-soluble non-ionized chemotherapeutic agent, was used in the treatment of 26 patients with malignant brain tumor, primarily glioblastoma, implying that thetreatment of asymptomatic patients may also be of considerable value.
Abstract: ✓ Oral 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), a lipid-soluble non-ionized chemotherapeutic agent, was used in the treatment of 26 patients with malignant brain tumor, primarily glioblastoma. Most patients had first received conventional surgery, and about one half had received x-ray therapy. Over 1½ years, 113 courses of CCNU (130–150 mg/m2) were given and analyzed for clinical results and agent toxicity. A new central nervous system (CNS) disease staging system was used to measure patient impairment and therapeutic response. Thirty-seven per cent of all symptomatic patients had significant remission of clinical disease, lasting a median of 5 months. Data are presented implying that the treatment of asymptomatic patients may also be of considerable value. The most significant toxicity was delayed reversible thrombocytopenia, which was less severe than that seen with nitrosourea BCNU. Despite the cumulative toxicity observed with all three bone-marrow elements, serious complications were rare...
TL;DR: It appeared that radiation therapy was the most important determinant of prolonged postoperative survival and the age of the patient was the only other factor of any significance.
Abstract: ✓ The records of 248 patients with supratentorial astrocytomas, Grades 3 and 4, treated surgically between 1960 and 1970 were analyzed. Abstracted clinical data were transferred to magnetic tape for computer analysis of postoperative survival factors using multiple chi square test and a step-wise multiple regression equation. All patients were followed, and only four were alive at the time of the study. It appeared that radiation therapy was the most important determinant of prolonged postoperative survival. The age of the patient was the only other factor of any significance.