Showing papers in "Journal of Neurosurgery in 1975"
TL;DR: The distribution of compliance and outflow resistance between cerebral and spinal compartments was measured in anesthetized, ventilated cats by analysis of the cerebrospinal fluid (CSF) pressure response to changes in CSF volume.
Abstract: ✓ The distribution of compliance and outflow resistance between cerebral and spinal compartments was measured in anesthetized, ventilated cats by analysis of the cerebrospinal fluid (CSF) pressure response to changes in CSF volume. Cerebral and spinal compartments were isolated by inflating a balloon positioned epidurally at the level of C-6. The change of CSF volume per unit change in pressure (compliance) and change of CSF volume per unit of time (absorption) were evaluated by inserting pressure data from the experimental responses into a series of equations developed from a mathematical model. It was found that 68% of total compliance is contributed by the cerebral compartment while the remaining 32% is contained within the spinal axis. The cerebral compartment accounted for 84% of total CSF absorption. The mechanism for spinal absorption appears to be similar in that no differences were obvious on the basis of pressure dynamics.
687 citations
TL;DR: Fifty adult sellae and surrounding structures were examined under magnification with special attention given to anatomical variants important to the transfrontal and transsphenoidal surgical approaches.
Abstract: Fifty adult sellae and surrounding structures were examined under magnification with special attention given to anatomical variants important to the transfrontal and transsphenoidal surgical approaches. The discovered variants considered disadvantageous to the transsphenoidal approach were as follows: 1) large anterior intercavernous sinuses extending anterior to the gland just posterior to the anterior sellar wall in 10%; 2) a thin diaphragm in 62%, or a diaphragm with a large opening in 56%; 3) carotid arteries exposed in the sphenoid sinus with no bone over them in 4%; 4) carotid arteries that approach within 4 mm of midline within the sella in 10%; 5) optic canals with bone defects exposing the optic nerves in the sphenoid sinus in 4%; 6) a thick sellar floor in 18%; 7) sphenoid sinuses with no major septum in 28% or a sinus with the major septum well off midline in 47%; and 8) a presellar type of sphenoid sinus with no obvious bulge of the sellar floor into the sphenoid sinus in 20%. Variants considered disadvantageous to the transfrontal approach were found as follows: 1) a prefixed chiasm in 10% and a normal chiasm with 2 mm or less between the chiasm and tuberculum sellae in 14%; 2) an acute angle between the optic nerves as they entered the chiasm in 25%; 3) a prominent tuberculum sella protruding above a line connecting the optic nerves as they entered the optic canals in 44%; and 4) carotid arteries approaching within 4 mm of midline within or above the sella turcica in 12%.
506 citations
TL;DR: A technique for radiofrequency localization and coagulation of articular nerves supplying the spinal facets is described and results are reported from a series of 207 patients followed 6 to 21 months (mean 13 months).
Abstract: ✓ A technique for radiofrequency localization and coagulation of articular nerves supplying the spinal facets is described and results are reported from a series of 207 patients followed 6 to 21 months (mean 13 months). Relief of pain was achieved in 79% of previously unoperated patients, in 41% of those with laminectomy but no fusion, and in 27% of those with an earlier fusion. No neurological complications were encountered.
314 citations
TL;DR: The author reviews modern information concerning the formation, flow and functions of the cerebrospinal fluid and gives particular attention to the lymphatic-like features of the third circulation.
Abstract: ✓ The author reviews modern information concerning the formation, flow, and functions of the cerebrospinal fluid. Particular attention is given to the lymphatic-like features of the third circulation and to its importance as an internal milieu for nervous tissue.
204 citations
TL;DR: The author reports the use of vertebral artery ligation, unilateral and bilateral, for the treatment of large vertebral-basilar aneurysms in 14 patients with one delayed death and results are encouraging and the technique deserves further consideration.
Abstract: The author reports the use of vertebral artery ligation, unilateral and bilateral, for the treatment of large vertebral-basilar aneurysms in 14 patients with one delayed death. Extracranial ligation was carried out unilaterally with a Selverstone clamp in three patients. In two, where the aneurysm filled only from one vertebral artery, there was extensive thrombosis within the sac and dramatic clinical improvement after decompression. Extracranial ligation was done bilaterally in three patients, temporarily in two. A 14-year-old boy is well after 5 years but the bilateral vertebrobasilar aneurysm did not undergo extensive thrombosis until both vertebral arteries were occluded at their intracranial entrance above collateral flow. In two others, the clamp had to be reopened on the second artery. In one patient, death from delayed thrombosis of a huge aneurysm and pontine infarction might have been prevented with anticoagulants. In the other, the aneurysm ruptured again fatally 18 months later. Unilateral intracranial occlusion of a vertebral artery was done in eight cases, with no morbidity and complete or nearly complete thrombosis in all but one aneurysm. Seven patients had excellent or good results while one showed little recovery from an existing medullary syndrome. Occlusion of the basilar artery was done in seven cases. In five it was used deliberately as the only treatment, but in two it was forced when an aneurysm burst during dissection. Only two of the patients in the first group and one of the second group have made complete recoveries. The results of vertebral artery occlusion are encouraging and the technique deserves further consideration. Extensive collateral circulation enhances the safety of cervical vertebral artery occlusion but can be of a degree to make the occlusion ineffective. For intracranial occlusion knowledge of the size and distribution of each vertebral artery is essential. Occlusion of the basilar artery is dangerous, although it seems to be effective in producing extensive thrombosis in the aneurysm. It should probably be done under anesthesia only when the artery fills spontaneously from the carotid circulation. Otherwise, even when reasonable posterior communicating arteries are demonstrated, it is best to test occlusion under local anesthesia.
187 citations
TL;DR: In patients with intracranial hypertension, intravenous mannitol and intramuscular betamethasone both reduce the volume-pressure response significantly more than they reduce intrac Cranial pressure, which suggests that these agents favorably alter the configuration of thevolume-pressure curve.
Abstract: The intracranial volume-pressure response was measured in 61 patients undergoing continous monitoring of intraventicular pressure This test, which determlnes the increase in intracranial pressure induced by an addition of 1 ml in ventricular CSF volume in 1 sencond, yields information concerning spatial compensation in patients with intracranial space-occupying processes On the basis of variability tests, a change in volume-pressure response of 2 mm Hg/ml was accepted as significant Pronounced enlargement of the ventricles interferes with the test In patients with intracranial hypertension, intravenous mannitol (05gm/kg) and intramuscular betamethasone (26 mg) both reduce the volume-pressure response significantly more than they reduce intracranial pressure This suggests that these agents favorably alter the configuration of the volume-pressure curve
186 citations
TL;DR: The guidelines and instrumentation for a safe and effective technique are presented, based on the authors' experience with more than 100 cases of vascular lesions of the brain and spinal cord.
Abstract: Therapeutic percutaneous embolization of extra-axial vascular tumors and arteriovenous malformations was performed 41 times in 27 patients. Twenty-one patients (78%) had a clinically favorable result. In 11 of these patients, the procedure was preoperative and caused a dramatic reduction of surgical blood loss. In the remaining 10 patients with a favorable result, therapeutic embolization alone resulted in a significant clinical amelioration documented by a detailed follow-up varying from 2 to 5 years. In patients with uncontrollable epistaxis, the procedure was life-saving. The guidelines and instrumentation for a safe and effective technique are presented, based on the authors' experience with more than 100 cases of vascular lesions of the brain and spinal cord. A low-viscosity silicone polymer was developed by the authors and used clinically as an intravascular adhesive for the embolization of vascular tumors.
185 citations
TL;DR: The authors present their experience with long-term epidural pressure recording in hydrocephalic patients and the technique identifies those with episodically raised intracranial pressure.
Abstract: ✓ The authors present their experience with long-term epidural pressure recording in hydrocephalic patients. The technique identifies those with episodically raised intracranial pressure. The effect of shunts on the pressure profile in these patients is described.
174 citations
TL;DR: It is concluded that transcutaneous stimulation is a valuable therapeutic modality for some patients with chronic pain and usually correlated with the continued existence of significant sensory input from the painful region.
Abstract: ✓ A series of 198 patients with chronic pain of diverse etiology was carefully analyzed for epidemiologic and descriptive factors which might influence the response to transcutaneous stimulation. The overall series included 12½% with long-term success, and 68% with partial or short-term relief. There were no consistent specific diagnoses, or epidemiologic or descriptive factors that made good results from stimulation predictable. Stimulation of the painful area itself was not always necessary for pain relief. Favorable responses to transcutaneous stimulation were usually correlated with the continued existence of significant sensory input from the painful region. The authors conclude that transcutaneous stimulation is a valuable therapeutic modality for some patients with chronic pain.
173 citations
TL;DR: The relationship of cerebral blood volume (CBV) to cerebral perfusion pressure (CPP), cerebral blood flow (CBF), and the cerebral metabolic rate for oxygen (CMRO2) was examined in rhesus monkeys.
Abstract: ✓ The relationship of cerebral blood volume (CBV) to cerebral perfusion pressure (CPP), cerebral blood flow (CBF), and the cerebral metabolic rate for oxygen (CMRO2) was examined in rhesus monkeys. In vivo tracer methods employing radioactive oxygen-15 were used to measure CBV, CBF, and CMRO2. Cerebral perfusion pressure was decreased by raising the intracranial pressure (ICP) by infusion of artificial cerebrospinal fluid (CSF) into the cisterna magna. The production of progressive intracranial hypertension to an ICP of 70 torr (CPP of 40 torr) caused a rise in CBV accompanied by a steady CBF. With a further increase in ICP to 94 torr, CBV remained elevated without change while CBF declined significantly. Cerebral metabolic rate for oxygen did not change significantly during intracranial hypertension. For comparison, CPP was lowered by reducing mean arterial blood pressure in a second group of monkeys. Only CBF was measured in this group. In this second group of animals, the lower limit of CBF autoregulat...
170 citations
TL;DR: The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented and no predictive criteria are yet available to determine which tumors are amenable to radical surgery excision.
Abstract: The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented. The patients are analyzed in regard to survival and quality of survival. While 22 of 34 children so treated at the initial operation are presently alive and tumor-free, high mortality and morbidity followed in cases where reoperation was performed. Properly treated endocrinological deficits need not be a serious problem, but persistent hyperosmolality carried a grave prognosis. No predictive criteria are yet available to determine which tumors are amenable to radical surgical excision.
TL;DR: The relationship of age to clinical and pathological findings was analyzed in 109 adult patients operated on because of chronic subdural hematoma and it was found that younger patients had more evidence of increased intracranial pressure; older patients hadMore evidence of mental deterioration and pyramidal tract lesions.
Abstract: The relationship of age to clinical and pathological findings was analyzed in 109 adult patients operated on because of chronic subdural hematoma. A well-formed membrane on the inner and outer surface of the hematoma was used as the criterion for chronicity of the hematoma. Younger patients had more evidence of increased intracranial pressure; older patients had more evidence of mental deterioration and pyramidal tract lesions. The interval from trauma to operation was shorter in the young patients. The thickness of the hematoma as measured from angiograms increased with the age of the patient. The cause of this difference is discussed.
TL;DR: In cases with neurological deficits, capillary endothelial cells in the capsule had many cytoplasmic protrusions and fenestrations, suggesting high permeability of the capillary wall, which was frequently observed in the cases treated by osmotherapy.
Abstract: ✓ The authors used light and electron microscope to examine the capsules of chronic subdural hematoma in 33 cases. In cases with neurological deficits, capillary endothelial cells in the capsule had many cytoplasmic protrusions and fenestrations, suggesting high permeability of the capillary wall. Endothelial degeneration was also observed in these cases. These morphological changes were reversed by osmotherapy. Formation of collagen fibrils from fibroblasts in the hematoma capsule was frequently observed in the cases treated by osmotherapy.
TL;DR: The author describes a technique for directly closing a carotid cavernous fistula with electrothrombosis while preserving the intracranial arterial circulation.
Abstract: ✓ The author describes a technique for directly closing a carotid cavernous fistula with electrothrombosis while preserving the intracranial arterial circulation. Copper wires are introduced through the superior ophthalmic vein or a frontotemporal craniotomy, and thus directly into the portion of the sinus into which the fistula drains; if posterior, into the posterior segment of Parkinson's triangle, if inferior, into the pterygoid plexus, and if anterior, through the sphenoparietal sinus and/or middle cerebral vein to the anterior-inferior portion of the sinus. A direct current is applied until a thrombus is confirmed angiographically and the wires are left in place. Four patients treated by this method are presented.
TL;DR: In eight of 590 consecutive patients operated on by the author for a proven brain tumor, the preoperative diagnosis was complicated by a spontaneous intracerebral hematoma caused by the neoplasm.
Abstract: In eight of 590 consecutive patients operated on by the author for a proven brain tumor, the preoperative diagnosis was complicated by a spontaneous intracerebral hematoma caused by the neoplasm. The presenting symptoms were those of hypertensive intracerebral hemorrhage or brain tumor. The pathology underlying spontaneous bleeding from a cerebral neoplasm is reviewed and diagnostic suggestions discussed.
TL;DR: An analysis of 300 patients in whom primary treatment for hydrocephalus was either a ventriculoperitoneal (VP) or Ventriculoatrial (VA) shunt found the VA shunt failures carried a higher morbidity than the VP placements.
Abstract: The authors report an analysis of 300 patients in whom primary treatment for hydrocephalus was either a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. Although differences in primary and total revision rates between placements were not statistically significant, the VA shunt failures carried a higher morbidity than the VP placements.
TL;DR: Blood flow in the lateral funiculus and center of the spinal cord in the rhesus monkey both before and after a 600 gm-cm injury is challenged to challenge the notion that spreading ischemia of the white matter is an important factor in the pathophysiology of experimental spinal cord injury.
Abstract: Focal blood flow was measured in the lateral funiculus and center of the spinal cord in the rhesus monkey both before and after a 600 gm-cm injury at T-10. Measurements made by the hydrogen clearance technique showed that blood flow in the lateral funiculus more than doubled within 4 hours after injury, returned to normal by 8 hours, and remained in the normal range for 24 hours. At no time was a hypoperfusion in the lateral funiculus present. Blood flow in the center of the spinal cord, at the level of the lesion, began to fall within 1 hour following injury and continued to fall for 4 hours. These data challenge the notion that spreading ischemia of the white matter is an important factor in the pathophysiology of experimental spinal cord injury.
TL;DR: Local ischemia of the cervical cord, caused by local deformation, when superimposed on a regional reduction in spinal cord blood flow, accounts for the myelopathy of cervical spondylosis whether produced experimentally in animals or occurring naturally in man.
Abstract: The authors report experiments designed to test the effect of regional ischemia induced by selective vascular ligations and anterior compression of the cervical cord at two adjacent segments (C-4, C-5) in the same dog. They conclude that local ischemia of the cervical cord, caused by local deformation, when superimposed on a regional reduction in spinal cord blood flow, accounts for the myelopathy of cervical spondylosis whether produced experimentally in animals or occurring naturally in man.
TL;DR: Retrospective analysis of 13 patients who had bifrontal decompressive craniectomy for the management of posttraumatic cerebral edema shows a significant decrease in expected mortality, but severe morbidity in the survivors.
Abstract: ✓ Retrospective analysis of 13 patients who had bifrontal decompressive craniectomy for the management of posttraumatic cerebral edema shows a significant decrease in expected mortality, but severe morbidity in the survivors. Only one patient returned to the pretrauma level of neurological function, No correlation could be found between the quality of survival and the neurological or operative findings. The need for more accurate prognostic criteria in the evaluation of severely head-injured patients is discussed.
TL;DR: The authors report their experience using the operating microscope in 52 anterior cervical discectomies without fusion to find long-term results highly satisfactory, even in difficult cases with multiple-level disease, and complications from bone grafting were obviated.
Abstract: The authors report their experience using the operating microscope in 52 anterior cervical discectomies without fusion. They found long-term results highly satisfactory, even in difficult cases with multiple-level disease, and complications from bone grafting were obviated. They highly recommend this approach for radicular, nonradicular, or myelopathic symptoms.
TL;DR: The authors conducted an autopsy study of 50 jugular foramina and surrounding tissue, using the dissecting microscope, to find out the cause of death in patients with jugular aneurysm prolapse.
Abstract: The authors conducted an autopsy study of 50 jugular foramina and surrounding tissue, using the dissecting microscope. Anatomical findings from this study are presented.
TL;DR: In four of five patients with other forms of neuralgia, the procedure did not relieve pain; the fifth patient experienced significant relief from pain due to carcinoma of the mandible.
Abstract: Percutaneous radiofrequency ablation of the Gasserian ganglion or posterior root, or both, was performed in 140 patients. Of the 135 patients with trigeminal neuralgia, satisfactory analgesia was achieved in 121. Postoperative complications included unintentional first-division analgesia (10), transient sixth-nerve palsy (1), neuroparalytic keratitis (2), and anesthesia dolorosa (2). The phenomenon of facial blush may be helpful in avoiding unwanted first-division analgesia. In four of five patients with other forms of neuralgia, the procedure did not relieve pain; the fifth patient experienced significant relief from pain due to carcinoma of the mandible.
TL;DR: Oligemic animals had earlier and better return of neurological function than their ischemic counterparts, although postinsult hypocapnia improved functional recovery in both groups, and the concept that oligemia is a more severe insult than complete ischemia is not supported.
Abstract: Cerebral blood flow, electrical activity, and neurological function were studied in rabbits subjected to either 15 minutes of oligemia (20 torr cerebral perfusion pressure) or complete cerebral ischemia produced by cisterna magna infusion. During oligemia, flow was reduced from 68.4 +/- 4.2 ml/100 gm/min to 26.3 +/- 4.4 (p less than .01), and during ischemia animals had no proven flow. By 5 minutes after oligemia or ischemia significant symmetrical hyperemia occurred and there was no evidence of the no-reflow phenomenon. The electroencephalogram became isoelectric significantly later and returned significantly sooner in oligemia than in ischemia. Oligemic animals had earlier and better return of neurological function than their ischemic counterparts, although postinsult hypocapnia improved functional recovery in both groups. These experiments do not support the concept that oligemia is a more severe insult than complete ischemia. In intracranial hypertension produced by this model, the no-reflow phenomenon does not occur.
TL;DR: The findings do not support the concept of ischemia as a factor in white matter failure and it may be possible to reverse these changes by exploiting the preserved white matter blood flow for chemotherapeutic intervention.
Abstract: ✓ The authors used indicator fractionation techniques to determine blood flow in normal and bluntly traumatized spinal cords of Macaca rhesus monkeys. Normal flow rates were determined for several levels of spinal cord as well as differential values for white and gray matter from representative areas. Flow rates in traumatized tissue, obtained at several different time intervals up to 4 hours after injury, demonstrated marked differences in regional perfusion of the white matter and gray matter after trauma. Gray matter perfusion was nearly obliterated while white matter blood flow persisted and in fact was higher than uninjured controls. The findings do not support the concept of ischemia as a factor in white matter failure. If toxic pathobiochemical alterations are induced by trauma, it may be possible to reverse these changes by exploiting the preserved white matter blood flow for chemotherapeutic intervention.
TL;DR: Four patients received 3H-thymidine 4 to 7 days and vinblastine 4 to 6 hours prior to operation for recurrent malignant gliomas (three glioblastomas and one anaplastic astrocytoma) and cell-cycle phase-specific drugs should be administered to maintain effective blood levels over 2 to 3 days for maximal tumor cell kill.
Abstract: ✓Four patients received 3H-thymidine 4 to 7 days and vinblastine 4 to 6 hours prior to operation for recurrent malignant gliomas (three glioblastomas and one anaplastic astrocytoma). Tumor biopsies obtained at operation were fixed for routine histological studies and radioautography. The tumors' growth fractions averaged 0.28 with a range of 0.14 to 0.39. The tumor cell cycle time calculated in three patients had a mean duration of 57 hours with a standard deviation of 6 hours. The authors concluded that: 1) single short-term courses of cell-cycle specific chemotherapeutic agents alone will probably fail to achieve either significant reduction in tumor mass or dramatic clinical improvement; 2) cell-cycle phase-specific drugs should be administered to maintain effective blood levels over 2 to 3 days for maximal tumor cell kill. Tumor growth rate appears to correlate with the fraction of proliferating cells rather than the length of the tumor cell cycle. The scientific basis for combination drug and multimo...
TL;DR: The authors favor radical surgery, believing that carotid ligation does not provide assurance against the risk of rebleeding, and frequently is associated with failure to restore useful vision.
Abstract: A surgeon who has to treat carotid-ophthalmic aneurysms is confronted with several problems, some common to all aneurysms and others peculiar to aneurysms of this site. The first problem, common to all intracranial aneurysms, hinges on the patient’s condition (grade I–V) and the length of the interval between hemorrhage and surgery. The second problem is what to do with a patient who has a subarachnoid hemorrhage from another aneurysm and who is found incidentally to have a carotid-ophthalmic aneurysm. The third problem is whether to opt for direct or indirect surgery by closure of the carotid at the neck.
TL;DR: Experimental evidence is offered that early diversion of the cerebrospinal fluid interrupts this chain of events in congenital murine hydrocephalus, suggesting the primary role of vascular changes in the production of brain damage.
Abstract: ✓ Microangiotomography was used to identify the normal and pathological pattern of cerebral vessels in the hy-3 murine mutant mouse (normal and hydrocephalic) at various developmental stages from birth through 21 days of life. The technique employed allows resolution, in the range of 7 to 10 µ of the surface and in-traparenchymal (perforating) microvasculature. Ventricular enlargement causes displacement of primary cerebral arteries, followed by both stretching and a decrease in the caliber of primary, secondary, and tertiary vessels (arterial and venous). Ultimately, there is a reduction in the number and caliber of the microvasculature, resulting in diminished cerebral blood flow and cerebral edema. Tissue destruction leading to ependymal rupture, parenchymal cavitation, and the formation of porencephalic cysts within the edematous parenchyma ensues. External ventricular drainage, by decompressing the ventricles, resulted in rapid restoration of the filling of the primary and secondary vessels, thereby ...
TL;DR: The authors believe the procedure is safe in properly selected patients and is useful as a preliminary to direct surgical excision, and usually reverses or stabilizes a progressive neurological deficit.
Abstract: ✓ The authors describe the clinical results of surgical embolization in 55 patients with large cerebral arteriovenous malformations. Follow-up intervals ranged from 2 months to 14 years, averaging 4½ years. The authors believe the procedure is safe in properly selected patients and is useful as a preliminary to direct surgical excision. It relieves associated headaches, and usually reverses or stabilizes a progressive neurological deficit. The potential for seizures probably is not altered. The incidence of hemorrhage following embolization is low for patients with no previous history of hemorrhage; however, the procedure does not reduce the likelihood of recurrence in patients with a prior history of hemorrhage.
TL;DR: The author describes the syndrome of suprascapular nerve entrapment neuropathy that occurs as that nerve passes beneath the transverse scapular ligament, and discusses the anatomy, comparative anatomy, and five case histories.
Abstract: ✓ The author describes the syndrome of suprascapular nerve entrapment neuropathy that occurs as that nerve passes beneath the transverse scapular ligament, and discusses the anatomy, comparative anatomy, and five case histories. The cardinal findings include pain in the shoulder, weakness, and wasting of spinati muscles, and a positive electromyogram. Treatment is by division of the transverse scapular ligament.
TL;DR: It is suggested that pre- and postoperative antibiotic therapy directed at a narrow spectrum of microorganisms reduced the incidence of significant wound infections in patients undergoing laminectomy for lumbar disc herniation.
Abstract: ✓ The authors review 531 consecutive operations for lumbar disc herniation performed on 496 patients by one neurosurgeon to determine the effect of prophylactic antibiotics upon postoperative wound infections. In this retrospective analysis 16 instances of sepsis were found, 11 considered to be major and five minor. In the 128 cases in which no antibacterial agents were given, 11 major and 1 minor infection occurred. Four minor infections developed in the 402 occasions when antibiotics were given in the perioperative period. Men had a significantly greater risk of developing infection than women. These data suggest that pre- and postoperative antibiotic therapy directed at a narrow spectrum of microorganisms reduced the incidence of significant wound infections in patients undergoing laminectomy for lumbar disc herniation.