Showing papers in "Neurosurgery in 1986"
TL;DR: The group presenting with clinical evidence of hemorrhage was distinguished by a dominant age at the time of diagnosis), by a high incidence of prior neurological evaluation, by a higher rate of diagnosis at autopsy than at operation, and by the absence of microscopic calcification within the lesion.
Abstract: The histopathological, clinical, and radiological features of the intracranial cavernous angioma are reviewed, based on an analysis of 138 symptomatic, histologically verified cases. Twelve of the cases are from our own series and 126 were collected from appropriately documented reports in the modern literature. The analysis indicated that, at the time of diagnosis, one-third of the patients (49 cases) were being evaluated for seizures, one-third (40 cases) for clinical evidence of hemorrhage, and one-third (49 cases) for mass lesions. Unlike the other two groups, the group presenting with clinical evidence of hemorrhage was distinguished by a dominant age at the time of diagnosis (41% were diagnosed during the 4th decade of life), by a high incidence of prior neurological evaluation (43%), by a higher rate of diagnosis at autopsy (28%) than at operation, and by the absence of microscopic calcification within the lesion.
458 citations
TL;DR: The frequency and pattern of brain malformations associated with neural tube defects of some children with meningomyelocele suggest that such mal Formations may seriously affect intellectual outcome.
Abstract: Complete gross and microscopic neuropathological examinations of 25 children who died with meningomyelocele, the Arnold-Chiari malformation, and hydrocephalus revealed a wide range and frequency of associated central nervous system malformations. The most remarkable of these anomalies were hypoplasia or aplasia of cranial nerve nuclei (20%), demonstrable obstruction of cerebrospinal fluid flow within the ventricular system (92%), cerebellar dysplasia (72%), a disorder of migration of cortical neurons (92%), fusion of the thalami (16%), agenesis of the corpus callosum (12%), and complete or partial agenesis of the olfactory tract and bulb (8%). The anomalies associated with posterior neural tube closure defects can no longer be considered secondary, but rather must be considered part of a spectrum of malformations caused by an unidentified primary insult to the central nervous system. The frequency and pattern of brain malformations associated with neural tube defects of some children with meningomyelocele suggest that such malformations may seriously affect intellectual outcome.
232 citations
TL;DR: The use of sharp microsurgical techniques with a systematic contingency plan for dealing with sudden hemorrhage and the judicious use of temporary clips should minimize the adverse effect of intraoperative rupture on overall management morbidity and mortality.
Abstract: Intraoperative rupture of an intracranial arterial aneurysm can dramatically interrupt a deliberate microsurgical procedure and jeopardize the patient's chances for a favorable outcome. Intraoperative rupture occurred in 58 of 307 (19%) consecutive aneurysm procedures done at The University of Texas Health Science Center. Rupture occurred during three specific periods: early or predissection in 7%, dissection in 48%, and clip application in 45%. Outcome after rupture during the predissection interval was poor, with only 1 of 4 patients surviving. Aneurysmal rupture during dissection could be attributed to blunt dissection techniques in 75% of the cases and to sharp subarachnoid dissection in 25%. The outcome was favorable in only 50% of the patients sustaining blunt dissection errors, whereas all patients sustaining intraoperative rupture during sharp dissection recovered well. Rupture during clip application was attributed to incomplete dissection in 65%, poor clip application in 31%, and a mechanical clip failure in 1 case. Eighty-eight per cent of the patients who underwent uneventful operative procedures had favorable outcomes, whereas only 62% of the patients suffering intraoperative rupture recovered well. The use of sharp microsurgical techniques with a systematic contingency plan for dealing with sudden hemorrhage and the judicious use of temporary clips should minimize the adverse effect of intraoperative rupture on overall management morbidity and mortality.
200 citations
TL;DR: It is believed that the safest approach to patients with this combination of lesions is to treat the aneurysm before microsurgical resection of the associated arteriovenous malformation.
Abstract: The presence of intracranial aneurysm in association with arteriovenous malformation has been well documented. Aneurysms have been described in typical proximal sites along the feeding system to the arteriovenous malformation, in abnormal distal locations along feeding vessels, and in sites remote and apparently hemodynamically unrelated to the arteriovenous malformation. Little attention has been focused on the most appropriate medical and surgical care of patients harboring these lesions. Since 1977, 22 patients with this combination of lesions have been evaluated at our institution. Nine patients (41%) presented after intracranial hemorrhage. The remaining 13 patients were investigated because of seizures in 5 patients (23%), headaches in 4 patients (18%), and progressive ischemia in 4 patients (18%). Among the patients suffering intracranial hemorrhage, 78% had bled from an aneurysm, with 22% having hemorrhaged from their arteriovenous malformation. All 7 of the patients who suffered aneurysmal hemorrhage bled from atypical distal aneurysms on major feeding vessels. Our experience and that of others has led us to believe that the safest approach to patients with this combination of lesions is to treat the aneurysm before microsurgical resection of the associated arteriovenous malformation. Hemodynamic changes associated with the abrupt elimination of an arteriovenous malformation may place associated aneurysms at immediate risk.
174 citations
TL;DR: Fracture reduction and halo immobilization are the treatments preferred for patients who are diagnosed within 1 week of injury, who are less than 65 years of age and who have anteriorly, nondisplaced, or minimally posteriorly subluxed Type II fractures, or who have any Type III injury.
Abstract: The authors present a retrospective analysis of 128 cases of odontoid process injury treated at the University of Minnesota and affiliated hospitals between the years 1967 and 1983. Of these 128 cases, 110 were acute fractures, while 18 patients suffered from old, unstable odontoid injuries. Motor vehicle accident was the leading cause of injury, and the largest group of patients was in their second decade. Type II fractures were the most commonly encountered type of injury, and anterior subluxation was the most common displacement. Posterior subluxation, however, had the highest incidence of associated neurological deficit. Regarding treatment, the 110 acute fracture patients fell into the following groups: 16 patients died during the acute phase, 14 patients underwent early posterior cervical fusion, and 80 patients underwent a course of external skeletal fixation. The remaining 18 patients with old unstable injuries underwent posterior cervical fusion. An analysis of the results in these groups led to the elucidation of certain factors that likely are important in determining the treatment of each individual patient. These factors include age of the patient, type of odontoid fracture, direction and degree of fracture displacement, and diagnostic delay. Fracture reduction and halo immobilization are the treatments preferred for patients who are diagnosed within 1 week of injury, who are less than 65 years of age and who have anteriorly, nondisplaced, or minimally posteriorly subluxed (less than 2 mm) Type II fractures, or who have any Type III injury.(ABSTRACT TRUNCATED AT 250 WORDS)
172 citations
TL;DR: These studies indicate that chemotherapeutic drug delivery to tumors (as well as surrounding brain) can be augmented by osmotic BBB modification and that such therapy can result in a prolongation of survival.
Abstract: Reversible osmotic blood-brain barrier (BBB) modification was used in 38 patients with glioblastoma to enhance the delivery of chemotherapeutic agents. The patients ranged in age from 14 to 70 years (mean, 43), and all had prior surgery and radiation; 5 had also received systemic chemotherapy. Karnofsky Performance Status (KPS) scores ranged from 60 to 100% (mean, 79) on admission to the treatment program. Barrier modification was achieved by intracarotid or intravertebral artery infusion of mannitol, and a chemotherapy regimen of methotrexate, cytoxan, and procarbazine was given in conjunction with barrier modification. The 38 glioblastoma patients were compared to two control groups of patients with glioblastoma; these encompassed 14 patients treated with surgery and radiation and 8 treated with surgery, radiation, and systemic chemotherapy. Survival analysis using the Cox Proportional Hazards Regression Model (corrected for age, sex, presence or absence of necrosis, and functional status) showed that patients receiving chemotherapy with BBB modification had a statistically significant (P = 0.0006) longer expected survival (17.5 months) than the control groups (12.8 and 11.4 months, respectively). Presently 16 patients of the barrier-enhanced treatment group are alive at 5 to 42 months from diagnosis (median, 20) with KPS scores ranging from 40 to 90% (median, 65). The neurological complications seen included a stroke-like syndrome in 3 patients (1 with decreased motor movement in the hand, 1 with marked hemiparesis, and 1 with hemiplegia), transient exacerbation of preexisting neurological deficits lasting 2 to 3 days, and a 15% incidence of seizures during or within 24 hours of the BBB modification. In 2 of the 38 patients, radiographic documentation of central nervous system tumor regression concurrent with the development of new tumor nodule(s) in portions of the brain distant from the region of osmotic BBB opening was seen. These studies indicate that chemotherapeutic drug delivery to tumors (as well as surrounding brain) can be augmented by osmotic BBB modification and that such therapy can result in a prolongation of survival.
161 citations
TL;DR: The author has assembled data about such attempts that were not included in a similar compilation published in 1980 that made some progress toward the satisfactory management of intracranial arterial spasm.
Abstract: Numerous approaches to the prevention and treatment of intracranial arterial spasm have been made during the past three decades. In the present article, the author has assembled data about such attempts that were not included in a similar compilation published in 1980. Since 1980, there has been som
155 citations
TL;DR: A modification of the technique of acoustic facial electromyographic (EMG) monitoring, involving the use of a bipolar wire electrode, was used to monitor facial EMG activity during 13 consecutive unselected acoustic neuroma resections, resulting in three general acoustic patterns: bursts, trains, and pulses.
Abstract: A modification of the technique of acoustic facial electromyographic (EMG) monitoring, involving the use of a bipolar wire electrode, was used to monitor facial EMG activity during 13 consecutive unselected acoustic neuroma resections. EMG activity was synchronously recorded on the audio channels of operative video tapes so that the patterns of evoked EMG activity could be analyzed in relation to specific intraoperative events. Despite a relatively wide variety of apparent eliciting mechanisms, evoked EMG activity occurred in only three general acoustic patterns; these were bursts, trains, and pulses. These respective patterns are described in detail and related to specific etiological mechanisms. The possible clinical significance of various patterns of evoked EMG activity is discussed.
155 citations
TL;DR: In comparison to meningiomas, the principal differences were that neurofibromas had an even sex distribution, a lower incidence of cord signs and symptoms, more frequent findings on plain x-rays, and higher cerebrospinal fluid protein.
Abstract: A series of 66 spinal cord neurofibromas was analyzed for history, signs, surgical approach, and outcome. The tumors presented primarily with sensory symptoms. Plain films were abnormal in ½ of cases and ½ had a complete block. They were primarily intradural, and primarily thoracic. A conservative e
153 citations
TL;DR: In all 10 UK dogs, intraventricular urokinase induced complete lysis in 3 to 6 days without causing local or systemic hemorrhages and the neurological status of all 10 dogs also improved promptly, indicating that canine cerebrospinal fluid normally possessed limited capacity for in situ fibrinolysis.
Abstract: Nine millilitres of preclotted autologous blood was injected into the ventricles of 10 adult mongrel dogs (control dogs) to create subtotal ventricular casts with solid clots. The neurological status and systemic fibrinolytic profiles were closely monitored, and the changes in clot and ventricular volumes were measured by serial computed tomography (CT) for 3 months. The control animals showed severe neurological impairment for 7 to 9 days. No visible lysis of the intraventricular clots occurred for 5 to 7 days, after which slow clot lysis occurred at a constant rate. Complete lysis of the 10 clots took 38 to 65 days, indicating that canine cerebrospinal fluid normally possessed limited capacity for in situ fibrinolysis. Of the 10 control dogs, 8 developed progressive ventricular enlargement after a transient initial shrinkage parallel with initial clot lysis. Their final ventricular volume at 3 months was as much as 14 times the base line ventricular volume. Necropsy studies disclosed increased basal subarachnoid fibrosis and extensive ependymal and subependymal damage in the lateral ventricular walls of the hydrocephalic dogs. Ten other dogs (UK dogs) were given similar ventricular clot injections. Six hours later, each UK dog was begun on a regimen of 20,000 IU of intraventricular urokinase every 12 hours until solid clots were no longer seen in the ventricles on CT. In all 10 UK dogs, intraventricular urokinase induced complete lysis in 3 to 6 days without causing local or systemic hemorrhages. The neurological status of all 10 dogs also improved promptly. In 8 UK dogs, the ventricles that were initially distended by clots showed rapid shrinkage parallel with thrombolysis to a final volume at 3 months of less than four times the initial ventricular volume. Only 2 animals had persistently large or expanding ventricles. At necropsy, the ependymal and subarachnoid spaces of the UK dogs were remarkably free of damage and fibrosis. The possible mechanisms by which intraventricular urokinase may prevent posthemorrhagic hydrocephalus are discussed.
150 citations
TL;DR: Surgical exposure and management of the upper cervical and petrous ICA may permit a total operative resection of extensive cranial base neoplasms and is also an alternative for the management of vascular lesions involving these segments of the artery.
Abstract: The exposure and operative management of the petrous and upper cervical internal carotid artery (ICA) in 29 patients is detailed. Twenty-seven of these patients had extensive cranial base neoplasms (benign or malignant), 1 had an inflammatory cholesteatoma, and 1 had an aneurysm of the upper cervical ICA immediately proximal to the carotid canal. Preoperative studies useful in the evaluation of these patients included computed tomography, magnetic resonance imaging, cerebral and cervical angiography, and a balloon occlusion test of the ICA with evaluation of neurological status and of cerebral blood flow. The exposure of the upper cervical and petrous ICA was useful to obtain proximal control of the cavernous ICA, aided in the operative approach to extensive petroclival, intracavernous, and parapharyngeal neoplasms, and enabled the total resection of 23 of 27 such tumors. A subtemporal and preauricular infratemporal fossa approach was most commonly used for the exposure of the artery. Intraoperative arterial management consisted of exposure and decompression only, dissection from encasing neoplasm, resection of the invaded arterial segment and vein graft reconstruction, or intentional arterial occlusion. Vascular complications included 1 stroke due to delayed arterial occlusion, 1 stroke and death due to infection spreading from the nasopharynx with bilateral ICA rupture, and 1 pseudoaneurysm formation secondary to wound infection necessitating postoperative balloon occlusion of the ICA. Nonvascular complications included facial nerve paralysis in 10 patients (usually temporary), glossopharyngeal and vagal paralysis in 13 patients requiring Teflon injection of the vocal cord in 9, temporary difficulties with mastication in 9 patients, and wound infection in 3. The surgical exposure and management of the upper cervical and petrous ICA may permit a total operative resection of extensive cranial base neoplasms and is also an alternative for the management of vascular lesions involving these segments of the artery. With malignant neoplasms extending from the nasopharynx, postoperative infection remains a problem and may best be resolved by the use of a vascularized rectus abdominis muscle flap to reconstruct defects of the nasopharynx. Bilateral ICA encasement by neoplasms is also a major problem to be solved. The value of such an aggressive approach to the management of malignant neoplasms remains to be proven.
TL;DR: Experimental and clinical evidence regarding the causes of cardiac abnormalities after subarachnoid hemorrhage, the types of abnormalities most frequently seen, their relationship with subendocardial lesions, and the role of autonomic blockers are reviewed.
Abstract: Electrocardiographic abnormalities, both morphological and rhythmic, are frequently seen in association with spontaneous subarachnoid hemorrhage. These changes, which often reflect subendocardial damage, seem to be caused by hypothalamic stimulation leading to an acute increase in sympathetic tone. As a result, potentially life-threatening ventricular arrhythmias may develop in subarachnoid hemorrhage patients. These arrhythmias have responded to sympathetic blocking agents, which may also have a protective effect on subendocardial tissue in this setting. There is no evidence that the prophylactic administration of propranolol or other autonomic blockers significantly alters outcome in these patients. Ultimate morbidity and mortality are clearly related to the degree of intracerebral-intraventricular hemorrhage and vasospasm. This article reviews experimental and clinical evidence regarding the causes of cardiac abnormalities after subarachnoid hemorrhage, the types of abnormalities most frequently seen, their relationship with subendocardial lesions, and the role of autonomic blockers.
TL;DR: A high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage is document, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.
Abstract: The incidence of hydrocephalus and vasospasm and the relationship between them were analyzed retrospectively in 87 patients with subarachnoid hemorrhage from ruptured intracranial aneurysms. Sixty-seven per cent of the patients showed ventricular enlargement on a computed tomographic scan done within 30 days of the hemorrhage; in patients whose first scan was done within 3 days of the hemorrhage, 63% seemed to have ventricular enlargement by a neuroradiologist's interpretation. Shunts were required in 14% of the patients because of delayed neurological deterioration or enlarging ventricles; 3% required ventriculostomy shortly after admission. Seventy-four per cent of the patients had angiographic spasm on an angiogram done within the first 30 days after hemorrhage. Sixty-two per cent of the patients had both hydrocephalus and vasospasm: 22% had neither. Five per cent had hydrocephalus, but no spasm; 11% had spasm, but no hydrocephalus. Hydrocephalus and vasospasm were significantly associated (P less than 0.01, chi2). These data document a high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage. They also emphasize that these two sequelae of subarachnoid hemorrhage are closely linked, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.
TL;DR: A review of 143 victims of craniocerebral gunshot wounds admitted to Hermann Hospital, Houston, Texas, during a recent 30-month period confirmed that a few apparently neurologically devastated patients can be saved.
Abstract: Craniocerebral gunshot wounds are a significant cause of injury and death in the United States. However, despite reports of occasional unexpectedly favorable outcome in surgically treated patients, these injuries have been viewed pessimistically and indeed have generally been excluded from modern studies of head injuries, which have concentrated on closed head injuries. A review of 143 victims of craniocerebral gunshot wounds admitted to Hermann Hospital, Houston, Texas, during a recent 30-month period confirmed that a few apparently neurologically devastated patients can be saved. A detailed analysis of these patients, including demographic details, general and neurological condition, anatomic injuries, laboratory findings, surgical care, neurological course, and neurological and functional outcome follows. The helpfulness of early resuscitation and appropriate criteria for surgery need to be studied using historic or randomized controls.
TL;DR: Measurements performed on the water, electrolyte, and albumin contents of brain tissue have clearly indicated that the brain edema developing in the acute stage of rat experimental subarachnoid hemorrhage could be classified as having a primarily vasogenic component as well.
Abstract: Models have been devised and characterized in the laboratory rat for studying the neuropathology of subarachnoid hemorrhage. Several ways of injecting blood via different routes have been tried; cortical subarachnoid administration is the most reproducible suitable model. The location of injected blood was detected in histological sections. In this rat model for subarachnoid hemorrhage, the arterial blood pressure and the intracranial pressure did not elevate significantly, and the influence of major ischemic components in the development of brain edema could also be ruled out. Measurements performed on the water, electrolyte, and albumin contents of brain tissue have clearly indicated that the brain edema developing in the acute stage of rat experimental subarachnoid hemorrhage could be classified as having a primarily vasogenic component as well. These findings may have implications in the treatment of subarachnoid hemorrhage.
TL;DR: Clinically, patients varied from those with mild concussions without focal neurological signs to those with severe neurological dysfunction including posttraumatic coma, and CT remains the procedure of choice in diagnosing head injury less than 72 hours old.
Abstract: Thirty-five patients who had incurred head trauma were studied with computed tomography (CT) and magnetic resonance imaging (MRI). CT was performed using a General Electric 8800 scanner. MRI was conducted with a Technicare Teslacon system using a 5.0 kG (0.5 T) magnetic field. Clinically, patients varied from those with mild concussions without focal neurological signs to those with severe neurological dysfunction including posttraumatic coma. MRI was superior to CT in imaging 23 of 41 extracerebral fluid collections, both in estimating the size of the collections and in diagnosing small collections. MRI was also superior to CT in distinguishing chronic subdural hematomas from hygromas. Further, MRI was superior to CT in visualizing nonhemorrhagic contusion in 15 of 21 lesions. Because of the potential failure of MRI to diagnose acute subarachnoid or acute parenchymal hemorrhage, CT remains the procedure of choice in diagnosing head injury less than 72 hours old.
TL;DR: In brain death, ADH plays a critical role in hemodynamic maintenance, and ADH administration permits long term hemodynamic stabilization of brain-death patients, offering increasing opportunities for organ transplantation.
Abstract: The present study attempted long term hemodynamic maintenance in 16 adult brain-dead patients, 14 with head injury and 2 with cerebrovascular accidents. In addition to respiratory and fluid management, 10 were treated with continuous infusion of epinephrine to maintain systolic blood pressure above 90 mm Hg. The remaining 6 patients each received a continuous infusion of synthetic arginine vasopressin (ADH) at a rate of 1 or 2 units/hour (285 +/- 45 microunits/kg/minute) simultaneously with epinephrine. The 10 patients treated with epinephrine alone all succumbed to cardiac arrest within 48 hours of brain death, with a mean survival time of 24.1 +/- 17.2 hours. In the patients who received simultaneous ADH infusion, a minimal dose of epinephrine of no more than 0.5 mg/hr in most instances sufficed to maintain blood pressure. Their mean survival time after brain death was remarkably prolonged to 23.1 +/- 19.1 days. In brain death, ADH plays a critical role in hemodynamic maintenance, and ADH administration permits long term hemodynamic stabilization of brain-death patients, offering increasing opportunities for organ transplantation.
TL;DR: A nonsurgical line of therapy is proposed for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims.
Abstract: The extent of treatment for the victims of gunshot wounds to the brain remains quite controversial, particularly when these patients present with extensive neurological dysfunction. We propose guidelines regarding the degree and aggressiveness of therapy. The factors that seem to have a significant impact on the patient's final outcome are the neurological examination at the time of admission, the radiological findings, and the motivation for the shooting. Thus, the authors propose a nonsurgical line of therapy for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims. Language: en
TL;DR: Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE.
Abstract: Because venous air embolism (VAE) has been considered to be a major deterrent to use of the sitting position, records of 255 patients undergoing neurosurgery in the sitting position from 1975 to 1982 were reviewed to determine the nature of morbidity and mortality in relation to the surgical procedure as well as to the occurrence of VAE. Complications were classified as surgical or anesthetic during joint review by a neurosurgeon and two neuroanesthesiologists. Outcome was classified on the basis of postoperative hospital course and discharge examination. The incidence of VAE was 30%. Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE. The episodes of VAE did not seem to be significant factors in the perioperative morbidity and mortality in our series of patients operated upon in the sitting position. Two case reports are discussed in detail.
TL;DR: Histological findings of myxoid degeneration, microcystic change, calcification, and hemosiderin deposits suggest that chronic microtrauma with occasional focal hemorrhage may play a major role in the etiology of the cysts.
Abstract: Most reports regarding synovial cysts of the spinal canal have been presentations identifying an unusual pathological entity that is to be included in the differential diagnosis of cauda equina compression syndromes. Most of the 26 cases reported represent isolated examples of this pathological process. We present five cases of lumbar synovial cysts encountered in our practice in the past 8 years. Patients with lumbar synovial cysts do not demonstrate any predictable clinical picture. They may present with a unilateral sciatica or neurogenic claudication. Lumbar extension is usually restricted, whereas flexion is full. Mechanical signs of nerve root entrapment or lumbosacral plexus irritation are unimpressive. Neurological deficits are usually mild, if present. Radiological findings include degenerative spondylosis, spondylolisthesis, and a rounded posterolateral extradural mass of low attenuation value adjacent to a facet shown on computed tomographic scan. The etiology of lumbar synovial cysts is not known. Histological findings of myxoid degeneration, microcystic change, calcification, and hemosiderin deposits suggest that chronic microtrauma with occasional focal hemorrhage may play a major role in the etiology of the cysts. With resection of the cyst, the postoperative course is usually uneventful. Recurrences have not yet been encountered in our patients.
TL;DR: Surgical indications for and operative approaches to transsphenoidal encephalocele in the infantile period are discussed on the basis of the authors' failure in transcranial repair, which resulted in early postoperative death due to hypothalamic dysfunction.
Abstract: Diagnosis of occult basal encephalocele is not difficult if the peculiar clinical and radiological signs of this anomaly are borne in mind. Recent surgery for transsphenoidal encephalocele has had better results than realized. However, high surgical risks may still be encountered in transsphenoidal encephalocele of the early infantile period, because the pituitary-hypothalamic structures are usually incorporated in the herniated encephalocele of this age group. Surgical indications for and operative approaches to transsphenoidal encephalocele in the infantile period are discussed on the basis of the authors' failure in transcranial repair, which resulted in early postoperative death due to hypothalamic dysfunction. Reviewing the reported cases of anterior basal encephalocele, a high correlation between transsphenoidal encephalocele, particularly in the pediatric age group, and allied malformations of the face, eye, and brain was disclosed. This characteristic malformation complex may be explained by a common pathogenetic mechanism operating in the embryonal period at about the stage of the anterior neuropore closure and occurring in the ventral surface of the cephalic end of the neural tube. Three cases of transsphenoidal encephalocele diagnosed in the neonatal period with progressive obstruction in the nasopharyngeal airway are also reported. A characteristic malformation complex consisting of median cleft face syndrome, optic nerve dysplasia, and agenesis of the corpus callosum was associated in two cases; the other patient had an extremely rare combination of septooptic dysplasia. Two patients died pre- and postoperatively, respectively; the other patient did not undergo operation because of grave multiple anomalies.
TL;DR: Impaired quality of life was observed in the areas of psychosocial functioning, social role functioning, leisure activities, and, to a lesser extent, physical functioning, during chronic phases of recovery.
Abstract: This study evaluated quality of life in 78 patients with closed head injury (CHI) 2 to 4 years postinjury. Using both interview data and mean data from the Sickness Impact Profile questionnaire, impaired quality of life was observed in the areas of psychosocial functioning, social role functioning, leisure activities, and, to a lesser extent, physical functioning, during chronic phases of recovery. Relatives and close friends reported by means of the Katz Adjustment Scale that the CHI patients showed a series of negative behavioral symptoms 2 to 4 years postinjury. These data suggest that CHI patients may experience impaired quality of life in a number of domains well beyond the acute postinjury phases. An attempt was also made to compare patients' and relatives' reports of patient quality of life. Preliminary analyses indicated modest correspondence between relatives' and patients' ratings of some areas of postinjury dysfunction, including cognitive and behavioral slowing and social withdrawal.
TL;DR: The results support the clinical impression of previous studies that the severity of spasm is related to the volume of hemorrhage and suggest that the time course of hemorrhages may play a significant role in determining the overall severity of chronic cerebral vasospasm.
Abstract: The effect of altering the volume and timing of hemorrhage on the severity of spasm was studied in a canine model. All animals received three cisterna magna injections of fresh unheparinized autologous arterial blood. Selective left vertebral arteriograms were obtained during the week before and exactly 7 days after the initial subarachnoid injection. Increasing volumes of hemorrhage (from 9 to 15 ml of blood) delivered over 24 hours produced increasingly more severe arterial spasm, with reductions in basilar artery diameter of 37% +/- 14 (SD) and 58% +/- 15, respectively. Delay of the final injection of blood to 96 hours in the 15-ml hemorrhage group resulted in even more intense spasm, with an average 71% +/- 12 reduction in basilar artery diameter. Serial angiographic evaluation demonstrated the resolution of spasm in this group over approximately 3 weeks. Finally, small, late rebleeding episodes resulted in the rapid onset of intense spasm. Our results support the clinical impression of previous studies that the severity of spasm is related to the volume of hemorrhage and, in addition, suggest that the time course of hemorrhage may play a significant role in determining the overall severity of chronic cerebral vasospasm.
TL;DR: The exaggerated nitrogen excretion experienced by patients fed large nitrogen loads illustrates a problem in achieving nitrogen equilibrium in acute head injured patients.
Abstract: Forty-five acute head trauma patients were randomized into a neurotrauma nutritional study to compare the efficacy of two forms of standard nutritional supplementation; namely total parenteral nutrition (TPN) versus enteral nutrition (NG) Forty patients were male, 5 were female, with a median age of 28 years The mean admitting Glasgow coma scale score was 58 Patients were given high calorie and nitrogen feedings for the 14 days of the study period in an attempt to achieve positive calorie and nitrogen balance TPN patients had significantly higher mean daily nitrogen intakes (P less than 001) and mean daily nitrogen losses (P less than 0001) than the NG fed patients; however, no significant differences were discovered with respect to maintenance of serum albumin levels, weight loss, the incidence of infection, nitrogen balance, and final outcome The exaggerated nitrogen excretion experienced by patients fed large nitrogen loads illustrates a problem in achieving nitrogen equilibrium in acute head injured patients
TL;DR: Proper management of the patient with spinal lipoma now requires early prophylactic resection of the lipoma and untethering of the spinal cord.
Abstract: The value of laser resection was assessed in the last 50 of 128 consecutive cases of pediatric spinal lipoma. In this series, there was no mortality. No patient suffered increase in neurological or urological deficit. Postoperatively, 8 of 20 patients with prior motor deficit (40%) had substantially improved motor function. Two of 17 previously incontinent patients became continent of urine (12%). Use of the CO2 laser reduced the length of operation, the intraoperative blood loss, and the degree of manipulation of the spinal cord and nerve roots. Most of the fat could be removed successfully from the liponeural junction, permitting more nearly anatomical removal of the intramedullary component of the lesion and greater ease in replacing the cord into a reconstructed arachnoid-dural canal. In the authors' opinions, proper management of the patient with spinal lipoma now requires early prophylactic resection of the lipoma and untethering of the spinal cord.
TL;DR: The anatomy needed to plan microoperative approaches to the lateral ventricles was examined in 20 cadaveric cerebral hemispheres and the neural, arterial, and venous structures in the walls of the lateral Ventricles were examined.
Abstract: The anatomy needed to plan microoperative approaches to the lateral ventricles was examined in 20 cadaveric cerebral hemispheres. The neural, arterial, and venous structures in the walls of the lateral ventricles and the relationship of the lateral ventricles to the third ventricle and basal cisterns were examined. The operative approaches to the lateral ventricle are reviewed.
TL;DR: Findings suggest that a low energy carbon dioxide microsurgical laser has potential beneficial clinical application for anastomosis of small vessels in Sprague-Dawley rats.
Abstract: A low power carbon dioxide laser was used to perform 212 end-to-end laser-assisted microvascular anastomoses (LAMA) of femoral arteries (mean diameter, 1.2 mm) in Sprague-Dawley rats. Eighty-two conventional microvascular suture anastomoses (CMSA) utilizing 10-0 monofilament interrupted sutures were done for comparison of techniques and wound healing. The mean duration of each anastomosis procedure was 16 minutes for the LAMA repairs, compared to an average of 27 minutes for the CMSA repairs (P less than 0.05). All anastomoses were patent at the completion of the procedure. Each laser-assisted anastomosis required an average of seven intermittent laser exposures of 0.1 to 0.3 seconds each with approximately 80 mW of CO2 (wavelength = 10.6 micron) radiation at a spot size of 150 micron. A patency rate of 95% was obtained on the LAMA vessels (202 of 212) compared to 96% for the CMSA repairs (79 of 82). A total of 14 aneurysms were noted in the LAMA group (7%) compared to 11 in the CMSA (13%). All aneurysms were in patent vessels. Histological analysis indicates that the progression of wound healing of LAMA and CMSA anastomoses follows similar paths chronologically and morphologically with increased scar tissue formation around the suture. Scanning electron microscopy confirms the comparable luminal healing of the LAMA and CMSA vessels, with complete reendothelialization occurring by 3 weeks postoperatively. The tensile strength of the LAMA repair, although low immediately after operation, is comparable to that of the intact artery at 21 days. These findings suggest that a low energy carbon dioxide microsurgical laser has potential beneficial clinical application for anastomosis of small vessels.
TL;DR: Injections of 11 ml of fresh, unclotted autologous blood into the ventricles of adult mongrel dogs did not produce a solid blood cast in the ventricular system, suggesting that the adult dogs have an unusual ability to clear uncoagulated whole blood from the Ventricles and subarachnoid space.
Abstract: To test the safety and feasibility of using direct instillation of urokinase to induce rapid lysis of intraventricular clots, an animal model of intraventricular blood cast is required. Injections of 11 ml of fresh, unclotted autologous blood into the ventricles of adult mongrel dogs did not produce a solid blood cast in the ventricular system, suggesting that the adult dogs have an unusual ability to clear uncoagulated whole blood from the ventricles and subarachnoid space. Injection of 9 ml of preclotted blood resulted in a subtotal cast of the ventricles, leaving only portions of the occipital horns free of solid clots. This volume of injected clots incurred no mortality and minimal morbidity, whereas injection of 10 to 12 ml resulted in a mortality of 42% and formidable morbidity. The technique of producing this intraventricular blood cast model, as well as that of implanting an indwelling ventricular catheter-reservoir system useful in chronic urokinase administration, is described.
TL;DR: Of these three methods, a subdural catheter is the preferred method of recording ICP, and complications of infection and intracerebral hemorrhage were observed mostly in the ventricular catheter patients.
Abstract: Fluid-coupled recording systems are the most popular method of recording intracranial pressure (ICP), but they can be prone to blockage and infection. A series of 378 recordings of ICP was analyzed to identify complications and cases in which recording had to be discontinued prematurely because of catheter blockage. Three different methods of ICP recording were used: a ventricular catheter, a Richmond screw, and a subdural catheter. Richmond screws became blocked more often (16%) than subdural catheters (2.7%) or ventricular catheters (2.5%). Complications of infection and intracerebral hemorrhage were observed mostly in the ventricular catheter patients. Of these three methods, a subdural catheter is the preferred method of recording ICP.
TL;DR: The clinical and diagnostic findings in 13 patients with leptomeningeal metastasis from supratentorial malignant gliomas are reported and Iophendylate myelography was the most reliable diagnostic tool and established the diagnosis whenever performed.
Abstract: The clinical and diagnostic findings in 13 patients with leptomeningeal metastasis from supratentorial malignant gliomas are reported. Criteria for inclusion in this study were positive myelographic examination, positive cerebrospinal fluid cytology on two or more samples, or evidence of leptomeningeal seeding at autopsy. Eight patients had premortem symptoms of leptomeningeal metastasis, with the diagnosis confirmed during life in 5 patients. Average survival after the onset of symptoms was 3 months (range, 1 to 5 months). Comparison of the autopsied group with 10 concurrent autopsied patients without leptomeningeal gliomatosis did not reveal any significant differences in age, but leptomeningeal gliomatosis was more prevalent in patients with longer postoperative survival. Leptomeningeal involvement at autopsy was more extensive in symptomatic patients. Cerebrospinal fluid examination often gave nondiagnostic or nonspecific results. Computed tomography of the brain showed evidence of ventriculomegaly, periventricular contrast enhancement, or multifocal tumor involvement in every case. Iophendylate myelography was the most reliable diagnostic tool and established the diagnosis whenever performed. The natural history and clinical significance of leptomeningeal metastasis from supratentorial malignant gliomas are discussed.