Neurosurgery
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The management of malignant posttraumatic cerebral edema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high despite refinements in medical and pharmacological means of controlling elevated intracranial pressure; therefore, a comparison of medical management versus decompressive craniectomy in the management of malignant posttraumatic cerebral edema was undertaken. ⋯ Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.
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Spinal epidural lipomatosis (SEDL) is a rare disorder often associated with the administration of exogenous steroids or the elevation of endogenous steroids. Spinal epidural lipomatosis develops in some patients in the absence of elevated steroid levels. The limited information known about idiopathic SEDL comes predominantly from isolated case reports. We proposed to study our experience with idiopathic SEDL and to review the literature. ⋯ A review of our patients in conjunction with other reported cases reveals the following: 1) idiopathic SEDL occurs almost exclusively in the obese population; 2) idiopathic SEDL seems to occur with equal frequency between the thoracic and lumber spine; 3) a strong male predominance exists; 4) thoracic SEDL presents at an earlier age compared with lumbar SEDL; 5) surgical decompression remains the treatment of choice for the immediate relief of symptoms. Our experience suggests that idiopathic epidural lipomatosis may be a pathological entity that has been underdiagnosed.
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To examine the incidences of hypertension, hypotension, and bradycardia after carotid endarterectomy (CEA) and to identify any hemodynamic variables predictive of postoperative stroke, death, or cardiac complications. ⋯ Hemodynamic instability was commonly observed after CEA, but only postoperative hypertension was associated with stroke or death and, possibly, with cardiac complications. Patients undergoing CEA, especially those at risk for postoperative hypertension, may be monitored best in settings suited to the expeditious management of neurological and cardiovascular emergencies.
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Review Case Reports
Eosinophilic granuloma of the clivus: case report, follow-up of two previously reported cases, and review of the literature on cranial base eosinophilic granuloma.
To our knowledge, this is the first reported case of the use of stereotactic radiotherapy for an eosinophilic granuloma (EG) of the clivus. We report follow-up information on two previously reported cases and suggest a management plan for this rare lesion. ⋯ These findings suggest a classification schema in which cranial base EG lesions be grouped with either the more common extracranial petrous temporal bone lesions or the very rare intracranial lesions. Although there are few cases in the literature, treatment results indicate that clival EG, and perhaps all intracranial cranial base EGs, be treated by a biopsy alone, followed by surgery or stereotactic radiotherapy if there is an incomplete resolution of the symptoms or if there is a recurrence.
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Although the Hunt and Hess Scale (HHS) and World Federation of Neurological Surgeons Scale (WFNSS) are the most widely used subarachnoid hemorrhage (SAH) grading systems, neither system has achieved universal acceptance. We propose a simplified grading system based entirely on the Glasgow Coma Scale (GCS), which compresses the 15-point GCS into five grades that are comparable with those of the HHS and WFNSS. We refer to this system as the GCS grading system and present a direct comparison with the HHS and WFNSS for predictive value regarding patient outcome and interrater reliability. ⋯ We conclude that the GCS grade has equal or greater predictive value regarding outcome after SAH than do the currently used grading systems and that it has greater reproducibility across observers. Broader familiarity with the GCS among medical and paramedical personnel may further enhance the usefulness of the GCS grade over the HHS and WFNSS in providing a standardized, universally accepted grading system for SAH.