Neurosurgery
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The mechanisms responsible for subarachnoid hemorrhage (SAH)-induced vasospasm are under intense investigation but remain incompletely understood. A consequence of SAH-induced vasospasm, cerebral infarction, produces a nonrecoverable ischemic tissue core surrounded by a potentially amenable penumbra. However, successful treatment has been inconsistent. ⋯ Recent findings of microvascular regulatory mechanisms and their failure after SAH suggest a role in the development and size of the ischemia. Progress is being made in identifying the various components in the blood that cause SAH-induced vasospasm. Thus, our evolving understanding of the underlying molecular mechanism may provide the basis for improved treatment after SAH-induced vasospasm, especially at the level of the microcirculation.
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Randomized Controlled Trial Clinical Trial
Intrathecal baclofen for intractable cerebral spasticity: a prospective placebo-controlled, double-blind study.
To conduct a placebo-controlled prospective study of the effectiveness of intrathecal bolus injections and continuous administration of baclofen on functional parameters in patients with severe spasticity of cerebral origin. To compare this functional evaluation with spasticity scores in different muscle groups. ⋯ Intrathecal administration of baclofen is a safe and effective treatment for spasticity of cerebral origin. Functional improvement was demonstrated. The presence of a placebo effect on the spasticity scores suggests the need for double-blind screening in each patient.
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Review Case Reports
Quadrigeminal variant of perimesencephalic nonaneurysmal subarachnoid hemorrhage.
Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) is a benign entity with a low risk of rebleeding. The most widely accepted definition emphasizes the presence of blood ventral to the midbrain or pons on early computed tomography. We sought to determine the frequency of PNSH with blood centered in the quadrigeminal cistern. ⋯ Quadrigeminal SAH is a variant of PNSH that is not well described in the literature. It may comprise up to one-fifth of PNSH cases and carries a similar benign prognosis.
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The goals of this report were to outline the clinical presentation, radiological characteristics, surgical techniques, postoperative morbidity, and long-term follow-up results for cystic jugular foramen (JF) schwannomas and to describe their differences, compared with solid schwannomas involving the JF. ⋯ Surgical treatment of cystic JF schwannomas can be very demanding because of generally stronger adhesion of the tumor capsule to the surrounding structures, fragile tumor capsules, and difficulty in identification of the arachnoidal planes in some cases. Early identification of the arachnoidal planes without opening of the cyst and sharp dissection may be useful. Careful intradural opening of the JF should be performed to achieve total removal of the last tumor portion within the JF. A comparison of these lesions with solid schwannomas involving the JF indicated that cystic tumors affected a younger population, with less preoperative swallowing impairment (P < 0.05). The immediate postoperative course in both types of cystic JF schwannomas was usually better than for solid lesions, because of minor postoperative cranial nerve morbidity, especially involving lower cranial nerve function, in the latter cases. Long-term follow-up data failed to demonstrate any significant differences in final patient outcomes, however.
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Case Reports
Safety and feasibility of continuous infusion of remifentanil in the neurosurgical intensive care unit.
Remifentanil is a selective mu-opioid agonist with a context-sensitive half-time of 3 to 5 minutes, independent of dose or administration duration. Other desirable effects include decreased cerebral metabolism and intracranial pressure (ICP) with minimal cerebral perfusion pressure changes. We present six cases illustrating indications for the use of remifentanil in the neurosurgical intensive care unit. ⋯ The ultrashort duration of action of remifentanil allowed easy performance of frequent neurological examinations in the neurosurgical intensive care unit. No patient experienced deleterious hemodynamic or neurological effects as a result of remifentanil use.