Neurosurgery
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Except for its role in shunt infections, Propionibacterium acnes has been of little interest to neurosurgeons. The rarity and indolent nature of focal intracranial infections by P. acnes limit their recognition. Three cases of serious intracranial infection due to this organism are described. CLINCAL PRESENTATION: Three patients with histories of immunosuppression and neurosurgical procedures developed nonspecific, delayed presentations (5 wk to 5 yr after surgery) of intracranial infections. In two patients, radiological investigations showed enhancing lesions that were later found to be brain abscesses. A subdural empyema was found in the third patient. ⋯ P. acnes is an indolent organism that may rarely cause severe intracranial infections. This organism should be suspected when an intracranial purulent collection is discovered in a patient with a history of neurosurgical procedures. Immunosuppressed patients may be susceptible to this otherwise benign organism. Surgical drainage and treatment with intravenous penicillin should be considered standard therapy.
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Hemorrhage associated with central neurocytoma has been described previously, but never in association with an aneurysm originating from a feeding artery. We present the first reported case of a central neurocytoma in a patient with intraventricular hemorrhage caused by rupture of an aneurysm on a lenticulostriate artery that supplied the tumor. ⋯ Previous reports have demonstrated that intraventricular neurocytoma may present with tumor hemorrhage. In this case, an aneurysm separate and distinct from the tumor was the bleeding culprit, and the aneurysm was on an artery that fed into the tumor. Any such aneurysm must be identified and treated appropriately for therapy to be complete.
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This presentation is designed to share with fellow neurosurgeons a topic, namely the oath of Hippocrates, that has been a subject of fascination to physicians, scholars, historians, and even the public for the past 2500 years. Its moral and ethical message has exhibited remarkable resiliency through the ages, in varied cultures. Although its language may appear odd, its precepts are as valid today as they were in Hippocrates' time. ⋯ The longevity of the oath, however, is clearly attributable to its intrinsic merit, its high moral reverent tone, and a literary eloquence that placed Hippocrates among the best writers of antiquity. Despite the fame of its author, the oath has experienced a life of its own, from relative obscurity during the Dark Ages to reverential study since the Renaissance. Five aspects are considered in this discussion, i.e., 1) oaths in antiquity; 2) a biographical sketch of Hippocrates; 3) the chain of transmission from antiquity to modern times; 4) comments on other oaths, prayers, codes, and credos; and 5) an analysis and some personal views of the oath.
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The senior author (REH) has changed his technique for performing carotid endarterectomy from the use of general anesthesia to the use of cervical block anesthesia. Because a randomized study was not performed, it is difficult to separate effects of increased surgical experience from those caused by a change in anesthetic regimen. ⋯ The use of cervical block anesthesia has practically eliminated the non-stroke-related complications associated with carotid endarterectomy in our practice. The technique for performing carotid endarterectomy under cervical block anesthesia is described in detail.