Neurosurgery
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Comparative Study
"Tangential" resection of medial temporal lobe arteriovenous malformations with the orbitozygomatic approach.
Arteriovenous malformations (AVMs) of the medial temporal lobe are usually resected through subtemporal-transcortical approaches that provide a trajectory that is perpendicular to the plane of the AVM. The pterional approach is sometimes used for AVMs in the uncus and amygdala, but it is not recommended for AVMs in the hippocampal region because it provides a "tangential" approach with limited access to posterior feeding arteries and draining veins. The orbitozygomatic approach enhances exposure along this tangential trajectory and was used in a consecutive series of 10 patients to determine its advantages. ⋯ The orbitozygomatic approach maximizes the exposure of the tangential approach to medial temporal lobe AVMs and has advantages over traditional lateral approaches. It provides early access to critical feeding arteries from the anterior choroidal artery, posterior cerebral artery, and posterior communicating artery; it minimizes temporal lobe retraction and risk to the vein of Labbé; and it avoids transcortical incisions or lobectomy that might impact language and memory function. For these reasons, it may be the optimal approach for small- and medium-sized compact AVMs in the dominant medial temporal lobe.
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Large provider caseloads are associated with better patient outcomes after many complex surgical procedures. Mortality rates for pediatric brain tumor surgery in various practice settings have not been described. We used a national hospital discharge database to study the volume-outcome relationship for craniotomy performed for pediatric brain tumor resection, as well as trends toward centralization and specialization. ⋯ Mortality and adverse discharge disposition rates for pediatric brain tumor craniotomy were lower when the procedure was performed at high-volume hospitals and by high-volume surgeons in the United States, from 1988 to 2000. There were trends toward lower mortality rates, greater centralization of surgery, and more specialization among surgeons during this period.
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Severely head-injured patients have traditionally been maintained in the head-up position to ameliorate the effects of increased intracranial pressure (ICP). However, it has been reported that the supine position may improve cerebral perfusion pressure (CPP) and outcome. We sought to determine the impact of supine and 30 degrees semirecumbent postures on cerebrovascular dynamics and global as well as regional cerebral oxygenation within 24 hours of trauma. ⋯ Routine nursing of patients with severe head injury at 30 degrees of head elevation within 24 hours after trauma leads to a consistent reduction of ICP (statistically significant) and an improvement in CPP (although not statistically significant) without concomitant deleterious changes in cerebral oxygenation.
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Intraventricular thrombolysis speeds blood clot resolution: results of a pilot, prospective, randomized, double-blind, controlled trial.
Animal models and clinical studies suggest that intraventricular thrombolysis improves clot resolution and clinical outcomes among patients with intraventricular hemorrhage. However, this intervention may increase the rates of rebleeding and infection. To assess the safety and efficacy of intraventricular thrombolysis, we conducted a pilot, randomized, double-blind, controlled, multicenter study. ⋯ Intraventricular thrombolysis with urokinase speeds the resolution of intraventricular blood clots, compared with treatment with ventricular drainage alone.