Neurosurgery
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An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score. An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center. ⋯ There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.
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Biography Historical Article
An essay concerning human understanding: how the cerebri anatome of Thomas Willis influenced John Locke.
Neurosurgeons are familiar with the anatomic investigations of Thomas Willis, but his intellectual legacy actually extends into the arena of philosophy. John Locke was a student of Willis while at Oxford, and this essay explores how some of Willis's anatomic discoveries might have influenced the ideas Locke expressed in his Essay Concerning Human Understanding. It also includes historical information about 17th century England and the group of men (including Christopher Wren and Robert Boyle) who worked with Willis and founded the Oxford Experimental Philosophy Club, which became the Royal Society.
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Neurocognitive dysfunction has been shown to occur in roughly 25% of patients undergoing carotid endarterectomy (CEA). Despite this, little is known about the mechanism of this injury. Recently, several groups have shown that new diffusion weighted imaging (DWI)-positive lesions are seen in 20% of patients undergoing CEA. We investigated to what degree neurocognitive dysfunction was associated with new DWI lesions. ⋯ Neurocognitive dysfunction after CEA does not seem to be associated with new DWI positive lesions.
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An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. ⋯ If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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Patients with open (compound) cranial fractures depressed greater than the thickness of the cranium should undergo operative intervention to prevent infection. Patients with open (compound) depressed cranial fractures may be treated nonoperatively if there is no clinical or radiographic evidence of dural penetration, significant intracranial hematoma, depression greater than 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus, or gross wound contamination. Nonoperative management of closed (simple) depressed cranial fractures is a treatment option. ⋯ Elevation and debridement is recommended as the surgical method of choice. Primary bone fragment replacement is a surgical option in the absence of wound infection at the time of surgery. All management strategies for open (compound) depressed fractures should include antibiotics.