Neurosurgery
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The infratemporal fossa (ITF) gives passage to most major cerebral vessels and cranial nerves. Dissection of the ITF is essential in many of the lateral cranial base approaches and in exposure of the high cervical internal carotid artery (ICA). We reviewed the surgical anatomy of this region. ⋯ The styloid diaphragm divides the ITF into prestyloid and retrostyloid regions and covers the high cervical ICA. Using landmarks for the exocranial portion of the lower cranial nerves is useful it identifying them and avoiding injury during approaches to the high cervical ICA, the upper cervical spine, and the ITF.
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Delayed cerebral vasospasm occurring after subarachnoid hemorrhage (SAH) is still responsible for a considerable percentage of the morbidity and mortality in patients with aneurysms. It has been suggested that the pathogenesis of delayed cerebral vasospasm is related to a number of pathological processes, including endothelial damage and smooth muscle cell contraction resulting from spasmogenic substances generated during lysis of subarachnoid blood clots, changes in vascular responsiveness, and inflammatory or immunological reactions of the vascular wall. It has been recognized that the endothelium plays an important role in the regulation of the cerebral vascular tone. In 1988, endothelin (ET)-1, a potent vasoconstrictor, was isolated from cultured porcine aortic endothelial cells. ⋯ The results of current clinical and experimental investigations support the hypothesis that ET-1 is a major cause of cerebral vasospasm after SAH. Other studies indicate that SAH causes complex changes in the ET system and increased ET-1 levels after SAH, which are not solely responsible for the development of vasospasm but may occur after cerebral ischemia. Further investigations are therefore needed to clarify these different hypotheses.
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Surgical management of traumatic internal carotid artery (ICA) dissection remains controversial. Therefore, the delayed outcomes and graft patency rates of patients who underwent bypass procedures for symptomatic traumatic ICA dissection were studied. ⋯ Revascularization for persistently symptomatic traumatic ICA dissection eliminated ischemia and was associated with excellent long-term outcomes and graft patency rates.
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Intraoperative magnetic resonance imaging (MRI) is now available with the General Electric MRI system for dedicated intraoperative use. Alternatively, non-dedicated MRI systems require fewer specific adaptations of instrumentation and surgical techniques. In this report, clinical experiences with such a system are presented. ⋯ Intraoperative MRI with the Magnetom Open provides considerable additional information to optimize resection during surgical treatment of supratentorial tumors, pituitary adenomas, and epilepsy. The twin operating theater is a true alternative to a dedicated MRI system. Additional efforts are necessary to improve patient transportation time and instrument guidance within the scanner.
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Traumatic intraventricular hemorrhage (IVH) can result in association with acute obstructive hydrocephalus, repetitive malfunction of external ventricular drains (EVDs), and uncontrollable increased intracranial pressure. We report a case showing the safe and effective use of intraventricular recombinant-tissue plasminogen activator in a child with severe brain injury and acute hydrocephalus from IVH. ⋯ With obstructive hydrocephalus secondary to acute traumatic IVH that cannot be controlled with EVD because of recurrent obstruction from intraventricular blood, intraventricular recombinant-tissue plasminogen activator can be effective and safe, despite preexisting multiple hemorrhagic intracranial injuries.