Neurosurgery
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Mild-to-moderate reductions in local cerebral blood flow (ICBF) have been reported to occur in rats after moderate (1.7-2.2 atm) fluid percussion brain injury. The purpose of this study was to determine whether evidence for severe ischemia (i.e., mean ICBF < 0.25 ml/g/min) could be demonstrated after severe brain injury. In addition, patterns of indium-labeled platelet accumulation and histopathological outcome were correlated with the hemodynamic alterations. ⋯ These data indicate that multiple cerebrovascular abnormalities, including subarachnoid hemorrhage, focal platelet accumulation, and severe ischemia, are important early events in the pathogenesis of cortical contusion formation after TBI. Injury severity is expected to be a critical factor in determining what therapeutic strategies are attempted in the clinical setting.
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Parasagittal meningiomas, especially when associated with the middle or posterior third of the superior sagittal sinus, pose difficult management challenges. Initial surgical excision is associated with high morbidity and frequent tumor recurrence after subtotal resection. Neurological deficits are cumulative when multiple resections are required. No consistent management approach exists for patients with such tumors. In addition to observation, management options include resection, stereotactic radiosurgery, or fractionated radiation therapy used alone or in combination. ⋯ In patients with smaller tumors (<3 cm in diameter) and patent sagittal sinuses, we advocate radiosurgery alone as the first surgical procedure. Patients with larger tumors and those with progressive neurological deficits resulting from brain compression should first undergo resection. Planned second-stage radiosurgery should be performed soon afterward for any residual tumor nodule or neoplastic dural remnant. Multimodality management may enhance long-term tumor control, reduce the need for multiple resections, and maintain the functional status of the patient.
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To assess the outcomes associated with C1-C2 transarticular screw fixation. ⋯ Rigidly fixating C1-C2 instability with transarticular screws was associated with a significantly higher fusion rate than that achieved using wired grafts alone. The risk of screw malpositioning and catastrophic vascular or neural injury is small and can be minimized by assessing the position of the foramen transversaria on preoperative computed tomographic scans and by using intraoperative fluoroscopy and frameless stereotaxy to guide the screw trajectory.
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Plexiform neurofibromas with sizable intraspinal extensions and resultant spinal cord compromise pose challenging management problems, because these lesions may involve multiple nerves and engulf adjacent vascular and visceral structures. In this report, we review our experience with the surgical treatment of these lesions. ⋯ Radical resection of intraspinal tumor components in patients with neurofibromatosis 1 and large plexiform neurofibromas can help to preserve excellent neurological function. Technical factors in the management of these lesions are presented.
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Few published studies have focused specifically on the unique management issues encountered in treating patients with arteriovenous malformations (AVMs) and associated intracranial aneurysms. The primary objective of this study was to retrospectively review the clinical and radiographic features of these patients. ⋯ Aneurysms associated with AVMs are at risk for rupture before, during, and immediately after treatment of the AVMs. New aneurysms may arise in patients with high-flow AVMs. The risk of intracranial hemorrhage from either source is higher in female patients. To reduce the complications of intracranial hemorrhage in these patients, we recommend a management protocol designed to treat the aneurysms by surgical or endovascular means before administering definitive therapy for the AVMs. Meticulous intraoperative blood pressure control and fluid management during aneurysm surgery is critical to avoid hemorrhage from the AVMs.