Neurosurgery
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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.
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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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Transcranial motor evoked potentials (tc-MEPs) are used to monitor the spinal cord intraoperatively. Volatile anesthetics considerably depress amplitudes of tc-MEPs. This study was undertaken to determine whether multipulse stimulation might overcome this depressant effect. ⋯ These data suggest that despite the powerful depressant effects of isoflurane on myogenic motor responses, tc-MEP monitoring during isoflurane anesthesia may be feasible, provided that multipulse stimulation paradigms are used and the concentration of isoflurane does not exceed 1 minimal anesthetic concentration unit.
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Review Case Reports
Nontraumatic atlanto-occipital and atlantoaxial rotatory subluxation: case report.
Concomitant atlantoaxial and atlanto-occipital subluxation resulting from any cause is extremely rare. We have found only five previously reported cases and describe another, suggesting a treatment plan. ⋯ Disruption of the occipito-atlanto-axial complex can result from relatively minor head and neck infections and should be suspected in children with persisting neck pain and decreased neck movements. It may not be necessary to perform an occipitoaxial fusion to treat these patients, and a more limited fusion may be successful.