Neurosurgery
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Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, early reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patients at risk for systemic embolization involving the brain. The risk of embolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular function. This dilemma exists because of a lack of data for a large series of patients. ⋯ Temporary interruption of anticoagulation therapy seems safe for patients with intracranial hemorrhage and mechanical heart valves but without previous evidence of systemic embolization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to clip or coil a ruptured aneurysm, or to evacuate an acute subdural hematoma.
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Randomized Controlled Trial Clinical Trial
Effect of 5% albumin solution on sodium balance and blood volume after subarachnoid hemorrhage.
Subarachnoid hemorrhage (SAH) predisposes patients to excessive natriuresis and volume contraction. We studied the effects of postoperative administration of 5% albumin solution on sodium balance and blood volume after SAH. We also sought to identify physiological variables that influence renal sodium excretion after SAH. ⋯ Supplemental 5% albumin solution given to maintain CVP values of >8 mm Hg prevented sodium and fluid losses but did not have an impact on blood volume in our patients, who were hypervolemic in base line measurements. The natriuresis that occurs after SAH may be mediated in part by elevations of GFR. In addition to acting as a colloid volume expander, 5% albumin solution lowers the GFR and promotes renal sodium retention after SAH. These properties may limit the amount of total fluid required to maintain a given CVP value and hence may minimize the frequency of pulmonary edema.
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Biography Historical Article
The contribution of Davide Giordano (1864-1954) to pituitary surgery: the transglabellar-nasal approach.
This report describes the fundamental contribution made by Davide Giordano, proposing the transglabellar surgical approach in a period in which transfacial and transbasal operative approaches to the pituitary gland were considered inadvisable because of their risk. His idea was to gain access through bilateral paranasal and frontal skin incisions, allowing removal of the ethmoid bone and the anterior wall of the sphenoidal cube. ⋯ The importance of his contribution was confirmed by Cushing, who reported his first use of the approach of Giordano in 1909 in a patient with a pituitary adenoma. The efforts of Giordano clearly inspired surgeons of his era to perform this operation clinically, giving impetus to the further development of neurosurgery.
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Some adult patients with moyamoya disease have been treated successfully by indirect revascularization alone, although surgical indications and hemodynamic changes for these patients have not been fully explored. To examine surgical indications for this procedure, we studied the regional cerebral blood flow (rCBF) and angiographic findings in adult patients with moyamoya disease preoperatively and postoperatively. ⋯ We conclude that for the surgical treatment of adult patients with moyamoya disease, indirect procedures, mainly encephaloduroarteriosynangiosis, are recommended for patients with lower rCBF and no or negative vascular reactivity in the noninfarcted cortices, as well as for those who have no indication for the direct procedure. It is possible to determine these indications by a xenon-133 inhalation single photon emission computed tomographic study including an acetazolamide challenge test.
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To evaluate the risk factors for postoperative complications among patients undergoing craniofacial resection for the treatment of anterior cranial base tumors, a retrospective analysis of patients treated in University of Tokyo Hospital between September 1987 and November 1996 was conducted. ⋯ Compared with previous reports, craniofacial resection has become a relatively safe and effective procedure for the treatment of tumors involving the anterior cranial base. However, additional care should be taken with patients who have experienced a previous craniotomy, frontal lobe involvement, or radiotherapy with a total dose of > or =60 Gy.