Neurosurgery
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Autosomal dominant polycystic kidney disease (ADPKD) is associated with increased prevalence of cerebral aneurysms and increased risk of subarachnoid hemorrhage. A decision analysis by Levey et al. in 1983 demonstrated that patients with ADPKD would not significantly benefit from routine arteriographic screening for cerebral aneurysms. We reexamined this conclusion in light of new clinical data and the introduction of magnetic resonance imaging (MRI) as a screening method. ⋯ A sensitivity analysis showed that the model was most sensitive to estimates of the prevalence of aneurysms in ADPKD, the annual incidence of rupture, and the morbidity and mortality rates associated with rupture. A financial analysis showed that a screening strategy is likely to cost less than a nonscreening strategy. The model predicts that an MRI screening strategy would increase the life expectancy of young patients with ADPKD and reduce the financial impact on society of ADPKD.
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This study proposes an anatomically based nomenclature for the internal carotid artery (ICA) that can be applied by all disciplines. In 1938, Fischer published a seminal paper describing five segments of the ICA that were designated C1 through C5. These segments were based on the angiographic course of the intracranial ICA rather than its arterial branches or anatomic compartments. ⋯ Histological sections in critical areas were examined. The authors' classification has the following seven segments: C1, cervical; C2, petrous; C3, lacerum; C4 cavernous; C5, clinoid; C6, ophthalmic; and C7, communicating. This classification is practical, accounts for new anatomic information and clinical interests, and clarifies all segments of the ICA.
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Research examining the neurobehavioral outcome after mild head injury has yielded inconsistent and contradictory findings. Such findings have been attributed to a variety of methodological weaknesses, such as failure to consider the preinjury status of the patient, lack of control groups, and variability in outcome time points. However, few researchers have examined the adequacy of the current diagnostic criteria. ⋯ This study demonstrates the need for more precise research diagnostic criteria in the study of neurobehavioral outcome after mild head injury. These findings also provide compelling evidence for the re-examination of the classification of mild head injury. Serious consideration must be given to the segregation of patients with GCS scores of 15 from those with scores of 14 and 13.
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We report the case of a 70-year-old man with a 17-year history of angina pectoris, who had previously suffered two documented myocardial infarctions and undergone multiple diagnostic cardiac catheterizations, two coronary artery bypass operations, and several percutaneous transluminal coronary angioplasty procedures. The patient had experienced unstable angina for the past 3 years refractory to maximal medical therapy and was unsuitable for further attempts at revascularization. After a successful trial of epidural infusion of morphine, a totally implantable programmable continuous-infusion device with an intrathecal catheter was implanted in the patient on August 18, 1993, resulting in maintained pain resolution. ⋯ Six months later, the pump treatment did not mask the development of a myocardial infarction. To the best of our knowledge, this is the first report of the use of continuous intrathecal infusion of morphine or the use of a totally implantable programmable infusion device for angina pectoris. We propose that in carefully selected patients with chronic unstable angina, continuous intrathecal infusion of morphine may relieve effort-induced pain without resulting in myocardial infarction.