Neurosurgery
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The majority of intracranial arteriovenous malformations (AVMs) do not require acute surgical intervention. Some patients, however, require emergent surgical treatment because of a profound neurological deterioration from a mass effect. We report 10 patients who underwent emergency AVM surgery after experiencing neurological deterioration from an intracranial hemorrhage. ⋯ Nine patients made a good-to-excellent recovery. One patient with a large motor-strip AVM remained hemiplegic. We conclude that in patients presenting with profound neurological deterioration after a spontaneous intracranial hemorrhage or one associated with an embolization procedure, prompt hematoma evacuation with simultaneous AVM excision as well as perioperative intracranial pressure control with mannitol and barbiturates can yield a good-to-excellent outcome.
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Temporary occlusion of intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. The current study considered 121 patients (from a group of 234 consecutive aneurysm patients treated during a 2-yr period) who underwent elective temporary arterial occlusion. Twenty-one patients were excluded from further study because of an intraoperative rupture of an aneurysm, the elective sacrifice of afferent or efferent vessels, or the performance of an extracranial-intracranial arterial bypass graft; the remaining 100 patients underwent elective temporary occlusion under a standard neuroanesthetic regimen, including etomidate-induced burst suppression, normotension, normovolemia, and normothermia. ⋯ Patients more than 61 years of age and those in poor neurological condition (Hunt and Hess Grades III to IV) did not tolerate temporary occlusion as well as patients who were younger and in better condition. Patients occluded for less than 14 minutes routinely tolerated the iatrogenic ischemia; the 95% confidence level for the toleration of occlusion without the development of infarction occurred at 19 minutes. All patients occluded for more than 31 minutes had both clinical and radiographic evidence of cerebral infarction.(ABSTRACT TRUNCATED AT 250 WORDS)
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The decision-making process whereby treatment is offered to a patient with an arteriovenous malformation (AVM) must be supported by an understanding of the risks related to the natural history of the AVM and the risks related to the treatment of that particular AVM. The ability to estimate the treatment risk for an individual patient is hampered by the marked variability in the complexity of AVMs. In 1986, an AVM grading system was proposed to predict surgical morbidity and mortality. ⋯ The AVM grading system accurately correlated with both new-temporary (P < 0.0001) and new-permanent (P = 0.008) neurological deficits. The permanent major neurological morbidity rates for Grades I through III were 0%, increasing to 21.9% in patients with Grade IV and 16.7% in patients with Grade V AVMs (P < 0.0001). One patient with a Grade III AVM died from an esophageal hemorrhage 15 months after her AVM was treated.(ABSTRACT TRUNCATED AT 250 WORDS)
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Historical Article
The development of neurological surgery at Cook County Hospital.
The development of neurosurgery in Chicago has rather unique beginnings. The key contributions by well-known general surgeon demonstrators who worked at Chicago's Cook County Hospital in the late 1800s and early 1900s are highlighted. The formation of neurosurgical academic programs and educational development in Chicago is detailed further and placed in perspective.
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The authors review the surgical management of nine complex paraclinoid aneurysms treated with the endovascular balloon catheter technique. With the patient under general anesthesia, the balloon catheter was guided into the feeding artery of the aneurysm by the Seldinger technique. After the aneurysm was exposed, the balloon was inflated temporarily to prevent premature rupture and to facilitate the dissection of the aneurysm. ⋯ An embolectomy was performed immediately, and there were no postoperative sequelae. We conclude that the combined endovascular and neurosurgical approach, particularly for the large ICA aneurysms, which are difficult to control proximally, can be a useful method of treatment. To prevent complications related to thrombus formation, further refinement in the balloon catheter itself is still needed.