Neurosurgery
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The incidence of hydrocephalus and vasospasm and the relationship between them were analyzed retrospectively in 87 patients with subarachnoid hemorrhage from ruptured intracranial aneurysms. Sixty-seven per cent of the patients showed ventricular enlargement on a computed tomographic scan done within 30 days of the hemorrhage; in patients whose first scan was done within 3 days of the hemorrhage, 63% seemed to have ventricular enlargement by a neuroradiologist's interpretation. Shunts were required in 14% of the patients because of delayed neurological deterioration or enlarging ventricles; 3% required ventriculostomy shortly after admission. ⋯ Hydrocephalus and vasospasm were significantly associated (P less than 0.01, chi2). These data document a high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage. They also emphasize that these two sequelae of subarachnoid hemorrhage are closely linked, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.
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Lesions of the peripheral part of the trigeminal nerve may cause trigeminal neuropathy associated with severe pain. Such pain usually does not respond to carbamazepine and analgesics, and it is continuous and lacks the characteristic paroxysmal character of tic douloureux. These patients often present with complex changes of facial sensibility in the form of dysesthesia, hyperalgesia, and allodynia. ⋯ For the selection of patients for permanent electrode implantation, a method has been developed for trial stimulation via a percutaneous electrode introduced into the trigeminal cistern. Temporary trial stimulation can be performed for several days. It is concluded that stimulation of the trigeminal ganglion and rootlets with the aid of an implanted electrode may effectively relieve certain forms of trigeminal pain that are otherwise extremely difficult to manage.
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Biography Historical Article
W. W. Keen: America's pioneer neurological surgeon.
The contributions of William Williams Keen to the development of neurological surgery were greater than those of any other American surgeon in the last quarter of the 19th century. His close association with S. Weir Mitchell, the father of American neurology, spanned more than 50 years. ⋯ He made contributions to the surgical treatment of hydrocephalus, craniostenosis, torticollis, trigeminal neuralgia, and nervous system trauma. Keen's surgical texts provided an important foundation for Cushing, Frazier, and those that followed. Showered with honors as America's dean of surgery, Keen lived to see the many specialties evolve.
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Sophisticated techniques for electrical stimulation of excitable tissue to treat neuromuscular disorders rationally have been developed over the past 3 decades. A historical review shows that electricity has been applied to the phrenic nerves to activate the diaphragm for some 200 years. Of the contemporary methods for stimulating the phrenic nerve in cases of ventilatory insufficiency, the authors prefer stimulation of the phrenic nerve in the thorax using a platinum ribbon electrode placed behind the nerve and an attached subcutaneously implanted radiofrequency (RF) receiver inductively coupled to an external RF transmitter. ⋯ Candidates for diaphragm pacing are those with ventilatory insufficiency due to malfunction of the respiratory control center or interruption of the upper motor neurons of the phrenic nerve. In the Yale series, there were 77 patients treated by diaphragm pacing; 63 (82%) started before 1981 and thus were available for follow-up for at least 5 years; 33 (52%) were paced for 5 to 10 years, and 15 (24%) were paced for 10 to 16. Long term stimulation of the phrenic nerves to pace the diaphragm is an effective method of ventilatory support in selected cases.
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Quantitative measurements of the epidural space between T-7 and L-4 were made in the sagittal and coronal planes utilizing x-ray films made after the injection of iodized oil into the epidural space in the low thoracic and upper lumbar areas. These data reveal a 1-mm ventral epidural space and a 2-mm lateral epidural space, with a sawtooth shape to the dorsal epidural space measuring between 1.1 and 2.9 mm at the rostral lamina and between 3.8 and 6.5 mm at the caudal lamina. Additionally, five patients with chronic pain were studied by computed tomography of T-8 to T-12, with confirmation of the sawtooth shape of the dorsal epidural space. Computed tomography showed the measurements of the epidural space at the rostral lamina to vary between 1.3 and 1.6 mm and those at the caudal lamina/interlaminar space to range from 6.9 to 9.1 mm.