Neurosurgery
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Historical Article
Perspectives in international neurosurgery: neurosurgery in Ireland.
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Pulmonary air embolism is recognized as a possible complication of neurosurgical procedures performed with the patient in the sitting position. A variety of preventive and therapeutic modalities have been proposed in the literature. We have used a consistent regimen consisting of precordial Doppler monitoring, measurement of end expiratory CO2, the semireclining position, and positive end expiratory pressure (PEEP). ⋯ This approach has given good results in 81 patients; there was significant air embolism in only 1 case (1.2%). We believe that PEEP is as important in the prevention as it is in the treatment of pulmonary air embolism. By flexibly adjusting the level of PEEP, one may recreate the hemodynamic equivalent of the prone position, thereby eliminating the risk of venous air embolism and simultaneously the need for right heart catheterization.
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Enlarged veins in two vascular malformations blocked the cerebrospinal fluid outflow pathways, causing hydrocephalus. Both patients presented not with the usual clinical picture (hemorrhage, seizure, etc.), but with signs of increased intracranial pressure. ⋯ An arteriovenous malformation was responsible for the first patient's headache, and a venous varix was the causative lesion in the second patient. Hydrocephalus caused by a venous varix has not been reported before.
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Comparative Study
Furosemide and mannitol in the treatment of acute experimental intracranial hypertension.
Intracranial hypertension was induced in dogs and a small number of baboons by the inflation of epidural balloons. The resulting increased intracranial pressure (ICP) was treated with standard clinical doses of furosemide (0.7 mg/kg), "mini" doses of mannitol (0.75 g/kg), or both agents in combination. ⋯ When results were averaged, furosemide used alone caused a slow reduction in ICP, but the results were variable in individual animals--with ICP actually increased in some. When furosemide and mannitol were given together, the ICP fell rapidly and remained low for considerably longer than after either agent alone.
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In the management of patients with acute cerebral disturbances, it is essential to determine precisely the degree of impaired consciousness. However, a coma scale for assessing impaired levels of consciousness has not yet been standardized internationally. The Edinburgh-2 coma scale (E2 CS) is introduced and compared with the Glasgow coma scale (GCS). ⋯ Also it is easier to grasp changes in a patient's condition shown on a chart because the levels of the E2 CS are arranged first-dimensionally. Use of the GCS should not preclude the use of other scales, such as the E2 CS; the E2 CS could be used together with the GCS. The accumulation of data on both scales would provide information useful in improving the existing coma scales.