Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewThe role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage.
Transcranial Doppler ultrasonography (TCD) is a tool employed by the neurosurgeon and neurointensivist in the management of vasospasm in the intensive care unit after aneurysmal subarachnoid hemorrhage. A review of the current indications, monitoring parameters, indices, and relevance of modern TCD technology is provided, as well as algorithms for the use of TCD ultrasonography in the management of patients with subarachnoid hemorrhage. Other current uses of TCD ultrasonography are also discussed in the setting of neurocritical care.
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Neurosurg. Clin. N. Am. · Apr 2010
Review Historical ArticleSurgical management of aneurysmal subarachnoid hemorrhage.
Aneurysmal subarachnoid hemorrhage (aSAH) is a common and often devastating condition that requires prompt neurosurgical evaluation and intervention. Modern management of aSAH involves a multidisciplinary team of subspecialists, including vascular neurosurgeons, neurocritical care specialists and, frequently, neurointerventional radiologists. This team is responsible for stabilizing the patient on presentation, diagnosing the offending ruptured aneurysm, securing the aneurysm, and managing the patient through a typically prolonged and complicated hospital course. ⋯ Following a brief historical perspective on the origin of aneurysm surgery, the topics discussed include the timing of surgical intervention after aSAH, commonly used surgical approaches and craniotomies, fenestration of the lamina terminalis, intraoperative neurophysiological monitoring, intraoperative digital subtraction and fluorescent angiography, temporary clipping, deep hypothermic cardiopulmonary bypass, management of acute hydrocephalus, cerebral revascularization, and novel clip configurations and microsurgical techniques. Many of the topics highlighted in this report represent some of the more debated techniques in vascular neurosurgery. The popularity of such techniques is constantly evolving as new studies are performed and data about their utility become available.
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewCerebral salt wasting: pathophysiology, diagnosis, and treatment.
Cerebral salt wasting (CSW) is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. The mechanisms underlying CSW have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. ⋯ Volume status, but not serum and urine electrolytes and osmolality, is crucial for making this distinction. Volume and sodium repletion are the goals of treatment of patients with CSW, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids.
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Cerebral vasospasm is a cause of significant morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Most cases of vasospasm can be managed medically. Medical strategies for treatment include hemodynamic augmentation to improve cerebral perfusion pressure and medical therapy to prevent or reduce cerebral vasospasm. ⋯ Balloon angioplasty is an effective technique in treating vasospasm and results in durable clinical improvement. It should be used judiciously, however, given a small risk of vessel rupture associated with intracranial angioplasty. The goal of angioplasty should be improvement of vessel caliber to augment flow rather than to achieve a picture-perfect result.
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewNoninvasive imaging techniques in the diagnosis and management of aneurysmal subarachnoid hemorrhage.
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition, requiring prompt diagnosis and therapeutic intervention as well as close monitoring for the development of complications including vasospasm (VS). Although digital subtraction angiography is still considered the gold standard for the diagnosis of aSAH (and vasospasm), new and less invasive modalities are emerging including ultrasound, CT, CT angiography and CT perfusion, and MR imaging. The current evidence for the use of these newer modalities is described for the diagnosis of aSAH and the management of its sequelae including VS.