Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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Comparative Study
Clinical characteristics and risk factors of chronic subdural haematoma associated with clipping of unruptured cerebral aneurysms.
Chronic subdural haematoma (CSDH) is an uncommon but potentially serious complication of clipping unruptured cerebral aneurysms. We conducted a study to identify the patients who are at risk of developing postoperative CSDH. The data from 713 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed, and risk factors correlated with CSDH were identified by multivariate regression analysis of demographic variables. ⋯ As in men, the risk of CSDH was significantly higher in the older women (OR 6.69, 95% CI 1.10-40.73). The interval between the aneurysm clipping and CSDH development was 0.5-6 months, suggesting that clinical observation should be continued up to 6 months after surgery. Although prognosis for patients with a postoperative CSDH complication is generally favourable, the risk of CSDH should be taken into account when considering elective clipping of unruptured aneurysms in patients ≥70 years of age.
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Ophthalmic segment aneurysms refer to superior hypophyseal artery aneurysms, true ophthalmic artery aneurysms, and their dorsal variant. Indications for treatment of these aneurysms include concerning morphological features, large size, visual loss, or rupture. Although narrow-necked aneurysms are ideal endovascular targets, more complex and larger lesions necessitating adjunctive stent or flow-diversion techniques may be suitably treated with long-lasting, effective clip ligation instead. ⋯ In the management of superior hypophyseal artery aneurysms, emphasis is placed on identifying and preserving superior hypophyseal artery perforators, using serial fenestrated straight clips rather than a single right-angled fenestrated clip to obliterate the aneurysm. Post-clipping indocyanine green dye angiography is a crucial tool to confirm aneurysm obliteration and the preservation of the parent vasculature and adjacent superior hypophyseal artery perforators. With careful attention to the nuances of microsurgical clipping of ophthalmic segment aneurysms, rewarding results can be obtained.
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Review Case Reports
Thoracic phosphaturic mesenchymal tumors causing oncogenic osteomalacia.
Oncogenic osteomalacia is a rare paraneoplastic syndrome induced by mesenchymal tumors. Just over 100 cases have been reported for this rare disorder, and only seven instances were caused by phosphaturic mesenchymal tumors of the spine. The authors present an illustrative case of a 61-year-old woman with oncogenic osteomalacia induced by a tumor of the spine, and review the literature describing the clinical presentation, surgical treatment, and follow-up of this syndrome.
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Comparative Study
Asleep-awake-asleep craniotomy: a comparison with general anesthesia for resection of supratentorial tumors.
The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. ⋯ The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen.
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Ophthalmic segment aneurysms present unique technical challenges because of their proximity to the optic nerve and the anterior clinoid process. The current study was performed to examine whether surgery for unruptured ophthalmic segment aneurysms is an effective treatment modality with acceptable complication rates. A consecutive case series (prospectively collected data) was retrospective reviewed for the period between April 1992 and August 2012. ⋯ Logistic regression analysis of risk factors revealed that age (p < 0.02), aneurysm size (p < 0.01) and the use of temporary clipping (p < 0.01) were significant negative predictors of outcome. The risk associated with surgical repairs for unruptured ophthalmic segment aneurysms is no greater than aneurysms in other locations (6.4% morbidity; 0.6% mortality) and no more hazardous than outcomes achieved by alternative therapies. The robustness of aneurysm repair achieved by open microsurgery is an important consideration.