Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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Deep brain stimulation (DBS) has emerged as a viable therapy for Parkinson's disease (PD). The impact of subthalamic nucleus (STN) lead placement (lateral versus medial) on motor outcome, however, has not been systematically evaluated. Forty-eight patients with PD underwent STN-DBS surgery and were evaluated postoperatively for 48 weeks for motor improvement as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) part III (standardized motor examination) and levodopa equivalent daily dose (LEDD). ⋯ No significant difference in stimulation voltage was noted with respect to lead location. Our study did not find a significant effect for the location of active contact and motor outcome neither within the subregions of the STN nor between the STN and surrounding fibers. Further research is needed to better understand the neurophysiological basis for these results.
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Although recent data suggests that lumbar fusion with decompression contributes to some marginal acceleration of adjacent segment degeneration (ASD), few studies have evaluated whether it is safe to perform a laminectomy above a fused segment. This study investigates the hypothesis that laminectomy above a fused lumbar segment does not increase the incidence of ASD, and assesses the benefits and risks of performing a laminectomy above a lumbar fusion. A retrospective review of 171 patients who underwent decompression and instrumented fusion of the lumbar spine was performed to analyze the association between ASD and laminectomy above the fused lumbar segment. ⋯ There was no significant increase in ASD in patients with decompressive laminectomy above the fused lumbar segment compared to patients with laminectomy limited to the fused segment. This retrospective review of 171 patients who underwent decompression and instrumented fusion with follow-up radiographs demonstrates that laminectomy decompression above a fused segment does not significantly increase radiographic ASD. There is, however, a significant increase in ASD over time, which was observed throughout the entire cohort likely representing a natural progression of lumbar spondylosis above the fusion segment.
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Review
New-generation oral anticoagulants for the prevention of stroke: implications for neurosurgery.
A new generation of oral anticoagulants, namely direct thrombin inhibitors and factor Xa inhibitors, have recently been approved for clinical use in patients with atrial fibrillation. These novel families of drugs have been shown to have favorable efficacy and safety profiles in multiple clinical settings, particularly in the prevention of atrial fibrillation-related stroke, and are likely to become part of everyday practice, making a crossover to neurosurgical patients inevitable. Concern has risen regarding the complexity of managing intracranial and intraspinal hemorrhages related to these drugs. ⋯ We discuss current evidence for the use of these novel agents, their limitations, existing methods of drug-level monitoring, and controversies related to anticoagulation reversal. We also discuss specific topics such as anticoagulation resumption after intracranial or intraspinal bleeding, perioperative anticoagulant administration, and the possibility of combination with tissue plasminogen activator in the setting of acute ischemic stroke. A special focus is given to the incidence of intracranial and intraspinal hemorrhage associated with each drug.
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The endovascular treatment of patients with tiny, wide-necked aneurysms is technically challenging, due to the small volume for microcatheterization and coil stabilization inside the aneurysm sac. We performed a retrospective study to evaluate the feasibility, effectiveness, and safety of stent-assisted embolization for patients with ruptured, tiny, wide-necked posterior communicating artery (PcomA) aneurysms. Between January 2007 and August 2011, 17 tiny, wide-necked PcomA aneurysms that had ruptured were treated at our institution using a modified stent-assisted technique, with delivery of the first coil inside the aneurysm followed by placement of a self-expanding stent via a second microcatheter. ⋯ Clinical follow-up of 16 patients for a mean of 23.8 months showed no death or rebleeding. These results imply that endovascular treatment of ruptured tiny, wide-necked PcomA aneurysms using our modified stent-assisted coiling technique is safe and feasible. This technique improves the long-term outcomes of these aneurysms by increasing the packing density and diverting the intra-aneurysmal blood flow.
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Esophageal perforation is an uncommon but potentially fatal complication of anterior cervical spinal surgery. This study aimed to investigate the diagnosis and treatment of cervical esophageal perforation related to spinal surgery. Among 1097 consecutive cases of anterior cervical spinal surgery that were managed at our institution over a 20 year period, five patients with esophageal perforation were identified. ⋯ The early diagnosis of esophageal perforation related to cervical spinal surgery relies on clinical suspicion and efficient investigation. The selection of appropriate treatment options, which include esophageal rest, antibiotic administration, nutrition support, wound debridement, open drainage, and surgical repair, largely depends on when the perforation is recognized. Early diagnosis and prompt management of this complication are likely to result in a good clinical outcome.