World Neurosurg
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Ischemic stroke is one of major complications of cardiac surgery. Although a current American Heart Association (AHA) guideline states that carotid endarterectomy is probably recommended before or concomitant to coronary artery bypass grafting (CABG) for the carotid stenosis, there is no report that analyzed optimal strategies in cardiac surgery for patients with total occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA). Therefore, this preliminary study was aimed to clarify whether preoperative blood flow measurements and prophylactic superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis could reduce the incidence of perioperative ischemic stroke during cardiac surgery in patients with total occlusion of the ICA or MCA. ⋯ This is the first report suggesting that preoperative identification of hemodynamic compromise and prophylactic STA-MCA anastomosis may reduce perioperative ischemic stroke during cardiac surgery in patients with ICA or MCA occlusion, although further studies are needed to assess the validity.
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The significance of medial and lateral opticocarotid recesses and the planum sphenoidale region in skull base pathologies for the transsphenoidal-transplanum approach were evaluated. ⋯ The lateral opticocarotid recess is a reliable and persistent indicator for extended transsphenoidal surgery. To approach the opticocarotid region near the internal carotid artery and optic nerve, a careful dissection is needed to minimize surgical injuries to the optic nerve and carotid artery. Other factors determining a reliable bone resection are the anteroposterior length of the planum sphenoidale and the distance and width of the angle between optic nerves. Attention should be given to individual anatomic variations of the region when planning and performing transsphenoidal-transplanum surgery.
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The endoscopic transsphenoidal approach has become widely used for pituitary and extended skull base operations. Intraoperative conversion to a microscopic approach may be an important option in selected cases. We aim to characterize the operative situations in which such conversion occurred and facilitated the procedure. ⋯ Although endoscopic transsphenoidal surgery provides superior visualization in most patients, conversion to a microscopic or endoscopic-assisted approach may provide essential visualization in selected patients. This may be especially true in patients undergoing reoperation and patients with acromegaly or Cushing's disease. Trainees learning the endoscopic transsphenoidal approach should become familiar with the benefits and limitations of the various transsphenoidal approaches.
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Restricted access to neurosurgical care in rural sub-Saharan Africa remains an unaddressed and formidable challenge. Despite the implementation of a rigorous 5-year curriculum to train and certify indigenous neurosurgeons "in continent" as Fellows of the College of Surgeons in Neurosurgery for East, Central, and Southern Africa (FCS-ecsa-NS), provincial and rural hospitals are likely to see no change in this woeful status quo for the foreseeable future. Modifying that curriculum with a two-tiered training experience that includes fast-track certification of general surgeons to perform basic neurosurgical procedures in their own hospitals is a viable alternative to redress this problem in a timely fashion. Founded on a competence-based as opposed to a time-served assessment of clinical/surgical skills along the lines of a 2002 landmark study in the United Kingdom, such an approach (in tandem with retaining separate FCS certification for prospective faculty in the NSTP-ECSA program) deserves urgent reconsideration.
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Although acute cocaine use has been correlated with aneurysmal subarachnoid hemorrhage, its effect on vasospasm and outcome is controversial. We investigated the effect of acute cocaine use on response to vasospasm treatment and neurologic outcome in patients with aneurysmal subarachnoid hemorrhage. ⋯ There is no significant difference in incidence of symptomatic vasospasm or neurologic outcome between cocaine users and nonusers. The severity of the vasospasm and the response to treatment, as indicated by the number of vasospasm interventions, did not differ between the two groups.