Articles: cations.
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J Stroke Cerebrovasc Dis · Nov 2002
International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial.
Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomized, multicenter trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n = 1070) or endovascular treatment by detachable platinum coils (n = 1073). ⋯ The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.
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Naturally occurring opiates (endorphins) diminish testosterone levels by inhibiting both hypothalamic gonadotrophin releasing hormone production and testicular testosterone synthesis. Heroin addicts treated with a single daily dose of methadone and nonaddicts receiving continuous intrathecal opioids quickly develop low luteinizing hormone and total testosterone levels. A similar pattern was sought in men consuming commonly prescribed oral opioids. ⋯ Either TT or E(2) level was subnormal in all 28 men consuming the equivalent of 100 mg of methadone daily and in 19 of 26 (73%) consuming smaller opioid doses. Eighty-seven percent (39 of 45) of opioid-ingesting men who reported normal erectile function before opioid use reported severe erectile dysfunction or diminished libido after beginning their opioid therapy. Commonly prescribed opioids in sustained-action dosage forms usually produce subnormal sex hormone levels, which may contribute to a diminished quality of life for many patients with painful chronic illness.
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The role of zygapophysial (facet) joints in chronic thoracic pain has received very little attention with only a few publications discussing these joints as sources of pain. In contrast, facet joints have been implicated as responsible for chronic pain in a significant proportion of patients with chronic neck and low back pain. However, thoracic spinal pain, though less common, has been reported to be as disabling as neck and low back pain. ⋯ Results showed that 46 patients underwent single blocks with lidocaine and 36 of these patients, or 78%, were positive for facet joint pain, reporting a definite response. Confirmatory blocks with bupivacaine were performed in all patients who were lidocaine-positive, with 61%, or 48% of the total sample of the lidocaine-positive group, reporting a definite response with improvement in their pain. Thus, comparative local anesthetic blocks showed the prevalence of facet joint pain to be 48%, with single blocks carrying a false-positive rate of 58%.
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Major complications after intracranial surgery occur in 13-27% of patients. These complications may have multiple causes, but a body of arguments suggests that the haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. The aim of this review is to explain the rationale of this hypothesis and analyse the recent studies relevant to neuroanaesthesia recovery. ⋯ Pain, hypothermia, hypercapnia, hypoxia, hypoosmolality, hypertension, and anaemia should be avoided during emergence. Early emergence is associated with minimal haemodynamic and metabolic changes. If there is any doubt as to whether the patient should be extubated in the operating room, a gradual emergence in the intensive care unit makes it possible to decide whether or not extubation can be performed safely.
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This prospective, non-randomized clinical trial was designed to determine the clinical outcome of patients who underwent Intradiscal Electrotherapy (IDET) for the treatment of chronic discogenic low back pain. Twenty-seven consecutive patients undergoing IDET were prospectively evaluated. All patients, as determined by provocative discography and/or MRI, had discogenic disease with chronic low back pain and were non-responsive to conservative treatment for at least 6 months. ⋯ This did not translate into a significant improvement in the SF-36 survey scores. The risks are negligible, and recovery time is minimal. The procedure may be useful in selected patients who would otherwise undergo an interbody fusion procedure.