Acta neurochirurgica
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Acta neurochirurgica · Jan 1998
Intraoperative facial nerve monitoring (IFNM) predicts facial nerve outcome after resection of vestibular schwannoma.
Intraoperative facial nerve monitoring (IFNM) is a suitable technique for intraoperative facial nerve identification and dissection, especially in large vestibular schwannomas (VS) (acoustic neuroma). To evaluate its feasibility for estimating functional nerve outcome after VS resection 60 patients underwent surgery using IFNM. Out of this group the last 40 patients were included in a prospective study evaluating the prognostic value of various IFNM parameters (proximal and distal absolute EMG amplitude, stimulation threshold, and proximal-to-distal amplitude ratio) for prediction of initial postoperative facial nerve function and recovery of function. ⋯ Two patients with initial mHB degree IV improved to mHB degree III despite intraoperative evidence of missing functional nerve integrity. Therefore, functional recovery cannot be predicted by IFNM in all cases of anatomical nerve preservation. We conclude that a minimum follow-up period of 1 year may still be advisable even in certain patients without evidence of intraoperative functional nerve integrity.
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Acta neurochirurgica · Jan 1998
Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP).
Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3-8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented. ⋯ The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.
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It is usually defficult in clinical practice to establish factors affecting final outcome in patients suffering severe diffuse brain injury (SDBI), due to the absence of specific semiology. ⋯ Clinical evaluation, early CT findings, ICP values and their response to medical treatment and clinical complications were found to be related (p < 0.05) to final outcome (GOS).
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Acta neurochirurgica · Jan 1998
Unco-parahippocampectomy for direct surgical treatment of downward transtentorial herniation.
Downward transtentorial herniation is a major cause of death and disability caused by acute supratentorial mass lesions. Thirteen patients, 7 men and 6 women aged from 23 to 75 years old, with progressive transtentorial herniation caused by cerebral contusion with acute subdural haematoma, acute brain swelling after aneurysmal subarachnoid haemorrhage, or massive cerebral infarction were treated by direct surgery using selective removal of the uncus and parahippocampal gyrus (unco-parahippocampectomy). All patients showed progressive deterioration of transtentorial herniation (late third nerve stage or midbrain stage) with unilateral pupillary dilation and absent light reflex. ⋯ Two of the 13 patients died (15%). Two of the 11 survivors (18%) were functionally independent and 1 (9%) required minimal assistance but was independent at home. This series suggests the lifesaving nature of unco-parahippocampectomy in patients with deteriorating clinical condition because of transtentorial herniation.