Journal of neurosurgery
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Journal of neurosurgery · Mar 2012
Comparative StudyAre routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?
More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13-15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12-24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics. ⋯ Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.
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Journal of neurosurgery · Mar 2012
Case ReportsTandem middle cerebral artery-internal carotid artery occlusions: reduced occlusion-to-revascularization time using a trans-anterior communicating artery approach with a penumbra device.
Rapid revascularization of tandem extracranial and intracranial acute thromboembolic occlusions can be challenging and can delay restoration of blood flow to the cerebral circulation. Taking advantage of collateral pathways in the circle of Willis for thrombectomy can reduce the occlusion-to-revascularization time significantly, thereby protecting brain tissue from ischemic injury. The authors report using the trans-anterior communicating artery (ACoA) approach by using the Penumbra microcatheter to rapidly restore blood flow to the middle cerebral artery (MCA) territory prior to treating the ipsilateral internal carotid artery (ICA) occlusion. ⋯ The trans-ACoA approach with the Penumbra microcatheter for rapid revascularization of an acutely thrombosed MCA in the setting of a simultaneous ipsilateral proximal ICA occlusion is feasible in patients with a competent ACoA. This technique can significantly minimize ischemic injury by reducing the occlusion-to-revascularization time and allow for MCA perfusion via collateral circulation while treating a proximal occlusion. To the best of the authors' knowledge, this is the first reported trans-ACoA approach with the Penumbra microcatheter and the first to report the utilization of the collateral intracranial circulation to reduce occlusion-to-revascularization time.
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Journal of neurosurgery · Mar 2012
Case ReportsDecompressive craniectomy in a neurologically devastated pregnant woman to maintain fetal viability.
Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. ⋯ The authors present the case of a young woman 21 weeks pregnant with a severe TBI (Glasgow Coma Scale Score 3) in whom safe medical ICP management became ineffective. A decompressive craniectomy was performed to obviate the need for aggressive medical management of elevated ICP using fetal-toxic medications, and thus providing the fetus the best chance of continued in utero development until a viable gestational age was reached.
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Journal of neurosurgery · Mar 2012
Rapid warfarin reversal: a 3-factor prothrombin complex concentrate and recombinant factor VIIa cocktail for intracerebral hemorrhage.
Intracerebral hemorrhage (ICH) is the most serious bleeding complication of vitamin K antagonist (VKA) therapy, carrying a high mortality. Rapid reversal of VKA in ICH is critical. Plasma therapy, the standard of care in the US, is not optimal. The ideal prothrombin complex concentrate (PCC) containing all vitamin K-dependent factors (VKDFs) is not available in the US. Therefore, the authors developed a Trauma Coumadin Protocol (TCP) consisting of a 3-factor PCC available in the US (which contains insufficient factor VII [FVII]) with a low-dose recombinant FVIIa to rapidly reverse VKA. ⋯ The TCP was very effective in rapidly reversing VKA-associated coagulopathy; however, this protocol should be used cautiously in patients at high risk for thrombosis.
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Journal of neurosurgery · Mar 2012
Case ReportsPharyngeal motor evoked potentials elicited by transcranial electrical stimulation for intraoperative monitoring during skull base surgery.
The purpose of this study was to determine whether monitoring of pharyngeal motor evoked potentials (PhMEPs) elicited by transcranial electrical stimulation during skull base tumor surgery might be useful for predicting postoperative swallowing deterioration. ⋯ Intraoperative PhMEP monitoring can be useful for predicting swallowing deterioration following skull base surgery, especially in patients with swallowing disturbances that are mainly due to reduction in the motor functions of the pharyngeal muscles.