Neurosurgery
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The excision of an arteriovenous malformation (AVM) located within eloquent neocortex presents a formidable neurosurgical challenge. Compromise of the vascular supply to normal surrounding brain or surgical trauma to essential neighboring neocortex may result in unacceptable postoperative neurological morbidity. In addition, successful removal of these lesions without the benefit of intraoperative corticography may leave in situ areas of highly epileptogenic brain, resulting in continued epilepsy. ⋯ Trial occlusion of feeding vessels was also carried out to document postocclusion neurological deterioration, if any. At a later time, a second procedure was performed under general anesthesia to excise the lesion and any epileptogenic foci, using the cortical maps derived earlier. Using these techniques, it was possible to effect complete excision of these lesions in seven of eight patients without causing additional neurological deficits.
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In patients with subarachnoid hemorrhage, delayed neurological deficits, often followed by infarction, are believed to result from ischemia caused by vasospasm. Cerebral blood flow (CBF) data have been useful in predicting the risk of vasospasm in these patients and in distinguishing those deficits caused by vasospasm. Although CBF thresholds for infarction have been established in animals, few clinical studies have correlated CBF values with neurological symptoms and infarction. ⋯ The blood flow studies caused neither significant complications nor neurological deterioration. The Xe/CT CBF method appears very sensitive to the early detection of symptomatic vasospasm. In most patients with subarachnoid hemorrhage, this noninvasive technique can replace angiography to delineate the location and severity of vasospasm, and may be useful in predicting the development of infarction.
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Seventeen head-injured patients with signs of brain stem compression at admission underwent emergency bilateral burr-hole exploration before computerized tomographic (CT) scanning. After exploration of the epidural and subdural spaces, real-time ultrasonography was performed intraoperatively to identify intraaxial hematomas. Epidural or subdural hematomas were identified surgically in 11 patients (65%) and immediately evacuated through a craniotomy; in 2 patients, bilateral subdural hematomas were removed. ⋯ These results confirm that patients with clinical evidence of brain stem compression soon after head injury often have extraaxial hematomas that can be readily identified by burr-hole exploration. Although intraparenchymal hematomas are rare immediately after head injury, they can usually be identified by intraoperative ultrasonography. This simple technique can reduce the risk of missing intracranial hematomas during emergency burr-hole exploration and improve intraoperative decision making in this population of severely head-injured patients.
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A case of successful combination chemotherapy using cisplatinum, vinblastine, and bleomycin (PVB therapy) to treat medulloblastoma disseminated by cerebrospinal fluid is presented. In this case, a locally recurrent tumor and several disseminated tumors were seen to decrease in size on CT examinations. Pain in the lower extremities and urinary incontinence improved during three courses of PVB therapy administered during a period of 9 weeks. These results suggest that combination PVB therapy may offer one of the treatments of choice for recurrent or disseminated medulloblastoma.