Neurosurgery
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Stroke is the third leading cause of death in the United States, behind only heart disease and cancer. With an estimated three million survivors of stroke in the United States, the cost to society, both directly in health care and indirectly in lost income, is staggering. Despite recent advances in basic and clinical neurosciences, which have the potential to improve the treatment of acute stroke, the general approach to the acute stroke patient remains one of therapeutic nihilism. ⋯ Comprehensive educational efforts aimed at clinicians and the public at large have dramatically reduced the time from symptom onset to presentation and treatment for acute myocardial infarction, enabling treatment methods such as thrombolysis to be effective. The Decade of the Brain offers a unique opportunity to all concerned with the treatment of the patient with acute stroke to engage in a concerted effort to bring patients with a "brain attack" to specialized neurological attention within the same timeframe that the "heart attack" patient is handled. Such an effort is justified because, although at the present time there are few therapeutic interventions of "proven" value in the treatment of acute stroke, there is more than sufficient suggestive evidence that a number of approaches may be beneficial within the first few hours after the onset of the stroke.
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The current literature reports many measurements (arteriovenous oxygen content difference and cerebral metabolic rate of oxygen, etc.) with samples from the internal jugular veins (IJs), obtained from either side of the neck, based on the assumption that a reliable sample of mixed venous blood can be drawn. We compared oxygen saturation in both IJs in 32 patients with head injuries to establish the similarities or discrepancies in the two veins. Both IJs were cannulated with 20-G catheters; in five patients, a fiberoptic catheter was used to obtain a continuous recording of the hemoglobin saturation. ⋯ Ultimately, only eight patients had differences of less than 5%. No relationship was found among the computed tomographic scan data and the pattern of hemoglobin saturation detected. Therefore, we were not able to identify the side more appropriate for monitoring in patients with bilateral, predominantly monolateral, cortical, or deeply located lesions.(ABSTRACT TRUNCATED AT 250 WORDS)
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The majority of intracranial arteriovenous malformations (AVMs) do not require acute surgical intervention. Some patients, however, require emergent surgical treatment because of a profound neurological deterioration from a mass effect. We report 10 patients who underwent emergency AVM surgery after experiencing neurological deterioration from an intracranial hemorrhage. ⋯ Nine patients made a good-to-excellent recovery. One patient with a large motor-strip AVM remained hemiplegic. We conclude that in patients presenting with profound neurological deterioration after a spontaneous intracranial hemorrhage or one associated with an embolization procedure, prompt hematoma evacuation with simultaneous AVM excision as well as perioperative intracranial pressure control with mannitol and barbiturates can yield a good-to-excellent outcome.
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The decision-making process whereby treatment is offered to a patient with an arteriovenous malformation (AVM) must be supported by an understanding of the risks related to the natural history of the AVM and the risks related to the treatment of that particular AVM. The ability to estimate the treatment risk for an individual patient is hampered by the marked variability in the complexity of AVMs. In 1986, an AVM grading system was proposed to predict surgical morbidity and mortality. ⋯ The AVM grading system accurately correlated with both new-temporary (P < 0.0001) and new-permanent (P = 0.008) neurological deficits. The permanent major neurological morbidity rates for Grades I through III were 0%, increasing to 21.9% in patients with Grade IV and 16.7% in patients with Grade V AVMs (P < 0.0001). One patient with a Grade III AVM died from an esophageal hemorrhage 15 months after her AVM was treated.(ABSTRACT TRUNCATED AT 250 WORDS)
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Temporary occlusion of intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. The current study considered 121 patients (from a group of 234 consecutive aneurysm patients treated during a 2-yr period) who underwent elective temporary arterial occlusion. Twenty-one patients were excluded from further study because of an intraoperative rupture of an aneurysm, the elective sacrifice of afferent or efferent vessels, or the performance of an extracranial-intracranial arterial bypass graft; the remaining 100 patients underwent elective temporary occlusion under a standard neuroanesthetic regimen, including etomidate-induced burst suppression, normotension, normovolemia, and normothermia. ⋯ Patients more than 61 years of age and those in poor neurological condition (Hunt and Hess Grades III to IV) did not tolerate temporary occlusion as well as patients who were younger and in better condition. Patients occluded for less than 14 minutes routinely tolerated the iatrogenic ischemia; the 95% confidence level for the toleration of occlusion without the development of infarction occurred at 19 minutes. All patients occluded for more than 31 minutes had both clinical and radiographic evidence of cerebral infarction.(ABSTRACT TRUNCATED AT 250 WORDS)