Neurosurgery
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A meta-analysis of published randomized studies comparing prophylactic antibiotics to placebo in craniotomies was performed. Ten studies were examined; eight met criteria for inclusion into the meta-analysis. The analysis showed an advantage of antibiotics over placebo at the P < 10-8 level. ⋯ Cumulative meta-analyses showed that this conclusion could have been confidently drawn by 1988, after only four of the eight eligible trials had been published. Trials published since that time have reinforced these conclusions but have not significantly altered them. Future studies should compare proposed new antibiotic regimens with one of those already demonstrated to be effective, not with a placebo.
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The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. ⋯ Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.
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In primary malignant brain tumors increased vascularity and marked edema strongly suggest a possible role of the vascular endothelial growth factor/vascular permeability factor (VEGF/VPF). This was confirmed by earlier in situ hybridization studies, by analysis of the expression of the mitogen in different subsets of glioblastoma cells, and by the fact that the VEGF/VPF receptor flt-1 (fms-like tyrosine kinase) is up-regulated in tumor cells in vivo. To assess and quantify the expression of the VEGF/VPF gene and of the receptor gene, 26 surgical specimens of brain tumor tissue from 24 patients were analyzed. ⋯ In addition, using a radioreceptor assay it was possible to detect high VEGF/VPF-like activity in the cyst fluids of brain tumors, indicating the accumulation of the mitogen and permeability factor in brain tumor cysts. Further investigations revealed that astrocytoma and glioblastoma cells in culture express the VEGF/VPF gene and secrete the VEGF/VPF protein, whereas gene expression of the two known VEGF/VPF receptors, kinase insert domain-containing receptor and flt-1, could not be detected. These data support previous reports, which stated that VEGF/VPF acts as a paracrine growth and permeability factor in brain tumors and may contribute to tumor growth by initiating tumor angiogenesis.