Neurosurgery
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We commonly observe progressive deterioration in somatosensory evoked potentials (SSEPs) after severe head injury. We had previously been unable to relate this deterioration to raised intracranial pressure but had noted a relationship with decreasing transcranial oxygen extraction (arteriovenous oxygen difference [AVDO2]). The purpose of this study was twofold: to prove the hypothesis that deterioration in SSEP values is associated with decreasing AVDO2 and to test the subsidiary hypotheses that deteriorating SSEPs were the result of either ischemia/reperfusion injury or failure of oxygen extraction/utilization. ⋯ The findings of increased oxygen utilization and lowered CBF in the patients with deteriorating SSEPs strongly imply that early ischemia rather than failure of O2 extraction or utilization is responsible for the associated SSEP deterioration. This issue of defining thresholds for ischemia based on AVDO2 is confounded by the dependency of CBF and AVDO2 values on the time after injury.
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Review Case Reports Comparative Study
The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage.
Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome. ⋯ Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.
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Review Case Reports
Intracranial aneurysms and sickle cell anemia: multiplicity and propensity for the vertebrobasilar territory.
We describe a case of sickle cell anemia and multiple intracranial aneurysms and review the English-language-reported cases of sickle cell disease associated with intracranial aneurysms proven angiographically or by autopsy, to assess whether there are associations with aneurysm multiplicity and sites of aneurysm occurrence. ⋯ There are strong statistical associations for aneurysm multiplicity and sites of aneurysm occurrence among reported patients with sickle cell disease. Patients with sickle cell anemia and neurological symptoms should undergo magnetic resonance angiography or four-vessel angiography to detect potentially harmful, but neurosurgically treatable, pathological conditions.
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Dural sinus thrombosis has rarely been associated with closed head injury. We present a unique case involving the use of endovascular thrombolysis in the treatment of traumatic dural sinus thrombosis, which has not been reported. ⋯ This case documents a rare instance of traumatic dural sinus thrombosis resulting from a closed head injury. In addition, endovascular thrombolysis resulted in subsequent opening of the dural sinuses and effective intracranial pressure management, despite the presence of a hemorrhagic contusion. Heparin was effective in maintaining sinus patency and was used safely in conjunction with urokinase in this setting of head injury.
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In some patients with moyamoya disease, the development of spontaneous leptomeningeal collateral channels between the anterior cerebral artery (ACA) and other major arteries is poor. These patients require revascularization not only to the territory of the middle cerebral artery (MCA) but also to that of the ACA. For reliable revascularization to the ACA territory, we performed superficial temporal artery (STA)-ACA direct anastomosis in 5 of 58 patients with moyamoya disease who underwent cerebral revascularization at our institute during the last 8 years. ⋯ Our method using a cortical branch of the ACA as a recipient and a branch of the STA for the interposed graft can be performed at the convexity and much more easily than in a deep operative field. Our experience with STA-ACA anastomosis indicates that this procedure is effective for revascularization of the ACA territory in patients with moyamoya disease.