Neurosurgery
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Vasospasm after subarachnoid hemorrhage remains a management challenge. The accepted treatment involves hypertensive, hypervolemic, hemodilution therapy. However, there is variation in the application of this treatment. Most authors increase mean arterial pressure (MAP), which can be associated with significant morbidity. Others increase cardiac output (CO). In this study, we examined the relationship between volume status, CO, and MAP and cerebral blood flow (CBF) in the setting of vasospasm. ⋯ This article reports the first human study that shows with direct measurements the independent influence of CO in the setting of vasospasm. Increases in CO without changes in MAP can elevate CBF. This finding has immediate clinical application because CO manipulation is much safer than increasing MAP. Because both interventions were equally efficacious, our protocol has been changed to augment CO as a first measure. Induced hypertension is reserved for patients in whom this initial treatment fails.
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Hyperperfusion syndrome is a rare and potentially devastating complication of carotid endarterectomy or carotid artery angioplasty and stenting. With the advent of new imaging techniques, we reviewed our experience with this phenomenon. ⋯ Hyperperfusion syndrome may be more common and more variable in clinical presentation than previously appreciated.
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Anterior cranial base tumors are surgically resected with combined craniofacial approaches that frequently involve disfiguring facial incisions and facial osteotomies. The authors outline three operative zones of the anterior cranial base and paranasal sinuses in which tumors can be resected with three standard surgical approaches that minimize transfacial incisions and extensive facial osteotomies. ⋯ The operative zones outlined offer minimally invasive craniofacial approaches to accessing lesions of the anterior cranial base and paranasal sinuses, obviating facial incisions and facial osteotomies. Case illustrations demonstrating the approach selection paradigm are presented.
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The management of cerebellar infarctions is controversial. The aim of this study was to determine which patients require surgical treatment and which surgical procedure should be performed when a patient with a cerebellar infarction exhibits progressive neurological deterioration. ⋯ For patients with worsening levels of consciousness and radiologically evident ventricular enlargement, we recommend external ventricular drainage. We reserve surgical resection of necrotic tissue for patients whose clinical status worsens despite ventriculostomy, those for whom worsening is accompanied by signs of brainstem compression, and those with tight posterior fossae.
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The optimal surgical treatment for symptomatic temporal arachnoid cysts is controversial. Therapeutic options include cyst shunting, endoscopic fenestration, and craniotomy for fenestration. We reviewed the results for patients who were treated primarily with craniotomy and fenestration at our institution, to provide a baseline for comparisons of the efficacies of other treatment modalities. ⋯ A microsurgical keyhole approach to arachnoid cyst fenestration is a safe effective method for treating middle fossa cysts. This procedure can be performed with minimal morbidity via a minicraniotomy. Compared with an endoscopic approach, better control of hemostasis can be obtained, because of the ability to use bipolar forceps and other standard instruments. The operative time and length of hospital stay were not excessively increased.