Neurosurgery
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Cerebral vasospasm is a common, formidable, and potentially devastating complication in patients who have sustained subarachnoid hemorrhage (SAH). Despite intensive research efforts, cerebral vasospasm remains incompletely understood from both the pathogenic and therapeutic perspectives. At present, no consistently efficacious and ubiquitously applied preventive and therapeutic measures are available in clinical practice. ⋯ Recent studies attempting to dissect the cellular and molecular basis of the inflammatory response accompanying SAH and cerebral vasospasm have provided a promising groundwork for future studies. It is plausible that the inflammatory response may indeed represent a critical common pathway in the pathogenesis of cerebral vasospasm pursuant to SAH. Investigations into the nature of the inflammatory response accompanying SAH are needed to elucidate the precise role(s) of inflammatory events in SAH-induced pathologies.
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For many years, the central nervous system (CNS) has been described as "immunologically privileged" and devoid of conventional immune reactivity. However, our more current understanding of neuroimmunology supports a different view. Although immune mechanisms within the CNS may behave differently from those located at peripheral anatomic sites, it is now widely accepted that biologically relevant immune responses can and do occur within the brain and that these responses can play important roles in CNS disease. The objective of this present review is to explore key aspects of recent insights into the cellular interactions involved in neuroimmunology, which may suggest more rational approaches to the immunotherapy of neurosurgical disorders. ⋯ Modern advances in molecular medicine and basic immunology have yielded a plethora of new data about CNS immunobiology. The design of effective immunotherapeutic strategies for CNS diseases requires a contemporary understanding of the basic tenets of how the immune system works. The current renaissance in this field may give neurosurgeons hope that, in the future, immunotherapy-based paradigms may be able to successfully treat neurosurgical diseases that are currently refractory to traditional therapies.
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Dolenc has pioneered the extradural approach to the anterior clinoid process (ACP) in approaching the cavernous sinus, clinoidal space, and orbital apex. A key step is the division of the frontotemporal dural fold (FTDF). Less experienced surgeons may not be as versatile in their three-dimensional understanding of the superior orbital fissure and thus may risk injury to its contents. Through our cadaveric and subsequent clinical experience, we have devised a modification of the approach that permits safer handling of the contents of the superior orbital fissure. ⋯ This technical modification of the extradural approach of Dolenc is a simple, safe, and valuable adjunct to the exposure of the ACP. We recommend its use particularly by relatively inexperienced surgeons.
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Giant arteriovenous malformations (AVMs) (i.e., those greater than 6 cm at maximum diameter) are difficult to treat and often carry higher treatment morbidity and mortality rates than do smaller AVMs. In this study, we reviewed the treatment, angiographic results, and clinical outcomes in 53 patients with giant AVMs who were treated at Stanford between 1987 and 2001. ⋯ The results in this series of patients with giant AVMs, which represents the largest series reported to date, suggest that selected symptomatic patients with giant AVMs can be treated successfully with good outcomes and acceptable risk. Multimodality treatment is usually necessary to achieve AVM obliteration.
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Little information about the natural history of incidental meningiomas exists in the literature. The aim of this study was to determine the natural history of asymptomatic meningiomas by comparing different methods of growth rate calculation to establish a strategy for dealing with these tumors. ⋯ The majority of incidental meningiomas show minimal growth; thus, they may be observed without surgical intervention unless specific symptoms appear. Tumor growth is associated with patient age. The initial tumor size is not considered a predictive factor for tumor growth. Radiological features, such as calcification or T2 signal intensity, may provide useful information to predict the growth potential of meningiomas.