Neurosurgery
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Rheumatoid arthritis frequently affects the craniovertebral junction (CVJ) and may lead to severe neck pain, quadriparesis, and respiratory dysfunction. Surgery in rheumatoid nonambulatory (Ranawat Class IIIb) patients carries a significant risk. This study presents the surgical outcome of Class IIIb patients with CVJ rheumatoid myelopathy and reviews the literature. ⋯ A large subset of patients with CVJ rheumatoid myelopathy may reach Class IIIb. These patients have unique management considerations. Surgery (despite high morbidity) often remains the best therapeutic option available to them. Improvement of even one grade in their Ranawat score from Class IIIb to Class IIIa brought about by surgery confers on them a significant benefit in terms of their quality of life and survival.
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In a recent article, our experience and knowledge of the clinical picture, microsurgical anatomy, and long-term surgical outcome of resecting tuberculum sellae meningiomas was described in detail. We now present our surgical technique in a pictorial and video format for the benefit of neurosurgeons in training, as well as for general critique. Attention is given to the details of surgery: patient positioning, surgical approaches, technique of tumor removal, and postoperative care.
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Acute disseminated encephalomyelitis (ADEM) varies widely in symptoms and severity. Some cases are associated with massive life-threatening cerebral edema refractory to conventional medical management. ⋯ This case report reinforces the place of this procedure in the armamentarium of treatment options for patients with medically refractory brain swelling and elevated intracranial pressure caused by ADEM. The potential for an increase in the incidence of ADEM with more frequent smallpox vaccinations emphasizes the significance of redefining the full range of management options for this treatable disease.
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The Sonic Flashlight (SF) is a new handheld ultrasound (US) display device being developed at our institution. It replaces the standard monitor on a conventional ultrasound (CUS) system with a miniature monitor and half-silvered mirror to reflect real-time US images into the body. With the SF, the imaged body part appears translucent, with the US image appearing to float below the surface of the anatomy, exactly where it is being scanned. The SF merges the patient, US image, instrument, and operator's hands into the same field of view, allowing the user to operate directly on the US image using normal hand-eye coordination. In contrast, CUS procedures result in displaced hand-eye coordination when the operator looks away from the patient to view the CUS monitor. Intraoperatively, the SF may make localizing and accessing tumors, foreign bodies, hematomas, vascular malformations, and ventricles easier and more accurate, especially for those without extensive CUS training. ⋯ The needle was easily and intuitively visualized and guided into the lesion, both within and outside of the US plane. By having the US image appear directly beneath the brain surface, the surgeon can easily and quickly guide the needle or surgical instrument to the lesion. The operator's eyes never have to leave the surgical field, as they do with CUS technology. The impact of this device on neurosurgical procedures could be significant. The ease of use, intuitive function, and small instrument size allow the surgeon to quickly localize lesions, confirm surgical positioning, and assess postoperative results.
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The pretemporal approach has gained popularity for the treatment of basilar apex aneurysms. However, it requires the sacrifice of anterior temporal bridging veins to allow posterior temporal lobe retraction and, for patients with dominant pretemporal venous drainage, has the attendant risk of venous hypertension, hemorrhagic venous infarction, or seizures postoperatively. Alternatively, we have found that splitting the sylvian fissure, resecting the uncus, and applying posterolateral retraction to the medial temporal lobe provides a similar exposure to the basilar apex while preserving the anterior temporal bridging veins. To evaluate the transsylvian, trans-uncal approach to the basilar apex, we report our initial clinical results using this exposure in eight consecutive patients. A morphometric cadaveric analysis comparing this approach with the pretemporal approach was also performed. ⋯ When approaching the basilar bifurcation, the transsylvian, trans-uncal approach provides superior exposure of the ipsilateral superior cerebellar and posterior cerebral arteries compared with the pretemporal approach, while preserving the anterior temporal bridging veins. This approach is most valuable in patients with dominant temporal venous drainage or when additional exposure of the ipsilateral posterior cerebral or superior cerebellar arteries is required.