Neurosurgery
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An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. ⋯ If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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To present the magnetic resonance imaging features, clinical findings, and possible embryologic bases for nonterminal myelocystoceles, a distinct subset of closed spinal dysraphisms. ⋯ The nonterminal myelocystocele is a distinct form of closed spinal dysraphism characterized by a skin-covered meningocele, which is either crossed by a fibroneurovascular stalk that extends from the dorsal aspect of the spinal cord to attach to the dome of the meningocele (abortive form, or myelocystocele manqué) or contains a hydromyelic cavity that is continuous with the ependymal canal of the spinal cord (complete form).
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Patients with mass effect on computed tomographic (CT) scan or with neurological dysfunction or deterioration referable to the lesion should undergo operative intervention. Mass effect on CT scan is defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns, or the presence of obstructive hydrocephalus. Patients with lesions and no significant mass effect on CT scan and without signs of neurological dysfunction may be managed by close observation and serial imaging. ⋯ Suboccipital craniectomy is the predominant method reported for evacuation of posterior fossa mass lesions, and is therefore recommended.
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We performed a biomechanical comparison of several C1 to C2 fixation techniques including crossed laminar (intralaminar) screw fixation, anterior C1 to C2 transarticular screw fixation, C1 to 2 pedicle screw fixation, and posterior C1 to C2 transarticular screw fixation. ⋯ All four screw fixation techniques limit motion at the C1 to 2 articulation. The addition of cable fixation improves resistance to flexion and extension for posterior transarticular screw fixation.
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This is the largest contemporary series examining long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. ⋯ Wrapping or clip-wrapping of unclippable intracranial aneurysms is safe and seems to confer protection against aneurysmal growth or subarachnoid hemorrhage.