Neurosurgery
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The subject of human pain can be subdivided into two broad categories: physical pain and psychological pain. Since the dawn of human consciousness, each of these two forms of pain-one clearly physical, the other having more to deal with the mind-have played a central role in human existence. Psychological pain and suffering add dimensions that go far beyond the boundaries of its physical counterpart. ⋯ Our results appear to be more than promising so far. It appears that neuropathic pain and psychoaffective disorders seem to be sharing an anatomophysiological common background at the Brodmann Area 25 of the anterior cingulated gyrus. On the basis of these exciting findings, we believe that it is reasonable to suggest that neuropathic pain and psychoaffective disorders may ultimately be managed with complementary or, at least, similar, therapeutic strategies, each of which lie within the domain of the neurosurgeon.
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To report our experience with the treatment of brain arteriovenous malformations (AVM) with microsurgical resection after embolization with Onyx liquid embolic agent (eV3, Irvine, CA). ⋯ Multimodality treatment with microsurgery is safe and effective after embolization with Onyx. High occlusion rates and low complication rates were observed after Onyx embolization and were comparable to those in previous reports. Superselective intranidal or perinidal catheter positions and slow, controlled injections that protect the draining veins make the therapy safe even in complex AVMs and critical locations. We recommend resection of the AVM despite apparently complete embolization with Onyx. Team work and coordination between the surgeon and the interventional neuroradiologist are important to achieve a good outcome.
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Vestibular schwannomas (VS) are common, benign, VIIIth cranial nerve tumors. Treatment in patients with the genetic disorder neurofibromatosis type II (NF2) is complicated by their development of bilateral VS and risk of complete deafness. Intervention decisions consider several clinical factors including tumor size and growth rate evaluated using magnetic resonance imaging. The current study evaluated the relative sensitivity of volumetric versus linear diameter measurement for assessing VS growth rate and progression. ⋯ Linear measurements underestimate VS growth rate compared with volumetric measures in NF2 patients. These results provide clear, quantitative proof that diameter measures are not as sensitive to change as volumetric measurements and that volumetric measurements should be strongly considered when making VS treatment decisions.
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Chiari I malformation is complicated by syringomyelia in many cases. Hindbrain decompression remains first-line surgical treatment; however, the incidence, time course, and predictors of syrinx resolution remain unclear. We set out to determine predictors of syrinx improvement after hindbrain decompression for Chiari I- associated syringomyelia. ⋯ In our experience, just more than one-half of patients with Chiari- associated syringomyelia demonstrated clinical and radiographic improvement after hindbrain decompression. Median time to radiographic improvement lagged behind clinical improvement by 10 months. Motor symptoms were more likely to improve with hindbrain decompression. Paresthesia or anesthesia symptoms were less likely to improve with hindbrain decompression. These findings may help guide surgical decision making and aid in patient education.
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The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. ⋯ Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.