Neurosurgery
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Case Reports
Cranial migration of a baclofen pump catheter associated with subarachnoid hemorrhage: case report.
Cephalad migration of an indwelling intrathecal catheter within the spinal canal has rarely been described. Cranial subarachnoid hemorrhage (SAH) related to movement of this type of catheter has not been described. We report a case of SAH coincident with the migration of a free fragment of a baclofen pump catheter into the prepontine cistern. ⋯ Cephalad catheter migration is a rare phenomenon. The mechanism of rostral migration remains unclear. The forces that propel a free fragment of catheter under these circumstances seem to be sufficient to cause a small vessel to rupture and bleed. Given the lack of an observed arterial injury, we postulate that venous bleeding caused this hemorrhage.
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Hearing loss after removal of vestibular schwannomas with preservation of the cochlear nerve can result from labyrinthine injury of the posterior semicircular canal and/or common crus during drilling of the posterior wall of the internal auditory meatus. Indeed, there are no anatomic landmarks that intraoperatively identify the position of the posterior semicircular canal or of the common crus. We investigated the usefulness of image guidance and endoscopy for exposure of the internal auditory canal (IAC) and its fundus without labyrinthine injury during a retrosigmoid approach. ⋯ Frameless navigation using high-resolution computed tomographic scans and bone-implanted reference markers can provide a "roadmap" to maximize safe surgical exposure of the IAC without violating the labyrinth and leaving a small segment of the lateral IAC unexposed. Further exposure and surgical manipulation of this segment, including the fundus without additional cerebellar retraction and labyrinthine injury, can be achieved using an endoscope. Use of image guidance and an endoscope can help in exposing the entire posterior aspect of the IAC including its fundus without violating the labyrinth through a retrosigmoid approach. This technique could improve hearing preservation in vestibular schwannoma surgery.
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Frequently, the cervicothoracic junction can be reached through a simple anterior approach. In some cases, access to this region requires a much more aggressive surgical intervention, such as manubriotomy or sternotomy. Information regarding the need for such interventions is particularly useful to have preoperatively to guide surgical planning as well as discussions regarding surgical risks and expected morbidities. Whereas methods utilizing magnetic resonance imaging have been proposed for determining the lowest level that can be accessed through a simple low cervical approach, we describe a simple technique using sagittal computed tomographic imaging. Our technique does not require any complex geometry and has given us very consistent results. ⋯ We propose a simple and consistent method for determining the need for manubriotomy or sternotomy for anterior approaches to the cervicothoracic junction.
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Clinical Trial
Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen.
Hypertonic saline is emerging as a potentially effective single osmotic agent for control of acute elevations in intracranial pressure (ICP) caused by severe traumatic brain injury. This study examines its effect on ICP, cerebral perfusion pressure (CPP), and brain tissue oxygen tension (PbtO2). ⋯ Hypertonic saline as a single osmotic agent decreased ICP while improving CPP and PbtO2 in patients with severe traumatic brain injury. Patients with higher baseline ICP and lower CPP levels responded to hypertonic saline more significantly.
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We sought to determine the frequency, risk factors, and impact on functional outcome and quality of life (QOL) of global cognitive impairment 1 year after subarachnoid hemorrhage. ⋯ Global cognitive impairment affects more than 20% of subarachnoid hemorrhage survivors at 1 year, is predicted by fever, anemia treated with transfusion, and delayed cerebral ischemia, and adversely affects functional recovery and QOL.