Neurosurgery
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Magnetically guided neuronavigation of flexible instruments is a new tool that can be used in the frameless navigation of deep-seated lesions or shunt placements. Disadvantages of optical systems such as the line-of-sight problem, the necessity of rigid pin fixation of the head, and missing tracking of the tip of flexible instruments should be solved by the new tracking system. Until now, the accuracy of magnetically guided systems was mostly estimated in laboratory setups. ⋯ Tracking of flexible instruments was easily accomplished as the tip of the instrument was followed within the patient's head. There were no major interferences with other metallic instruments within the surgical field.
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Cerebral revascularization is an important part of the treatment of complex intracranial aneurysms that require deliberate occlusion of a parent artery. In situ bypass brings together intracranial donor and recipient arteries that lie parallel and in close proximity to one another rather than using an extracranial donor artery. An experience with in situ bypasses was retrospectively reviewed. ⋯ In situ bypass is a safe and effective alternative to extracranial-intracranial bypasses and high-flow bypasses using saphenous vein or radial artery grafts. Although in situ bypasses are more demanding technically, they do not require harvesting a donor artery, can be accomplished with one anastomosis, and are less vulnerable to injury or occlusion.
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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.
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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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Controlled Clinical Trial
Temporal window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes--part III.
In the present study, the occurrence of the temporal window of brain vulnerability was evaluated in concussed athletes by measuring N-acetylaspartate (NAA) using proton magnetic resonance (H-MR) spectroscopy. ⋯ Results of this pilot study carried out in a cohort of singly and doubly concussed athletes, examined by H-MR spectroscopy for their NAA cerebral content at different time points after concussive events, demonstrate that also in humans, concussion opens a temporal window of brain metabolic imbalance, the closure of which does not coincide with resolution of clinical symptoms. The recovery of brain metabolism is not linearly related to time. A second concussive event prolonged the time of NAA normalization by 15 days. Although needing confirmation in a larger group of patients, these results show that NAA measurement by H-MR spectroscopy is a valid tool in assessing the full cerebral metabolic recovery after concussion, thereby suggesting its use in helping to decide when to allow athletes to return to play after a mild traumatic brain injury.