Neurosurgery
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We review the anatomic features of the lateral ventricle, the foramen of Monro, the third ventricle, and the choroidal fissure, and we describe the transchoroidal approach to the third ventricle. This approach consists of opening the taenia fornicis of the choroidal fissure in the body of the lateral ventricle and approaching the third ventricle between the two internal cerebral veins. This route allows further posterior enlargement of the foramen of Monro without sacrificing any neural structures. When necessary, the anterior septal vein can be sacrificed. ⋯ An understanding of the choroidal fissure is fundamental for use of the transchoroidal approach. Unlike transforaminal, subchoroidal, subforniceal, and interforniceal approaches to the third ventricle, which sacrifice some neural or vascular structures, the transchoroidal approach follows a natural route, and certainly it is one of the options to be considered when entry into the third ventricle is required.
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Low-grade fibrosarcomas and desmoid tumors present a surgical challenge in that they have a strong tendency for local invasion, surgical margins are poorly delineated, and complete resections are difficult. Nowhere is this more evident than in those lesions involving the brachial plexus. We review our experience with these difficult lesions. ⋯ Surgical resection plus postoperative radiotherapy is the treatment of choice for low-grade fibrosarcomas and desmoid tumors involving the brachial plexus. However, aggressive surgical management with the goal of achieving a gross total resection with negative histological margins can produce unnecessary morbidity. Preserving function should be a primary goal of the operations, although this will be associated with residual disease and will risk local recurrence but rarely death resulting from the disease.
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Review
Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors.
The goals were to critically review all complications resulting within 30 days after craniotomies performed for excision of intra-axial brain tumors relative to factors likely to affect complication rates and to assess the value of these data in predicting the risk of surgical morbidity, particularly for surgery in eloquent brain regions. ⋯ The finding that gross total resections could be performed in eloquent brain regions with an acceptable level of neurological impairment suggested that the mere presence of a tumor in eloquent brain does not automatically contraindicate surgery. Our results have practical risk-predictive value, and they should aid in the construction of subsequent outcome studies, because we have identified the key areas to monitor.
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Review Case Reports Comparative Study
The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage.
Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome. ⋯ Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.
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Review Case Reports
Intracranial aneurysms and sickle cell anemia: multiplicity and propensity for the vertebrobasilar territory.
We describe a case of sickle cell anemia and multiple intracranial aneurysms and review the English-language-reported cases of sickle cell disease associated with intracranial aneurysms proven angiographically or by autopsy, to assess whether there are associations with aneurysm multiplicity and sites of aneurysm occurrence. ⋯ There are strong statistical associations for aneurysm multiplicity and sites of aneurysm occurrence among reported patients with sickle cell disease. Patients with sickle cell anemia and neurological symptoms should undergo magnetic resonance angiography or four-vessel angiography to detect potentially harmful, but neurosurgically treatable, pathological conditions.