Neurosurgery
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An aggressive surgical strategy was applied to cranial gunshot wound victims at Cook County Hospital in Chicago from 1983 to 1992. A series of 480 patients with an overall mortality rate of 34% is presented. ⋯ Criteria for operation were Glasgow Coma Scale scores of 3 through 7 without hypotension or fixed and dilated pupils or Glasgow Coma Scale scores of 8 through 15 with intracranial bone fragments or significant clot. This study supports previous reports that even patients with severe neurological deficits and massive cerebral damage can benefit from aggressive treatment and make satisfactory recoveries.
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Invasive hemodynamic monitoring has become standard in the management of aneurysmal subarachnoid hemorrhage. This study is a retrospective analysis of 630 Swan-Ganz catheters placed in 184 patients with aneurysmal subarachnoid hemorrhage. Evaluation of complications demonstrated a 13% incidence of catheter-related sepsis (81 of 630 catheters), a 2% incidence of congestive heart failure (13 of 630 catheters), a 1.3% incidence of subclavian vein thrombosis (8 of 630 catheters), a 1% incidence of pneumothorax (6 of 630 catheters), and a 0% incidence of pulmonary artery rupture. In the management of patients with aneurysmal subarachnoid hemorrhage, invasive hemodynamic monitoring continues to be an important tool with acceptable complications.
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We report a case of the complete resection of a parasagittal meningioma, including an 8-cm length of the superior sagittal sinus and adjacent dura. Flow through the sagittal sinus was reestablished through an interposed saphenous vein graft. ⋯ Follow-up magnetic resonance angiography 9 months after surgery demonstrated continued patency of the graft. Sagittal sinus replacement with a vein graft can be safely performed during Simpson Grade I resection of parasagittal meningiomas.
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FROM THE RECORDS of approximately 1500 shunt operations performed between 1987 and 1992, we identified 37 adults between ages 38 and 86 years (mean, 70 yr) with the normal-pressure hydrocephalus (NPH) syndrome who underwent surgery by a single surgeon. Since 1990, we have routinely used a flow-regulated shunt system (Orbis-Sigma valve [OSV]; Cordis Corporation, Miami, FL) in these patients. In this study, we compared the OSV system with conventional differential-pressure (DP) shunt systems uniformly used before 1990. ⋯ Realizing the limitations of a retrospective analysis and on the basis of the limited number of patients in this study, we conclude that using actuarial methods, we found no significant difference in shunt survival when comparing the OSV with the standard DP valve shunt systems with antisiphon devices in patients with NPH. Contrary to previous reports, the OSV is not free of overdrainage complications. Most patients (89%) with the NPH syndrome who primarily presented with gait disorder experienced significant improvement in gait after either OSV or DP shunting procedures when selected for surgery on the basis of the clinical syndrome and confirmatory radiographic data.
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From January 1, 1990, to April 30, 1994, 412 patients were admitted to our intensive care unit in coma after head injuries. Our study group consisted of 37 patients who were retrospectively identified as harboring lesions or developing new lesions within a 12-hour period from the time of admission. We defined the evolution of a lesion as an increase or decrease in the size of an already present hematoma or as the appearance of a totally new lesion. ⋯ There was a trend toward a poorer result among the patients with clinical deterioration, which, however, was not significant. A significant proportion of post-traumatic patients, particularly those who are unconscious, harbor early evolving intracranial lesions. When the first CT scan is performed within 3 hours after injury, a CT scan should be repeated within 12 hours.