Neurosurgery
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A technique for achieving a combined pterional (subfrontal) and anterior temporal exposure for aneurysms of the upper basilar complex is described. The technique is not new, but it does involve several modifications not previously described. A standard pterional skin incision that extends below the zygoma just anterior to the tragus is used. ⋯ After opening the dura on a flap centered on the sylvian fissure, the medial cisterns are opened widely and the fissure is opened all the way to the middle cerebral bifurcation. Posterolateral temporal retraction and, when necessary, subpial resection of the anteromedial portion of the uncus enhance the exposure posterolateral to the oculomotor nerve. The advantages of this combined approach are as follows: it combines the more anterior angle of vision offered by the pterional approach with the lateral line of vision offered by the subtemporal approach; it eliminates the need for temporal lobe elevation and it allows simultaneous clipping of other aneurysms of the ipsilateral anterior circle of Willis; and it also reduces the frequency and severity of oculomotor palsy, when compared with the subtemporal approach.
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Review Comparative Study
Chronic subdural hematoma: the role for craniotomy reevaluated.
The management of chronic subdural hematoma in the adult patient is approached with a variety of different surgical techniques. The trend in recent years has been toward treatment with burr holes or twist-drill holes rather than craniotomy. The rationale for this has been based on the assumption that burr holes and twist-drill holes offer equivalent efficacy and lower morbidity and mortality. ⋯ There was no significant difference in the incidence of postoperative complications, hematoma recurrence, or operative mortality among the different surgical groups. Previous reports concerning the superiority of burr holes over craniotomy are not substantiated by this review. Although the issue concerning optimal therapy has not been resolved by this review, at this time, craniotomy remains a valid and safe technique for the management of patients with chronic subdural hematoma.
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Review Case Reports
Giant aneurysms of the proximal anterior cerebral artery: report of three cases.
Aneurysms of any size involving the A1 segment of the anterior cerebral artery are unusual, but giant aneurysms in this location are exceedingly rare, with only five cases previously reported in the literature. We report three cases of A1 segment giant aneurysms presenting with mass effect that were successfully treated. ⋯ The three patients were treated by direct exploration, trapping, and endaneurysmal decompression. Giant A1 segment aneurysms present a unique opportunity to safely trap and decompress the aneurysm with definitive cure.
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During recent years, the management of subarachnoid hemorrhage (SAH) has changed, resulting in an increase in early operations and routine administration of nimodipine. Both influenced the indication for transcranial Doppler sonography (TCD). Furthermore, investigations detected discrepancies between Doppler findings and neurological status. ⋯ Eight patients showed either constant high or constant low velocities or even, in some cases, decreasing time courses. High flow velocities did not necessarily mean impending neurological deficits: 8 of 66 patients tolerated flow velocities over 200 cm/s. Therefore, it no longer seems to be justified to proclaim that TCD is able to predict neurological deficits, although it is doubtless able to detect vasospasm.(ABSTRACT TRUNCATED AT 250 WORDS)
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In previous publications on the diagnostic value of transcranial Doppler sonography (TCD), conflicting results concerning predictive capacities for evaluating vasospasm by measuring flow velocities were reported, and the necessity to examine pulsatility indices (PIs) was stressed. PIs are known to give useful information on cerebral hemodynamics in cases of stenosis of the extracranial internal carotid artery and cerebral arteriovenous malformations. Whether the examination of PIs can give additional information in cases of subarachnoid hemorrhage (SAH) and allow prediction of impending delayed ischemic deficits (DIDs) is still unclear. ⋯ In a prospective study of 455 follow-up TCD examinations in 66 SAH patients treated routinely with nimodipine, three different groups were analyzed separately: Group I, patients without DIDs; Group II, patients with DIDs; and Group III, patients with neurological deficits not strictly classifiable as DIDs. The analysis of all three groups together showed a typical time course after the onset of SAH: initially elevated PIs normalized around the tenth day after bleeding. According to Fisher grading, the amount of subarachnoid blood influences the increase in PIs significantly.(ABSTRACT TRUNCATED AT 250 WORDS)