Neurosurgery
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Harvey Cushing made fundamental and seminal contributions to pediatric neurosurgery. Early in his surgical career, he described the diagnosis and treatment of subdural hematomas in newborn infants. Important investigations on the cerebrospinal fluid and the nature of hydrocephalus were carried out under his direction, first by Walter Dandy and Kenneth Blackfan in the Hunterian Laboratory at the Johns Hopkins School of Medicine, and shortly afterward by Lewis Weed at the Laboratory of Surgical Research at Harvard. ⋯ In the closing years of Cushing's surgical practice, he published three major papers summarizing the characteristics, clinical picture, and treatment of the more common brain tumors in the pediatric age group. As a result of his exceptional surgical skill and innovations, he was able to achieve a surgical mortality of only 4% in operations on brain tumors in children. These landmark papers secured Cushing's place as a pioneer in pediatric neurosurgery.
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Case Reports
Paraplegia after a routine lumbar laminectomy: report of a rare complication and successful management.
Arachnoid cysts of the spinal canal are relatively common lesions that may be either intra- or extradural. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots. We report a case in which an intradural thoracic arachnoid cyst became symptomatic after a routine decompressive lumbar laminectomy for spinal stenosis. ⋯ A change in the flow dynamics of the cerebrospinal fluid probably allowed the development of spinal cord compression due to one of the following: expansion of the cyst, decreased cerebrospinal fluid buffer between the cord and the cyst, or epidural venous engorgement. A concomitant and more cephalad lesion such as an arachnoid cyst should be considered when myelopathic complications arise after lumbar surgery. Magnetic resonance imaging and computed tomography after myelography are useful to demonstrate the additional pathological processes.
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Noninvasive duplex scanning of carotid artery atherosclerotic plaque was performed in 286 consecutive patients referred to a cerebrovascular diagnostic laboratory. The presence and thickness of such plaque in the region of the carotid bifurcation were examined for association with the degree of vessel stenosis, age, sex, smoking history, history of prior transient ischemic attack or stroke, and systemic manifestations of atherosclerotic disease. Atherosclerotic plaque thickness was positively correlated with degree of vessel stenosis (P less than 0.0001). ⋯ Such noninvasive scanning of carotid artery atherosclerotic plaque demonstrates the significant role of age and smoking in the progression of disease. It also suggests a significant role for carotid atherosclerotic artery plaque in the pathophysiology of cerebrovascular events, especially transient ischemic attacks, even prior to the production of a flow-limiting stenosis. Finally, noninvasive screening of carotid artery plaque may provide a useful marker for the patient at risk for systemic atherosclerotic disease and identify the patient for whom maximal atherosclerotic risk factor modification is needed.
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Early changes in intracranial pressure (ICP), ICP volume index, and resistance to absorption of cerebrospinal fluid induced by experimental subarachnoid hemorrhage were studied in cats. After SAH, the ICP was slightly elevated, and there was a decrease in the buffering capacity of the intracranial space and a sharp rise in outflow resistance. ⋯ It is suggested that the marked increase in ICP during blood infusion into the subarachnoid space is caused by intracranial volume loading and the simultaneous increase in cerebrospinal fluid outflow resistance. It is concluded that the reported relationship between increased cerebrospinal fluid outflow resistance and increased ICP supports the hypothesis of a strong increase in ICP during subarachnoid hemorrhage in human subjects.
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Inconsistencies across studies concerning outcome after mild head injury may reflect differences in the diagnostic criteria used for selection of patients. Consequently, we compared the neurobehavioral outcome in three groups of consecutively hospitalized patients (aged 16 to 50 years) who sustained a closed head injury (CHI) and had a Glasgow Coma Scale (GCS) score in the 9 to 15 range. These groups included patients with uncomplicated CHI with mild impairment of consciousness as reflected by a GCS score in the 13 to 15 range (n = 78), patients with initially mild impairment of consciousness complicated by brain lesion or depressed skull fracture (n = 77), and patients with moderate CHI (n = 60). ⋯ Although moderate CHI produced longer durations of impaired consciousness and posttraumatic amnesia than complicated mild head injury, patients in these groups did not differ in neurobehavioral performance. Global outcome at 6 months was better in the patients with mild CHI than in patients with complicated mild and moderate injuries. Analysis of the various complications of mild CHI revealed that the presence of an intracranial lesion was related to more severe neurobehavioral sequelae than injuries complicated by a depressed fracture.