Neurosurgery
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We evaluated 95 hospitalized patients (50 women and 45 men) aged 15 to 45 who had nontraumatic subarachnoid hemorrhage (SAH). Aneurysmal SAH was identified in 75 patients. Other causes for SAH were ruptured arteriovenous malformations (2 cases), amphetamine arteritis (1 case), and leptomeningeal melanoma (1 case). ⋯ Operation was performed in 71 patients, with only 3 (4.2%) deaths. The overall mortality was 8.4% (8 of 95), with all deaths due to neurological causes. Our data suggest that the overall management and surgical results of treatment of ruptured aneurysms in young adults are excellent, diabetes is rare among young adults with SAH, recent alcohol consumption does not seem to be a major factor predisposing to SAH in young adults, and misinterpretation of the early symptoms of SAH continues to be a serious problem.
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Twenty-six cases of chronic intrathecal morphine administration are described: 19 cases utilizing the Spinalgesic injectable subcutaneous reservoir and 7 cases utilizing the Infusaid implanted infusion pump. In 25 cases, the morphine was delivered into the spinal subarachnoid space, and in 1 case of thalamic pain it was delivered into the temporal horn of the ipsilateral cerebral ventricle. The average duration of usage of the system was 132 days. ⋯ A special and relatively absolute indication for the pump is the situation of pain in the arm, head, or neck areas, in which case the constant morphine levels likely to be achieved with the pump may prevent failure of the method due to intractable nausea or emesis. The subcutaneous reservoir is otherwise to be preferred if the patient's disease is progressing rapidly, if the patient is already institutionalized and likely to remain so, or where the cost of the implanted pump would cause hardship. Either method of delivery of morphine to the subarachnoid space can provide incomparable analgesia without clouding of consciousness, with a very low complication rate.
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In patients with Cushing's syndrome or morbid obesity, excessive accumulation of fat in the hips, upper back, abdomen, and mediastinum is well known (1, 3, 7). Excessive deposition of fat in the epidural space is less common, but must be recognized as a potential cause of neurological deficit (1-8). We report a patient with iatrogenic Cushing's syndrome, in whom magnetic resonance imaging (MRI) established the specific diagnosis of spinal cord compression secondary to excess epidural fat.
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The technique of percutaneous radiofrequency (RF) upper thoracic sympathectomy mandates an exact knowledge of the anatomical location of the sympathetic ganglia. Because conflicting descriptions are given in anatomy texts, we examined the T2 and T3 sympathetic ganglia in 48 sympathetic chains in adult cadavers to measure the exact location of the ganglia. Measurements were made relative to their distances (a) dorsal to the ventral surface of the vertebral body and (b) rostral or caudal to the midpoint of the vertebral body. ⋯ The sympathetic chains lay lateral to and between the heads of the ribs at these levels. A clinical-radiographic correlation study of the sympatholytic effectiveness of various needle electrode placement sites during sympathectomy confirmed these findings. These data have been used to modify the technique of percutaneous RF sympathectomy.
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Sixteen patients each received infusions of 1 g of mannitol per kg over 5 to 10 minutes, and serial determinations of intracranial pressure (ICP), systemic arterial blood pressure (SABP), central venous pressure, cerebral perfusion pressure (CPP), hematocrit, hemoglobin, serum Na+, K+, osmolarity, and fluid balance were carried out for 4 hours. Urine output was replaced volume for volume with 5% dextrose in 0.45% NaCl solution. We tested the hypothesis that patients with high (greater than or equal to 70 torr) CPP would respond less well to mannitol by either ICP or CPP criteria than patients with low (less than 70 torr) CPP. ⋯ These data suggest that mannitol infusion is at least partly dependent upon hemodynamic mechanisms that allow vasoconstriction to occur with reduction in cerebral blood volume and that little may be gained by using mannitol when CPP greater than or equal to 70 either by SABP, ICP, or CPP criteria because vasoconstriction is already nearly maximal. This mechanism is not exclusive of other potential mechanisms of action. Mannitol "rebound" may be a function of net dehydration, hemoconcentration, and SABP decline.