Neurosurgery
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Because venous air embolism (VAE) has been considered to be a major deterrent to use of the sitting position, records of 255 patients undergoing neurosurgery in the sitting position from 1975 to 1982 were reviewed to determine the nature of morbidity and mortality in relation to the surgical procedure as well as to the occurrence of VAE. Complications were classified as surgical or anesthetic during joint review by a neurosurgeon and two neuroanesthesiologists. Outcome was classified on the basis of postoperative hospital course and discharge examination. ⋯ Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE. The episodes of VAE did not seem to be significant factors in the perioperative morbidity and mortality in our series of patients operated upon in the sitting position. Two case reports are discussed in detail.
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Review Comparative Study
Intraoperative chemical hemostasis in neurosurgery.
Of the various electrical, mechanical, and chemical methods used in neurosurgical hemostasis, the chemical methods are the least well understood. In this review, data concerning seven modern chemical hemostatic agents are presented and special emphasis is placed on their neurosurgical applications. ⋯ Several conclusions have been formulated to assist the neurosurgeon in the proper selection and use of these chemical agents. It is our belief that the use of chemical hemostatics in neurosurgery should be based on a thorough knowledge of their mechanism of action and should be supported by continuing laboratory and clinical research.
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Lethargy, hyperpyrexia, tremor, and rigidity associated with leukocytosis and elevation of the creatine kinase level occurred in a patient with a closed head injury who was being treated with haloperidol for control of agitation. This constellation of symptoms, known as the neuroleptic malignant syndrome (NMS), partially improved when the neuroleptic medication was stopped, but complete resolution of the syndrome did not occur until the patient was treated with bromocriptine. ⋯ The NMS is caused by neuroleptic medications and may initially present with unexplained hyperpyrexia, leukocytosis, and elevated creatine kinase levels. Halting the neuroleptic, supportive care, and the use of dantrolene sodium and bromocriptine are the treatment modalities of choice for this syndrome, which has a mortality rate of 20 to 30% and may be linked to malignant hyperthermia.
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The incidence of hydrocephalus and vasospasm and the relationship between them were analyzed retrospectively in 87 patients with subarachnoid hemorrhage from ruptured intracranial aneurysms. Sixty-seven per cent of the patients showed ventricular enlargement on a computed tomographic scan done within 30 days of the hemorrhage; in patients whose first scan was done within 3 days of the hemorrhage, 63% seemed to have ventricular enlargement by a neuroradiologist's interpretation. Shunts were required in 14% of the patients because of delayed neurological deterioration or enlarging ventricles; 3% required ventriculostomy shortly after admission. ⋯ Hydrocephalus and vasospasm were significantly associated (P less than 0.01, chi2). These data document a high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage. They also emphasize that these two sequelae of subarachnoid hemorrhage are closely linked, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.
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Case Reports
Spontaneous migration of a bullet in the spinal subarachnoid space causing delayed radicular symptoms.
The authors report a case of a gunshot wound to the left lower quadrant of the abdomen in a patient who initially was neurologically intact. The bullet had lodged at the T-11, T-12 level in the spinal canal. ⋯ Repeat x-ray films and a myelogram showed that the bullet had migrated to the L-4, L-5 level on the left. Bullet emboli and delayed sequelae of gunshot wounds to the spine are discussed.