Neurosurgery
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Case Reports
Real-time ultrasonography: a useful tool in the evaluation of the craniectomized, brain-injured patient.
Real-time ultrasonography is being used increasingly to establish the diagnosis of and serially assess intraventricular hemorrhage and hydrocephalus in neonates. The procedure requires an open fontanel because scatter from the bone occurs from direct application of the transducer to the skull and bone density precludes satisfactory imaging. With an adult, under circumstances where a bone flap is left out after intracranial procedures and the patient's clinical status is such that the patient cannot be transferred for computed tomographic scanning, real-time ultrasonography allows a safe, noninvasive, bedside demonstration of ventricular size, degree of shift of midline structures, and intraparenchymal and intraventricular lesions.
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Twenty-three of 538 patients undergoing elective craniotomy had a seizure within 24 hours after operation. The lesion had been located extra-axially in 15 patients and intra-axially in 8 patients. Except for 1 patient who had a parietal craniotomy for an arteriovenous malformation, all patients had a frontal or temporal exposure. ⋯ This review suggests that an early postoperative seizure is unlikely to be due to a postoperative hematoma or to metabolic abnormality. The most common association in this series was with inadequate anticonvulsant prophylaxis. An approach to postoperative seizure prophylaxis and management is presented.
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Operations on the 4th ventricle offer the potential for injury of the brain stem, cerebellum, cranial nerves, and major cerebellar arteries and veins. Twenty-five cadaver brains were examined using 3x to 25x magnification to define the relationship of these vital structures to the 4th ventricle. The 4th ventricle has a roof, a floor, and two lateral recesses. ⋯ The lateral recesses and adjoining parts of the roof and floor are intimately related to the cerebellopontine fissures, the anterior inferior cerebellar arteries, and the veins of the cerebellopontine fissure. The cerebellar peduncles converge on and form a major part of the ventricular surface. The hili of the dentate nuclei abut on the superolateral recesses of the ventricle near the superior poles of the tonsils.
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Patients with ankylosing spondylitis frequently experience back pain and they have a well-known propensity for spinal fractures, but they rarely manifest motor and sensory nerve root impairment. We recently encountered a patient with ankylosing spondylitis who complained of classical spinal claudication with urinary sphincter dysfunction. Computed axial tomography revealed marked lumbosacral lateral recess and foraminal spinal stenosis that was not evident on the myelogram; at operation the stenosis appeared to be the result of extensive posterior soft tissue ossification. This heretofore unrecognized yet potentially treatable complication of ankylosing spondylitis is discussed.