Neurosurgery
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Case Reports
Foreign body embolization of the middle cerebral artery: review of the literature and guidelines for management.
Two cases of traumatic middle cerebral artery occlusion secondary to migratory intravascular metallic pellets are presented. Surgical removal of the occlusive pellet was achieved in one patient, and vessel patency was restored. ⋯ Factors such as the availability of a microvascular surgeon, the status of the neurological deficit resulting from the embolus, the time interval from injury to the proposed operation, and the extent of ancillary injuries sustained concurrently all bear weight on the decision to explore surgically or treat by medical measures. We believe that in cases of trauma an attempt to remove intravascular emboli is warranted to prevent migration of the embolus and distal propagation of thrombus, to avoid chronic sepsis, to prevent arterial erosion, and to restore the integrity of the vascular tree.
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A hypothesis of the pathophysiology of midcervical quadriplegia after posterior fossa operation with the patient in the sitting position under general anesthesia is presented. Observations and experimental evidence are presented to support the theory that stretch of the cervical spinal cord associated with neck flexion may be sufficient to impair the autoregulation of spinal cord blood flow enough so that the reduced, but otherwise acceptable, hemodynamic parameters associated with general anesthesia in the sitting position contribute to the risk of spinal cord infarction.
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In 58 patients with progressive neurological deterioration from angiographically confirmed cerebral vasospasm after spontaneous subarachnoid hemorrhage, arterial hypertension was induced in an attempt to improve their deficits. The most effective regimen consisted of intravascular volume expansion, blockade of the vagal depressor response, and the administration of antidiuretics and vasopressor agents. With this protocol, arterial blood pressure could be sustained at high levels for prolonged periods. ⋯ Elevating systemic arterial pressure in states of cerebrovascular insufficiency resulting from vasospasm is safe if meticulous attention is paid to physiological, biochemical, and hematological parameters, with the exception that it may be hazardous in the presence of an untreated ruptured or intact aneurysm. Intravascular volume expansion and induced hypertension are effective in reversing ischemic deficits from vasospasm provided that treatment commences before cerebral infarction and that adequate pressures are maintained for a sufficient period. The production of a hypervolemic state by the use of colloid and crystalloid infusion accompanied by atropine blockade of the vagal depressor response and blunting of the diuresis with vasopressin enables arterial pressure to be elevated for longer than 1 week.
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We have divided head injury into three categories based on the Glasgow Coma Scale (GCS) (severe, 3-8; moderate, 9-12; and minor, 13-15). In a previous report, we described significant disability after minor head injury. The present report describes 199 patients with moderate head injury, 159 of whom underwent follow-up examinations at 3 months. ⋯ The major predictors of unemployment after minor head injury were premorbid characteristics (age, education, and socio-economic status). In contrast, all predictors in moderate head injury were measures of the severity of injury (length of coma, CT diagnosis, GCS on discharge). We conclude that: (a) moderate head injury, not described previously in the literature, results in mortality and substantial morbidity intermediate between those of severe and minor head injury; (b) unlike minor head injury, the principal predictors of outcome after moderate head injury are measures of the severity of injury; and (c) more attention should be directed to patients with moderate head injury than to those with the most severe injuries, in whom brain damage is probably irreversible and all forms of management have demonstrated little success.
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With the rapid expansion of knowledge and techniques for the care of critically ill patients, the organization and recording of data have become increasingly complex and increasingly important for patient care. A flow sheet for the Neurosurgical Intensive Care Unit has been developed in a series of pilot studies with input from general and cardiovascular surgeons and nurses specializing in critical care medicine.