Neurosurgical review
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Neurosurgical review · Jun 2019
ReviewCould propranolol be beneficial in adult cerebral cavernous malformations?
Surgery is the only therapeutic option for cerebral cavernous malformations (CCM) and is proposed, whenever possible, after haemorrhagic events, neurological symptoms, or epilepsy, radiosurgery being a controversial alternative in some cases. However, there is no treatment for non-accessible lesions, such as brainstem CCM, multiple CCM, or those located in functional areas. ⋯ We herein review the histological, in vitro data and clinical findings that support the idea of propranolol as a potential treatment for CCM. Since one retrospective study has not been conclusive, we support the idea that prospective trials are necessary.
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Neurosurgical review · Jun 2019
Meta Analysis Comparative StudyHypertonic saline or mannitol for treating elevated intracranial pressure in traumatic brain injury: a meta-analysis of randomized controlled trials.
Hyperosmolar therapy is regarded as the mainstay for treatment of elevated intracranial pressure (ICP) in traumatic brain injury (TBI). This still has been disputed as application of hypertonic saline (HS) or mannitol for treating patients with severe TBI. Thus, this meta-analysis was performed to further compare the advantages and disadvantages of mannitol with HS for treating elevated ICP after TBI. ⋯ Both serum sodium (WMD = 5.30, 95% CI: 4.37 to 6.22, p < 0.001) and osmolality (WMD = 3.03, 95% CI: 0.18 to 5.88, p = 0.037) were increased after injection of hypertonic saline. The results do not lend a specific recommendation to select hypertonic saline or mannitol as a first-line for the patients with elevated ICP caused by TBI. However, for the refractory intracranial hypertension, hypertonic saline seems to be preferred.
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Neurosurgical review · Jun 2019
ReviewDeep brain stimulation of the anterior nucleus of the thalamus for drug-resistant epilepsy.
Despite the use of first-choice anti-epileptic drugs and satisfactory seizure outcome rates after resective epilepsy surgery, a considerable percentage of patients do not become seizure free. ANT-DBS may provide for an alternative treatment option in these patients. This literature review discusses the rationale, mechanism of action, clinical efficacy, safety, and tolerability of ANT-DBS in drug-resistant epilepsy patients. ⋯ Based on the available evidence ANT-DBS and VNS therapies are currently both superior compared to non-invasive neuromodulation techniques such as t-VNS and rTMS. Additional in-vivo research is necessary in order to gain more insight into the mechanism of action of ANT-DBS in localization-related epilepsy which will allow for treatment optimization. Randomized clinical studies in search of the optimal target in well-defined epilepsy patient populations, will ultimately allow for optimal patient stratification when applying DBS for drug-resistant patients with epilepsy.
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Neurosurgical review · Jun 2019
Comparative StudyComparison of radiological and clinical characteristics between blood blister-like aneurysms (BBAs) and non-blister aneurysms at the supraclinoid segment of internal carotid artery.
Blood blister-like aneurysms (BBAs) were considered a therapeutic challenge for both microsurgeons and endovascular therapists. While a great deal of efforts had been put to refining the treatment of BBAs, the diagnostic criteria had not been established yet. In this study, we reviewed data of 43 suspicious, small (< 1 cm), broad-necked aneurysms at supraclinoid segment of internal carotid artery (ICA) in 41 patients who had been treated with microsurgery in our hospital during the past 5 years. ⋯ BBAs and non-blister aneurysms were difficult to differentiate by clinical and radiological features as they share many characteristics in common. Dome/neck ratio < 1 did not guarantee accurate diagnosis of BBAs. A discriminant function incorporating dome/neck ratio and degree of distal angle as factors might increase the accuracy of pre-surgical diagnosis of BBAs.
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Neurosurgical review · Jun 2019
What is the best therapeutic approach to a pediatric patient with a deep-seated brain AVM?
Although brain arteriovenous malformations (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous intracranial hemorrhages. Pediatric bAVMs tend to rupture more frequently and seem to have higher recurrence rates than bAVMs in adults. Thus, the management of pediatric bAVMs is particularly challenging. ⋯ GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population.