British journal of neurosurgery
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Review Case Reports
Surgical management of previously coiled intracranial aneurysms.
With the increased use of endovascular therapy in the treatment of ruptured intracranial aneurysms the number of incompletely coiled aneurysms presenting for further management either due to lack of universal durability of this method or due to recurrent rupture is increasing. Since 1998, seven patients with previously coiled aneurysms underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry. ⋯ Surgery of recurrent or residual aneurysms resulted in a good outcome in four and a moderate outcome in one patient. Despite early clipping after recurrent haemorrhage after coil occlusion one of the two patients died, the other one had a moderate outcome. Our experience indicates that good results are obtainable, although technical challenges are frequently encountered.
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The rationale for 'awake' resective brain tumour surgery and brain mapping is that the amount of tumour removed is optimized, and risks of damage to adjacent eloquent brain minimized by intraoperative patient assessments. Both goals are generally attained, but occasionally patients may have iatrogenic postoperative deficits. Five such cases (20%) are described from a consecutive series of 25 awake craniotomies. ⋯ These cases highlight both the benefits and limitations of awake craniotomy and intraoperative assessment. Although sensory-motor deficits can be recognized early, some high-level neurological functions may not be readily assessed intraoperatively and vascular catastrophes may occur without warning. The pathophysiological basis of these iatrogenic neurological deficits, and techniques to minimize such problems are discussed.
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Ninety-two patients with trigeminal neuralgia (TGN) were investigated prior to posterior fossa surgery with magnetic resonance imaging (MRI) and contrast-enhanced magnetic resonance angiography (MRA). The preoperative investigation was matched to one consultant neuroradiologist (co-author) who was blinded to the side of symptomotology. The imaging results were compared with the operative findings in all patients. ⋯ Only two cases had clinically bilateral TGN. We conclude that MRA with gadolinium enhancement is an extremely sensitive and specific method for demonstrating compression in TGN. As a result posterior fossa surgery can be recommended with confidence, and microvascular decompression remains the treatment of choice for TGN at the authors' centre.
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Age-specific norms are necessary to determine potential secondary brain insult after head injury in children. We describe and quantify the secondary physiological derangement recorded in children of different ages following traumatic brain injury, and relate it to outcome at 12 months post-injury. Prospective time-series data (including intracranial pressure, arterial blood pressure, cerebral perfusion pressure, oxygen saturation, temperature and heart rate) downloaded from ICU monitors, were examined to identify abnormal (i.e. outside normal age-specific limits) recordings lasting more than 5 min. ⋯ Univariate and multivariate logistic regression modelling was used to evaluate predictors of outcome. Age-specificity allows realistic comparisons of physiological data among children. Duration of age-specific derangement of CPP was found to predict outcome (dead v. alive: p = 0.003 and Glasgow Outcome Score 1-3 v. 4-5, i.e. poor v. independent outcome p = 0.004).
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The purpose of this study was to evaluate the potential of high quality computed tomographic angiography (CTA) to replace digital subtraction angiography (DSA) in cases of ruptured saccular aneurysms and perform early surgical clipping or coiling on the basis of CTA alone. In a prospective study, 100 patients with aneurysmal subarachnoid haemorrhage (SAH) diagnosed by computed tomography underwent CTA. CTA revealed a total of 118 aneurysms including all ruptured aneurysms. ⋯ A total of six unruptured aneurysms were missed initially, but were visible retrospectively on CTA in all but one case and were found in patients with multiple aneurysms in whom the ruptured aneurysm was detected by CTA. Current quality CTA allows reliable pretreatment planning for the majority of cases of aneurysmal subarachnoid haemorrhage and diminishes the pretreatment evaluation time critically. Complementary pretreatment DSA is required in situations where CTA characteristics of the ruptured aneurysm is unsatisfactory.