Pediatric neurosurgery
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Subspecialty training in pediatric neurosurgery has been a widely discussed topic over the past several years. This paper will discuss the rationale for subspecialization in neurosurgery, describe what makes pediatric neurosurgery unique as a subspecialty area of neurosurgery, and present a rationale for fellowship training in pediatric neurosurgery following the completion of a general residency in neurosurgery. The difference between fellowship and residency training is outlined, and the importance of integrating the fellowship with the neurosurgical training program is emphasized. Controversies regarding structure of the pediatric neurosurgical fellowship, 'certification' of the fellowship training, and issues of supply and demand are reviewed.
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Pediatric neurosurgery · Jul 1992
Case ReportsPreliminary experience with controlled external lumbar drainage in diffuse pediatric head injury.
Our experience with the use of external lumbar subarachnoid drainage in 5 children with severe diffuse head injuries is presented. All patients had Glasgow Coma Scale scores of 8 or less at 24 h after injury and were initially treated with ventriculostomies. Two children required surgical evacuation of focal mass lesions. ⋯ Two patients died, most likely from uncontrolled ICP before the lumbar drain was placed. We conclude that controlled external lumbar subarachnoid drainage is a potentially useful treatment for severe diffuse pediatric head injury when maximal medical therapy and ventricular cerebrospinal fluid (CSF) evacuation have failed to control high ICP. Posttraumatic CSF circulation disruption, white matter cerebral edema, and intracranial venous hypertension can be treated with this modality in the absence of focal mass lesions.
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We have analyzed predictors of mortality following closed head injury in a series of 1,031 consecutive patients with closed head injury admitted to hospital from January 1986 through December 1990. All patients were treated in a uniform manner and surgical intervention was performed as soon as possible in patients with intracranial mass lesions. Logistic analysis was used to identify patient and injury characteristics that were independent predictors of mortality within this patient group. ⋯ Sixty-four percent of the variability in reported mortality rates could be accounted for by differences in mean age of the patients and mass lesion incidence (p = 0.0035). We conclude that apparent improvements in head injury mortality in the last 2 decades may be partly or wholly due to different population characteristics in the reported series. Multiple injuries appear to be important contributors to patient mortality, and in the interest of improved description of head injury populations, the Injury Severity Score should be reported with age, mass lesion incidence, and Glasgow Coma Score.
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Pediatric neurosurgery · Jan 1992
Intraoperative uses of ultrasound in the pediatric neurosurgical patient.
Ultrasound imaging has become a common method for intraoperative evaluation of the central nervous system. Real-time monitoring aids in guidance for aspiration of fluid collections and placement of catheters as well as the localization and evaluation of masses, and confirmation of their complete removal. Color Doppler is useful in the evaluation of blood flow in arteriovenous malformations, aneurysms, and neoplasms. Consultation among the ultrasound staff, neuroradiologists, and neurosurgeons before the operative procedure maximizes the usefulness of ultrasound, thus aiding in the success of surgery.
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The ability to detect and differentiate intracranial infection has markedly improved, first with the introduction of computed tomography and, more recently, with magnetic resonance. Enhanced magnetic resonance imaging is the procedure of choice in the evaluation of nearly all intracranial infections. ⋯ Computed tomography remains useful primarily in those infections associated with intracranial calcification, such as TORCH syndrome. This article summarizes the most recent CT and MR findings of infection involving the meninges and brain parenchyma.