Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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The importance of the extent of resection for gliomas, and the utility of aminolevulinic acid (ALA) and protoporphyrin IX fluorescence in increasing the extent of resection, has become increasingly evident over the past decade. This review continues from Part 1 and focuses on the biochemical mechanisms by which ALA ingestion leads to tumour fluorescence, and discusses practicalities of the equipment and techniques needed to introduce ALA and fluorescence guided resection into neurosurgical practice.
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Intensive care units (ICU) specializing in the treatment of patients with neurological diseases (Neuro-ICU) have become increasingly common. However, there are few data on the longitudinal demographics of this patient population. Identifying admission trends may provide targets for improving resource utilization. ⋯ When comparing the time period prior to construction of a larger Neuro-ICU (2000-2004) to that after completion (2005-2008), patient age (56.0 ± 17.6 compared to 56.9 ± 17.5 years, p=0.012) and median length of stay (1 compared to 2 days, p<0.001) both significantly increased. Construction of a newer, larger Neuro-ICU at CUMC led to a substantial increase in admissions and changes in diagnoses from 2000 to 2008. Advances in neurocritical care, neurosurgical practices, and the local and global expansion and utilization of ICU resources likely led to differences in lengths of stay.
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Cervical intervertebral disc replacement using a rectangular titanium stand-alone cage has become a standard procedure for anterior cervical discectomy and fusion (ACDF). We examined outcomes resulting from the contemporary use of rectangular titanium stand-alone cages for ACDF, particularly focusing on cage subsidence and subsequent kyphotic malalignment. Patient data were collected prospectively, and a total of 47 consecutive patients who underwent periodic follow-up of at least 1 year's duration after ACDF were studied retrospectively. ⋯ Cage subsidence resulted in early deterioration of local angle and total alignment of the cervical spine. Although a longer follow-up is warranted, a good surgical outcome with negligible complications appears to justify the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF. Excessive distraction at the fusion level should be avoided, and cage position should be adjusted to the anterior vertical line.
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We reviewed a series of 46 consecutive, surgically treated patients with clinoidal meningioma to compare the classical pterional approach (32 patients) to an extended approach including extradural clinoidectomy and removal of the optic canal roof (14 patients). The tumor size and Al-Mefty type, the extension into the optic canal, the time to identification of the optic nerve and internal carotid artery, and the visual outcome were evaluated. Complete tumor resection was obtained in 81% of patients with the classic pterional approach compared to 93% of patients using an extended approach. The extended skull base approach should be used routinely in clinoidal meningiomas >2.5 cm in size, in ones of Al-Mefty type III, and in all patients with tumor extension into the optic canal.
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The intraoperative identification and resection of glioma is a significant and important challenge in neurosurgery. Complete resection of the enhancing tumour increases the median survival time in glioblastoma compared to partial glioma resection; however, it is achieved in fewer than half of eligible patients when conventional tumour identification methods are used. Increasing the incidence of complete resection, without causing excess morbidity, requires new methods to accurately identify neoplastic tissue intraoperatively, such as use of the drug 5-amino-levulinic acid (ALA). ⋯ ALA use led to a significant increase in the incidence of complete resection (65% compared to 36%), improved progression-free survival at 6 months (41% compared to 21%), fewer reinterventions, and delayed onset of neurological deterioration. This review provides a broad assessment of ALA-PpIX fluorescence-guided resection, with Part 1 focusing on its clinical efficacy, and correlations with imaging and histology. The theoretical, biochemical and practical aspects of ALA use are reviewed in Part 2.