Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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Although many scales attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH), none have achieved universal acceptance, and most scales in common use are not statistically derived. We propose a statistically validated scale for poor grade aSAH patients that combines the Hunt and Hess grades and the Glasgow Coma Scale (GCS) scores; we refer to this as the Poor Grade GCS (PGS). The GCS scores of 160 poor grade aSAH patients (Hunt and Hess Grades 4 and 5) were recorded throughout their hospital stay. ⋯ No patients with a PGS-C or PGS-D over the age of 70 had a favorable long-term outcome. Therefore, elements of the Hunt and Hess and GCS can be combined into the PGS to predict long-term outcome in poor grade aSAH patients. However, patients with PGS-C and PGS-D over the age of 70 should be assessed carefully prior to definitive treatment.
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Case Reports
Use of spontaneous ventilation to monitor the effects of posterior fossa surgery in the sitting position.
We describe the successful excision, guided by spontaneous ventilation, of a cervico-medullary hemangioblastoma in a 22-year-old female in the sitting position. A balanced anesthesia technique comprising an oxygen, nitrous oxide, sevoflurane, fentanyl and vecuronium mixture was used. ⋯ The intraoperative and postoperative course were uneventful. The patient recovered without any major neurological deficit.
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Although venous air embolism (VAE) in neurological surgery is mainly associated with posterior fossa procedures, this complication may also occur, with comparable severity, in the posterior cervical spine approach in patients who are semi-sitting. We report a patient with a massive VAE that occurred in the semi-sitting position during a posterior approach to an extended cervical-thoracic level (C3-T2) intramedullary tumor, which interrupted the surgical procedure. We discuss the possible causes of air embolism, the anatomic and pathogenetic mechanisms, treatment and preventive measures.
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Gliomas are intrinsic brain tumours that are frequently associated with cerebral oedema. As such, keyhole approaches may not be appropriate because if the craniotomy is small, intraoperative cerebral oedema may occur, resulting in cortical compression at the bone edge. ⋯ Two such cases of intraoperative brain swelling are described to illustrate this point. The authors suggest doing a larger craniotomy for glioma patients undergoing awake surgery to prevent compression of normal brain at the craniotomy edge and to allow for a more complete resection by providing access to the tumour even if intraoperative swelling does occur.
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Cluster headache is a severely debilitating disorder that can remain unrelieved by current pharmacotherapy. Alongside ablative neurosurgical procedures, neuromodulatory treatments of deep brain stimulation (DBS) and occipital nerve simulation have emerged in the last few years as effective treatments for medically refractory cluster headaches. ⋯ Controversy remains over which surgical treatments are best and in which circumstances to intervene. Here we review current data on neurosurgical interventions for chronic cluster headache focusing upon DBS and occipital nerve stimulation, and discuss the indications for and putative mechanisms of DBS including translational insights from functional neuroimaging, diffusion weighted tractography, magnetoencephalography and invasive neurophysiology.