Neurochirurgie
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Comparative Study Clinical Trial
[Ruptured anterior communicating artery aneurysm. Therapeutic options in 119 consecutive cases].
The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed. ⋯ In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.
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Significant progress in prognosis after brain injury has been achieved over the last 20 years. Knowledge of post-traumatic brain hypersensitivity to ischemic events is critical for management. Therefore, all recommended emergency treatments (intubation, oxygenation, prevention of hypotension) focus on situations where oxygen delivery to the brain is compromised (peripheral hypoxia or hypotension but also compressible cerebral hematoma). ⋯ After controlling peripheral hemodynamics and hemostasis, multimodal monitoring (intracranial pressure, transcranial Doppler, SvjO(2)) is necessary to achieve cerebral hemodynamic equilibrium. Management during the first hours after trauma is important for outcome in patients with traumatic brain injury. A well-organized medical referral system with close collaboration between specialists will be able to control this socially accepted silent epidemic.
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The results of a series of 100 patients operated on for hemifacial spasm (HFS), using microsurgical vascular decompression (MVD), are reported. ⋯ Our data are consistent with those of the literature, especially concerning high rate of long-term success and low complication rate of MVD for HFS. We do not recommend early re-operation in case of initial poor result. Again, the necessity of intraoperative BAEP monitoring to prevent hearing morbidity is highlighted.
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Posterior transarticular screw fixation of the C1-C2 complex has become an accepted method of arthrodesis for patients requiring posterior C1-C2 fusion. Since 2000, four patients (2 males and 2 females) were treated with this surgical approach for management of atlantoaxial instability, including odontoid fracture with unilateral C1-C2 luxation, odontoid pseudarthrosis, complex congenital malformation of the craniovertebral junction and rheumatoid arthritis. All patients underwent stabilization with 2 transarticular C1-C2 screws, without any posterior interspinous graft. ⋯ Results were good, without any complication, after a short mean follow-up (8 months). Technical aspects of the technique are reported, The risk of screw malpositioning and vertebral artery or neural injury is minimal and can be lowered by using preoperative CT scan and MRI, and by using intraoperative fluoroscopy. Transarticular C1-C2 screw fixation proves to be a major surgical approach for treatment of atlantoaxial instability.
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Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. ⋯ No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.