Neurosurg Focus
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The World Health Organization (WHO) reclassified atypical meningiomas in 2000, creating a more clear and broadly accepted definition. In this paper, the authors evaluated the pathological and clinical transition period for atypical meningiomas according to the implementation of the new WHO grading system at their institution. ⋯ The authors documented a significant change in the proportion of meningiomas designated as atypical during a transition period from 2002 to 2004, and propose a conservative strategy for the use of radiation therapy in atypical meningiomas.
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Lamotrigine is an antiepileptic drug that inhibits presynaptic voltage-gated sodium channels and reduces the presynaptic release of glutamate in pathological states. Neuroprotective effects of this drug have already been demonstrated in cerebral ischemia models. The aim of the present study was to determine the effects of presynaptic glutamate release inhibition on experimental spinal cord injury (SCI). ⋯ Currently, no available agent has been identified, that can block all the glutamate receptors at the same time. To prevent excitotoxicity in SCI, inhibiting glutamate release from the presynaptic buttons instead of blocking the postsynaptic glutamate receptors seems to be a more rational approach. Further research, such as neurobehavioral assessment, is warranted to demonstrate the probable neuroprotective effects of presynaptic glutamate release inhibition in SCI.
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Over the past 2 decades, advances in understanding the pathophysiology of spinal cord injury (SCI) have stimulated the recent emergence of several therapeutic strategies that are being examined in Phase I/II clinical trials. Ten randomized controlled trials examining methylprednisolone sodium succinate, tirilizad mesylate, monosialotetrahexosylganglioside, thyrotropin releasing hormone, gacyclidine, naloxone, and nimodipine have been completed. Although the primary outcomes in these trials were laregely negative, a secondary analysis of the North American Spinal Cord Injury Study II demonstrated that when administered within 8 hours of injury, methylprednisolone sodium succinate was associated with modest clinical benefits, which need to be weighed against potential complications. ⋯ Several current or planned clinical trials are exploring interventions such as early surgical decompression (Surgical Treatment of Acute Spinal Cord Injury Study) and electrical field stimulation, neuroprotective strategies such as riluzole and minocycline, the inactivation of myelin inhibition by blocking Nogo and Rho, and the transplantation of various cellular substrates into the injured cord. Unfortunately, some experimental and poorly characterized SCI therapies are being offered outside a formal investigational structure, which will yield findings of limited scientific value and risk harm to patients with SCI who are understandably desperate for any intervention that might improve their function. Taken together, recent advances suggest that optimism for patients and clinicians alike is justified, as there is real hope that several safe and effective therapies for SCI may become available over the next decade.
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Cardiovascular complications in the acute stage following traumatic spinal cord injury (SCI) require prompt medical attention to avoid neurological compromise, morbidity, and death. In this review, the authors summarize the neural regulation of the cardiovascular system as well as the pathophysiology, diagnosis, and management of major cardiovascular complications that can occur following acute (up to 30 days) traumatic SCI. Hypotension (both supine and orthostatic), autonomic dysreflexia, and cardiac arrhythmias (including persistent bradycardia) are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with severe spinal cord lesions at T-6 or higher. ⋯ Although there is insufficient evidence to recommend (or refute) the use of screening tests for DVT in asymptomatic adults with acute SCI, this strategy may detect asymptomatic DVT in at least 9.4% of individuals who undergo thromboprophylaxis using lowmolecular- weight heparin. Indications and treatment of DVT and acute pulmonary embolism are well established and are summarized in this review. Recognition of cardiovascular complications after acute SCI is essential to minimize adverse outcomes and to optimize recovery.
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The author presents his personal perspective on ablative neurosurgical techniques used to perform bilateral anterior cingulotomy (BACI) and bilateral anterior capsulotomy (BACA) for ameliorating the symptoms of refractory obsessive-compulsive disorder (OCD) and treatment refractory depression (TRD). With depression predicted to be the second most common cause of disability in the world by the year 2020 and the birth of electric neurostimulation representing an attractive alternative treatment option for TRD and OCD, it is desirable to revisit the pros and cons of these treatment options. ⋯ There is still place for BACI and BACA in modern neurosurgery for mental disorders, at least in the short term for those who do not want to commit to lifelong device programming and maintenance.