Surg Neurol
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Randomized Controlled Trial
Slope of the intracranial pressure waveform after traumatic brain injury.
The measurement and treatment of ICP within the management of TBI generally focuses on keeping the mean ICP to less than 20 mm Hg. More sophisticated analysis of the intracranial pressure waveform has yielded important relationships, but those methods have not gained widespread use. Prior analysis of the slope of the ICP waveform during inspiration and expiration in patients with hydrocephalus has provided valuable information that has never been applied to patients with TBI. This study used digital methods to examine ICP and the slope of the ICP waveform in relation to the respiratory cycle in subjects with TBI. ⋯ Greater systolic ICP waveform slope during inspiration has not been described previously after TBI and is consistent with prior observations in subjects with hydrocephalus. The strong correlation between ICP slope and simultaneous mean ICP suggests that increasing ICP slope might indicate loss of intracranial compliance after TBI.
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Anterior communicating artery complex is the most frequent site of intracranial aneurysms in most reported series. Anterior communicating artery aneurysms are the most complex aneurysms of the anterior circulation due to the angioarchitecture and flow dynamics of the ACoA region, frequent anatomical variations, deep interhemispheric location, and danger of severing the perforators with ensuing neurologic deficits. The authors review the practical microsurgical anatomy, importance of preoperative imaging in surgical planning, and microneurosurgical steps in dissection and clipping of ACoAAs. ⋯ Anterior communicating artery aneurysms present frequently with SAH at small size. Furthermore, unruptured ACoAAs may have increased risk of rupture regardless of size, also as an associated aneurysm, and require treatment. The aim in microneurosurgical management of an ACoAA is total occlusion of the aneurysm sac with preservation of flow in all branching and perforating arteries. This demanding task necessitates perfect surgical strategy based on review of the 3D angioarchitecture and abnormalities of the patient's ACoA complex with its ACoAA and to orientate accordingly during the microsurgical dissection. The surgical trajectory should provide optimal visualization of the ACoA complex without massive brain retraction. Precise dissection in the 3D anatomy of the ACoA complex and perforators requires not only experience and skill but patience to work the dome and base under repeated protection of temporary clips and pilot clips. This is particularly important with the complex, large, and giant aneurysms.
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Previous reports of the efficacy of percutaneous pulsed radiofrequency have been confounded by fewer case numbers, poor patient selection, and limited data on cervical or lumbar radicular pain. We used percutaneous pulsed radiofrequency for cervical and lumbar radicular pain, and the study has more than 100 cases for the analysis of the efficacy of percutaneous pulsed radiofrequency. ⋯ The results of this retrospective analysis showed that the application of pulsed radiofrequency is a safe and useful intervention for cervical and lumbar radicular pain. The satisfactory pain relief obtained by most of our patients justifies the start of this study for at least 6 months. Although pulsed radiofrequency appears to provide intermediate-term relief of pain, further studies with long-term follow-up are necessary.
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Clearing the cervical spine is a vital part of the treatment of trauma patients, and the failure to accurately diagnose an injury to the cervical spine can result in paralysis and even death. For decades, plain film imaging, primarily LCSX, was the standard imaging method used to initially evaluate the cervical spine, with CSCT used as an adjunct. With advancements in CSCT over the past decade, it is generally accepted that CSCT should be used as the screening method for clearance of the cervical spine in patients with trauma. In this study our goal was to determine whether lateral cervical spine radiographs (LCSX) are warranted in the initial evaluation of trauma patients or whether they should be eliminated completely in favor of CSCT scans as the initial method of evaluating the cervical spine in trauma patients. ⋯ Our research supports previous studies demonstrating the greater accuracy of CT in evaluating the cervical spine in acute trauma patients. Moreover, with spiral CT scanning, the length of time required to obtain images has been eliminated as an issue. We conclude that LCSX should be eliminated from trauma protocols and that CSCT should be the sole imaging modality used in the initial evaluation of the cervical spine after trauma.