World Neurosurg
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As the aged population is rapidly growing globally, geriatric traumatic brain injury (TBI) becomes an increasing problem. There are higher mortality and poorer functional outcome in the geriatric TBI population (≥65 years) compared with younger groups despite neurosurgical interventions. Therefore, current treatment priorities and cost-effectiveness should be critically examined. We evaluated the benefit of surgical management in the elderly (≥65 years) after TBI. ⋯ We confirmed that age is a major determinant of outcome after TBI. In addition, we found that neurosurgical management is associated with the improvement of the prognosis and a decrease in the rate of mortality in geriatric TBI. However, surgical management was not shown to be an effective treatment in elderly patients with GCS scores of 3-5.
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Case Reports
The pterional transsylvian transtentorial approach to ventrolateral pontine cavernomas: indications and techniques.
The authors describe a pterional transsylvian transtentorial approach to the ventrolateral pons based on its clinical application to cavernomas. ⋯ Although a comprehensive comparison with other approaches needs a large patient volume and a prospective designed study, the pterional transsylvian transtentorial approach could be an alternative for ventrolateral pontine cavernomas. The principle for this approach to ventrolateral pontine cavernomas is that if the thinnest parenchyma layer over the cavernoma could be defined in the ipsilateral upper ventrolateral pons, facilitated by an oblique multiangled working space, cavernomas in even the entire ventrolateral pons could be removed.
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Various modalities have been used to confirm the blood flow through parent arteries or surrounding perforating arteries during surgical aneurysm clipping, including motor-evoked potentials (MEPs), Doppler ultrasound, and indocyanine green videoangiography. Nonetheless, contralateral hemiparesis due to arterial blood flow insufficiency may arise because of false-positive or false-negative errors. By performing controlled intraoperative awakening during aneurysm clipping, we compared patients' voluntary movements with simultaneous MEP. ⋯ Intraoperative neurological assessment during aneurysmal clipping under awake craniotomy is feasible and safe, and should be valuable for the assessment of ischemia, especially in the anterior choroidal artery. From a neurophysiologic viewpoint, MEP may be insufficiently sensitive for evaluating voluntary movement under ischemia.
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To determine the clinical utility of laser speckle flow imaging (LSFI) and its comparability to (123)I-iodoamphetamine single photon emission computed tomography (IMP-SPECT), we used LSFI to monitor cerebral blood flow (CBF) during extracranial-intracranial (EC-IC) bypass surgery. ⋯ Although LSFI clearly demonstrated a decrease in CBF, the information is taken only from the surface of the brain. Combined use of LFSI with an electrophysiologic examination is required for intraoperative diagnosis of ischemia. LSFI was not sensitive enough to detect increased CBF by superficial temporal artery-to-middle cerebral artery anastomosis, because CBF changes are minimized during anesthesia, probably owing to low metabolic activity.
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To report our clinical experience with an advanced navigation protocol that provides seamless integration into the operating workflow of endoscopic transsphenoidal surgery. ⋯ The advanced navigation protocol permits continuous suction-tracked navigation guidance during endoscopic transsphenoidal surgery and optimal visualization of solid bone, fine paranasal sinus structures, soft-tissue and vascular structures. This may add to the safety of the procedure especially in cases of anatomical variations and in cases of recurrent adenomas with distorted anatomy.