World Neurosurg
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Total intravenous anesthesia with propofol can be administered by target-controlled infusion pumps, which work on the principles of pharmacokinetic modeling. While designing this model, neurosurgical patients were excluded as the surgical site and drug action site remained the same (brain). Whether the predicted set propofol concentration and the actual brain site concentration correlate, especially in neurosurgical patients with impaired blood-brain barrier (BBB), is still unknown. In this study we compared the set propofol effect-site concentration in the target-controlled infusion pump with actual brain concentration measured by sampling the cerebrospinal fluid (CSF). ⋯ CSF propofol level did not correlate with set concentration in spite of acceptable clinical anesthetic effect. Also, the CSF-to-blood albumin measurement did not provide information on the BBB integrity.
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The precise definition of the accessory meningeal artery was not available until 1961. It can originate from the maxillary artery or middle meningeal artery and supplies the meatus and membranous portion of the auditory tube, the lateral pharyngeal muscle, and the medial pterygoid muscle; Laterally, it supplies the lateral pterygoid muscle, the extracranial part of the mandibular nerve, the pterygoid venous plexus, and the sphenoid periosteum. Here, we present a 70-year-old male patient who applied to the neurosurgery clinic with complaints of chronic headaches and dizziness. Magnetic resonance angiography and computed tomography angiography showed hypoplasic appearance of the left internal carotid artery and an enlarged accessory meningeal artery variant merging with its ophthalmic segment.
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The neurosurgery chief resident year is traditionally completed during the final residency year; however, a recent directive decried that enfolded fellowships should be undertaken following completion of the chief experience for most fellowships. ⋯ Fervent bimodal opinions exist among residency program and fellowship directors regarding the directives for enfolded fellowships to follow successful completion of the chief resident experience. However, there was broad support for allowing greater program discretion for directing certain enfolded fellowship timing and structure.
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Dural arteriovenous fistulas (dAVFs) are vascular malformations of the central nervous system that feature an arteriovenous shunt fed by dural arteries and can be intracranial or spinal.1-3 Spinal dAVFs are classically found at the nerve root sleeve.3 The arterial supply can often be predicted by the fistula location, whereas the symptomatology and risk of hemorrhage is determined by the venous drainage pattern.1-3 Craniocervical fistulas, a subset of dAVFs, may arise in association with the anterior condylar venous confluence or more dorsally in association with the transdural segment of the vertebral artery.1-3 This latter type of fistula typically has spinal venous drainage and may present with myelopathy from spinal cord venous congestion. We present a 61-year-old man who presented with a 2-week history of neck pain and paraparesis. Magnetic resonance imaging of the cervical spine revealed diffuse T2 hyperintensity of the cord from the pons to the level of the T1 vertebra. ⋯ It confirmed a dAVF associated with the transdural segment of the left vertebral artery, with small dural feeders from the left vertebral artery and venous drainage into the anterior spinal vein. The patient underwent a modified suboccipital craniectomy and C1 laminectomy for dAVF ligation (Video 1). He was extubated postoperatively and discharged to a rehabilitation unit with improvement in lower extremity strength.
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Trigeminal neuralgia, or tic douloureux, clinically presents as a unilateral paroxysmal, stabbing, intense pain of the face, lasting for seconds but occurring frequently. Alternative causes including multiple sclerosis or mass of the brainstem or cranial nerves must be ruled out. ⋯ Ultimately, if medical management becomes refractory or symptoms progressive, then procedural and surgical options including microvascular decompression, stereotactic radiosurgery, radiofrequency thermocoagulation, and others should be considered. Most notably, microvascular decompression, as in this case, can be considered with an 85%-95% initial success rate.