World Neurosurg
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To review the pathophysiology and therapeutic modalities availble for Nelson syndrome. ⋯ An up-to-date understanding of the pathophysiology underlying Nelson Syndrome and evidence-based management is imperative. Early detection may allow for more successful therapy in patients with Nelson Syndrome. Improved radiotherapeutic interventions and rapidly evolving pharmacologic therapies offer an opportunity to create targeted, multifocal treatment regiments for patients with Nelson Syndrome.
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Fungal granulomas of the central nervous system are rare and have a high rate of mortality and morbidity, irrespective of treatment. The authors report their experience of managing 66 patients during 15 years and discuss the clinical, radiological, surgical, and pathologic findings. This series is among the largest reported. ⋯ ICFGs have high rates of morbidity and mortality. Early diagnosis, radical surgery, and antifungal treatment for 6 weeks may improve outcome. Poor neurologic status of patients at the time of presentation, immunocompromised state, contamination of ventricular cerebrospinal during surgery, and renal failure (attributable to amphotericin-B) are associated with poor outcome.
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Review Case Reports
Basilar Invagination: Case Report and Literature Review.
Basilar invagination is a rare clinical condition characterized by upward protrusion of the odontoid process into the intracranial space, leading to bulbomedullary compression. It is often encountered in adults with rheumatoid arthritis. Transoral microscopic or endonasal endoscopic decompression may be pursued, with or without posterior fixation. We present a case of basilar invagination with C1-C2 autofusion and discuss an algorithm for choice of anterior versus posterior approaches. ⋯ Endoscopic endonasal odontoidectomy offers a safe and effective method for anterior decompression of basilar invagination. Preoperative assessment for existing posterior fusion, absence of posterior compression, and preservation of the anterior C1 ring during operative decompression help stratify the need for lone anterior approach versus a combined anterior and posterior treatment.
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Review Case Reports
Computational Fluid Dynamics to Evaluate the Management of a Giant Internal Carotid Artery Aneurysm.
Giant intracranial aneurysms are rare lesions that present uniquely complex therapeutic challenges. Computational fluid dynamics (CFD) has been used to simulate the hemodynamic environments of developing and ruptured cerebral aneurysms. In this study, we use CFD to examine retrospectively hemodynamic changes during the complicated clinical course of a giant carotid aneurysm. ⋯ The application of CFD to the management of a giant intracranial aneurysm showed unexpected posttreatment changes in flow and WSS profiles. The simulation results offer a viable explanation for the observed clinical course. This study demonstrates potential for the use of CFD preoperatively for decision-making in the surgical and endovascular management of intracranial aneurysms.
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Delayed cerebral ischemia (DCI) is a major cause of morbidity and mortality in aneurysmal subarachnoid hemorrhage. Endovascular management of this condition offers a new hope in preventing adverse outcome; however, a uniform standard of practice is lacking owing to a paucity of clinical trials. We conducted an international survey on the use of investigative and endovascular techniques in the treatment of DCI to assess the variability of current practice. ⋯ Treatment practices for DCI vary considerably, with the greatest variability in the choice of agent for intra-arterial therapy. Our data demonstrate the wide variation of approaches in use at present. However, without further clinical trials and development of a uniform standard of best practice, variability in treatment and outcome for DCI is likely to continue.