World Neurosurg
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Randomized Controlled Trial
Efficacy of low-dose tissue-plasminogen activator intracisternal administration for the prevention of cerebral vasospasm after subarachnoid hemorrhage.
Vasospasm is one of the important factors associated with the functional prognosis after subarachnoid hemorrhage (SAH). Intracisternal administration of thrombolytic agents to dissolve subarachnoid clots may be responsible for bleeding complications. The efficacy and safety of cisternal irrigation therapy using low-dose tissue plasminogen activator were evaluated. ⋯ Cisternal irrigation therapy using low-dose tissue plasminogen activator is effective and safe. Intermittent injection is most effective and may decrease the risk of symptomatic vasospasm in patients with SAH.
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Delayed ischemic neurologic deficit (DIND) is a serious and poorly understood complication of aneurysmal subarachnoid hemorrhage. Although advances in treatment have improved prognosis for these patients, long-term clinical outcomes remain disappointing. ⋯ Although our understanding of the underlying molecular processes and pathophysiology is improving, responsible mediators or pathways have yet to be identified. The aim of this review is to summarize the key historical events that have helped shape our understanding of the pathophysiology of this phenomenon (microcirculation, autoregulation, microthrombosis, inflammation, apoptosis, spreading depolarization, oxidative stress) and to present the evidence underlying current treatment strategies (hemodynamic therapy, oral nimodipine, endovascular therapy, statins, cerebrospinal fluid drainage, thrombolysis, magnesium) and the translational and clinical research investigating DIND.
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Review Case Reports
The role of external drains and peritoneal conduits in the treatment of recurrent chronic subdural hematoma.
A considerable body of evidence supporting the use of external drainage after evacuation of primary chronic subdural hematoma (CSDH) exists in the literature. However, no systematic study of the value of postoperative drainage in the treatment of recurrent CSDH has been published. The aim of the study was to investigate external drains and subdural-to-peritoneal conduit in the treatment of recurrent CSDH. ⋯ The results indicate that, as in the treatment of primary CSDHs, the use of drain (SED or SPC) with burr hole evacuation is safe and is associated with lower recurrence rate. Further investigation is needed to clarify the indications of currently available surgical techniques in the treatment of recurrent CSDH.
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There has been marked evolution in techniques in skull base surgery including the development of minimally invasive endoscopic supraorbital, transnasal, and more recently, transorbital approaches. These have been typically described as isolated, rather than concerted approaches. It is possible that rather than using these approaches alone, they could be combined with transnasal approaches to provide improved manipulation angles, shorter working distances, and optimal visualization of the pathology. The primary objective of this study is therefore to determine whether these pathways can be combined in "multiportal" approaches to further improve the surgeon's ability to access and manipulate pathology in the central anterior cranial fossa. ⋯ The precaruncular transorbital approach provided rapid, direct, coplanar access to the clivus, sella, and suprasellar/parasellar regions. The supraorbital minicraniotomy augmented access to the planum sphenoidale, sella, tuberculum sella, and suprasellar regions. These approaches provided shorter working distances, improved visualization, and working angles that offer more direct access to the pituitary gland, suprasellar region, clivus, medial and lateral cavernous sinus than the endoscopic transnasal approach alone. The combination of endoscopic approaches to the central anterior skull base significantly improved instrument access, particularly to lateral targets, as well as better visualization of the vital structures in these regions. These ports provide the surgeon with a more expansive surgical field and improved the ability to perform two-handed microsurgical dissections.
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Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis has been used in moyamoya disease (MD) and non-moyamoya ischemic stroke (non-MD). It is important to monitor hemodynamic changes caused by bypass surgery for postoperative management. We evaluated the bypass blood flow during STA-MCA anastomosis by using indocyanine green (ICG) fluorescence angiography. ⋯ ICG angiography with injection of ICG into the bypass artery allowed quantitative assessment of bypass blood flow. The bypass supplies blood flow to a greater extent in MD than in non-MD during surgery. This might be caused by a larger pressure gradient between the anastomosed STA and recipient vessels in MD. These observations indicate that MD requires careful control of systemic blood pressure after surgery to avoid cerebral hyperperfusion syndrome. ICG angiography is considered useful for facilitating safe and accurate bypass surgery and providing information for postoperative management.