No shinkei geka. Neurological surgery
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Historical Article
[Operative neurosurgery: personal view and historical backgrounds (4). Selective amygdalohippocampectomy SAHE].
Selective amygdalohippocampectomy SAHE has been pioneered by Yasargil et al in the mid 1970 within the scope of surgical treatment for intractable mesial temporal lobe epilepsy MTLE. In this article, the author has emphasized microsurgical points to be kept in mind in carrying out the procedure from the experience of just more than 200 surgeries performed by himself during the last 14 years. Historical backgrounds of development of this technique, necessary topographic anatomy, perioperative management and our results were also presented. (1) Simple temporal lobectomy (S-lobectomy)--> Epilepsy temporal lobectomy (E-lobectomy)--> SAHE has been the way of development, in which the amygdala and hippocampus are resected together at Elobectomy while not at S-lobectomy. ⋯ Mediocranial group in the vicinity of the brain stem: Crus cerebri, AchoA, Tractus opticus, A. parietooccipitalis, Corpus geniculatum laterale. (5) In order to avoid surgical complications to be kept in mind. 1: AchoA should be preserved at any cost. 2: hemorrhagic diathesis due to longstanding medication of antiepileptics especially valproate should be corrected with fresh frozen plasma FFP, thrombocyte-preparation and/or Minirin. (6) Good results (Engel I+II) to stop or alleviate intractable seizures remarkably could be obtained in more than 80% of patients in our previous report and also in this series of consecutive 190 cases. Strict indication based on presurgical epileptological examinations including special electroencephalography EEG leading like Foramen ovale electrode, selective Wada test and interdisciplinary discussion are mandatory. These careful procedures bring good outcome by preventing complications especially postoperative deterioration of cognitive function.
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We encountered a case of superior petrosal sinus dural arteriovenous fistula (SPS DAVF) which was treated by a combination of a transvenous and a transarterial approach after the failure of the transvenous approach alone. A 69-year-old man presented with a complaint of progressive left bulbar conjunctival conjestion, exophthalmos, and impaired vision. Cerebral angiography revealed a left SPS DAVF fed by the left middle meningeal artery, the meningeal branches of the left internal carotid artery and the left posterior meningeal artery. ⋯ The postoperative angiogram confirmed complete obliteration of the DAVF and the patient's ocular symptoms disappeared. DAVF is usually difficult to treat by transarterial embolization with NBCA because of its multiple feeders and high flow drainage. We should therefore carefully observe its structure and the blood flow change with 3D-DSA and the selective angiography while embolizing the DAVE.
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Spontaneous intracranial hypotension (SIH) is reported to cause chronic subdurai hematoma (SDH), however diagnosis of SIH in patients with SDH is not always easy. We report a case of chronic SDH refractory to repeated drainage, which was attributed to SIH. A forty-five-year-old man who had been suffering from orthostatic headache for one month was admitted to our hospital presenting with unconsciousness and hemiparesis. ⋯ After treatment with epidural blood patching, the hematoma rapidly disappeared and he was discharged without symptoms. In the treatment of chronic SDH, especially in young to middle aged patient without preceding trauma or hematological disorders, physicians should pay attention to underlying SIH to avoid multiple surgery. MRI of the spine as well as radionuclide cisternography is useful in evaluation of this condition.
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Under the title of anterior circulation aneurysms and the pterional approach, followings are presented and emphasized along with mentioning their historical development in our present performance status. Pterional approach: head positioning with Mayfield-Kees fixation apparatus using one pin around the processus matoideus and the other 2 pins on the contralateral side behind the hair line the head turned 30 degrees and reclined chin-up l5-20 grade. Skin incision beginning just in front of the tragus ending up at the midline hair line in a curvilinear fashion always including the superficial temporal artery STA in its frontal branch and the facial nerve (frontal branch) in the skin flap. ⋯ Its predilection site is at the medial anterior wall of the C1 portion but may occur also in any other portion of the ICA. (3) Middle cerebral artery MCA aneurysms; (a) For dissection, superior temporal gyrus ablation is not necessary but opening of the Sylvian fissure by retrograde tracing of a cortical artery on the surface of the temporal lobe. This cortical artery can be used as recipient when a bypass surgery turns out to be necessary with the use of a donor artery from the frontal branch of the STA. (b) Importance of interpreting DSA or 3DCT angiography in regard to whether the aneurysm dome is outside (lateral) or inside (medial) of the MCA bifurcation. This helps in anticipating whether the aneurysm dome or MCA branches come into view first at the time of intraSylvian dissection. (c) In case of presence of aneurysms at the contralateral MCA, accessibility from the ipsilateral side depends on the distance form the midline (for example early bifurcation), the relationship to the sphenoid wing (not below the level of the sphenoid wing) and no strong Sylvian vein darining into the sphenoparietal sinus being in the way.