No shinkei geka. Neurological surgery
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In this study, 21 patients with subarachnoid hemorrhage (SAH) but negative angiography were evaluated. Angiography was performed twice on each patient, that is, on admission and at 2 weeks following admission. All patients had severe headache of sudden onset, a characteristic manifestation of SAH. ⋯ While small aneurysms or microaneurysms are often found through exploratory craniotomy, we do not agree with the opinion that surgery may be appropriate for certain patients with SAH but with negative angiography. The natural history concerning rebleeding in such cases, as well as morbidity and mortality associated with hemorrhage, remains to be defined. Furthermore, there are reservations regarding whether coagulation of these abnormalities with bipolar cautery constitutes definitive treatment.
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Case Reports
[Neurophysiological monitoring during surgery for astrocytoma at the motor strip with awake craniotomy].
We present a case of a 26-year-old male with fibrillary astrocytoma at the right face motor cortex. Surgery was performed with the patient under propofol anesthesia. Stimulation mapping techniques for localization of the motor and sensory cortex were applied. ⋯ In order to simulate the operative fieled preoperatively, we superimposed the superficial venous image obtained by magnetic resonance angiography (MRA) upon the surface anatomy scan (SAS). Magnetoencephalography (MEG) provided precise localization of the central sulcus, preoperatively. The methods of direct cortical stimulation to localize sensorimotor pathways with awake craniotomy enabled us to resect the tumor maximally and to minimize morbidity.
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Three cases of acute subdural hematoma without head injury, but associated with bleeding from cortical artery are described. Case 1: a 74-year-old male had sudden headache during a bronchial asthma attack followed by deterioration of consciousness. He was deeply comatose on admission, and CT scans revealed a huge subdural hematoma. ⋯ Our three cases suggested that the etiology might be the rupture of a cortical artery at the site of adhesion with the dura mater. This would predispose the artery to tearing with minor trauma. Hematoma evacuation by craniotomy and treatment of the ruptured cortical artery were necessary for favorable outcome.
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The authors report four cases of patients with documented asymptomatic intact aneurysms that subsequently ruptured. Case 1 involves a 64-year-old woman who had two unruptured aneurysms, i.e., an anterior communicating artery aneurysm and a posterior inferior cerebellar aneurysm, both were discovered during evaluation of cerebral ischemic symptoms. At that time, only the posterior inferior cerebellar aneurysm was clipped. ⋯ The cases reported herein show that asymptomatic aneurysms, especially anterior communicating aneurysms and aneurysms once exposed surgically, do carry a certain risk for future hemorrhage and should not be dismissed as innocuous. Neurosurgeons have recognized the importance of considering life expectancy in managing patients with asymptomatic, unruptured, intracranial aneurysms. With the rapid aging of the population, withholding aneurysm surgery merely because a patient is elderly may not necessarily be the most appropriate decision.