1/211. Intraoperative loss of auditory function relieved by microvascular decompression of the cochlear nerve.BACKGROUND: Brainstem auditory evoked potentials (BAEP) are useful indicators of auditory function during posterior fossa surgery. Several potential mechanisms of injury may affect the cochlear nerve, and complete loss of BAEP is often associated with postoperative hearing loss. We report two cases of intraoperative auditory loss related to vascular compression upon the cochlear nerve. methods: Intra-operative BAEP were monitored in a consecutive series of over 300 microvascular decompressions (MVD) performed in a recent twelve-month period. In two patients undergoing treatment for trigeminal neuralgia, BAEP waveforms suddenly disappeared completely during closure of the dura. RESULTS: The cerebello-pontine angle was immediately re-explored and there was no evidence of hemorrhage or cerebellar swelling. The cochlear nerve and brainstem were inspected, and prominent vascular compression was identified in both patients. A cochlear nerve MVD resulted in immediate restoration of BAEP, and both patients recovered without hearing loss. CONCLUSION: These cases illustrate that vascular compression upon the cochlear nerve may disrupt function, and is reversible with MVD. awareness of this event and recognition of BAEP changes alert the neurosurgeon to a potential reversible cause of hearing loss during posterior fossa surgery.- - - - - - - - - - ranking = 1keywords = brain (Clic here for more details about this article) |
2/211. Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke.PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.- - - - - - - - - - ranking = 1131.7802290171keywords = cerebral, intracerebral (Clic here for more details about this article) |
3/211. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms.OBJECTIVE: cardiopulmonary bypass with profound hypothermia and circulatory arrest has seen a resurgence as an adjunct technique in neurological surgery. We report our experience with this technique in treating seven complex vertebro-basilar aneurysms. methods: skull base approaches were used in all cases, providing excellent exposure and minimizing brain retraction. There were six basilar artery aneurysms and one giant fusiform vertebro-basilar artery aneurysm. All aneurysms but one had an apparent neck, which could be clipped. The fusiform vertebro-basilar artery aneurysm was trapped, partially resected, and the circulation was reestablished with a saphenous vein graft from the cervical internal carotid artery to the mid-basilar artery. RESULTS: Five patients had an excellent outcome and two had a good outcome at one year or at latest follow up. Two of the patients showed improvement of neurological deficits which were present before the surgical intervention. CONCLUSION: Applying very strict selection criteria in this small series of patients with posterior circulation aneurysms, excellent or good results were achieved using the profound hypothermic circulatory arrest technique.- - - - - - - - - - ranking = 1keywords = brain (Clic here for more details about this article) |
4/211. intelligence test scores from infancy to adulthood for a craniopagus twin pair neurosurgically separated at 4 months of age.Long-term effects in a neurosurgically separated twin pair were illuminated by standard psychological test scores obtained over a period from 2 to 38 years of age. Interdigitation of the gyri of their right frontal lobes had necessitated separation in two stages at 4 months of age. One twin clearly suffered some brain injury and showed some impairment during the testing at 5 years of age. The scores of both twins rose at the adult testing. The brighter twin has an IQ comparable to that of the mother. The unique data set is a kind of model for long-term assessment of early brain surgery, particularly with craniopagus twins.- - - - - - - - - - ranking = 2keywords = brain (Clic here for more details about this article) |
5/211. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis.Three children with cystic fibrosis (CF) had significant pulmonary haemorrhage during anaesthetic induction prior to bronchial artery embolization (BAE). Haemorrhage was associated with rapid clinical deterioration and subsequent early death. We believe that the stresses associated with intermittent positive pressure ventilation (IPPV) were the most likely precipitant to rebleeding and that the inability to clear blood through coughing was also an important factor leading to deterioration. Intermittent positive pressure ventilation should be avoided when possible in children with CF with recent significant pulmonary haemorrhage.- - - - - - - - - - ranking = 9030.8499130274keywords = haemorrhage (Clic here for more details about this article) |
6/211. Internal iliac artery embolisation for intractable bladder haemorrhage in the peri-operative phase.Intractable haemorrhage from the bladder wall during transurethral resection of bladder tumour is uncommon but potentially catastrophic. Internal iliac artery embolisation is a minimally invasive technique, which is now widely practised to stop bleeding from branches of these arteries is situations including pelvic malignancy, obstetric and gynaecological emergencies and trauma. We report its successful use peri-operatively, in an unfit, elderly patient with uncontrolled bleeding.- - - - - - - - - - ranking = 7525.7082608561keywords = haemorrhage (Clic here for more details about this article) |
7/211. life-threatening haemorrhage following obturator artery injury during transurethral bladder surgery: a sequel of an unsuccessful obturator nerve block.In spite of prior blockade of the obturator nerve with 1% mepivacaine (8 ml) utilizing a nerve stimulator, violent leg jerking was evoked during transurethral electroresection of a bladder tumour approximately 1 h after the blockade in a 68-year-old man. The patient became severely hypotensive immediately following the jerking, and a large lower abdominal swelling concurrently developed. The urgent laparotomy indicated that the left obturator artery was severely injured by the resectoscope associated with the bladder perforation, causing acute massive haemorrhage. The patient recovered uneventfully after adequate surgery. Investigation of the literature suggested that both our nerve stimulation technique and anatomical approach were appropriate. It was therefore unlikely that our block resulted in failure because of an inappropriate site for deposition of the anaesthetic. However, consensus does not appear to have been obtained as to the concentration and volume of the anaesthetic necessary for prevention of the obturator nerve stimulation during the transurethral procedures. The concentration and volume of mepivacaine we used might have been too low and/or small, respectively, to profoundly block all the motor neuron fibres of the nerve. Alternatively, stimulation of the obturator nerve might occur because of the presence of some anatomical variant, such as the accessory obturator nerve or its abnormal branching. In conclusion, some uncertainty appears to exist in the effectiveness of the local anaesthetic blockade of the obturator nerve. In order to attain profound blockade of the motor neuron fibres of the obturator nerve and thereby prevent the thigh-adductor muscle contraction which can lead to life-threatening situations, we recommend, even with a nerve stimulator, to use a larger volume of a higher concentration of local anaesthetic with a longer duration in the obturator nerve block for the transurethral procedures.- - - - - - - - - - ranking = 7525.7082608561keywords = haemorrhage (Clic here for more details about this article) |
8/211. Quantitative assessment of vessel flow integrity for aneurysm surgery. Technical note.Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischemic injury and improve patient outcome. The authors report a case of a superior cerebellar artery (SCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in both the SCA and the posterior cerebral artery before and after aneurysm clipping. Following aneurysm clipping, blood flow in the SCA was reduced to less than 25% of its initial baseline value. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip and restore SCA flow to its preclipping value within 5 minutes of initial clip placement. Quantitative vessel-flow measurements were integral to the safe progression of the operation and may have prevented an adverse neurological outcome in this patient. The recommended surgical technique and the principle of operation are described.- - - - - - - - - - ranking = 450.15911250456keywords = cerebral (Clic here for more details about this article) |
9/211. Biochemical changes related to hypoxia during cerebral aneurysm surgery: combined microdialysis and tissue oxygen monitoring: case report.OBJECTIVE AND IMPORTANCE: The objective of this study was to monitor brain metabolism on-line during aneurysm surgery, by combining the use of a multiparameter (brain tissue oxygen, brain carbon dioxide, pH, and temperature) sensor with microdialysis (extracellular glucose, lactate, pyruvate, and glutamate). The case illustrates the potential value of these techniques by demonstrating the effects of adverse physiological events on brain metabolism and the ability to assist in both intraoperative and postoperative decision-making. CLINICAL PRESENTATION: A 41-year-old woman presented with a World Federation of Neurological Surgeons Grade I subarachnoid hemorrhage. angiography revealed a basilar artery aneurysm that was not amenable to coiling, so the aneurysm was clipped. Before the craniotomy was performed, a multiparameter sensor and a microdialysis catheter were inserted to monitor brain metabolism. INTERVENTION: During the operation, the brain oxygen level decreased, in relation to biochemical changes, including the reduction of extracellular glucose and pyruvate and the elevation of lactate and glutamate. These changes were reversible. However, when the craniotomy was closed, a second decrease in brain oxygen occurred in association with brain swelling, which immediately prompted a postoperative computed tomographic scan. The scan demonstrated acute hydrocephalus, requiring external ventricular drainage. The patient made a full recovery. CONCLUSION: The monitoring techniques influenced clinical decision-making in the treatment of this patient. On-line measurement of brain tissue gases and extracellular chemistry has the potential to assist in the perioperative and postoperative management of patients undergoing complex cerebrovascular surgery and to establish the effects of intervention on brain homeostasis.- - - - - - - - - - ranking = 910.31822500912keywords = cerebral, brain (Clic here for more details about this article) |
10/211. Successful treatment of massive arterial air embolism during open heart surgery.We report a case of a 5-year-old girl who suffered a massive arterial air embolism during surgical closure of an atrial septal defect. The risk of permanent neurologic deficits or even fatal outcome is significant (mortality rate, 31%). We successfully treated a proven arterial air embolism with intraoperative (retrograde cerebral perfusion) combined with postoperative procedures (deep barbiturate anesthesia and hyperbaric oxygenation). At discharge the girl had fully recovered from the initial neurologic defects.- - - - - - - - - - ranking = 225.07955625228keywords = cerebral (Clic here for more details about this article) |
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