摘要:

IN REVIEWS IN the 1980s, we discussed both indications for and surgical techniques in carotid endarterectomy. Significant changes in the practice of extracranial cerebrovascular reconstruction have occurred over the past few years. The newest indications and cooperative study data have recently been discussed by Camarata and Heros in this topic review series. In this article, we aim to review the advances in operative monitoring and surgical techniques of the last decade. We would be remiss, however, not to note that the latest Asymptomatic Carotid Atherosclerosis Study data, released in September 1994, indicate that carotid endarterectomy is significantly superior to medical therapy for asymptomatic stenosis of >60%. These data, along with the North American Symptomatic Carotid Endarterectomy Trial results, will revitalize and lend scientific validity to carotid artery reconstruction.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

DUPLEX ULTRASONOGRAPHY IS frequently used for noninvasive screening for extracranial occlusive disease. In a multicenter, prospective, randomized trial for carotid endarterectomy in symptomatic patients, the duplex ultrasound examination was compared with conventional angiographic findings for internal carotid artery (ICA) stenosis in 178 patients. Angiograms were interpreted by radiologists both at local medical centers and at a central site; the angiographic determination of ICA stenosis was calculated as percent diameter at the point of maximal narrowing compared with the normal distal ICA. Comparisons were made for 328 arteries, including both the symptomatic (>50% stenosis determined by angiography) and the asymptomatic (variable degrees of stenosis) sides. Duplex ultrasonography sensitivity varied from 0.24 for 30 to 49% stenosis to 0.71 for 50 to 79% stenosis and 0.91 for ICA occlusion. Using a 50% stenosis cutpoint, duplex ultrasonography sensitivity was 0.90 with a specificity of 0.76. Duplex scan readings underestimated the degree of stenosis in the 30 to 49% stenosis group in 48% of the cases. There was no apparent relationship between the accuracy of stenosis determinations and that of external carotid artery stenosis, carotid plaque morphology, or ulceration determinations by ultrasound. On the basis of the benefit provided by carotid endarterectomy in symptomatic patients with high-grade lesions, duplex ultrasound accuracy is essential if noninvasive testing is used to make clinical decisions. In situations in which duplex findings may not be reliable, such as in the mild-to-moderate stenosis and occlusion categories, carotid angiography may be indicated.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

WE REPORT TWENTY-FOUR patients with cirsoid aneurysms of the scalp. For nine patients (38%), the lesions were related to trauma. Each of the patients presented with a pulsatile scalp swelling with a bruit. No focal neurological deficits were noted in any of the patients. Scalp malformations in all patients were confirmed by selective internal and external carotid angiography, with no intracerebral component revealed in any of the patients. Twenty-one patients had the lesions surgically excised, with good results. The remaining three refused surgical intervention. Meticulous surgical technique, which includes removal of the pericranial component of the malformation, was paramount.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

SIX ANEURYSMS IN five patients with acute aneurysmal subarachnoid hemorrhages were treated with direct thrombosis using cellulose acetate polymer within 4 hours of rupture. The aneurysms involved the internal carotid and posterior communicating arteries (two patients), the anterior choroidal artery (one patient), the bifurcation of the basilar artery (one patient), and the middle cerebral artery (two patients). Four patients underwent aggressive volume expansion after direct thrombosis with cellulose acetate polymer. The aneurysms remained thrombosed until operations on the necks were performed 2 to 7 weeks after the subarachnoid hemorrhages. Three patients were given intrathecal tissue plasminogen activator. One patient, who remained at neurological Grade V, was not treated surgically and died from cardiac failure. Five aneurysms in the remaining four patients were successfully clipped. These preliminary data suggest that immediate aneurysmal thrombosis, then aggressive preoperative prophylactic volume expansion and/or administration of intrathecal tissue plasminogen activator, can help prevent new bleeding and reduce delayed cerebral ischemia in patients after aneurysmal subarachnoid hemorrhages.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

THE SURGICAL TREATMENT of large pituitary adenomas with suprasellar extensions has been controversial. To elucidate the indications for transsphenoidal surgery of large adenomas and to evaluate the techniques for removing the suprasellar portions of the tumors, surgical procedures on 100 consecutive patients with suprasellar extensions of nonfunctioning pituitary adenomas were retrospectively investigated. Patients were followed up for 1 to 12 years (mean, 4.5 yr). One hundred twenty-five transsphenoidal operations were performed on 100 patients. The removal of each suprasellar tumor was facilitated by the placement of a lumbar subarachnoid catheter and the injection of lactated Ringer's solution or saline. This method was used in 77 operations and was effective on 60 of 72 adenomas with <30-mm suprasellar extensions (Hardy's Grades A, B, and C) but not on those that were fibrous or dumbbell-shaped. The descent of the remaining suprasellar tumor was facilitated by keeping the sella and sellar floor open with an intrasellar drain, and the subsequent removal was achieved with staged transsphenoidal operations. Of nine fibrous or dumbbell-shaped adenomas with 10- to 30-mm suprasellar extensions, gross total removal in eight was achieved by the open sella technique and two-stage transsphenoidal operation, whereas one required transcranial surgery. Adenomas with >30-mm suprasellar or lateral extensions (Grade D) could not be removed sufficiently by transsphenoidal operations, except one adenoma for which a subtotal removal was achieved in the third staged operation. The disease-free rate 10 years after operation was 74% for all patients: 91% for Grade A, 74% for Grade B, and 61% for Grade C. These results suggest that pituitary adenomas with <30-mm suprasellar extensions can be safely removed via a transsphenoidal approach using our techniques.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

BECAUSE OF THE common belief that there is an increase in surgical risk and morbidity involved in the surgical therapy of elderly patients with acromegaly, physicians tend to either neglect therapy altogether or choose radiation therapy combined with medical treatment. In consideration of the expected increasing number of elderly patients resulting from social structure change in the coming years, we decided to investigate the outcome in 15 patients with acromegaly (13 women and 2 men) older than 64 years (mean, 68.3 yr) at the time of surgery in the form of a retrospective study. Medical treatment using either dopamine agonists (9 patients) and/or octreotide (4 patients) were attempted in 11 patients. For various reasons, however, medical therapy could not be permanently continued in any of these patients. The mean preoperative growth hormone (GH)-plasma level without medical treatment was 47.4 ± 64.2 (mean ± standard deviation) μg/L. At the time of operation, 13 of 15 patients had additional diseases, which led to an increased anesthesiological risk. Transnasal tumor removal was performed without anesthesiological or surgical complications in all patients. The radicality of tumor removal was controlled intraoperatively by GH measurements in eight patients. There was no postoperative mortality or serious morbidity. Postoperative basal GH-plasma levels were normal (<4.5 μg/L) in all patients. None of the 13 patients who participated in long-term follow-up examinations (mean, 4.2 yr) revealed signs of definite tumor recurrence. The mean GH-plasma level at follow-up was 1.6 ± 0.9 (mean ± standard deviation) μg/L. One patient died 2 years after the operation of causes unrelated to pituitary surgery. The subjectively perceived benefit of surgery was stated to be high by all 13 patients asked. For this reason, we conclude that pituitary surgery is the treatment of choice even in elderly patients with acromegaly.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

THE DEVELOPMENT OF sarcoma subsequent to cranial irradiation is a rare but serious and potentially fatal event. We describe seven patients who had undergone cranial irradiation (range, 1600–6000 cGy) to treat their primary disease and who developed sarcomas within the irradiated field. The median time from radiation therapy to the development of a sarcoma was 8 years (range, 4 to 15 yr). Fibrosarcomas developed in four patients, and malignant fibrous histiocytomas developed in three. Despite aggressive treatment, the prognosis was poor; the median survival from the diagnosis of sarcoma was 19 months. Sarcoma should be considered in the differential diagnosis of a new lesion or a lesion that progresses several years after radiation therapy.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

COLLINS' LAW (CL) states that the period of risk for recurrence for a tumor is the age of the patient plus 9 months. Originally a clinical observation in Wilms' tumor, CL has been applied to other tumors such as medulloblastoma (MB). Although CL does not apply to all childhood tumors, it seems to be a valid observation for childhood MB, despite several reports of violations or exceptions to CL in the literature. We sought to test CL in a large population of children with MB from the Childhood Brain Tumor Consortium (CBTC). We analyzed data from 602 children with MB, of whom 421 died and 181 were censored but alive at the last follow-up. We found 16 additional CL exceptions to supplement the 22 already present in the literature. This is both the greatest number of exceptions and the largest MB study population for CL reported to date. We provide clinical data on our 16 uncensored exceptions to CL and critically review those 22 cases cited previously in the literature. All of the CBTC exceptions were under 6 years of age at the time of initial diagnosis and were followed for an average of 7.5 years. All 16 CBTC exceptions died. Children older than 8 years of age could not be followed for a sufficient period of time to be able to state whether CL applies; as age at initial diagnosis increases, the period of observation required to determine CL validity becomes impractically long. Exceptions to CL are rare and amounted to 3.8% of 405 uncensored CBTC patients who died. Some exceptions to a clinical observation are always expected, but application of CL to children below the age of 8 years seems to be a useful predictor of survival in childhood MB.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ENDOSCOPIC CHOROID PLEXUS coagulation has been used for the treatment of hydrocephalus at this unit for the past 20 years, and 156 operations have been performed on 116 patients. These patients were analyzed retrospectively to determine the rate of long-term clinical control of hydrocephalus, factors associated with successful control, change in ventricular size after surgery, and rate of surgical complications. Data were found for 104 patients with a median age at surgery of 5 months (range, 1 wk-30 yr) and a mean follow-up of 10.5 years. Control of hydrocephalus by choroid plexus coagulation was found to be best in children with communicating hydrocephalus and a slow to moderate rate of increase in head circumference (18 of 28, 64% long-term control), whereas those who presented with tense fontanels and rapidly progressive hydrocephalus had the lowest rate of success. Overall, 36 of 104 (35%) achieved long-term control without cerebrospinal fluid shunts. The ventricular size was not significantly reduced by choroid plexus coagulation (ventricular index before and after surgery, 0.64 and 0.58, respectively;P= 0.13), although sulcal markings became more prominent in all successfully treated patients, indicating reduced intracranial pressure. There were no deaths resulting from surgery, and serious morbidity was low. Eight patients developed infections (five meningitis and three implant infections). Other complications included postoperative fits (two patients), respiratory arrest in a premature infant (one patient), low-pressure state (one patient), ventricular drain displacement or blockage (eight patients), subdural effusion (one patient), and intraoperative minor ventricular bleeding, forcing abandonment of the procedure (two patients). The procedure was not associated with a greater risk of long-term epilepsy, and patients who subsequently required cerebrospinal fluid shunts suffered fewer mechanical blockages than would normally be expected. These results support the more widespread use of endoscopic choroid plexus coagulation as an alternative to a cerebrospinal fluid shunt in selected patients with milder communicating hydrocephalus and in patients with intractable shunt failure.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

WE PERFORMED A retrospective study of 107 consecutive patients with syndromic forms of craniosynostosis (craniofacial dysostosis) seen by the craniofacial team at the Hospital for Sick Children between 1986 and 1992. There were 51 patients with Crouzon's syndrome, 33 with Apert's syndrome, 8 with Pfeiffer syndrome, 11 with Saethre-Chotzen syndrome, and 4 with kleeblättschadel anomaly. Six patients developed raised intracranial pressure (ICP) after initial suture release and decompression (Apert's syndrome, three patients; Pfeiffer syndrome, one patient; Saethre-Chotzen syndrome, two patients). Raised ICP was considered in those children who returned with a bulging fontanelle, progressive frontal bone protrusion, intermittent headaches, irritability, and vomiting. The diagnosis of raised ICP was based on papilledema (four patients), progressive macrocephaly (one patient), and ICP monitoring (one patient). No child in this group had hydrocephalus requiring cerebrospinal fluid diversion. Once raised ICP was detected in these children, a second operation was immediately performed to reduce the ICP with the intention of expanding the volume of the cranial cavity. The second procedures included: anterior cranial vault and upper orbital reshaping (four patients), posterior cranial vault reshaping (one patient), and total cranial vault reshaping (one patient). There were no perioperative complications in these patients, although one patient showed subsequent recurrence of raised ICP requiring further cranial vault re-expansion. At follow-up, ranging from 3 to 7 years, all six patients were asymptomatic without evidence of raised ICP. In our series, raised ICP occurred in 6% of the children with a craniofacial dysostosis syndrome after initial suture release and decompression. Accordingly, all children undergoing an early suture release and reshaping procedure for a craniofacial dysostosis syndrome require serial neurosurgical, craniofacial, and neuro-opthalmological examinations postoperatively. Despite an initial suture release and reshaping procedure in craniofacial dysostosis syndrome patients, the cranial vault may lack adequate growth potential to accommodate the growing brain. Appropriate timing of the revision craniotomy and reshaping procedure can prevent irreversible complications.

ISSN:0148-396X    

出版商:OVID    

年代:1995

数据来源: OVID