摘要:

Laboratory studies have identified numerous potential therapeutic interventions that might have clinical application for the treatment of human traumatic brain injury. Many of these therapies have progressed into human clinical trials in severe traumatic brain injury. Numerous trials have been completed, and many others have been prematurely terminated or are currently in various phases of testing. The results of the completed Phase III trials have been generally disappointing, compared with the expectations produced by the successes of these interventions in animal laboratory studies. In this review, we summarize the current status of human traumatic brain injury clinical trials, as well as the animal laboratory studies that led to some of these trials. We summarize criteria for conducting clinical trials in severe traumatic brain injury, with suggestions for future improvements. We also attempt to identify factors that might contribute to the discrepancies between animal and human trials, and we propose recommendations that could help investigators avoid certain pitfalls in future clinical trials in traumatic brain injury.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEThis investigation was performed to construct a grading system for cranial base meningiomas that augments the current system of topographic labeling. This new system classifies cranial base meningiomas based on predicted surgical resection and patient outcomes.METHODSTwo hundred thirty-two consecutive patients with cranial base meningiomas were surgically treated by the two senior authors between April 1993 and August 1997. Using standard statistical tests, a large number of preoperative, intraoperative, and follow-up findings were analyzed for correlation with the extent of resection. These included the presence of previous radiotherapy, Cranial Nerve III, V, and VI palsies, multiple fossa involvement, and vessel encasement.RESULTSAnalysis revealed that each variable tested was independently and inversely correlated with total tumor resection (P< 0.002). We were able to construct a grading system based on these variables; when more variables are present, the grade is higher. With the grading system, lower-grade tumors were correlated with increased probabilities of total resection (r2= 0.9947) and better patient outcomes, as measured by Karnofsky performance scale scores (r2= 0.9291). We also found that, as a group, patients who underwent subtotal resection exhibited worse Karnofsky performance scale scores and had longer hospital stays.CONCLUSIONThe current system of classifying cranial base meningiomas provides no information regarding the tumor except location and no information concerning patient prognosis. We present a more useful system to categorize these tumors. Our scheme must be tested at other centers to corroborate our findings. This new grading system should serve to guide surgical treatment, inform patients, and improve communication among surgeons.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEIntracranial meningiomas extending into the infratemporal fossa (ITF) are uncommon. This series describes the radiographic characteristics, histological pattern of invasion, and implications for surgical treatment of intracranial meningiomas.METHODSNine patients (median age, 52 yr) underwent resection of a transcranial meningioma extending into the ITF. Five patients (56%) had undergone a previous resection; however, none had involvement of the ITF. Four patients (44%) had received prior radiation therapy to the area.RESULTSPreoperative neuroradiography uniformly showed erosion of the middle fossa floor and extension of the tumor through cranial base foramina. Histological results indicated tumor invasion of the middle fossa floor and skeletal muscle in all patients. Perineural invasion was present in four patients. Mucosal invasion was observed in six patients. A middle fossa/zygomatic approach provided access to the intra- and extracranial components of the tumor, as well as the cavernous sinus, ITF structures, paranasal sinuses, and nasopharynx. Reconstruction was performed using the temporalis muscle, which provides a vascularized flap between exposed mucosa and the carotid artery and intradural structures. A gross total resection was performed in seven patients (78%). Postoperative complications included soft tissue ischemia (one patient), worsening of preoperative cranial neuropathy (two patients), and lower extremity deep vein thrombosis (two patients). One patient died 2 months postoperatively from a pulmonary embolus. Two patients had recurrence of intracranial meningiomas extending into the ITF at 2 and 3 years postoperatively, necessitating further resection.CONCLUSIONUnderstanding the pertinent clinical and morphological aspects of meningioma transcranially involving the ITF is essential to surgical treatment of patients with this condition.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEThe goal of surgical treatment for Cushing’s disease is “endocrinological cure.” The purpose of this study was to determine predictors for postoperative endocrinological cure in Cushing’s disease.METHODSPostoperative endocrinological studies were evaluated in 18 patients with Cushing’s disease who underwent transsphenoidal surgery for selective adenomectomy. Serum adrenocorticotropic hormone (ACTH) levels were measured by radioimmunoassay during the first week after surgery. One week after surgery, a test using corticotropin-releasing hormone (CRH) was performed on each patient to check the reserve function of normal ACTH-secreting cells.RESULTSIn eight patients, postoperative ACTH levels were below the measurable level for 1 week, and ACTH showed no response to the CRH test. In these patients, serum ACTH and cortisol levels were kept in the normal range with a normal diurnal variation during long-term follow-up. These patients can be defined as endocrinologically cured. In seven patients, the ACTH level returned to within normal range on the day after surgery, but ACTH was provoked by the CRH test. Five of these seven patients showed subsequent re-elevation of ACTH above the normal range. ACTH levels were never normalized in the remaining three patients, and medical treatments were unavoidable.CONCLUSIONThe most reliable indicators for predicting endocrinological cure in Cushing’s disease are no response of ACTH to the CRH test in the early postoperative stage and an unmeasurably low ACTH level in the week after surgery. Obtaining a normal range of ACTH level postoperatively is insufficient to define endocrinological cure.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVETo determine whether perioperative subcutaneous heparin is safe to use for patients undergoing craniotomy and to determine the incidence of venous thromboembolism in patients undergoing craniotomy.METHODSPerioperative prophylaxis with subcutaneous heparin, 5000 U every 12 hours, was begun at induction of anesthesia for craniotomy and continued for 7 days postoperatively or until the patient was ambulating. Entry criteria to the study included patient age over 18 years and no evidence of deep vein thrombosis (DVT) preoperatively as judged by lower limb duplex ultrasound. Patients were excluded if they had duplex evidence of DVT or clinical evidence of pulmonary embolus (PE) preoperatively, had hypersensitivity to heparin or related products, had sustained a penetrating head injury, or refused informed consent. Any patient undergoing craniotomy was eligible, including patients with a ruptured aneurysm or arteriovenous malformation and those with spontaneous intracranial hemorrhage. Patients underwent duplex study 1 week after surgery and 1 month of clinical follow-up. Records were also kept on 68 nonstudy patients who refused consent. All patients were treated with lower limb pneumatic compression devices.RESULTSOne hundred six patients were treated. No differences were noted between study and nonstudy patients in some individual risk factors for DVT or PE, such as obesity, smoking, paralysis, infection, pregnancy or postpartum state, varicose veins, heart failure, or previous DVT or PE. Significantly more (43 of 106) patients in the study group had a history of risk factors for DVT or PE, particularly malignancy, however, compared with nonstudy patients (20 of 68 patients; &khgr;2,P< 0.01). There were no differences between groups in intraoperative blood loss, transfusion requirements, or postoperative platelet counts. Four clinically significant hemorrhages occurred during surgery in patients receiving heparin. Three resulted from intraoperative aneurysm rupture and one from intraventricular bleeding during resection of an arteriovenous malformation. These events were believed to be related to known complications of these operations, not to heparin. Of the study patients, two developed symptomatic DVT and one developed a nonfatal PE during the 1-month postoperative period. One additional study patient developed DVT below the popliteal veins, which was not treated. Four study patients developed DVT 1 to 2 months after surgery. In nonstudy patients, three developed DVT and two developed PE (one fatal, one nonfatal).CONCLUSIONPerioperative heparin may be safe to administer to patients undergoing craniotomy, but a larger study is needed to demonstrate efficacy.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEThe aim of this study is to classify nonatherosclerotic aneurysms unrelated to the branching zones (including fusiform aneurysms and dissecting aneurysms).METHODSDamage to the internal elastic lamina (IEL) is often an associated factor in the pathogenesis of aneurysm formation. In this study, 85 nonatherosclerotic aneurysms arising from an arterial trunk unrelated to the branching zones were classified into four different types, based on the lesional patterns of the IEL and the state of the intima. Type 1 corresponded to classic dissecting aneurysms, the pathogenesis of which was characterized by acute widespread disruption of the IEL without intimal thickening. Patients with Type 1 aneurysms had an ominous clinical course, and many presented with sudden subarachnoid hemorrhage with frequent rebleeding. Type 2 aneurysms were segmental ectasias, which had an extended and/or fragmented IEL with intimal thickening. Weakness of the arterial wall caused by the damaged IEL was assumed to be compensated by the intimal thickening. The luminal surface of the thickened intima was smooth without thrombus formation. The patients with Type 2 aneurysms had a placid clinical course. Type 3 aneurysms were dolichoectatic dissecting aneurysms, pathologically characterized by fragmentation of the IEL, multiple dissections of thickened intima, and organized thrombus in the lumen. Most of them were symptomatic and progressively enlarged over time. Type 4 aneurysms were saccular aneurysms unrelated to the branching zones. They arose in areas with minimally disrupted IEL without intimal thickening, and there was a risk of rupture.CONCLUSIONThere was a strong relationship between the pathological features of the aneurysms and their clinical courses. This classification may provide a rationale for modes of treatment.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID