Development Of New Neurological Deficits Research Articles

Intracerebral hemorrhage complicating cervical “hourglass” schwannoma removal

The authors report a case of infra- and supratentorial intracerebral hemorrhage complicating the postoperative course of a patient who had undergone surgical removal of a cervical schwannoma with an hourglass configuration. To their knowledge, this is the first case in which this neurosurgical procedure was followed by such a complication. Possible mechanisms are discussed; however, pathological events leading to this complication are unclear. The development of new neurological deficits not attributable to the surgical procedure should suggest this possibility.

Neglected craniocerebral gunshot wound resulting in an encephalocele: case report

During military conflicts, surviving victims traditionally underwent large enough craniectomy or craniotomy to achieve extensive debridement of the in-driven bone, shell fragments, and debris. Meanwhile, the completely as well as the partially devitalized adjacent brain tissue would also be debrided. This might have led to additional neurologic deficit or lesser degree of recovery of functions.We studied the efficacy and safety of much more limited or even absence of surgical intervention in a selected group of wartime head-wounded patients. Among 1,150 war victims with penetrating head wounds referred to two major centers affiliated with Tehran University of Medical Sciences during the 8-year period spanning the Iran-Iraq conflict, there were 191 head-wounded patients who underwent either no surgical intervention or a very limited debridement. We have attempted to follow up as closely as possible for more than 8 years. Ninety-nine of them fulfilled the criteria to be included in this series. Close follow-up for development of cerebral infections, functional recovery, or development of new neurologic deficits and epilepsy were performed. At least 3 contrast-enhanced CT scans were taken for each patient. All patients were victims of the battle-field areas with low- to moderate-velocity missile or shell fragment injury. The Glasgow Coma Scale (GCS) scores of the patients were between 8–14 when visited by the first attending neurosurgery staff. The factors considered to be effective in the outcome analysis were the entry point, the number of the in-driven bone fragments, the retained shell fragments, the brain compartments affected, and the paranasal sinus or skull base involvement with or without cerebrospinal fluid (CSF) fistula.There were 13 unilobar, 44 bilobar, 4 trilobar, 38 transventricular, and 3 skull base lesions. The number of retained metal fragments varied between 1 to 6. The number of retained bone fragments varied between 1 to 5 in 73 victims and more than five chips in other cases. The outcome was good (back to work) in 90 patients and poor (severely disabled) in 4. Five patients died because of severity of brain damage and meningitis. The effect of the different enumerated variables upon the outcome was measured using χ2 and Fisher exact test, which was nonsignificant for all of the variables except for the orbitofacial entry point of injury (p = 0.00006).This study seems to indicate that not only is reoperation for retained bone or shell fragments unnecessary, but surgeons having modern neuroradiological instruments available to detect the proper explanation for changes in GCS of the patients may decide not to proceed with any surgical intervention in a good number of patients. As a result of the “no surgical treatment protocol,” one can preserve cerebral tissue without exposing the patient to undue risk of seizures, infection, or death by leaving behind some or all the in-driven bone and shell fragments.

Carotid endarterectomy after a completed stroke: Reduction in long-term neurologic deterioration

The merit of carotid endarterectomy for patients who previously have sustained a completed stroke remains controversial. Between January 1976 and December 1983, 118 stroke patients with mild to severe permanent neurologic deficits were evaluated. Fifty-nine patients were managed nonoperatively and 59 operatively. Both cohorts were similar in age and sex distribution, incidence of hypertension (69%), diabetes mellitus (25%), and cardiac disease (39%). In the long-term follow-up (medical cohort average was 44.1 ± 5.0 months; surgical cohort average, 41.8 ± 3.7 months) the overall survival rate was comparable, that is, there were nine medical deaths and eight surgical deaths. However, there was a significant difference in the development of new neurologic deficits. Twelve of the 59 unoperated patients had new neurologic deficits and three patients died at 12, 36, and 48 months as a result of a recurrent stroke. New neurologic deficits developed in only two of the 59 surgical patients and there were no stroke-related deaths. When the cumulative probability of remaining free from recurrent deficits was examined in the surviving patients at 6 years, all of the patients in the operated group remained free from recurrent deficits, whereas only 58% of the patients in the unoperated group were free of new neurologic deficits (p = 0.02). These data suggest that stroke patients with fixed mild to moderate neurologic deficits and with carotid lesions may be protected from recurrent neurologic complications by carotid endarterectomy.