Neurosurgical Intervention In Patients Research Articles

Choroid Plexectomy Reduces Neurosurgical Intervention in Patients with Hydranencephaly

Introduction: The removal of the choroid plexus from the lateral ventricles was attempted by Dandy in the early 20th century but later discarded as complications arose and other methods of cerebrospinal fluid (CSF) diversion were introduced. We compare our experience with a variation of this operation to CSF diversion in patients with hydranencephaly or near hydranencephaly. Methods: The hospital and office charts of patients with a diagnosis of hydranencephaly were reviewed from the two institutions spanning the career of the senior author. Thirteen patients were identified, of whom 9 underwent CSF diversionary procedures (group A) and 4 underwent choroid plexectomy (group B). Results: The mean number of reoperations (2 in group A, 0 in group B), neurosurgical readmissions (1.5 in group A, 0 in group B) and days of hospitalization related to neurosurgical readmissions (43.5 in group A, 0 in group B) were all less in patients who underwent choroid plexectomy. The total incidence of complications related to surgery was also lower in this group (7 in group A, 0 in group B). Conclusion: In our experience, choroid plexectomy in patients with hydranencephaly reduces the incidence of reoperation and readmission, the number of days of hospitalization related to the surgical procedure and the total number of complications in comparison to patients undergoing CSF diversion. Further neurosurgical intervention is minimized as is the financial burden from multiple emergency department visits and radiological procedures for shunt evaluation. Choroid plexectomy is a viable alternative to CSF diversion in patients with hydranencephaly and a rapidly enlarging head. It avoids the chronic issues and complications surrounding CSF diversion in this difficult group of patients.

Utility of routine serial computed tomography for blunt intracranial injury.

To determine the utility of routine serial head computed tomography (H-CT) for predicting need for invasive neurosurgical intervention in patients with blunt intracranial injuries (BICI). Patients treated at a Level I trauma center with BICI over a 4-year period were reviewed. Of the 4,273 blunt trauma patients evaluated, 9.7% (415/4,273) were diagnosed as having BICI. Invasive intervention (craniotomy, ICP monitoring, ventriculostomy, or angiogram) was performed in 41.2% (171/415) of patients with BICI. Of these, 94.7% (162/171) had the procedure performed as a result of the initial H-CT. The remaining 5.3% (9/171) had the intervention performed as a result of a subsequent H-CT. Serial H-CT documented worsening of BICI in 32.3% (64/198) of the patients, but only those who had significant corresponding clinical deterioration had an invasive procedure as a result. In patients with an unchanged or normal neurologic exam, a routine serial H-CT did not influence subsequent invasive neurosurgical intervention.

Conservative management of extra-axial hematomas diagnosed by CT.

Our purpose was to assess the role of serial CT in recently traumatized patients with clinically stable extra-axial intracranial hematomas (EACH) and a midline shift of less than 0.5 cm. A retrospective review of 91 imaging studies in 41 patients (with 45 EACH) was done to assess the time between trauma and CT; the presence and type of skull fracture; the volume, type, and location of the EACH; the presence of associated edema and/or contusion. Over a 19-day follow-up, 11% of the dense EACH increased in volume and 27% decreased. An adjacent skull fracture was seen most frequently in patients with a decrease in EACH volume. Clinical data remain the key to determining the need for neurosurgical intervention in patients with EACH. Follow-up CT afforded no data which altered the medical management of these patients. However, it may be said to have alerted the clinician to an increase in the size of the EACH in 11% of cases, which could mandate close observation of this group.

LONG-TERM BENEFITS OF EARLY NEUROSURGERY FOR LIPOMYELOMENINGOCELE

Purpose Our previous experience with early neurosurgery for lipomyelomeningocele revealed that patients undergoing repair before age 1.5 years were more likely to have normal bladder function. We evaluate the durability of the urological benefits in patients with lipomyelomeningocele with longer followup. Materials and Methods A retrospective chart review was performed on all patients who underwent urodynamic testing before and after primary neurosurgical repair of lipomyelomeningocele. A total of 43 patients presented between 1983 and 1995 with at least 12 months of followup (median 68, range 15 to 167). Results Of the 43 patients 36 (84%) maintained stable clinical and urodynamic function, and 7 (16%) had late deterioration, which occurred between 9 months and 8 years postoperatively. Of 19 patients with normal urodynamic studies preoperatively 14 (74%) maintained normal function. Overall, 14 of 43 patients (33%) with lipomyelomeningocele had normal bladder and sphincter function during followup. The principal predictor of long-term normal bladder function was preoperative urodynamic status, since urodynamic studies were preoperatively normal in 13 of 14 patients (93%) who maintained normal bladder and sphincter function. Late neurosurgery was equally efficacious if urodynamic studies were normal. Conclusions Our data continue to support early diagnosis and neurosurgical intervention in patients with lipomyelomeningocele, since there is a higher likelihood of normal preoperative function that can be preserved. Furthermore, the results are durable in 84% of cases. However, close followup is necessary, since deterioration can occur up to 8 years postoperatively.

Clinicopathological heterogeneity in the classification of mild head injury.

Research examining the neurobehavioral outcome after mild head injury has yielded inconsistent and contradictory findings. Such findings have been attributed to a variety of methodological weaknesses, such as failure to consider the preinjury status of the patient, lack of control groups, and variability in outcome time points. However, few researchers have examined the adequacy of the current diagnostic criteria. A Glasgow Coma Scale (GCS) score of 13 to 15 is one of the primary criteria in the classification of mild head injury. We propose that the use of GCS Scores 13 to 15 permits excessive heterogeneity in injury severity and contributes to variability in neurobehavioral outcome. The purpose of this study is to examine the relationship of admission GCS scores to variables indicative of injury severity. The case records of 3370 patients consecutively admitted to a Level I trauma center with nonmissile head injuries, positive loss of consciousness, and admission GCS scores of 13 to 15 were reviewed. The frequency of positive computed tomographic scan findings and the need for neurosurgical intervention within the first 24 hours were recorded. A chi 2 analysis revealed statistically significant differences between the frequency of positive computed tomographic scans and the need for neurosurgical intervention in patients with GCS scores of 13 versus 14, 14 versus 15, and 13 versus 15. These results indicate significant differences in injury severity among patients with admission GCS scores of 13 to 15. The implicit assumption of clinicopathological homogeneity among patients with such scores is challenged by these data. This study demonstrates the need for more precise research diagnostic criteria in the study of neurobehavioral outcome after mild head injury. These findings also provide compelling evidence for the re-examination of the classification of mild head injury. Serious consideration must be given to the segregation of patients with GCS scores of 15 from those with scores of 14 and 13.

Tuberous sclerosis. Surgical therapy for seizures.

TUBEROUS sclerosis was first recognized as a pathological entity by Bourneville 1 who described the potato-like appearance of the sclerotic areas in the cerebral convolutions of a mentally defective epileptic patient. The syndrome of mental deficiency, epilepsy, and adenoma sebaceum was clearly defined by Vogt. 2 In general, a poor prognosis has been associated with the patients who have had a fully developed clinical picture, but in the last few decades it has become increasingly apparent that there are formes frustes of this disease, including patients with normal intelligence. 3,4 Patients may be encountered with any of the stigmata of the disease as isolated findings, or they may occur in various combinations. The disease is a heredofamilial one involving different tissue types in widespread areas of the body. Common sites include the brain, lung, kidney, spleen, bone, retina, and soft tissues. The indications for neurosurgical intervention in patients with this