Variety Of Neurosurgical Procedures Research Articles

Craneoplastía con implante de polimetilmetacrilato (PMMA) para corregir secuela de trauma. Reporte de caso

Introducción: los defectos del cráneo y las anomalías del hueso craneofacial que requieren reconstrucción son comunes en una variedad de procedimientos neuroquirúrgicos. Después de una craniectomía o de fracturas craneofaciales posteriores a traumatismos cráneoencefálicos, los pacientes pueden desarrollar defectos cosméticos importantes. Algunos de estos son la depresión de la piel y un defecto de hundimiento que lleva a una apariencia asimétrica de la cabeza, sin dejar de lado las repercusiones físicas, neurológicas y psicológicas que estas lesiones conllevan. La reconstrucción craneofacial y la craneoplastía tienen una larga historia, pero las nuevas técnicas quirúrgicas y una multitud de opciones de materiales han impulsado recientemente el avance en esta área. Los implantes de polimetilmetacrilato (PMMA) han demostrado ser estables, biocompatibles, no conductores, radiotransparentes y de bajo costo. Es así que se pueden colocar y modificar fácilmente, con lo que se elimina la morbilidad del sitio donante. Presentación del caso: en este artículo presentamos un caso de craneoplastía de defecto frontal, posterior a traumatismo, cuya reconstrucción fue realizada mediante una prótesis de polimetilmetacrilato (PMMA) en el Hospital General Xoco de la Cuidad de México. Conclusión: se reporta la reducción del tiempo quirúrgico, además de un costo de la prótesis accesible para el paciente; de esta manera, se obtuvieron resultados satisfactorios y mejoras en el contorno estético facial, en tanto se permitió cobertura y protección para el tejido encefálico.La reconstrucción craneofacial y la craneoplastía tienen una larga historia, pero las nuevas técnicas quirúrgicas y una multitud de opciones de materiales han impulsado recientemente el avance en esta área.1 Los implantes de polimetilmetacrilato (PMMA) han demostrado ser estables, biocompatibles, no conductores, radiotransparentes y de bajo costo.6 Se pueden colocar y modificar fácilmente y se elimina la morbilidad del sitio donante. En este artículo presentamos un caso de craneoplastía de defecto frontal posterior a traumatismo realizada mediante una prótesis de polimetilmetacrilato (PMMA) en el Hospital General Xoco de la Cuidad de México, con la cual se logró reducir el tiempo quirúrgico, además el costo de la prótesis fue accesible para el paciente y se obtuvieron resultados satisfactorios.

Introduction of intraoperative neuromonitoring does not necessarily improve overall long-term outcome in elective aneurysm clipping.

Intraoperative neuromonitoring (IOM), particularly of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs), evolved as standard of care in a variety of neurosurgical procedures. Case series report a positive impact of IOM for elective microsurgical clipping of unruptured intracranial aneurysms (ECUIA), whereas systematic evaluation of its predictive value is lacking. Therefore, the authors analyzed the neurological outcome of patients undergoing ECUIA before and after IOM introduction to this procedure. The dates of inclusion in the study were 2007-2014. In this period, ECUIA procedures before (n = 136, NIOM-group; 2007-2010) and after introduction of IOM (n = 138, IOM-group; 2011-2014) were included. The cutoff value for SSEP/MEP abnormality was chosen as an amplitude reduction ≥ 50%. SSEP/MEP changes were correlated with neurological outcome. IOM-undetectable deficits (bulbar, vision, ataxia) were not included in risk stratification. There was no significant difference in sex distribution, follow-up period, subarachnoid hemorrhage risk factors, aneurysm diameter, complexity, and location. Age was higher in the IOM-group (57 vs 54 years, p = 0.012). In the IOM group, there were 18 new postoperative deficits (13.0%, 5.8% permanent), 9 hemisyndromes, 2 comas, 4 bulbar symptoms, and 3 visual deficits. In the NIOM group there were 18 new deficits (13.2%; 7.3% permanent, including 7 hemisyndromes). The groups did not significantly differ in the number or nature of postoperative deficits, nor in their recovery rate. In the IOM group, SSEPs and MEPs were available in 99% of cases. Significant changes were noted in 18 cases, 4 of which exhibited postoperative hemisyndrome, and 1 suffered from prolonged comatose state (5 true-positive cases). Twelve patients showed no new detectable deficits (false positives), however 2 of these cases showed asymptomatic infarction. Five patients with new hemisyndrome and 1 comatose patient did not show significant SSEP/MEP alterations (false negatives). Overall sensitivity of SSEP/MEP monitoring was 45.5%, specificity 89.8%, positive predictive value 27.8%, and negative predictive value 95.0%. The assumed positive impact of introducing SSEP/MEP monitoring on overall neurological outcome in ECUIA did not reach significance. This study suggests that from a medicolegal point of view, IOM is not stringently required in all neurovascular procedures. However, future studies should carefully address high-risk patients with complex procedures who might benefit more clearly from IOM than others.

A NEW TECHNIQUE FOR SINGLE-PERSON FASCIA LATA HARVEST

Reconstitution of a watertight dural closure at the conclusion of most neurosurgical operations is a very important step to prevent cerebrospinal fluid leak, encephalocele formation, or infection. If sufficient native dura is not available to accomplish this goal, a dural substitute is required. We have developed a system of single-person fascia lata harvest that is fast, safe, and easily mastered. Through a standard incision along the iliotibial band, the fascia lata is dissected from the underlying muscle, and with the use of a simple system of stainless steel plates, a tray, and 2 nonperforating towel clips, a large volume of fascia is harvested. We have used this technique on 23 patients in the past 12 months, with good results. We have had fewer postoperative pain complaints and less seroma formation compared with the standard technique. This technique requires only simple instrumentation and, because the harvesting is done by 1 person, it can proceed independently of the main operation, thus eliminating any added operative time and inconvenience. It reliably produces a large volume of high-quality fascia that can be used in a variety of neurosurgical procedures.

Psychosurgery for Self-Injurious Behavior in Tourette's Disorder

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.

Intracranial Hypotension after Intraoperative Lumbar Cerebrospinal Fluid Drainage

OBJECTIVE Intraoperative lumbar cerebrospinal fluid drainage is frequently performed in a variety of neurosurgical procedures. A retrospective review is presented of the complications of lumbar cerebrospinal fluid drainage. METHODS The records from 75 consecutive operations requiring intraoperative lumbar cerebrospinal drainage during a 1-year period at the Hospital of the University of Pennsylvania were reviewed to assess the types of complications attributable to spinal drainage and their rates of occurrence. The operations were categorized into 46 aneurysm clippings, 21 craniotomies for tumors, and 8 other cranial base procedures. RESULTS Two patients developed transient postoperative neurological complications as a result of intracranial hypotension that resolved after epidural blood patching, with a reexploration craniotomy to drain an epidural collection performed in one patient. A third patient in the study developed a persistent deficit when intracranial hypotension led to intraoperative transtentorial herniation, which resulted in an unusual constellation of multiple brainstem infarcts that caused cranial neuropathy. CONCLUSION Complications of intraoperative lumbar cerebrospinal fluid drainage resulting in transient (2 of 75 patients, 3%) or persistent (1 of 75 patients, 1%) neurological deficits caused by intracranial hypotension occur infrequently and may be related to preexisting conditions such as hydrocephalus.

Intraoperative imaging--MRI.

Neuronavigation has become a standard technique in many neurosurgical procedures where its use allow better positioning of the craniotomy flap, precise targeting of lesions, and better anatomical orientation. However, the imaging used in such procedures is acquired preoperatively and thus, cannot project the dynamic changes that occur during surgery and result in many cases in significant brain shift and decreased accuracy. Recent technological developments have yielded a variety of MRI machines that can be used intraoperatively and provide the surgeon with updated images, integrated navigation capabilities, full compensation for brain shifts, and the ability to assess the extent of resection of the lesion. The concepts behind such technologies vary from one manufacture to another resulting in systems that vary in complexity, ease of use, spatial demands, and cost. In this chapter we review our experience with two intraoperative MRI systems used in a variety of neurosurgical procedures: the GE Signa SP System and the Odin PoleStar System.

Intraoperative on-line monitoring of cerebral pH by microdialysis in neurosurgical procedures

The objective of this study was to improve the ability to detect cerebrovascular complications in patients undergoing complicated neurosurgical procedures using on-line monitoring of cerebral pH with in viva microdialysis. We employed on-line pH monitoring in patients with a variety of neurosurgical procedures including high-flow bypass surgery, aneurysm clipping, and temporal resection in epilepsy treatment. The pH was monitored with a microdialysis probe, usually inserted into the frontal cortex and pH of the dialysate was measured on-line with a pH electrode. We monitored 17 cases: 12 high-flow extracranialintracranial (fC-IC) bypass procedures, 3 surgeries to clip large basilar tip aneurysms under protection of hypothermic circulatory arrest, and 2 surgeries for intractable seizure disorders. In the patients undergoing high-flow bypass, the pH remained stable in 5 patients and all had an uneventful outcome. In 3 patients, the pH decreased during surgery. One patient had a severe hemiparesis on awaking from anesthesia. The fall in pH in another patient was corrected when the blood pressure was raised during surgery. The pH was also responsive to changes in intraoperative ventilation and probably also to brain edema with elevation of pH values. In the three patients undergoing basilar tip aneurysm clipping under hypothermic circulatory arrest, the pH fell to 6.41 in one patient. This patient awoke with a mild hemiparesis. In the other two patients, the pH was stable during the hypothermia and neither patient had complications. In the patients undergoing temporal lobectomy and hippocampectomy, the pH fell rapidly with the onset of ischemia. We conclude that it is possible to monitor the cerebral extracellular pH with on-line microdialysis. The information obtained may alert the surgeon to the possibility of impending cerebral ischemia or other complications. However, further experience is needed before the technique can be recommended for general use. [Neural Res 1998; 20: 142–148]