Vagus nerve stimulation: indications and limitations.

Vagus nerve stimulation (VNS) is an established treatment for selected patients with medically refractory seizures. Recent studies suggest that VNS could be potentially useful in the treatment of resistant depressive disorder. Although a surgical procedure is required in order to implant the VNS device, the possibility of a long-term benefit largely free of severe side effects could give VNS a privileged place in the management of resistant depression. In addition, VNS appears to affect pain perception in depressed adults; a possible role of VNS in the treatment of severe refractory headache, intractable chronic migraine and cluster headache has also been suggested. VNS is currently investigated in clinical studies, as a potential treatment for essential tremor, cognitive deficits in Alzheimer's disease, anxiety disorders, and bulimia. Finally, other studies explore the potential use of VNS in the treatment of resistant obesity, addictions, sleep disorders, narcolepsy, coma and memory and learning deficits.

Neurostimulation for refractory angina pectoris.

Spinal cord stimulation (SCS) has been shown to be particularly useful, safe and effective treatment in the management of patients with refractory angina pectoris and those unsuitable for percutaneous or surgical revascularisation. Clinical and experimental research has shown that it decreases myocardial ischemia without masking the clinical symptoms of its imminent development. In addition to providing pain relief, neurostimulation has also been shown to improve microcirculatory blood flow and increase the myocardial threshold for ischaemia. The anti-ischaemic effects of SCS have been evaluated by: (a) exercise testing, (b) ambulatory electrocardiogram (ECG), and (c) invasive measurements of lactate from coronary sinus blood samples. Patients have reported not only significantly fewer angina attacks but also decreased consumption of glyceryl trinitrate and improved quality of life. A number of mechanisms have been proposed including placebo effects, primary anti-nociceptive effects, involvement of endogenous opiates, anti sympathetic nervous system effects, increases in coronary blood flow, and redistribution of myocardial blood flow.

Benign osteoblastoma of the parietal bone.

A 5-year-old girl presented with a 1-year history of a subcutaneous swelling in the right parietal region. There were no cerebral symptoms or signs. Plain X-ray of the skull showed a lytic bony lesion with sclerotic margin. Computed tomography showed a hypodense, osteolytic lesion with thinned and bulged inner and outer skull tables with intact continuity. There was no intracranial lesion. At operation, the mass was found to be pink and granular, and was totally enucleated. Histology revealed it to be a benign osteoblastoma.

Penetrating craniocerebral shrapnel injuries during "Operation Desert Storm": early results of a conservative surgical treatment.

A follow-up study is presented of the initial neurosurgical treatment of 20 patients who sustained penetrating craniocerebral injuries during "Operation Desert Storm". Fifteen of these patients had received intracranial debridement through a craniectomy and five patients had received care of scalp wounds only. Following treatment and stabilisation in a frontline hospital, these patients were transferred to the Riyadh Armed Forces Hospital for further evaluation and management. On admission, all the patients received a computerised tomographic scan which revealed shrapnel fragments inside their brain. No attempt had been made to remove the metal fragments. A patient with an infected scalp wound was treated with a course of appropriate antibiotics and the wound dressed. Dexamethasone was not used. Anticonvulsants were used only in one patient who had been treated for a presumed cerebral abscess. The neurological status of the patients improved along with the reduction of oedema and the swelling of the brain as shown in the follow-up CT scans. No patient died or developed a seizure disorder. These results suggest that re-operation for removal of retained fragments is unnecessary. It is concluded that the initial treatment of shrapnel wounds of the brain should be to preserve maximal cerebral tissue and function either by limiting the wound debridement performed through a craniectomy or by care of scalp wounds only.

Multiple cervical spine fractures without neurologic deficit after a helicopter crash. Case report.

The case of a soldier with multiple cervical fractures without neurologic deficit sustained after a helicopter crash during Operation Desert Storm is presented. The fractures involved the C2 body and the right facet joint and pedicle of C4. This fracture pattern, in association-with lack of neurologic deficit, is the first such case reported in the literature.

Multicentric glioma of the spinal cord.

A 24-year-old woman with neurofibromatosis presented with a 1.5-year history of pain in the neck, both shoulders and back, and a 4-month history of progressively increasing weakness of all the limbs and inability to walk. The limb weakness fluctuated and, at the height of the weakness, it was associated with hesitancy and retention of urine. Magnetic resonance imaging (MRI) showed a fusiform enlargement of the upper cervical cord with obliteration of the subarachnoid space. Imaging after gadolinium-DTPA injection revealed inhomogeneous enhancement extending from the lower medulla down to the C4 cord level, and homogeneous enhancement at D3 to D4 and D6 to D8 cord levels. The spinal cord at the lower two levels appeared morphologically normal. At operation the fusiform enlargement of the cervical cord was confirmed. The tumour was partially removed. Histology revealed it to be a fibrillary astrocytoma.