Clinical outcomes of aneurysmal subarachnoid hemorrhage patients treated with oral diltiazem and limited intensive care management.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) patients are frequently treated with prophylactic nimodipine and undergo invasive monitoring of blood pressure and volume status in an intensive care unit (ICU) setting to decrease the incidence of delayed ischemic neurological deficit (DIND) and improve functional outcomes. The goal of this study was to examine the incidence of DIND and poor functional outcomes in a consecutive series of SAH patients treated with a different regimen of prophylactic oral diltiazem and limited use of intensive care monitoring. METHODS: The study involved a consecutive series of 123 aneurysmal SAH patients treated by the senior author who were admitted within 72 hours of hemorrhage and who never received nimodipine or nicardipine. Functional outcomes were graded using the Glasgow Outcome Scale (GOS). RESULTS: Of the 123 patients identified, favorable outcomes (GOS 4 and 5) were achieved in 74.8%. The incidence of DIND was 19.5%. Hypertensive, hypervolemic, hemodilutional (HHH) therapy was used in 10 patients (8.1%) and no patients were treated for DIND by endovascular means. Seven patients (5.7%) had a poor functional outcome or death because of DIND and two of these were related to complications of HHH therapy. These results were compared to contemporary series of SAH patients managed with other treatment protocols. CONCLUSIONS: Functional outcomes of patients treated with a regimen of oral diltiazem, limited use of ICU monitoring and HHH therapy for DIND compare favorably with other contemporary series of SAH patients.

Shoulder numbness in a patient with suprascapular nerve entrapment syndrome: cutaneous branch of the suprascapular nerve: case report.

OBJECTIVE AND IMPORTANCE: The ability to diagnose peripheral nerve disorders is dependent on knowledge of the anatomic course and function of the nerves in question. The classic teaching regarding the suprascapular nerve (SScN) is that it has no cutaneous branches, despite the fact that a cutaneous branch was first reported in the anatomic literature 20 years ago. CLINICAL PRESENTATION: We describe a case of a 35-year-old male patient who presented with right shoulder pain and atrophy and weakness of the right supra- and infraspinatus muscles. During the examination, he was also noted to have an area of numbness involving the right upper lateral shoulder region. Electrical study results were consistent with SScN entrapment at the suprascapular notch. INTERVENTION: The patient underwent surgical decompression 7 months after the onset of his symptoms. The patient noted resolution of his shoulder pain immediately after the procedure, and his shoulder sensory disturbance had improved by 2 weeks. At 9 months after surgery, he remained pain-free, his shoulder sensation was normal, and his motor abnormalities had improved significantly. CONCLUSION: This case provides clinical evidence for the presence of a cutaneous branch of the SScN, as described in cadaveric studies. Although shoulder numbness demands a search for alternative diagnoses, it does not necessarily exclude the diagnosis of SScN entrapment.

Anatomic considerations in the treatment of extracranial cerebrovascular disease.

This article outlines the anatomic relationships and variants of structures encountered during surgical approaches for the treatment of extracranial cerebrovascular disease.

Strategies in the surgical management of malignant gliomas.

The overall prognosis for patients with malignant gliomas remains poor. The infiltrative nature of the tumor into normal brain and the presence of tumor foci in regions remote from the main tumor burden make cure with current therapies virtually impossible. Management therefore consists of tumor control while maintaining the patient's quality of life. Surgery comprises only one arm of the overall treatment plan. Biopsy allows diagnosis and tumor grading even when tumors are located in eloquent or deep areas of brain. Craniotomy decreases overall tumor burden and provides room for the normal brain, edema and recurrent tumor. Many adjuncts are available to assist in gaining surgical access to tumors with minimal violation of normal functioning brain. Important among these are stereotaxy and surgery within a specially designed magnetic resonance scanner. The strategies for the surgical management of malignant gliomas utilized at our institution will be discussed.

Ganglion cyst involvement of peripheral nerves.

Despite their benign histological appearance and the current literature composed primarily of case reports with favorable outcomes, ganglion cysts involving peripheral nerves (GCPNs) can cause permanent neurological deficits. The authors present a 27-year Louisiana State University Medical Center (LSUMC) experience with the surgical management of GCPNs. From 1968 to 1995, 27 patients were surgically treated for 27 cysts that involved nerves at nine locations. Cysts of the peroneal nerve were the most common, comprising 52% of the cases. Motor deficit, pain, and sensory changes were present in 83%, 78%, and 48% of cases, respectively. A history of acute trauma was noted in 22%. The mean follow-up duration in these cases was 61 months. Motor recovery was good in only 58% of cases and was related to the severity of the preoperative motor deficit. Pain resolved or was significantly improved in 89% of cases. Five patients underwent nine procedures before referral to LSUMC for treatment of recurrence of their ganglion cysts. None of these patients suffered recurrence after undergoing surgery at LSUMC. However, four additional patients (17%) experienced a total of six recurrences after undergoing their initial procedure. The mean time to recurrence for the patient group as a whole was 16 months. On the basis of their experience, the authors conclude that GCPNs can behave in an aggressive fashion. Patients should be counseled preoperatively about the potential for limited motor recovery and a significant chance for recurrence.

Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions.

BACKGROUND AND PURPOSE: It is not known what fraction of patients with symptomatic cerebral aneurysms are misdiagnosed at initial medical presentation. It is also not clear whether misdiagnosed patients more frequently deteriorate before definitive aneurysm diagnosis and therapy or achieve a poorer outcome than correctly diagnosed patients. METHODS: We reviewed records of consecutive patients with symptomatic cerebral aneurysms managed by four tertiary-care neurosurgical services during a recent 19-month period. Clinical course and outcome were analyzed according to misdiagnosis or correct diagnosis at initial medical evaluation. RESULTS: Fifty-four of 217 patients (25%) were misdiagnosed at initial medical evaluation, including 46 of 121 patients (38%) initially in good clinical condition (clinical grade 1 or 2). Forty-six of 54 patients (85%) in the misdiagnosis group were initially grade 1 or 2 compared with 75 of 163 patients (46%) with correct initial diagnosis (P < .01). Twenty-six of 54 misdiagnosed patients (48%) deteriorated or rebled before definitive aneurysm treatment compared with 4 of 165 correctly diagnosed patients (2%) (P < .001). Among patients initially presenting as clinical grade 1 or 2, overall good or excellent outcome was achieved in 91% of those with correct initial diagnosis and 53% of patients with initial misdiagnosis (P < .001). Deterioration before correct diagnosis accounted for 16 of 67 patients (24%) with poor or worse final outcome in this series. CONCLUSIONS: Patients in good clinical condition with symptomatic cerebral aneurysms were commonly misdiagnosed. Misdiagnosed patients were more likely than correctly diagnosed patients to deteriorate clinically and had a worse overall outcome. Misdiagnosed cases accounted for a significant fraction of overall poor outcomes among consecutive cases of symptomatic aneurysms.

Neuroprotective effects of preischemia intraarterial magnesium sulfate in reversible focal cerebral ischemia.

The known cytoprotective properties of MgSO4 led the authors to study its effects on infarct size in rats when administered intraarterially before reversible focal ischemia. Following an intracarotid infusion of MgSO4 in the amount of 30 mg/kg (24 animals), 90 mg/kg (18 animals), or an equal volume of vehicle (23 animals), middle cerebral artery occlusion was produced in rats by means of an intraluminal suture technique. Reperfusion occurred after 1.5 (42 animals) or 2 hours (23 animals) of ischemia. Automated, volumetric measurements of 2',3',5'-triphenyl-2H-tetrazolium chloride-stained coronal brain sections demonstrated a statistically significant decrease in infarct size for MgSO4 treatment groups compared to controls. Cytoprotection was greater in animals subjected to 1.5 hours of ischemia (28.4% reduction in infarct volume, p < 0.001, Student's t-test), than in those having 2 hours of ischemia (19.3% reduction, p < 0.05). Animals given 90 mg/kg MgSO4 prior to 1.5 hours of ischemia (12 animals) showed a 59.8% reduction in infarct volume compared to controls (11 animals, p < 0.001) and a 43.1% reduction compared to the 30 mg/kg group (11 animals, p < 0.001). Analysis of variance demonstrated the statistically significant effects of MgSO4 doses on infarct volume across all groups (F = 22.95, p < 0.0001). The neuroprotective effect of intraarterial MgSO4 in this model is robust, dose dependent, and related to the duration of ischemia. The compound may be valuable for limiting infarction if given intraarterially before induction of reversible ischemia during cerebrovascular surgery.

Early discharge after carotid endarterectomy.

A consecutive series of 233 carotid endarterectomies performed over a 4-year period by one neurosurgeon was reviewed to analyze the number, nature, cause, and time to occurrence of complications. The time to discharge was analyzed regarding the type of anesthesia used and the time period during which surgery was performed. The records were reviewed to determine whether any complication could have been prevented by routine postoperative monitoring in an intensive care unit or by longer postoperative hospitalization. There were no perioperative deaths. The incidence of ipsilateral stroke was 1.7% and of major stroke was 0.9%. Nondisabling myocardial infarctions occurred in 1.3% of the patients. Complications occurred in a bimodal time course, less than 48 hours or greater than 1 week. The time to discharge decreased during the study period from 4.44 +/- 4.22 days for the first year of the study to 1.56 +/- 1.31 days for the last year of the study (P < 0.0001). A trend toward earlier discharge for patients who received cervical block anesthesia rather than general anesthesia did not reach statistical significance. No adverse patient outcome could be attributed to lack of intensive care unit monitoring or to early discharge. Our data demonstrate that patients who have undergone carotid endarterectomies do not routinely require intensive care unit monitoring and that discharge 24 to 48 hours after surgery is safe for the majority of patients. This regimen can result in considerable savings without compromising the quality of patient care.

Arteriovenous malformations in elderly patients.

This article discusses the presentation, natural history, and management of arteriovenous malformations (AVMs) in elderly patients, based on our experience at the Dartmouth-Hitchcock Medical Center. We also present a review of the literature. In our series of 50 patients with AVMs who were operated on by one surgeon, six patients were 65 years old or older at the time of presentation. All six patients presented with intracerebral hemorrhage, and one patient had developed a seizure disorder 2 months before hemorrhaging. In three patients, the clinical course was consistent with the occurrence of two hemorrhages within a 48-hour period. The patients' preoperative neurological status varied from intact to moribund. In two patients, the diagnosis of AVM was made intraoperatively. Preoperative angiography revealed the diagnosis in the remaining patients. All the patients underwent surgical excision of their AVMs. Despite concurrent medical illnesses, all patients tolerated the procedure well with no new, persistent neurological deficits. At follow-up, all patients showed sufficient neurological recovery to return to the community and four of the patients were neurologically intact. Based on this experience and a review of the literature, we conclude that AVMs in elderly patients are not benign lesions and that surgical excision should be considered among the management options for these patients.