Inhalation versus total intravenous anesthesia for lumbar disc herniation: comparison of hemodynamic effects, recovery characteristics, and cost.

The clinical effects, recovery characteristics, and costs of total intravenous anesthesia (TIVA), sevoflurane, and isoflurane anesthesia have been measured in various out-patient operations, but have not been evaluated in patients undergoing laminectomy or discectomy. In the current study, the authors assessed the hemodynamic characteristics, recovery, and cost analyzes after laminectomy and discectomy operations, comparing TIVA, sevoflurane, and isoflurane anesthesia. Sixty American Society of Anesthesiologists I and II patients were randomly divided into three groups, each consisting of 20 patients. Group I received propofol-alfentanil, Group 2 received sevoflurane-N2O, and Group 3 received isoflurane-N2O. At the end of surgery, the anesthetics were discontinued, and recovery from anesthesia was assessed by measuring the time until spontaneous eye opening and the time until response to verbal commands. The drug and delivery costs were calculated in United States dollars. No significant differences were found in the demographic data. Heart rate and mean arterial pressure decreased significantly after induction of anesthesia in the TIVA group, compared to the two other groups ( P < .05 for both comparisons). The fastest recovery was seen in the TIVA group. Incidences of postoperative nausea, vomiting, and pain were significantly reduced after TIVA ( P < .05 for both comparisons). Thus, TIVA patients required fewer additional drugs and showed the lowest additional costs in the post-anesthesia care unit. However, the total cost was significantly higher in the TIVA group than in the sevoflurane and isoflurane groups (52.73 dollars, 29.99 dollars, and 24.14 dollars, respectively) ( P < .05). Total intravenous anesthesia was associated with the highest intraoperative cost but provided the most rapid recovery from anesthesia, and the least frequent postoperative side effects.

The effects of intravenous fentanyl and lidocaine infiltration on the hemodynamic response to skull pin placement.

The aim of this study was to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the hemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received fentanyl 2 microg/kg IV 5 min before placement of the MH, group L was administered plain lidocaine 3 ml 1% by infiltration at each pin site 1 minute before placement, and both methods were applied together in group FL. Mean blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. In group F during and after MH placement, MAP and HR were significantly higher than in the L and FL groups. In the L group, there was significantly higher MAP and HR during the placement of MH than in the FL group. In the FL group, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the hemodynamic response to MH placement in patients undergoing craniotomy.

The effects of intravenous fentanyl and lidocane infitration on the haemodynamic response to skull placement.

The aim of this study is to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the haemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received 2 microg/kg(-1) fentanyl i.v. 5 min before placement of the MH, group L was administered 3 ml 1% plain lidocaine by infiltration at each pin site 1 minute later and before placement of the MH, and both methods were applied together in group FL. Mean arterial blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. Both were significantly increased during and after MH placement in group F compared to groups L and FL. In group L, there was a significant increase in MAP and HR during the placement of MH compared to group FL. In group FL, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the haemodynamic response to MH placement in patients undergoing craniotomy.

A new subtype of meningioma.

Three patients with small meningiomas presented with diffuse cerebral edema that was out of proportion to the size of tumors. All lesions were small and no brain invasion or unusual tumor vascularity or dural sinus involvement was noted in any of the three cases. Tumor material was subjected to conventional and immunohistochemical stains. All three tumors showed benign meningothelial components, prominent formation of hyaline inclusions (pseudopsammoma bodies), and striking vascular mural proliferation of small dark cells. All patients have remained asymptomatic without any evidence of tumor recurrence after a follow-up of 4-6 years. These tumors showed proliferation of pericytes in blood vessel walls and, therefore, represent a new subtype of meningothelial meningioma. In the study presented here, the location, size, histotype, and clinical findings that may influence the development of peritumoral brain edema are discussed in detail.

Extradural hematoma of the posterior cranial fossa.

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological finds are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Endogenous neuropeptides in patients with acute traumatic head injury. II: Changes in the levels of cerebrospinal fluid substance P, serotonin and lipid peroxidation products in patients with head trauma.

The cerebrospinal fluid (CSF) levels of substance P (SP), serotonin (5-HT) and lipid peroxidation (LPx) products were measured in patients with traumatic head injury and then compared to the levels obtained from control subjects. CSF samples were collected from 45 patients (31 male, 14 female, aged 19.2 +/- 17.79) within 24 h of the head trauma and the control CSF samples were obtained from 25 healthy subjects (23 male, 2 female, aged 51.44 +/- 17.6 years) having minor surgical operations under spinal anaesthesia. CSF SP and 5-HT levels in patients with head trauma were significantly lower than the levels in controls (P < 0.005, P < 0.001, respectively). On the other hand, the CSF Lpx products were significantly increased in patients with head trauma (P < 0.001). No significant correlation was found between the CSF changes and the admission Glasgow Coma Scale scores of the patients. This study constitutes the second part of our work on endogenous neuropeptides in patients with traumatic head injury and it emphasizes the role of SP, 5-HT and lipid peroxidation as additional endogenous factors in traumatic head injuries.

Acute spontaneous subdural hematoma of arterial origin: a report of five cases.

Acute spontaneous subdural hematoma of arterial origin is very rare. We report five patients who presented with a history of sudden onset of severe headache and vomiting and who developed progressive neurologic deficits, three becoming comatose. The symptomatologic onset was indistinguishable from other cerebrovascular disorders; none of the patients had a history of head trauma. In all our patients, the source of bleeding was identified at operation as a cortical artery located near the Sylvian region. Comparable cases in the literature are reviewed and the etiologic possibilities are discussed.

Ganglioglioma of conus medullaris: a case report.

A case of a ganglioglioma of the conus medullaris extending between T-12 and L2 segments is reported. The tumor was successfully removed by third stage operation. Ganglioglioma located in the conus medullaris is extremely rare. The best treatment of spinal cord ganglioglioma is totally tumor excision even when multiple stage operations are necessary.

Endogenous neuropeptides in patients with acute traumatic head injury, I: cerebrospinal fluid beta-endorphin levels are increased within 24 hours following the trauma.

The changes in the cerebrospinal fluid (CSF) beta-endorphin (beta-end) levels within 24 h following the trauma were examined in 45 patients with head injuries. CSF samples obtained from 25 healthy subjects who had minor surgical operations under spinal anaesthesia were included as the controls. Patients with head injuries were evaluated according to their Glasgow Coma Scale (GCS) scores on admission to the neurosurgery clinic and four subgroups were formed as follows: Group I: minor head trauma (GCS: 13-15) without skull fracture; Group II: mild head injury (GCS: 13-15) with skull fracture; Group III: moderate head injury (GCS: 8-12) and Group IV: severe head injury (GCS: < 8). All patients with head injury had significantly higher CSF beta-end levels than the controls (P < 0.001). The levels in patients with mild head injury (Group II) were significantly higher than those with severe head trauma (Group IV) (P < 0.001). There was not any correlation between the CSF beta-end changes and the GCS scores of the patients. Endogenous opioid peptides are suggested to have a role in central nervous system (CNS) injuries. However, the CSF levels of beta-end in patients with varying degrees of head trauma have not yet been clearly documented in the literature. In the present study, significant changes in CSF beta-end levels are detected in patients with a wide range of head trauma (from minor head trauma to severe injury); however, the increased CSF beta-end levels were not correlated to the early prognosis of the patients.

Cranioplasty with bone flaps preserved under the scalp.

Cranial bone defects in 27 patients were repaired with bone flaps preserved under the scalp. Head trauma (thirteen patients), cerebrovascular disorder (five patients), postoperative brain swelling (seven patients), and cerebral infective disease (two patients) accounted for the cranial defects. The bone flaps are reimplanted after 14-98 days. The follow-up period was 6 to 26 months. We have encountered no complications related to this technique in 27 consecutive cases.

Cerebellopontine angle germinoma. A case report.

A case of ectopic germinoma in the cerebellopontine angle with peripheral facial palsy and complete hearing loss on the left side is presented. The diagnosis was confirmed histopathologically. The unusual location of the tumor is stressed, and current management recommendations are reviewed.

Migration of bullet in the spinal canal: a case report.

As the spinal canal expands at T10 level naturally, it has been thought that the migration of a bullet within the spinal canal above this level is prevented and the migration of a bullet may only occur between T10 and S1 level. Here, a very rare case of a bullet traversing the length of the spinal canal is reported.

Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase.

During the last three years, seven patients with severe intraventricular hemorrhage admitted to our clinic were treated with direct intraventricular infusion of urokinase. In each case, hemorrhage extended into the entire ventricular cavity and cast formation as well as an expansion of third and fourth ventricles were found. On the average, both the third and fourth ventricles became clear on the third day and the lateral ventricle on the ninth day after hemorrhage. Five of the seven patients showed good recovery or only moderate disability, and two died. Infection, convulsion, rebleeding, and peripheral or secondary hemorrhage due to the side effects of urokinase was not encountered during therapy. We conclude that this procedure can be applied effectively and safely in severe intraventricular hemorrhage.

Lipid peroxidation in experimental spinal cord injury. Comparison of treatment with Ginkgo biloba, TRH and methylprednisolone.

Ischaemia-induced lipid peroxidation is one of the most important factors producing tissue damage in spinal cord injury. In our study, the protective effects of Ginkgo biloba, thyroid releasing hormone (TRH) and methylprednisolone (MP) on compression injury of the rat spinal cord were investigated. For this study 45 rats in four groups, including control, MP, TRH and Gingko biloba, were used to determine the formation of malondialdehyde (MDA). All the animals were made paraplegic by the application clip method of Rivlin and Tator. Rats were divided randomly and blindly to one of four treatment groups (ten animals in each). MP and Ginkgo biloba treatments significantly decreased MDA levels (F = 54.138, P < 0.01). These results suggest that MP and Ginkgo biloba may have a protective effect against ischaemic spinal cord injury by the antioxidant effect.

Management of primary intracerebral hematomas.

112 cases of primary intracerebral hematomas treated surgically, 25 cases aspirated with urokinase infusion and 25 cases treated conservatively in the last five years were reviewed in detail. In the craniotomy group, 17 out of 44 survivors showed good recovery and returned to normal life, 18 of them went home needing no care, 8 went home needing partial care, and one was bedridden. The overall mortality rate in this group was 59.8%. In the urokinase group, 6 out of 21 survivors showed good recovery and returned to normal life, 11 of them went home needing no care, 3 went home needing partial care and one was bedridden. The overall mortality rate in this group was 16%. In the conservative group, 8 out of 19 survivors showed good recovery and returned to normal life, 9 of them went home needing no care, and two went home needing partial care. The overall mortality rate in this group was 24%. Although the mortality rate was lower in the urokinase group compared with the conservative group, there was no statistically significant difference between the two groups (P > 0.05). These results indicate that surgery is useless in deeply comatose patients and CT-guided aspiration with urokinase is a simple, effective, and safe method in appropriately selected patients.

The therapeutic value of naloxone and mannitol in experimental focal cerebral ischemia. Neurological outcome, histopathological findings, and tissue concentrations of Na+, K+ and water.

In this study, the effect of naloxone and mannitol was investigated on focal cerebral ischemia induced by middle cerebral artery occlusion with the transorbital approach in the rabbit model. Rabbits were randomly and blindly assigned to one of three groups (six animals in each): (1) a control group that received equal volumes of physiological saline solution; (2) a naloxone group that received a 5 mg/kg bolus of naloxone i.v. 1 h after occlusion, followed by 2 mg/kg per hour i.v. infusion for 5 h; (3) a mannitol group that received 0.2 g/kg twice with an interval of 10 min at 5 h. The neurological outcome was better in rabbits treated with naloxone than in the others. The ratio of ischemic to total neurons in the cortex was smaller in the naloxone group than in the control and mannitol groups (P < 0.05). In addition, there was a statistically significance reduction in infarct size in the naloxone group compared with the other groups (P < 0.05). Edema was severe in the control and mannitol groups, but moderate in the naloxone group. There was no statistically significant difference in Na+, K+, and water content between groups. Our data provide evidence for the beneficial effects of naloxone on promoting neurological recovery and preserving the ischemic area.

Prevention of adhesions after laminectomy: an experimental study in dogs.

An experimental study was designed to compare the efficacy of Vicryl mesh and autogenous fat in minimizing postoperative epidural scar formation. Three-level noncontiguous laminectomies were performed on ten adult dogs. Exposed dura at the three levels was covered with (1) nothing (control group), (2) fat, and (3) Vicryl mesh. Animals were sacrificed 6 and 12 weeks postoperatively and the specimens were examined histologically. Compared with the use of free fat grafts after laminectomy in dogs, Vicryl mesh produced slightly more scarring, but consistently less than observed in controls. Although no surgical zone treated with Vicryl mesh exhibited evidence of neural compression, one of the ten fat-grafted zones showed gross evidence of neural compression. These findings indicate that the use of Vicryl mesh at laminectomy sites may be an alternative method of minimizing postoperative epidural scar formation.

Effects of TRH and high-dose corticosteroid therapy on evoked potentials, and tissue Na+,K+ and water content in experimental spinal injury.

The therapeutic effects of continuous infusion of thyrotropin-releasing hormone (TRH) and methylprednisolone (MP) in experimental spinal cord injury were studied in Swiss albino rats. Thirty rats received a 53-g clip-compression injury on the cord at T1, then were allocated randomly and blindly to one of three treatment groups (ten animals in each): (1) control; received equal volumes of saline solution; (2) MP; received 30 mg/kg methylprednisolone i.v. 1h after trauma, followed by infusion of 5.4 mg/kg/per hour i.v. for 3h; (3) TRH; received 2 mg/kg TRH i.v. 1h after trauma, followed by infusion of 1 mg/kg/per hour i.v. for 3h. MP and TRH treatments significantly improved somatosensory-evoked potentials (SEPs; P < 0.001). Both treatments significantly reduced water content, decreased Na+ content and increased the K+ content of the cord segment that included the centre of the impact (P < 0.01). Our data provide evidence for the beneficial effects of high-dose corticosteroid and TRH in promoting electrophysiological recovery and preserving spinal cord tissue following experimental injury.