The importance of cerebral ischemia during carotid endarterectomy.

The importance of cerebral ischemia produced by carotid clamping during carotid endarterectomy remains controversial. In an effort to determine the importance of cerebral ischemia during carotid endarterectomy, 369 patients undergoing 431 consecutive carotid endarterectomies were studied by Xenon-133 (133Xe) clearance and electroencephalogram (EEG) monitoring. None of the patients was shunted during the procedures. The severity of ischemia as indicated by 133Xe clearance from the ipsilateral hemisphere during 20 to 30 minutes of carotid occlusion did not predict the appearance of complications in this group of patients (chi 2 = 1.417; P = 0.841). There was a highly significant relationship between the depth of cerebral ischemia as demonstrated by 133Xe clearance and the appearance of abnormalities on the EEG (chi 2 = 42.043, P less than 0.0001). In the subgroup of patients developing abnormalities as shown by EEG, there was a negative correlation (chi 2 = 17.495; P less than 0.002) between reduction in blood flow and the appearance of complications, in that the higher the blood flow during occlusion the more likely the patient developing EEG changes would develop complications.

Reconstruction of cranial defects with porous hydroxylapatite blocks.

Repair of cranial defects for brain protection and aesthetics is currently a surgical problem for which there is no completely satisfactory solution. Material used for repair of cranial defects should ideally be incorporated by the body and provided a blood supply. No substance to date, including autologous bone, consistently achieves this. Hydroxylapatite is a polycrystalline, nonresorptive, biocompatible ceramic that allows osseous tissue ingrowth and ultimate transformation into vascularized bone. The authors have used granular hydroxylapatite successfully for reconstructing calvarial defects, but have experienced problems with migration of granules, prolonged mobility, and, in one patient, resorption of an underlying supporting bone graft. The use of hydroxylapatite in block form precludes most of these problems. Porous block or strips are easily contoured and can be fixed at the margin of the calvarial defect, providing immediate stability. Ingrowth of osteoblastic and fibrous tissue provides added strength and stability. This paper describes our experience with porous hydroxylapatite blocks for reconstructive cranioplasty.

Comparison of chemonucleolysis and microsurgical discectomy for the treatment of herniated lumbar disc.

A series of 126 patients with symptomatic herniated lumbar disc who were treated by either chemonucleolysis (CN) or microsurgical lumbar discectomy (MLD) was reviewed retrospectively. Of the 45 patients who chose chemonucleolysis, 27 (60%) reported a good outcome. The minor morbidity in this group was 52% and the major morbidity (infection) was 2.2%. Of the 81 patients who selected microsurgical discectomy, 72 (89%) reported a good result. The minor morbidity was 5%, and the major morbidity (infection) was 1.2%. The lower incidence of treatment success and higher percentage of patients suffering morbidity in the chemonucleolysis group make this procedure less desirable in the treatment of patients with herniated lumbar disc.

A prospective analysis of 142 carotid endarterectomies for occlusive vascular disease, 1979-1985.

Carotid endarterectomy may carry a substantial risk of morbidity and mortality from major stroke, thus offsetting any statistical benefit in reduction of future stroke. Because of the disturbing ranges in the incidence of stroke morbidity and mortality reported from the several institutional series studying carotid endarterectomy, the authors undertook a prospective review of 142 consecutive carotid endarterectomies performed for symptomatic atherosclerotic occlusive vascular disease on the neurosurgical service. The University of Alabama Hospital. Preoperative risk assessment was performed in each case according to the Mayo Clinic classification system. The overall mortality rate was 1.4% and the major stroke morbidity rate was 0.7%, for a combined major morbidity and mortality rate of 2.1%. The incidence of minor neurological morbidity was 1.4%. There was no morbidity or mortality in the Grade I and II (low-risk) patient groups. This low combined major morbidity and mortality rate of 2.1% for carotid endarterectomy causes the surgical stroke-free survival curve to intersect the medical stroke-free survival curve at an earlier point in time, and thus demonstrates the greater reduction in risk of stroke which accrues over time for the surgically treated patient.

Complications following enucleation and implantation of multiple glass spheres in the orbit.

The technique of subperiosteal implantation of multiple, small glass beads for correction of enophthalmos associated with anophthalmos was first described in 1967. Reported complications of this procedure include ptosis, anesthesia of the distribution of the supraorbital or infraorbital nerve, and migration of the implants into the orbit or sinuses. A case of orbital cellulitis has been reported. We now report a case in which the extremely serious complication of intracranial migration of glass bead implants, with subsequent cerebrospinal fluid leak, occurred 17 years postimplantation.

Intervertebral disc infection after lumbar chemonucleolysis: report of a case.

Intervertebral disc space infection can be a serious and disabling complication of any procedure that affords entry for bacteria into the susceptible disc space. Most disc space infections occur after cervical or lumbar laminectomies. Discitis has been reported after myelography, lumbar puncture, paravertebral injection, and obstetrical epidural anesthesia. A case of septic discitis occurring after intradiscal therapy with chymopapain is presented. Patients who return for evaluation of recurrent spinal pain after chemonucleolysis, especially those with paravertebral muscle spasm, should be evaluated for the possibility of disc space infection by obtaining an erythrocyte sedimentation rate, peripheral white count, differential cell count, and plain roentgenograms. Radionuclide bone scans, although not specific, may provide further objective evidence leading to the diagnosis of an intervertebral disc space infection.

Appendicular tremor as a late complication of intracerebral hemorrhage.

A 23-year-old woman without demonstrable risk factors for cerebral hemorrhage was admitted after the acute onset of hemiparesis of the left side. A computed tomography scan showed a small right thalamic hemorrhage. Cerebral angiography was normal, and she was managed conservatively. Three months after the original ictus the patient developed severe tremor on the left side. Angiography again revealed no abnormalities and the tremor was successfully treated with a stereotaxic thalamic lesion superimposed on the area of the hemorrhage. The patient's disease, its treatment, and the current knowledge of the anatomy and physiology of movement disorders are reviewed.

Brain biopsy for encephalitis.

Brain biopsy is justified in patients suspected of having encephalitis or viral encephalopathy because those patients are most likely to be helped if a diagnosis is made rapidly and with the greatest certainty possible. Neurosurgeons are occasionally reluctant to undertake brain biopsy because the procedure is diagnostic rather than therapeutic in intent. However, using currently available techniques a 1 cm3 sample of brain tissue can be taken with very low risk of morbidity or mortality. We recommend that the sample be taken from the anterior portion of the inferior temporal gyrus on the more affected side in patients with herpes simplex encephalitis, and from an area of maximum demonstrated involvement in other situations, using stereotactic techniques and intraoperative ultrasound as necessary. The risk to the operating surgeon and to the other members of the operating team appears very low in all of the situations discussed in this chapter. However, the authors feel that every patient should be approached as if he carries the hepatitis B virus. As indicated, the incidence of contracting hepatitis B after sustaining needle stick exposure to blood from persons positive for hepatitis B surface antigen is 10-15%. Conjunctival contamination by splash from the wound is a known method of inoculation of surgeons with hepatitis B virus and is a possible means for transmission of other viral diseases. We recommend that every patient be approached as if he has hepatitis B, not because the agent diseases discussed are known to be as infectious as hepatitis B, but because constant vigilance and careful technique offer the best protection to the surgeon and the members of the operating team in most situations, and because one can never be certain what agent diseases a given patient may harbor. With the exception of the Creutzfeldt-Jakob virus, the agents responsible for all of the viral diseases discussed are inactivated by standard procedures for sterilization of operating room instruments. Procedures necessary to inactivate the Creutzfeldt-Jakob disease virus have been presented. In the report documenting transmission of Creutzfeldt-Jakob disease through human growth hormone preparations the authors state, "We are once again dramatically reminded that human tissues are a source of infectious disease, and that any therapeutic transfer of tissue from one person to another carries an unavoidable risk of transferring the infection.(ABSTRACT TRUNCATED AT 400 WORDS)

Correlation of cerebral blood flow and EEG during carotid occlusion for endarterectomy (without shunting) and neurologic outcome.

One hundred twenty-nine consecutive carotid endarterectomies performed for atherosclerotic ulcerative stenosis without the use of intraoperative shunting were analyzed prospectively in an effort to determine the significance of intraoperative ischemia. Intraoperative EEG and regional cerebral blood flow measurements were used to monitor these patients. Ten of the patients were excluded because of inadequate data, but none of these 10 patients experienced a complication. Factors analyzed included preoperative risk assessment according to the Mayo Clinic system of Sundt et al., intraoperative regional cerebral blood flow measurements, and intraoperative EEG changes. The overall mortality rate was 2.5%, the major morbidity rate was 2.5%, the minor morbidity rate was 1.7%, and the rate of transient neurologic dysfunction was 1.7%. The patients' preoperative state as determined according to the Mayo Clinic system of Sundt et al. was more useful in identifying patients at risk than was intraoperative EEG and regional cerebral blood flow monitoring.

Pupil-sparing oculomotor palsies with internal carotid-posterior communicating artery aneurysms.

The charts of 84 patients admitted to the Neurosurgery Service of the Washington University Medical Center between January, 1960, and July, 1981, with aneurysms at or near the junction of the internal carotid and posterior communicating arteries (ICA-PoCA) were reviewed. Special emphasis was placed on the pupillary size and reactivity of 51 patients with oculomotor nerve involvement. Seven initially had normal pupils, representing 8% of the total group and 14% of those presenting with oculomotor palsies. In 4 of these patients pupillary involvement developed within 5 days, and in 1 pupillary involvement developed in 4 months. Pupillary sparing appears to be more common than previously appreciated in patients with ICA-PoCA aneurysms and oculomotor nerve involvement. Patients with acute somatic oculomotor paresis should be observed closely for at least one week for the development of pupillary involvement. Arteriography may be indicated more frequently than previously recommended.

Glossopharyngeal neuralgia with syncope secondary to tumor. Treatment and pathophysiology.

A patient with metastatic laryngeal carcinoma had glossopharyngeal neuralgia and syncope due to hypotension and bradycardia. Treatment of bradyarrhythmias failed to prevent hypotension. The administration of carbamazepine failed to prevent pain or syncope in this patient despite previous reports of success. Symptoms did resolve with intracranial section of the glossopharyngeal nerve and the upper two rootlets of the vagus. Plasma catecholamines were studied during a hypotensive episode. The values obtained demonstrated a suppressed sympathetic adrenergic neural response but an intact adrenomedullary response, suggesting that suppression of adrenergic vasoconstriction contributed to episodes of hypotension. The administration of intravenous atropine produced a transient increase in blood pressure suggesting that, in the presence of suppressed adrenergic vasoconstriction, cholinergic vasodilation may have contributed to the hypotension in this patient.

Head injury in children and teenagers; functional recovery correlated with the duration of coma.

Residual impairments and mortality were assessed in 48 patients under 20 years of age at least two years after a traumatic head injury had caused coma lasting more than seven days. In this study the duration of coma was defined as the period of time when it is impossible to establish intellectual contact with the patient. A classification of functional levels 1 to 8 was used to identify the residual impairment and relate this impairment to the duration of coma for each patient. Of 30 patients who remained in coma less than three month, only one did not have independent ambulation with or without equipment at the time of his last follow-up evaluation. This was one parameter among others to show that the prognosis for recovery in this age group is much better than expected following severe head injury. These follow-up data, correlated with the duration of coma, can assist rehabilitation personnel in the prognostic planning for younger people with severe head injuries. Rehabilitation medicine needs to be involved in patient care during the period of coma to prevent contractures and other complications which often interfere with and delay later rehabilitation programs, making them more costly and less successful.

Heterotopic ossification in spinal cord-injured patients.

Therapy programs during the development of heterotopic ossification in spinal cord injury range widely from complete rest to aggressive exercise programs. The literature is confusing by its multiplicity of recommendations because the basic etiology and pathophysiology are unknown and because some basic differences exist between traumatic myositis ossificans and heterotopic ossification associated with severe neurological impairments. Prospective heterotopic ossification roentgenographic (x-ray) surveys of the hips, knees, shoulders, and elbows were made on 250 consecutive spinal cord-injured patients. Those who had x-ray evidence of early or immature heterotopic ossification or who developed early clinical signs of possible heterotopic ossification were treated with an aggressive program of passive progressive range of motion exercises. Several patients who developed bilateral heterotopic ossification had one side used as their own control. Follow-up x-ray studies and range of motion evaluation suggest that an aggressive range of motion exercise program is indicated for patients who are developing or have heterotopic ossification. There is no evidence that exercise increases inflammation with subsequent ossification, and it frequently causes a pseudarthrosis, permitting adequate functional range of motion.