Management of traumatic supraorbital neuroma.

Traumatic neuromas represent proliferative overgrowth of axons, Schwann cells, and fibroblasts at the proximal end of nerve injury or transsection. Although common elsewhere, traumatic neuromas have rarely been noted in the orbits. All but one of these reported lesions occurred after orbital surgery. We present a patient with a painful traumatic neuroma of the supraorbital nerve due to application of a halo fixation device. Neuroma resection and microneural repair resulted in prompt resolution of symptoms without compromise of nerve function.

Intraoperative measurement of spinal cord blood velocity using pulsed Doppler ultrasound. A Case report.

Blood velocity in the anterior spinal artery was measured with a 20 MHz doppler ultrasound microvascular probe through a standard laminectomy during syringoperitoneal shunt placement. Velocity increased with increasing levels of pCO2, with dural opening, and with syrinx drainage. These observations support the use of the doppler signal as an index of arterial blood flow. Doppler measurements are easily performed, do not require dural opening, and may be performed repetitively without risk of tissue damage. Pulsed doppler techniques provide a rapid, safe method for intraoperative evaluation of spinal cord blood velocity and may emerge as a useful tool for assessment of spinal cord blood flow.

Observations on the perioperative management of aneurysmal subarachnoid hemorrhage.

Thirty-two patients with aneurysmal subarachnoid hemorrhage (SAH) were managed according to a protocol based on pain control and hemodynamic manipulation, monitored by an arterial line and Swan-Ganz catheter. Hemodynamic parameters were adjusted to four clinical situations. 1) For the unoperated patient with no neurological deficit, the regimen aims to maintain pulmonary wedge pressure (PWP) at 10 to 12 mm Hg, and the cardiac index (CI) and blood pressure (BP) at normal levels. 2) For the unoperated patient presenting with or developing neurological deficit, the PWP is increased until the deficit is reversed or the CI falls; the CI is high, and the BP normal. 3) For the postoperative patient with no neurological deficit, the PWP is maintained at 12 to 14 mm Hg, the CI is a high normal, and the BP is normal. 4) For the postoperative patient developing neurological deficit but showing no surgical complication on the computerized tomography scan, the PWP is increased until the deficit is reversed or the CI falls; the CI is high and the BP is increased with vasopressors if necessary. Fourteen patients developed neurological deficits either preoperatively, postoperatively, or both. Neurological deficits were repeatedly reversed by increasing the PWP, as measured hourly. In several patients an optimal wedge pressure was determined, below which deficits would reappear. In one patient whose neurological deficit was reversed on several occasions by increasing the PWP, the optimal PWP rose after each episode until it reached 22 mm Hg. Detailed event-related analysis of these patients' course illustrates these phenomena well. The optimal PWP varied from patient to patient, but ranged most frequently from 14 to 16 mm Hg. Meticulous monitoring of the patients' neurological status coupled with prompt correction of low PWP (assuming an adequate CI) has proven to be an effective way to prevent and reverse neurological deficits following aneurysmal SAH.