Neurosurgical management of dialyzed patients]

Cerebrovascular disease is a lethal complication for patients with renal failure because of the hemostatic disturbance and equivocality about management of the central nervous system. Appropriate management of the renal failure in neurosurgical patients was considered on the basis of experience. Hemodialysis (HD), which is the most common dialysis method, has a serious disadvantage: the elevation of intracranial pressure during dialysis due to the "disequilibrium syndrome." It is important to stabilize the serum osmolarity during dialysis in order to prevent the disequilibrium syndrome. From this point of view, continuous ambulatory peritoneal dialysis (CAPD) has great advantages; serum osmolarity is not rapidly changed and no anticoagulants are required during dialysis. CAPD is recommended as the first method of choice in neurosurgical management of renal failure patients. However, if a patient has to be maintained with HD because of a history of laparotomy or peritonitis, it is essential to keep the serum osmolarity as stable as possible using the extracorporeal ultrafiltration method, hypernatremic HD, bicarbonate HD, and intravenous administration of glycerol.     

Surgical experience in the management of spontaneous pneumothorax, 1972-82

In the past 11 years 233 patients have undergone 241 parietal pleurectomies for either recurrence of their spontaneous pneumothorax or failure to respond adequately to management by tube drainage. Major complications occurred in 3.7% of cases, with transaxillary apical pleurectomy engendering significantly fewer complications than full pleurectomy through a posterolateral thoracotomy. The significantly larger number of minor complications, however, in patients undergoing full pleurectomy was largely due to the larger number of patients with chronic obstructive lung disease in this group. On the basis of our experience we advocate the use of transaxillary apical pleurectomy for the younger age group with recurrent pneumothoraces and a full pleurectomy in the older age group, who frequently present because of failure to respond satisfactorily to tube drainage during their initial pneumothorax and often have lung disease secondary to chronic obstructive lung disease which is not confined to the apex of the upper lobe.     

Neurosurgical management of patients with lumbosacral myeloschisis

Myeloschisis is the most serious and complex congenital anomaly in spina bifida manifesta (cystica). However, with improvements in medical care and increased understanding of its pathophysiology, the associated long-term morbidity and mortality rates have been significantly reduced. This article reviews various issues associated with the neurosurgical management of patients with myeloschisis, such as perinatal management, repair surgery for myeloschisis, neurosurgical management of hydrocephalus, Chiari malformation type II, tethered cord syndrome and epilepsy, and intrauterine fetal surgery.     

Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy

OBJECTIVE: With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients. METHODS: During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively. RESULTS: Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery. CONCLUSION: With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.     

Neurosurgical management of patients with brain metastasis

Brain metastasis is a serious complication in patients with systemic cancer. The main goal of the treatment in patients with brain metastasis is to control the disease in the brain, to prevent death from neurological disease and provide a satisfactory quality of life. Management of a patient with brain metastasis is important and sometimes demanding, and several factors such as tumor histology, status of primary disease, number of brain lesions, size of lesions, and performance status may influence the decision making process. We reviewed the neurosurgical treatment modalities in patients with metastatic brain tumor and suggested a treatment paradigm for different clinical conditions. The PubMed database was searched using combinations of search terms and synonyms for “management of brain metastasis,” “stereotactic radiosurgery for brain metastasis,” and “surgery for brain metastasis” between January 1, 1990, and January 1, 2018. This review would guide physicians to solve challenging problems in the treatment of patients with brain metastasis. In summary, local aggressive treatments such as surgical resection and stereotactic radiosurgery are reasonable in patients with limited intracranial disease, controlled primary disease, and high performance status. Besides, WBRT is still the standard treatment in patients with low performance score and leptomeningeal dissemination of cancer.     

Neurosurgical management of neuropathic pain.

Neuropathic pain is a very difficult problem with which the neurosurgeon frequently must deal. The neurosurgical methods to be considered are: (1) modulative, by using neurostimulation or implanted drug delivery systems, and (2) ablative, by making selective therapeutic lesions in well-defined and identified targets proven to sustain pain mechanisms (especially DREZotomy).     

Primary lung cancer in young patients: a study of 82 surgically treated patients.

The aim of this study was to evaluate the prognosis for surgically treated young patients with primary lung cancer, a prognosis generally considered to be very poor. Eighty-two patients less than 40 years of age were operated on at Marie-Lannelongue Hospital between 1982 and 1990. There were 72 male and 10 female patients. Ten patients (12%) had never smoked, whereas 48 patients (59%) had smoked for more than 20 pack-years. The lung cancer was asymptomatic in 27 patients (33%) and symptomatic in the others. Adenocarcinoma was found in 42% of the patients, epidermoid carcinoma in 28%, mixed cell carcinoma in 16%, small cell carcinoma in 8.5%, and undifferentiated large cell carcinoma in 6%. Among the 69 resected tumors, 22 were stage I, ten were stage II, 32 were stage IIIa, and five were stage IIIb. The resection was considered complete and curative in 56 patients (68%) and noncurative in 26 (32%) either because of an incomplete resection (12 in stage IIIa; 1 in stage IIIb) or because of an exploratory thoracotomy only (13). The overall actuarial 5-year survival rate was 41%, and the actuarial 5-year survival for patients who had a complete resection was 56%. The actuarial 5-year survival rates were as follows: patients in stage I, 70%; stage II, 54%; stage IIIa, 28%; stage IIIb, 0%; and patients having exploratory thoracotomy only, 18%. These survival rates are similar to those of patients older than 40 years with similar stages of disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Joint chondromatosis. Results in 40 surgically and conservatively treated patients

The clinical findings seen in chondromatosis (Henderson-Jones syndrome) and the treatment of this rare disease are presented. The etiology is also discussed. The authors suggest a therapy, drawing on their own experience in 40 patients with an average follow-up of 12.6 years and on numerous articles from the literature. They recommend total synovectomy with removal of loose bodies at an early stage to prevent mechanical destruction of articular cartilage.     

Neurosurgical management of orbital inflammations and infections

Summary Background. We present an overview of the treatment and clinical outcome of 22 orbital inflammations and infections, carried out in our center from 1991 to 2002.Method. The surgical approach was determined by the location, and type of the lesion. Lateral orbitotomy was performed in 2 laterally located lesions, a transconjunctival approach in 8 medial, basal, extra-, intraconal lesions. Pterional intradural (5), and extradural (3) approaches were used in case of intracranial involvement or location in the orbital apex and optic canal. Lesions of the lid were operated via eyebrow incision.Findings. Bacterial infections were confirmed in 5 cases (1 mucocele, 3 abscesses, 1 necrotizing inflammation). 15 patients were diagnosed as chronic inflammatory pseudotumors, 6 of whom showed a granulomatous subtype, and 3 involvement of the optic nerve. All patients failed to reveal systemic disease and had a localized orbital inflammatory process. 7 of the patients responded rapidly to systemic corticosteroid treatment with no episodes of recurrence. 3 patients showed recurrence despite corticosteroids.Conclusions. Orbital infections are cured by antibiotic treatment. The course of inflammatory pseudotumor is variable and requires multidisciplinary treatment. Therapeutic options include surgical biopsy or debulking, corticosteroids, chemotherapy, and radiation therapy.     

Neurosurgical management of birth injuries of the brachial plexus.

While most newborns with birth injury of the brachial plexus make a full spontaneous recovery, the minority who do not can expect lifelong disability from weakness, disturbed patterns of muscle activity, contracture, and deformity. Those children who are destined to a poor recovery can be identified in early infancy. Early reconstruction of the brachial plexus carries low morbidity and has been shown by many to support useful shoulder and elbow function. Patients who are referred later in childhood may still benefit from plexus exploration, but how to best use clinical and electrophysiologic data to plan a surgical intervention that will improve on the natural history remains to be elucidated for this group.     

Primary small intestinal non-Hodgkin's lymphoma in Finland 1972-1977. Clinical presentation and results of treatment.

During the period of 1972-1977, 29 patients were treated for primary non-Hodgkin's small intestinal lymphoma (PSIL) in different hospitals in Finland. Most frequently the disease occurred in patients in middle age and there was a male predominance. Clinical symptoms were non-specific. An abdominal mass was felt in 31% of the patients. Radiological findings were mostly non-specific, and often a stricture was revealed. All patients underwent surgery, ten patients curative resection, 15 patients palliative resection and 4 patients exploration and biopsy only. Sixty per cent of the patients who underwent curative resection survived five years compared with ten per cent who underwent palliative resection. The stage of the disease was an important prognostic factor. The five-year survival was 60% for patients with stage I disease, while all the patients with stage IV disease died during the first two years.     

Neurosurgical techniques in the management of chronic pain

Neurosurgical treatment for pain can be classified into three parts: treatment of the cause; neuromodulation using electrical stimulation or drug delivery systems; and neuro-ablative techniques. Treatment of the cause is exemplified by microvascular decompression for trigeminal neuralgia, arguably the treatment of choice for this condition. Lumbar microdiscectomy for sciatica can also be viewed in this light. Neuromodulation is a growing field. The most common technique is spinal cord stimulation and a growing body of evidence supports its use (e.g. for treatment of persistent pain following spinal surgery and complex regional pain syndrome). Rarer and more specialist techniques of stimulation are motor cortex and deep-brain stimulation. Intrathecal drug delivery systems are increasingly used, and may have increasing application in pain associated with malignancy. Neuro-ablative techniques are used less frequently, but find a place in restricted situations such as cordotomy for focal pain of malignancy and the DREZ lesion following spinal cord avulsion injury. All of these treatments are now delivered in a multidisciplinary context, with availability of other adjunctive treatments (be they comprehensive medical management) and the use of cognitive techniques – pain management programmes.     

Neurosurgical management of carotid sinus hypersensitivity. Report of three cases

Carotid sinus hypersensitivity (CSH) can cause severe bradycardia, hypotension, asystole, and cardiac arrest. Three patients with the combined (mixed) cardioinhibitory and vasodepressor form of CSH were studied with intensive cardiovascular monitoring. After medical management failed, the patients were successfully treated by transection of the glossopharyngeal nerve and upper rootlets of the vagus nerve at their exit from the brain stem. Methods of diagnosis of CSH, and the benefits and limitations of medical and surgical therapies are discussed.     

Incidence of ovarian neoplasms at the Bloemfontein Academic Hospitals, 1972-1977.

In the Orange Free State patients with gynaecological tumours are mainly referred to the National and Pelonomi Hospitals and the Department of Oncotherapy. During the 6 years 1972-1977 there were 1 895 admissions to the gynaecological wards of the National Hospital and 9 807 admissions to those of the Pelonomi Hospital. A total of 205 cases of primary ovarian neoplasia was seen, comprising 97 Whites and 108 Blacks. These cases were further divided into benign and malignant tumours and histologically classified into four main groups. Comparisons were made between cases seen in Bloemfontein and cases at other institutions.     

Results of surgical management in 92 consecutive patients with Zollinger-Ellison syndrome.

Hospital records and follow-up information on 92 patients with surgically proven Zollinger-Ellison syndrome have been reviewed, and data relating to symptomatology, age and sex incidence, pathologic findings, and early and late results of surgical procedures have been summarized. The postoperative mortality rate was 15%, and was adversely affected by previous peptic ulcer surgery, by the necessity of urgent operation for complications of peptic ulcer, and by employment of a procedure that failed to control acid secretion. Thirteen patients were found to have primary gastrinomas of the duodenum and an additional 13 patients had islet cell hyperplasia without evidence of frank neoplasm; prognosis in these two groups appears to be particularly favorable. Despite the current availability of effective nonoperative measures for control of gastric hypersecretion, surgical exploration is warranted in all patients to determine location and extent of tumor and to attempt to control the ulcer diathesis by resection of tumor. Long-term therapy with H2 receptor antagonists is advised for patients whose hypersecretory state has not been alleviated by tumor resection or whose gastrinoma cannot be removed. Total gastrectomy is still indicated in patients whose tumors are not amenable to resection and who are resistant to, or cannot follow, a rigid medical regimen.     

Results of 50 surgically treated temporal epileptic patients

Summary Author gave an account of his experience on 50 patients operated upon with temporal epilepsy. Resection was performed in 48 cases of which 25 were free from seizures, 16 markedly improved, 4 improved and 3 were unchanged. On the basis of the two first (seizure free and markedly improved) categories we may say that the result in 85% is good. To have such a good result, the extirpation of the uncus amygdala and hippocampus is indispensable, but it is even as necessary to find the pathological lesion, and to remove it. It is to be noted that the seizures may recede in 2 to 3 years, thus we can speak about definite results only after 5 years. The postoperative medication is necessary for at least 2 years even when the patients are seizure free. Amelioration of the epileptic character shows conformity with cessation of the seizures, but the psychotic tendencies improve only moderately, and only in some cases.

---

Zusammenfassung Der Autor gibt eine Zusammenstellung seiner Erfahrungen bei 50 Fällen, die wegen einer Temporallappen-Epilepsie operiert wurden.Die Temporallappenexstirpation wurde bei 48 Fällen ausgeführt. Davon wurden 25 anfallsfrei, 16 deutlich gebessert, 4 gebessert und 3 blieben unbeeinflußt. Faßt man die beiden ersten Gruppen —anfallsfrei und wesentlich gebessert usammen, so ergibt sich als Ergebnis, daß der Effekt bei 85% der Fälle gut ist.Um ein solch gutes Ergebnis zu erhalten, ist es unbedingt notwendig, den Uncus und Gyrus hippocampi mit dem Nucl. amygdalac zu exstirpieren. Ebenso wichtig ist es, eventuelle pathologische Gewebsveränderungen zu finden und zu entfernen.Weil Anfälle selbst noch nach 2 bis 3 Jahren wieder auftreten können, kann erst nach 5 Jahren von einem endgültigen Ergebnis gesprochen werden.Postoperativ sollten für mindestens 2 Jahre antiepileptische Medikamente gegeben werden, auch dann, wenn die Patienten anfallsfrei sind. Die Rückbildung der epileptischen Wesensveränderung geht dem Aufhören der Anfälle parallel; allerdings klingen psychotische Züge nur langsam und nur in einigen Fällen ab.

---

Resumen El autor resume su experiencia de 50 casos operados por una epilepsia temporal. El lóbulo temporal fué extirpado en 48 pacientes, de los cuales 25 no tuvieron más accesos, 16 mejoraron netamente, 4 mejoraron y 3 quedaron igual. Resumiendo el resultado operatorio de los dos primeros grupos, resulta que en un 85% de los casos fué bueno. Para obtener tales resultados es necesario extirpar el uncus el N. amigdalino y el hipocampo, siendo de igual importancia localizar lesiones patológicas eventualmente existentes y resecarlas.Como las crisis epilépticas suelen presentarse aún después de 2 a 3 años, puede hablarse de un resultado definitivo recién después de 5 años. Como medicación postoperatoria debe instituirse la anticonvulsivante durante por lo menos 2 años aún en el caso de que los pacientes no presenten más crisis. La desaparición de los signos de cambio de caracter marcha paralela al la disminución de las crisis. Merece mencionarse que los signos psicóticos desaparecen tan sólo lentamente y solamente en algunos casos.

---

Résumé Travail concernant 50 cas opérés pour épilepsie temporale. Dans 48 des cas une extirpation du lobe temporale a été effectuée. 25 de ces malades n'avaient plus de crises, 16 cas ont vu une amélioration considérable, 4 cas sont un peu améliorés et 3 cas sont inchangés. En somme c'est un beau résultat dans 85% des cas. Pour un tel résultat il est nécessaire de faire une ablation de l'hippocampe et de l'uncus, y compris le N. amygdalien, ainsi que de tissu anormal.On ne peut juger d'un résultat définitif qu'avant un recul de 5 ans. — Dans la période postopératoire il faut un traitement antiépileptique au moins pendant 2 années, même dans les cas qui ne montrent plus de crises. — La régression des altérations psychiques va-t-en parallèle avec la disparition des crises. La disposition totale cependant n'est que très lente et seulement dans un nombre réduit des malades.