Neurological surgery.
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Craniocerebral Trauma↗
Biomedical subjects
R H Wilkins
Publications and source records attributed to R H Wilkins.
Spinal subdural hematoma formation following ventriculoperitoneal shunting for hydrocephalus. Case report.
A case of a 14-year-old girl who developed a spinal subdural hematoma after placement of a ventriculoperitoneal shunt is presented. Such a complication has not been previously reported. We believe that this represented an extension of intracranial subdural hematoma fluid into the spinal subdural space.
Adolescent↗
Hemifacial spasm: a review.
Hemifacial spasm can be diagnosed by observation and clinical history. It is thought to arise primarily from compression of the facial nerve at the pons, usually by an adjacent artery. Although many approaches to treatment have been tried, the most effective is microvascular decompression of the facial nerve at the pons. That operation has well-recognized risks, including ipsilateral deafness. The latter complication ordinarily can be avoided by the use of intraoperative monitoring of auditory evoked potentials.
Animals↗
Modifying the translabyrinthine approach to preserve hearing during acoustic tumour surgery.
Removing an acoustic schwannoma using the translabyrinthine approach has previously been considered incompatible with hearing preservation. By modifying the approach and preventing the loss of endolymph, we have successfully removed an intracanalicular acoustic schwannoma, which originated from the inferior vestibular nerve, and preserved hearing in the operated ear. This report represents the preliminary findings using this particular technique in the management of an intracanalicular acoustic tumour.
Audiometry↗
Surgical treatment of cluster headache.
Cluster headache is ordinarily managed medically, but may become refractory to such medical management. In this setting, surgical treatment has occasionally been performed, based on evidence that pertinent pain pathways and parasympathetic pathways may be interrupted at the main sensory root of the trigeminal nerve and at the nervus intermedius. Between 1976 and 1987, 13 patients underwent surgery for treatment of cluster headache that was refractory to medical therapy (15 procedures). Partial sectioning of the main sensory root and sectioning of the nervus intermedius were performed in nine patients; only partial sectioning of the main sensory root in one; only sectioning of the nervus intermedius in one; and nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve in two. The average postoperative period for the 13 patients was 37 months (range 2 to 135 months). All patients had return of their headaches postoperatively except for one patient who obtained relief after a repeat procedure. Headache began to return between 2 days and 2 years postoperatively. Three patients are currently free of headache, including both patients who had nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve. Together with recurrence of headache, cluster-associated autonomic disturbances recurred after 14 of the 15 operations but are currently absent in the three headache-free patients. Partial sectioning of the main sensory root and sectioning of the nervus intermedius, as performed in these patients, seem to have limited value in the treatment of cluster headache.
Cluster Headache↗
Cerebral vasospasm in conditions other than subarachnoid hemorrhage.
Intracranial arterial spasm is an arteriographically evident narrowing of the lumen of one or more of the major intracranial arteries at the base of the brain that develops in some patients 1 or more days after the rupture of an intracranial aneurysm. If it is severe enough, such cerebral vasospasm may be accompanied by cerebral ischemia or infarction. Because of its usual setting, cerebral vasospasm is thought to arise from some chemical factor or factors in the blood that accumulates within the basal subarachnoid cisterns and bathes the arteries that subsequently develop spasm. There seem to be exceptions to this basic plan, however. In patients with a ruptured aneurysm, only some of the arteries bathed in subarachnoid blood develop spasm. Of more significance, some patients develop intracranial arterial spasm without apparent subarachnoid bleeding. Until the development of CT scanning, the evidence for the lack of subarachnoid hemorrhage in such patients was weak. We now have the ability to assess cerebral vasospasm repetitively in a noninvasive manner with TCD ultrasonography and to quantitate subarachnoid hemorrhage by CT scanning. We should take advantage of this opportunity to document cases that are exceptions to the rule. Does hypothalamic damage explain such cases, or is there some other explanation? This question may be the key for unlocking the mysteries of the pathogenesis of cerebral vasospasm.
Animals↗
Cerebral vasospasm.
Cerebral vasospasm (specifically, intracranial arterial spasm) is variously defined as: (1) an arteriographically evident narrowing of the lumen of one or more of the major intracranial arteries at the base of the brain due to contraction of the smooth muscle within the arterial wall, or due to the morphological changes in the arterial wall and along its endothelial surface that occur in response to vessel injury; (2) the delayed onset of a neurological deficit following subarachnoid hemorrhage, thought to be due to ischemia or infarction of a portion of the brain; or (3) the combination of these two features (symptomatic vasospasm). The arterial contraction of intracranial arterial spasm typically develops a few days after the rupture of an intracranial aneurysm and lasts 2 to 3 weeks. Such arterial spasm can also occur in other conditions such as head trauma. If it is severe enough it can lead to cerebral infarction. The pathogenesis of this condition is still unclear. Many ingenious attempts have been made to prevent or treat cerebral vasospasm, but most have failed. The best current approach is to ensure adequate blood volume, and to elevate the patient's blood pressure (especially if the aneurysm has been secured by an early operation). The continuing investigation of drugs such as calcium channel blocking agents to improve the cerebral circulation has begun to provide additional help.
Animals↗
Intraoperative brainstem auditory evoked potentials: significant decrease in postoperative morbidity.
Evoked potentials are commonly used for intraoperative monitoring of neural tissue under surgical threat despite the lack of unequivocal evidence demonstrating its effectiveness in preventing neural injury. This study retrospectively compares the auditory morbidity of posterior fossa microvascular decompressive surgery before and after the introduction of intraoperative brainstem auditory evoked potentials (BAEPs). All patients underwent a similar operative procedure performed by a single surgeon. The two groups were comparable with regards to age, sex, and indications for surgery. In the nonmonitored group, auditory morbidity had not declined with increasing experience of the surgeon. Ten of 152 patients (6.6%) suffered a profound hearing loss in the nonmonitored group. In the monitored group, none of 70 patients suffered a profound hearing loss. We attribute this significant decline (p = 0.02) in morbidity to the introduction of intraoperative BAEPs. We believe this to be the first demonstration of a significant decrease in operative morbidity directly associated with the use of intraoperative evoked potential monitoring.
Audiometry↗
CSF TRAP: a procedure to improve laboratory testing with myelography.
CSF TRAP (Transport and Rapid Accessioning for Additional Procedures) is a procedure that provides storage of and rapid access to cerebrospinal fluid (CSF) specimens and allows clinicians to review initial findings before ordering low-yield CSF studies. The cost-effectiveness of routinely using the CSF TRAP procedure with myelography is examined in a study group of 819 patients, 74% with disc diseases, spinal stenosis, spondylolisthesis, or pain syndromes, 10% with cancer, and 16% with neuropathies and miscellaneous conditions. Routine studies on CSF obtained during myelography provided little additional clinical information, except for patients with cancer (of 80 patients with cancer, the results of cytological examination of the CSF were positive in 12) and patients with multiple sclerosis, for whom oligoclonal band and IgG analysis provided supportive diagnostic data. The utilization of the CSF TRAP procedure with elimination of unnecessary culture and cytological studies on patients with disc diseases, spinal stenosis, spondylolisthesis, and pain syndromes, reduces myelographic CSF procedures by 20%, for a savings exceeding $14,000. The CSF TRAP procedure allows for a more cost-efficient analysis of CSF obtained using myelography, while providing fluid for analysis in patients with unexpected findings.
Adult↗
Attempts at prevention and treatment of delayed ischaemic dysfunction in patients with subarachnoid haemorrhage.
Rupture of an intracranial aneurysm is frequently followed by evidence of intracranial arterial narrowing, which often is accompanied by the delayed onset of a related neurological deficit. During the decades since these detrimental phenomena were first recognized, many attempts have been made to prevent or treat them. Current emphasis in prophylaxis and treatment is on: 1. early operation to eliminate the threat of rebleeding and to allow the gentle removal of as much blood as feasible from the basal subarachnoid cisterns, 2. maintenance or elevation of circulating blood volume, and 3. maintenance or elevation of systemic blood pressure. In recent years, there has also been increasing evidence that the administration of the calcium channel blocking agent nimodipine can reduce the incidence of delayed ischaemic neurological deficits in patients with a ruptured aneurysm.
Animals↗
Surgical therapy of neuralgia: vascular decompression procedures.
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Cranial Nerves↗
Osteoporotic sacral fractures: a clinical study.
Traumatic sacral fractures are most often due to motor vehicle or industrial accidents and are commonly associated with pelvic, urogenital, and neurological injuries. In recent years, a more subtle type of sacral fracture, not associated with major trauma, has been described. It is an osteoporotic insufficiency fracture that presents as low back pain in elderly patients, especially postmenopausal Caucasian women. It may escape detection unless radionuclide bone scans, tomograms, or computed tomograms are obtained. The radiographic features have been detailed in various publications, but little has been reported about the clinical features, treatment, or ultimate outcome of patients with osteoporotic sacral fractures. We have reviewed the charts and radiological studies of 13 women and 3 men who sustained this type of fracture between 1983 and 1986. All of these patients were Caucasian. The average age was 71 years. The most common presenting symptom complex was diffuse low back pain accompanied by hip, buttock, or thigh pain. Pertinent physical findings were limited to tenderness on palpation of the sacrum and a decreased range of low back motion. The osteoporotic fractures were seldom noted on plain roentgenograms of the sacrum, but were readily defined by sacral tomography or computed tomography. Radionuclide bone scanning also proved helpful in making the diagnosis by localizing the process. Treatment was medical and consisted of therapies designed to reduce pain and to combat the associated osteopenia. Of our 16 patients, 11 had complete pain relief, 2 had substantial pain relief, 2 noted decreasing pain before they died of other causes, and 1 was followed less than 1 month.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Benign intraparenchymal brain cysts without an epithelial lining.
Three patients are presented who had benign intraparenchymal cysts of the brain. The wall of each cyst was biopsied and had no epithelial lining or other microscopic feature to indicate the etiology of the cyst. The authors review published information about benign brain cysts and speculate about the origin of those having a wall composed solely of neuroglial tissue.
Adult↗
Evaluation in cats of a new material for cranioplasty: a composite of plaster of Paris and hydroxylapatite.
The materials ordinarily used to reconstruct bone defects in the calvaria and facial bones either are difficult to shape, are partially resorbed by the body, or are likely to become infected if used near a contaminated area such as the frontal sinus. Calcium sulfate hemihydrate (plaster of Paris) has been known for years to have excellent reparative qualities in bone defects, but ordinarily it is quickly resorbed. Consequently, a new material, a composite of a dense form of plaster of Paris and hydroxylapatite, was devised to provide nonabsorbable hydroxylapatite particles for bone to form around and within during the phase of plaster absorption. Two types of this material were evaluated in cranial defects in cats. Each of the plaster of Paris/hydroxylapatite mixtures was placed into a surgically unroofed frontal sinus and into a contralateral parietal trephine hole in a group of 32 cats. Two cats in each group succumbed to anesthesia, leaving two sets of 30 cats. During the entire follow-up period there was only one other death, with no evidence of wound infection, wound dehiscence, implant rejection, or cerebral dysfunction among the survivors. The cats in each group were sacrificed at 1, 2, 3, 5, 7, 8, 9, 10, or 12 months after operation. Following sacrifice, both the frontal and parietal defects were exposed and examined visually, histologically, and with histomorphometric analysis for new bone formation. New bone formation was present as early as 1 month after operation and continued to increase during the 12 months of the study. Based upon these osteogenic qualities, the ease of shaping the composite, and the lack of infection in the frontal sinus region, it is concluded that this substance could be a valuable new material for human cranioplasty.
Animals↗
Segmental neurofibromatosis.
Of the various forms of neurofibromatosis, the best known are peripheral neurofibromatosis (von Recklinghausen's disease) and central neurofibromatosis. There is a rare form called segmental neurofibromatosis, in which the cutaneous and neural changes are limited to one sector of the body and with which there is usually no family history of neurofibromatosis. We report four patients with this disorder and stress the value of repetitive, limited excision of peripheral nerve tumors in their management.
Adult↗
Self-report of depressive symptoms in low back pain patients.
Two studies designed to examine the self-report of depressive symptoms in low back pain patients are presented. Symptoms of depression were assessed with the Beck Depression Inventory. In the first study, a sample (N = 134) of patients who presented for neurosurgical evaluation were evaluated. In the second study, a subgroup of patients found to have lumbar disc protrusion were compared to a subgroup with few or no positive physical findings at the time of physical examination. If the cut-off scores recommended by Beck were used, patients in both studies would be classified as mildly depressed. Both studies found that patients were significantly more likely to report somatic than cognitive symptoms of depression. Patients with multiple physical findings or a disc abnormality at the time of operation were not found to be more likely to report somatic symptoms than patients with few physical findings.
Adult↗
Attempts at prevention or treatment of intracranial arterial spasm: an update.
Numerous approaches to the prevention and treatment of intracranial arterial spasm have been made during the past three decades. In the present article, the author has assembled data about such attempts that were not included in a similar compilation published in 1980. Since 1980, there has been some progress toward the satisfactory management of this detrimental condition, but much remains to be done.
Animals↗
Spontaneous CSF otorrhea from tegmen and posterior fossa defects.
Spontaneous cerebrospinal otorrhea (SCSFO) from tegmen or posterior fossa defects is uncommon. Twenty-nine cases have been detailed in the literature to date. We report an additional four cases from three patients. This group of 33 cases of SCSFO from tegmen or posterior fossa defects is characterized by certain clinical features. These patients are usually older adults (mean age 48 years, range 8 months to 80 years). Aural fullness with a serous appearing middle ear effusion, or clear otorrhea, often subsequent to tube myringotomy, are the usual initial symptoms. Meningitis was the initial manifestation in eight patients (24%), and ultimately occurred in an additional four patients (12%). The pathophysiologic basis for SCSFO from tegmen defects is discussed. Methods for diagnosing and treating CSF otorrhea from tegmen defects are reviewed.
Adolescent↗