Biomedical subjects

R P Tummala

Publications and source records attributed to R P Tummala.

6 recordsLinked to original sources

PubMed2001

Focal intracranial infections due to Propionibacterium acnes: report of three cases.

OBJECTIVE AND IMPORTANCE: Except for its role in shunt infections, Propionibacterium acnes has been of little interest to neurosurgeons. The rarity and indolent nature of focal intracranial infections by P. acnes limit their recognition. Three cases of serious intracranial infection due to this organism are described. CLINCAL PRESENTATION: Three patients with histories of immunosuppression and neurosurgical procedures developed nonspecific, delayed presentations (5 wk to 5 yr after surgery) of intracranial infections. In two patients, radiological investigations showed enhancing lesions that were later found to be brain abscesses. A subdural empyema was found in the third patient. INTERVENTION: All three patients underwent surgical drainage of the purulent collections. P. acnes was isolated in each case, and each patient was treated with a 6-week course of intravenous penicillin. All three patients made good recoveries, and subsequent imaging showed no recurrence of the infectious collections. CONCLUSION: P. acnes is an indolent organism that may rarely cause severe intracranial infections. This organism should be suspected when an intracranial purulent collection is discovered in a patient with a history of neurosurgical procedures. Immunosuppressed patients may be susceptible to this otherwise benign organism. Surgical drainage and treatment with intravenous penicillin should be considered standard therapy.

Adult↗

PubMed2001

Outcomes after aneurysm rupture during endovascular coil embolization.

OBJECTIVE: Intracranial aneurysm rupture during placement of Guglielmi detachable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosurgical interventions to improve outcomes. METHODS: We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The management and outcomes were recorded, and the pertinent literature was reviewed. RESULTS: All 10 cases involved previously ruptured aneurysms. This complication occurred sporadically and was not observed in the first 100 cases. Perforation occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysms were located in the anterior circulation and three in the posterior circulation. Six of the 10 patients made good or fair recoveries; all three patients with posterior circulation lesions died immediately after rehemorrhage. Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly completed, and total or nearly total occlusion was achieved in all cases. Emergency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persistent dye extravasation after deployment of the first Guglielmi detachable coil, and persistent prolongation of contrast dye transit time (suggesting ongoing ICP elevation), were correlated with poor outcomes. CONCLUSION: Previously ruptured aneurysms seem to be more susceptible to endovascular treatment-related perforation than are unruptured lesions. Worse prognoses are associated with iatrogenic rupture during coiling of posterior circulation lesions, compared with those in the anterior circulation. When perforation is recognized, the definitive treatment seems to be reversal of anticoagulation therapy and completion of Guglielmi detachable coil embolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.

Adult↗

PubMed2001

Pseudomyasthenia resulting from a posterior carotid artery wall aneurysm: a novel presentation: case report.

OBJECTIVE AND IMPORTANCE: Painful oculomotor palsy can result from enlargement or rupture of intracranial aneurysms. The IIIrd cranial nerve dysfunction in this setting, whether partial or complete, is usually fixed or progressive and is sometimes reversible with surgery. We report an unusual oculomotor manifestation of a posterior carotid artery wall aneurysm, which mimicked ocular myasthenia gravis. CLINICAL PRESENTATION: A 47-year-old woman developed painless, intermittent, partial IIIrd cranial nerve palsy. She presented with isolated episodic left-sided ptosis, which initially suggested a metabolic or neuromuscular disorder. However, digital subtraction angiography revealed a left posterior carotid artery wall aneurysm, just proximal to the origin of the posterior communicating artery. INTERVENTION: The aneurysm was successfully clipped via a pterional craniotomy. During surgery, the aneurysm was observed to be compressing the oculomotor nerve. The patient's symptoms resolved after the operation. CONCLUSION: The variability of incomplete IIIrd cranial nerve deficits can present a diagnostic challenge, and the approach for patients with isolated IIIrd cranial nerve palsies remains controversial. Although intracranial aneurysms compressing the oculomotor nerve classically produce fixed or progressive IIIrd cranial nerve palsies with pupillary involvement, anatomic variations may result in atypical presentations. With the exception of patients who present with pupil-sparing but otherwise complete IIIrd cranial nerve palsy, clinicians should always consider an intracranial aneurysm when confronted with even subtle dysfunction of the oculomotor nerve.

Angiography, Digital Subtraction↗

PubMed2001

Optimizing brain tumor resection. High-field interventional MR imaging.

High-field strength iMRI guidance is an effective tool for brain tumor resection. Although its use lengthens the average time for a craniotomy, the reward is a more extensive tumor excision compared with conventional neurosurgery without an increased risk to the patient (Table 4). Although intraoperative patient transfer into and out of the magnet is cumbersome, the possibility for complete resection, especially for a low-grade glioma, makes the effort worthwhile. The cost and technical support required for this system presently limits its use to only a few sites worldwide. As with any technology, further refinements will make this system less expensive and more attainable. Practical consideration aside, high-field strength iMRI is presently [table: see text] the most effective tool available for brain tumor resection. Because of its novelty, future studies are necessary to determine if this technology lowers the incidence of and extends the duration to tumor recurrence as the preliminary data in children suggests. These are the ultimate measures of efficacy for any brain tumor treatment. Based on the rapid advancement of technology, will today's high-field strength interventional magnet become tomorrow's low-field system? Very high-field strength designs may improve diagnostic capabilities through higher resolution, but their interventional applications may be hindered by increased sensitivity for clinically insignificant abnormalities and decreased specificity for clinically relevant lesions. As new technology is developed, clinicians must continue to explore and refine the existing high-field strength iMRI to make it cost-effective and widely applicable.

Adolescent↗

PubMed2001

Minimally invasive procedures. Interventional MR image-guided functional neurosurgery.

Intraoperative MR imaging techniques have the potential to greatly improve the stereotactic methods used for functional neurosurgery. No longer are neurosurgeons and patients always constrained by uncomfortable head frames and conventional stereotaxy. Accuracy and complication avoidance are improved by intraoperative imaging. Safety of operative machinery and equipment in an MR imaging operative suite is attainable, even with deep brain stimulating electrodes in depth electrodes for epilepsy. Although cost-effectiveness remains to be determined (see article by Kucharczyk et al in this issue), the minor inconveniences of operating within an iMRI environment seem to be significantly outweighed by the benefits.

Brain↗

PubMed1998

A prospective algorithm for the management of air leaks after pulmonary resection.

BACKGROUND: Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management. METHODS: An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H2O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H2O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. RESULTS: There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) (p = 0.005), increased age (p = 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) (p = 0.04), increased RV (p = 0.02), and an increased functional residual capacity (FRC) (p = 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients' ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. CONCLUSIONS: Most ALs after pulmonary resection are expiratory only. A low FEV1/FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment.

Adult↗