Dynamic changes in cerebrospinal fluid pressure during neurosurgical operations

The effects of hyperventilation, osmotic and diuretic agents (urea, frusemide), thiopentone and succinylcholine chloride on the intracranial pressure were studied in neurosurgical patients with brain tumours. We have shown that hyperventilation together with osmotic and diuretic agents is very useful for reducing increased intracranial pressure.     

History of autologous blood transfusion in neurosurgical operations]

Two Caucasian patients are described who had destructive postpartum thyroiditis (PPT) before the subsequent onset of Graves' hyperthyroidism (GH). HLA class II DQ typing in these two subjects identified putative susceptibility alleles previously detected in GH and PPT. Although PPT destructive thyroiditis preceding the development of GH is relatively uncommon, the occurrence of both these syndromes in the same patient suggests the possibility of an etiological role for thyroid antigen release and genetic susceptibility as pathogenic factors in the development of Graves' disease.     

Antigravity suit used for neurosurgical operations in sitting position

Isoproterenol is a chiral catecholamine with a half-life of elimination of less than 10 min. In order to study the pharmacokinetics of this compound using microdialysis sampling, an analytical method was needed which could resolve the individual enantiomers of isoproterenol and required less than 1 microliter of sample. A capillary electrophoretic method using a run buffer containing methyl-O-beta-cyclodextrin as a chiral recognition agent was developed which could resolve the enantiomers of isoproterenol. The detection limits using UV absorbance detection were found to be too high to determine the concentration of isoproterenol in plasma for a sufficient time following administration to establish the pharmacokinetics. The detection limits were decreased three orders of magnitude to 3 ng/ml by using an amperometric detector. The detection limits were decreased to 0.6 ng/ml using an on-column concentration technique in which peak stacking was accomplished by following the sample injection with a plug of acid.     

Intraoperative magnetic resonance tomography for control of extent of neurosurgical operations

The outcome of 703 patients who underwent surgery following aneurysmal subarachnoid hemorrhage were analyzed with regards to age, associated medical conditions, vasospasm and clinical status at the time of operation. Patients with Hunt and Hess grade I, II, and III had a 96%, 90% and 93% favorable (good and fair) outcome respectively. In contrast only 58% of patients with grade IV had the same result. The outcome was unfavorable in 13% of the patients who were older than 60 years of age and only in 9% of the patients between 30-59 years of age. All the patients younger than 30 years old had a good outcome. Associated medical condition increased the incidences of poor outcome (7% vs. 12%). Patients harboring vertebro basilar aneurysms had a poorer outcome, as opposed to those with aneurysms located in the anterior circulation (20% vs. 8%). The presence of angiographic vasospasm alone did not influence outcome. A proposed point value was given for each of the adverse factors and from this the optimal surgical time was determined for each individual patient. This concept of Risk Score Estimation approach may improve the management outcome of patients with ruptured intracranial aneurysms.     

Pediatric neurosurgical disease

The most common, primary referrals to a pediatric neurosurgeon's office are the evaluation and management of the child with a large head (to rule out hydrocephalus and other space occupying lesions) a mishappen head (to rule out various forms of craniosynostosis), or some form of congenital spinal abnormality (spinal dysraphism). The authors discuss the pathogenesis and clinical features of these disorders, provide a framework for diagnostic evaluation and referral, and discuss the various treatment options available for each.     

Autotransfusion of shed mediastinal blood after open heart operation

This prospective study was designed to determine whether the autotransfusion of shed mediastinal blood (ATS) after open heart surgery is safe and effective. Forty-two patients undergoing cardiac operation were randomized to receive either nonwashed shed mediastinal blood (group 1; n = 22) or banked blood (group 2: n = 20). No difference in mean age (group 1: 49 +/- 11 years; group 2: 45 +/- 12 years), coronary artery bypass grafting (group 1: n = 5, 23%; group 2: n = 6, 30%), valve replacement (group 1: n = 17, 77%, group 2: n = 14, 70%), and mean preoperative hemoglobin level (group 1: 13.7 +/- 2.3, group 2: 14.4 +/- 1.6) was noted between non-ATS and ATS groups (p = not significant). The mean hemoglobin levels after operation were similar in the two groups (group 1: 11.89 +/- 1.52; group 2: 12.03 +/- 1.34). No difference in the mean blood loss 4, 6 and 24 hours after operation (group 1: 33 +/- 190, 420 +/- 340 and 550 +/- 300; group 2: 340 +/- 230, 420 +/- 280 and 670 +/- 380) was observed between the two groups. The mean volume autotransfused in group I was 380 +/- 230 ml (200 approximately 1300 ml). In group I, the patients required bank blood 1080 +/- 720, compared with 1780 +/- 1045 in group II. The bank blood requirement in group I reducted by 40%. These data demonstrate that ATS after open heart surgery is safe and effective.     

Pentobarbital coma in neurosurgical patients: nutrition considerations

Neurosurgical patients in pentobarbital coma are a complex nutrition support population. Physiologic changes associated with the primary injury to the brain, combined with the pharmacodynamic influences of barbiturate therapy, contribute to the difficulties of initiating aggressive nutrition support. Early nutritional repletion is important to the overall outcome of traumatically injured patients. Consequently, factors that influence nutrition support decisions must be understood to assure appropriate intervention. The metabolic changes associated with traumatic head injury, pentobarbital therapy, and nutrition support strategies are reviewed.     

Nosocomial infections in a neurosurgical intensive care unit

The occurrence of nosocomial infections in 1017 consecutive patients seen in a neurosurgical intensive care unit (ICU), over a period of 18 months is reported. The frequency of infections is low, which may possibly be due partly to the short stay in the ICU. Close interdisciplinary cooperation is stressed as an important factor in limiting infections. BACKGROUND. The aim of this study was to analyse the nosocomial infections in a neurosurgical intensive care unit over a period of 18 months, emphasizing localization and cause of infection, in order to adapt treatment and to take preventive measures. From 15% to 27% of patients treated in ICUs acquire nosocomial infections. In Germany this means 500,000-800,000 patients a year, and the annual costs related to nosocomial infections are estimated at 1.7 billion Deutschmarks. PATIENTS AND METHODS. In all, 1017 consecutive patients were evaluated. The patients were divided into two groups, depending on the duration of treatment in the ICU: Patients who remained for less than 48 h (1017 patients) Patients who were treated for a period exceeding 48 h (314 patients) The evaluation was performed retrospectively from the medical documentation. Criteria for registration are those of the Centers for Disease Control (Atlanta 1988). When more than one infection was diagnosed, each was considered as a new infection, regardless of the bacteria involved. Among the 314 patients who were in the ICU for more than 48 h a total of 114 nosocomial infections were recorded. The frequency of infection referred to all patients treated during that time (n = 1017) was 11.2%, while the frequency among those who were treated for longer than 48 h was 36.3%. Most infections (38.6%) affected the respiratory tract, followed by infections of the urinary tract. Of the bacteria determined 56.7% were gram-negative. In this group E. coli was the most frequently found (29.8%). In the group of gram-positive bacteria, S. aureus was diagnosed in 56.3% of cases. Twelve (16%) of the infected patients died and lethality referred to all patients was 8.6%. DISCUSSION. Compared with other studies, this study revealed a low the infection rate, at 11.2%. This can be explained partly by the short stay in this ICU (mean 3.7 days) and partly by the retrospective method of registration and the particular medical characteristics of neurosurgical patients. The well-known general risk factors for infection, such as age, mechanical ventilation, continuous catheterization of the bladder, and long duration of stay, are also found in neurosurgical ICUs. It is quite difficult to determine to what extent nosocomial infections prolong the treatment necessitated by the primary neurosurgical disease. We were not able to extrapolate the influence of immunosuppressant treatment on the appearance of nosocomial infections, as almost all patients in this study were receiving steroids. This study underlines the necessity of interdisciplinary cooperation between neurosurgeons, anaesthesiologists, microbiologists and nurses in neurosurgical ICUs, where most patients staying longer than 48 h are immunosuppressed and ventilated and thereby particularly at risk of nosocomial infections.     

Hydrocephalus in children: neurosurgical and neuroimaging concerns

The neuroimaging of hydrocephalus from the perspective of the pediatric neurosurgeon is discussed. Processes with new developments in therapy and imaging are described, including congenital causes of hydrocephalus, unilateral hydrocephalus, trapped fourth ventricle, and benign external hydrocephalus.     

Perspectives on neurosurgical practice: neurosurgery in Jordan

Neurosurgery as a specialty medical field is new in Jordan. This article documents the history, current status, and projected future of neurosurgery in Jordan. Resident training is also highlighted, and challenges for the future of the profession are presented.     

The retraction pressure during neurosurgical operations on the brain. III. An analysis of the efficacy of prophylactic methods aimed at reducing brain volume

The comparison was undertaken to examine 31 patients with various brain neurosurgical abnormalities to evaluate the efficiency of some of the most widely used preventive measures for retraction ischemia, which are aimed at reducing the brain volume at surgery: preoperative administration of a saluretic, osmodiuretic solution, hyperventilation, tumor cyst puncture, lumbar and ventricular drainage. The findings suggest the efficacy of such approaches, as tumor cyst puncture, intravenous administration of an osmodiuretic, ventricular and, possibly, lumbar drainage. Such methods as preadministration of saluretic hyperventilation are ineffective.     

Ambulatory operations in orthopedics

Outpatient surgery in orthopedics, which ist becoming increasingly popular and is promoted by present-day health care legislation, is associated with a whole range of ifs and buts. Patient-related factors, including age, readiness and ability to cooperate, and home care, need just as much consideration as physician-related factors (experience of the surgeon, anesthesist und surgical team). Architectural and equipment-related facilities need to be investigated. Not every intervention that is theoretically possible on an outpatient basis can be recommended--for example if intensive aftercare, which is better performed on an inpatient basis, should be necessary. The usual postoperative risks (e.g. thrombosis) must be taken into account, and in such cases, proper care must be guaranteed.