Collagen vascular diseases

Collagen vascular diseases are multisystem disorders that frequently affect the skin. At times, cutaneous disease is the initial manifestation. This article focuses on lupus erythematosus, dermatomyositis, and sclerodermoid syndromes.     

An evidence-based approach to management of increased intracranial pressure

This article reviews the current understanding of genetic factors involved in the development of intracranial aneurysms. Of the large number of heritable connective tissue disorders that have been associated with intracranial aneurysms, three are discussed in detail: autosomal dominant polycystic kidney disease, Ehlers-Danlos syndrome type IV, and alpha 1-antitrypsin deficiency. The author reviews the familial occurrence of intracranial aneurysms, which is found in about one-fifth of patients with aneurysm subarachnoid hemorrhage. Guidelines are provided for the evaluation of patients with familial intracranial aneurysms and screening of their relatives.     

Endovascular interventions training and credentialing for vascular surgeons

This article reviews issues concerning the training and credentialing of vascular surgeons in the use of endovascular techniques in the peripheral vascular system. These guidelines update a prior document that was published in 1993. They have been rewritten to accommodate the rapid evolution that has occurred in the field and to provide the appropriate requirements that a vascular surgeon should fulfill to be competent in the basic skills needed to safely and effectively perform all presently accepted diagnostic and therapeutic endovascular procedures.     

The surgical approach to invasive orbital tumors

The orbital exenteration is less and less practiced today, because of the reduced pathology which may impose such a radical intervention, but also because it has been transferred, in the lest two decades, to the maxillofacial plastic surgery. The paper presents three orbital exenterations, accomplished in the spinous-cell carcinoma of the inferior eye lid invading in the orbit, basal-cell epithelioma of internal angle recidivated during repeated interventions and conjunctival malignant melanoma invading the orbit. It is shown that orbital exenteration must not to abandoned by the ophthalmologists, which are the first doctors contracted by these patients and the only ones which can decide when the ocular globe may be sacrificed, with a recovery of the region as aesthetic as can be.     

The open surgical approach to subglottic hemangioma

The monthly distribution of relapses in ulcerative colitis was analysed retrospectively to assess seasonal variation. In 338 patients who were regularly followed up at the colitis clinic, 1013 relapses occurred during the period 1977 to 1988. A peak of relapses occurred in the spring and autumn, with a decrease in the summer; the ratio of the observed to expected number of relapses was 201:255.3 for the summer, 289:252.6 for the autumn, 243:249.8 for the winter, and 280:255.3 for the spring. In contrast, month of diagnosis was evenly distributed without seasonality. The data support the concept that exacerbations in ulcerative colitis are influenced by seasonal factors.     

Common peripheral vascular diseases

Among the most common causes of morbidity and mortality in elderly individuals are the manifestations of the various peripheral vascular diseases. Many chronic degenerative diseases, which begin in middle age, are associated with peripheral vascular disease. Heart disease, hypertension, hyperlipidemia and diabetes are all risk factors for peripheral vascular diseases and also common degenerative conditions in our society. Other risk factors, such as diet, smoking, stress, lack of exercise, and obesity, are also closely associated with peripheral vascular disease. Aging itself is also a risk factor. Appropriate treatment for disease processes such as diabetes and hypertension and control of other preventable risk factors have been shown to reduce the morbidity and mortality seen in peripheral vascular disorders. Our rapidly aging population requires increasing amounts of medical resources, placing an enormous burden on society because the aged population are generally more dependent upon government-sponsored health care services. The podiatric practitioner is in a position as a primary care provider to influence the health practices of our aging population. The implementation of a health practice that stresses prevention and wellness as well as the appropriate management and a referral of patients with peripheral vascular disorders will limit the morbid results of peripheral vascular diseases.     

Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds

BACKGROUND: Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects. METHODS: We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly. RESULTS: All patients had successful obliteration of their lesions using a variety of therapeutic modalities aimed at preserving neurologic function while at the same time eliminating the aneurysm from the circulation. CONCLUSION: Both microneurosurgery and endovascular surgery have important roles to play in the management of TICAs. In some cases, both methods can be combined to eliminate lesions and maximize patient recovery in a safe, efficient, and effective fashion.     

Parry-Romberg syndrome associated with intracranial vascular malformations

We describe a 23-year-old woman with iridocyclitis, enophthalmos, facial hemiatrophy, and transient numbness of her contralateral upper and lower extremities. The patient was found to have white matter densities in the right hemisphere in magnetic resonance T2-weighted images and vascular malformations involving right vertebral, right carotid, and right anterior cerebral arteries. Histopathologic evaluation of a biopsy specimen of anterior orbital fat and lacrimal gland revealed fibrosis and chronic inflammation. These findings were consistent with the diagnosis of progressive facial hemiatrophy (Parry-Romberg syndrome) in association with iridocyclitis and intracranial vascular malformations.     

A neuropathologic approach to human disease: the intracranial mass effect

This review describes insults to the brain which result in either an increased or decreased mass effect. These mechanisms produce certain derangements in the central nervous system, which can lead to the patient's death. Increased intracranial mass effect characterized by brain tumors may produce lethal brain-stem ischemia. On the other hand, decreased intracranial mass effect as seen in Alzheimer's disease leads to aspiration pneumonia and terminal sepsis.     

Obesity and thrombotic vascular diseases

Obesity may either be unspecific as indicated by an increased body mass index (BMI) or due to an abnormal fat-distribution as indicated by an increased waist-to-hip ratio (WHR). The latter is frequently associated with deteriorations of glucose tolerance, hypertriglyceridaemia and hypertension (the metabolic syndrome), a syndrome which is among the strongest risk factors of ischemic heart disease. It is important to note that visceral obesity is a frequent feature of the polycystic ovary syndrome. Also, weight gain after menopause is often associated with a particular increase of the WHR. Obesity as indicated by an increased BMI (> 30 kg/m2) is a weak but easily detectable risk marker of venous thrombotic disease. This risk needs to be considered in clinical practice since obesity was shown to enhance the power of precipitating risk factors of venous disease such as pregnancy, surgery or estrogen treatment.     

Spontaneous intracranial hematomas. A surgical solution?

INTRODUCTION: Spontaneous intracranial haematomas pose a fundamental question for the neurosurgeon: Should he operate or not? The main objective of this paper is to consider recent ideas on this subject. A detailed review of the literature was carried out and then discussed. DEVELOPMENT: This study has been structured as supratentorial haematomas, infratentorial haematomas (cerebellum and brainstem) and multiple cerebral haematomas. We emphasize the importance of CT scanning to surgical decision-making. In supratentorial haematomas, surgery is considered to be indicated in patients with blood clots of between 2 and 3 cm in diameter, and whose neurological state is starting to deteriorate. Patients with cerebellar haematomas are classified into four groups, depending on the level of consciousness and the diameter of the clot. In these patients surgery is indicated basically in patients, both alert and somnolent, with haematomas greater than 3 cm. Medical treatment is recommended in patients with multiple haematomas and haematomas localized to the brain-stem. It is suggested that the best time to evacuate the haematoma is between 2 and 6 hours after onset. CONCLUSIONS: We consider that with the development of modern neuro-imaging techniques, intensive care units, neurological monitorization, developments in neurosurgical techniques with the use of magnification, the ultrasonic aspirator and stereotactic techniques, there will be more and more patients with spontaneous intracranial haematomas who can be successfully treated surgically in the next few years.     

Interactive image-guided surgical resection of intracranial arteriovenous malformations

Febrile seizures occur in 2 to 5% of children ages three months to five years. Evaluation of children with febrile seizures begins with a thorough history and physical examination. Therapy and long-term management should focus on treatment of the febrile illness and counseling.     

The UCLA surgical approach to sphincteric incontinence in women

Stress urinary incontinence (SUI) in the female may be treated by a variety of non-surgical and surgical therapies. However, once the patient has chosen to undergo operative repair the ideal procedure is based on three considerations: the degree of anterior vaginal wall prolapse, the degree of incontinence and associated anatomic abnormalities requiring surgical repair. In the vast majority of cases vaginal wall sling is our procedure of choice for the surgical treatment of SUI in the female. Vaginal wall sling is based on sound anatomic principles, may be performed as an outpatient procedure and is equally efficacious for the treatment of SUI due to anatomic incontinence (urethral hypermobility) and intrinsic sphincter deficiency. Since vaginal wall sling is performed through a transvaginal approach, other associated manifestations of pelvic floor prolapse such as rectocele can be addressed and repaired simultaneously. When necessary the vaginal wall sling can be easily modified to repair large grade cystoceles.     

Extracranial to intracranial vascular anastomosis for occlusive cerebrovascular disease: experience in 110 patients

In an attempt to ascertain the value of extra- to intracranial arterial bypass for cerebrovascular disease, the general topic of bypass surgery is reviewed and the results of this procedure in 110 patients are analyzed. The feasibility of high patency rates of the anastomosis with acceptably low permanent morbidity and operative mortality rates is demonstrated. Lesions producing transient ischemic attacks which previously were considered to be inoperable or inaccessible can be bypassed by this procedure, and there appears to be a dramatic improvement in the symptomotology of virtually all patients. Patients with a mild stroke or "progressive stroke" also appear to benefit from bypass, but the erratic natural history of these entities precludes irrefutable substantiation of this conclusion. Patients with moderate-to-serve neurological deficits do not appear to be improved by this procedure. In our group of 20 patients presenting with transient ischemic attacks who have had more than 3 years of follow-up, only one patient has suffered a stroke and that was located in the opposite hemisphere.