Isolated cases of spontaneous cerebrospinal fluid (CSF) leakage with and without middle ear encephalocele have been reported. These leaks are usually accompanied by episodes of recurrent meningitis, ...hearing loss, or chronic headache. In this article, we report seven new cases of spontaneous CSF leakage. Six of these patients had conductive hearing loss and serous otitis media, and three had recurrent meningitis. Prior to a definitive diagnosis, six patients had received myringotomy tubes, which produced profuse clear otorrhea. Three patients had positive beta-2 transferrin assays. Computed tomography and magnetic resonance imaging confirmed a defect in the temporal bone tegmen. A combined transmastoid and middle fossa surgical approach with a three-layer closure was used to repair the tegmen defect. All patients had a lumbar drain placed prior to surgery. In addition to describing the seven new cases, we review the history of CSF leakage and discuss diagnostic methods, surgical findings, and our recommendations for management.
The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for ...stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes.
In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning.
There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance.
Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.
This investigation examined the efficacy of psychostimulant therapy in alleviating neurobehavioral dysfunction attendant to pediatric brain injury. The most commonly reported neurobehavioral sequelae ...associated with head injury in the pediatric population involve deficits along the attentional matrix. This is also the most common objectively documented neurobehavioral finding among children as well as adults. There are several investigations in the adult literature which have employed the use of psychostimulants in treating both psychiatric and neuropsychological residua associated with head injury. Overall, the results of these studies are equivocal, but suggest a beneficial impact on general functioning. The present prospective investigation utilized a double-blind, placebo-controlled, cross-over experimental design to examine the efficacy of methylphenidate in treating children with acquired attentional disorders secondary to brain injury. A cohort of 14 children with varying degrees of head injury were recruited for participation. As expected, differences between drug and placebo conditions uniformly achieved statistical significance. Additionally, there were no differences in performance between baseline and placebo conditions on neurobehavioral tasks of attention and concentration. Current findings suggest that methylphenidate (and probably other psychostimulants such as Cylert, Adderal, Wellbutrin and dextroamphetamine sulfate) is an extremely effective agent in treating attentional disorders secondary to brain injury in children.
Extracranial-intracranial arterial bypass is a microneurosurgical procedure recently introduced in the treatment of a variety of cerebrovascular ischemic states. Fifty patients with transient ...ischemic attacks (TIAs) localized to the distribution of the internal carotid artery underwent this procedure during a 48-month period. All have been followed up for at least 14 months after surgery. There were no operative deaths, and notable postoperative morbidity has been experienced in less than 8% of cases. Seventy-six percent of patients have been asymptomatic since surgery, 14% have continued to experience TIAs, and 6% have had completed strokes (2% occurring in the operative hemisphere).
The natural history of unruptured asymptomatic aneurysms in nuclear. Because of this uncertainty regarding risk of ultimate enlargement and/or hemorrhage, and in view of the significant mortality and ...morbidity traditionally involved in aneurysm surgery, clinicans have varied in their advocacy of surgical management of such lesions. Forty-nine consecutive patients harboring 52 such aneurysms were treated surgically over a 57-month period. There were no surgical deaths and morbidity was within acceptable limits. Patient population characteristic and surgical technique are discussed.
The microsurgical correlates the pterional approach to the distal basilar circulation were evaluated in 20 cases of posterior circulation aneurysms, 50 human cadaver dissections, and a variety of ...other intracranial surgical lesions. The pterional approach permitted successful clipping of the aneurysm in 13 of 15 basilar bifurcation aneurysms, 1 of 2 basilar-posterior cerebral aneurysms, and 2 of 3 basilar-superior cerebellar aneurysms. In each of the failed attempts via the pterional approach, the subtemporal route ultimately resulted in proper clip application. The interposition of the posterior clinoid process was the impediment to successful clipping in three of the four cases that could not be managed via the pterional approach. All 3 of these patients had a basilar bifurcation that was below the level of the posterior clinoid on angiography, whereas none of the remaining 17 aneurysm patients demonstrated a low-lying bifurcation. Posterior displacement of the basilar artery away from the posterior clinoid exceeded 1 cm in only 13% of our cases and was not an impediment to successful clipping of the aneurysm via the pterional route. We conclude that, when the anatomical situation is appropriate, the pterional approach offers the advantages of less brain retraction and better visualization of the parent arteries and important perforating branches when compared to the subtemporal approach.
Saphenous vein interposition grafts of varying lengths have been used in 25 extracranial-intracranial bypasses since 1974. Indications for operation included transient ischemic episodes (13 cases), ...prophylactic augmentation of middle cerebral artery (MCA) collateral flow prior to surgical treatment of intracranial aneurysm (four), and traumatic occlusion of cervical or intracranial internal carotid arteries (eight). Vein grafts to cortical branches of MCA originated from superficial temporal or occipital arteries in ten cases, common or external carotid arteries in ten, and subclavian or innominate vessels in five. Twenty-one patients have been followed up for a minimum of 12 months. Immediate patency rate was 84%; one late graft occlusion decreased overall patency to 80%. There was one operative mortality. Early technical problems, including donor-recipient size disparity, anastomotic distortion, and inappropriate graft routing, have been overcome by the use of 2-mm veins, the avoidance of hydrostatic dilation, and the construction of retroauricular tunnels. It is reasonable to assume that long-term patency of these reconstructions will parallel that of extracranial-intracranial bypasses using autologous arteries.
The use of polyl (methyl methacrylate) for tooth replica implants, as developed by Hodosh, is described as to indications, ingredients, and fabrication technique. Laboratory testing of this material ...for mechanical and thermal expansion properties, and porosity content were determined as a function of foaming agent and and anorganic bone particle content.
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