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Biomedical subjects

J V Rosenfeld

Publications and source records attributed to J V Rosenfeld.

At least 19 recordsLinked to original sources
PubMed2005

The role of decompressive craniectomy in the management of traumatic brain injury: a critical review.

Brain swelling and intracranial hypertension following severe head injury are known to contribute to secondary brain damage, and have been shown to adversely affect patient outcome. The use of unilateral craniectomy following the evacuation of a mass lesion, such as acute subdural haematoma or traumatic intracerebral haematoma, is accepted practice. The following review focuses on a bi-fronto-temporal decompressive craniectomy, used as an isolated operation for the control of intracranial hypertension, secondary to diffuse brain swelling refractory to medical management. Though the operation is being increasingly used, current opinion is still divided regarding its overall effects on outcome. This review examines the experimental and clinical evidence for and against the use of decompressive craniectomy, highlights the lack of class I evidence relevant to this topic and emphasises the necessity for well-designed prospective randomised controlled trials.

Animals↗
PubMed2005

A review of the current management of severe traumatic brain injury.

Traumatic brain injury accounts for up to half of trauma related fatalities. This review describes current management practices including pre-hospital care, surgical interventions and various treatment modalities for intracranial hypertension. The lack of class I evidence for the majority of interventions is highlighted.

Brain↗
PubMed2005

Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children.

OBJECTIVE: To examine the contributions of injury severity, physical and cognitive disability, child and family function to outcome 30 months after traumatic brain injury (TBI) in children. DESIGN: A prospective, longitudinal, between group design, comparing function before and after injury across three levels of injury severity. SUBJECTS: One hundred and fifty children, 3.0-12.11 years old, admitted to hospital with a diagnosis of TBI. The sample was divided according to injury severity: mild (n = 42), moderate (n = 70), severe (n = 38). Children with a history of neurological, developmental, and psychiatric disorders were excluded from participation. MAIN OUTCOME MEASURES: Post injury physical function, cognitive ability (incorporating intellect, memory, and attention), behavioural and family functioning, and level of family burden. RESULTS: A dose-response relation was identified for injury severity and physical and cognitive outcome, with significant recovery documented from acute to six months after TBI. Behavioural functioning was not related to injury severity, and where problems were identified, little recovery was noted over time. Family functioning remained unchanged from preinjury to post injury assessments. The level of family burden was high at both six and 30 months after injury, and was predicted by injury severity, functional impairment, and post injury child behavioural disturbance. CONCLUSIONS: These results suggest ongoing problems for the child and significant family burden 30 months after TBI. The nature and severity of the physical and cognitive problems are closely related to injury severity, with child and family function predicted by psychosocial and premorbid factors.

Adaptation, Psychological↗
PubMed2004

Evaluation of management of road trauma survivors with brain injury and neurologic disability in Victoria.

BACKGROUND: Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999. METHODS: The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records. RESULTS: The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units. CONCLUSION: Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

Accidents, Traffic↗
PubMed2003

Generalized epilepsy in hypothalamic hamartoma: evolution and postoperative resolution.

OBJECTIVE: To better understand the epileptogenesis of symptomatic generalized epilepsy in patients with hypothalamic hamartoma and intractable epilepsy, many of whom experience remission of generalized seizures and slow spike-wave discharges following surgery. METHODS: The authors documented the evolution of symptomatic generalized epilepsy in 12 of 20 children who underwent transcallosal microsurgical hypothalamic hamartoma resection. In seven patients they recorded intraoperative EEG from the hamartoma and simultaneously from the scalp and frontal cortex before, during, and after resection. RESULTS: Gelastic seizures began on average at 6 months of age (range birth to 3 years); tonic seizures began at 6 years (range 2 months to 9 years). Normal EEG were reported in early childhood; thereafter, abnormalities were progressive. Interictal spike-wave was recorded intraoperatively over the scalp and cortex in six patients, but not from the hypothalamic hamartoma. Hamartoma resection had no immediate effect on cortical spike-wave, but waking spike-wave was absent in seven patients on subsequent postoperative EEG. Tonic seizures ceased in 11 of 12 patients, but 6 of these had postoperative generalized seizures that resolved over 1 to 6 months. CONCLUSION: Gelastic seizures in hypothalamic hamartoma arise from the hamartoma itself; the interictal spike-wave does not. The evolution of EEG abnormalities, the development of generalized seizures years after onset of gelastic seizures, and the postoperative running down of interictal spike-wave and generalized seizures in these patients may reflect secondary epileptogenesis.

Child↗
PubMed2002

James IV Lecture. Epilepsy surgery, hypothalamic hamartomas and the quest for a cure.

This presentation reviews the epidemiology of epilepsy, the evolution of epilepsy surgery, the selection of cases for surgery, the range and results of epilepsy surgery, and the future development of this burgeoning field. Hypothalamic hamartoma (HH) is a rare developmental lesion which causes intractable gelastic epilepsy which is refractory to medical therapy. Hypothalamic hamartoma presents a formidable surgical challenge. The application of a midline transcallosal interforniceal approach to resect the HH from within the third ventricle, in a series of 28 patients, is presented. This has produced excellent results with minimal morbidity. This surgery is placed within the context of epilepsy surgery in general.

Epilepsy↗
PubMed2001

Upper cervical spinal cord injury in neonates: the use of magnetic resonance imaging.

Neonatal upper cervical spinal cord injury is associated with rotational forceps delivery and presents with quadriparesis and diaphragmatic paralysis. The underlying pathology determines neurologic outcome but is difficult to assess clinically or with simple radiographic techniques. We report 4 cases in which early magnetic resonance imaging demonstrated the extent and severity of the injury and guided management.

Cervical Vertebrae↗
PubMed2001

Frontoethmoidal encephaloceles: reconstruction and refinements.

Frontoethmoidal encephaloceles are herniations of the intracranial contents through a defect in the skull at the junction of the frontal and ethmoidal bones. They are generally classified as nasofrontal, nasoethmoidal, and naso-orbital, although there may be some overlap or multiplicity. The records of 35 patients treated for frontoethmoidal encephaloceles were examined. Of these, 12 cases with complete and accurate medical records were evaluated in detail. The successful correction of frontoethmoidal encephaloceles was shown to depend on the following: a detailed understanding of the pathological anatomy (such as interorbital hypertelorism rather than true orbital hypertelorism and the presence of secondary trigonocephaly), careful planning of the bone movements to correct these deformities, and attention to detail regarding the placement of scars, positioning of the medial canthi, and the nasal reconstruction. Avoiding the "long-nose" deformity often seen after repair should be a priority. In general, the authors recommend a one-stage repair with both a transcranial and external approach.

Adolescent↗
PubMed2001

Transcallosal resection of hypothalamic hamartomas, with control of seizures, in children with gelastic epilepsy.

OBJECTIVE: Hypothalamic hamartomas (HHs) are associated with precocious puberty and gelastic epilepsy; the seizures are often refractory to antiepileptic medications and associated with delayed development and disturbed behavior. The current opinion is that surgery to treat intrahypothalamic lesions is formidable and that complete excision is not technically achievable. We report our experience with a transcallosal approach to the resection of HHs. METHODS: Five children (age, 4-13 yr) with intractable epilepsy and HHs underwent preoperative clinical, electroencephalographic, and imaging evaluations. Two patients experienced only gelastic seizures, and three patients experienced mixed seizure disorders with drop attacks; all experienced multiple daily seizures. Patients were evaluated with respect to seizures, cognition, behavior, and endocrine status 9 to 37 months (mean, 24 mo) after surgery. The HHs were approached via a transcallosal-interforniceal route to the third ventricle and were resected using a microsurgical technique and frameless stereotaxy. RESULTS: Complete or nearly complete (>95%) excision of the HHs was achieved for all patients, with no adverse neurological, psychological, or visual sequelae. Two patients experienced mild transient diabetes insipidus after surgery. Two patients developed appetite stimulation, but no other significant endocrinological sequelae were observed. Three patients are seizure-free and two patients have experienced only occasional, brief, mild gelastic seizures after surgery, all with reduced antiepileptic medications. On the basis of parental reports and our own subjective observations, the children also exhibited marked improvements in behavior, school performance, and quality of life. CONCLUSION: Complete or nearly complete resection of HHs can be safely achieved via a transcallosal approach, with the possibility of seizure freedom and neurobehavioral improvements.

Child Behavior↗
PubMed2001

Awake craniotomy in an adolescent.

We present our approach to management of awake craniotomy for epilepsy surgery for an adolescent. The importance of patient selection and preoperative preparation is stressed. Anaesthetic management included regional scalp block and preincisional surgical infiltration of local anaesthetic and light sedation with propofol, fentanyl and midazolam. The patient remained responsive to voice for all but a small part of the procedure.

Adolescent↗
PubMed2001

Endovascular management of vein of Galen aneurysmal malformations presenting in the neonatal period.

BACKGROUND AND PURPOSE: Neonates with vein of Galen aneurysmal malformations (VGAMs) presenting with cardiac failure have high morbidity and mortality, and outcomes are significantly better in those presenting in later childhood. Neurologic outcomes in survivors are perceived to be uniformly poor, which may lead to the neonate being denied treatment. We assessed outcomes of modern neonatal intensive care and endovascular embolization in a consecutive series of such neonates presenting with cardiac failure. METHODS: Between 1996 and 1998, five infants (three male, two female) were diagnosed with symptomatic VGAMs in the first week of life, four of whom had intractable, high-output cardiac failure and underwent initial endovascular treatment. There were 15 endovascular procedures and one neurosurgical clipping in these five patients. Transarterial and transvenous routes were required, using multiple embolic agents. We emphasized the use of sonographically guided, percutaneous transtorcular-venous-access, moveable-core guidewire as an embolic agent; routine MR imaging; and MR angiography. RESULTS: Immediate outcomes included control of cardiac failure with normal neurologic function in four (80%) patients and one (20%) death from intractable cardiac failure. On follow-up examination, three (60%) infants showed no evidence of neurologic abnormality or cardiac failure; one (20%) infant showed moderate developmental delay. Two have had no further shunting on angiography, one has minimal flow, and one is awaiting follow-up imaging. CONCLUSION: Endovascular therapy with modern neuroanesthetic and neurointensive care can provide good outcomes even in the highest-risk neonates with VGAMs and cardiac failure. If medical management of cardiac failure fails, and there is no evidence of gross cerebral parenchymal damage on imaging, urgent endovascular treatment is feasible and can reduce the almost-100% mortality otherwise expected, without invariably severe morbidity. Use of multiple embolization strategies in multiple stages usually is necessary in these patients, and novel approaches and embolic agents may be necessary.

Cerebral Veins↗
PubMed2000

Tension pneumo-orbitus and pneumocephalus induced by a nasal oxygen cannula: report on two paediatric cases.

The present paper highlights the potential dangers of misplaced nasopharyngeal oxygen cannulae causing secondary pneumo-orbitus and pneumocephalus in two paediatric patients. While this complication is uncommon, early recognition allows prompt and appropriate intervention, with cessation of nasal oxygen, cannula removal, early investigation with computed tomography (CT) head/orbit scan and orbital or cranial decompression, if required. Early CT imaging identifies medial orbital or paranasal sinus fractures, the presence of sinusitis, associated intracranial air and assessment of the degree of orbital or intracranial tension. Antibiotics are not usually required for this type of clean injury unless pre-existing sinusitis is identified. In both cases, direct orbital decompression was performed with excellent results after identification of marked unilateral tense exophthalmos, delayed pupillary reactions to light and ophthalmopegia.

Catheterization↗
PubMed2000

Physiological localisation in functional neurosurgery for movement disorders: a simple approach.

Controversy exists between anatomical methods and single cell recording as the preferred approach in target localisation in functional neurosurgery for movement disorders. The controversy centres on accuracy as compared to practicality. We describe a mapping technique of semi-microstimulation utilising threshold measurements which has been used in 66 procedures in 50 subjects. We compared the accuracy of anatomical localisation with the final chosen target using the above technique. We also compared the benefit, the side effects and the surgical complication rate with published data on single cell recording and anatomical localisation. The mean difference in 3-dimensional space between the anatomical target and the physiological target was 6.85 mm (P < 0.0001). A good response was obtained in 80% of procedures. Mortality was 1.5%. The surgical complication rate was 1.5%. Mild side effects, serious side effects, transient side effects and permanent side effects were evident in 4.5%, 10.6%, 6.1% and 9.1% of procedures. These figures compared better than anatomical studies and similar to single cell recording studies. It is concluded that this approach provides both accuracy and simplicity and is recommended as a compromise to the currently available methods.

Adolescent↗
PubMed2000

The efficacy of spinal cord stimulation for chronic pain.

A prospective study was undertaken to evaluate the efficacy of spinal cord stimulation (SCS) in the management of chronic pain syndrome. The study included all patients who underwent this procedure at the Royal Melbourne Hospital and the Melbourne Private Hospital over a period of two years. A total of 29 patients were managed by the end of June 1996. These patients were carefully screened by a neurosurgeon (JVR) and a psychiatrist. Of these, 26 patients had a follow up evaluation at the end of August 1996. From the group of 29 patients, four patients failed to obtain any relief during the trial phase of the procedure and thus did not have the stimulator implanted permanently. From the 25 patients who proceeded to have the stimulator implanted, 11 patients had a variable beneficial response, three patients found it to be of marginal benefit, six had no benefit, three patients initially had a good response but subsequently gained no benefit whilst two patients were uncertain of its benefit. It thus appears that SCS was of benefit in 50% of our carefully selected patients with chronic pain syndromes.

Adult↗
PubMed2000

The preventability of death in road traffic fatalities with head injury in Victoria, Australia. The Consultative Committee on Road Traffic Fatalities.

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) has examined the medical management of patients who died following motor vehicle accidents. Three hundred and fifty-five fatalities with head injury occurring between 1 July, 1992 and 31 December 1997 were assessed by the CCRTF. They represented 79% of the total 449 fatalities examined by the Committee. Following examination of the complete medical records and multidisciplinary discussion, the Committee considered 237 (67%) of the 355 neurotrauma deaths to be non-preventable, 105 (30%) potentially preventable and 13 (4%) preventable. The present analysis excludes the non-preventable deaths in order to focus on preventable factors. Problems identified in the 118 patients pre-hospital included: no intubation; prolonged scene time; and no intravenous access; in 139 emergency room attendances: inappropriate reception including delay in arrival of a consultant, no neurosurgical consultation, no CT scan of the head, inadequate blood gases and oxygen monitoring, inadequate fluid resuscitation, delayed respiratory resuscitation and delayed dispatch to the operating room; in 111 operating room visits: no ICP monitoring, inadequate fluid administration and inappropriate anaesthetic technique; and in 90 intensive care unit admissions: no ICP monitoring. Overall, 1745 individual problems in the various areas of care were identified, of which 1104 (63%) were judged to have contributed to death. Improved delivery and quality of trauma care could reduce the identified problems in emergency services and clinical management. Basic principles of trauma management remain the most important means of reducing morbidity and death following road trauma. The leadership role of the neurosurgeon in neurotrauma care is emphasised.

Accidents, Traffic↗
PubMed2000

Neurosurgery at the Royal Melbourne Hospital.

The Department of Neurosurgery of the Royal Melbourne Hospital (RMH) is a major neurosurgery program and academic leader in Australasia. In 1998, the RMH marked its 150th anniversary. The department of neurosurgery was established in 1945 under the direction of R.S. Hooper and has produced many distinguished neurosurgeons since its founding. The department is currently directed by Andrew Kaye, who is also the James Stewart Professor of Surgery at the University of Melbourne. In 1997-1998, the neurosurgery department received 2930 admissions and performed 2225 operations, with 11 neurosurgeons on staff and a strong focus on subspecialization. The neurosurgeons have varying time commitments to the hospital and to research, but many are on site full-time. The RMH is a university teaching hospital as well as a public hospital; therefore, there is no financial burden for any patient. The RMH is closely linked to the adjacent Melbourne Private Hospital, where privately insured patients are treated. The department of neurosurgery maintains close links with the departments of neurology, ophthalmology, and neuropsychiatry, which together form the Melbourne Neuroscience Centre. There is a strong emphasis on undergraduate and postgraduate teaching, as well as clinical and laboratory research. Neurosurgery trainees are encouraged to undertake laboratory research and pursue higher academic degrees. Despite economic restraints, the department continues to grow in strength, and we remain optimistic of exciting times ahead for neurosurgery at the RMH in the new millennium.

Australia↗
PubMed1999

Pineal region tumours in childhood. A 30-year experience.

Patients aged under 16 years presenting to the Royal Children's Hospital between 1967 and 1997 with pineal region tumours were retrospectively reviewed. Thirty-seven patients were identified, with 13 germinomas, 7 nongerminomatous germ cell tumours, 6 pineoblastomas, 2 pineocytomas, and 3 astrocytomas, while in 6 patients no histopathological diagnosis was obtained. The most common presentation was with symptoms of raised intracranial pressure due to hydrocephalus. Thirty-two of the 37 patients required a shunt. Thirteen had a biopsy as a separate procedure, 3 of which were stereotactic. Tumour excision was performed in 21 patients and was complete in 4 and subtotal in 17. There were 2 perioperative deaths and 6 patients who were neurologically worse after surgery. Twenty-six patients had radiotherapy and 16 chemotherapy, with significant complications of radiotherapy in half of the patients who received it. The 5-year survival of patients with benign tumours was 75%, 5-year survival with germinomas 62% and with other malignant tumours 14%. This series demonstrates significant improvements in management of pineal region tumours in the last 30 years and highlights some of the current controversies. A collaborative research approach is necessary to determine optimal management of the varied tumour types occurring in the pineal region in childhood.

Adolescent↗