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A new modified vascular clip applier has proved to be more efficient in providing occlusion of the internal maxillary artery and its branches, as well as the ethmoidal arteries. Better visualization and more efficient closure has resulted in a shortened operating time.
We report a case of carotid endarterectomy and clipping of an ipsilateral internal carotid artery aneurysm in a patient with complete contralateral carotid stenosis. The patient developed an ischaemic electroencephalographic (EEG) tracing on temporary carotid clamping and bypass shunt was contraindicated. We used thiopentone titrated to EEG burst suppression for pharmacological cerebral protection during the subsequent prolonged carotid clamp necessary for carotid endarterectomy. We review the use of thiopentone for this purpose, in particular the evidence for efficacy, mechanism of action and optimal dosage and timing of administration.
To describe the integration of magnetic resonance angiography (MRA) in neuronavigation procedures for microsurgery of intracranial aneurysms. MRA was combined with standard magnetic resonance image (MRI) acquisition in the image-guided planning for the microsurgical clipping of a saccular aneurysm in two patients (one 3-mm large middle cerebral artery and one 8-mm large pericallosal artery aneurysm, diagnosed by catheter angiography in both patients) using two different neurosurgical navigation systems. Conventional 3-D T1-weighted MRI with gadolinium and MRA pulse sequences were acquired in frameless stereotactic conditions the day before surgery and thereafter registered, allowing the definition a minimally invasive straight trajectory to the aneurysm neck. MRA-guided neurosurgery allowed a direct approach to the aneurysms at their proper location, reducing the invasiveness of the approach by tailoring the bone opening and reducing the duration and extension of brain retraction. The technique also avoided unnecessary dissection and exposure of the main trunks and collateral vessels. The aneurysms were successfully eradicated without complication. Integration of MRA in the planning and neuronavigation procedure for intracranial aneurysms may minimize the morbidity related to the surgical approach. This technique may be applicable more routinely using standard neuronavigation equipment.
OBJECTIVES: The 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs before an acute massive subarachnoidal hemorrhage (SAH), was first described in 1967. The present study was performed to compare the complications and prognosis for 214 patients with and without a warning leak; aneurysm clipping had been performed in all. METHODS: The interval between the warning headache and the actual SAH was calculated. The following complications were examined: preoperative hemorrhage, intra-operative rupture of the aneurysm, postoperative re-bleeding, symptomatic vasospasm, shunt-requiring hydrocephalus, ventriculitis, postoperative wound infection, and outcome according to the Glasgow Outcome Scale (GOS). RESULTS: Sixty-seven (31%) out of the 214 patients had a warning leak with a median distance of 11 days before suffering from major SAH. Preoperative angiographic vasospasms occurred more frequently in the group with a warning bleeding (22.4 versus 6.1%; p<0.05), which means that the warning leaks induce vascular reactions similar to SAH. The outcome of both groups after a mean follow-up time of 22 months did not show any difference. But 30 out of the 67 patients with a warning leak were graded H&H III-V at admission to hospital after a major SAH. The overall outcome for patients graded H&H I and II was in 92% favorable, compared with only a 54% favorable outcome for H&H III-V patients. Long-term outcome in the warning leak group was not impaired by angiographically proven vasospasm. DISCUSSION: To give patients the chance to start their treatment in a better clinical condition it is important to recognize the early warning signs.
BACKGROUND: A considerable number of patients require opioids during recovery after laparoscopic sterilization. This implies nausea, dizziness and sedation and increases the number of unplanned admissions. Gabapentin has shown excellent postoperative analgesic effect in a number of recent studies with few side effects. This study was designed to test whether gabapentin given preoperatively can reduce the number of patients needing morphine in the recovery period. METHODS: 80 females scheduled for laparoscopic sterilization using Filshie clips were randomized to two treatment groups (Gaba group and control group). All patients received lornoxicam 8 mg p.o. 30 min. before the procedure. Patients in the Gaba group received gabapentin 1200 mg p.o. and patients in the control group received placebo capsules prior to the procedure. All patients were anesthetized according to a protocol, using remifentanil and propofol. Postoperative analgesia was obtained with patient controlled infusion of morphine. Pain, nausea, dizziness and sedation were scored at 2 and 4 hours after end of anesthesia. The expenditure of morphine was the primary measure for the effect of analgesia and the number of patients demanding morphine was the primary endpoint. RESULTS: Three patients were excluded because of procedural errors and one because of conversion to open surgery. 38 patients completed the study in each group.32 (84%) patients in the gabapentin group and 37 (97%) patients in the control group did require morphine in the recovery period. (p = 0,049). There was no significant difference between mean morphine consumption, pain scores and frequency of adverse effects (nausea, dizziness, sedation and vomiting) CONCLUSION: The postoperative analgesic effect of gabapentin given preoperatively was confirmed in this study. For this procedure, with pain predominantly in the immediate recovery period, and of less intensity than after major surgical procedures, the effect demonstrated is much less pronounced than in similar studies of major surgery. General use of gabapentin as analgesic for laparoscopic sterilization is not supported by this study. TRIAL REGISTRATION: Current Controlled Trials ISCRTN39209275.
The authors investigated the evolution of third nerve palsy in patients with posterior communicating artery aneurysms who underwent coiling vs clipping. There was no statistical difference of complete third nerve palsy recovery in both treatments. Both techniques were of clinical benefit. Older age, diabetes, delayed interventions, and complete third nerve palsy at presentation indicated a poor prognosis for recovery.
The cardiovascular effects of large dose thiopental anesthesia and induced hypotension were examined in 22 patients undergoing clipping of ruptured intracranial aneurysms. Eleven patients operated on within 4 days of the initial bleed (early group) were compared with those operated on more than 10 days after the bleed (late group). Systemic and pulmonary arterial pressures, central venous pressure, and cardiac output were measured. The cardiac index and the systemic and pulmonary vascular resistance were calculated. Before the induction of anesthesia, the cardiac index was 4.00 +/- 0.3 litres/minute/m2 in the early group compared with 2.89 +/- 0.23 litres/minute/m2 in the late group (P less than 0.05). Five and 10 minutes after the administration of mannitol (1 g/kg) and at an induced hypotensive level of 60 torr, the cardiac index remained significantly higher in the early group (P less than 0.05). There was no significant difference in the mean arterial blood pressure between the groups. Systemic vascular resistance was significantly higher in the late group during the postinduction and the pre-mannitol infusion periods and at induced hypotensive levels of 50 and 40 torr. Central venous pressure was significantly higher in the early group only at the preanesthesia (control) measurement. There was no significant difference between the groups in the pulmonary artery wedge pressure or the pulmonary vascular resistance.
A case of postoperative tension pneumocephalus of unusual cause after carotid-ophthalmic artery aneurysm clipping is presented. A second craniotomy for decompression and exploration demonstrated a small fistula in the planum sphenoidale, which presumably had been made when the right optic canal was unroofed during the first operation.
We describe the use of stereotactic, angiographic guidance for localization and clipping of a small, distal intracranial bacterial aneurysm. The technique uses the commercially available Suetens-Gybels-Vandermeulen angiographic localizer with the widely used Cosman-Roberts-Wells stereotactic system. This method is simple and easy to use and significantly decreased the operative time. It may be quite useful for surgically treating mycotic and other peripheral aneurysms.
The direct surgical treatment of intracranial aneurysms is not always possible, especially in posterior circulation aneurysms. This is usually because of their complex anatomy and location next to the skull base and brain stem, where proximal vascular control is usually not attainable. Four patients at our institution underwent intraoperative transfemoral catheterization of the basilar artery with a nondetectable endovascular balloon for proximal control of the basilar artery. The flow control in the basilar artery was excellent and facilitated the surgery. Before surgery, each patient underwent the placement of a 10-cm 8-French femoral introducer sheath and were taken to the operating room where they were placed in a supine position and a subtemporal or pterional craniotomy was performed. After the initial exposure and before aneurysm manipulation, a nondetachable silicone balloon catheter was passed through an introducer catheter and was placed into the rostral basilar artery, using flow direction, microguidewires, and angiographic "road-mapping" techniques. In two patients, temporary basilar occlusion was used to collapse the aneurysm and to facilitate clip placement. In the third patient, intraoperative aneurysm rupture occurred and was controlled by temporary basilar artery occlusion. Using intraoperative angiography, complete aneurysm obliteration and vessel patency was confirmed in all four patients. All patients made a complete recovery except for initial postoperative third nerve palsies in three patients. This technique achieves intraoperative control of the basilar artery proximal to an aneurysm by the use of a nondetachable occlusive balloon in the basilar artery. An added benefit is the ease with which intraoperative angiography can be obtained in this context.(ABSTRACT TRUNCATED AT 250 WORDS)
A 74-year-old woman sought treatment after an initial subarachnoid hemorrhage verified on computed tomographic scan with no focal neurological deficit. Shortly after admission, she sustained a second subarachnoid hemorrhage with acute neurological decompensation. A repeat computed tomographic scan revealed increased blood along the right medial temporal region, as well as in the interhemispheric fissure and bilateral sylvian cisterns. Also evident was a right hemispheric acute subdural hematoma. The patient's rapidly deteriorating neurological status precluded a cerebral angiogram; therefore, a double-dose infusion computed tomographic scan was performed. This revealed a cerebral artery aneurysm adjacent to the right medial temporal hematoma. She was taken to the operating room on the basis of this study. After evacuation of the right hemispheric subdural hematoma and clipping of the right posterior communicating artery aneurysm, the patient made a rapid, full neurological recovery.
A suggested design with respect to the tips of aneurysm clips is described. Its advantages are mentioned.
OBJECTIVE: Recent reports in the literature have described a significant discrepancy in adverse outcomes between coil embolization (CE; 10%) and surgical clipping (SC; 25%) for the management of unruptured intracranial aneurysms (UIA). This discrepancy led us to analyze our experience. METHODS: In 1996, we designed a prospective study of patients with UIA in which CE was considered the treatment of choice and was performed if the interventional neuroradiologists deemed the aneurysm's fundus-to-neck ratio accessible for CE. SC was performed only if complete CE was unlikely to be achieved or in patients in whom CE already had failed. RESULTS: CE was performed in 38 patients with at least one UIA (41 UIAs, 83% in the anterior circulation). SC was performed in 39 patients with at least one UIA unsuitable for CE (59 UIAs, including 6 after failed CE, 96.5% in the anterior circulation). For CE, the total obliteration rate was 56.1%, the subtotal was 14.6%, and CE failed in 29.3%. There were transient complications in 10% of the cases and permanent complications in 7.5%. Of the 12 failed CE procedures, 7 (58%) were performed for middle cerebral artery aneurysms. For SC, the total obliteration rate was 93.2%, the subtotal was 1.7%, and SC failed (wrapping) in 5.1%. There were transient complications in 16.3% of the patients and permanent complications in 1.7%. The success rate for CE was similar to that for SC only when CE was used for aneurysms with a fundus-to-neck ratio of at least 2.5. CONCLUSION: SC can produce better results than CE in patients with UIA of the anterior circulation. CE as a first-line treatment should be reserved for patients with UIAs with a fundus-to-neck ratio of 2.5 or greater.
OBJECTIVE: Only one-third of patients regain functional independence after aneurysmal subarachnoid hemorrhage (SAH). Despite this recovery, many of these patients experience psychosocial problems. We assessed the long-term effects of SAH on employment, relationships, personality, and mood. METHODS: We included patients who had been treated by clipping after SAH between 1985 and 2001 and who resumed independent living. Patients underwent structured interviews regarding employment, relationships, and personality before and after the SAH. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale, and scores were compared between the study group and a control population. RESULTS: Six hundred and ten patients were interviewed (mean follow-up after SAH, 8.9 yr). Of the employed patients, 26% stopped working and 24% worked shorter hours or had a position with less responsibility. On average, patients returned to work 9.4 months after discharge (range, 0-96 mo). Seven percent of patients were divorced because of SAH-related problems. Fifty-nine percent of the patients reported changes in personality, with the most commonly noted changes being increased irritability (37%) or emotionality (29%). Patients with SAH had a statistically significant higher mean depression score than the control population. Approximately 10% of the patients had a Hospital Anxiety and Depression Scale score in the range of a probable depressive or anxious state. Only 25% reported a complete recovery without psychosocial or neurological problems. CONCLUSION: The long-term psychosocial effects of SAH are considerable, even in patients who regain functional independence. Treating physicians should be aware of these long-term effects of SAH when discussing prognosis and reintegration to work after initial recovery with patients and family.
To assess possible time-related changes in total venous capacity, mean circulatory filling pressure (MCFP) and blood volume (BV, Evans blue) were determined in conscious rats with early, intermediate and chronic phases of two-kidney, one clip Goldblatt hypertension. MCFP, and index of whole-body venous activity, was measured while the circulation was arrested by the brief inflation of a balloon inserted into the right atrium. Compared with shamoperated control rats, Goldblatt rats showed unchanged MCFP and BV in early phase, unchanged MCFP with marginally (0.05 less than p less than 0.10) decreased BV in intermediate phase, and significantly (p less than 0.05) increased MCFP with unchanged BV in chronic phase. Thus, decreased total venous capacity, which is reflected in increased MCFP relative to BV, occurred with a continuation of hypertension. MCFP/BV curves, obtained by measuring MCFP before and after rapid BV change, appeared to shift toward the pressure axis in all Goldblatt groups. There were no significant differences in total vascular compliance, which is the inverse of the slope of this curve and is an index of total venous compliance, between Goldblatt and control groups at any time-period studied. These results suggest that decreased venous capacity observed in chronic hypertensive rats may be a secondary hemodynamic state and may not be related to decreased venous compliance.
The angiotensin converting enzyme (ACE) activity in tissues and plasma renin activity (PRA) were measured in 2-kidney, 1-clip renal hypertensive rats (2K-RHR) and normotensive rats after a single and 3-weeks oral administrations of ACE inhibitors such as MK-421 and captopril. In the single dose study, MK-421 (1 and 3 mg/kg) and captopril (3 and 10 mg/kg) inhibited the ACE activities in kidney, aorta and plasma in a dose-dependent fashion. The inhibition of ACE activity in kidney or aorta was observed for a longer time than that in plasma. PRA took a time course reversal to that of plasma ACE activity. In the 3-weeks repeated dose study, the ACE activity in kidney and aorta was strongly inhibited after the administration of each ACE inhibitor, while there was no significant change in lung ACE activity at any time point examined. The plasma ACE activity markedly elevated after the administration of each agent. PRA significantly increased after the administration of either agent, while the plasma angiotensin II level was significantly inhibited. These results indicate that the inhibition of the ACE activity in blood vessel or kidney correlate well with the antihypertensive activity in 2K-RHR after a single and repeated administration of both ACE inhibitors, but not well with the inhibition of plasma ACE activity.
If the Internet could be used as a method of transmitting ultrasound images taken in the field quickly and effectively, it would bring tertiary consultation to even extremely remote centres. The aim of the study was to evaluate the maximum degree of compression of fetal ultrasound video-recordings that would not compromise signal quality. A digital fetal ultrasound videorecording of 90 s was produced, resulting in a file size of 512 MByte. The file was compressed to 2, 5 and 10 MByte. The recordings were viewed by a panel of four experienced observers who were blinded to the compression ratio used. Using a simple seven-point scoring system, the observers rated the quality of the clip on 17 items. The maximum compression ratio that was considered clinically acceptable was found to be 1:50-1:100. This produced final file sizes of 5-10 MByte, corresponding to a screen size of 320x240 pixels, running at 15 frames/s. This study expands the possibilities for providing tertiary perinatal services to the wider community.
Earrings are very popular jewelry and ear piercing is performed in very young children. Complications that have been reported in the literature are mainly dermatologic, ranging from embedded foreign body to pressure sores in the post-auricular region. During panoramic radiographic evaluation, precise examination of this area can be used to determine the presence of foreign bodies. In this case, a patient referred to our clinic with panoramic film for an impacted third molar who was not aware of an earring clip impacted in her ear lobe is presented.