搜索结果：No shinkei geka. Neurological surgery

BACKGROUND AND PURPOSE: Greater availability and improvement of neuroradiological techniques have resulted in more frequent detection of unruptured aneurysms. Because prognosis of subarachnoid hemorrhage is still poor, preventive surgery is increasingly considered as a therapeutic option. Elective surgery requires reliable data on its risks. Therefore, we performed a meta-analysis on the mortality and morbidity of surgery for unruptured intracranial aneurysms. METHODS: Through Medline and additional searches by hand, we retrieved studies on clipping of unruptured (additional, symptomatic, or incidental) aneurysms published from 1966 through June 1996. Two authors independently extracted data. We used weighted linear regression for data analysis. RESULTS: We included 61 studies that involved 2460 patients (57% female; mean age, 50 years) and at least 2568 unruptured aneurysms (27% >25 mm, 30% located in the posterior circulation). Mortality was 2.6% (95% confidence interval [CI], 2.0% to 3.3%). Permanent morbidity occurred in 10.9% (95% CI, 9.6% to 12.2%) of patients. Postoperative mortality was significantly lower in more recent years for nongiant aneurysms and aneurysms with an anterior location; the last 2 characteristics were also associated with a significantly lower morbidity. CONCLUSIONS: In studies published between 1966 and 1996 on clipping of unruptured aneurysms, mortality was 2.6% and morbidity was 10.9%. In calculating the pros and cons of preventive surgery, these proportions should be taken into account.

Intracranial DAVFs are pathologic dural-based shunts and account for 10%-15% of all intracranial arteriovenous malformations. These malformations derive their arterial supply primarily from meningeal vessels, and the venous drainage is either via dural venous sinuses or through the cortical veins. DAVFs have a reported association with dural sinus thrombosis, venous hypertension, previous craniotomy, and trauma, though many lesions are idiopathic. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging. Cross-sectional imaging techniques by using CT and MR imaging aid in the diagnosis, but conventional angiography remains the most accurate method for complete characterization and classification of DAVFs. The pattern of venous drainage observed on dynamic vascular imaging determines the type of DAVF and correlates with the severity of symptoms and the risk of hemorrhage.

OBJECTIVE The clinical significance of the Simpson system for grading the extent of meningioma resection and its role as a predictor of the recurrence of World Health Organization (WHO) Grade I meningiomas have been questioned in the past, echoing changes in meningioma surgery over the years. The authors reviewed their experience in resecting WHO Grade I meningiomas and assessed the association between extent of resection, as evaluated using the Simpson classification, and recurrence-free survival (RFS) of patients after meningioma surgery. METHODS Clinical and radiological information for patients with WHO Grade I meningiomas who had undergone resective surgery over the past 20 years was retrospectively reviewed. Simpson and Shinshu grading scales were used to evaluate the extent of resection. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional-hazards regression. RESULTS Four hundred fifty-eight patients were eligible for analysis. Overall tumor recurrence rates for Simpson resection Grades I, II, III, and IV were 5%, 22%, 31%, and 35%, respectively. After Cox regression analysis, Simpson Grade I (extensive resection) was revealed as a significant predictor of RFS (p = 0.003). Patients undergoing Simpson Grade I and II resections showed significant improvement in RFS compared with patients undergoing Grade III and IV resections (p = 0.005). Extent of resection had a significant effect on recurrence rates for both skull base (p = 0.047) and convexity (p = 0.012) meningiomas. Female sex and a Karnofsky Performance Scale score > 70 were also identified as independent predictors of RFS after resection of WHO Grade I meningioma. CONCLUSIONS In this patient cohort, a significant association was noted between extent of resection and rates of tumor recurrence. In the authors' experience the Simpson grading system maintains its relevance and prognostic value and can serve an important role for patient education. Even though complete tumor resection is the goal, surgery should be tailored to each patient according to the risks and surgical morbidity.

OBJECTIVE: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. METHODS: A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty. RESULTS: 48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation). CONCLUSIONS: The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.

OBJECTIVE: To review the use of transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography (TCCS) for diagnosis. METHODS: The authors searched the literature for evidence of 1) if TCD provides useful information in specific clinical settings; 2) if using this information improves clinical decision making, as reflected by improved patient outcomes; and 3) if TCD is preferable to other diagnostic tests in these clinical situations. RESULTS: TCD is of established value in the screening of children aged 2 to 16 years with sickle cell disease for stroke risk (Type A, Class I) and the detection and monitoring of angiographic vasospasm after spontaneous subarachnoid hemorrhage (Type A, Class I to II). TCD and TCCS provide important information and may have value for detection of intracranial steno-occlusive disease (Type B, Class II to III), vasomotor reactivity testing (Type B, Class II to III), detection of cerebral circulatory arrest/brain death (Type A, Class II), monitoring carotid endarterectomy (Type B, Class II to III), monitoring cerebral thrombolysis (Type B, Class II to III), and monitoring coronary artery bypass graft operations (Type B to C, Class II to III). Contrast-enhanced TCD/TCCS can also provide useful information in right-to-left cardiac/extracardiac shunts (Type A, Class II), intracranial occlusive disease (Type B, Class II to IV), and hemorrhagic cerebrovascular disease (Type B, Class II to IV), although other techniques may be preferable in these settings.

This study aimed to determine the accuracy of the quick Sequential Organ Failure Assessment (qSOFA) score in predicting mortality among prehospital patients with and without infection. This single-center, retrospective, cross-sectional study was conducted among patients who arrived via the emergency medical services (EMS). We calculated the qSOFA score and Modified Early Warning Score (MEWS) from prehospital records. We identified patients as infected if they received intravenous antibiotics at the emergency department or within the first 24 hours. Receiver operating characteristic analysis was used to evaluate and compare the performance of the qSOFA score, each physiological parameter, and the MEWS in predicting admission and in-hospital mortality in patients with and without infection. Multivariate analysis was used to evaluate the qSOFA score and other risk factors. Out of 1574 prehospital patients, 47.1% were admitted and 3.2% died in the hospital. The performance of the qSOFA score in predicting in-hospital mortality in noninfected patients was 0.70, higher than for each parameter and the MEWS. The areas under the curve for the qSOFA+ model vs. the qSOFA- model was 0.77 vs. 0.68 for noninfected patients (p <0.05) and 0.71 vs. 0.68 for infected patients (p = 0.41). The likelihood ratio test comparing the qSOFA- and qSOFA+ groups demonstrated significant improvement for noninfected patients (p <0.01). Multivariate regression analysis for in-hospital mortality demonstrated that the qSOFA score is an independent prognosticator for in-hospital mortality, especially among noninfected patients (odds ratio, 3.60; p <0.01). In conclusion, the prehospital qSOFA score was associated with in-hospital mortality in noninfected patients and may be a beneficial tool for identifying deteriorating patients in the prehospital setting.

Among the various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. After the publication of the first edition of the Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus in 2004 (the English version was published in 2008), clinical awareness of iNPH has risen dramatically, and the number of shunt surgeries has increased rapidly across Japan. Clinical and basic research on iNPH has increased significantly, and more high-level evidence has since been generated. The second edition of the Japanese Guidelines was thus published in July 2011, to provide a series of timely evidence-based recommendations related to iNPH. The revision of the Guidelines has been undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project on "Studies on the epidemiology, pathophysiology, and treatment of normal pressure hydrocephalus." This English version of the second edition of the Guidelines was made to share these ideas with the international community and to promote international research on iNPH.

BACKGROUND AND OBJECTIVE: The prevalence and mortality of chronic obstructive pulmonary disease (COPD) in elderly patients are increasing worldwide. Low body mass index (BMI) is a well-known prognostic factor for COPD. However, the obesity paradox in elderly patients with COPD has not been well elucidated. We investigated the association between BMI and in-hospital mortality in elderly COPD patients. METHODS: Using the Diagnosis Procedure Combination database in Japan, we retrospectively collected data for elderly patients (>65 years) with COPD who were hospitalized between July 2010 and March 2013. We performed multivariable logistic regression analysis to compare all-cause in-hospital mortality between patients with BMI of <18.5 kg/m2 (underweight), 18.5-22.9 kg/m2 (low-normal weight), 23.0-24.9 kg/m2 (high-normal weight), 25.0-29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obesity) with adjustment for patient backgrounds. RESULTS: In all, 263,940 eligible patients were identified. In-hospital mortality was 14.3%, 7.3%, 4.9%, 4.3%, and 4.4%, respectively, in underweight, low-normal weight, high-normal weight, overweight, and obese patients. Underweight patients had a significantly higher mortality than low-normal weight patients (odds ratio [OR]: 1.55, 95% confidence interval [CI]: 1.48-1.63), whereas lower mortality was associated with high-normal weight (OR: 0.76, CI: 0.70-0.82), overweight (OR: 0.73, CI: 0.66-0.80), and obesity (OR: 0.67, CI: 0.52-0.86). Higher mortality was significantly associated with older age, male sex, more severe dyspnea, lower level of consciousness, and lower activities of daily living. CONCLUSION: Overweight and obese patients had a lower mortality than low-normal weight patients, which supports the obesity paradox.

Goreisan is a herbal Kampo medicine used for treating chronic subdural hematoma (CSDH) in Japan. Experimental studies have suggested that Goreisan exerts a hydrogogue effect, but clinical evidence for the effectiveness of Goreisan in CSDH is currently lacking. Using a national Japanese inpatient database, we examined the association between Goreisan use and reoperation rates after burr-hole surgery for CSDH. We identified 36,020 patients, including 3,889 Goreisan users and 32,131 nonusers. Propensity scores of receiving Goreisan were calculated based on hospital characteristics and patient backgrounds (age, sex, body mass index, activities of daily living, consciousness level, comorbidities, antithrombotic agent use, mannitol infusion, and corticosteroid infusion). One-to-one propensity-score matching created 3,879 pairs of Goreisan users and nonusers. Propensity-matched analysis revealed that Goreisan use was significantly associated with a lower reoperation rate (4.8%) compared with nonuse (6.2%) (risk difference, -1.4%; 95% confidence interval (CI), -2.4% to -0.38%). The number needed to prevent one reoperation was 72 (95% CI, 41-265). Instrumental-variable analysis showed similar results to the propensity-matched analysis. These results suggest that Goreisan use reduced the need for reoperation after burr-hole surgery for CSDH.

Importance: Chronic subdural hematoma (CSDH) is a trauma-associated condition commonly found in elderly patients. Surgery is currently the treatment of choice, but it carries a significant risk of recurrence and death. Nonsurgical treatments remain limited and ineffective. Our recent studies suggest that atorvastatin reduces hematomas and improves the clinical outcomes of patients with CSDH. Objective: To investigate the safety and therapeutic efficacy of atorvastatin to nonsurgically treat patients with CSDH. Design, Setting, and Participants: The Effect of Atorvastatin on Chronic Subdural Hematoma (ATOCH) randomized, placebo-controlled, double-blind phase II clinical trial was conducted in multiple centers in China from February 2014 to November 2015. For this trial, we approached 254 patients with CSDH who received a diagnosis via a computed tomography scan; of these, 200 (78.7%) were enrolled because 23 patients (9.1%) refused to participate and 31 (12.2%) were disqualified. Interventions: Patients were randomly assigned to receive either 20 mg of atorvastatin or placebo daily for 8 weeks and were followed up for an additional 16 weeks. Main Outcomes and Measures: The primary outcome was change in hematoma volume (HV) by computed tomography after 8 weeks of treatment. The secondary outcomes included HV measured at the 4th, 12th, and 24th weeks and neurological function that was evaluated using the Markwalder grading scale/Glasgow Coma Scale and the Barthel Index at the 8th week. Results: One hundred ninety-six patients received treatment (169 men [86.2%]; median [SD] age, 63.6 [14.2] years). The baseline HV and clinical presentations were similar between patients who were taking atorvastatin (98 [50%]) and the placebo (98 [50%]). After 8 weeks, the HV reduction in patients who were taking atorvastatin was 12.55 mL more than those taking the placebo (95% CI, 0.9-23.9 mL; P = .003). Forty-five patients (45.9%) who were taking atorvastatin significantly improved their neurological function, but only 28 (28.6%) who were taking the placebo did, resulting in an adjusted odds ratio of 1.957 for clinical improvements (95% CI, 1.07-3.58; P = .03). Eleven patients (11.2%) who were taking atorvastatin and 23 (23.5%) who were taking the placebo underwent surgery during the trial for an enlarging hematoma and/or a deteriorating clinical condition (hazard ratio, 0.47; 95% CI, 0.24-0.92; P = .03). No significant adverse events were reported. Conclusions and Relevance: Atorvastatin may be a safe and efficacious nonsurgical alternative for treating patients with CSDH. Trial Registration: ClinicalTrials.gov Identifier: NCT02024373.

Our aim is to study the varied posterior segment manifestations, level of visual impairment (VI) and its causes in carotid cavernous fistula (CCF) patients. A retrospective study was done, wherein data was obtained from 48 digital subtraction angiogram (DSA) proven CCF patients. CCF was classified according to Barrow et al., based on DSA into type A (high flow) and types B, C and D (low flow). High flow CCF was present in 8 (16.7%) and low flow CCF was present in 42 (83.3%). Compared to low flow group, patients in high flow group were younger and had a history of trauma (p < 0.05). Posterior segment findings ranged from familiar stasis retinopathy and optic neuropathy (both, glaucomatous and ischemic) to uncommon findings of central retinal artery occlusion, Terson syndrome and combined retinal and choroidal detachment. Retinal vein dilatation was the most common finding in both groups. The high flow CCF group had 6 (75%) patients that had VI. This was acute in 4 (50%) patients and delayed in 2 (25%). In the low flow group 10 (23.8%) of patients had delayed VI. The identification of "3 point sign" is a novel finding of this study, not described before. While none of three findings (disc hyperaemia, retinal vein dilatation and intra-retinal haemorrhage) in isolation were predictive of visual loss, but when present together results in visual loss. Posterior segment changes were varied, some are uncommon and can occur in various combinations. "3 point sign" must be identified at the earliest to prevent visual impairment. The incidence of VI in CCF patients is high.

Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

A 39-year-old man presented to our hospital with a four-week history of headache and a two-week history of low-grade fever. Chest X-rays showed a tumor of approximately 50 mm in size in the right lower field. A histopathological examination of a transbronchial lung biopsy specimen from the right S9/10 revealed numerous fungal elements that appeared as encapsulated yeast with clear halos. Gadolinium-enhanced brain magnetic resonance images showed multiple cerebral nodules. Cryptococcus gattii (Genotype VGIIa) was isolated from the bronchial lavage and cerebrospinal fluid specimens. The patient was an immunocompetent Japanese man who had not recently traveled to a C. gattii-endemic area.

The chick embryo chorioallantoic membrane (CAM) is a highly vascularized extraembryonic membrane. Because of its ease of accessibility, extensive vascularization and immunodeficient environment, the CAM has been broadly used in the oncology, biology, pharmacy, and tissue regeneration research. The present review summarizes the application of the CAM in neurosurgery disease research. We focused on the use of the CAM as an assay for the research of glioma, vascular anomalies, Moyamoya Disease, and the blood-brain barrier.

The factors affecting outcome were analyzed in 1,064 patients, 621 males and 443 females aged 10 to 104 years (mean 46 +/- 23 years), with mild head injury (Glasgow Coma Scale [GCS] score > or =14) but no neurological signs presenting within 6 hours after injury. Intracranial lesion was found in 4.7% (50/1,064), and 0.66% (7/1,064) required surgical treatment. The Japan Coma Scale (JCS) and GCS assessments were well correlated (r = 0.797). Multivariate analysis revealed significant correlations between computed tomography (CT) abnormality and age > or =60 years, male sex, JCS score > or =1, alcohol consumption, headache, nausea/vomiting, and transient loss of consciousness (LOC)/amnesia. Univariate analysis revealed that pedestrian in a motor vehicle accident, falling from height, and mechanisms of injuries except blows were correlated to intracranial injury. No significant correlations were found between craniofacial soft tissue injury and intracranial injury. Patients with occipital impact, nonfrontal impact, or skull fracture were more likely have intracranial lesions. Bleeding tendency was not correlated with CT abnormality. The following indications were proposed for CT: JCS score >0, presence of accessory symptoms (headache, nausea/vomiting, LOC/amnesia), and age > or =60 years. These criteria would reduce the frequency of CT by 29% (309/1,064). Applying these indications to subsequent patients with GCS scores 14-15, 114 of 168 patients required CT, and intracranial lesions were found in 13. Two refused CT. Fifty-four of the 168 patients did not need CT according to the indications, but 38 of the 54 patients actually underwent CT because of social reasons (n = 21) or patient request (n = 17). These indications for CT including JCS may be useful in the management of patients with mild head injury.

Brainstem hemorrhage is presumed to be invariably associated with a poor prognosis in people with spontaneous hypertensive cerebral hemorrhage. The optimal timing of tracheostomy placement in brainstem hemorrhage patients, who generally require endotracheal intubation for airway protection, remains uncertain. Our research aim was to analyze the impact of early tracheostomy versus late tracheostomy on brainstem hemorrhage patients related outcomes and prognostic factors at 30 days. We identified early tracheostomy and how it could benefit the patients with brainstem hemorrhage and ameliorate the predictors of functional recovery at 30 days. Data on 136 patients with brainstem hemorrhage and Glasgow Coma Scale score ≤ 8, were retrospectively collected from 2012 to 2019. Patients were divided into the early tracheostomy group and the late tracheostomy group. Patients in the early tracheostomy group had a significantly lower neurosurgical intensive care unit stay (both overall and survival) compared with the late tracheostomy group (15.6 days vs. 19.0 days, P = 0.041, overall and 14.5 vs. 19.5 days, P = 0.023, survival). Also, the good outcomes (modified Rankin Score ≤ 3) were higher in the early tracheostomy group (P = 0.036). Multivariate analysis demonstrated that less hemorrhagic volume, high Glasgow Coma Scale score on admission, young age, and early tracheostomy were significantly associated with a better 30-day functional outcome. In conclusion, an early tracheostomy in patients with brainstem hemorrhage can reduce neurosurgical intensive care unit stay, and in addition to improvements in prognosis at 30 days.

The combination of pituitary adenomas (PA) and phaeochromocytomas (phaeo) or paragangliomas (PGL) is a rare event. Although these endocrine tumours may occur together by coincidence, there is mounting evidence that, in at least some cases, classical phaeo/PGL-predisposing genes may also play a role in pituitary tumorigenesis. A new condition that we termed '3Pas' for the association of PA with phaeo and/or PGL was recently described in patients with succinate dehydrogenase mutations and PAs. It should also be noted that the classical tumour suppressor gene, MEN1 that is the archetype of the PA-predisposing genes, is also rarely associated with phaeos in both mice and humans with MEN1 defects. In this report, we review the data leading to the discovery of 3PAs, other associations linking PAs with phaeos and/or PGLs, and the corresponding clinical and molecular genetics.

Cutaneous microvasculopathy complicates wound healing. Functional assessment of gated individual dermal microvessels is therefore of outstanding interest. Functional performance of laser speckle contrast imaging (LSCI) systems is compromised by motion artefacts. To address such weakness, post-processing of stacked images is reported. We report the first post-processing of binary raw data from a high-resolution LSCI camera. Sharp images of low-flowing microvessels were enabled by introducing inverse variance in conjunction with speckle contrast in Matlab-based program code. Extended moving window averaging enhanced signal-to-noise ratio. Functional quantitative study of blood flow kinetics was performed on single gated microvessels using a free hand tool. Based on detection of flow in low-flow microvessels, a new sharp contrast image was derived. Thus, this work presents the first distinct image with quantitative microperfusion data from gated human foot microvasculature. This versatile platform is applicable to study a wide range of tissue systems including fine vascular network in murine brain without craniotomy as well as that in the murine dorsal skin. Importantly, the algorithm reported herein is hardware agnostic and is capable of post-processing binary raw data from any camera source to improve the sensitivity of functional flow data above and beyond standard limits of the optical system.

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