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Professor, Joan C. Edwards School of Medicine at Marshall University
The limits of tumor resection were extended gastritis diet áèëàéí buy biaxin with amex, and improvements in outcome followed chronic gastritis histology discount biaxin line. Our experience at the University of Virginia with 50 patients showed disease-free survival rates of 86 gastritis diet òàíêè quality 500 mg biaxin. However gastritis diet à10 buy biaxin 250 mg low price, published reports have demonstrated success with radiosurgical treatment of recurrent or residual disease. Radiosurgery may be complicated by the difficulty of determining an accurate target in the setting of postoperative changes, including extensive packing for cranial base reconstruction. In addition, doses may be limited by the proximity of the target volume to the optic nerves and chiasm. When postoperative radiosurgery is anticipated, clearance of tumor from the area near the optic apparatus should be attempted to aid planning of the radiosurgical dose. In most cases, moderate frontal lobe elevation without the use of retractors provides adequate exposure to perform osteotomies as far posteriorly as the tuberculum sellae. Avoiding rigid fixation allows small movements of the head, which aid visualization during the transfacial portion of the operation. General anesthesia with controlled ventilation is maintained through the use of an orotracheal tube. Appropriate intravenous lines and an intra-arterial line are placed, but we do not generally use central venous access. Broad antibiotic coverage is provided with nafcillin and ceftriaxone preoperatively and continued postoperatively until the nasal packing is removed, usually between 7 and 10 days. The lesion was treated by Gamma Knife radiosurgery with a marginal dose of 18 Gy at the 50% isodose curve. The tumor volume (red curve) is encircled in the 18-Gy isodose curve (yellow curve). The abdomen and lateral aspect of the thigh are prepared for grafting of skin, fat, and fascia. The transcranial portion of the procedure is accomplished through a bicoronal incision. The scalp and galea are initially reflected inferiorly to the level of the orbital rims while leaving the pericranium intact. The pericranial flap is based inferiorly along the brow line, and the posterior part of the scalp incision can be undermined to provide a larger pericranial flap if a large anterior fossa floor defect is anticipated. The inferior portion of the flap involves the frontal sinus, and there are several methods to enter and address the frontal sinus during this portion of the exposure. When the frontal sinus is small, a bur hole may be placed at the glabella to provide entry into the sinus; this site is then covered with a bur hole microplate at closure for cosmesis. In patients with more pneumatized frontal sinuses, a preoperative 6-ft Caldwell skull film can be used to create a cutout template of the frontal sinus. The template is sterilized and placed in position, and the edge of the sinus is traced. Another alternative involves using the nonfootplate drill guard and a pediatric side-cutting craniotomy bit to drill through the anterior wall of the sinus and then elevate the frontal bone flap and "crack" the posterior wall of the sinus. A more recent alternative is the use of a frameless image guidance system to delineate the extent of the frontal sinus. The anterior wall of the frontal sinus is next removed to provide entry into the sinus, and the mucosa of the frontal sinus is exenterated. The dura is exposed with the use of a drill and a rongeur to remove the posterior wall of the sinus. In a patient with a well-pneumatized sinus and no appreciable intracranial extension of tumor, the frontal sinus itself provides adequate exposure. If additional exposure is necessary, a single bur hole is placed on the midline of the frontal bone and a craniotomy tt h s p a /k:/. The dura over the medial orbital roof and midline is elevated, and the crista galli is removed. Next, the dural coverings of the olfactory fibers are identified as they pass through the cribriform plate and sharply divided as close to the cribriform as possible. When the last of these coverings is divided, epidural dissection can be continued posteriorly as far as necessary. After verifying hemostasis of the intracranial ends of the cut fibers, the dura is closed primarily with a watertight continuous stitch. If the tumor has extended through the dura, the intracranial portion of the tumor and involved dura are removed. A number of dural graft options are available to assist in closure by suturing the graft to the remaining dural edge in watertight fashion to close such a defect. Osteotomies of the skull base must be carefully planned so that they extend beyond the edges of the tumor. Some consideration of the portion of the tumor below the skull base must be made so that the osteotomies extend beyond the margin of the tumor and radical resection of the neoplasm can be accomplished. The inferior dura is covered by cottonoid patties to aid identification by the otolaryngologist during the transfacial portion of the procedure. The otolaryngologic portion of the procedure is usually accomplished through a lateral rhinotomy incision beginning within the eyebrow and extending down halfway between the nasal dorsum and the nasomaxillary groove. The pericranial flap may be based along the brow line or laterally along the temporalis muscle.
It is especially important to identify the cause of chronic pain of nonmalignant origin in order to reduce the likelihood of significant underlying or primary psychological dysfunction gastritis chronic fatigue cheap biaxin 500 mg with mastercard. Psychological dysfunction can be common in patients with chronic pain disorders and might preclude a good outcome to surgical treatment gastritis journal pdf generic biaxin 500mg without prescription. Thus gastritis medication buy biaxin from india, a formal psychological evaluation might be appropriate for many (or most) patients being considered for surgical treatment of intractable pain xango gastritis purchase biaxin 500mg visa. Contraindications to surgical intervention include overt psychological dysfunction, such as active psychosis, suicidal or homicidal behavior, major uncontrolled depression or anxiety, serious alcohol or drug abuse, or serious cognitive deficits. Other psychological problems, which may be viewed as "risk factors," include somatization disorder, personality disorders. Patients with psychological risk factors are not necessarily precluded from surgical treatment, but the treatment program should address the psychological issues to facilitate a good outcome. Specific interventions vary in their appropriateness as a treatment for pain in specific body regions (Tables 164-2 through 164-5). The relative advantages and disadvantages of anatomic, augmentative, and ablative therapies should be weighed in view of these factors, and a choice among these three general approaches should be made before choosing a specific intervention. Selecting the right treatment for the right patient at the right time increases the likelihood of a successful outcome. These neuromodulation therapies have largely replaced ablative techniques as procedures of choice for pain management and are generally preferred as initial surgical treatments because of their relative safety and reversibility and the availability of a specific prognostic trial. Ablative therapies, however, have a role in the treatment of certain pain syndromes12,13 and can target almost every level of the peripheral and central nervous systems. Ascending nociceptive pathways can be disrupted at the level of the spinal cord or brainstem (cordotomy, myelotomy, tractotomy) or within the brain (thalamotomy, cingulotomy). Augmentative and ablative therapies are reviewed briefly here to provide a broad perspective about the applications of neurosurgical pain therapies. A detailed discussion of indications, techniques, and outcomes of many of these techniques is available in other chapters. AugmentativeTherapies Augmentative therapies offer the advantages of relative safety, reversibility, and "adjustability. Augmentative therapies cost more (initial device cost and upkeep) than ablative therapies, require maintenance. In addition, (especially for treatment of cancer pain), estimated patient life expectancy should be sufficient to warrant implantation of a neuroaugmentative device. Continuous neuropathic pain responds most consistently to paresthesia-producing stimulation of the sensory thalamus (nucleus ventrocaudalis). Patients might also be given a morphine-naloxone test to clarify the extent of nociceptive and neuropathic pain components and facilitate selection of the best stimulation target. Of those who receive a permanent stimulation system, about 25% to 80% (generally 50% to 60%)29 will gain acceptable long-term pain relief. Neuraxial drug infusion has become a popular interventional treatment for intractable pain,39-44 especially for pain with a significant nociceptive component. Thus, the use of intrathecal analgesics for the treatment of cancer pain is well accepted. In contrast, the use of this therapy for chronic nonmalignant pain has been controversial,44 reflecting concern that neuropathic pain (common in chronic nonmalignant pain syndromes) does not respond adequately to opioids and that the efficacy and costeffectiveness of neuraxial drug infusion for neuropathic pain have not been determined in controlled trials. The key advantage of neuraxial analgesic administration is its versatility, which allows it to be applied to a wide range of indications, including nociceptive and mixed nociceptive-neuropathic pain syndromes. Neuraxial analgesia is commonly used to treat pain below cervical levels but can be effective for head and neck pain, especially if analgesic agents are delivered intraventricularly. Significant disadvantages of neuraxial analgesics include the high cost of the device and medication and the need for maintenance. About 60% to 80% of patients with neuraxial analgesics achieve good long-term relief of pain, and, despite the controversy about the use of neuraxial analgesics for noncancer pain, outcomes are similar (degree of pain relief, patient satisfaction, and dose requirements) in patients with cancer and noncancer pain. AblativeTherapies Augmentative pain therapies are becoming increasingly common, but ablative therapies maintain a role in the treatment of intractable pain. Ablative therapies are often placed on the top and final rung on the pain treatment ladder. For example, a patient with cancer pain who has a short life expectancy might be treated more appropriately with cordotomy than with an implanted intrathecal analgesic infusion system. In such cases, as in every case, pain therapy must be tailored to meet the needs of individual patients. Ablative therapies include peripheral techniques that interrupt or alter nociceptive input into the spinal cord. As with augmentative techniques, a successful outcome requires appropriate patient and intervention selection. Sympathectomy, however, has fallen into disfavor as a treatment for intractable pain of nonmalignant origin because of inconsistent results and concerns about complication rates. If an identifiable neuroma is the cause of pain, its resection can provide significant relief. The utility of neurectomy is limited because pain arising from a pure sensory nerve is uncommon, and mixed sensorymotor nerves cannot be sectioned without risking functional impairment. Some specific exceptions to this general observation exist, however; for example, section of the lateral femoral cutaneous nerve might provide long-lasting relief of meralgia paresthetica,54 and section of the ilioinguinal or genitofemoral nerves might relieve some inguinal pain syndromes. In contrast, ganglionectomy effectively eliminates input from ventral root afferent fibers by removing their cell bodies, which are located within the dorsal root ganglion. Rhizotomy and ganglionectomy can be used to treat pain in the neck, trunk, or abdomen. Neither procedure is useful for the treatment of pain in the extremities unless function of the extremity is already lost because denervation removes proprioceptive as well as nociceptive input and produces a functionless limb. Limited denervation does not provide adequate pain relief, probably because of overlap of segmental innervation of dermatomes. These procedures are most appropriate for the treatment of cancer pain; noncancer pain does not improve consistently on a long-term basis,59,60 although ganglionectomy might be useful for relief of occipital neuralgia.
Results from early series demonstrated a remarkably high mortality rate gastritis diet êèâè cheap biaxin 250mg with visa, with Borchardt reporting an operative mortality of 72%; Eiselberg gastritis gi bleed generic biaxin 500 mg on line, 74%; and Krause gastritis antibiotics discount biaxin online mastercard, 84% gastritis diet öööþïùùïäóþñùü purchase genuine biaxin online. Cushing was the most influential in ushering in a new era of acoustic surgery with significantly improved survival. In the early 20th century, Cushing refined surgical technique to reduce mortality significantly from higher than 50% to approximately 11%. Compilations of surgeons infrequently performing the surgery demonstrated a 31% mortality rate. Although the history of stereotactic radiosurgery is shorter, there has been significant advances in dose adjustment, conformal planning, and planning software. However, understanding the overall incidence of acoustic neuromas and their growth rate is important in determining treatment options. Asymptomatic, slow-growing tumors with no neurological deficit can often be monitored clinically and with serial radiographic studies for signs of progression. The proximity of acoustic neuromas to the brainstem raises concern that continued growth could lead to brainstem compression. Increased tumor size complicates tumor resection and can limit the chance of hearing preservation. The increased sensitivity of current imaging modalities allows physicians to detect tumors at smaller sizes and also brings up the dilemma of what to do with small tumors in asymptomatic or mildly symptomatic patients. The expected rate of growth plays an important role in determining whether observation will suffice or a surgical intervention is indicated. Including only published series with at least 50 patients, the proportion of tumors that demonstrate growth ranges from 30% to 85% (Table 133-1). Stangerup and colleagues, in a large series of 522 patients with a mean observation time of 3. Acoustic neuromas in these patients occur at a younger age and may have a more unpredictable growth rate with more rapid growth the younger the patient at the time of diagnosis. Obviously, the loss of bilateral serviceable hearing is a more debilitating neurological deficit than unilateral hearing loss. Cystic acoustic tumors are believed by some to have a more aggressive course with more rapid neurological deterioration. The exact composition of the tumor varies, but the tissue is often composed of yellow and gray areas with interspersed foci of hemorrhage and cyst. Acoustic neuromas are encapsulated tumors, and the nerve of origin can be splayed thinly over the tumor, which makes it somewhat difficult to determine the site of origin. The extent of cerebellopontine spread is variable, but it is the meatal origin that gives acoustic neuromas their "ice-cream cone" shape. In recent surgical studies, the most common origin has been from the inferior vestibular nerve, followed by the superior vestibular nerve. Patients may have vestibular symptoms and complain of progressive imbalance or dizziness. Neurological examination may demonstrate evidence of vestibular dysfunction such as gait ataxia, nystagmus, and a positive Romberg sign. Headaches, facial paresthesia, and facial weakness or fasciculation are currently uncommon initial manifestations of acoustic neuromas. We have never saved hearing in a patient with a latency greater than 2 msec in comparison to the normal ear. Therightsidehasspindle-shapedcellswithrod-shapednucleiand dense reticulin arranged in fascicles consistent with Antoni A areas. Classically, the microscopic appearance consists of two main histologic patterns: Antoni A and Antoni B. Antoni A areas contain spindle-shaped cells with rod-shaped nuclei and dense reticulin arranged in compact intertwining fascicles. Antoni B areas have stellate or spindled-shaped cells with smaller and more hyperchromatic nuclei, less reticulin, prominent cytoplasmic processes, and a loose myxoid stroma. Foamy histiocytes may be observed and are responsible for the bright yellow color associated with the tumor. Immunohistochemical studies, although not routinely necessary, can be helpful in distinguishing a meningioma from a schwannoma in select cases. Although S-100 can be positive in meningiomas, it is generally focal and cytoplasmic. Merlin has been identified as a putative tumor suppressor, and increased understanding of related molecular mechanisms has recently identified potential targets for the development of pharmacotherapy, such as ErbB and Nrg. Tumors can have variable enhancement patterns: homogeneous (50% to 60%), heterogeneous (30% to 40%), or cystic (5% to 15%). Homogeneous small tumors are composed predominantly of the Antoni A type, whereas larger, more heterogeneous tumors have mixed Antoni A and Antoni B types or only the Antoni B type. However, imaging never replaces the need for intraoperative observation and neurophysiologic monitoring because the facial nerve is often intimate with the tumor capsule. Although there is significant variability in the initial clinical findings, the most common initial symptom is asymmetric hearing loss. Patients can ultimately decide to be managed by observation until growth is observed or new clinical findings occur, or they may choose surgery or radiation therapy. Observation is an acceptable option for many patients with small or medium-sized tumors, particularly in elderly patients.
As new technology becomes available gastritis diet åëüäîðàäî biaxin 250 mg for sale, the contribution to outcome of poorly characterized physiologic variables such as cerebral blood flow autoregulation will be better understood gastritis h pylori generic 500 mg biaxin visa. New strategies to optimize patient management will pave the way for future clinical trials of pharmacologic neuroprotective and rehabilitative interventions gastritis test buy cheap biaxin 250mg on line. Treatment of refractory status epilepticus: literature review and a proposed protocol gastritis symptoms in tamil buy 250mg biaxin with visa. Cerebrovascular response in infants and young children following severe traumatic brain injury: a preliminary report. Incidence of hypo- and hypercarbia in severe traumatic brain injury before and after 2003 pediatric guidelines. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Risk of recurrent childhood arterial ischemic stroke in a population-based cohort: the importance of cerebrovascular imaging. Nonconvulsive seizures: developing a rational approach to the diagnosis and management in the critically ill population. Cerebral salt wasting syndrome in children with acute central nervous system injury. Perioperative fluid and electrolyte management in children undergoing surgery for craniopharyngioma. Hyponatremia in the postoperative craniofacial pediatric patient population: a connection to cerebral salt wasting syndrome and management of the disorder. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Variability in pediatric brain death determination and documentation in southern California. Abnormal regulation of thirst and vasopressin secretion following surgery for craniopharyngioma. PeriodsfortheDiagnosisofBrainDeath 7 days to 2 months: Two examinations separated by 48 hr 2 mo to 1 yr: Two examinations separated by 24 hr >1 yr: An observation period of 12 hr is recommended. Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. Stroke in childhood: Clinical guidelines for diagnosis, management and rehabilitation. Multimodal monitoring in traumatic brain injury: current status and future directions. Encephalopathy and cerebral edema in the setting of acute liver failure: pathogenesis and management. Partington A working knowledge of normal embryology, as well as an appreciation of the ways in which normal development might go awry, is helpful for the neurosurgeon to appreciate both the demographics and the surgical anatomy of these malformations. Although the usual classification schemes tend to "lump" all congenital craniospinal malformations into simple classification schemes such as "open" versus "closed," such schemes have done little to foster our understanding of either the nature of the malformations or their embryogenesis. For example, confusion about early nervous system development has led to the erroneous use of such designations as "closed myelomeningocele" to refer to a skin-covered myelocystocele. Misuse of these terms results in both improper identification and poor understanding of the anatomy of both malformations. A working knowledge of normal embryology leads to better understanding that a myelomeningocele, arising from localized failure of primary neurulation, produces a placode connected at its edges to the adjacent cutaneous ectoderm and therefore, by definition, forms an open malformation. In contrast, a terminal myelocystocele, probably arising from a localized disorder of secondary neurulation, a process occurring beneath a layer of intact cutaneous ectoderm, would therefore form a closed malformation. It is increasingly becoming apparent that although congenital brain and spinal cord malformations share some common clinical features, the morphology, epidemiology, and natural history of these disorders suggest a diverse and heterogeneous embryologic origin. We review the normal embryology of the nervous system, as well as the presumed embryonic mechanisms that have been proposed to give rise to various neural tube malformations, with the intent of providing a mechanistic embryonic framework on which to hang these various disorders. At the outset, it is important to understand that most of the embryologic mechanisms proposed for congenital craniospinal malformations are putative; that is, there is no absolute proof that they are the cause of a particular human malformation, and there are few adequate animal models to test our hypotheses about the origin of human malformations. However, we can gain considerable insight into the embryopathology of congenital malformations through the study of normal neural development. Because this chapter reviews only cranial malformations, it does not include discussions specific to spinal cord development or to congenital spinal cord malformations; interested readers are referred elsewhere for this information. The blastocyst later forms a two-layered structure with a dorsal layer, the epiblast, adjacent to the amnionic cavity and a ventral layer, the hypoblast, adjacent to the yolk sac. All three germ layers, ectoderm, mesoderm, and endoderm, are derived from the epiblast. Gastrulation transforms the embryo from a two-layered structure to a threelayered structure. A, Continued proliferation of cells produces a sphere containing a blastocystic cavity surrounded by an eccentrically located inner cell mass and a surrounding ring of trophoblast cells. B, the inner cell mass develops further into a two-layered structure, the blastodisc, which contains the epiblast adjacent to the amnionic cavity and the hypoblast adjacent to the yolk sac. C, With further development, the blastodisc thickens cranially to form the prochordal plate. A, Prospective endodermal and mesodermal cells of the epiblast migrate toward the primitive streak and ingress (arrows) through the primitive groove to become the definitive endoderm and mesoderm. The striped region illustrates localization by earlier mapping studies that used carbon particles; the hatched area illustrates additional caudal areas demonstrated by more recent mapping studies using horseradish peroxidase injections and chimeric transplantation.
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