RESUMEN
BACKGROUND: Although surgical decompression of large hemispheric infarction is often a life-saving procedure, many patients remain functionally dependent. The aims of this study were to identify specific factors that can be used to predict functional outcome, thus establish predictive criteria to reduce poor surgical results. METHOD: In this non-randomized prospective study, we performed decompressive craniectomy in 32 patients (age range, 27 to 77 years) with large hemispheric infarctions. Based on their modified Rankin Score (RS), which was calculated 6 months postoperatively, patients were divided into two functional groups: good (RS 0-3, n = 7) and poor (RS 4-6, n = 25). The characteristics of the two groups were compared using statistical analysis. FINDINGS: One-month mortality was 31%. However, most of the surviving patients were severely disabled (RS 4 or 5), and 6-month total mortality reached 50%. Increased age (> or = 60 years) (P = 0.010), preoperative midline shift greater than 10 mm (P = 0.008), low preoperative Glasgow Coma Score (GCS < or = 7) (P = 0.002), presence of preoperative anisocoria (P = 0.032), early (within the first three days of the stroke) clinical deterioration (P = 0.032), and an internal carotid artery infarct (P = 0.069) were the positive predictors of a poor outcome. INTERPRETATION: We view decompressive craniectomy for space-occupying large hemispheric infarction as a life-sparing procedure that sometimes yields good functional outcomes. A dominant hemispheric infarction should not be an exclusion criterion when deciding to perform this operation. Early operation and careful patient selection based on the above-mentioned factors may improve the functional outcome of surgical management for large hemispheric infarction.
Asunto(s)
Edema Encefálico/cirugía , Infarto Cerebral/complicaciones , Craneotomía , Descompresión Quirúrgica , Adulto , Anciano , Edema Encefálico/etiología , Edema Encefálico/mortalidad , Infarto Cerebral/mortalidad , Infarto Cerebral/patología , Femenino , Estudios de Seguimiento , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Prospectivos , Recuperación de la Función , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
The endogenous activity of the neuroprotective enzyme superoxide dismutase (SOD) and the amount of lipid peroxidation in the early phase of experimental spinal cord injury, together with the effects of N-methyl-D-aspartate (NMDA) antagonist CPP and non-NMDA antagonist NBQX on lipid peroxidation were evaluated. The clip compression model was used for the production of a standardized spinal cord trauma. SOD activity and malondialdehyde (MDA) levels--as an indicator of lipid peroxidation--were determined in the injured segment of the spinal cord 30 and 60 min after injury. SOD activity did not change in this period, whereas MDA levels at 30 and 60 min after trauma were significantly elevated. Intrathecal administration of CPP or NBQX 15 min after injury produced statistically significant reductions in MDA elevation 60 min after injury. NBQX was found to be more effective than CPP. These results demonstrated that intrathecal local application of excitatory amino acid receptor antagonists can protect the spinal cord from secondary damage caused by the generation of lipid peroxides in experimental spinal cord injury.
Asunto(s)
Antagonistas de Aminoácidos Excitadores/farmacología , Peroxidación de Lípido/efectos de los fármacos , Piperazinas/farmacología , Quinoxalinas/farmacología , Traumatismos de la Médula Espinal/metabolismo , Médula Espinal/metabolismo , Superóxido Dismutasa/metabolismo , Animales , Masculino , Malondialdehído/metabolismo , N-Metilaspartato/antagonistas & inhibidores , Ratas , Ratas Sprague-Dawley , Médula Espinal/efectos de los fármacos , Médula Espinal/enzimología , Traumatismos de la Médula Espinal/enzimologíaRESUMEN
Bilateral epidural hematomas are very rare and are associated with high mortality. The purpose of this study is to identify the clinical features, mechanisms, and outcomes of bilateral epidural hematomas. This report considers 19 cases of bilateral epidural hematoma hospitalized between 1987 and 1997. All of the cases, with the exception of three, were diagnosed within the first 6 h. The neurologic evaluations on admission and during hospital stay were based on the Glasgow Coma Scale. Hematomas were determined by CT scans in all cases. The patients were evaluated using the Glasgow Outcome Scale after 6 months. In 13 patients, the bilateral epidural hematoma was in the midline. In six patients, hematomas were at different locations on either side. Surgical approach was chosen as the primary treatment modality in 18 patients. One was treated conservatively. The mortality rate was 15.7% in this series. With the widespread use of CT scan, diagnosis before deterioration of the neurological status affects the results of surgery and prognosis or even presents the possibility of a conservative treatment.
Asunto(s)
Hematoma Epidural Craneal/cirugía , Procedimientos Neuroquirúrgicos , Adolescente , Adulto , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Edema Encefálico/cirugía , Niño , Preescolar , Femenino , Lateralidad Funcional/fisiología , Escala de Coma de Glasgow , Hematoma Epidural Craneal/diagnóstico por imagen , Hematoma Epidural Craneal/etiología , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Turquía , Heridas y Lesiones/complicacionesRESUMEN
N-methyl-D-aspartate (NMDA) receptor antagonists have been found to be protective after cerebral ischemia. However most of these drugs have limited value as neuroprotectives in clinical therapy because of their side effects. Memantine is a noncompetitive NMDA receptor antagonist and it has been used for the treatment of various cerebral disorders with relatively few side effects. We investigated the beneficial effects of Memantine and compared its effect with MK-801 in a temporary focal cerebral ischemia model. As cerebral ischemia model three hours middle cerebral artery occlusion (MCAO) with intraluminal thread and three hours reperfusion was used. 78 male Spraque-Dawley rats were divided into three groups as follows: Control (Saline), treatment 1 (MK-801), and treatment 2 (Memantine) groups. In the treated groups, 15 minutes after MCAO, MK-801 and Memantine were administered in amounts of 1 mg/kg and 10 mg/kg intraperitoneally respectively. After a 3 hour period of reperfusion, the animals were examined for neurological deficits and then killed. The following values were measured; cerebral water content, blood brain barrier (BBB) permeability at the core and periphery of the ischemic hemisphere and contralateral hemisphere and infarct volumes. The severity of neurological deficit (p < 0.001) and infarct volume (p < 0.001) was reduced in both Memantine and MK-801 treated groups compared with saline treated groups. Memantine attenuated brain edema formation and BBB permeability at the periphery (p < 0.01), MK-801 both at the core (p < 0.05) and the periphery (p < 0.01) of the ischemia. These results demonstrated that the NMDA receptor antagonists Memantine and MK-801 were neuroprotective when given 15 min after MCAO in temporary focal cerebral ischemia.
Asunto(s)
Edema Encefálico/prevención & control , Isquemia Encefálica/tratamiento farmacológico , Maleato de Dizocilpina/farmacología , Dopaminérgicos/farmacología , Antagonistas de Aminoácidos Excitadores/farmacología , Memantina/farmacología , Animales , Maleato de Dizocilpina/administración & dosificación , Dopaminérgicos/administración & dosificación , Relación Dosis-Respuesta a Droga , Antagonistas de Aminoácidos Excitadores/administración & dosificación , Infusiones Parenterales , Masculino , Memantina/administración & dosificación , Ratas , Ratas Sprague-DawleyRESUMEN
Free radicals, lipid peroxidation and excitatory amino acids have been implicated in the secondary mechanisms of traumatic brain injury. We used the cold injury model in rats to assess the endogenous activity of the protective enzyme superoxide dismutase (SOD) and the lipid peroxidation level in the contused tissue at an early phase of injury. Furthermore, we treated the rats with two different N-methyl-D-aspartate receptor antagonists, namely MK-801 and CPP, and evaluated their effect on lipid peroxidation in the contused tissue. Rats were divided into four groups: sham, control, treatment 1 and treatment 2 groups (n= 16 for each group). Thirty and 60 min after craniectomy or injury, tissue samples were removed. SOD activity didn't change in this period. However, lipid peroxidation in terms of malondialdehyde (MDA) amount showed a significant increase at 60 min. Fifteen minutes after injury, MK-801 (1 mg/kg), CPP (10 mg/kg) or saline (1 ml) were applied intraperitoneally in treatment 1, treatment 2 and the control groups. Treatment with MK-801 attenuated MDA levels, whereas treatment with CPP did not. The protective effect of MK-801 achieved statistical significance. These results demonstrate that SOD activity does not change in the early period of cold injury. Moreover, these results show that lipid peroxidation increases after 60 min of cold injury, and treatment with MK-801 15 min after injury can prevent this elevation.
Asunto(s)
Conmoción Encefálica/enzimología , Hipotermia/metabolismo , Peroxidación de Lípido/efectos de los fármacos , Receptores de N-Metil-D-Aspartato/antagonistas & inhibidores , Superóxido Dismutasa/metabolismo , Animales , Frío , Modelos Animales de Enfermedad , Maleato de Dizocilpina/farmacología , Antagonistas de Aminoácidos Excitadores/farmacología , Radicales Libres/metabolismo , Hipotermia/tratamiento farmacológico , Masculino , Piperazinas/farmacología , Ratas , Ratas Sprague-DawleyRESUMEN
Cold injury model in rat was used to determine the effect of treatment with the competitive NMDA antagonists CPP and the non-competitive NMDA antagonist MK-801 in cerebral oedema. MK-801 was applied in doses of 1 mg/kg and CPP of 10 mg/kg, 15 min. after injury. Control animals received 1 ml saline at the same time interval after injury. Tissue samples from the core and periphery of the lesion of the injured hemisphere and from the symmetrical location of the undamaged contralateral hemisphere were removed 24 hours after injury. Blood brain barrier permeability, brain water content and tissue specific gravity values were determined. MK-801 was found beneficial for reducing the oedema and restore the blood brain barrier permeability at the penumbral zone of the lesion, whereas both MK-801 and CPP were found ineffective for prevention of oedema accumulation at the core of the lesion.
Asunto(s)
Edema Encefálico/prevención & control , Frío/efectos adversos , Maleato de Dizocilpina/uso terapéutico , Antagonistas de Aminoácidos Excitadores/uso terapéutico , Fármacos Neuroprotectores/uso terapéutico , Piperazinas/uso terapéutico , Análisis de Varianza , Animales , Barrera Hematoencefálica/efectos de los fármacos , Agua Corporal/efectos de los fármacos , Edema Encefálico/etiología , Modelos Animales de Enfermedad , Azul de Evans/farmacocinética , Masculino , Ratas , Ratas Sprague-Dawley , Gravedad EspecíficaRESUMEN
Extraneural scarring is one of the factors negatively influencing the result of peripheral nerve surgery. Many organic materials have been used to prevent fibrosis. The effect of aprotinin on peripheral nerve scarring in rats was investigated in this study. Three types of surgical intervention were carried out; namely external neurolysis (I), abrasive injury (II), and anastomosis (III). The coded samples which consisted of pure collagen fibers soaked with aprotinin or phosphate-buffered saline were applied around the left sciatic nerves of rats whereas only sham operations were performed on the right sciatic nerves. Animals were sacrificed after 4 or 6 weeks. Neurological examination, gross evaluation of extraneural fibrosis, and histological study were undertaken. The results have demonstrated that aprotinin is a promising agent in the prevention of extraneural scarring.
Asunto(s)
Aprotinina/farmacología , Cicatriz/prevención & control , Nervio Tibial/cirugía , Animales , Fibrosis , Masculino , Ratas , Ratas Sprague-Dawley , Valores de Referencia , Nervio Tibial/patología , Nervio Tibial/fisiopatologíaRESUMEN
Modification of a type of end-to-side anastomosis that has been described before is studied. The recipient artery is occluded for only 3-4 minutes to complete the anastomosis by using only the running suture. The anastomotic site was studied by inspection and Scanning Electron Microscope (SEM) at different times after the operation on 30 rats.
Asunto(s)
Anastomosis Quirúrgica/métodos , Arterias Carótidas/cirugía , Revascularización Cerebral/métodos , Técnicas de Sutura , Animales , Arterias Carótidas/patología , Masculino , Microscopía Electrónica de Rastreo , Ratas , Ratas Wistar , Cicatrización de Heridas/fisiologíaRESUMEN
A left-sided L5-S1 lumbar disc herniation operation was performed on a 36-year-old woman in 1987. After a 6-year period, the same patient came back to the clinic with the problem of severe sciatic pain on the same side as before. Upon diagnosis, it was seen that the left S1 radix was compressed with a piece of free autofat graft in the foramen, which was used in the first operation. As far as the writers are informed, this is the first report about a later complication of epidural autofat graft in lumbar spine disc surgery.
Asunto(s)
Tejido Adiposo/trasplante , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Complicaciones Posoperatorias/etiología , Ciática/etiología , Adulto , Femenino , HumanosRESUMEN
We present a case of a 16-year-old boy with an atypical form of spinal tuberculosis, which circumferentially involved two noncontiguous vertebral levels without destruction of the adjacent vertebral bodies and intervertebral discs. The lesions caused paraplegia and loss of sphincter control, and they were confined to a single vertebra at each site; the findings more closely mimicked spinal malignancies. There was no evidence of pulmonary or other extrapulmonary tuberculous disease. The patient was successfully treated both surgically and medically using posterior decompression and a stabilizing procedure in combination with postoperative antituberculous therapy. Magnetic resonance imaging played a major role in determining the extent of the disease and the type of surgical procedure and in monitoring adequate medical treatment.
Asunto(s)
Tuberculosis de la Columna Vertebral/cirugía , Adolescente , Antituberculosos/uso terapéutico , Diagnóstico Diferencial , Quimioterapia Combinada , Humanos , Imagen por Resonancia Magnética , Masculino , Examen Neurológico , Complicaciones Posoperatorias/diagnóstico , Fusión Vertebral , Vértebras Torácicas/patología , Vértebras Torácicas/cirugía , Tomografía Computarizada por Rayos X , Tuberculosis de la Columna Vertebral/diagnóstico , Tuberculosis de la Columna Vertebral/patologíaRESUMEN
Two cases of diastematomyelia are presented and the related literature is reviewed. Diastematomyelia, a complete or incomplete sagittal division of the neural axis into two halves, is usually accompanied by a number of other malformations. One of the cases in this paper appeared to have an epidermoid tumor which is rarely associated with this seldom seen congenital anomaly. Diastematomyelia, which becomes symptomatic in childhood, requires early surgical intervention to relieve the tethering effect on the cord by removal of the splitting pathology which is thought to be the main cause of neurological deterioration in the ensuing years.