Background: Hyperosmolar therapy is the mainstay of treatment to reduce brain bulk and optimize surgical exposure during craniotomy. This study investigated the effect of equiosmolar doses of 7.5% hypertonic saline (HTS) and 20% mannitol on intraoperative cerebral oxygenation and metabolic status, systemic hemodynamics, brain relaxation, markers of cerebral injury, and perioperative craniotomy outcomes.Methods: A total of 51 patients undergoing elective supratentorial craniotomy were randomly assigned to receive 7.5% HTS (2 mL/kg) or 20% mannitol (4.6 mL/kg) at scalp incision. Intraoperative arterial and jugular bulb blood samples were collected at predefined time intervals for assessment of various indices of cerebral oxygenation; multiple hemodynamic variables were concomitantly recorded. S100B protein and neuron-specific enolase levels were determined at baseline, and at 6 and 12 hours after surgery for assessment of neuronal injury. Brain relaxation and perioperative outcomes were also assessed.Results: Demographic and intraoperative data, brain relaxation score, and perioperative outcomes were comparable between groups. Jugular bulb oxygen saturation and partial pressure of oxygen, arterial-jugular oxygen and carbon dioxide differences, and brain oxygen extraction ratio were favorably affected by 7.5% HTS up to 240 minutes postinfusion (P < 0.05), whereas mannitol was associated with only a short-lived (up to 15 min) improvement of these indices (P < 0.05). The changes in cerebral oxygenation corresponded to transient expansion of intravascular volume and improvements of cardiovascular performance. Increases in S100B and neuron-specific enolase levels at 6 and 12 hours after surgery (P < 0.0001) were comparable between groups.
Conclusions:The conclusion is that 7.5% HTS has a more beneficial effect on cerebral oxygenation than an equiosmolar dose of 20% mannitol during supratentorial craniotomy, yet no clearcut clinical superiority of either solution could be demonstrated.
The management of superficial femoral artery occlusive disease remains challenging for vascular surgeons. Despite the advances and dramatic changes we have seen in modern practice with the development and introduction of new endovascular techniques, long-term results with these interventions remain disappointing when compared to the "gold standard" of a vein bypass with a good run-off. Furthermore, there is little Level 1 evidence to guide us with regards to the best treatment strategy. In this article, we review some of the currently available open surgical and endovascular options for the management of superficial femoral artery disease.
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