Direct therapeutic drainage and intracranial pressure monitoring from the posterior fossa has never been accepted in neurosurgical practice. Potential complications including cerebrospinal fluid leak, cranial nerve palsies, and brain-stem irritation have been a major deterrent. The authors placed a catheter for pressure monitoring in the posterior fossa of 20 patients in the course of posterior fossa surgery: 14 patients with acoustic schwannomas, four with posterior fossa meningiomas, one with cerebellar hemangioblastoma, and one with a solitary cerebellar metastatic lesion. A Richmond bolt was also placed in the frontal area. Continuous monitoring of the supratentorial and infratentorial compartments was performed for 48 hours. During the first 12 hours the posterior fossa pressure was 50% greater than that of the supratentorial space in all patients (p less than 0.01). Over the next 12 hours the supratentorial pressure was 10% and 15% higher than the posterior fossa pressures in all patients, and by 48 hours of monitoring the pressures had equilibrated. There was no mortality or morbidity referable to insertion of the posterior fossa catheter. The conclusions drawn from this study are that: 1) direct monitoring and drainage of the posterior fossa is safe and effective; and 2) within the early postoperative period, the supratentorial pressures failed to reflect what is taking place within the posterior fossa. The implications and advantages of direct posterior fossa monitoring in the postoperative patient are discussed.
Thirty hypertensive patients with subarachnoid hemorrhage were divided randomly into two groups. The treated group was begun on preliminary volume expansion, and control of hypertension was carried out using vasodilators and centrally acting drugs. The control group was treated in the classical manner for hypertension, with a diuretic as the foundation for therapy. The incidence of clinical vasospasm was compared to that of angiographic spasm. The incidence of preoperative vasospasm in the treated group was 20%, as compared to 60% in the untreated group (P less than 0.01). Of the treated group, 87% survived to operation, whereas only 53% of the control group survived to operation (P less than 0.01).
A retrospective analysis of 162 consecutive cases in 160 patients who underwent microsurgical resection of vestibular schwannomas between October 1995 and June 2001 was undertaken to compare the results with those of other treatment modalities. Patient hospital records, operative video pictures, neuroimaging studies, audiograms, and follow-up data were reviewed. The mean follow-up period was 24 months.There were 34 small (<1.5 cm), 92 medium (1.5-3 cm), and 36 (>3 cm) large tumors. Six were recurrent tumors. Gross total resection was accomplished in all 34 small tumors and 92 medium tumors but only in 50% of the large tumors. Among the 126 small and medium tumors, the facial nerve was saved anatomically in 124 patients. On long-term follow up, facial function was preserved in 94.4% of all patients. Anatomically, the cochlear nerve was preserved in 55.9% of the small and 20.7% of the medium tumors. Function was preserved (Gardner-Robertson class 1 and 2) in 25% of the small and in 19.4% of the medium tumors. Cerebrospinal leakage was present in 10.5%, meningitis in 9.9%, wound infection in 3.7%, and hematoma or contusion in 2.5%. Only one patient died (mortality rate 0.6%). Our data reflect that surgical removal should be the standard management for acoustic tumors, particularly for large and medium tumors, and can be accomplished with acceptable complication rates.
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