Two patients with mycotic intracranial aneurysms were successfully treated with only antibiotic therapy. One patient, who had subacute bacterial endocarditis, rheumatic valvular disease, and an abscessed tooth, sustained a subarachnoid hemorrhage from a ruptured right middle cerebral artery trifurcation aneurysm. The other patient, who had Turner's syndrome and probable congenital aortic stenosis, developed multiple neurological findings during an ipisode of acute bacterial endocarditis precipitated by an infected ingrown toenail; a false aneurysm of the distal left middle cerebral artery and two lesions involving the left superior cerebellar artery were found. A study of the literature shows that only 45 patients with mycotic intracranial aneurysms have received adequate antibiotic therapy and angiographic documentation. Statistically, there does not appear to be a clear-cut advantage to antibiotic plus surgical therpy over antibiotic alone. In fact, in 21 patients who underwent serial angiography, lesions were smaller in six and not visualized in 11. In four patients the aneurysms increased in size; in two others fresh lesions formed. The author proposes the following diagnostic and therapeutic regimen: 1) earliest possible diagnosis of the underlying disorder; 2) appropriate antibiotic therapy; 3) early four-vessel cerebral angiography and follow-up studies every 2 to 3 weeks; study; 5) definitive operation upon completion of antibiotic therapy if the lesion is larger or the same size; and 6) postoperative angiography to evaluate the effectiveness of treatment and to search for interim lesions.
Before the turn of the century, W. W. Keen was the most celebrated neurosurgeon in the United States. During the Civil War he served as a surgeon in the Union Army. He collaborated with Mitchell and Morehouse in clinical studies that culminated in their publishing Gunshot Wounds and Other Injuries of Nerves. In 1887, he was the first surgeon in the Americas to remove a benign brain tumor. He perfected a technique for ventricular puncture, devised operations for spasmodic torticollis, microcephalus, and tic douloureaux, and introduced many European neurosurgical techniques to the United States. An astute clinician and excellent teacher, Keen had no research interests other than anatomical and pathological dissections. He published over 50 papers on neurosurgical topics, in addition to articles on numerous other subjects. Although recognized as a pioneer in neurosurgery, he is not usually considered a founder of neurosurgery in the United States because of his failure to develop the specialty further than his contemporaries in the remainder of the neurosurgical world. This failure related not to his abilities, but probably to the fact that he was elderly before it became technically possible to perform safe and effective intracranial procedures.
✓ The author describes the many early advances in neuroanesthesiology made by pioneer neurosurgeons. Macewen first employed endotracheal intubation for anesthesia. Horsley vigorously promoted chloroform research and the development of the Vernon Harcourt regulator, the first anesthesia machine to provide safe and accurate concentrations. With the aid of the Harcourt inhaler he made many brilliant neuroanesthetic observations. Codman and Cushing collaborated on the first intraoperative anesthetic records while still medical students. Cushing later introduced the Riva-Rocci blood pressure apparatus to the United States. His early intracranial procedures were performed under ether narcosis, but Cushing's experiences during World War I led him to adopt local anesthesia for the remainder of his career. The first clinical application of insufflation anesthesia was made by Elsberg. Frazier introduced rectal ether for neurosurgical procedures. Local anesthesia enjoyed its greatest popularity during the 1920's and 1930's. Endotracheal intubation and complete respiratory control were accepted by most neurosurgical clinics around the time of World War II.
Present diagnostic criteria for ankylosing spondylitis (AS) lean heavily on the x-ray examination, but there is much dispute as to its efficacy, especially in mild or early cases. Determinations of the HLA B27 histocompatibility antigen appear to define the population at risk far better than any other means. Of 31 patients who had the HLA B27 antigen, all had negative latex fixation tests and axial polyarthritic complaints (seronegative spondyloarthropathy or rheumatoid variant). Three had Reiter's syndrome and one had ulcerative colitis. Of the remaining 27 patients, nine had definite AS, 11 had probable AS, and seven had possible AS. Eleven of the 27 underwent at least one invasive spinal procedure (myelogram, laminectomy, fusion, facet denervation) before a diagnosis of AS was made.
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