Early tracheostomy for primary airway management in the surgical critical care setting.

During a 12-month period, 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit. One hundred twenty patients (46%) were disengaged from the ventilator, and 38 patients (14%) died. Of the remaining 106 patients (40%) 51 patients (group I) were to receive tracheostomy within 1 to 7 days, and 55 patients (group II) underwent late (8 or more days after admission) tracheostomy. Multiple variables in four categories (admission, operative, ventilatory, and outcome) were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation, intensive care stay, and hospital stay. Morbidity and mortality rates of the procedures were assessed. Early tracheostomy, in a homogeneous group of critically ill patients, is associated with a significant decrease in duration of mechanical ventilation, as well as shorter intensive care unit and hospital stays, compared with translaryngeal endotracheal intubation. There were no deaths attributable to tracheostomy, and overall morbidity of the procedures was 4%. We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation. Furthermore, early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation.

Balloon test occlusion of the internal carotid artery with hypotensive challenge.

PURPOSE: To evaluate the usefulness of provocative testing with hypotensive challenge during balloon test occlusion of the internal carotid artery before carotid sacrifice and to correlate tolerance of balloon test occlusion with clinical outcome after carotid artery sacrifice. METHODS: Forty-seven consecutive cases of balloon test occlusions performed at our institution during the past 4 years were retrospectively reviewed. Occlusion was performed under normotensive conditions with distal perfusion of heparinized saline for 20 minutes, or until a deficit was perceived. If 20 minutes of normotension was tolerated, hypotension was induced to two thirds of mean arterial pressure for 20 minutes, or until a deficit was perceived. RESULTS: Of 47 patients, 4 (9%) had deficits at normotension. Of the remaining 43 patients, 9 (21%) had deficits at hypotension. One patient with a positive hypotensive test occlusion underwent carotid artery sacrifice after extracranial-intracranial bypass without sequelae. In one of the 19 patients who clinically tolerated test occlusion with hypotension and had carotid sacrifice (surgical ligation of the intracranial carotid artery), a mild embolic stroke developed, probably from the giant carotid wall aneurysm. This patient fully recovered; MR imaging showed mild changes consistent with emboli distal to the aneurysm. Symptomatic complications were noted in 2 (4%) patients, and asymptomatic arterial dissections were noted in 3 (6%) patients. CONCLUSION: Balloon test occlusion with hypotensive challenge is safe, economical, and greatly increases the sensitivity of balloon test occlusion. The predictive value of a negative test is high. However, to determine the test's specificity compared with quantitative imaging, controlled trials will be necessary.

Lumbar discectomy: use of an epidural morphine sponge for postoperative pain control.

A technique for extended ambulatory epidural pain control after lumbar discectomy is described; preliminary results with 45 patients are reported; and alternative methods of narcotic analgesia are reviewed. In this technique, an absorbable gelatin sponge (Gelfoam, Upjohn Co., Kalamazoo, MI) is contoured to the laminotomy defect, placed in methylprednisolone acetate (40-80 mg), and then injected with 2 to 4 mg of preservative-free morphine (a small needle was used to fill the sponge). The sponge is placed over the defect before closure. A review of office and hospital records was conducted. The series consisted of 33 men and 12 women (mean age, 39 yr; range, 24-57 yr); records showed narcotic use in 34 patients (parenteral in 3) and work-related injuries in 14 patients. Thirty-three patients were ambulatory postoperatively on the day of surgery; all were ambulatory by postoperative day (POD) 1. On the day of surgery, 18 patients did not require any postoperative analgesics; on POD 1, 22 patients did not require analgesics. Six patients received parenteral narcotics; four received one dose only, and two had two or more doses. Thirty-one patients were discharged from the hospital on POD 1, and 10 were discharged POD 2. The other patients were discharged from the hospital on POD 3 (three patients) or POD 4 (one patient). When they were discharged, all patients received a limited supply of acetaminophen with codeine for pain control at home. After discharge, phone follow-up (at 1 week) and office follow-ups (at 3-5 weeks) revealed only one patient with more than mild discomfort. Three patients required one-time bladder catheterization, and one patient had presumed discitis 1 month postoperatively. In a control group who had undergone surgery 3 months previously, the average day of discharge had been POD 3.07; no control patient had been discharged on POD 1, and only 20% had been discharged on POD 2. This method provides effective, safe, and extended analgesia after lumbar discectomy.

Microvascular surgical anatomy of the vertebrobasilar junction.

OBJECTIVE: We examined the pertinent microvascular anatomy of 28 formalin-fixed brains to develop anatomic guidelines for aneurysm surgery in the region of the vertebrobasilar junction. METHODS: Using a surgical microscope, the outer diameters were observed for the following main arteries: vertebral, basilar, posteroinferior cerebellar, and anteroinferior cerebellar. The number of lower brain stem perforating arteries was examined in relation to their course. The distance between the arteries and their perforators was measured with respect to anatomic landmarks. RESULTS: The anatomy of the main arteries was characteristically variable, whereas the anatomy of the perforators was constant, particularly in terms of their numbers and points of penetration into the brain substance. The four major points of entry were the lateral medullary area just caudal to the posterior olivary sulcus, the posterior olivary sulcus, the small lateral fossa at the superior olivary groove, and the foramen cecum. Each of these areas coincides with the origin of common vertebrobasilar aneurysms. CONCLUSION: The anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations, regardless of the caliber of the main artery. Despite a small vertebral artery or its major branches, perforators penetrating the brain are significant and may effect the outcome of aneurysm surgery or endovascular procedures.

Thrombolysis of the cervical internal carotid artery before balloon angioplasty and stent placement: report of two cases.

The application of endovascular techniques to the treatment of cervical carotid artery bifurcation atherosclerosis has been delayed because of the fear of causing embolic events while traversing the diseased portion of the artery with an angioplasty balloon catheter. Symptomatic carotid arteries often contain fresh or partially digested intraluminal thrombus. Before we cross certain carotid bifurcation lesions with angioplasty catheters, we deliver 100,000 to 200,000 units of urokinase in an attempt to digest loose thrombus. We have witnessed changes in the angiographic appearance of the diseased portion of the vessel after urokinase treatment, such as widening of the lumen, that suggest clot lysis. We present two patients who had symptomatic internal carotid artery stenosis. Angiography showed irregular narrowing of the internal carotid artery origin. One patient was selected for angioplasty instead of carotid endarterectomy because of severe cardiac risk factors. The other patient had major angiographic risk factors manifested by poor collateral circulation. The angiographic findings and history of transient ischemic attacks led us to suspect the presence of soft, loose plaque debris or thrombus in both cases. Therefore, we performed thrombolysis with urokinase before angioplasty. Repeat angiography showed widening of the arterial lumen and smoothing of the plaque profile. Subsequent angioplasty and stent placement were uneventful. Intraarterial thrombolysis can produce a change in the angiographic appearance of symptomatic atherosclerotic lesions of the cervical carotid artery bifurcation. Digestion of intralesional thrombus may provide a safer environment for deployment of endovascular remodeling devices by decreasing the likelihood of embolic phenomena. We believe thrombolysis should be done before angioplasty in select patients.

Neurological injury and patterns of sacral fractures.

To evaluate the morphological and neurological findings in sacral spine injuries, a retrospective study was conducted of all patients admitted to Erie County Medical Center over a 2-year period with the diagnosis of pelvic or sacral injury. Of these 253 patients, 44 were found to have sacral fractures and form the basis of this study. The type of fracture, neurological deficit, treatment, and outcome in these patients were analyzed. The patient population consisted of 25 males and 19 females, with a mean age of 34 years (range 15 to 80 years). The fractures were classified by the degree of involvement of the foramina and central canal. Fractures through the ala sacralis only (Zone I, 25 cases) or involving the foramina but not the central canal (Zone II, seven cases) were less likely to cause nerve injury (24% and 29%, respectively). Fractures involving the central canal (Zone III), both vertical (five cases) and transverse (seven cases), were more likely to cause neurological injury (60% and 57%, respectively). Neurological deficits in Zone I and II injuries were usually unilateral lumbar and sacral radiculopathies. Zone III deficits were usually bilateral and severe; bowel and/or bladder incontinence was present in six of the 12 patients in this group. Deficits generally improved with time; however, operative reduction and internal fixation may have been useful, particularly in patients with unilateral root symptoms. The treatment options are discussed, and previously published series of sacral fractures are reviewed. The authors conclude that the classification of sacral fractures described is useful in predicting the incidence and severity of neurological deficit.

Spinal leptomeningeal hemangioblastomatosis in von Hippel-Lindau disease: magnetic resonance and pathological findings.

A 55-year-old man with von Hippel-Lindau disease presented with quadriparesis. Multiple enhancing cervical and thoracic spinal masses were seen on magnetic resonance imaging (MRI). A rim of diffuse, nodular enhancement linking all of the discrete masses was apparent on the surface of the cervical and thoracic regions of the cord. Surgical exploration revealed multiple extramedullary-intradural and intramedullary masses, extending to and infiltrating the cord; the leptomeninges contained numerous small tumor seeds at several levels. The excised spinal masses were diagnosed as capillary hemangioblastomas, which infiltrated the pia mater. Diffuse, intense, spinal leptomeningeal enhancement on MRI associated with multiple hemangioblastomas has not been previously reported and may be referred to as spinal "leptomeningeal hemangioblastomatosis."

Endovascular therapy of central nervous system tumors.

This article discusses the presentation of various central nervous system lesions and the role of endovascular techniques in their treatment. Basic principles of endovascular technique are described. The normal arterial anatomy of the spine is reviewed.

Patient management, complications, and intensive care.

Advances in endovascular therapy have resulted in more acute care applications for more seriously ill patients. The use of standard neurological critical care techniques and specific preparations for minimizing the deleterious effects of ischemia facilitates the treatment of high-risk patients. Standardization of care also allows accurate comparison of newer endovascular and surgical advances.

Iatrogenic intracerebral hemorrhage.

Intracerebral hemorrhage as a result of a diagnostic or therapeutic procedure is a rare but potentially devastating event. The fear of hemorrhagic complications influences neurosurgical decision making. The incidence of iatrogenic intracerebral hemorrhage and risk factors for this complication are reviewed for neurosurgical procedures as well as for non-neurosurgical procedures with a known risk of intracerebral hemorrhage.

A technique for rigid fixation of methyl methacrylate cranioplasty: the vault-locking method.

BACKGROUND: Current treatment of difficult to reach lesions of the central nervous system favors extensive bone removal for improved visualization and access with minimal brain retraction. Particularly in the posterior fossa, bone is often removed piecemeal, and a standard craniotomy flap is not always available for simple reattachment. Cranioplasty with methyl methacrylate is used to provide cosmesis and neural protection. A method for the fixation of methyl methacrylate cranioplasty is described, and the results of technique application in 30 patients during a 14-month period are reported. METHODS: A series of notches are burred in the cancellous margin of the surrounding cranium, preserving the inner and outer tables. Methyl methacrylate is applied to the defect. Overflow of methyl methacrylate into the notches assures solid fixation. The resultant construct resembles the locking mechanism of a bank vault. No mesh, wire, or miniplates are required. Prolene buttresses may be placed through the outer table of the notches to identify their location, should removal of the plasty be required. Removal of the outer table over the notches facilitates rapid removal. RESULTS: Solid plasty and good cosmesis occurred in all patients. There were no infections or complications related to this technique. CONCLUSIONS: Firm fixation, molding and hardening in situ, and technical ease are potential advantages over established methods of cranioplasty.

Endovascular management of giant intracranial aneurysms.

The role of endovascular therapy for the treatment of giant aneurysms is presently being defined. Results derived from the endovascular treatment of giant aneurysms must be compared to the effectiveness and safety of operative treatment and the natural history of the disease. Most reports on the results of endovascular aneurysm treatment are of patients who have failed operative intervention or in whom operative intervention was not attempted because of their poor medical condition or other factors. Thus, the results of these techniques are from a high-risk subgroup. In a recent series of 19 giant aneurysms treated by a variety of techniques, including coils, balloons, and rapidly solidifying polymers, one death resulted after aneurysm rupture during the procedure (86). However, the major cause of mortality was cardiopulmonary complications within the first 2 weeks after the procedure. At present, it may be appropriate to reserve endovascular techniques for patients with no other reasonable therapeutic option. As experience with these techniques is gained, a comparison must be undertaken in a series of patients clinically equivalent to those in surgical series. Presently, the consensus is that endovascular therapy for giant aneurysms is efficacious for parent-vessel occlusion after balloon test occlusion to assess tolerance to sacrifice. Endosaccular occlusion is most effective if the aneurysm contains little thrombus, as determined by the size of the aneurysm seen on CT or MRI (87), as compared to the angiographic image. Small-necked aneurysms are particularly suited to coil occlusion if the aneurysm can be tightly packed. In wide-necked aneurysms, coil occlusion is possible, although the risk of parent-vessel occlusion is high. We often perform balloon test occlusion of the vessel before placing coils in wide-necked aneurysms. Failure of endovascular therapy after complete angiographic obliteration is based on recanalization or regrowth, resulting from device migration or remodeling at the junction of the device with the inflow tract and aneurysm wall, or by migration of the device into thrombus. The effect of aneurysm remnants after balloon or coil occlusion will be determined by long-term follow-up, as emphasized by Fox et al. (20, 63). Whenever there is an aneurysm remnant, some risk of subsequent hemorrhage exists (66). Further device refinement will enhance the safety and effectiveness of the endovascular treatment of giant aneurysms. The use of combined endovascular and conventional surgical techniques may be an increasingly important option in the treatment of giant aneurysms. Endosaccular packing of an aneurysm with occlusive material may not provide the ability to completely exclude the aneurysm from the circulation, and thus, will not necessarily prevent the process of regrowth. A further limitation of the currently implemented endovascular treatment of aneurysms is that fluoroscopy does not provide detailed information of aneurysm remnants due to the superimposition of occlusive materials, which may necessitate the development of new real-time imaging modalities for interventional procedure, such as intravascular ultrasound and ultrafast-sequence MRI.

Pneumonia: incidence, risk factors, and outcome in injured patients.

One hundred thirty (44.2%) of 294 patients hospitalized for trauma and admitted to the Surgical Intensive Care Unit for mechanical ventilation developed hospital-acquired bacterial pneumonia. The predominant pathogens isolated were gram-negative enteric bacilli (72%), but there was not an increase in mortality associated with gram-negative pneumonia compared with similar patients without pneumonia. Of the seven admission risk factors univariately associated with the development of acquired bacterial pneumonia, only emergent intubation (p less than 0.001), head injury (p less than 0.001), hypotension on admission (p less than 0.001), blunt trauma as the mechanism of injury (p less than 0.001), and Injury Severity Score (p less than 0.001) remained significant after stepwise logistic regression. Not surprisingly, as mechanical ventilation is continued, the probability of pneumonia emerging increases. The consequences of hospital-acquired bacterial pneumonia are a significant seven-, five-, and two-fold increase in mechanically ventilated days, intensive care, and hospital stay, respectively. We conclude that the incidence of hospital-acquired pneumonia in injured patients admitted to the ICU for mechanical ventilation occurs in nearly half the patients, is associated with specific risk factors, and significantly increases morbidity but does not increase mortality.

Aggressive giant pituitary adenoma presenting as a nasopharyngeal mass: magnetic resonance imaging and pathologic findings.

We report a giant pituitary adenoma with aggressive histologic features that prominently invaded the nasopharynx. Magnetic resonance imaging (MRI) demonstrated a large heterogeneous nodular mass that was hypointense to isointense on T1-weighted images and mixed hypointense, isointense, and hyperintense on T2-weighted images. The mass measured 7.5 x 5 x 7 cm, extending from the nasopharynx posteriorly through the clivus, and superiorly through the paranasal sinuses, and sellar-suprasellar region. After contrast administration, heterogeneous nodular enhancement was noted. A nasopharyngeal neoplasm extending into the sella was suspected because voice change and nasal speech long preceded the patient's visual symptoms. A biopsy disclosed an aggressive, infiltrating, hemorrhagic tumor, which was diagnosed as a non-secreting pituitary macroadenoma. This report indicates that pituitary adenomas may grow invasively to tremendously large sizes resulting in their initial presentation as nasopharyngeal masses.