Saphenous vein interposition grafts in the microsurgical treatment of cerebral ischemia.

Saphenous vein interposition grafts of varying lengths have been used in 25 extracranial-intracranial bypasses since 1974. Indications for operation included transient ischemic episodes (13 cases), prophylactic augmentation of middle cerebral artery (MCA) collateral flow prior to surgical treatment of intracranial aneurysm (four), and traumatic occlusion of cervical or intracranial internal carotid arteries (eight). Vein grafts to cortical branches of MCA originated from superficial temporal or occipital arteries in ten cases, common or external carotid arteries in ten, and subclavian or innominate vessels in five. Twenty-one patients have been followed up for a minimum of 12 months. Immediate patency rate was 84%; one late graft occlusion decreased overall patency to 80%. There was one operative mortality. Early technical problems, including donor-recipient size disparity, anastomotic distortion, and inappropriate graft routing, have been overcome by the use of 2-mm veins, the avoidance of hydrostatic dilation, and the construction of retroauricular tunnels. It is reasonable to assume that long-term patency of these reconstructions will parallel that of extracranial-intracranial bypasses using autologous arteries.

Microsurgical evaluation of the pterional approach to aneurysms of the distal basilar circulation.

The microsurgical correlates the pterional approach to the distal basilar circulation were evaluated in 20 cases of posterior circulation aneurysms, 50 human cadaver dissections, and a variety of other intracranial surgical lesions. The pterional approach permitted successful clipping of the aneurysm in 13 of 15 basilar bifurcation aneurysms, 1 of 2 basilar-posterior cerebral aneurysms, and 2 of 3 basilar-superior cerebellar aneurysms. In each of the failed attempts via the pterional approach, the subtemporal route ultimately resulted in proper clip application. The interposition of the posterior clinoid process was the impediment to successful clipping in three of the four cases that could not be managed via the pterional approach. All 3 of these patients had a basilar bifurcation that was below the level of the posterior clinoid on angiography, whereas none of the remaining 17 aneurysm patients demonstrated a low-lying bifurcation. Posterior displacement of the basilar artery away from the posterior clinoid exceeded 1 cm in only 13% of our cases and was not an impediment to successful clipping of the aneurysm via the pterional route. We conclude that, when the anatomical situation is appropriate, the pterional approach offers the advantages of less brain retraction and better visualization of the parent arteries and important perforating branches when compared to the subtemporal approach.

Risk of intracranial aneurysm surgery in the good grade patient: early versus late operation.

To evaluate the risk of definitive intracranial microsurgical aneurysm obliteration as a function of the timing of the operative intervention, we retrospectively reviewed 106 consecutive patients in good clinical condition who underwent such surgery. The patients who were operated upon within the first 8 days of their most recent subarachnoid hemorrhage formed the "early" group; the patients operated upon between the 9th and 31st day were considered to have undergone "late" surgery. On the basis of their clinical outcome the patients were allocated to one of four outcome categories ("good," "fair," "death") both at the time of their hospital discharge and at their most recent clinical re-evaluation, a minimum of 6 months after discharge from the hospital. There was no significant difference in the operative mortality in each group (early surgery, 5%; late surgery, 4%); additionally, no significant difference was noted in the incidence of either intraoperative complications or postoperative morbidity. A suggestive but statistically insignificant increase in the incidence of postoperative cerebral ischemic events was seen in the "early" surgery group (8% vs. 4% for the "late" surgery group). The potential significance of these findings for the timing of intracranial aneurysm surgery is discussed.

Surgical management of unruptured asymptomatic aneurysms.

The natural history of unruptured asymptomatic aneurysms in nuclear. Because of this uncertainty regarding risk of ultimate enlargement and/or hemorrhage, and in view of the significant mortality and morbidity traditionally involved in aneurysm surgery, clinicans have varied in their advocacy of surgical management of such lesions. Forty-nine consecutive patients harboring 52 such aneurysms were treated surgically over a 57-month period. There were no surgical deaths and morbidity was within acceptable limits. Patient population characteristic and surgical technique are discussed.

Microsurgical pterional approach to aneurysms of the basilar bifurcation.

The authors describe a microsurgical frontolateral pterional approach to aneurysms of the basilar bifurcation. Results of surgery in 38 patients are presented.

Carotid-ophthalmic aneurysms: direct microsurgical approach.

A series of 30 carotid-ophthalmic aneurysms, some of them bilateral, is reported. All of them were treated by a direct surgical approach. There were 25 patients in this series, 23 female and two male. In some cases there were associated pituitary adenomas and other aneurysms. The anatomy, clinical manifestations, and surgical treatment are discussed. There were no deaths among these 25 patients. Twenty-two of these patients recovered completely.

Spontaneous cerebrospinal fluid leakage and middle ear encephalocele in seven patients.

Isolated cases of spontaneous cerebrospinal fluid (CSF) leakage with and without middle ear encephalocele have been reported. These leaks are usually accompanied by episodes of recurrent meningitis, hearing loss, or chronic headache. In this article, we report seven new cases of spontaneous CSF leakage. Six of these patients had conductive hearing loss and serous otitis media, and three had recurrent meningitis. Prior to a definitive diagnosis, six patients had received myringotomy tubes, which produced profuse clear otorrhea. Three patients had positive beta-2 transferrin assays. Computed tomography and magnetic resonance imaging confirmed a defect in the temporal bone tegmen. A combined transmastoid and middle fossa surgical approach with a three-layer closure was used to repair the tegmen defect. All patients had a lumbar drain placed prior to surgery. In addition to describing the seven new cases, we review the history of CSF leakage and discuss diagnostic methods, surgical findings, and our recommendations for management.

Effects of polyethylene IUDs and unilateral ovariectomy in golden hamsters.

PIP: The effect of unilateral ovariectomy and ployethylene IUDs was studied in golden hamsters 2.5-8.5 months of age of proven fertility. After anesthesia by ip injection of sodium pentobarbitol (Diabutal), 1 of 6 different operative procedures was performed unilaterally on 1 ovary or horn per animal, leaving the contralateral horn for comparison. The 6 groups were 1) insertion of an IUD, 2) ovariectomy, 3) IUD + ovariectomy, 4) sham IUD, 5) sham ovariectomy, and 6) sham IUD + ovariectomy. There were 10 females in each group, they were paired 1 week after the operation and sacrificed 2 weeks after mating. Implantations in each uterus were counted and sizes estimated. Embryos were considered living by heartbeat or muscle movement. Total numbers of implantations and live embryos were compared by 2-way analysis of variance with Tukey's method for multiple comparisons. The presence of an IUD or removal of ovary completely blocked pregnancy in the uterine horn on that side. The 3 sources of variance all contributed significantly to the total nubmer of implantations for the 6 groups. The values for the live embryos were also significant for the groups. There were no significant differences with respect to the sizes of implantations and live embryos. In Group 3, the numbers of implantations in the contralateral horn were equivalent to those in Group 2, suggesting that the IUD did not counteract the compensatory ovulation caused by the unilateral ovariectomy, nor result in increased numbers of live young.^ieng

Microsurgical treatment of transient cerebral ischemia. Preliminary results in 50 patients.

Extracranial-intracranial arterial bypass is a microneurosurgical procedure recently introduced in the treatment of a variety of cerebrovascular ischemic states. Fifty patients with transient ischemic attacks (TIAs) localized to the distribution of the internal carotid artery underwent this procedure during a 48-month period. All have been followed up for at least 14 months after surgery. There were no operative deaths, and notable postoperative morbidity has been experienced in less than 8% of cases. Seventy-six percent of patients have been asymptomatic since surgery, 14% have continued to experience TIAs, and 6% have had completed strokes (2% occurring in the operative hemisphere).

The morphology of the sex pheromone gland in Drosophila grimshawi.

The morphology of a sex pheromone-producing gland found in the abdomen of Drosophila grimshawi males was studied by light and electron microscopy. This gland, consisting of two intra-anal lobes, contains cells that resemble those of other insect pheromone glands. However, in contrast to many other insect pheromone glands that release pheromone through the cuticle, cells of the intra-anal lobes secrete into a canaliculi-duct system that empties into the anal region. The liquid secretory product flows along the surface of the intra-anal lobes and is brushed onto the substrate by fingerlike projections on the lobes' surfaces.

Psychopharmacologic treatment of acquired attention disorders in children with brain injury.

This investigation examined the efficacy of psychostimulant therapy in alleviating neurobehavioral dysfunction attendant to pediatric brain injury. The most commonly reported neurobehavioral sequelae associated with head injury in the pediatric population involve deficits along the attentional matrix. This is also the most common objectively documented neurobehavioral finding among children as well as adults. There are several investigations in the adult literature which have employed the use of psychostimulants in treating both psychiatric and neuropsychological residua associated with head injury. Overall, the results of these studies are equivocal, but suggest a beneficial impact on general functioning. The present prospective investigation utilized a double-blind, placebo-controlled, cross-over experimental design to examine the efficacy of methylphenidate in treating children with acquired attentional disorders secondary to brain injury. A cohort of 14 children with varying degrees of head injury were recruited for participation. As expected, differences between drug and placebo conditions uniformly achieved statistical significance. Additionally, there were no differences in performance between baseline and placebo conditions on neurobehavioral tasks of attention and concentration. Current findings suggest that methylphenidate (and probably other psychostimulants such as Cylert, Adderal, Wellbutrin and dextroamphetamine sulfate) is an extremely effective agent in treating attentional disorders secondary to brain injury in children.