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1/17. Direct spinal cord electrical stimulations during surgery of intramedullary tumoral and vascular lesions.

    Despite the use of somatosensory evoked potentials during surgery for spinal cord tumors or vascular lesions, postoperative neurological disorders, particularly motor deficits, frequently occur after aggressive surgery with an attempt of gross total resection. We report the use of peroperative direct spinal cord electrical stimulation to decrease morbidity while improving the quality of resection. Three patients with intramedullary lesions (1 ependymoma and 2 cavernomas), initially revealed by pain and followed by neurological deficit, were operated at our institution using peroperative direct medullary electrical stimulations (60 Hz, biphasic square wave pulses with 1 ms/phase, 0.9 mA) under general anesthesia without curare. In all cases, gross total resection was performed until motor responses to stimulation, which indicated anterior and lateral boundaries between the lesion and the functional tissue, were obtained. There was no postoperative neurological worsening, but an immediate partial improvement of sensory and bladder disorders in the patient with ependymoma. Postoperative MRI confirmed total resection in the 3 patients. These cases demonstrate that direct medullary electrical stimulation is a safe, easy, precise and reliable method to reduce morbidity during spinal cord surgery. ( info)

2/17. Intraspinal hemorrhage complicating oral anticoagulant therapy: an unusual case of cervical hematomyelia and a review of the literature.

    Intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient taking anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. We describe a patient with hematomyelia, review the literature on hematomyelia and other intraspinal hemorrhage syndromes, and summarize intraspinal hemorrhage associated with oral anticoagulant therapy. The patient (a 62-year-old man) resembled previously described patients with hematomyelia in age and sex. However, he was unusual in having cervical rather than thoracic localization. As with intracranial bleeding, the incidence of intraspinal hemorrhage associated with anticoagulant therapy might be minimized by close monitoring and tight control of the intensity of anticoagulation. However, it is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. If intraspinal hemorrhage is suspected, anticoagulation must be reversed immediately. Emergency laminectomy and decompression of the spinal cord appear mandatory if permanent neurologic sequelae are to be minimized. A high index of suspicion, prompt recognition, and immediate intervention are essential to prevent major morbidity and mortality from intraspinal hemorrhage. ( info)

3/17. Infarct presenting with a combination of Wallenberg and posterior spinal artery syndromes.

    This is the first report of a patient presenting with a combination of Wallenberg and posterior spinal artery syndromes. The patient developed right hemiplegia and sensory disturbances on the right side of the face and over the whole body. MRI showed infarcts of the cerebellum, medulla oblongata, and upper cervical cord. These lesions were in the territory of the right posterior inferior cerebellar artery (pica) and the right posterior spinal artery (PSA). The combination was due to severe stenosis of the right vertebral artery. ( info)

4/17. Endoscopically assisted closure of an anteriorly based spinal pial arteriovenous fistula.

    The intraoperative use of an endoscope to localize an anteriorly based spinal pial arteriovenous fistula with minimal cord retraction and vessel manipulation is described. ( info)

5/17. Nonsurgical treatment of an upper thoracic spinal subdural hemorrhage.

    STUDY DESIGN: A case report of an upper thoracic spinal subdural hemorrhage which was managed successfully by conservative treatment. OBJECTIVES: Spinal subdural hemorrhage is rare and can cause serious neurologic symptoms. Surgery is the most common treatment and is believed to prevent further neurologic injury. A case of an upper thoracic spinal subdural hemorrhage which was managed successfully by conservative therapy is reported. SETTING: Department of Orthopaedic Surgery, Tokai University School of medicine, Isehara, japan. methods: A 29-year-old woman presented with acute severe back pain. She experienced acutely developed weakness of both lower extremities, hypesthesia below T6 and urinary retention. magnetic resonance imaging performed on the day of hospital admission revealed the existence of a subdural hematoma in the upper thoracic spine. muscle strength of the lower extremities was grade 0 on admission, but improved slightly on day 1. The decision was made to manage the patient nonoperatively by corticosteroid and diuretic administration. RESULTS: Improvement was gradual but progressive. muscle strength was grade 4 out of 5 on the 28th day. magnetic resonance imaging at 3 months except for mild urinary retention. CONCLUSIONS: Spinal subdural hemorrhage can be treated nonoperatively by correlating magnetic resonance image findings with the clinical condition. ( info)

6/17. Cervical hematomyelia secondary to oral anticoagulant therapy: case report.

    We report a patient with cervical hematomyelia associated with oral anticoagulant therapy, which is a very rare case. Intraspinal hemorrhage is a rare but life-threatening complication of anticoagulant therapy. early diagnosis by magnetic resonance imaging (MRI) prevents major morbidity and mortality from intraspinal hemorrhage. ( info)

7/17. Cervical hematomyelia: a rare entity in a neonate with cesarean section and surgical recovery.

    spinal cord injury with or without trauma has been reported in the perinatal period. The prognosis depends primarily on diagnosis of the level, extent and nature of the lesion, established by correlations between clinical, imaging and electrophysiological data. A 25-day-old boy with normal birth weight delivered at term by cesarean section was transferred to Inonu University Turgut Ozal Medical Center because of respiratory distress and brachial diplegia. A suspicious medullary lesion on cervical computerized tomography was confirmed as an intramedullary lesion extending from C3 to D1 on magnetic resonance imaging (MRI). Emergent surgery consisting of exposure of the lesion site and interlaminar direct puncture of the lesion under fluoroscopy revealed that the pathology was an intramedullary hematoma. The partial evacuation of the lesion with direct puncture, the patient's neurological improvement and close follow-up of the patient with ultrasonography, electrophysiology and MRI are discussed in the light of recent literature. ( info)

8/17. Paradoxical air embolism from patent foramen ovale in scoliosis surgery.

    STUDY DESIGN: A case was reported in which paradoxical air embolism arose from the patent foramen ovale in scoliosis surgery. OBJECTIVES: To present a case of suspected paradoxical air embolism after scoliosis surgery. SUMMARY OF BACKGROUND DATA: Embolic accident during scoliosis surgery may be caused by air, thrombus, or fat. There is growing attention on patent foramen ovale involved in paradoxical embolism. The devastating consequences are caused by multiple artery occlusions. methods: Details of a recent documented neurologic complication (paraplegia, weakness of right arm, and blurry vision) after scoliosis surgery have been analyzed in medical publications. RESULTS: The surgical procedure was not imputed. The causative role of epidural catheter for analgesia was considered, but it is likely that a paradoxical embolism occurred in this case, based on the multifocal (cerebral and spinal) neurologic dysfunction, the evidence of cerebral ischemia (on computed tomography), and the presence of a patent foramen ovale (on postoperative transesophageal echocardiography). Although no intraoperative embolism detection was available, air embolism was highly suspected because there was no absolute argument to exclude cruor or fatty embolism. CONCLUSIONS: It is critical to detect a patent foramen ovale before surgery and cerebral embolization intraoperatively. This might permit ascertainment of the etiologic diagnosis in case of a complication in surgery for scoliosis. ( info)

9/17. A case of ruptured aneurysm associated with spinal arteriovenous malformation presenting with hematomyelia: case report.

    BACKGROUND: spinal cord arteriovenous malformation (AVM) associated with spinal aneurysm is not particularly rare, but cases presenting with hematomyelia are relatively rare compared to those with subarachnoid hemorrhage (SAH). We report a rare case of successfully treated spinal AVM associated with ruptured aneurysm presenting with hematomyelia. CASE DESCRIPTION: A 52-year-old male was admitted to our hospital with sudden onset of tetraplegia, respiratory disturbance, and superficial sensory disturbance. Computed tomography revealed hematomyelia at the level of C3-4. gadolinium-enhanced magnetic resonance imaging showed small, enhanced lesions. angiography revealed an intradural perimedullary arteriovenous malformation associated with two aneurysms on the feeding arteries. Administration of high-dose methylprednisolone gradually ameliorated his symptoms. Direct surgical obliteration was performed on the 30th day after the onset. The bilateral C3 cervical radicular arteries and the nidus were coagulated. angiography performed after surgery showed neither the aneurysms nor the nidus. He was discharged with only mild weakness in the left upper extremity and mild left hypesthesia 3 months after surgery, and was fully independent. CONCLUSION: We report a case of hematomyelia caused by ruptured aneurysm associated with spinal arteriovenous malformation that was successfully treated with surgical obliteration. ( info)

10/17. Intraoperative spinal digital subtraction angiography: technique and results.

    OBJECTIVE: To evaluate technical and methodological aspects of intraoperative spinal digital subtraction angiography (ISDSA) in our clinical practice and to assess its practicability, safety, and accuracy for the surgical treatment of spinal vascular malformations. methods: Between August 1997 and February 2002, a total of 30 patients were treated either surgically (n = 18) or endovascularly (n = 12) for spinal vascular lesions at our institution. The clinical records of five patients who underwent ISDSA were analyzed retrospectively. The thoracic segment was involved in three patients and the medullary cone in two. RESULTS: ISDSA could be performed in four cases. In one patient, the segmental artery could not be probed sufficiently while the patient was prone. No complications occurred from the application of ISDSA. The method was beneficial for the neurosurgeon in all but one patient because the vascular anatomy of the malformation was shown with respect to the surgical approach, including the nidus, and immediate resection control could be performed before wound closure. The duration of the procedure was prolonged by 45 minutes on average. CONCLUSION: ISDSA is safe and effective, especially in surgery for complex vascular and recurrent malformations. Benefits to the patient outweigh the additional expense and prolongation of the surgical procedure. ( info)
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