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H. Richard Winn, Alan E. Richardson and John A. Jane

✓ The long-term evaluation of 60 patients who suffered a subarachnoid hemorrhage and survived 6 months is reported. By bilateral carotid arteriography, all patients were shown to have a single aneurysm at the vicinity of the posterior communicating artery at its junction with the internal carotid artery. The patients had previously been randomly assigned to treatment either by bed rest or by common carotid ligation. Average duration of survival among those followed is 8 years. Late rebleeding episodes were found to occur at a similar rate, irrespective of mode of treatment in the studied populations, but morbidity following operation continued to remain somewhat less over the ensuing years of follow-up study compared with the patients treated conservatively. On final assessment many years after the original hemorrhage, there is little improvement in degree of morbidity in either treatment group, and hypertension is noted to develop in the patients undergoing carotid ligation. A larger number of cases will be required to validate these findings.

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K. Maurits Persson, William A. Roy, John A. Persing, George T. Rodeheaver and H. Richard Winn

✓ Premature fusion of the coronal suture was produced in 9-day-old rabbits by immobilization of the suture area bilaterally with methyl-cyanoacrylate adhesive. The effects of suture fusion and its surgical release on suture growth and on skull morphology were evaluated by radiographic cephalometry. Immobilization resulted in significant changes in the angular dimensions in the vault toward an anteroposterior shortening. No permanent deformity was observed in the angular relationship between the cranial base and the facial skeleton. Craniectomy at 30 days, when a skull deformity had been established, resulted in rapid separation of the bones at the suture site which returned the deformed skull to a normal configuration by 90 days of age. Surgical removal of a normal suture in a control group also resulted in accelerated separation of the bones at the excised suture site, but it was less than after removal of an immobilized suture. The experimental data indicate that premature fusion of rapidly growing sutures results in consistent skull deformity. Early release of the fusion, when this is the primary abnormality, will result in spontaneous correction of the deformity.

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Primary cerebellar nocardiosis

Report of two cases

George W. Tyson, Joseph E. Welsh, Albert B. Butler, John A. Jane and H. Richard Winn

✓ The authors describe two cases of primary cerebellar nocardiosis. Confinement of Nocardia abscesses to a localized, accessible portion of the central nervous system should favor surgical cure of this aggressive and often fatal disease. In our two cases multilocularity, tenuous encapsulation, and proximity to the brain stem prevented complete primary excision. Nevertheless, the infections were effectively treated by intensive postoperative antibiotic therapy and, in one case, a second operation to excise the residual abscess. The need for the latter was suggested by the results of sequential computerized tomographic brain scans that were used to monitor the response to antibiotic therapy.

In the absence of any apparent extracranial focus of infection and any overt condition that might impair immunological competence, nocardiosis is likely to be omitted from the preoperative differential diagnosis of a posterior fossa space-occupying lesion.

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H. Richard Winn, Michael Mendes, Paul Moore, Clarabelle Wheeler and George Rodeheaver

✓ Experimental evaluation of brain abscess has been inhibited by the lack of a simple and reproducible model in small animals. A stereotaxic headholder and slow infusion of 1 µl of saline, containing a known number of bacteria, were used to produce brain abscess consistently in the rat. The natural history of the brain abscess produced by this technique closely simulated that found in the human clinical situation.

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George Tyson, W. Ellis Strachan, Peter Newman, H. Richard Winn, Albert Butler and John Jane

✓ A consecutive series of 48 adult patients with a chronic subdural hematoma is reported. These patients were treated according to a protocol consisting of a sequence of conventional surgical procedures ranging from simple burr-hole drainage to craniotomy and subdural membranectomy. Seven patients (15%) continued to demonstrate severe neurological dysfunction, or suffered acute neurological deterioration after completion of this protocol. However, after undergoing excision of the cranial vault overlying the hematoma site, six of these seven patients demonstrated a significant clinical improvement. Based on analysis of these seven cases, the authors suggest that craniectomy be considered in those patients who suffer a symptomatic reaccumulation of subdural fluid following craniotomy and membranectomy, or who demonstrate further neurological deterioration as a result of cerebral swelling subjacent to the hematoma site. However, this procedure probably has no efficacy once extensive cerebral infarction has occurred.

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Michael Mendes, Paul Moore, Clara Belle Wheeler, H. Richard Winn and George Rodeheaver

✓ The brain is a uniquely protected organ. Once the protective barriers are overcome, the brain is susceptible to bacterial infection. Using a reproducible rat model, the susceptibility of brain tissue to challenge by S. aureus or E. coli was quantitatively compared to that of skin. Brain was significantly more susceptible to the presence of bacteria than was the skin of the scalp. The development of infection in skin required at least 105 organisms, while brain infection could be produced with as few as 100 organisms.

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John Persing, William Babler, H. Richard Winn, John Jane and George Rodeheaver

✓ The effect of timing of the surgical release of prematurely immobilized coronal sutures was studied in rabbits. At 9 days of age, the coronal suture was mechanically immobilized by the application of methyl cyanoacrylate adhesive. These animals and a control group then received metallic implants on each side of the suture to monitor growth. At 30, 60, or 90 days after suture immobilization, separate groups of animals underwent a linear suturectomy to release the restriction. In animals in which the suture was not released, growth at the coronal suture was significantly restricted and resulted in severe deformities in the neurocranium. The benefits derived from surgical release were time-dependent. Suturectomy at 30 days of age resulted within 60 days in achievement of 100% of the growth in sham-treated controls. In contrast, delayed surgery at 60 or 90 days of age resulted in achievement of only 38% and 17% of normal growth, respectively. Angular measurements of the vault and base of the cranium showed a similar graded response toward normality, with the greatest correction occurring with the earliest operation. These results support the clinical impression that early surgical correction of craniosynostosis results in superior cosmetic appearance. A further implication of this work is that abnormality at a single suture strongly influences the development of other areas in the craniofacial complex.