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Shervin R. Dashti, Humain Baharvahdat, Robert F. Spetzler, Eric Sauvageau, Steven W. Chang, Michael F. Stiefel, Min S. Park and Nicholas C. Bambakidis

P ostoperative infection following cranial surgery is a serious complication that requires immediate recognition and treatment. After neurosurgical procedures, infection most commonly presents as meningitis, subdural empyema, or cerebral abscess. 6 , 9 , 14 , 17 , 21 Although meningitis can occur after any type of cranial surgery, it is most common after approaches to the posterior fossa and is often associated with CSF leak. A high index of suspicion can lead to prompt investigation, including lumbar puncture for CSF studies. Once diagnosed

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Mark N. Hadley, Neil A. Martin, Robert F. Spetzler and Peter C. Johnson

T he dimorphic mycotic organism Coccidioides immitis is endemic in the southwestern United States and Central and South America and is a common human pathogen in those regions. 4 It is estimated that there are 100,000 infections due to this organism annually, most of which are mild and localized to the respiratory system. Approximately 1% of patients with a C. immitis infection will not develop lasting immunity to the organism and will develop systemic disease. One-third of these patients will become symptomatic from central nervous system (CNS

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Leonardo Rangel-Castilla and Robert F. Spetzler

surgery. None of the DVAs were taken or sacrificed during surgery. There were no major complications related to the procedures. Four minor complications occurred, including 1 small epidural hematoma that was managed conservatively, 1 wound infection requiring long-term antibiotics, and 2 pseudomeningoceles that required surgical repair. Patient Outcome All patients were followed clinically and radiographically for at least 6 months after surgery. The mean follow-up period was 1.7 years (range 6 months–9 years). There were no deaths. Ten patients (22%) had

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Srdjan Babic and Djordje Radak

causes, such as hypotension and otological and cardiac disorders. Of the possible management options for VA stenosis, surgical treatment is technically demanding because of difficult access to the vessel origin, and it may seem too aggressive for this small, but important, artery. Reported complications after surgical treatment, such as cranial neuropathies, lymphocele, wound infection, pneumothorax, and perioperative posterior circulation stroke or TIA, clearly lead us to question the validity of this procedure. The improvements that have occurred in surgical

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Neurosurgical Forum: Letters to the Editor To The Editor James M. Vascik , M.D., F.R.C.S.(C) Lexington Clinic Lexington, Kentucky 626 627 I found the recent article by Hadley, et al. (Hadley MN, Martin NA, Spetzler RF, et al: Multiple intracranial aneurysms due to Coccidioides immitis infection. Case report. J Neurosurg 66: 453–456, March, 1987) worthwhile from the point of view of discussing the rarity of true fungal cerebral aneurysms. However, I had a great deal of difficulty understanding why the

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Robert F. Spetzler, Charles B. Wilson and John M. Grollmus

defect, for instance, those seen in some posterior fossa craniotomies or subarachnoid hemorrhages, for it eliminates multiple daily taps or external CSF drainage with its associated risk of infection. Furthermore, the shunt can be removed easily with a small incision in the flank under local anesthesia. We have also employed this procedure to decrease CSF pressure postoperatively in persistent CSF rhinorrhea. TABLE 1 Summary of results in 14 patients treated by percutaneous lumboperitoneal shunt Case No. Age Diagnosis

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The transoral approach to the superior cervical spine

A review of 53 cases of extradural cervicomedullary compression

Mark N. Hadley, Robert F. Spetzler and Volker K. H. Sonntag

deformities of the axis/skull base, or chronic traumatic dislocations of the dens. 1–3, 11, 14, 15, 19, 21–25 Extradural tumor masses have also been resected via the transoral approach with good results. 3, 4, 8, 11, 16, 17 Recent refinements in surgical techniques and intraoperative retraction have facilitated these procedures and low morbidity and mortality rates can be achieved. 3, 14, 21, 22, 24 Despite these advances, the procedure has not been widely accepted or employed. Infection and cerebrospinal fluid (CSF) fistulae remain major concerns among surgeons who

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Robert F. Spetzler, Richard A. Roski, Robert S. Rhodes and Michael T. Modic

artery branch. Right: Postoperative angiogram revealing good patency of the internal carotid artery after resection of the aneurysm and placement of a polytetrafluoroethylene graft. Arrow depicts the suture line. Excision of the graft was then required to prevent the consequences of graft infection, but during temporary carotid artery occlusion the patient developed aphasia. This complication cleared with restoration of flow. Due to previous chemotherapy and multiple skin rotations, neither the external carotid nor the subclavian artery was available as a

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Mark C. Preul, Patrick K. Campbell, William D. Bichard and Robert F. Spetzler

6-0 Prolene polypropylene sutures (Ethicon, Inc.). The temporal muscle, fascia, and galea were repaired with a running 3-0 polyglactin 910 Vicryl suture in layers (Ethicon). The scalp was closed with 3-0 Ethilon nylon suture (Ethicon). After extubation, the dogs were monitored until they fully recovered from anesthesia. Postoperatively, all animals were examined from the first day after the surgery and for 8 weeks thereafter. Evaluations included assessment of general health, wound condition (such as infection, overt CSF leakage, and subcutaneous accumulations

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Mark C. Preul, Patrick K. Campbell, David S. Garlick and Robert F. Spetzler

, and the skin was closed using 2-0 nylon sutures. Animals recovered and were managed by a veterinary service, including administration of antibiotics and appropriate pain relief. F ig . 2. Intraoperative view of hydrogel after application using the Dual Liquid applicator. The blue colorant helps visualize the thickness and coverage of the hydrogel. Outcome Assessment Animals were kept alive for 2 months (2 per group) or 4 months (3 per group). In addition to normal daily health monitoring, detailed examinations for wound healing (infection, overt CSF