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Jonathan E. Martin, Christopher J. Neal, William T. Monacci and David J. Eisenman

✓ Superior semicircular canal dehiscence is a recently described condition resulting in pressure-induced vertigo in affected patients. The diagnosis is established with the appearance of characteristic electronystagmographic and neuroimaging findings. This condition is amenable to surgical treatment by resurfacing of the dehiscence in the defect in the middle cranial fossa floor with preservation of superior semicircular canal function. The authors report on the treatment of a 35-year-old man with superior semicircular canal dehiscence by a joint neurosurgical and otolaryngological team.

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J. Alexander Marchosky, Christopher J. Moran, Neal E. Fearnot and Charles F. Babbs

✓ For the treatment of malignant gliomas, a technique for implanting hyperthermia catheters was developed that utilized a stereotactic template and head-stabilization frame mounted on a computerized tomography (CT) scanner. Computerized tomography scans were used to measure tumor dimensions and to determine the number, implantation depths, and active heating lengths of the catheters, which were implanted through twist-drill holes while the patient was in the CT room. Heat was subsequently delivered via implanted catheters using a computer-controlled hyperthermia system, which partially compensates for heterogeneous and time-varying tumor blood flow.

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Richard S. Polin, Murad Bavbek, Mark E. Shaffrey, Kevin Billups, Christopher A. Bogaev, Neal F. Kassell and Kevin S. Lee

Object. The goal of this study was to explore whether the levels of soluble adhesion molecules were elevated in cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH). This association was suggested by the known inflammatory response in vasospasm and the role of vascular adhesion molecules in regulating leukocytic adhesion to, and migration across, vascular endothelium.

Methods. A prospective analysis was performed on CSF samples obtained in 17 patients who had suffered a recent aneurysmal SAH and in 16 control patients by using quantitative enzyme-linked immunosorbent assays for E-selectin, intercellular adhesion molecule—1 (ICAM—1), vascular adhesion molecule—1 (VCAM-1), and L-selectin.

Levels of soluble forms of E-selectin (p = 0.0013), ICAM-1 (p = 0.0001), and VCAM-1 (p = 0.048) were found to be elevated in the CSF of patients after SAH compared with levels in the CSF of normal controls, patients with unruptured aneurysms, and patients tested months after SAH occurred. In addition, individual patients tested at the time of their initial ictus demonstrated a fall in adhesion molecule levels over time. Levels of E-selectin (p = 0.044) were highest in patients who later developed moderate or severe vasospasm.

Conclusions. Adhesion molecules are known to be involved in white cell adherence to the endothelium and subsequent diapedesis and migration in which a role in initiation of tissue damage is postulated. The authors have demonstrated the elevation of three adhesion molecules, with severely elevated levels of E-selectin seen in patients who later develop vasospasm. A correlation with a role of vascular adhesion molecules in the pathogenesis of cerebral vasospasm is suggested.

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Frank L. Acosta Jr., Jamal McClendon Jr., Brian A. O'Shaughnessy, Heiko Koller, Chris J. Neal, Oliver Meier, Christopher P. Ames, Tyler R. Koski and Stephen L. Ondra

Object

As the population continues to age, relatively older geriatric patients will present more frequently with complex spinal deformities that may require surgical intervention. To the authors' knowledge, no study has analyzed factors predictive of complications after major spinal deformity surgery in the very elderly (75 years and older). The authors' objective was to determine the rate of minor and major complications and predictive factors in patients 75 years of age and older who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure.

Methods

Twenty-one patients who were 75 years of age or older and underwent thoracic and/or lumbar fixation and arthrodesis across 5 or more levels for spinal deformity were analyzed retrospectively. The medical and surgical records were reviewed in detail. Age, diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Factors predictive of perioperative complications were identified by logistic regression analysis.

Results

The mean patient age was 77 years old (range 75–83 years). There were 14 women and 7 men. The mean follow-up was 41.2 months (range 24–81 months). Fifteen patients (71%) had at least 1 comorbidity. A mean of 10.5 levels were fused (range 5–15 levels). Thirteen patients (62%) had at least 1 perioperative complication, and 8 (38%) had at least one major complication for a total of 17 complications. There were no perioperative deaths. Increasing age was predictive of any perioperative complication (p = 0.03). However, major complications were not predicted by age or comorbidities as a whole. In a subset analysis of comorbidities, only hypertension was predictive of a major complication (OR 10, 95% CI 1.3–78; p = 0.02). Long-term postoperative complications occurred in 11 patients (52%), and revision fusion surgery was necessary in 3 (14%).

Conclusions

Patients 75 years and older undergoing major spinal deformity surgery have an overall perioperative complication rate of 62%, with older age increasing the likelihood of a complication, and a long-term postoperative complication rate of 52%. Patients in this age group with a history of hypertension are 10 times more likely to incur a major perioperative complication. However, the mortality risk for these patients is not increased.

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Dueng-Yuan Hueng, Ming-Ying Liu and Hsin-I Ma

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Letter to the Editor

Traumatic brain injury or decompression

Satoru Takeuchi, Kojiro Wada, Kimihiro Nagatani, Naoki Otani and Hiroshi Nawashiro

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Randy S. Bell, Corey M. Mossop, Michael S. Dirks, Frederick L. Stephens, Lisa Mulligan, Robert Ecker, Christopher J. Neal, Anand Kumar, Teodoro Tigno and Rocco A. Armonda

Object

Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater.

Methods

The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1–2 years.

Results

Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 ± 4.2 vs 10.8 ± 4.0, p < 0.05) and higher ISSs (32.5 ± 9.4 vs 26.8 ± 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1–2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 ± 0.9 vs 3.7 ± 0.9, 3.5 ± 1.2 vs 4.0 ± 1.0, and 3.7 ± 1.2 vs 4.4 ± 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3.

Conclusions

This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.