Richard G. Robinson
Richard G. Robinson
✓ Eighty-four consecutive patients with ruptured aneurysms of the middle cerebral artery were operated on between 1947 and 1969 at the Neurosurgical Unit, Dunedin Hospital, Dunedin, New Zealand. The lesions were commoner in women. Poor clinical condition, hypertension, retinal hemorrhage, age over 50 years, intracerebral hematoma, and very early operation each affected the surgical mortality adversely. The over-all mortality was 36.6%, and better patient selection reduced this to 7.8%. Clipping the aneurysm proved to be a better method of treatment than investment with muscle and gauze. Two-thirds of the surviving patients returned to full or partial working capacity.
Richard G. Robinson
✓ One hundred and thirty-three patients with chronic subdural hematoma were treated surgically between 1943 and 1980. The patients, aged 5 to 84 years, were graded retrospectively according to the Bender scale; 28% were in Grades 3 and 4. There were 107 unilateral and 26 bilateral hematomas. The clots were removed mostly via burr-holes without drainage. The treatment of 121 patients included an active policy of brain expansion at operation and the postoperative management of intracranial hypotension by lumbar injection. Two patients died, for a mortality rate of 1.5%. The patients who died were 54 and 59 years old, both from among the 26 cases with bilateral lesions; 107 unilateral lesions were treated, with no deaths. None of 51 patients who were aged 61 years and over died. The mean postoperative stay was 17.2 days, and at 3 weeks 77% had been discharged home. Fifteen percent of survivors had permanent disabilities. The common residual deficits were personality and memory disorders, and there was hemiparesis in Grade 4 cases. The high-riskm groups of chronic subdural hematoma were those in Grades 3 and 4, bilateral hematomas, and the elderly. These seemed to be benefited by brain inflation and lumbar injections for intracranial hypotension.
Report of Two Cases
Richard G. Robinson
A. Leland Albright, Richard E. Latchaw and Alan G. Robinson
✓ Experiments were carried out to compare the effectiveness of oncotic and osmotic therapy in dogs with experimental cerebral edema caused by a left parietal cold lesion. Animals were divided into five groups and treated for 6 hours with either crystalloid (control group), or mannitol, albumin, furosemide, or albumin/furosemide (treatment groups). The cerebral effects of therapy were evaluated by intracranial pressure (ICP) measurements and by postmortem evaluations of water content, using computerized tomography (CT) density measurements and wet-dry weight measurements. The ICP was significantly reduced by all treatments except albumin alone, and was reduced equally by mannitol, furosemide, and albumin/furosemide. The CT density of the lesion area was significantly increased by all treatments. The density of the contralateral nonlesioned hemisphere was significantly increased by all treatments except albumin. The water content of the lesion area was significantly decreased by all treatments; water content of the opposite hemisphere was not significantly reduced. The systemic effects of therapy were evaluated by measuring net fluid balance, wedge pressures, hematocrits, free water clearance, and vasopressin. Negative fluid balance without an increase in hematocrit or in vasopressin secretion occurred only in dogs treated with albumin/furosemide. Such oncodiuretic therapy seems to cause normovolemic dehydration and to have cerebral effects similar to mannitol and furosemide, without their undesirable systemic effects.
Matthew D. Smyth, David D. Limbrick Jr., Jeffrey G. Ojemann, John Zempel, Shenandoah Robinson, Donncha F. O'Brien, Russell P. Saneto, Monisha Goyal, Richard E. Appleton, Francesco T. Mangano and Tae Sung Park
The authors conducted a multiinstitutional, retrospective analysis to better define outcome and prognostic indicators for temporal lobe epilepsy surgery for suspected mesial temporal sclerosis (MTS) in young children.
Data were collected for all children undergoing temporal resections at four epilepsy centers over approximately 10 years. Children with a histopathological diagnosis of neoplasm were excluded.
Forty-nine patients (28 boys and 21 girls) were included in the study. Their mean age at surgery was 9.1 years (range 1.25–13.9 years). The mean age at seizure onset was 3.2 years (range birth–10 years). Histopathological examination demonstrated MTS in 26 cases, gliosis in nine, dysplasia in five, gliosis with dysplasia in four, and nonspecific or normal findings in five. Forty-one anterior temporal lobectomies (nine tailored) and eight selective amygdalohippocampectomies were performed (28 left side, 21 right side). Twenty-nine children (59.2%) underwent invasive monitoring. Operative complications included extraaxial hematomas (two cases), cerebrospinal fluid leaks (two cases), and hydrocephalus (one case), each in children undergoing invasive monitoring. The mean duration of follow up was 26.4 months (range 5–74 months) overall and 23.9 months (range 6–74 months) for the Engel Class I subgroup. Outcomes at the most recent follow-up examination were categorized as Engel Class I–II in 31 (63.3%) of 49 children overall, 20 (76.9%) of 26 children with confirmed MTS, four (36.4%) of 11 children with gliosis, and four (57.1%) of seven children with dysplasia. All patients who underwent selective amygdalohippocampectomies had confirmed MTS and Engel Class I outcomes. Patients with more than one seizure type (p = 0.048) or moderate to severe developmental delay (p = 0.03) had significantly worse outcomes (Engel Class III or IV). Age at seizure onset, age at surgery, and duration of seizure disorder were not significantly related to outcome. There was a trend for bilateral or extratemporal findings on electroencephalography (EEG) (p = 0.157), high preoperative seizure frequency (p = 0.097), and magnetic resonance (MR) imaging findings inconsistent with MTS (p = 0.142) to be associated with worse outcome, although it did not reach statistical significance. In only 12 (46.1%) of the 26 patients with confirmed MTS was the condition prospectively diagnosed on preoperative MR imaging.
Younger children with temporal lobe epilepsy have satisfying surgical outcomes, particularly when MTS is present. Magnetic resonance imaging may not be as sensitive in detecting MTS in children as in older patients. Negative predictors identified include multiple seizure types and preoperative developmental delay. Multifocal or bilateral EEG findings, high preoperative seizure frequency, and MR imaging findings inconsistent with MTS also independently suggested worse outcome.