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Robert F. Bedford, Wayne K. Marshall, Albert Butler and Joseph E. Welsh

C ontroversy continues to surround the use of right heart catheter monitoring for venous air embolism during neurosurgical operations performed in the seated position. Recovery of air from the right heart has been shown to be valuable in resuscitating patients from near fatal air embolism, 7 and, although pulmonary artery pressure (PAP) changes clearly reflect the severity of air embolism and its successful treatment, 4 the insertion of right heart catheters is not without hazard. 8 Thus, some experienced clinicians doubt that the benefits from invasive

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Steven M. Toutant, Melville R. Klauber, Lawrence F. Marshall, Belinda M. Toole, Sharon A. Bowers, John M. Seelig and James B. Varnell

hypercarbia (pCO 2 in categories of 30 mm Hg or less, 31 to 49 mm Hg, and 50 mm Hg or more), shock (systolic blood pressure under 90 mm Hg), bradycardia (heart rate less than 45 beats/min), and number of seizures were considered as possible predictors. The best predictor by far was the highest ICP during the first 24 hours (p < 0.0001). This, however, requires an invasive monitoring procedure. A noninvasive method of prediction would be highly desirable. Shock and abnormal ventricles were the only other predictors that were of statistical significance at the 10% level (p

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Melville R. Klauber, Steven M. Toutant and Lawrence F. Marshall

of less than 10% for developing an ICP greater than 30 mm Hg. Thus, in such a patient, invasive monitoring could be discontinued within a relatively short period of observation. In patients with adverse risk factors, however, the model indicates that monitoring should be continued for a longer period. This demonstrates that multiple noninvasive variables can be used in conjunction with the level of ICP during the first 24 hours to develop a predictive index of the risk of developing intracranial hypertension. These observations are important, as Mayhall, et al

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H. Dennis Mollman, Gaylan L. Rockswold and Sandra E. Ford

cases. No additional risks were associated with SAC's in comparison to IVC's. As with all forms of invasive monitoring, a coagulopathy should be considered a contraindication for the procedure. Subcutaneous tunneling appears to reduce the risk of infection, allowing prolonged periods of monitoring without changing the site. The low profile of a tunneled catheter system makes nursing care easier, with less chance of damage to the monitor. The system requires little maintenance, and the simplicity of a fluid-filled pressure transducer system makes technical malfunctions

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Allen R. Wyler, Bruce P. Hermann and E. T. Richey

continued. The remaining three patients showed no seizure improvement following either the corpus callosotomy or the subsequent focal resection. Of these three patients, one had a temporal lobectomy and one had a right and one a left frontal lobectomy. The three patients who did not improve after focal resection did not have invasive monitoring at any time during either of their evaluations. TABLE 5 Outcome from a focal resection after initial anterior corpus callosotomy Case No. Resection Outcome 8 rt frontal no change 13

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Julian E. Bailes, Robert F. Spetzler, Mark N. Hadley and Hillel Z. Baldwin

replaced at another site. As the patient began to recover and was free of symptomatic vasospasm, the height of the drainage gradient was increased progressively, and, if this was tolerated, finally closed to drainage. Once patients had surpassed the period of predicted vasospasm and were medically and neurologically stable, invasive monitoring was discontinued and they were transferred to a general hospital ward for further recovery. If it was not possible to successfully wean a patient from ventriculostomy drainage, a lumboperitoneal or ventriculoperitoneal shunt was

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Bruce P. Hermann, Allen R. Wyler and Grant Somes

improved if patients underwent invasive ictal monitoring preoperatively 26, 27 and had surgery while under general anesthesia. 25 The strategy of invasively monitoring most patients has been previously practiced by the University of California at Los Angeles group 5 and the Yale group; 21, 22 however, they have used depth electrodes rather than subdural strip electrodes. In accord with the experience of others, 23 the majority of patients with idiopathic (nonlesional) intractable complex partial seizures were found to have seizures beginning from medial temporal

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Kimball S. Fuiks, Allen R. Wyler, Bruce P. Hermann and Grant Somes

corpus callosotomy. However, patients who had either complex partial seizures or seizures that were not easily classified were considered for invasive long-term seizure monitoring. At our center invasive monitoring is performed by implantation of subdural strip electrodes. 23 Unless there are compelling reasons for an alternative montage, we use a bifrontal and bitemporal array of electrodes similar to those reported previously. 24 A minimum of three typical seizures were clearly recorded before monitoring was discontinued. Patients were given the option of

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Allen R. Wyler, Gail Walker and Grant Somes

) recordings. Yet, little prospective data are available on the morbidity of invasive monitoring. We prospectively maintain a databank for all patients evaluated at the EpiCare Center. That databank includes information on all presurgical diagnostic tests. During the past 6 years we have been conducting a study on the morbidity of invasive ictal monitoring. Included in that study has been an evaluation of the prophylactic use of antibiotic treatment during the period of electrode implantation. The purpose of this paper is to report the general morbidity associated with

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Julian E. Bailes, Marc L. Leavitt, Edward Teeple Jr., Joseph C. Maroon, Shou-Ren Shih, Merlin Marquardt, Amr El Rifai and Leo Manack

temperature continued to climb, more concentrated blood was added. At 20°C, the dogs were placed on 0.25% Flether. Any calculated base deficit was corrected with intravenous administration of a 2.5% NaHCO 3 solution. After recovery of cardiovascular function and spontaneous respiration, all invasive monitors and intravenous catheters were removed. The animals were allowed to awaken and recover without dietary or activity restraints. They were monitored for behavioral and neurological function during the subsequent days. At the end of the observation period, they were