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Variable aspiration tissue resectors are emerging as a potential solution to decrease the time involved in the dissection and debulking of tumors antibiotics for sinus infection types myambutol 600 mg without prescription. They have been reponed to be safe and effective in reaching and removing tumors accessible only through narrow working corridors. It is considered a coaxial approach, as the components ofthe endoscopic system (lighting, camera, working channels, irrigant channels, and instruments) are in parallel and enclosed in a single sheath. Damage to surrounding brain from the retraction and introduction of instruments is minimized. Endoscope-assisted microsurgery and endoscope-controlled microsurgery are considered extra axial. In endoscope-assisted microsurgery, instruments are used in a bimanual technique under the microscope, and the endoscope assists visualization in, and around, corners. With endoscope-controlled microsurgery, the video image is used for guidance of microsurgical instruments rather than the microscope. In this scenario, curved instruments and suckers can be utilized to operate around corners. This results in a greater degree of technical difficulty due to peripheral distortion, disorientation from using an angled scope, and the proximity of the surgical field to the tip of the endoscope. However, mastering this skill can lead to more precise dissections and greater completeness of resection. For the management of selected colloid cysts and ventricular tumors, purely endoscopic techniques can be used safely and effectively. The resection of large or vascular intraventricular or periventricular tumors is enhanced by using both the microscope and the endoscope for visualization. Image becomes brighter when the endoscope is closer to the object viewed Wide range of view Pure endoscopic techniques are more minimally invasive Good visualization of objects in a straight path Good overview of surgical bed Allows for free bimanual technique Disadvantages Learning curve for instrumentation and orientation View easily obscured by hemorrhage Cannot see behind the endoscope Surgical manipulation limited to one hand Requires an assistant to hold endoscope, or endoscope holder View easily obscured by bleeding Umited instrumentation Pure endoscopic techniques should only be used for small tumors Difficulty seeing deeper structures and hidden corners-may require brain retraction Needs to be focused; field of view is limited as lens focuses on one depth Requires larger incision Microscopy Introduction to Colloid Cysts the management of colloid cysts has been a topic of conten~ tion in neurosurgical practice due to the risk of treatment and the relativdy benign nature of these lesions. They can cause obstruction of the foramen of Monro and cerebrospinal fluid outflow. This can result in a spectrum of symptoms from headaches to loss of consciousness and, on occasion, sudden death. In general, enlarged ventricles are more easily accessed and provided a natural working area. We have been able to demonstrate good results in our series of 16 patients without ventriculoegaly. Near total resection was achieved in all patients with no difference in morbidity or mortality. Stereotactic guidance is used to locate the ventricles and plan an appropriate trajectory. Care should be taken to avoid damage to the fornix, which lies in the superior and anterior borders of the foramen of Monro. Maintaining the size of the ventricles while operating can be facilitated through the use of a peel~away sheath, such that a natural vacuum is formed around the endoscope. The tumor and ventricles are observed for enlargement ("watch and wait") · Placement of a ventriculoperitoneal shunt to treat hydrocephalus · Surgical resection of the lesion, which is the only definitive treatment Surgery is generally indicated in symptomatic patients or patients with ventriculomegaly, due to the risk of acute obstruc~ rive hydrocephalus and sudden death. This is the main advantage of the endoscopic approach; there was no statisti~ cally significant difference in mortality rate or shunt depen~ dency, whereas open microsurgical resections generally resulted in higher gross total resection and lower recurrence. A thorough history should also be taken in the workup of the patient prior to surgery. Colloid cysts are often found incidentally in patients whose underlying cause of headache may not be clear. Symptoms such as visual disturbance, loss of consciousness, positional headache, sensory disturbance, shon~ term memory loss, urinary incontinence, dementia, or ataxia suggests intermittent ventricular obstruction. A neurologist should also review surgical candidates to rule out other causes of headache. For patients with incidental colloid cysts that are not causing secondary hydrocephalus and are less than 1 em in size, options are contentious. Conversdy, if the patient is truly asymptomatic, has an acceptable levd of anxiety about the risk of sudden death, appreciates the fact that the devdopment of hydrocephalus may sometimes be occult and insidious, and is willing to have regular imaging and consultations, then observation alone is reasonable. In bald males, where the incision cannot be hidden behind the hairline, consider an incision in the sagittal plane to reduce damage to sensory nerves. Create a burr hole large enough for easy maneuvering of the endoscope; 11 mm is usually sufficient. Tap into the lateral ventricle under stereotactic guidance, targeting the frontal horn: a. Use a 0-degree scope to identify landmarks of the colloid cyst and foramen of Monro, such as the septal and thalamostriate veins and choroid plexus. Large amounts of fluid are replaced in endoscopic ventricular surgery, and the use of saline has the potential to cause neural cell damage and postoperative electrolyte disturbance. The anesthesiologist should be monitoring for a Cushing response indicating raised intracranial pressure. If the cyst is small, L Coagulate the overlying choroid plexus, avoiding the fornix. If the cyst is mucinous, the cut end can be used to morselize the cyst and aspirate its contents. If the cyst is large, L Attempt to decompress the cyst through the foramen or the ipsilateral thinned-out septum pellucidum that is stretched over the underlying cyst. Beware that the ipsilateral fornix is also stretched over the cyst, and every attempt should be made to minimize damage to this structure.
For patients with malformations of cortical development virus evolution buy genuine myambutol line, such as hemi~ megalencephaly, anatomic hemispherectomy is the most direct way to completely remove the malformed tissue. These patients often have small ventricles and no clearly defined gray/white interface; it is difficult to complete disconnection via a less invasive hemispherectomy technique. However, the disadvan~ tage to the anatomic technique is a slighdy higher risk of peri~ operative morbidity and a higher incidence of postoperative hydrocephalus. The functional technique is well suited to patients with Rasmussen encephalitis, where the normal gray/ white anatomy is preserved. Advantages to these less invasive techniques include reduced blood loss and risk of hydrocepha~ Ius. The disadvar~tage is the higher reoperation rate when sei~ zures persist postoperatively and cortical tissue is left in place. Anatomic Hemispherectomy the patient is positioned either on a rigid fixation device or resting on a head support. After local anesthesia, a large C-shape incision is made extending inferiorly to the zygomatic root just anterior to the tragus and extending medially well superior to the lateral ventricle. After skull flap removal, dural tack-up sutures are then placed and the dura is opened, typically based on the midline. Bridging veins are either protected or raken to avoid catastrophic venous hemorrhage. The ventricle is opened anteriorly to the amygdala and then posteriorly so that the temporal horn is exposed from its anterior aspect to the trigonal region. The lateral ventricular sulcus of the temporal horn is then opened, and the collateral sulcus is followed to the tentorial edge and mesial temporal pia. The lateral amygdala and mesial temporal lobe (including the hippocampus) may be removed at this point, resecting the structures off of the mesial pia. The parahippocampal gyrus is aspirated, exposing the tentorial edge, and the pia is coagulated and divided from the temporal pole to the trigonal region. The posterior cerebral artery branches are encountered and may be ligated as they course over the tentorial edge on their way to the temporooccipital cortex. For suprasylvian dissection, the superior circular sulcus is opened to divide the corona radiata and expose the lateral ventricle longitudinally. The ipsilateral foramen of Monro is occluded with a cottonoid or Gelfoam pad to prevent blood from entering the dependent hemisphere. The frontoparietal white matter is aspirated to open the entire ventricular system, connecting to the posterior temporal disconnection from the infrasylvian dissection. The middle cerebral artery branches in the posterior aspect of the Sylvian fissure are coagulated and divided. Identification of the corpus callosum is facilitated by careful aspiration of the roof of the lateral ventricle just above its intersection with the septum pellucidum. Aspiration of a portion of the cingulate allows clear visualization of the pericallosal arteries and corpus callosum. During this portion of the procedure the surgeon must be careful to avoid injuring either pericallosal artery, as it is difficult to ascertain which branch supplies the contralateral hemisphere. The cingulate and corpus callosum are then aspirated to achieve complete disconnection, being careful to avoid injury to the contralateral frontal lobe. The ipsilateral fornix is then interrupted by aspiration just anterior to the splenium in the posterior aspect of the lateral ventricle. The anterior callosal dissection is continued, dividing the pia of the mesial frontal lobe and any branches from the anterior circulation until the olfactory nerve is reached. The falx and pericallosal arteries provide an excellent anatomic reference to ensure complete frontal disconnection. The mesial frontoparietal pia and anterior circulation branches should be coagulated and divided above the inferior aspect of the falx to ensure that the contralateral frontal lobe is not injured. Posterior dissection is then performed along the falx until it transitions to the tentorium, effectively connecting to the infrasylvian basal temporal disconnection. At this point, the only remaining connection is that of the basal orbitofrontal surface. The remaining orbitofrontal tissue, extending from the anterior Sylvian fissure to the posterior basal frontal lobe, is aspirated and the orbitofrontal pia divided. The gyrus rectus is aspirated, and care should be taken to protect the contralateral frontal lobe. The lateral aspect of the pia along the olfactory nerve is divided to avoid injury to the olfactory nerve. The residual basal frontal lobe is removed with a posterior limit of the internal carotid artery. Coagulation of the ipsilateral choroid plexus may reduce the risk of postoperative hydrocephalus. Functional Hemispherectomy Functional hemispherectomy as described by Rasmussen implies removal of the temporal lobe (including mesial structures) followed by a limited central resection of frontoparietal tissue. The majority of the disconnected hemisphere is then left in situ in an attempt to reduce perioperative morbidity (blood loss, hydrocephalus) and the long-term risk of superficial cerebral hemosiderosis. There are different variant approaches, such as a vertical or lateral approach, to achieve the similar result of disconnection. The main variation among these procedures is the amount of tissue resected as the surgeon enters the ventricular space, with more recent refinements of technique focusing on reducing the amount of tissue resected.
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Over 6 months antibiotics drugs myambutol 800 mg on-line, 29% of patients were seizure free; with follow-up over 1 year, 15% of patients were seizure free. Device-related adverse effects included intraoperative intracranial hemorrhage and infection over device-implanted sites. Fisher and colleagues reported on a double-blind, randomized trial of 11 0 patients with medically refractory partial seizures, including secondarily generalized seizure treated by bilateral stimulation of the anterior nuclei of the thalamus. For the 2-year follow-up, 54% of patients had a seizure reduction and 14 patients were seizure free for at least 6 months. The evidence demonstrated that anterior thalamic and responsive ictal onset zone stimulation is of moderate to high efficacy, and hippocampal stimulation is of low to moderate efficacy. There is no strong evidence to support efficacy of stimulation in other locations, such as the centromedian nucleus of the thalamus, cerebellum, or nucleus accumbens. Forty patients were treated with the standard An, and others were treated with medication alone. At the 1-year follow-up, the cumulative percentage of seizure freedom was 58% in the An group and 8% in the medical group (p <. The quality of life in the surgical group was also significantly higher than that in the medical group. The total hippocampectomy group had a statistically superior seizure outcome to that of the partial group; there were no greater neuropsychological side effects with the more extensive hippocampus resection. Seizure-freedom outcomes across various surgical approaches have been well discussed. At the 1-year postoperative follow-up, there was no statistical difference in seizure-freedom rate between the two groups. Another study by Schmeiser and associates reviewed 458 patients undergoing surgery for drug-resistant mesiotemporallobe epilepsy. These proportions remained stable at the 2-year follow-up as well as at the long-term follow-up of over 5 years. There was no statistically significant difference regarding seizure outcome among the different surgical procedures at short- or long-term follow-up. Positive predictive factors for seizure freedom after temporal lobe resection include preoperative unilateral hippocampal sclerosis, focal localization of interictal epileptiform discharges, absence of preoperative generalized seizures, tumor etiology, and complete resection of the lesion with or without medial structures. The postoperative seizure outcome was not statistically different between patients with or without a history of febrile convulsion in childhood. Surgical complications, including hemorrhage, infarction, infection, hydrocephalus, neurologic complications, cranial nerve deficits, hemiparesis, aphasia, and hemianopia, had no significant association with any of the surgical procedures. A visual field with quadrant deficits from damage to the Meyer loop can be present even in selective approaches. Mesiotemporal as well as neocortical temporal structures play an important role in memory functions, especially in the dominant hemisphere. Regardless of the type of surgery, more disoriented verbal learning and verbal delayed free recall and recognition were observed in dominant versus nondominant resections. Initial studies imply comparable but slightly inferior results for seizure control. One prospective study included 20 patients undergoing laser ablation for intractable mesial temporal epilepsy. The proportion of patients who were free of seizures was 60% at the 2-year follow-up Temporal lobectomy is a highly effective treatment for epilepsy in the appropriate population. Advances in diagnosis through novel radiologidanatomic and physiologic techniques may expand the population that may benefit from surgical treatment strategies. Systematic review and meta-analysis of standard vs selective temporal lobe epilepsy surgery. A clinical, electroencephalographic and neuropathological study of the brain in epilepsy, with particular reference to the temporal lobes. Surgical treatment of patients with single and dual pathology: relevance of lesion and of hippocampal atrophy to seizure outcome. Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy fur mesial temporal lobe epilepsy. Subtemporal amygdalohippocampectomy for treating medically intractable temporal lobe epilepsy. Collateral brain damage, a potential source of cognitive impairment after selective surgety fur control of mesial temporal lobe epilepsy. Seizure outcome following transcortical selective amygdalohippocampectomy in mesial temporal lobe epilepsy. The role of stereotactic laser amygdalohippocampotomy in mesial temporal lobe epilepsy. Treatment of temporal-lobe epilepsy by temporal lobectomy; a survey of findings and results. The localizing value of the abdominal aura and its evolution: a study in fucal epilepsies. Decision-making in temporal lobe epilepsy surgery: the contribution of basic non-invasive tests. Postictal nose-rubbing in the diagnosis, lateralization, and localization of seizures. Voxel based morphometty of grey matter abnormalities in patients with medically intractable temporal lobe epilepsy: effects of side ofseizure onset and epilepsy duration. An objective method for the assessment of psychological and social problems among epileptics.