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Diagnosis and Surgical Options for Craniosynostosis

Clinical Pearls In craniosynostosis, skull growth is arrested in the direction perpendicular to the fused suture and expanded at the sites of unaffected sutures (Virchow's law), leading to characteristic calvarial deformations. In addition, the skull base and calvarial development are interrelated, and changes at one location may affect the growth parameters at the other location. Intracranial hypertension may accompany craniosynostosis and is a function of the…

Hydrocephalus in Children

Clinical Pearls Hydrocephalus is one the most common conditions treated by neurologic surgeons, particularly among the pediatric population. It can also be one of the most challenging. Obstruction of cerebrospinal fluid (CSF) pathways or impaired CSF resorption causes hydrocephalus, which is characterized by a pathologic accumulation of CSF that ultimately leads to elevated intracranial pressure, neurologic compromise, and, if untreated, coma and death. CSF shunts are…

Spinal Dysraphism and Tethered Spinal Cord

Clinical Pearls Spinal dysraphism is a spectrum of disorders resulting from incomplete formation of the neural tube or abnormal development of structures immediately associated with the neural tube and nearby somites. Several forms of dysraphism, including myelomeningocele, have been linked to maternal nutritional deficiencies. Folate supplementation for expecting mothers and women of childbearing age has resulted in a dramatic decline in the incidence of open neural…

Surgical Positioning, Navigation, Important Surgical Tools, Craniotomy, and Closure of Cranial and Spinal Wounds

Clinical Pearls Surgical positioning aims to optimize access to surgical pathologies, avoid secondary injuries, and decrease operator fatigue. Commonly used patient positions for cranial and spine cases are discussed. Neuronavigation helps to improve surgical accuracy and decrease injury to critical neurovascular structures. It is an indispensable tool for minimally invasive “keyhole” surgeries on suitable lesions. Proper selection and use of available surgical tools enhances a surgeon's…

Neuroanesthesia and Monitoring for Cranial and Complex Spinal Surgery

Clinical Pearls A systematic preanesthesia evaluation including optimization of coexisting diseases is critical for optimal perioperative care, preventing last-minute cancellations and reducing the risk of adverse outcomes. The perioperative surgical home is a team-based model of care, the goals of which are to guide patients through their surgical experience, enhancing the quality of care and recovery, improving outcomes, reducing costs, and improving patient satisfaction. The overarching…

Principles of Modern Neuroimaging

Clinical Pearls Noncontrast head computed tomography (CT) is the imaging test of choice in the evaluation of acute neurologic disease such as head trauma, hemorrhage, and acute hydrocephalus. Noncontrast head CT can also detect early signs of ischemic stroke, including sulcal effacement, loss of gray-white matter differentiation, and dense vessel signs. In CT perfusion of acute stroke, areas of ischemic penumbra show prolonged mean transit times…

Clinical Evaluation of the Nervous System

Clinical Pearls Listen and observe the patient whether in a chair, bed, or on an examining table before beginning the clinical examination. If you focus on an obvious deficit, you may miss an important detail such as a weak limb or a speech deficit. A thorough and artfully elicited history and examination are still essential and constitute the cornerstone of what we do as neurosurgeons. “Listen…

Challenges in Global Neurosurgery

Clinical Pearls Approximately 80% of the world's population in more than 100 developing countries will share the same fate of limited availability of standard neurosurgery. Limitations commonly encountered in a low-income setting include ignorance and illiteracy, lack of political will from government as well as private sectors, a low number of practitioners in the neurosurgical workforce, limited availability of neurosurgical equipment and supporting services, uneven distribution…

Landmarks in the History of Neurosurgery

Open full size image In the history of neurosurgery there have occurred a number of events and landmarks, and these will be the focus of this chapter. In understanding the history of our profession, perhaps the neurosurgeon will be able explore more carefully the subsequent chapters in this volume to avoid having his or her “hands cut off.” To identify major trends and events in neurosurgery,…

Treatment of Mood Disorders Following Traumatic Brain Injury

Introduction Mood disorders are a common development in cases of traumatic brain injury (TBI). A number of factors contribute to the outcome of this phenomenon. For instance, factors preceding the trauma (eg, personal medical history, genetic vulnerability), characteristics of the head injury (eg, severity, mechanism and location of brain damage), and external factors (eg, type of treatment, motivations for recovery) may influence the outcome of the…

Docosahexaenoic Acid and Omega 3 Fatty Acids

Docosahexaenoic Acid and Omega 3 Fatty Acids Administration of omega 3 polyunsaturated fatty acids (n-3 PUFAs) is a biologically plausible, yet clinically untested, candidate therapeutic strategy to prevent or blunt neurologic disability after traumatic brain injury (TBI). The biologic plausibility of n-3 PUFAs rests on evidence that supports at least three putative mechanisms of neuroprotection after TBI. First, n-3 PUFA supplementation may address an acquired or…

Interventional Drugs for TBI Rehabilitation of Cognitive Impairment: The Cholinesterase Inhibitor Rivastigmine

Introduction Traumatic Brain Injury: Prevalence, Affected Population, and Sequelae Traumatic brain injury (TBI) is a noncongenital injury arising from blunt or penetrating injury to the head or from acceleration/deceleration forces. TBI is an important public health problem; an estimated of 1.5–2.0 million Americans are injured each year. TBI accounts for at least 1.4 million of the emergency room visits, close to 300,000 hospital admissions and 52,000…

Memantine: A Safe and Tolerable NMDA Antagonist with Potential Benefits in Traumatic Brain Injury

Introduction Excitotoxicity is known to contribute to neuropathology in acute neurological insults such as traumatic brain injury (TBI) and stroke, as well as chronic and insidious neurodegenerative disorders such as dementia of the Alzheimer’s type (AD). Although experimental models have provided compelling evidence that N -methyl- d -aspartate (NMDA) antagonism confers neuroprotection from excitotoxic insults, initial clinical trials of NMDA antagonists in TBI and stroke proved…

Ceftriaxone Treatment of TBI

Traumatic Brain Injury and Glutamate Excitotoxicity Traumatic brain injury (TBI) is among the most common causes of morbidity and mortality in the USA across all age groups ( ). Beyond the mechanical injury, TBI triggers a cascade of biochemical events that, while incompletely understood, offers prospects for therapeutic intervention. Among such posttraumatic consequences is disruption of glutamate homeostasis and glutamate excitotoxicity. Progressively increasing levels of extracellular…

TrkB Receptor Agonist 7,8-Dihydroxyflavone and Its Therapeutic Potential for Traumatic Brain Injury

Introduction Approximately 350,000 individuals in the United States are affected annually by severe and moderate traumatic brain injuries (TBIs) that may result in long-term disability. This rate of injury has produced over 3 million disabled citizens in the United States alone. Despite generally improving rates of survival after TBI, approximately 80,000 individuals in the United States annually sustain TBIs that result in significant long-term disability. These…

Carbonyl Scavenging as an Antioxidant Neuroprotective Strategy for Acute Traumatic Brain Injury

Acknowledgments This work was partially supported by grants from the National Institute of Neurological Disorders and Stroke (NINDS) including 5R01 NS083405 and 5R01 NS084857 and 5T32 NS077889 and with funds from the Kentucky Spinal Cord & Head Injury Research Trust. Introduction Oxygen radical-induced membrane lipid peroxidation (LP) is a highly validated secondary injury mechanism that occurs following traumatic brain injury (TBI) that has been firmly established…

5-Lipoxygenase-Activating Protein Inhibitors: Promising Drugs for Treating Acute and Chronic Neuroinflammation Following Brain Injury

Leukotrienes The 5-lipoxygenase (5-LO) pathway mediates the production of leukotrienes, a class of potent inflammatory lipid mediators made in leuko cytes that contain a conjugated triene as part of their structure. The biosynthesis of leukotrienes is under strict control (for review see ). Upon infection or tissue injury, cells of the innate immune system (neutrophils, monocytes, basophils, eosinophils, and tissue specific macrophages, ie, brain microglia) recognize…

Voltage-Gated Calcium Channel Blockers for the Treatment of Traumatic Brain Injury

Traumatic Brain Injury The most recent reports from the Centers for Disease control estimate that over 3.2 million individuals experience a traumatic brain injury (TBI) annually in the United States, with well over 5.3 million patients reporting injury-induced chronic disability ( ). A fiscal analysis indicated that the annual total cost of TBI management exceeds $221 billion dollars annually with 93% (or $205 billion dollars) associated…

The Use of Estrogen for the Treatment of Traumatic Brain Injury

Acknowledgments We wish to acknowledge the expert operators of the LFP model system and TBI assays, Drs. Ahmar Ayub, Betul Cam, Huadong Zeng, and Thian Ng. Thanks go to Dr. Candace Floyd of the UAB Physical Medicine and Rehabilitation Department for providing the neuronal stretch assay data, to Dr. Thomas VanGroen and the UAB Rodent Behavioral Assessment Core for Morris Water Maze studies, and to Dr.…

Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

Introduction Paroxysmal sympathetic hyperactivity (PSH) is a dysautonomic syndrome characterized by paroxysmal and episodic increases in sympathetic and motor activity ( ). PSH occurs after severe acquired brain injury of diverse etiology, and core clinical features of PSH include tachycardia, hypertension, tachypnea, hyperthermia, diaphoresis, and increased motor activity ( ). Additional clinical features may include agitation, mydriasis, decreased level of consciousness, horripilation, and flushing. Most reported…