October 15, 2007
Dr. Saeed
Bajwa of Southern NY Neurosurgical Group, P.C. performs
artificial cervical disc surgery
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January 6, 2006
CyberKnife brings full-body radiosurgery to Wilson Regional
Medical Center
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Epidemiology of Head Injury- Trauma is the US's leading cause of death in individuals under 45 years of age, with brain injury as the leader of traumas. Around 400,000 new cases of brain injury occur each year in the U.S., with most patients either younger, or elderly.
Brain injury incidence is highest in the youth and elderly population, with males twice as likely to endure injury as females. Motor vehicle crashes account for the major proportion of head and brain injuries, including pedestrians, motorcyclists and bicyclists.
However, these numbers are beginning to decrease as laws become more strict involving the use of helmets, seatbelts, and drunk driving.
Approximately half of hospital patients suffer from mild trauma. Another quarter experience moderate injuries, with the remainder receiving treatment for severe or life-threatening injuries. These numbers are improving as managed care becomes more prevalent across the U.S. Many individuals that endure a severe head injury possess some degree of further disability, while few may also experience ongoing neuropsychological problems. Overall, a sense of urgency is recommended to seek out immediate medical attention to avoid further damage.
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Head Injury Prevention- Over the last two decades, the key force in head injury prevention has been public education initiatives on brain and spinal cord injury such as the Think First program, and enactment of safety legislation. Seatbelts, airbags, and motorcycle helmets have increased safety, and decreased serious injury and death. The uses of infant restraint seats, increased educational efforts and strict law enforcement of drunk-driving laws have also played a part in head injury prevention.
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Brain Tumor- A tumor, also known as a neoplasm, refers to a "new growth" of cells that already exist in the brain. They often cause headaches, seizures or neurological deficits. Tumors can be either benign or malignant. Malignant tumors are considered cancers. Tumor treatments can consist of surgical resection or biopsy, radiation approaches or drug treatment approaches such as chemotherapy. Tumors can also be treated with modification of the body's own immune system, known as immunotherapy.
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Glasgow Coma Scale- The GCS is the most widely used method of defining a patient's level of consciousness and neurological status. The GCS is determined by the patient's best motor, verbal and eye-opening responses and is generally categorized into three levels of mild, moderate and severe head injury. The effectiveness of this scaling system is objectivity, reproducibility and simplicity. The system also helps predict the eventual neurological recovery of a head-injured patient.
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Concussion- A relatively mild form of traumatic brain injury causing temporary neurological changes ranging from disorientation and confusion to amnesia and unconsciousness. Patients who may experience these symptoms need neurosurgical evaluation. Most are released under reliable observation for the following 12 hours, and advised to abstain from alcohol and any pain medications stronger than Tylenol.
Patients suffering a more severe concussion must undergo further workup. These patients may remain drowsy or confused, have nausea or vomiting, severe headache, convulsions, drainage of spinal fluid from the ear or nose, and develop weakness or loss of feeling in the extremities, pupillary asymmetry, double vision, or other neurological symptoms. A CT scan is necessary to check for a skull fracture and/or brain hemorrhage.
After a concussion, 50 percent of patients make a full recovery almost immediately, while most of the other half may need more time. Some patients further suffer from what is known as post-concussion syndrome; complaining of headache, irritability, anxiety, impaired memory and cognition, impaired concentration and attention, fatigue, personality changes, insomnia, vertigo, tinnitus (ringing in the ears), hearing loss, visual changes, increased sensitivity to light and noise, decreased taste and smell and decreased libido.
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Skull Fractures- Can follow both a mild or severe head injury with only slight symptoms such as a mild headache. Other fractures can be followed by concussion syndromes or more severe brain injury.
CT scans can help diagnose fractures. Fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base. Open skull fractures occur when the overlying skin has also been opened. A depressed skull fracture occurs when one of the bony fragments is compressing the brain structures. This can result in direct injury to the brain, or a laceration of the dura mater and a cerebrospinal fluid leak. Surgery entails repair of the fracture when indicated. Recovery is generally good, and as long as no brain injury occurred.
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Traumatic Hematomas- Approximately 30 to 40 percent of moderate and severe head injury patients will develop an intracranial hematoma (blood clot) that requires removal through an emergency craniotomy. Named by the space inside the skull in which they occur, hematomas include epidural, subdural and intracerebral. A head CT is the most reliable way to determine the trauma and determines whether urgent neurosurgical intervention is necessary.
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Epidural Hematoma- A blood clot located between the bone (cranium) and the dura (fibrous covering of the brain). An epidural hematoma is usually associated with a skull fracture that has caused tearing of an underlying epidural vessel. These hematomas can become large and compress the underlying brain causing significant neurological problems. An EDH is best diagnosed through use of a CT scan. Treatment often consists of surgery to remove the initial clot and stop intracranial pressure, stop ongoing bleeding, and prevent reaccumulation of the hematoma. Smaller lesions are handled with medical observation. Rapid diagnosis and urgent evacuation are crucial for a positive outcome.
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Acute Subdural Hematoma- A collection of blood that develops between the surface of the brain and the dura mater. An SDH usually results from stretching and tearing of veins over the surface of the brain, and is among the most lethal of all head injuries. They are often associated with more severe generalized brain injury, and often occur with cerebral contusions. This hematoma is best diagnosed by a CT scan and usually treated with rapid surgical evacuation with a large craniotomy. Removal of a cerebral contusion is also conducted during the same surgery. Because patients have a high mortality rate due the intracranial pressure that develops within the days following the injury, it is crucial to seek out treatment immediately.
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(Chronic) Subdural Hematoma- A collection of old blood located over the surface of the brain in the subdural space, accumulating over at least two weeks. This type of hematoma typically results from past or minor head injuries in brain atrophy patients over 60 years of age. (Brain atrophy causes the brain to shrink inside the skull, increasing the possibility of a blood vessel tearing during injury). Many patients are not aware of a developing hematoma until the clot has become quite sizable.
Most individuals will complain of a headache, while more severe cases may develop paralysis or coma, or may mimic neurological conditions
including dementia, stroke, transient ischemic attacks, brain tumors or abscess.
Chronic subdural hematomas are diagnosed with a CT scan or an MRI, and can be managed with close observation or drainage via burr holes.
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Cerebral Contusion- Cerebral contusions are scattered areas of hemorrhage that form over the surface of the brain, taking place when the brain strikes a ridge on the skull or a dural fold. Most patients with cerebral contusions have endured a serious head injury with a loss of consciousness. As with other types of intracranial hemorrhages, cerebral contusions are best and most rapidly diagnosed by CT scan. If, within 48 to 72 hours post-injury, cerebral edema (swelling) causing considerable pressure develops, or if the hemorrhage progresses to form a substantial blood clot in the brain, a surgical craniotomy is necessary. The outcome of a patient suffering a cerebral contusion depends upon size and location, age, the Glasgow Coma Scale, and the presence of other types of intracranial injuries.
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Subarachnoid Hemorrhage- Occurs when the small blood vessels in the subarachnoid space (immediately over the surface of the brain) are traumatized in a head injury. Approximately 25 - 40 percent of individuals who sustain a moderate or severe head injury experience a subarachnoid hemorrhage, which is diagnosed using a CT scan. The presence of SAH can hinder a patient's neurological recovery because it induces arterial vasospasm (narrowing of the arteries supplying blood to the brain), which can result in a stroke. The best way to prevent vasospasm from occurring or to minimize its impact is to maintain an adequate or slightly elevated fluid status (hypervolemia) of the patient and a normal or even elevated blood pressure. Vasospasm can be diagnosed non-invasively with the use of Transcranial Doppler or with an angiogram. A subarachnoid hemorrhage is most commonly seen in a traumatic setting where blood vessels in the brain are injured.
However, this needs emergent neurological attention because it may represent an undiagnosed aneurysm.
The best way to detect a subarachnoid hemorrhage is through a CT scan.
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Post-Traumatic Seizures- Early post-traumatic seizures are seen within the first week following an injury, and may accompany a traumatic intracranial hematoma and contusion. The best way to reduce the risk of a post-traumatic seizure is to use the anticonvulsant drug phenytoin with maintenance of high therapeutic serum levels during the first week following an injury. Continuing anti-seizure medicine after the first week does not prevent future seizures or epilepsy.
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Recovery after Brain Injury- Neurological recovery is often difficult to predict accurately. While many patients make dramatic recoveries within several months to a year after suffering very severe initial injuries, other patients cannot adapt to factors working against them. Factors that may result in a poor recovery are older age (50+), low Glasgow Coma Scale score (deep coma), pupil dilatation, low blood pressure or inadequate oxygenation early after the injury, and prolonged intracranial pressure. CT scans also help predict what may cause a poor recovery. These factors include acute subdural hematoma, intracerebral hematomas, multiple contusions, subarachnoid hemorrhage, presence of compressed basilar cisterns, and large degrees of brain shift from one side to the other (midline shift). The more factors a patient suffers from, the lower the possibility he or she has of a positive recovery.
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Endoscopies- Examination of the inside of the brain (or other organs of the body) using a fiberoptic instrument. The report should describe the condition of the organ with reference to swelling, blockage, lesions, growths, and other abnormalities.
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AVM's- Arteriovenous Malformations: A spectrum of congenital (developmental) blood vessel malformations. An AVM occurs when brain or spinal cord arteries attach directly to veins without the blood passing through the capillary network. AVM's may cause a stroke in the form of bleeding within the nervous system, or progressive neurologic deficits, headaches or seizures. They occur in a variety of brain locations, sizes and shapes. Treatments include observation, surgical resection, embolization or radiosurgery.
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Aneurysm- A weak bulge on the wall of a brain artery that causes bleeding in the brain. Aneurysms form silently from wear and tear on the arteries, injury, infection, or inherited tendency. There are two types of aneurysms. The most common type is a Saccular aneurysm, also known as a 'berry' aneurysm because of its shape with a neck and stem. A Fusiform aneurysm is a less common outpouching of an arterial wall on both sides of the artery that does not have a stem.
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Shunt-Hydrocephalus/Encephalus- A shunt system is used to divert cerebral spinal fluid from the brain to another body compartment, and is usually used to treat hydrocephalus. Ventricular peritoneal shunts are used to divert fluid from the cerebral ventricles to the abdomen, and Ventricular pleural shunts are used to divert fluid to the chest.
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