This document discusses epilepsy and anaesthesia. It provides definitions of seizures and epilepsy. It then discusses various factors that influence neuronal excitability like intrinsic factors related to ion channels and extrinsic factors like ion concentrations and synaptic remodeling. It explains the mechanisms of seizure initiation and propagation. It discusses the effects of various anaesthetic agents like inhalational agents, opioids, IV agents and local anaesthetics on seizures. It provides guidelines on perioperative management of anti-epileptic drugs. It also discusses status epilepticus, its treatment and refractory status epilepticus. The document concludes by covering various aspects of presurgical evaluation of epilepsy patients like neuroimaging, EEG, video-EEG, neuropsychological testing and WADA test
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
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Intra-operative bronchospasm is a deadly complication during general anaesthesia especially immediately after intubation. This presentation is a guide to tackle such a situation.
Management of Refractory, Super refractory SE and.pptxsumeetsingh837653
diagnosis and treatment of refractory and super refractory status epilepticus and NORSE
treatment guidelines of status epilepticus
dosages of various antiepileptic used in management of status epilepticus
This presentation describes the concept of temporal plus syndrome, pseudotemporal epilepsy and paradoxical temporal lobe epilepsy and how to differentiate them from temporal lobe epilepsy.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Basic Definitions
• Seizure (from the Latin sacire—to take
possession of) is the clinical manifestation of
an abnormal, excessive, hypersynchronous
discharge of a population of cortical neurons.
• Epilepsy is a disorder of the central nervous
system characterized by recurrent seizures
unprovoked by an acute systemic or neurologic
insult.
3. Mechanisms of Neuronal
Excitability
• Intrinsic Factors:
1. The type, number and distribution of voltage- and
ligand-gated channels.
2. Biochemical modification of receptors
3. Activation of second-messenger systems
4. Modulating gene expression, as by RNA editing
• Extrinsic Factors:
1. Changes in extracellular ion concentration
2. Remodeling of synaptic contacts and neuronal network
3. Modulating transmitter metabolism by glial cells
4. Seizure Initiation
Seizure initiation is characterized by two concurrent
events:
1) High-frequency bursts of action potentials
(paroxysmal depolarization shift)
2) Hypersynchronization of a neuronal population (local
spread).
3) Distal Seizure propagation (loss of surround
inhibition)
Epileptogenesis
1) Neuronal network reorganization.
2) Kindling.
5. Antiepileptic Drug Interactions
• Induction and inhibition of the cytochrome
P450 isoenzymes.
• Inducers – CBZ, Phenytoin, Phenobarbital,
Topiramate
• Inhibitors – Valproate
• No effect - Gabapentin, lamotrigine,
levetiracetam, tiagabine, and vigabatrin
Drugs to be careful about – Antibiotics,
Amiodarone, β-Blockers, CCB, NMBA, Opioids.
Carbepenems induce Valproate metabolism.
6. Effect of Anaesthetic agents
on Epilepsy
• Inhalational Agents:
1) N2O – Proconvulsant in animal models; Suppresses
Ecog epileptiform potentials intraoperatively;
Myoclonus observed in humans at hyperbaric doses
and along with other inhaled agents.
2) Sevoflurane – Well known proconvulasant activity in
children and when combined with hypocapnea.
Widespread EEG activation.
3) Isoflurane & Desflurane – Well known anticonvulsant
properties, even used in SE.
7. • Opioids (Proconvulsant):
1) Pethidine – Association with myoclonus and tonic clonic
seizure activity.
2) Alfentanyl and Remifent – Used to induce spike activity
and help in localization of epileptogenic zones
intraoperatively.
3) GTCS in low to moderate doses – Fent, alfent, sufent and
morphine.
• IV Anaesthetic agents:
1) Propofol, thiopentone, methohexital, etomidate, ketamine
all have proconvulsant effects (myoclonus, ophistotonus,
GTCS) in low doses and anticonvulsant at high doses.
2) Benzodiazepines – always anticonvulsant.
3) LA – GTCS at high plasma levels. Lignocaine used to treat
SE in children in small case series.
4) NMBA – Laudanosine.
8. • Perioperative AEDs: -
1. IV is better than oral (doses are equal)
2. Continue AEDs perioperatively, without missing out a
single dose.
3. ICU stay with changes in pH and S. Albumin levels
and other drug interactions warrant serum drug
level measurements (esp. Phenytoin).
9. STATUS EPILEPTICUS
• Status epilepticus is defined as 5 min or more of
(i) continuous clinical and/or electrographic seizure activity or
(ii) recurrent seizure activity without recovery (returning to
baseline) between seizures.
• Refractory status epilepticus (RSE) is defined as SE that fails
to respond to first- and any two drugs in the second-line
therapy and it is observed in 9% to 31% of patients with SE .
• Most convulsive seizures abate within 2–3 min and a seizure that
continues for more than 5 min has a low chance of terminating
spontaneously, so should be treated with emergency
antiepileptic medications.
• The traditional definition of 30 min for SE definition has been
revised to 5 min because permanent neuronal injury and
pharmacoresistance may occur before deadline of 30 min
(Brophy 2012).
15. Epilepsy Surgery -
Identifying Surgical Candidates
1) Medical intractability:
–Two appropriately chosen, well-tolerated first line
antiepileptic drug regimens have failed due to lack of
efficacy.
2) Sufficient Disability
3) Minimum duration from diagnosis – 2 yrs (Adults)
4) Difference between Adults and Paediatric
population.
• Plasticity phenomenon: Early surgical intervention can
maximize efficacy, recovery, and cognitive potential.
• No defining concept of disability.
16. Surgical candidacy to be determined on a case by case basis
using data from an extensive multimodality assessment.
• Timing of Surgery - People suffering from epileptic
syndromes with a high probability of medical intractability
and a favourable surgical prognosis should be considered
for surgery early.
• Presurgical Evaluation:-
1) Medical History with ictal and interictal symptoms.
2) High resolution Neuroimaging.
3) Identifying Epileptogenic Zone – EEG, Neurophysiological
evaluation, Video EEG..
4) Invasive intracranial recordings.
5) Other ancillary neurophysiologic techniques - evoked
potential studies, cerebral functional mapping, MEG and
magnetic stimulation.
6) Identifying Functional deficit zone and lateralization of
eloquent cortex - interictal SPECT and/or PET, and the
intracarotid sodium amytal (Wada) test, fMRI
18. EEG for Diagnosis and Localization
• Interictal sharp or spike wave is cornerstone for
epilepsy diagnosis.
• Represents cortical hyperexcitability and
hypersynchrony, which may persists in the “normal”
interictal state.
• Montage specificity of EEG abnormality helps localize
epileptogenic zone.
• Chowdhary et al (2013) found overall sensitivity of
EEG in yielding abnormal interictal epileptiform
discharges was 62.7% in epilepsy patients.
19. Right posterior temporal spike. This EEG is from a 15-year-old boy with a history of complex
partial seizures. The spike phase reverses at T6. The field of the discharge extends into the
parietal and occipital regions.
22. Video EEG
Useful to diagnose distinguish Psychogenic seizures, Syncope, Parasomnias,
Hemifacial spasms from actual epilepsy.
Interictal EEG findings – Sharp waves, Spike & wave complexes, Polyspikes,
TIRDA, Continuous Polymorphic Delta etc.
Ictal EEG findings – Generalized, Lateralized or Focal spikes accompanied with
clinical seizure in patients. There may be post-ictal slowing of EEG.
24. Advantages:
1) Recordings that can be done before as well as after the
resection, to estimate the potential residual epileptic activity in
the neighbouring of the resection zone,
2) Intraoperative electrical stimulation to map cortical functions
Disadvantages:
1) Llimited placement of the electrodes to the craniotomy,
2) Limited sampling time,
3) Recording almost exclusively of spontaneous interictal epileptic
activity and very rarely epileptic seizures,
4) Difficulty to differentiate between primary epileptic discharges
from secondarily propagated discharges from a distant
epileptic zone,
5) Alterations by anaesthetics and analgesics as well as the
surgery, of both the background activity as well as the epileptic
discharges,
6) Ambient artefacts in the operating room.
25. fMRI
• Functional MRI (fMRI) methods use currently
standard MRI scanning hardware to detect changes in
regional blood flow and metabolism that accompany
regional brain activation.
• Major applications of fMRI in epilepsy include the
localization of task-correlated language and memory
function, and the localization of ictal and paroxysmal
phenomena.
• Language lateralization by fMRI provides comparable
results to intracarotid amobarbital testing.
26.
27. SPECT
• Ictal SPECT is of great value.
• I-123 & Tec 99
• Due to low temporal resolution, both ictal onset zone
and propagation pathways get delineated.
28. PET
• PET with fluorine-18
fluorodeoxyglucose
([18F]FDG) localizes
areas of glucose
hypometabolism in
epileptogenic zone.
• Interictal PET has
sensitivity of 75-
80% in TLE and 30-
40% in no TLE.
• Ictal PET not
logistically possible.
29. Neuropsychologic evaluation &
WADA Test
• For improvement of QoL:
1. Optimum resection of Seizure focus.
2. Minimal post operative neurological deficits.
Factors predicting good seizure outcome - presence of
MRI abnormalities, extent of resection and the
Wada Memory Asymmetry (WMA) score
Factors predicting post op cognitive decline - age at
onset of seizures, side of surgery, preoperative
neuropsychological test performance, presence or
absence of MRI abnormalities, and the WMA.
30. Aims of Neuropsychological Testing:
1) Identify any pre-existing cognitive deficits.
2) Whether the deficits are concordant with the
suspected epileptogenic focus.
3) If the suspected epileptogenic focus subserves
important skill with no apparent deficits.
WADA Test:- Developed by Juhn Wada to establish
speech dominance prior to temporal lobe resection .
Test extended to evaluate memory function also.
Modification – Usage of other agents Lignocaine,
Etomidate instead of or along with amobarbital.
WMA – WADA Memory Assymetry.
31. Key Considerations for Surgery
1. Is a structural lesion identified? (MRI)
2. Is an epileptogenic zone identified? (EEG,
functional imaging)
3. Are the lesion and epileptogenic zone
concordant?
4. Location? Relationship to eloquent cortex?
(MR landmarks, functional imaging,
Neuropsychologic evaluation, WADA)
5. Focal or extensive? Single or multiple?
Unilateral or bilateral?
32. Common Types of Epilepsy Surgery
Goals of surgery:
• To resect the epileptogenic zone, OR
• To disconnect avenues of seizure spread
Types of surgery
• Lesionectomy
• Temporal Lobectomy
• Hemispherectomy
• Corpus Callosotomy
• Multiple Subpial Transections
• Radiosurgery
• Vagal nerve stimulators
35. Hemispherectomy
Indications: Secondary generalized seizures where focus is large or
multifocal involving only one hemisphere
• Anatomical Hemispherectomy :- Epileptogenic hemisphere is
usually severely dysfunctional with Hemiparesis & Language
mediated by the contralateral hemisphere
•Therefore extensive resection may be justified.
Anatomic Hemispherectomy Functional Hemispherectomy
36. • Functional Hemispherectomy:- A “window” of cortex
may be removed to then make the appropriate white
matter transections.
White matter tracts that are disconnected
–Corpus Callosum
–Coronal radiata/internal capsule
–Fornix
–Anterior Commisure
–Outflow tracts of the amygdala
38. Multiple Subpial Transections
Typical Indications:
Epileptogenic zone in
dominant eloquent
cortex
A “disconnection” type
procedure to avoid
resecting eloquent
structures:
39.
40. Vagal Nerve Stimulation
• Simple device with two electrodes anchored and
looped around the mid-cervical portion of left vagus
nerve.
• Causes on demand summation to abort or deintensify
oncoming seizures.
• Indications: Medically intractable seizures in >12 yrs
old patient who is not suitable or willing for surgical
management.
• Adverse effects: Laryngeal irritation; Hoarseness;
Cough; SOB in COPD; Change in voice quality;
Bradycardia; Periodic apnoea; Cardiac arrest
• To be careful in MRI, Monopolar diathermy.
41. Anaesthetic Considerations
• Anaesthesia for ECog Monitoring:
1) Effect of Anaesthetic agents on Ecog output.
2) Usage of agents and techniques to increase
epileptiform activity (Opioids, Hyperventilation, low
dose Methohexital)
3) Awake craniotomy is the best option.
• Anaesthesia for Surgeries near eloquent cortex:
1. Anaesthetic technique – Awake craniotomy with
conscious sedation or asleep-awake-asleep
technique with intraop neuropsychological monitoring
of the patient.
2. General Anaesthesia with traditional anaesthesia
practice.
42. • Common Anaesthetic regimens for Awake
craniotomy:-
1) Scalp block and Incision area field block + Propofol/
Opioid/ Dexmedetomidine infusion for sedation.
2) Scalp block + Asleep –awake-asleep technique using
LMA as airway control.
43. Awake Craniotomy vs. GA
• Gupta et al (2007) studied 53 patients with intrinsic eloquent
cortex lesions and compared Awake craniotomy vs GA for
excision of such lesions (with electrophysiologic guidance).
• They found:
1) More than 90% tumor excision was observed in 57% patients in
awake group versus 73.7% in GA group
2) Mean operative time, blood loss was found to be was found to
be less in GA group patients than in awake group.
3) Better tumor cytoreduction, neurological improvement was
seen in GA group (motor improvement in 35.7%, speech
improvement in 62.5%) than in awake group patients (motor
improvement in 18.7%, speech improvement in 14.3%) – in
immediate postop, with no difference at 3 mths.
However only significant difference was for duration of surgery
parameter.