bluuebunny/crossref_metadata_2025 huggingface dataset:
A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions
Authors: Sawin Paul D. , Traynelis Vincent C. , Menezes Arnold H.
Published: June 2009

Object.Autogeneic bone graft is often incorporated into posterior cervical stabilization constructs as a fusion substrate. Iliac crest is used frequently, although donor-site morbidity can be substantial. Rib is used rarely, despite its accessibility, expandability, unique curvature, and high bone morphogenetic protein content. The authors present a comparative analysis of autogeneic rib and iliac crest bone grafts, with emphasis on fusion rate and donor-site morbidity.

Methods.A review was conducted of records and radiographs from 600 patients who underwent cervical spinal fusion procedures in which autogeneic bone grafts were used. Three hundred patients underwent rib harvest and posterior cervical fusion. The remaining 300 patients underwent iliac crest harvest (248 for an anterior cervical fusion and 52 for posterior fusion). The analysis of fusion focused on the latter subgroup; donor-site morbidity was determined by evaluating the entire group. Fusion criteria included bony trabeculae traversing the donor—recipient interface and long-term stability on flexion—extension radiographs. Graft morbidity was defined as any untoward event attributable to the graft harvest. Statistical comparisons were facilitated by using Fisher's exact test.

Conclusions.Demographic data obtained in both groups were comparable. Rib constructs were placed in the following regions: occipitocervical (196 patients), atlantoaxial (35 patients), and subaxial cervical spine (69 patients). Iliac crest grafts were placed in the occipitocervical (28 patients), atlantoaxial (10 patients), and subaxial cervical (14 patients) regions. Fusion occurred in 296 (98.8%) of 300 rib graft and 49 (94.2%) of 52 iliac crest graft constructs (p = 0.056). Graft morbidity was greater with iliac crest than with rib (p < 0.00001). Donor-site morbidity for the rib graft was 3.7% and included pneumonia (eight patients), persistent atelectasis (two patients), and superficial wound dehiscence (one patient). Pneumothorax, intercostal neuralgia, and chronic chest wall pain were not encountered. Iliac crest morbidity occurred in 25.3% of the patients and consisted of chronic donor-site pain (52 patients), wound dehiscence (eight patients), pneumonia (seven patients), meralgia paresthetica (four patients), hematoma requiring evacuation (three patients), and iliac spine fracture (two patients). Even when chronic pain was not considered, morbidity encountered in obtaining iliac crest still exceeded that encountered with rib harvest (p = 0.035).

The fusion rate and donor-site morbidity for rib autograft compare favorably with those for iliac crest when used in posterior cervical constructs. To the authors' knowledge, this represents the largest series to date in which the safety and efficacy of using autogeneic bone graft materials in spinal surgery are critically analyzed.
Intracranial repair of a divided trochlear nerve
Authors: van Overbeeke Jacobus J. , Cruysberg Johannes R. M. , Menovsky Tomas
Published: June 2009

✓ The authors report the case of a 37-year-old woman in whom the trochlear nerve was transected during removal of a meningioma in the cavernous sinus and subsequently repaired by using microsurgical techniques. This patient presented with a tumor in the posterior part of the right cavernous sinus with expansion over the tentorium. Preoperatively, she suffered from partial deficit of the right trochlear nerve. Intraoperatively, the trochlear nerve was noted to be completely encased by the tumor and was totally divided during removal of the lesion. After tumor resection, the trochlear nerve was repaired by using a sural nerve fascicle secured with sutures and fibrin glue. Six months after the operation, trochlear nerve regeneration became evident as the patient's binocular vision gradually improved. The patient regained normal functioning of the superior oblique muscle 3.5 years after surgery. It is concluded that repair of a divided trochlear nerve is worthwhile and can be followed by successful regeneration and an excellent functional recovery of the superior oblique muscle.
Role of surgical resection in the treatment of hypothalamic hamartomas causing precocious puberty
Authors: Stewart Laura , Steinbok Paul , Daaboul Jorge
Published: June 2009

✓ Hypothalamic hamartomas (HHs) are benign tumors that are often associated with central precocious puberty. Resection of HHs has been recommended as a treatment option for selected cases of pedunculated lesions, especially in young children. The role of surgery has to be evaluated in the light of the availability of effective medical treatment with gonadotropin-releasing hormone analogs (GnRHas). The authors report the long-term results of total resection of HHs in two children with central precocious puberty and compare it with medical management in four children.

The two surgically treated patients underwent total resection of pedunculated HHs at 1.75 (Case 1) and 3.25 years (Case 2) and have received follow-up care for 9 and 8 years, respectively. There were no postoperative complications and computerized tomography scanning confirmed complete tumor removal in both patients. Both patients subsequently experienced some regression of secondary sexual characteristics. The response of luteinizing hormone to GnRH became prepubertal in one patient and was diminished in the other. However, the growth velocity remained elevated (> 7 cm/year), bone age remained advanced (> +2 standard deviations) 5 years after surgery, decreasing adult height prediction. In one child, GnRHa therapy was initiated 7 years postsurgery.

Four children were treated solely with GnRH agonists and have received follow-up care for 2.3, 6, 9, and 9 years, respectively. These patients have had a complete regression of endocrinological abnormalities, including a normalization of growth velocity and reduction in the rate of skeletal maturation. No side effects were noted with decapeptyl treatment, and one child developed sterile abscesses while receiving Lupron-Depot.

The proven efficacy of GnRHa in suppressing puberty and reducing bone age advancement leads the authors to advise against surgery as the initial management of central precocious puberty caused by HHs.
Role of intraoperative angiography in the surgical treatment of cerebral aneurysms
Authors: Payner Troy D. , Horner Terry G. , Leipzig Thomas J. , Scott John A. , Gilmor Richard L. , DeNardo Andrew J.
Published: June 2009

The benefit of using intraoperative angiography (IA) during aneurysm surgery is still uncertain.

Object. In this prospective study, the authors evaluate the radiographically demonstrated success of surgical treatment in 151 consecutive patients harboring 173 aneurysms who selectively underwent IA examination. The authors also assess the frequency with which IA led to repositioning of the aneurysm clip.

Methods. Intraoperative angiography was used selectively in this series, based on the surgeon's concern about the potential for residual aneurysm, distal branch occlusion, or parent vessel stenosis. Specific variables were analyzed to determine their impact on the incidence of clip repositioning and the accuracy of IA was evaluated by direct comparison with postoperative angiography (PA) in 90% of the cases in which IA was used.

Conclusions. The selective use of IA led to successful treatment as shown by PA, with a low incidence of unexpected residual aneurysm (3.2%), distal branch occlusion (1.9%), and parent vessel stenosis (0%). Intraoperative angiography led to immediate repositioning of the aneurysm clip in 27% of the cases. Anterior cerebral artery aneurysms required clip repositioning less often and superior hypophyseal artery aneurysms required repositioning more often than aneurysms in other locations. Large and giant aneurysms required clip repositioning more often than small aneurysms; however, they were also more likely to display false success on IA as determined by PA. Aneurysms arising along the internal carotid artery were more likely to display successful clipping on IA, as determined by PA, than were aneurysms in other locations.

The results of this series support the selective use of IA in the treatment of complex aneurysms, particularly large and giant aneurysms as well as superior hypophyseal artery aneurysms. As measured by PA, IA will improve the outcome of these patients.
Ventricular shunt removal: the ultimate treatment of the slit ventricle syndrome
Authors: Baskin Jonathan J. , Manwaring Kim H. , Rekate Harold L.
Published: June 2009

Object. The aim of this study was to assess the effectiveness of an algorithm used to evaluate and prescribe treatment for patients having slit ventricle syndrome (SVS).

Methods. All patients included in this protocol underwent fiberoptic intracranial pressure monitoring after removal or externalization of their ventricular shunt systems. A significant number of patients did not need extracranial cerebrospinal fluid (CSF) diversion and tolerated removal of their shunt systems without requiring further intervention. Patients who demonstrated a need for CSF drainage underwent an endoscopic third ventriculostomy, regardless of the putative cause of their hydrocephalus. Sixteen (72.7%) of 22 patients experienced resolution of or significant improvement in their SVS complaints after their inclusion in the protocol. Concomitantly, 14 (64%) of 22 patients were no longer shunt dependent after a mean follow-up period of 21.4 months.

Conclusions. A significant number of patients debilitated by SVS may experience improvement in their symptoms and undergo shunt removal according to this protocol, improving their quality of life and simplifying their medical follow up.
Vascular endothelial growth factor expression and vascular density as prognostic markers of survival in patients with low-grade astrocytoma
Authors: Abdulrauf Saleem I. , Edvardsen Klaus , Ho Khang L. , Yang Xiao Yi , Rock Jack P. , Rosenblum Mark L.
Published: June 2009

It has long been recognized that some patients with low-grade astrocytoma may survive for many years, whereas in others the disease follows a more malignant course resulting in a short survival time, usually due to malignant transformation into higher-grade tumors.

Object. The aim of this study was to investigate angiogenesis in the initial biopsy specimen of tumor tissue as a biological marker to identify patients with low-grade astrocytoma who are at high risk of malignant tumor transformation or death.

Methods. Tumor tissue was studied in 74 consecutively treated adult patients in whom a diagnosis of diffuse supratentorial hemispheric histologically proven fibrillary low-grade astrocytoma was made and who underwent surgery between January 1972 and January 1994. Studies were conducted using monoclonal antibodies to the antigens of the proliferation-associated Ki-67 (MIB-1), factor VIII, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and epidermal growth factor (EGF).

The overall 5-year survival rate for the entire patient population was 65%, with a median survival time of 7.5 years. The total mean follow-up period was 6.1 years. All tumors showed a low proliferative potential at the time of the initial operation, as demonstrated by an MIB-1 labeling index of less than 1.5%. Patients with more than seven microvessels in tumor tissue (29 cases) had a shorter survival time (mean 3.8 years) than those with seven or fewer microvessels (mean survival 11.2 years). This difference in survival times was significant by univariate (p = 0.001) and stepwise multivariate analyses (p < 0.001). Tumors with a larger number of microvessels also had a greater chance of undergoing malignant transformation (p = 0.001). Similarly, significant staining for VEGF was correlated with shorter survival times when using univariate (p = 0.003) and multivariate (p = 0.008) analyses and with a greater chance of malignant transformation (p = 0.002). Patients with tumors staining positive for VEGF (39 individuals) had a median survival time of 5.3 years, and those with tumors negative for VEGF (35 patients) had a median survival time of 11.2 years. No association was observed between bFGF, EGF, and survival or malignant transformation. The stepwise multivariate analysis included histological and clinical variables simultaneously.

Conclusions. The authors have shown that microvessel density and VEGF levels are independent prognostic markers of survival in fibrillary low-grade astrocytoma. This finding leads them to propose that fibrillary diffuse low-grade astrocytoma is not a single pathological entity but is composed of a spectrum of tumors with differing propensities to undergo malignant transformation that is at least partly based on their inherent angiogenic potential.
Sensitization of rat glioblastoma multiforme to cisplatin in vivo following restoration of wild-type p53 function
Authors: Dorigo Oliver , Turla Sally T. , Lebedeva Svetlana , Gjerset Ruth A.
Published: June 2009

Object. To study the combined potential of wild-type p53 gene transfer and administration of cisplatin for the treatment of glioblastoma multiforme, the authors used the 9L rat glioblastoma cell line, which expresses a mutant p53.

Methods. Stable expression of wild-type p53 in 9L cells was achieved by transfection of the cells with a wild-type p53—expressing plasmid (pCEP4p53). The resultant cell line, 9LpCEP4p53, was found to be more sensitive to cisplatin treatment in vitro than control (9LpCEP4) cells. The in vitro growth rates of control cells and wild-type p53—modified cells were similar in the absence of cisplatin.

Fischer 344 rats were implanted intracerebrally with 9LpCEP4p53 cells and intraperitoneally administered 4 mg/kg cisplatin weekly for 7 weeks. These animals survived significantly longer than animals that were implanted with 9LpCEP4p53 cells but were given no cisplatin treatment. In contrast, concurrent cisplatin treatment provided no benefit for animals implanted with 9LpCEP4 cells. Tumors that developed in animals that had been implanted with 9LpCEP4p53 cells and treated with cisplatin had lost expression of wild-type p53, indicating a correlation between expression of wild-type p53 and cisplatin sensitivity in vivo.

Conclusions. The findings of this study suggest that p53-based gene therapy in combination with cisplatin-based chemotherapy may be superior to single-modality treatment in dealing with glioblastoma multiforme.
Familial meningioma: analysis of expression of neurofibromatosis 2 protein Merlin
Authors: Maxwell Marius , Shih Sarah D. , Galanopoulos Theofanis , Hedley-Whyte E. Tessa , Cosgrove G. Rees
Published: June 2009

✓ Meningiomas are primarily benign brain tumors thought to arise through multistep tumorigenesis, involving both the activation of oncogenes and the loss of tumor suppressor genes. The recently isolated neurofibromatosis 2 (NF2) tumor suppressor gene has been found to be mutated in a large proportion of meningiomas. Almost all cases of familial meningioma occur in association with NF2. Familial meningioma in isolation from NF2 (sporadic) is exceedingly rare, with only 14 reports since 1959. The authors report the existence of a family lacking any stigmata of NF2, in which two members had spinal meningiomas. Tumor specimens were subjected to immunocytochemical analysis for the NF2 protein product Merlin, which has been implicated in the tumorigenesis of meningioma. Merlin immunoreactivity was present in both tumor specimens, implying that the NF2 tumor suppressor gene was not deleted in these tumors. This supports the hypothesis that a second tumor suppressor gene locus, other than NF2, acts in the formation of familial sporadic meningioma. The results are discussed in the context of putative oncogenic mechanisms of familial meningiomas.
Long-term survival in rhinocerebral mucormycosis
Authors: Weprin Bradley E. , Hall Walter A. , Goodman Jesse , Adams George L.
Published: June 2009

✓ Mucormycosis refers to a group of rapidly progressive infections caused by fungi belonging to the order Mucorales. Infection most often develops in individuals with immunological or metabolic compromise, although patients without underlying abnormalities have been affected. Specific clinical manifestations are associated with various predisposing factors. Rhinocerebral mucormycosis is the most common form and most frequently develops in individuals with poorly controlled diabetes mellitus. The extent of anatomical involvement and clinical course are unpredictable, depending on the intrinsic factors of the host. Over the past 20 years the prognosis for patients with rhinocerebral mucormycosis, once considered to be a uniformly fatal disease, has improved. Coordinated medical and surgical treatment, including rapid diagnosis, the advent of systemic antifungal agents, aggressive surgical debridement, and control of the underlying disease process, have been credited with its successful management. The range of survival rates recorded with the regimen of combined therapies is wide because the number of patients reported is limited and anatomical involvement is diverse. Survival with intracerebral abscess is rare.

The authors describe the successful management of a patient who developed a bifrontal fungal abscess during treatment for rhinocerebral mucormycosis associated with ketoacidosis and diabetes mellitus. The patient remains without radiographic or clinical evidence of infection more than 2 years after treatment. The authors review the characteristic clinical, radiographic, and pathological features of previously reported infections and emphasize the importance of early detection and aggressive treatment in the management of this frequently fulminant and fatal disease.
Possible common origin of α-fetoprotein- and human chorionic gonadotropin—secreting cells in intracranial germ cell tumor
Authors: Kishima Haruhiko , Shimizu Keiji , Miyao Yasuyoshi , Mabuchi Eiichiro , Hayakawa Toru
Published: June 2009

✓ A primary intracranial germ cell tumor in a 16-year-old boy secreted both a-fetoprotein (AFP) and human chorionic gonadotropin (HCG). The tumor, located in the right thalamus, contained germinomatous, trophoblastic, and endodermal sinus components. To identify AFP- and HCG-secreting cells, germ cells from the surgical specimen were cultured in vitro. These cultured cells secreted AFP and HCG for 10 weeks, and immunohistochemical studies showed that some of the cells secreted both AFP and HCG. These findings suggest that multipotential germ cells migrate to the encephalic region and may become germ cell tumors containing various types of tissue.
Basal perforating artery aneurysm within the cavum septi pellucidi
Authors: Yanaka Kiyoyuki , Meguro Kotoo , Narushima Kiyoshi , Takano Shingo , Doi Mikio , Nose Tadao
Published: June 2009

✓ The authors describe the case of a 16-year-old boy presenting with clinical onset of subarachnoid hemorrhage. The patient was found to have a small aneurysm arising from the distal portion of a basal perforating branch of the anterior cerebral artery (ACA), lying within a cavum septi pellucidi. Neuroimaging demonstrated a hematoma within the cavum septi pellucidi and the aneurysm was resected via a transcallosal approach guided by an intraoperative portable digital subtraction angiography (DSA) system. The origin of the aneurysm was presumed to be idiopathic. This report is the first to describe an aneurysm of a basal perforating artery arising from the ACA that resulted in an intracaval hematoma. When approaching small vascular lesions during surgery, intraoperative DSA is the method of choice to identify the precise trajectory and distance to the lesions.
Reversibility of functionally injured neurotransmitter systems with shunt placement in hydrocephalic rats: implications for intellectual impairment in hydrocephalus
Authors: Tashiro Yuzuru , Drake James M.
Published: June 2009

Intellectual impairment has been related to alteration of neuronal innervation in the following regions: cholinergic basal forebrain nuclei (Ch1–Ch6, learning and memory), dopaminergic ventral tegmental area (emotional control), and noradrenergic locus ceruleus (cognition). Recent studies have implicated neuronal injury in the pathogenesis of hydrocephalus.

Object. The authors used immunohistochemical techniques to investigate functional injury in these regions in animals with progressive hydrocephalus, following shunt placement for cerebrospinal fluid (CSF) drainage.

Methods. Hydrocephalus was induced in 20 Wistar rats by intracisternal injection of 0.05 ml of 25% kaolin solution. Four control animals (Group 1) received the same volume of saline. Ventriculoperitoneal shunts were inserted in eight rats at 2 and 4 weeks after kaolin injection and the animals were killed at 8 weeks (Group 2). The other 12 hydrocephalic animals were killed at 2, 4, and 8 weeks without undergoing shunt placement (Group 3). Immunoreactive (IR) neurons to choline acetyltransferase (ChAT) in Ch1–Ch6, tyrosine hydroxylase (TH) in the ventral tegmental area, and dopamine B-hydroxylase (DBH) in the locus ceruleus, as well as IR projection fibers in the terminal areas, were compared between groups. The number of ChAT- and TH-IR neurons in rats with and without shunt placement was counted for quantitative analysis. The number of ChAT-IR neurons was progressively reduced during the development of hydrocephalus in Ch1, Ch2, Ch3, and Ch4 (p < 0.05). Tyrosine-hydroxylase-immunoreactive neurons were also reduced in number, and demonstrated decreased projection fibers and terminals. Early shunting (at 2 weeks) restored ChAT and TH immunoreactivity to control levels, but late shunting (at 4 weeks) did not (p < 0.05). The DBH—IR neurons in the locus ceruleus were remarkably compressed by the dilated fourth ventricle, and diminished immunoreactivity was observed in the terminal areas. Shunt placement for CSF also restored the immunoreactivity in this system.

Conclusions. These findings indicate that a progressive functional injury occurs in the cholinergic, dopaminergic, and noradrenergic systems as a result of hydrocephalus. This may contribute to intellectual impairment and might be prevented by early treatment with shunt placement.
Microanatomy of the hypophyseal fossa boundaries
Authors: Destrieux Christophe , Kakou Médard K. , Velut Stéphane , Lefrancq Thierry , Jan Michel
Published: June 2009

Object.The authors studied the heads of 17 adult cadavers and one fetus to clarify the anatomy of the sellar region, particularly the lateral boundaries of the hypophyseal fossa.

Methods.Vascular injections and microdissection or histological techniques were used in this study. The roof of the cavernous sinuses and diaphragma sellae were part of a single horizontal dural layer that joined the two anterior petroclinoid folds. Laterally, the direction of this layer changed; it became the lateral wall of the cavernous sinus and joined the dura mater of the middle cerebral fossa. On the midline, this layer ballooned toward the sella through the diaphragmatic foramina, created a dural bag containing the hypophysis, and attached to the inferior aspect of the diaphragma sellae. As a consequence, no straight sagittal dural wall existed between the pituitary gland and cavernous sinus; the lateral border of the hypophyseal fossa was part of this anteroposterior and superoinferior convex bag. The authors stress the importance of the venous elements of the region and discuss the structure of the cavernous and coronary sinuses.

Conclusions.Invasion of the cavernous sinus makes surgery more risky and difficult and may necessitate modification of the surgical treatment plan. The preoperative diagnosis of cavernous sinus invasion is thus of great interest, but the possibility of normal lateral expansions of the pituitary gland must be kept in mind. A lateral expansion of this gland into the cavernous sinus was encountered in 29% of the specimens, and an adenoma that developed in such an expansion could easily mimic cavernous sinus invasion.
Prolonged survival in a patient with sinonasal teratocarcinosarcoma with cranial extension
Authors: Terasaka Shunsuke , Medary Max B. , Whiting Donald M. , Fukushima Takanori , Espejo Evalynne J. , Nathan Girija
Published: June 2009

✓ Sinonasal teratocarcinosarcoma is a rare malignant neoplasm characterized by the combined histological features of carcinosarcoma and teratoma. The primary symptoms of this tumor are usually nasal obstruction and epistaxis, and a nasal cavity mass is the most common clinical finding. The authors describe an exceptionally rare case in which the patient presented with massive intracranial extension and exhibited confusion as an initial symptom. He subsequently underwent combined radical surgery and radiation therapy and has remained free of disease for 31 months. The surgical approach to the lesion, histological features, and clinical course are detailed.
Brain metastasis from germinal tumors of the testis
Authors: Yoshida Seiichi , Morii Ken
Published: June 2009

✓ Brain metastasis in patients with disseminated nonseminomatous germ cell tumor (NSGCT) has been considered to occur rarely. The authors present the case of a 43-year-old man with an enlarged left testicle, a palpable inguinal tumor, multiple lung tumors, and a large cerebellar tumor. In separate operations, performed 1 month apart, the large cerebellar tumor and the testicular tumor were excised. Elements of teratocarcinoma, embryonal carcinoma, and choriocarcinoma were present in both the brain and testicular tumors. After chemotherapy in which bleomycin, etoposide, and cisplatin were used, the lung tumors and also the surrounding metastasis disappeared; the patient now leads a useful life and remains free from cancer in all organs. The authors suggest that surgical removal of tumor before initiating radiotherapy and chemotherapy for large brain metastasis from NSGCT will produce better results than using the nonsurgical treatments alone.
Acute quadriplegia with delayed onset and rapid recovery
Authors: Latronico Nicola , Rasulo Frank A. , Recupero Daniela , Beindorf Andrea , Liberini Paolo , Stefini Roberto , Candiani Andrea
Published: June 2009

✓ The authors describe a patient with severe head injury and sepsis who became acutely quadriplegic 3 days postinjury because of a critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), which resolved rapidly after treatment of the underlying infection.

In only 3 days the patient developed septic shock together with flaccid quadriplegia and absent deep tendon reflexes with no clinical or radiological evidence of central nervous system deterioration. Neurophysiological studies showed an acute axonal sensorimotor polyneuropathy, whereas the clinical course strongly suggested a concurrent myopathy. A severe Staphylococcus epidermidis infection accompanied by bacteremia was treated and the patient recovered fully within a few days.

Although the case described here is unique because of its very early onset and rapid resolution, CIP and CIM are frequent complications of sepsis and multiple organ failure. The authors suggest that severely head injured patients with sepsis should be evaluated for CIP and CIM when presenting with unexplained muscle weakness or paralysis.
Unusual occipitoatlantal fracture dissociation with no neurological impairment
Authors: Ide Christophe , Nisolle Jean-François , Misson Nicolas , Trigaux Jean-Paul , Gustin Thierry , De Coene Béatrice , Gilliard Claude
Published: June 2009

✓ The authors describe an unusual case of a complex traumatic fracture-dissociation injury of the craniovertebral junction, which the patient survived with no neurological damage. This case featured the rare combination of an avulsion of both the right occipital condyle and clivus and a fracture of the left lateral mass of the atlas. Because of the craniocervical ligament injury and the slight anterior occipitoatlantal dislocation, the lesion was considered to be unstable and was treated successfully with a cervical collar. The authors emphasize that thin-slice computerized tomography scanning with multiplanar reconstructions is essential to visualize these fractures, whereas magnetic resonance imaging is useful to assess soft tissues.
Development of neurosurgery in Greece: past, present, and future
Authors: Stranjalis George , Singounas Evangelos
Published: June 2009

✓In this study the authors examine the historical tradition as well as current features of neurosurgery in Greece and compare the available data with international standards. In particular, they describe the organizational structure of neurosurgery with reference to manpower, unit distribution, training, and qualification. They discuss problems such as overproduction of neurosurgeons and the poor control of training and qualification procedures in the neurosurgical profession.

The findings are examined in a critical way and solutions are proposed that could improve the present situation.
Catamenial mononeuropathy and radiculopathy: a treatable neuropathic disorder
Authors: Zager Eric L. , Pfeifer Samantha M. , Brown Mark J. , Torosian Michael H. , Hackney David B.
Published: June 2009

Object. The aim of this study was to investigate the indications and treatment options in patients with lower-extremity neuropathies and radiculopathies caused by endometriosis.

Methods. The authors identified five patients whose symptoms included catamenial pain, weakness, and sensory loss involving the sciatic and femoral nerves and multiple lumbosacral nerve roots. Radiographic studies supported the diagnosis of catamenial neuropathy or radiculopathy, but definitive diagnosis depended on surgical and pathological examination. Treatment of symptoms, including physical therapy and a course of antiinflammatory or analgesic medication, was not helpful. Patients responded favorably to hormonal therapy. Laparoscopy or open exploration for extrapelvic lesions was performed for diagnosis or for treatment when hormone therapy failed. Pain and sensory symptoms responded well to therapy. Weakness improved, but never recovered completely.

Conclusions. Catamenial neuropathy or radiculopathy should be considered when evaluating reproductive-age women with recurring focal neuropathic leg pain, weakness, and sensory loss.
Selective intraarterial gene delivery into a canine meningioma
Authors: Chauvet Anne E. , Kesava Prabhakar P. , Goh Chern Sing , Badie Behnam
Published: June 2009

Object. The goal of this study was to evaluate gene delivery to a benign brain tumor.

Methods. A recombinant adenovirus vector bearing the Escherichia coli β-galactosidase reporter gene was selectively injected into the vascular supply of a spontaneously occurring canine olfactory groove meningioma. The tumor and a small amount of peritumoral brain tissue were removed 5 days after viral injection and stained with X-Gal to assess gene delivery. The authors noted significant β-galactosidase gene expression by the tumor, but not by surrounding brain tissue. No obvious viral-related cytotoxicity was noted.

Conclusions. The authors found that meningiomas can be successfully transduced by adenovirus vectors by using endovascular techniques.
Antagonistic effect of insulin-like growth factor I on protein kinase inhibitor—mediated apoptosis in human glioblastoma cells in association with bcl-2 and bcl-x-L
Authors: Toms Steven A. , Hercbergs Aleck , Liu Jinbo , Kondo Seiji , Haqqi Talat , Casey Graham , Iwasaki Koichi , Barnett Gene H. , Barna Barbara P.
Published: June 2009

Object. Tamoxifen (TAM) has been found to be effective in inhibiting proliferation of glioblastoma cells in vitro, but clinical studies have been disappointing. The purpose of this study was to determine whether insulin-like growth factor I (IGF-I), a potential autocrine/paracrine mitogen produced by glioblastomas, interferes with the antimitogenic actions of TAM.

Methods. Human glioblastoma cells were treated with or without TAM and/or IGF-I in vitro and evaluated for: viability by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenol tetrazolium bromide cleavage assay; apoptosis by histochemical analysis of nuclear morphology and 3′-OH DNA fragments; and expression of the IGF-I receptor, and the bcl-2, bcl-xL, and bax proteins by immunoblot analysis. In addition, p53 status was determined by DNA sequencing and by transient transfection with luciferase reporter plasmids containing wild-type or mutant p53. Results indicated that after 72 hours of exposure to 2 mg/ml TAM in vitro, 56.3% of WITG3 and 43.8% of U87-MG glioblastoma cells contained apoptotic nuclei (p < 0.01 compared with untreated cells). Apoptosis was independent of the presence of p53 because the WITG3 cells, in contrast to the U87-MG cells, expressed a mutant, nonfunctional p53. The WITG3 cells expressed IGF-I receptor proteins and demonstrated IGF-I binding. Exogenous IGF-I stimulated WITG3 cell proliferation and significantly (p < 0.05) antagonized the cytotoxic effects of TAM in a dose-dependent fashion; IGF-I, but not TAM, enhanced expression of bcl-2 and bcl-xL proteins; however, bax protein expression was unchanged by either treatment.

Conclusions. Because many gliomas secrete large amounts of IGF-I in autocrine/paracrine growth pathways, these data may, in part, explain the failure of TAM to achieve clinical results as dramatic as those in vitro.
Spinal meningeal melanocytoma presenting with superficial siderosis of the central nervous system
Authors: Matsumoto Shigeo , Kang Yoo , Sato Shinichi , Kawakami Yasuto , Oda Yoshifumi , Araki Manabu , Kawamura Junichiro , Uchida Hiroya
Published: June 2009

✓ Meningeal melanocytoma is a benign melanocytic tumor that originates most frequently from the melanocytes in the posterior fossa or along the spinal cord. This tumor generally occurs as an extraaxial mass that compresses adjacent neural structures to produce various neurological signs. The authors describe an unusual case in which a patient with a meningeal melanocytoma located at the thoracic spinal cord presented with superficial siderosis of the central nervous system (CNS). Extensive neuroradiological studies identified the presence of a spinal cord tumor, and postsurgical histological examination revealed the meningeal melanocytoma as a bleeding source. After surgery, lumbar puncture demonstrated normalization of the patient's cerebrospinal fluid; however, no neurological improvement occurred. The neurological deficits seem irreversible.

Meningeal melanocytoma is biologically benign and can be cured by complete surgical resection; therefore, this tumor should be included in the differential diagnosis of pigmented lesions of the CNS. The authors reviewed 14 cases of well-documented meningeal melanocytoma in the literature and discuss the clinical, radiological, and pathological features of the present case to emphasize the importance of early diagnosis and identification of the source of bleeding in patients with superficial siderosis.
Thoracoscopic microsurgical excision of a thoracic schwannoma
Authors: Dickman Curtis A. , Apfelbaum Ronald I.
Published: June 2009

✓ A 6-cm-diameter schwannoma located at T-2 was resected completely by using transthoracic microsurgical endoscopy. The partially cystic tumor widened the neural foramen and extended into the apex of the right thoracic cavity but did not extend intradurally. The tumor was accessed by means of three 15-mm incisions made in the intercostal spaces. The operative blood loss was only 200 ml, and there were no complications. The patient was discharged on the 2nd postoperative day and returned to full activity 1 week after surgery.

Thoracoscopy provides an excellent alternative to thoracotomy for peripheral thoracic nerve sheath tumors that originate within the neural foramen or more distally along the intercostal nerves within the thorax. An anterior approach is required for intrathoracic tumors but is not suited for intradural tumors. An open posterior or posterolateral approach to the thoracic spine is required for intradural tumors to allow the dura to be closed adequately.
High-flow bypass using the nonocclusive excimer laser—assisted end-to-side anastomosis of the external carotid artery to the P1 segment of the posterior cerebral artery via the sylvian route
Authors: Tulleken Cornelis A. F. , van der Zwan Albert , Jan van Rooij Willem , Ramos Lino Moreira Pereira
Published: June 2009

✓ In a patient with a giant aneurysm of the basilar artery trunk, a vein graft was interposed between the external carotid artery in the neck and the P1 segment of the posterior cerebral artery. Balloon occlusion of both vertebral arteries was performed 3 days later. The sylvian route was used for the grafting procedure and the connection to the posterior cerebral artery was made by using the excimer laser—assisted nonocclusive anastomosis technique.
Spinal hamartomas: a distinct clinical entity
Authors: Morris Gabrielle F. , Murphy Katrina , Rorke Lucy B. , James Hector E.
Published: June 2009

Object.Congenital spinal hamartomas are defined as tumors of well-differentiated mature elements situated in an abnormal location. In this report, the authors document the clinical and pathological features of spinal hamartomas in 10 patients.

Methods.Ten patients presented with midline dorsal malformations at birth, initially diagnosed as teratomas or myelomeningoceles. The locations of the masses were variable: two were located in the thoracic region, four at the thoracolumbar junction, two in the lumbar region, one at the lumbosacral junction, and one in the sacral region. The results of the neurological examination were normal in nine patients. All but one mass had intact skin and seven had palpable bone components. Neuroimaging studies revealed widening of the spinal canal, heterotopic bone located dorsally in some patients, and varying degrees of involvement of the intraspinal contents. During surgery, six patients were found to have involvement of the spinal cord or cauda equina. The pathological characteristics of the masses included three or more of the following: bone, cartilage, synovial membrane, urinary tract tissue, cyst wall, yellow or brown fat, and nerves. The well-differentiated cellular elements, which formed mature structures, along with the absence of primitive cellular components and neoplastic characteristics are more consistent with a diagnosis of hamartoma than teratoma.

Conclusions.In this series, the authors describe a lesion that is overt on physical examination, yet can have occult spinal canal involvement. Complete neurosurgical evaluation is essential to provide appropriate treatment and prognosis.
Changes in cerebral blood flow during PaCO2 variations in patients with severe closed head injury: comparison between the Fick and transcranial Doppler methods
Authors: Ter Minassian Aram , Melon Eliane , Leguerinel Caroline , Lodi Carlo Alberto , Bonnet Françis , Beydon Laurent
Published: June 2009

Object. The aim of this study was to reassess whether middle cerebral artery blood flow velocity (MCAv) variations measured by transcranial Doppler ultrasonography during acute PaCO2 manipulation adequately reflect cerebral blood flow (CBF) changes in patients with severe closed head injury.

Methods. The study was performed by comparing MCAv variations to changes in CBF as assessed by measurements of the difference in the arteriovenous content in oxygen (AVDO2). The authors initiated 35 CO2 challenges in 12 patients with severe closed head injury during the acute stage. By simultaneous recording of systemic and cerebral hemodynamic parameters, 105 AVDO2 measurements were obtained. Patients were stratified into two groups, “high” and “low,” with respect to whether their resting values of MCAv were greater than 100 cm/second during moderate hyperventilation. Four patients displayed an elevated MCAv, which was related to vasospasm in three cases and to hyperemia in one case. The PaCO2 and intracranial pressure levels were not different between the two groups. The slope of the regression line between 1 divided by the change in (Δ)AVDO2 and ΔMCAv was not different from identity in the low group (1/ΔAVDO2 = 1.08 × ΔMCAv − 0.07, r = 0.93, p < 0.001) and significantly differed (p < 0.05) from the slope of the high group (1/ΔAVDO2 = 1.46 × ΔMCAv − 0.4, r = 0.83, p < 0.001).

Conclusions. In patients with severe closed head injury, MCAv variations adequately reflect CBF changes as assessed by AVDO2 measurements in the absence of a baseline increase in MCAv. These observations indicate that both moderate variations in PaCO2 and variations in cerebral perfusion pressure do not act noticeably on the diameter of the MCA. The divergence from the expected relationship in the high group seems to be due to the heterogeneity of CO2-induced changes in cerebrovascular resistance between differing arterial territories.
Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy
Authors: Gerszten Peter C. , Albright A. Leland , Johnstone Graham F.
Published: June 2009

Intrathecal baclofen infusion (IBI) is an effective treatment for spasticity secondary to cerebral palsy (CP).

Object. To assess the need for orthopedic surgery of the lower extremities in such cases, the authors retrospectively reviewed the outcome in 48 patients with spastic CP who were treated with IBI.

Methods. Pumps were placed in 40 patients (84%) suffering from spastic quadriplegia and eight patients (16%) with spastic diplegia. The patients' ages ranged from 5 to 43 years (mean 15 years). The mean follow-up period was 53 months (range 24–94 months). The mean baclofen dosage was 306 µg/day (range 25–1350 µg/day). At the time of pump placement, subsequent orthopedic surgery was planned in 28 patients (58%); however, only 10 (21%) underwent surgery after IBI therapy. In all 10 cases, the surgical procedure was planned at the time of initial evaluation for IBI therapy. In the remaining 18 patients, who did not subsequently undergo their planned orthopedic operation, it was believed that their lower-extremity spasticity had improved to the degree that intervention was no longer indicated. In addition, although six patients had undergone multiple orthopedic operations before their spasticity was treated, no patient required more than one operation after IBI treatment for spasticity.

Conclusions. The authors conclude that IBI for treatment of spastic CP reduces the need for subsequent orthopedic surgery for the effects of lower-extremity spasticity. In patients with spastic CP and lower-extremity contractures, spasticity should be treated before orthopedic procedures are performed.
Combined supra/infratentorial—transsinus approach to large pineal region tumors
Authors: Ziyal Ibrahim M. , Sekhar Laligam N. , Salas Eduardo , Olan Wayne J.
Published: June 2009

Object. The authors sought to confirm that the combined supra/infratentorial—transsinus approach offers a safer means of resecting large pineal region tumors than other approaches currently being used. The aforementioned method provides a wider exposure of the pineal region with less brain retraction than the infratentorial—supracerebellar or the occipital—transtentorial approach alone and is applicable to some large and giant tumors of this area. This combined approach was used in six patients to remove large pineal region tumors including four tentorial meningiomas, one pineocytoma, and one epidermoid cyst.

Methods. The transverse sinus and tentorium were sectioned after review of preoperative angiographic studies, after taking intraoperative measurements of the venous pressure in the nondominant transverse sinus before and after clipping and while monitoring the somatosensory evoked potentials. The occipital lobe cortex and cerebellum were retracted slightly along the tentorium. Deep veins of the galenic system, the quadrigeminal area, and the tumor were well exposed. Before it was used for tumor resection the approach was studied in five cadaveric head specimens, and the projection of different approaches was compared radiologically.

The tumors were removed in a gross-total manner in all patients, and none of the major veins of the galenic system was injured. Resuturing of the nondominant transverse sinus was performed postoperatively in one patient. One of the six patients experienced transient visual loss, and another suffered mild right sixth cranial nerve paresis; however, both recovered in 3 weeks. The wide exposure of the combined approach was also confirmed on radiological and anatomical studies.

Conclusions. The combined supra/infratentorial—transsinus approach is preferred for the resection of certain large pineal region tumors.
Symptomatic hamartoma of the spinal cord associated with neurofibromatosis type 1
Authors: Brownlee Richard D. , Clark Arthur W. , Sevick Robert J. , Myles S. Terence
Published: June 2009

✓ The authors present a case in which a symptomatic hamartoma was found in the spinal cord of a patient with neurofibromatosis type 1 (NF-1). This 52-year-old woman presented with painful urinary incontinence. Magnetic resonance (MR) imaging revealed an intramedullary lesion within the lower thoracic spinal cord and conus medullaris, which was surgically removed. Pathological investigation showed a hamartomatous lesion consisting of glial cells, ganglion cells, abundant disoriented axons, and thin-walled vessels. This case provides a pathological correlate to the hamartomatous lesions demonstrated on MR imaging in patients with NF-1 and illustrates that these benign lesions may become symptomatic and require neurosurgical intervention.
Malignant meningioma of the oculomotor nerve without dural attachment
Authors: Hart Alister J. , Allibone James , Casey Adrian T. H. , Thomas David G. T.
Published: June 2009

✓ Meningiomas, thought to arise from arachnoid cap cells, are usually attached to the dura. Malignancy is present in approximately 1% of these tumors. The authors report the case of a patient with a malignant meningioma arising from the oculomotor nerve with no dural attachment. The patient presented with a 7-month history of left-sided ptosis and diplopia. Magnetic resonance imaging demonstrated an extrinsic mass compressing the root of the oculomotor nerve at its exit from the midbrain. During surgery, a left-sided subtemporal approach revealed the tumor to be arising from the oculomotor nerve. Histological investigation showed a malignant spindle cell lesion with an immunohistochemical profile that was consistent with malignant meningioma. To the authors' knowledge, this is the first documented case of a malignant meningioma arising from the oculomotor nerve.
Palatal myoclonus induced by extirpation of a cerebellar astrocytoma
Authors: Nishigaya Kazuyuki , Kaneko Masami , Nagaseki Yoshishige , Nukui Hideaki
Published: June 2009

✓ A 45-year-old woman developed a rare case of palatal myoclonus with no other neurological signs after undergoing extirpation of a small cerebellar low-grade astrocytoma that was located in the right dentate nucleus. The palatal myoclonus has persisted for 4 years after the operation. Magnetic resonance T2-weighted imaging revealed a high-intensity lesion in the left inferior olive. Palatal myoclonus associated with the removal of cerebellar tumors is unusuall but may easily be overlooked.