bluuebunny/crossref_metadata_2025 huggingface dataset:
Ruptured anterior communicating artery aneurysm encased in a tuberculum sellae meningioma
Authors: Ogino Masahiro , Nakatsukasa Masashi , Nakagawa Toru , Murase Ikuro
Published: May 2009

✓ This 70-year-old woman suffered a subarachnoid hemorrhage (SAH) from a ruptured anterior communicating artery aneurysm encased in a meningioma in the tuberculum sellae. Although preoperative magnetic resonance imaging disclosed that the aneurysmal complex was completely enclosed in the tumor, angiographic studies did not reveal arterial narrowing. The embedded aneurysm caused diffuse SAH rather than intratumoral hemorrhage. These factors indicated very little adhesion between the tumor and the encased arteries. Surgery was performed on the 20th day post-SAH. Intraoperative findings revealed that the tumor did not adhere to the enclosed vasculature except at the point of rupture of the aneurysm. The authors were able to clip the aneurysm safely after piecemeal removal of the tumor, which was finally extirpated without fear of aneurysm rupture. Careful stepwise procedures were essential to treat the aneurysm and the tumor simultaneously.
Fatal secondary increase in serum S-100B protein after severe head injury
Authors: Raabe Andreas , Seifert Volker
Published: May 2009

✓ The S-100B protein is a small cytosolic protein that is found in astroglial or Schwann cells. It is highly specific for brain tissue and is increasingly being investigated as a diagnostic tool to assess the neurological damage after head injury, stroke, subarachnoid hemorrhage, and cardiopulmonary bypass.

The authors report on three patients with severe head injury with otherwise normal cerebral perfusion pressure, SaO2, PaCO2, and controlled intracranial pressure (ICP), in whom a secondary excessive increase in serum S-100B was observed. In all cases, the S-100B increase was followed by an increase in ICP. All three patients died within 72 hours after the excessive increase in S-100B. These findings indicate that major secondary brain damage may occur at a cellular level without being identified by current neuromonitoring techniques.
Stereotactic radiofrequency ablation for the treatment of gelastic seizures associated with hypothalamic hamartoma
Authors: Parrent Andrew G.
Published: May 2009

✓ The author presents the case of a patient with gelastic seizures associated with a hypothalamic hamartoma, in whom partial resection of the hamartoma followed by temporal lobectomy and orbitofrontal corticectomy failed to reduce the seizures. Subsequent stereotactic radiofrequency ablation of the hamartoma resulted in progressive improvement in the seizure disorder during a 28-month follow-up period.

There is support in the literature for the concept that gelastic seizures originate directly from the hamartoma; however, direct surgical approaches to these lesions pose significant risks. It is proposed that the technique of radiofrequency ablation provides a minimally invasive, low-risk approach for the treatment of hypothalamic hamartomas.
Posteroventral pallidotomy for midbrain tremor after a pontine hemorrhage
Authors: Miyagi Yasushi , Shima Fumio , Ishido Katsuya , Moriguchi Masashi , Kamikaseda Kazufumi
Published: May 2009

✓ This 49-year-old man gradually developed a disabling action tremor in the proximal right upper extremity 8 months after suffering a pontine tegmental hemorrhage. The intraoperative microrecording in the nucleus ventralis intermedius (VIM) of the left thalamus revealed tremor-synchronous grouped discharges with a vigorous (2.7 Hz) action tremor predominantly in the shoulder and upper arm. High frequency electrical stimulation in the VIM did not affect the tremor. A posteroventral pallidotomy (PVP) was performed and resulted in the successful alleviation of all tremor activity. Posteroventral pallidotomy is known to alleviate parkinsonian tremors, especially those occurring in the contralateral lower extremity, trunk, and proximal segment of the contralateral upper extremity. The authors consider the pallidoreticular pathway to be an important tremor-mediating pathway for the proximal segment of the upper extremities and believe it can be controlled more effectively by PVP than by VIM thalamotomy, as demonstrated by the PVP-induced resolution of the midbrain tremor observed in this case.
Transciliary subfrontal craniotomy for anterior skull base lesions
Authors: Sánchez-Vázquez Miguel A. , Barrera-Calatayud Pablo , Mejia-Villela Manuel , Palma-Silva Julio F. , Juan-Carachure Isidro , Gomez-Aguilar Jose M. , Sanchez-Herrera Federico
Published: May 2009

✓ Microsurgical approaches are the procedures of choice for high-risk patients with lesions requiring surgical treatment. The use of a microscope reduces the extent of the surgical invasion, thus minimizing the handling of healthy tissues. The authors present a surgical approach described for the first time in 1981, which has been used for the past 17 years in more than 260 patients with different tumors and vascular lesions of the anterior cranial fossa. The modification set forth in this article makes better exposure possible, allows more space for instrument handling, and improves cosmetic results. This particular report was based on the treatment of 41 patients who were observed for longer than 3 months. All of the patients were satisfied with the cosmetic result.
Localization of hand motor activation in Broca's pli de passage moyen
Authors: Boling Warren , Olivier André , Bittar Richard G. , Reutens David
Published: May 2009

Object. The object of this study was to identify a reliable surface landmark for the hand motor area and to demonstrate that it corresponds to a specific structural component of the precentral gyrus.

Methods. Positron emission tomography (PET) activation studies for hand motor function were reviewed in 12 patients in whom magnetic resonance imaging results were normal. Each patient performed a hand opening and closing task. Using a computer-assisted three-dimensional reconstruction of the surface of each hemisphere studied, the relationship of the hand motor area with cortical surface landmarks was evaluated.

Conclusions. The region of hand motor activation can be reliably identified on the surface of the brain by assessing anatomical relationships to nearby structures. After identification of the central sulcus, the superior and middle frontal gyrus can be seen to arise from the precentral gyrus at a perpendicular angle. A bend or genu in the precentral gyrus is constantly seen between the superior and middle frontal gyrus, which points posteriorly (posteriorly convex). The location of hand motor function, identified using PET activation studies, is within the central sulcus at the apex of this posteriorly pointing genu. The apex of the genu of the precentral gyrus leads to a deep cortical fold connecting the pre- and postcentral gyri and elevating the floor of the central sulcus. This deep fold was described by Paul Broca as the pli de passage fronto-pariétal moyen, and the precentral bank of the pli de passage represents the anatomical substratum of hand motor function. Observers blinded to the results of the activation studies were able to identify the hand motor area reliably after instruction in using these surface landmarks.
Noninvasive evaluation of the malignant potential of intracranial meningiomas performed using proton magnetic resonance spectroscopy
Authors: Shiino Akihiko , Nakasu Satoshi , Matsuda Masayuki , Handa Jyoji , Morikawa Shigehiro , Inubushi Toshiro
Published: May 2009

Object. Controversy exists about correlations between histological tumor grade and magnetic resonance (MR) spectroscopy data. The authors studied single-voxel proton MR spectroscopy as a noninvasive way to evaluate grade of malignancy in intracranial meningiomas.

Methods. The authors compared the results of MR spectroscopy with those derived by the MIB-1 staining index (SI) in 29 meningiomas. Proton MR spectroscopy was performed using stimulated echo acquisition and volume-localized solvent-attenuated proton nuclear MR sequences before surgery or other therapy.

Twenty-four tumors were histologically benign (13 meningothelial, three fibrous, four transitional, three angiomatous, and one chordoid); four were atypical (Grade II), and one was papillary (Grade III). The mean MIB-1 SI in the benign group was significantly lower than those in the other groups (p = 0.0041). The mean choline-containing compound (Cho)/creatine and phosphocreatine (Cr) ratios in the benign and nonbenign groups were 2.56 ± 1.26 and 7.85 ± 3.23, respectively (p = 0.0002). A significant linear correlation was observed between the Cho/Cr ratio and the MIB-1 SI (r0.05 = 0.74, p < 0.001). Necrosis was present histologically in four of the five meningiomas classified either as atypical or papillary. Magnetic resonance spectroscopy revealed a methylene signal in these meningiomas that was not detected in benign meningiomas. Of the five meningiomas in which only a lactate signal was observed, two were benign and the MIB-1 SI in these two benign meningiomas was higher than the mean value for the benign group. Alanine, detected in 12 of 30 meningiomas, did not correlate with either tumor grade or Cho/Cr ratio.

Conclusions. Proton MR spectroscopy is a useful diagnostic method for determining the proliferative or malignant potential of meningiomas according to the Cho/Cr ratio. A lactate and/or methylene signal suggests a high-grade tumor.
Apoptotic elimination of peripheral T lymphocytes in patients with primary intracranial tumors
Authors: Morford Lorri A. , Dix Amy R. , Brooks William H. , Roszman Thomas L.
Published: May 2009

Object. Patients with gliomas exhibit severe T lymphopenia during the course of the disease. This study was conducted to determine the mechanism(s) responsible for the lymphopenia.

Methods. Using two-color fluorescent staining techniques, the authors show that significant numbers of T cells undergo apoptosis in the peripheral blood of patients with gliomas. To determine whether a glioma-derived factor(s) induces this apoptosis, rosette-purified T cells obtained from healthy donors were treated with glioma cell culture supernatant (GCCS) and examined for apoptosis. It is demonstrated that treatment of normal T cells with GCCS induced apoptosis only with concurrent stimulation of the T-cell receptor/CD3 complex. The addition of neutralizing antibodies to interleukin (IL)-10, IL-4, transforming growth factor-α, or tumor necrosis factor-β (lymphotoxin) did not rescue these T cells from apoptosis. Experiments were also conducted in which the degree of monocyte involvement in the induction of T-cell apoptosis was explored. The U937 cells were pretreated for 20 hours with a 1:20 dilution of GCCS. After the removal of GCCS, the U937 cells were cultured in transwell assays with stimulated T cells. Although control U937 cells did not induce apoptosis of the activated T cells, GCCS-pretreated U937 cells induced appreciable apoptosis in normal, stimulated T-cell cultures.

Conclusions. These data indicate that one mechanism by which gliomas cause immunosuppressive effects is the induction of monocytes to release soluble factors that promote activated T-cell apoptosis. The loss of activated T cells leads to T lymphopenia and contributes to the deficiencies in cell-mediated immunity that have been observed during testing of glioma patients' immune function.
Improved efficiency of hypervolemic therapy with inhibition of natriuresis by fludrocortisone in patients with aneurysmal subarachnoid hemorrhage
Authors: Mori Tatsuro , Katayama Yoichi , Kawamata Tatsuro , Hirayama Teruyasu
Published: May 2009

Object. To reduce the risk of ischemic complications in patients with subarachnoid hemorrhage (SAH), hypervolemic therapy is generally advocated. However, such conventional treatment cannot always ensure the maintenance of an effective intravascular volume expansion, because excessive natriuresis and osmotic diuresis occur after SAH. In this prospective study the authors examined the effects of inhibition of natriuresis with fludrocortisone acetate on intravascular volume expansion during hypervolemic therapy.

Methods. Thirty patients with SAH were randomized and divided into two groups: controls (Group 1, 15 patients) and patients treated with 0.3 mg/day of fludrocortisone (Group 2, 15 patients). In all patients sodium and fluid intake levels were in excess of maintenance requirements in an attempt to maintain a positive water balance and a central venous pressure (CVP) of 8 to 12 cm H2O. The mean sodium and water intake levels for 14 days after SAH were significantly reduced by fludrocortisone in Group 2 (487 ± 34.52 mEq/day and 5159.2 ± 249.29 ml/day, respectively; p < 0.01) compared with Group 1 (634.2 ± 42.86 mEq/day and 6611.7 ± 365.67 ml/day). Fludrocortisone significantly reduced the urinary sodium excretion (p < 0.01) and urine volume (p < 0.01) in parallel, and effectively prevented a negative shift in the sodium as well as water balance (p < 0.01). The serum sodium level tended to decrease in Group 1, reaching 135 mEq/L on average, but not in Group 2 (p < 0.01). Hyponatremia in Group 1 was always observed at the optimal range of CVP values. A decrease in serum potassium level within the range of 2.8 to 3.5 mEq/L was transiently noted in 11 patients (73.3%) of Group 2, but was easily corrected. Possible side effects of fludrocortisone, such as pulmonary edema, were not encountered.

Conclusions. Intravascular volume expansion in the presence of excessive natriuresis requires a large sodium and water intake and is often associated with hyponatremia. Inhibition of natriuresis with fludrocortisone can effectively reduce the sodium and water intake required for hypervolemia and prevent hyponatremia at the same time.
Induction of cyclooxygenase-2 messenger RNA after transient and permanent middle cerebral artery occlusion in rats: comparison with c-fos messenger RNA by using in situ hybridization
Authors: Kinouchi Hiroyuki , Huang Haiyen , Arai Shouichi , Mizoi Kazuo , Yoshimoto Takashi
Published: May 2009

Object. Recently, two different cyclooxygenase (COX) genes, COX-1 and -2, were identified. In this study, topographic and chronological profiles of COX-2 messenger (m)RNA and c-fos mRNA expression were investigated using in situ hybridization after focal cerebral ischemia.

Methods. Rats undergoing permanent ischemia were decapitated at 30 and 90 minutes and at 2, 4, 8, and 24 hours after middle cerebral artery (MCA) occlusion, and rats undergoing transient ischemia were decapitated at 4, 8, and 24 hours after MCA occlusion that lasted for either 30 or 90 minutes. After brief transient MCA occlusion, c-fos mRNA was induced in the whole MCA territory, adjacent cortex (cingulate cortex), and distant brain regions such as the hippocampus and substantia nigra. In contrast, COX-2 mRNA was not induced in the ischemic core (lateral striatum) but only in the penumbral area (MCA cortex). Long transient and permanent MCA occlusion did not induce c-fos and COX-2 mRNAs in the ischemic core but strongly induced both mRNAs in the penumbral area (medial striatum and periphery of MCA cortex) and adjacent cortex (cingulate cortex). In brain regions distant from the ischemic territory, although c-fos mRNA was induced in the thalamus, substantia nigra, and hippocampus after extended transient and permanent occlusion, COX-2 mRNA was only induced in the bilateral hippocampi. The induction of COX-2 mRNA persisted in all locations even at 24 hours after MCA occlusion.

Conclusions. The distribution of COX-2 mRNA induction was apparently different from that of c-fos mRNA after MCA occlusion. These results pertaining to COX-2 mRNA agree well with the previous observations of changes in prostaglandin metabolism induced by focal cerebral ischemia. However, whether this induction of the COX-2 gene contributes to the histopathological outcome of cerebral ischemia remains to be elucidated.
Intraosseous orbitosphenoidal cavernous angioma
Authors: Slaba Samy G. , Karam Rita H. , Nehme Jad I. , Nohra George K. , Hachem Kamal S. , Salloum Joseph W.
Published: May 2009

✓ Primary orbital intraosseous angiomas are rare. The authors report the case of a 55-year-old man who harbored a multifocal cavernous angioma in an unusual sphenoorbital location. The lesion was responsible for unilateral exophthalmos and blindness. Characteristic imaging findings, which included a honeycomb pattern on plain x-ray films and computerized tomography scans, a heterogeneous high signal intensity on T2-weighted magnetic resonance images, and slowly flowing venous lakes on power Doppler ultrasonograms and angiograms, are presented and discussed.
Glioblastoma multiforme at the site of metal splinter injury: a coincidence?
Authors: Sabel Michael , Felsberg Jörg , Messing-Jünger Martina , Neuen-Jacob Eva , Piek Jürgen
Published: May 2009

✓ The authors report the case of a man who had suffered a penetrating metal splinter injury to the left frontal lobe at 18 years of age. Thirty-seven years later the patient developed a left-sided frontal tumor at the precise site of the meningocerebral scar and posttraumatic defect. Histological examination confirmed a glioblastoma multiforme adjacent to the dural scar and metal splinters. In addition, a chronic abscess from which Propionibacterium acnes was isolated was found within the glioma tissue. The temporal and local association of metal splinter injury with chronic abscess, scar formation, and malignant glioma is highly suggestive of a causal relationship between trauma and the development of a malignant brain tumor.
En bloc resection of an intracavernous oculomotor nerve schwannoma and grafting of the oculomotor nerve with sural nerve
Authors: Mariniello Giuseppe , Horvat Alenka , Dolenc Vinko V.
Published: May 2009

✓ A case in which a left oculomotor nerve schwannoma treated by en bloc resection of the lesion and grafting of the oculomotor nerve with sural nerve is presented. Recovery of nerve function was partial, but useful and cosmetically good. The last follow-up examination performed 2 years after surgery revealed recovery of function in the elevator muscle of the upper eyelid, together with slight vertical movement of the eye.
Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury
Authors: Juul Niels , Morris Gabrielle F. , Marshall Sharon B. , _ _ , Marshall Lawrence F.
Published: May 2009

Object. Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.

Methods. The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-d-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.

Conclusions. Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.
No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury
Authors: Diringer Michael N. , Yundt Kent , Videen Tom O. , Adams Robert E. , Zazulia Allyson R. , Deibert Ellen , Aiyagari Venkatesh , Dacey Ralph G. , Grubb Robert L. , Powers William J.
Published: May 2009

Object. Hyperventilation has been used for many years in the management of patients with traumatic brain injury (TBI). Concern has been raised that hyperventilation could lead to cerebral ischemia; these concerns have been magnified by reports of reduced cerebral blood flow (CBF) early after severe TBI. The authors tested the hypothesis that moderate hyperventilation induced early after TBI would not produce a reduction in CBF severe enough to cause cerebral energy failure (CBF that is insufficient to meet metabolic needs).

Methods. Nine patients were studied a mean of 11.2 ± 1.6 hours (range 8–14 hours) after TBI occurred. The patients' mean Glasgow Coma Scale score was 5.6 ± 1.8 and their mean age 27 ± 9 years; eight of the patients were male. Intracranial pressure (ICP), mean arterial blood pressure, and jugular venous oxygen content were monitored and cerebral perfusion pressure was maintained at a level higher than 70 mm Hg by using vasopressors when needed. Measurements of CBF, cerebral blood volume (CBV), cerebral metabolic rate for oxygen (CMRO2), oxygen extraction fraction (OEF), and cerebral venous oxygen content (CvO2) were made before and after 30 minutes of hyperventilation to a PaCO2 of 30 ± 2 mm Hg. Ten age-matched healthy volunteers were used as normocapnic controls.

Global CBF, CBV, and CvO2 did not differ between the two groups, but in the TBI patients CMRO2 and OEF were reduced (1.59 ± 0.44 ml/100 g/minute [p < 0.01] and 0.31 ± 0.06 [p < 0.0001], respectively). During hyperventilation, global CBF decreased to 25.5 ± 8.7 ml/100 g/minute (p < 0.0009), CBV fell to 2.8 ± 0.56 ml/100 g (p < 0.001), OEF rose to 0.45 ± 0.13 (p < 0.02), and CvO2 fell to 8.3 ± 3 vol% (p < 0.02); CMRO2 remained unchanged.

Conclusions. The authors conclude that early, brief, moderate hyperventilation does not impair global cerebral metabolism in patients with severe TBI and, thus, is unlikely to cause further neurological injury. Additional studies are needed to assess focal changes, the effects of more severe hyperventilation, and the effects of hyperventilation in the setting of increased ICP.
Temporal lobectomy in children: cognitive outcome
Authors: Westerveld Michael , Sass Kimberlee J. , Chelune Gordon J. , Hermann Bruce P. , Barr William B. , Loring David W. , Strauss Esther , Trenerry Max R. , Perrine Kenneth , Spencer Dennis D.
Published: May 2009

Object. The authors sought to determine the impact of early temporal lobectomy (in patients younger than age 17 years) on intellectual functioning. The efficacy of temporal lobectomy for treating seizures is well established and the procedure is becoming more acceptable as a treatment for children whose seizures are intractable. However, cognitive outcomes of temporal lobectomy in children and adolescents are largely unreported. The present study takes advantage of a unique multicenter collaboration to examine retrospectively intellectual functioning in a large sample of children who underwent temporal lobectomy.

Methods. Intellectual functioning was assessed before and after temporal lobectomy for treatment of medication-resistant seizures in 82 patients at eight centers of epilepsy surgery. All children underwent standard presurgical examinations, including electroencephalography—video monitoring, magnetic resonance (MR) imaging, and neuropsychological testing, at their respective centers.

Forty-three children underwent left temporal lobectomy and 39 underwent right temporal lobectomy. For the entire sample, there were no significant declines in intelligence quotient (IQ) following surgery. Children who underwent left temporal lobectomy demonstrated no significant loss in verbal intellectual functioning and improved significantly in nonverbal intellectual functioning. Children who underwent right temporal lobectomy did not demonstrate significant changes in intellectual functioning. Although group scores showed no change in overall IQ values, an analysis of individual changes revealed that approximately 10% of the sample experienced a significant decline and 9% experienced significant improvement in verbal functioning. Significant improvement in nonverbal cognitive function was observed in 16% of the sample and only 2% of the sample showed significant declines. Risk factors for significant decline included older patient age at the time of surgery and the presence of a structural lesion other than mesial temporal sclerosis on MR imaging.

Conclusions. The present study provides preliminary data for establishing the risk of cognitive morbidity posed by temporal lobectomy performed during childhood. With respect to global intellectual functioning, a slight improvement was significantly more likely to occur than a decline. However, there were several patients in whom significant declines did occur. It will be necessary to study further the factors associated with such declines. In addition, further study of more specific cognitive functions, particularly memory, is needed.
Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus
Authors: Tuli Sagun , Drake James , Lawless Jerry , Wigg Melanie , Lamberti-Pasculli Maria
Published: May 2009

Object. Repeated cerebrospinal fluid (CSF) shunt failures in pediatric patients are common, and they are a significant cause of morbidity and, occasionally, of death. To date, the risk factors for repeated failure have not been established. By performing survival analysis for repeated events, the authors examined the effects of patient characteristics, shunt hardware, and surgical details in a large cohort of patients.

Methods. During a 10-year period all pediatric patients with hydrocephalus requiring CSF diversion procedures were included in a prospective single-institution observational study. Patient characteristics were defined as age, gender, weight, head circumference, American Society of Anesthesiology class, and cause of hydrocephalus. Surgical details included whether the procedure was performed on an emergency or nonemergency basis, use of antibiotic agents, concurrent surgical procedures, and duration of the surgical procedure. Details on shunt hardware included: the type of shunt, the valve system, whether the shunt system included multiple or complex components, the type of distal catheter, the site of the shunt, and the side on which the shunt was placed.

Repeated shunt failures were assessed using multivariable time-to-event analysis (by using the Cox regression model). Conditional models (as established by Prentice, et al.) were formulated for gap times (that is, times between successive shunt failures).

There were 1183 shunt failures in 839 patients. Failure time from the first shunt procedure was an important predictor for the second and third episodes of failure, thus establishing an association between the times to failure within individual patients. An age younger than 40 weeks gestation at the time of the first shunt implantion carried a hazard ratio (HR) of 2.49 (95% confidence interval [CI] 1.68–3.68) for the first failure, which remained high for subsequent episodes of failure. An age from 40 weeks gestation to 1 year (at the time of the initial surgery) also proved to be an important predictor of first shunt malfunctions (HR 1.77, 95% CI 1.29–2.44). The cause of hydrocephalus was significantly associated with the risk of initial failure and, to a lesser extent, later failures. Concurrent other surgical procedures were associated with an increased risk of failure.

Conclusions. The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus, there is significant association between repeated failure times for individual patients.
Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition
Authors: Spinner Robert J. , O'Driscoll Shawn W. , Jupiter Jesse B. , Goldner Richard D.
Published: May 2009

Object. Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition.

Methods. Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms.

Conclusions. Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.
Diffusion-weighted magnetic resonance imaging in the early evaluation of corticospinal tract injury to predict functional motor outcome in patients with deep intracerebral hemorrhage
Authors: Karibe Hiroshi , Shimizu Hiroaki , Tominaga Teiji , Koshu Keiji , Yoshimoto Takashi
Published: May 2009

Object. Diffusion-weighted (DW) magnetic resonance imaging was used to visualize corticospinal tract injury in patients with deep intracerebral hemorrhage (ICH), and the results were used to predict motor impairment of the extremities.

Methods. Twenty-eight patients with deep ICH (17 men and 11 women, mean age 58 ± 14 years) were examined. The volume of the ICH was assessed on initial computerized tomography scans. Twelve patients had ICH volumes of 40 ml or more and were treated surgically, and 16 patients who had an ICH volume of less than 40 ml were treated medically. Initial corticospinal tract injury was classified into four grades according to the anatomical relationship between the corticospinal tract and the ICH on DW images. Motor impairment of both the upper and lower extremities was assessed at admission and 1 month poststroke by using the National Institutes of Health Stroke Scale. The extent of correlation was determined between motor impairment and corticospinal tract injury.

Initial corticospinal tract injury was not correlated with the impairment of extremities at admission but was closely correlated with motor impairment of the upper (r = 0.843, p < 0.001) and lower (r = 0.868, p < 0.001) extremities at 1 month poststroke. Impairment of the upper extremities correlated better with anterior than with posterior corticospinal tract injury (r = 0.911 compared with r = 0.600), and impairment of the lower extremities correlated better with posterior than with anterior injury (r = 0.890 compared with r = 0.787).

Conclusions. Early evaluation of corticospinal tract injury based on DW imaging can provide predictive value for motor functional outcome in patients with deep ICH.
Disruption of intracerebral progression of rat C6 glioblastoma by in vivo treatment with anti-CD44 monoclonal antibody
Authors: Breyer Roger , Hussein Sami , Radu Dorel L. , Pütz Klaus-Martin , Gunia Sven , Hecker Hartmut , Samii Madjid , Walter Gerhard F. , Stan Alexandru C.
Published: May 2009

Object. Glioblastoma multiforme (GBM) invasiveness is a complex process that involves recognition and attachment of GBM cells to particular extracellular matrix (ECM) molecules before migrating into proteolytically modified matrix and inducing angiogenesis. The CD44 molecule, which is a transmembrane adhesion molecule found on a wide variety of cells including GBM, has been suggested as the principal mediator of migration and invasion. The aim of the present study was to demonstrate whether an antibody specific to the standard form of CD44 (CD44s, 85–90 kD) might prevent invasion and thus disrupt progression of C6 GBM in vivo.

Methods. Immunostaining demonstrated homogeneous expression of CD44s on the surface of C6 GBM cells and tumors. Flow cytometric analysis demonstrated binding saturation of anti-CD44s monoclonal antibody (mAb) to the receptor at 1 µg/5 × 105 cells. Blocking of CD44s in vitro resulted in a dose-dependent progressive (up to 94 ± 2.7%; mean ± standard deviation [SD]) detachment of C6 cells from ECM-coated culture. Blocking of CD44s in vivo resulted in significantly reduced C6 brain tumors (3.6 ± 0.4% [SD])—measured as the quotient: tumor surface (mm2)/brain surface (mm2) × 100—compared with untreated (19.9 ± 0.9%) or sham-treated (19.2 ± 1.1 to 19.3 ± 2.5% [SD]) rats. Disruption of C6 GBM progression correlated with an improved food intake; treated rats were significantly less cachectic (166.6 ± 16.4 g [SD]) than those that were untreated (83 ± 2.7 g [SD]) or sham-treated (83.4 ± 1.1 to 83 ± 2.2 g [SD]) rats.

Conclusions. The authors conclude that CD44s-targeted treatment with specific mAb may represent an effective means for preventing progression of highly invasive GBMs.
Motor cortex stimulation for central pain and peripheral deafferentation pain
Authors: Saitoh Youichi , Shibata Masahiko , Hirano Shun-ichiro , Hirata Masayuki , Mashimo Takashi , Yoshimine Toshiki
Published: May 2009

✓ The authors tested a modified motor cortex stimulation protocol for treatment of central and peripheral types of deafferentation pain. Four patients with thalamic pain and four with peripheral deafferentation pain were studied. Preoperative pharmacological tests of pain relief were performed using phentolamine, lidocaine, ketamine, thiopental, and placebo. In five patients we placed a 20- or 40-electrode grid in the subdural space to determine the best stimulation point for pain relief for a few weeks before definitive placement of a four-electrode array. In three patients, the four-electrode array was implanted in the interhemispheric fissure as a one-stage procedure to treat lower-extremity pain. In two patients with pain extending from the extremity to the trunk or hip, dual devices were implanted to drive two electrodes.

Six of eight patients experienced pain reduction (two each with excellent, good, and fair relief) from motor cortex stimulation. No correlation was apparent between pharmacological test results and the effectiveness of motor cortex stimulation. Patients with peripheral deafferentation pain, including two with phantom-limb pain and two with brachial plexus injury, attained pain relief from motor cortex stimulation, with excellent results in two cases. Testing performed with a subdural multiple-electrode grid was helpful in locating the best stimulation point for pain relief. Motor cortex stimulation may be effective for treating peripheral as well as central deafferentation pain.
Infantile hemangioendothelioma of the pericranium presenting as an occipital mass lesion
Authors: Carlotti Carlos G. , Jay Venita , Rutka James T.
Published: May 2009

✓ The case of a newborn infant with a large midline mass in the occipital region is presented. Skull x-ray films demonstrated multiple radiolucent defects in the occipital bone. A computerized tomography scan revealed an extracranial mass lesion with marked contrast enhancement. A magnetic resonance image demonstrated that the venous drainage of the lesion passed through the occipital bone into the dural venous sinuses. The anatomy of the hindbrain was normal. The neonate was treated by complete surgical removal of the mass. The histopathological diagnosis was infantile hemangioendothelioma, a tumor commonly found in the liver but rarely in this location. The classification, histopathological characteristics, imaging studies, and treatment of this tumor are discussed.
Solitary sciatic nerve lymphoma as an initial manifestation of diffuse neurolymphomatosis
Authors: Qui£ones-Hinojosa Alfredo , Friedlander Robert M. , Boyer Philip J. , Batchelor Tracy T. , chiocca E. Antonio
Published: May 2009

✓ Solitary peripheral nerve lymphomas are exceedingly rare primary manifestations of diffuse peripheral nervous system or central nervous system (CNS) lymphomatosis. A 52-year-old man presented with progressive weakness in gastrocnemius and anterior tibial muscle function, which was associated with radiating pain in the right leg. Magnetic resonance imaging studies revealed a solitary fusiform tumor, extending from the sciatic nerve, at the level of the lesser trochanter of the femur, into the posterior tibial nerve below the popliteal fossa. Intraoperative gross examination found that the tumor diffusely expanded the nerve, but did not extend from or into surrounding muscle or tendons. The final histological diagnosis was a solitary extranodal lymphoma (Burkittlike high-grade B-cell lymphoma). Postoperative staging did not reveal evidence of lymphomatous involvement of other organs, but additional chemo- and radiotherapies were administered. Four months after the surgical biopsy, the patient presented with a right facial nerve palsy. The results of cytological examination of cerebrospinal fluid were positive for the presence of atypical lymphocytes, which was consistent with apparently progressive neurolymphomatosis; however, the results of radiological studies were negative for systemic progression. The patient underwent intrathecal chemotherapy followed by systemic myelosuppressive chemotherapy with bone marrow rescue, but died of respiratory failure while still receiving treatment. Postmortem examination revealed extensive lymphomatosis in the peripheral nerves and spinal nerve roots without evidence of cranial nerve, CNS, or other organ system involvement. The aggressive biological characteristics of these tumors, their management, and pertinent literature are reviewed.
Digital recording in microsurgery
Authors: Houkin Kiyohiro , Kuroda Satoshi
Published: May 2009

✓ The authors examine the quality of intraoperative photography in which digital recording technology, including a microdigital camera and digital video paired with an operating microscope, is used during neurosurgery. A microdigital camera developed for this purpose (1.4 million pixels) was attached to an operating microscope and used during surgery. The same surgical views with precisely the same optical conditions were taken through the microscope by using both a conventional 35-mm camera and the microdigital camera, and the quality of the final output was compared. In addition, the quality of the digital camera photographs was compared with the still photograph clipped from the digital video recording.

The quality of the photographs taken with a microdigital camera was superior to the quality of those obtained with the conventional 35-mm camera. The success rate of recording (what you see is what you get) was almost 100%. The quality of the still photographs clipped from the digital video was nearly equal to those taken with the digital camera. The microdigital camera system is superior to the conventional 35-mm camera in neurosurgery in terms of its success rate and the quality of the photography. It is also a space-saving system for storing the huge amount of data generated in the recording of surgical procedures, and the cost/performance ratio is superior to that of the conventional method. Digital technology including digital cameras and videos is very useful for clear recording of microsurgical procedures.
Cortical motor and somatosensory representation: effect of cerebral lesions
Authors: Bittar Richard G. , Olivier André , Sadikot Abbas F. , Andermann Frederick , Reutens David C.
Published: May 2009

Object. Changes in cortical representation in patients with cerebral lesions may alter the correlation between cortical anatomy and function. This is of potential clinical significance when the extent of cortical resection is based on surface anatomical landmarks.

Methods. Fifty-one patients with supratentorial lesions were studied. Nineteen harbored noncentral lesions (no involvement of pre- or postcentral gyrus), whereas 32 had central lesions. Control studies consisted of stimulation of the hand contralateral to the unaffected hemisphere. Positron emission tomography activation studies were performed using the [15O]H2O tracer. Somatosensory stimulation of the hand or foot was performed using a mechanical vibrator. Motor activation consisted of hand clenching or foot tapping. The t-statistic volumes were generated from images showing the mean change in regional cerebral blood flow, and coregistered with a T1-weighted magnetic resonance image. At the threshold selected, exclusive contralateral primary sensorimotor cortex activation was elicited in 100% of the control studies. A different pattern of cortical activation was associated with central lesions in 35 (78%) of 45 patients, which occurred significantly more often than with noncentral lesions (eight [31%] of 26 patients). The most common difference in the pattern of activation with central lesions was activation of cortical regions outside the central area (including the supplementary sensorimotor area and the secondary somatosensory cortex). No sensorimotor activation was observed in gyri adjacent to the pre- or postcentral gyrus.

Conclusions. Central lesions are more frequently associated with altered patterns in activation than lesions in noncentral locations. Characteristic patterns include activation of secondary sensorimotor areas. The absence of activation in gyri adjacent to the sensorimotor strip has clinical significance for the planning of resections in the central area.
Clinical presentation and management of giant anterior communicating artery region aneurysms
Authors: Lownie Stephen P. , Drake Charles G. , Peerless Sydney J. , Ferguson Gary G. , Pelz David M.
Published: May 2009

Object. The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods.

Methods. In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test.

Conclusions. At least 3.5 cm of aneurysm mass effect was required to produce dementia in the patient (p = 0.0004). Dementia was usually caused by direct brain compression by the aneurysm rather than by hydrocephalus. Optic apparatus compression occurred with smaller aneurysms (2.7–3.2 cm) when they pointed inferiorly.

Aneurysm neck clipping was possible in half of the cases. Special techniques, including temporary clipping, evacuation of intraluminal thrombus, tandem and/or fenestrated clipping, and clip reconstruction were often required. Occlusion of or injury to the anterior cerebral artery (ACA) was the main cause of poor outcome or death.

Proximal ACA occlusion, even of dominant A1 segments with small or no contralateral A1 artery, was an effective treatment alternative and was well tolerated as a result of excellent leptomeningeal collateral circulation.
An implantable guide-screw system for brain tumor studies in small animals
Authors: Lal Sumeer , Lacroix Michel , Tofilon Philip , Fuller Gregory N. , Sawaya Raymond , Lang Frederick F.
Published: May 2009

Object. To overcome the problems associated with using stereotactic techniques to establish intracranial xenografts in nude mice and to treat engrafted tumors with intratumoral therapies (such as gene or viral therapies), the authors developed an implantable guide-screw system. In this study, they describe the guide-screw system, its method of implantation, and their experience with establishing xenografts and delivering intratumoral therapy.

Methods. The system consists of a 2.6-mm guide screw with a central 0.5-mm diameter hole that accepts the 26-gauge needle of a Hamilton syringe. The screw is implanted into a small drill hole made 2.5 mm lateral and 1 mm anterior to the bregma. A stylet is used to cap the screw between treatments. Tumor cells or therapeutic agents are injected in a freehand fashion by using a Hamilton syringe and a 26-gauge needle fitted with a cuff to determine the depth of injection. To test this system, guide screws were successfully implanted in 44 (98%) of 45 nude mice. After 1 to 2 weeks of recovery, 38 mice were inoculated with U87MG cells and killed 5 days later. On histological studies in 37 (97%) of these animals, xenografts were evident within the caudate nucleus (mean diameter 2.5 mm). To determine whether injections into the center of an established xenograft could be reproducibly achieved with the guide-screw system, an adenovirus vector containing the β-galactosidase gene was injected 3 days after cell implantation in 15 of the mice. All of these animals demonstrated transduced cells within the tumor. To demonstrate that engrafted animals have a uniform survival time that is indicative of reproducible tumor growth, the survival of six mice was assessed after engraftment with U87MG cells. All six animals died within 28 to 35 days.

Conclusions. The guide-screw system allows a large number of animals to be rapidly and reproducibly engrafted and for intratumoral treatments to be accurately delivered into established xenografts.
Recurrent intraneural ganglion cyst of the tibial nerve
Authors: Spinner Robert J. , Atkinson John L. D. , Harper C. Michel , Wenger Doris E.
Published: May 2009

✓ Different theories have evolved to explain the pathogenesis and the cell of origin of intraneural ganglion cysts. Reportedly only three cases of intraneural ganglion of the tibial nerve have been located within the popliteal fossa, and all of these were thought to arise within the nerve. The authors report a case of a recurrent tibial intraneural ganglion in which a connection to the proximal tibiofibular joint was demonstrated on magnetic resonance (MR) images and at surgery. Surgical ligation of the articular branch and evacuation of the cyst led to symptomatic relief, and an MR image obtained 1 year after surgery documented no recurrence. This case reinforces the fact that surgeons need to consider and search for an articular connection in all cases of intraneural ganglia, especially in those that have recurred.