bluuebunny/crossref_metadata_2025 huggingface dataset:
Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains
Authors: Lind Christopher R. P. , Lind Christina J. , Mee Edward W.
Published: May 2009

Object. The aim of this study was to determine the influence of closed-system subdural drainage on repeated operation rates after burr hole evacuation of subacute and chronic subdural hematomas (SDHs).

Methods. Five hundred consecutive operations for the treatment of SDH via burr holes were performed between January 1, 1996, and April 15, 2002, at the Auckland Hospital. Hospital records were used to ascertain demographic data, operation, and repeated operation details. Rates of repeated surgeries were compared in patients with and without subdural drains.

Repeated operations were performed less frequently in patients with subdural drains, occurring in 31 (10%) of 310 cases involving drains and in 35 (19%) of 188 cases without drains (p < 0.01). Demographics between the two groups were not significantly different except for mean patient age, which was higher among patients with a subdural drain. A lower rate of repeated operation was observed in patients who had undergone drain placement, regardless of whether there was visible evidence of brain reexpansion.

Conclusions. Patients have lower rates of repeated surgeries if subdural drains are placed following evacuation of an SDH via a burr hole. To reach high clinical significance, 12 patients must undergo this simple intervention. If technically feasible, subdural drains should be inserted regardless of any occurrence of brain expansion during surgery.
Transcranial Doppler ultrasound study of the effects of nitrous oxide on cerebral autoregulation during neurosurgical anesthesia: a randomized controlled trial
Authors: Iacopino Domenico G. , Conti Alfredo , Battaglia Calogero , Siliotti Clotilde , Lucanto Tullio , Santamaria Letterio B. , Tomasello Francesco
Published: May 2009

Object. Nitrous oxide has an adverse effect on cerebrovascular hemodynamics. Increased intracranial pressure, cerebral blood flow (CBF), cerebral metabolic rate of O2 (CMRO2), and reduced autoregulation indices have been reported, but their magnitudes are still being debated.

This study was designed to evaluate the effect of N2O on CBF and autoregulatory indexes during N2O—sevoflurane anesthesia in a prospective randomized controlled series of patients.

Methods. Two groups of 20 patients were studied on the basis of the use of N2O in the anesthetic gas mixture. The transient hyperemic response test, which relies on transcranial Doppler ultrasound techniques, was used to assess cerebral hemodynamics.

The time-averaged mean flow velocity, considered to be an index of actual CBF, increased significantly (p < 0.001) after introduction of N2O. The hyperemic response, considered as the index of autoregulatory potential, decreased significantly after introduction of N2O into the gas mixture (p < 0.001).

Conclusions. The increase in CBF and the reduction in autoregulatory indices suggest caution in using N2O during sevoflurane anesthesia, especially in patients with reduced autoregulatory reserve and during neurosurgical interventions. Transcranial Doppler ultrasonography is an efficacious method to evaluate the effects of anesthetic agents on CBF.
Bilateral subthalamic stimulation in patients with Parkinson disease: long-term follow up
Authors: Pahwa Rajesh , Wilkinson Steven B. , Overman John , Lyons Kelly E.
Published: May 2009

Object. Bilateral subthalamic nucleus (STN) stimulation is increasingly used in patients with advanced Parkinson disease (PD). This study was performed to evaluate the long-term efficacy and safety of bilateral STN stimulation in cases of PD.

Methods. The authors performed a prospective, open-label study in patients with PD who underwent bilateral STN stimulation. The authors compared motor scores and activities of daily living (ADL) scores based on the Unified PD Rating Scale (UPDRS) obtained before surgery while patients were in the medication-off state with scores obtained at follow-up evaluations of these patients while in the medication-off/stimulator-on state. Data contained in patient diaries were also compared.

Thirty-three patients with PD were evaluated 12 months postoperatively and 19 were evaluated at a mean follow-up time of 28 months. A comparison between UPDRS scores obtained in patients in the medication-off/stimulator-on state and those obtained when patients were in the baseline medication-off state showed a 27% improvement in ADL scores and a 28% improvement in motor scores after surgery. There was a 57% reduction in the use of levodopa-equivalent medication doses. The percentage of the waking day that patients were in the medication-on state increased from 38 to 72%. Surgical complications included seizures (three patients), confusion (five patients), hemiballismus (one patient), and visual disturbance (one patient). Stimulation-related adverse effects were mild. Device-related events included nine lead replacements, seven lead revisions, six extension replacements, and 12 implantable pulse generator (IPG) replacements; one IPG was cleaned and one IPG was placed in a pocket because of the presence of a shunt.

Conclusions. Bilateral STN simulation is associated with a significant improvement in the motor features of PD. Device-related events were common in the first 20 patients who underwent surgery, often requiring repeated surgeries.
Loss of sensory discrimination after median nerve injury and activation in the primary somatosensory cortex on functional magnetic resonance imaging
Authors: Hansson Thomas , Brismar Tom
Published: May 2009

Object. The aim of this study was to assess the effects of median nerve injury and regeneration on neuronal activation in the somatosensory cortex by means of functional magnetic resonance (fMR) imaging and somatosensory evoked potentials (SSEPs).

Methods. Ten injured male patients (mean age 26 years) were examined 15 to 58 months after a total transection of the median nerve at the wrist that was repaired with epineural sutures. Two-point discrimination was lost in Digit II–III and sensory nerve conduction displayed decreased velocity (−29%) and amplitude (−84%) in the median nerve at the wrist. The fMR images were obtained during tactile stimulation (gentle strokes) performed separately on the volar surface of either Digit II–III or Digit IV–V (eight patients: two were excluded because of movement artifacts). The SSEPs were obtained using electrical stimulation proximal to the median nerve lesion.

Conclusions. Patients with loss of sensory discrimination after median nerve damage and regeneration had larger areas of activation in fMR imaging near the contralateral central sulcus during tactile stimulation of the injured compared with the noninjured hand. The increase relative to the unaffected hand was 43% (p < 0.02) for Digit II–III stimulation and 46% (p < 0.02) for Digit IV–V stimulation. The SSEP data showed normal latency and amplitude. The enlarged area of cortical activation may be the result of reorganization, and it may indicate that larger cortical areas are involved in the discriminatory task after a derangement of the peripheral input.
Successful treatment of intracranial nongerminomatous malignant germ cell tumors by administering neoadjuvant chemotherapy and radiotherapy before excision of residual tumors
Authors: Kochi Masato , Itoyama Youichi , Shiraishi Shoji , Kitamura Isao , Marubayashi Toru , Ushio Yukitaka
Published: May 2009

Object. The goal of this study was to confirm the effectiveness of our novel treatment strategy, neoadjuvant therapy (NAT) consisting of combined chemo- and radiotherapy, which are performed before complete excision of residual tumor in patients with intracranial nongerminomatous malignant germ cell tumors (NGMGCTs).

Methods. The authors treated 11 consecutive patients with NGMGCTs by applying NAT consisting of combined platinum-based chemotherapy and radiotherapy, followed by complete excision of residual tumors. The pretreatment diagnosis, based on tumor markers with or without biopsy, was yolk sac tumor in five patients, embryonal carcinoma in one patient, immature teratoma in one patient, and mixed germ cell tumor containing malignant tumor components in four patients.

Among the 11 patients, NAT achieved a complete response in two and a partial response in six patients; two patients manifested no change and one suffered disease progression. Residual tumors that occurred post-NAT were surgically removed in nine patients. Of the 11 patients, 10 are currently alive without recurrence of their disease, 30 to 177 months (mean 96 months) after diagnosis. In one patient a leptomeningeal tumor recurred and he died of the disease 21 months after diagnosis.

Conclusions. Neoadjuvant therapy, consisting of combined chemo- and radiotherapy, followed by complete excision of residual tumors is highly effective in patients with intracranial NGMGCTs.
Neuroprotective activity of tamoxifen in permanent focal ischemia
Authors: Kimelberg Harold K. , Jin Yiqiang , Charniga Carol , Feustel Paul J.
Published: May 2009

Object. The authors have previously shown that tamoxifen is effective in protecting brain tissue from ischemic injury in a rat model of reversible focal ischemia. In this study the authors tested whether similar protective effects are found in a rat model of permanent focal ischemia (permanent middle cerebral artery [MCA] occlusion).

Methods. Tamoxifen (20 mg/kg) was given either before or at 1, 3, or 6 hours after permanent MCA occlusion in rats, with sustaining doses given every 12 hours thereafter. The median infarct volume measured after 72 hours was 113 mm3 for the vehicle (dimethyl sulfoxide) groups, compared with 31 mm3 for pretreatment, and 14, 27, and 98 mm3 for treatment beginning at 1, 3, and 6 hours, respectively, after permanent MCA occlusion. The infarct reductions in the pretreated and 1- and 3-hour post—MCA occlusion treatment groups were statistically significant (p < 0.05). At 3 hours after permanent MCA occlusion, tamoxifen also significantly reduced the infarct size at a lower dose of 5 mg/kg but not at 1 mg/kg; the same sustaining doses of 5 and 1 mg/kg were given every 12 hours.

Conclusions. Tamoxifen is as effective in a permanent model of focal ischemia as it is in the reversible model, and the therapeutic window of 3 hours after initiation of ischemia is identical. This effectiveness is likely due to several properties of the drug, including its known ability to cross the blood—brain barrier. Because tamoxifen has been administered safely in humans for treatment of gliomas at similarly high doses to those used in this study, it may be clinically useful as a treatment for ischemic stroke.
Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants
Authors: Prange Michael T. , Coats Brittany , Duhaime Ann-Christine , Margulies Susan S.
Published: May 2009

Object. Rotational loading conditions have been shown to produce subdural hemorrhage and diffuse axonal injury. No experimental data are available with which to compare the rotational response of the head of an infant during accidental and inflicted head injuries. The authors sought to compare rotational deceleration sustained by the head among free falls, from different heights onto different surfaces, with those sustained during shaking and inflicted impact.

Methods. An anthropomorphic surrogate of a 1.5-month-old human infant was constructed and used to simulate falls from 0.3 m (1 ft), 0.9 m (3 ft), and 1.5 m (5 ft), as well as vigorous shaking and inflicted head impact. During falls, the surrogate experienced occipital contact against a concrete surface, carpet pad, or foam mattress. For shakes, investigators repeatedly shook the surrogate in an anteroposterior plane; inflicted impact was defined as the terminal portion of a vigorous shake, in which the surrogate's occiput made contact with a rigid or padded surface. Rotational velocity was recorded directly and the maximum (peak—peak) change in angular velocity and the peak angular acceleration were calculated.

Analysis of variance revealed significant increases in the and associated with falls onto harder surfaces and from higher heights. During inflicted impacts against rigid surfaces, the and were significantly greater than those measured under all other conditions.

Conclusions. Vigorous shakes of this infant model produced rotational responses similar to those resulting from minor falls, but inflicted impacts produced responses that were significantly higher than even a 1.5-m fall onto concrete. Because larger accelerations are associated with an increasing likelihood of injury, the findings indicate that inflicted impacts against hard surfaces are more likely to be associated with inertial brain injuries than falls from a height less than 1.5 m or from shaking.
Bilateral retro-auricular dermal sinus tracts with intradural extension
Authors: Nejat Farideh , Dias Mark S. , Eftekhar Behzad , Roodsari Nahid Nasri , Hamidi Saiid
Published: May 2009

✓ The authors describe a previously unreported malformation involving paired, bilaterally symmetrical dermal sinus tracts in the retro-auricular area, both of which passed through the asterion and posterior fossa dura mater to end intracranially. Cranial dermal sinus tracts are congenital lesions that virtually always originate from the midline scalp posteriorly at the external occipital protuberance, anteriorly at the nasion or along the nasal dorsum, or in the posterior parietal midline. A lateral origin is extremely rare, and intracranial extension of a lateral dermal sinus tract has not been reported previously. The authors propose an embryological mechanism to explain the origin of this rare malformation and discuss its management.
A new, miniature ultrasonic surgical aspirator with a handpiece designed for transsphenoidal surgery
Authors: Yamasaki Toshiki , Moritake Kouzo , Nagai Hidemasa , Uemura Takeshi , Shingu Takashi , Matsumoto Yoshifumi
Published: May 2009

✓ The authors describe an innovative surgical instrument designed to remove hard fibrous masses from the pituitary region, which cannot be completely removed using standard transsphenoidal surgical procedures. The innovative features of the instrument include a miniature ultrasonic surgical aspirator and an extra-long bayonet handpiece with a 1.9-mm-diameter translucent tip. Intraoperative use of this refined device may increase the effectiveness of the removal of fibrous lesions within a narrow operative field, while also preserving surgical safety.
End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries
Authors: Öğün Tunç C. , Özdemir Mustafa , Şenaran Hakan , Üstün Mehmet E.
Published: May 2009

✓ After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.
Spontaneous fusiform middle cerebral artery aneurysms: characteristics and a proposed mechanism of formation
Authors: Day Arthur L. , Gaposchkin Christopher G. , Yu Chun Jiang , Rivet Dennis J. , Dacey Ralph G.
Published: May 2009

Object. The goal of this study was to identify the origins of spontaneous fusiform middle cerebral artery (MCA) aneurysms.

Methods. One hundred two cases of spontaneous fusiform MCA aneurysms were reviewed, including 40 from the authors' institutions and 62 identified from the literature. The mean age at symptom onset was 38 years, and the male/female ratio was 1.4:1. At presentation, the MCA lumen was stenosed or occluded in 12 patients, focally dilated in 57, and appeared “serpentine” in 33. Most lesions originated from the M1 or M2 segments, and most (80%) presented with nonhemorrhagic symptoms or were discovered incidentally.

The presenting clinical features correlated with morphological findings in the aneurysms, which could be observed to progress from a small focal dilation or vessel narrowing to a serpentine channel. Hemorrhage was the most common presentation in small lesions; the incidence of bleeding progressively diminished with larger lesions. Patients with stenoses or occluded vessels most often presented with ischemic symptoms, and occasionally with hemorrhage. Giant focal dilations or serpentine aneurysms were rarely associated with acute bleeding; clinical presentation was most often prompted by mass effect or thromboembolic stroke.

Conclusions. Analysis of results after various treatments indicates that for symptomatic lesions, therapies that reverse intraaneurysmal blood flow and augment distal cerebral perfusion are associated with better outcomes than other strategies, including conservative management. Based on the spectrum of clinical, pathological, neuroimaging, and intraoperative findings, dissection is proposed as the underlying cause of these lesions.
Multicenter clinical trial of the NexStent coiled sheet stent in the treatment of extracranial carotid artery stenosis: immediate results and late clinical outcomes
Authors: Qureshi Adnan I. , Knape Charlene , Maroney John , Suri M. Fareed K. , Hopkins L. Nelson
Published: May 2009

Object. Carotid angioplasty with stent placement has been proposed as an alternative method for revascularization of carotid artery (CA) stenosis. A novel stent with a coiled sheet design (NexStent; EndoTex Interventional Systems, Inc., Cupertino, CA) has been introduced because it provides improved flexibility over conventional tubular designs during navigation through tortuous arterial segments. The authors report the results of a multicenter study in which they evaluated the safety, feasibility, and effectiveness of this stent in the treatment of CA stenosis.

Methods. Enrollment was limited to patients with 70% or more symptomatic or asymptomatic stenosis of the internal CA. The primary end point was a technically successful implantation procedure (delivery of the stent to the target site and retrieval of the delivery device) resulting in less than 30% residual stenosis on angiograms obtained immediately postprocedure and no death or ipsilateral stroke immediately after or within 30 days following the procedure. The secondary effectiveness end point was prevention of an ipsilateral stroke within 31 days to 1 year postprocedure. The tertiary effectiveness end point was less than 70% residual stenosis demonstrated on CA Doppler ultrasonography performed at 6 and 12 months.

Forty-four patients (mean age 71 years, range 51–89 years; 30 patients were men and 18 [41%] had symptomatic stenotic lesions) were treated using 45 NexStents (two stents were placed in one patient). Residual stenosis on postprocedure angiograms was less than 30% in all patients. The 1-month primary end point was achieved in 41 patients (93%). The three major adverse events that occurred within 30 days were one death related to congestive heart failure and two ipsilateral strokes, one of which resulted in death. No ipsilateral stroke occurred between 1 and 12 months postprocedure among 35 patients who completed the follow-up evaluation. Asymptomatic recurrent stenosis was identified in one patient at 6 months postprocedure, requiring the performance of repeated angioplasty.

Conclusions. Placement of the NexStent was feasible and resulted in the effective treatment of patients with CA stenosis, with promising long-term results.
Aneurysmal subarachnoid hemorrhage in young adults: a comparison between patients in the third and fourth decades of life
Authors: Horiuchi Tetsuyoshi , Tanaka Yuichiro , Hongo Kazuhiro , Kobayashi Shigeaki
Published: May 2009

Object. Aneurysmal subarachnoid hemorrhage rarely occurs in young adults. The aim of this work was to clarify the clinical characteristics of ruptured aneurysms in young adults in the third and fourth decades of life and to compare these two age groups.

Methods. The authors retrospectively investigated 2493 patients who underwent surgical repair for ruptured cerebral aneurysms during a 14-year period (1988–2001). There were 25 patients (1%) in the third decade of life and 106 patients (4.3%) in the fourth decade. In general, favorable outcome was achieved in both groups. There were significant differences in the sizes and locations of aneurysms between the two age groups. Among patients in the fourth decade of life, the aneurysm was large and was located more often on the anterior cerebral artery.

Conclusions. In this study the authors summarize the clinical characteristics of a large series of 131 young adult patients with ruptured cerebral aneurysms. Congenital factors as well as hemodynamic stress may contribute to differences in aneurysm size and location between the two age groups.
Surveillance neuroimaging of intracranial medulloblastoma in children: how effective, how often, and for how long?
Authors: Saunders Dawn E. , Hayward Richard D. , Phipps Kim P. , Chong Wui Khean , Wade Angela M.
Published: May 2009

Object. The goal of this paper was to review brain and spine images obtained in children with medulloblastomas to determine the risk factors for tumor recurrence and to assess the impact of surveillance imaging on patient outcomes among patients who remain alive 1 month postsurgery.

Methods. Imaging studies and clinical data obtained in children with medulloblastomas, who presented between January 1987 and August 1998, were retrospectively reviewed. Images were termed surveillance if they were follow-up studies and symptom prompted if they were obtained to investigate new symptoms.

One hundred seven patients (mean age 6 years and 3 months, range 2 months–15 years and 6 months) were entered into the study. Fifty-three children experienced tumor recurrence; 41 had one recurrence, nine had two, and three had three recurrences. Surveillance imaging revealed 10 of the first 53 recurrences and 15 of all 68 recurrences. When the first recurrence was identified by the emergence of symptoms (42 patients), the children tended to survive for a shorter time (hazard ratio 3.72, 95% confidence interval 1.42–9.76, p = 0.008) than children in whom the first recurrence was detected before symptoms occurred (10 patients). The median survival time following symptomatic tumor recurrence was 4 months and that after surveillance-detected tumor recurrence was 17 months. The median increased survival time among patients whose recurrence was asymptomatic and identified by imaging studies was 13 months, more than half the mean time between surveillance imaging sessions. Incomplete tumor resection was associated with a significantly reduced time to recurrence (p = 0.048) and to death (p = 0.002). The number of recurrences that were experienced was associated with a reduced time to death (p < 0.001).

Conclusions. Surveillance imaging is associated with an increase in survival in children with medulloblastomas. More frequent surveillance imaging in children with incomplete tumor excision and recurrent disease may further improve the length of survival.
Evaluation of extracranial—intracranial arterial bypass function by using near-infrared spectroscopy
Authors: Murata Yoshihiro , Katayama Yoichi , Sakatani Kaoru , Fukaya Chikashi , Kano Tsuneo
Published: May 2009

Object. It has been reported that extracranial—intracranial (EC—IC) arterial bypass surgery can be useful in preventing stroke in patients with hemodynamic compromise. Little is yet known, however, regarding the extent to which the bypass contributes to maintaining adequate cerebral blood oxygenation (CBO) and its temporal changes following surgery. The authors evaluated bypass function repeatedly by using near-infrared spectroscopy (NIRS) after surgery.

Methods. The authors investigated 30 patients who had undergone EC—IC bypass surgery. Single-photon emission computerized tomography revealed a decrease in regional cerebral blood flow (rCBF) and a lowered rCBF response to acetazolamide. Changes in CBO were evaluated in the sensorimotor cortex during compression of the anastomosed superficial temporal artery (STA). When decreases in oxyhemoglobin (HbO2) and total hemoglobin (Hb) concentrations were observed, the bypass was considered to have maintained CBO in the sensorimotor cortex given that decreases in HbO2 and total Hb indicate cerebral ischemic changes. The bypass maintained CBO immediately after surgery in 36.7% of patients (Group I, 11 patients) and at some time after surgery, mostly within 1 year, in 43.3% of patients (Group II, 13 patients); however, it did not maintain it throughout the follow-up period in 20% of patients (Group III, six patients). Note that the preoperative rCBF in patients in Groups I and II was lower than that in patients in Group III (p < 0.004). In fact, the preoperative rCBF predicted whether a bypass would maintain CBO at a cutoff value of 24.5 to 25 ml/100 g/min. Among Groups I and II, 18 patients demonstrated an increase in deoxyhemoglobin during STA compression. The preoperative rCBF in these cases was lower than that in the six remaining patients (p < 0.006). Note that the preoperative rCBF predicted the postoperative deoxyhemoglobin response at a cutoff value of 22.2 to 24 ml/100 g/min.

Conclusions. The EC—IC bypass surgery can maintain CBO immediately after surgery or gradually within 1 year when the preoperative rCBF is below 24.5 to 25 ml/100 g/min. Furthermore, bypass flow plays a critical role in maintaining an adequate CBO when preoperative rCBF is below 22.2 to 24 ml/100 g/min.
Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory
Authors: Spinner Robert J. , Atkinson John L. D. , Tiel Robert L.
Published: May 2009

Object. Based on a large multicenter experience and a review of the literature, the authors propose a unifying theory to explain an articular origin of peroneal intraneural ganglia. They believe that this unifying theory explains certain intriguing, but poorly understood findings in the literature, including the proximity of the cyst to the joint, the unusual preferential deep peroneal nerve (DPN) deficit, the absence of a pure superficial peroneal nerve (SPN) involvement, the finding of a pedicle in 40% of cases, and the high (10–20%) recurrence rate.

Methods. The authors believe that peroneal intraneural lesions are derived from the superior tibiofibular joint and communicate from it via a one-way valve. Given access to the articular branch, the cyst typically dissects proximally by the path of least resistance within the epineurium and up the DPN and the DPN component of the common peroneal nerve (CPN) before compressing nearby SPN fascicles. The authors present objective evidence based on anatomical, clinical, imaging, operative, and histological data that support this unifying theory.

Conclusions. The predictable clinical presentation, electrical studies, imaging characteristics, operative observations, and histological findings regarding peroneal intraneural ganglia can be understood in terms of their origin from the superior tibiofibular joint, the anatomy of the articular branch, and the internal topography of the peroneal nerve that the cyst invades. Understanding the controversial pathogenesis of these cysts will enable surgeons to perform operations based on the pathoanatomy of the articular branch of the CPN and the superior tibiofibular joint, which will ultimately improve clinical results.
Widespread central nervous system cavernous malformations associated with café-au-lait skin lesions
Authors: Musunuru Kiran , Hillard Virany Huynh , Murali Raj
Published: May 2009

✓ The simultaneous presence of cavernous malformations in the brain and spinal cord is a very rare finding and is typically associated with familial cavernous malformations. Although they are uncommon, various skin lesions can manifest in patients with familial cavernous malformations. The authors report on a 60-year-old man in whom more than 100 lesions consistent in appearance with cavernous malformations, including several intramedullary spinal cord lesions, were found throughout the neuraxis. This patient also displayed prominent café-au-lait skin lesions, but had no additional signs of neurofibromatosis or other neurocutaneous disorders. Analysis of his DNA revealed a novel mutation in the KRIT1/CCM1 gene, thereby confirming the diagnosis of familial cavernous malformation. The presence of these lesions in every major compartment of this patient's central nervous system underscores their indiscriminate nature and the need to screen throughout the neuraxis in patients in whom familial cavernous malformations are suspected. The findings in this case add to the growing list of skin lesions associated with genetically confirmed familial cavernous malformations. In patients presenting with seizures, focal neurological deficits, or hemorrhagic stroke, the presence of unusual skin lesions should prompt consideration of familial cavernous malformations, and appropriate screening should be performed.
Spontaneous hemorrhage associated with a pilomyxoid astrocytoma
Authors: Gottfried Oren N. , Fults Daniel W. , Townsend Jeannette J. , Couldwell William T.
Published: May 2009

✓ Pilomyxoid astrocytomas have been identified as a more aggressive variant of pilocytic astrocytomas that occur in infants and in young children. These tumors are characterized by a perivascular arrangement of pilocytic cells that has a monomorphous architecture with uniform, elongated bipolar cells loosely arranged within a prominent myxoid background. The authors present the case of a 24-year-old man with a pilomyxoid astrocytoma of the temporal lobe, who presented with a hemorrhage. The patient underwent gross-total tumor resection, and no evidence of residual or recurrent tumor was found on magnetic resonance images at the 6-month follow-up examination. The occurrence of a pilomyxoid astrocytoma in an adult suggests that this tumor is not limited to children. The tumor described in this report is unique because of its presentation with a hemorrhage, which has not been previously described in cases of pilomyxoid astrocytomas and is rarely found in those of pilocytic astrocytomas. Although this tumor predominantly exhibited the pattern of a pilomyxoid astrocytoma, there was a small focus of pilocytic astrocytoma, indicating that there is a spectrum of histological components found in these tumors and that certain elements may be associated with a more aggressive phenotype. In this paper the authors review the literature on pilomyxoid astrocytomas and discuss the unique aspects of this particular tumor presentation.
A multifunctional, modified rigid neuroendoscopic system: clinical experience with 83 procedures
Authors: Bakshi Ajay , Patir Rana , Bakshi Asha , Banerji Ajit Kumar
Published: May 2009

✓ The authors combined a monopolar electrode and a suction/irrigation channel with a 0°, 4-mm Hopkins rigid telescope into a single multifunctional unit. This three-in-one instrument is inserted through a lightweight 7.5-mm outer sheath, which is fixed separately. A fourth instrument (for example, a balloon catheter or a biopsy forceps) can be introduced and manipulated independently with the other hand.

All endoscopic procedures were performed with a trephine to create a 15-mm craniotomy. After opening the dura mater, ventricles were tapped with a brain needle, which was followed by the insertion of the rigid scope for visualization. The telescope was then withdrawn momentarily; the outer sheath was introduced into the ventricle and fixed over the area of interest. The definitive procedure was then performed with ease by using the multifunctional three-inone instrument in one hand and a fourth instrument in the other hand.

This novel neuroendoscopic system has been used in clinical testing at the Vidyasagar Institute of Mental Health and Neurosciences since May 1998. Thus far, 83 neuroendoscopic procedures have been successfully performed with the aid of this instrumentation system, which has proven to be safe, versatile, and cost-effective, allowing a greater degree of freedom for the neurosurgeon.
Relative survival rates and patterns of diagnosis analyzed by time period for individuals with primary malignant brain tumor, 1973–1997
Authors: Barnholtz-Sloan Jill S. , Sloan Andrew E. , Schwartz Ann G.
Published: May 2009

Object. The purpose of this study was to examine patterns of diagnosis and relative survival rates in individuals in whom a primary malignant brain tumor was diagnosed between 1973 and 1997; follow-up review of these patients continued through the end of 1999.

Methods. The study population was composed of 21,493 patients with primary malignant brain tumors that were diagnosed between 1973 and 1997. Data on these patients were obtained from the population-based Surveillance, Epidemiology, and End Results Program. The study population was divided into three cohorts based on the year of diagnosis, and these groups were compared with respect to variables of interest by performing chi-square tests and relative survival analysis with the life table method.

Over time, there were consistently more men, more Caucasians, more patients undergoing surgery, and more individuals 70 years and older who received the diagnosis of primary malignant brain tumor. An examination of proportions of individuals with astrocytoma, other; oligodendroglioma, other; and oligodendroglioma Grade III showed significant temporal changes with frontal and temporal lobe tumors occurring most often. The diagnosis was obtained at an earlier age in African-American than in Caucasian patients. Caucasians had higher proportions of glioblastoma multiforme (GBM), which was associated with decreased survival times, and of oligodendroglioma, other, whereas African Americans had higher proportions of astrocytoma, other; ependymoma Grade II or III; and medulloblastoma, all of which were associated with increased survival times. The relative survival case demonstrated a continuous improvement over time, although older patients, those who underwent biopsy only, and those with GBMs continue to have the poorest survival times. The relative survival rates of African Americans consistently were similar or worse than those of Caucasians when the groups were stratified by prognostic factors.

Conclusions. Over time, the relative survival rate of individuals with primary malignant brain tumor has improved and differences in survival are seen by examining the race of the patients.
Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project
Authors: Laws Edward R. , Parney Ian F. , Huang Wei , Anderson Fred , Morris Angel M. , Asher Anthony , Lillehei Kevin O. , Bernstein Mark , Brem Henry , Sloan Andrew , Berger Mitchel S. , Chang Susan , _ _
Published: May 2009

Object. The Glioma Outcomes Project represents a contemporary analysis of the management of malignant (Grade III and Grade IV/GBM) gliomas in North America. This observational database was used to evaluate the influence of resection, as opposed to biopsy, on patient outcome as measured by the length of survival. Attempts were made to reduce the impact of selection bias by repeating the data analysis after omitting patients with major negative prognostic factors.

Methods. Outcome data from 788 patients accrued from multiple sites over a 4-year period (1997–2001) were analyzed with the primary outcome measure being length of survival. Of these, 565 patients with recent diagnoses formed the basis of the present analysis. Patients were systematically followed up until death or up to 24 months after enrollment in the study, and survival data were correlated with the histopathological grade and location of the tumor, the extent of surgery, the patient's performance status, and demographic factors.

The median length of survival was 40.9 weeks for patients with recently diagnosed GBMs. The true median length of survival for patients with Grade III gliomas was not reached, although there was a 58% survival rate at 104 weeks. In multivariate analysis, resection rather than biopsy (p < 0.0001), age 60 years or younger (p < 0.0001), and a Karnofsky Performance Scale (KPS) score of 70 or greater (p = 0.0004) were associated with a prolonged survival time for patients with Grade III or IV gliomas. The prognostic value of resection compared with biopsy was maintained (p < 0.0001), even after eliminating patients considered to be “poor risk” (those with age > 60 years, KPS score < 70, or presence of multifocal tumors), who may have been overrepresented in the biopsy group. Survival “tails” at 24 months were 58% for Grade III gliomas and 11% for GBMs.

Conclusions. These data provide Class II evidence to support tumor grade, patient's age, and patient's functional status as prognostic factors for survival in individuals with recently diagnosed malignant gliomas. Resection (compared with biopsy) is also a strong prognostic factor; however, no quantitative attempt was made to assess the true extent of the resection.
Use of 18F-choline and 11C-choline as contrast agents in positron emission tomography imaging—guided stereotactic biopsy sampling of gliomas
Authors: Hara Toshihiko , Kondo Tatsuya , Hara Tetsuo , Kosaka Noboru
Published: May 2009

Object. Neuroimaging-guided stereotactic biopsy procedures are commonly used for diagnosis of gliomas. A number of the imaging modalities currently in use are not reliable enough in depicting these tumors. The authors developed 18F-choline and 11C-choline as tumor imaging agents for positron emission tomography (PET) scanning, and used them to visualize gliomas prior to stereotactic biopsy procedures.

Methods. The PET studies were performed in 12 patients who were thought to be affected by gliomas observed on computerized tomography and magnetic resonance images. The 18F- and 11C-choline were injected separately, and the PET scanning was started 5 and 20 minutes postinjection. The PET scans gave quantitative information about the distribution of 18F- and 11C-choline in the brain. The tumor uptake was constant between 5 and 20 minutes with both agents. Stereotactic biopsy sampling was performed to obtain tissues from the most radioactive areas on the PET scan; histological diagnoses were made using these tissues. The results were as follows: oligodendroglioma was found in two patients, astrocytoma in one, anaplastic astrocytoma in two, and glioblastoma in seven.

Conclusions. The uptake of contrast agents was always low in low-grade gliomas, and the uptake in high-grade glioma was always high. The tumor/normal (T/N) ratio of 18F-choline was 10.5:12 in anaplastic astrocytoma and 13.2:21 in glioblastoma. The 18F-choline yielded slightly superior results compared with 11C-choline with regard to the T/N ratio. In one case of oligodendroglioma the tumor showed no uptake of 18F- and 11C-choline. With this exception, the PET scans of gliomas in which 18F- and 11C-choline contrast agents were added would guide the approach to the most malignant areas for stereotactic biopsy sampling.
Prospective analysis of diplopia after anterior temporal lobectomy for mesial temporal lobe sclerosis
Authors: Cohen-Gadol Aaron A. , Leavitt Jacqueline A. , Lynch James J. , Marsh W. Richard , Cascino Gregory D.
Published: May 2009

Object. In this prospective study the authors investigated the incidence and natural history of postoperative diplopia in patients undergoing anterior temporal lobectomy (ATL) and amygdalohippocampectomy for medically intractable mesial temporal lobe epilepsy.

Methods. Forty-seven patients scheduled for ATL for medically refractory seizures were examined preoperatively, 2 to 7 days postoperatively, and 3 to 6 months postoperatively. Ophthalmological examination including pupillary measurements, stereoacuity measurements, palpebral fissure measurements, vertical fusional amplitudes, Lancaster red green testing, visual field testing, and alternate cover testing was performed. Antiepileptic drug levels were monitored.

Nine (19%) of 47 patients developed diplopia postoperatively. The diplopia was caused by trochlear nerve palsy in every case. No oculomotor nerve dysfunction was documented. Trochlear nerve function recovered completely in all patients within 3 to 6 months postoperatively.

Conclusions. Postoperative diplopia following ATL occurs more often than previously thought and is primarily due to trochlear nerve dysfunction. Awareness of this transient complication is important in preoperative patient counseling.
Complications of chronic vagus nerve stimulation for epilepsy in children
Authors: Smyth Matthew D. , Tubbs R. Shane , Bebin E. Martina , Grabb Paul A. , Blount Jeffrey P.
Published: May 2009

Object. The aim of this study was to define better the incidence of surgical complications and untoward side effects of chronic vagus nerve stimulation (VNS) in a population of children with medically refractory epilepsy.

Methods. The authors retrospectively reviewed the cases of 74 consecutive patients (41 male and 33 female) 18 years of age or younger (mean age 8.8 years, range 11 months–18 years) who had undergone implantation of a vagal stimulator between 1998 and 2001 with a minimum follow up of 1 year (mean 2.2 years). Of the 74 patients treated, seven (9.4%) had a complication ultimately resulting in removal of the stimulator. The rate of deep infections necessitating device removal was 3.5% (three of 74 patients who had undergone 85 implantation and/or revision procedures). An additional three superficial infections occurred in patients in whom the stimulators were not removed: one was treated with superficial operative debridement and antibiotic agents and the other two with oral antibiotics only. Another four stimulators (5.4%) were removed because of the absence of clinical benefit and device intolerance. Two devices were revised because of lead fracture (2.7%). Among the cohort, 11 battery changes have been performed thus far, although none less than 33 months after initial implantation. Several patients experienced stimulation-induced symptoms (hoarseness, cough, drooling, outbursts of laughter, shoulder abduction, dysphagia, or urinary retention) that did not require device removal. Ipsilateral vocal cord paralysis was identified in one patient. One patient died of aspiration pneumonia more than 30 days after device implantation.

Conclusions. Vagus nerve stimulation remains a viable option for improving seizure control in difficult to treat pediatric patients with epilepsy. Surgical complications such as hardware failure (2.7%) or deep infection (3.5%) occurred, resulting in device removal or revision. Occasional stimulation-induced symptoms such as hoarseness, dysphagia, or torticollis may be expected (5.4%).
Three-dimensional blood flow analysis in a wide-necked internal carotid artery—ophthalmic artery aneurysm
Authors: Tateshima Satoshi , Viñuela Fernando , Villablanca J. Pablo , Murayama Yuichi , Morino Taku , Nomura Kiyoe , Tanishita Kazuo
Published: May 2009

Object. The aim of this study was to evaluate axial and secondary flow structures in a wide-necked internal carotid artery—ophthalmic artery aneurysm, one of the most common locations for endovascular coil placement.

Methods. A clear acrylic aneurysm model was manufactured from a three-dimensional computerized tomography angiogram. Intraaneurysm blood flow analysis was conducted using an acrylic aneurysm model together with laser Doppler velocimetry and particle imaging velocimetry. The maximal axial blood flow velocities in the inflow and outflow zones at the aneurysm orifice were noted at the peak systolic phase, measuring 46.8 and 24.9% of that in the parent artery, respectively. The mean size of the inflow zone during one cardiac cycle was 44.3 ± 9.8% (range 35.6–58.7%) the size of the axial section at the aneurysm orifice. In the lower and upper planes of the aneurysm dome, the mean size of inward and outward flow areas were 43.3 ± 6.7% and 43.8 ± 6.8% the size of the axial cross-sectional plane, respectively. The axial flow velocity structures were dynamically altered throughout the cardiac cycle, particularly at the aneurysm orifice. The fastest secondary flow at the opening was also noted at the peak systolic and early diastolic phases. Axial blood flow velocity was slower in the upper axial plane of the aneurysm dome than in the lower one. Conversely, the secondary flow component was faster in the upper plane.

Conclusions. The side-wall aneurysm in this study did not demonstrate a simple flow pattern as was previously seen in ideally shaped experimental aneurysms in vitro and in vivo. The flow patterns of inflow and outflow zones were very difficult to predict based on the limited flow information provided on standard digital subtraction angiography, even in an aneurysm with a relatively simple dome shape.
Growth factor enhancement of peripheral nerve regeneration through a novel synthetic hydrogel tube
Authors: Midha Rajiv , Munro Catherine A. , Dalton Paul D. , Tator Charles H. , Shoichet Molly S.
Published: May 2009

Object. The authors' long-term goal is repair of peripheral nerve injuries by using synthetic nerve guidance devices that improve both regeneration and functional outcome relative to an autograft. They report the in vitro processing and in vivo application of synthetic hydrogel tubes that are filled with collagen gel impregnated with growth factors.

Methods. Poly(2-hydroxyethyl methacrylate-co-methyl methacrylate) (PHEMA-MMA) porous 12-mm-long tubes with an inner diameter of 1.3 mm and an outer diameter of 1.8 mm were used to repair surgically created 10-mm gaps in the rat sciatic nerve. The inner lumen of the tubes was filled with collagen matrix alone or matrix supplemented with either neurotropin-3 at 1 µg/ml, brain-derived neurotrophic factor at 1 µg/ml, or acidic fibroblast growth factor (FGF-1) at 1 or 10 µg/ml. Nerve regeneration through the growth factor—enhanced tubes was assessed at 8 weeks after repair by histomorphometric analysis at the midgraft level and in the nerve distal to the tube repair. The tubes were biostable and biocompatible, and supported nerve regeneration in more than 90% of cases. Nerve regeneration was improved in tubes in which growth factors were added, compared with empty tubes and those containing collagen gel alone (negative controls). Tubes filled with 10 µg/ml of FGF-1 dispersed in collagen demonstrated regeneration comparable to autografts (positive controls) and showed significantly better regeneration than the other groups.

Conclusions. The PHEMA-MMA tubes augmented with FGF-1 in their lumens appear to be a promising alternative to autografts for repair of nerve injuries. Studies are in progress to assess the long-term biocompatibility of these implants and to enhance regeneration further.