bluuebunny/crossref_metadata_2025 huggingface dataset:
Elevation of the Petrous Bone Caused by Hyperplasia of the Occipital Bone Presenting as Hemifacial Spasm: Diagnostic Values of Magnetic Resonance Imaging and Three-Dimensional Computed Tomographic Images in a Bone Anomaly
Authors: Tanaka Akira , Tanaka Tatsuroh , Irie Yutaka , Yoshinaga Shinya , Tomonaga Masamichi
Published: April 2011

A case of elevation of the petrous bone due to hyperplasia of the occipital bone presenting as hemifacial spasm is reported. A 44-year-old man sought treatment for twitching of the buccal muscles on the right side that progressed rapidly in severity within 2 weeks of the onset. The anatomical details of the petrous and occipital bones were delineated clearly by computed tomographic scans of a bone window level. Details of the brain stem were shown by magnetic resonance images. The bone anomaly was displayed more realistically by three-dimensional computed tomographic reconstructions. The faithful representation of structures with these radiological studies should be mandatory, to prepare the surgical planning of such a complicated bone anomaly.
Traumatic Intracranial Aneurysms Caused by Missiles: Their Presentation and Management
Authors: Haddad Fuad Sami , Haddad Georges F. , Taha Jamal
Published: April 2011

Only 30 cases of traumatic intracranial aneurysm (TICA) secondary to missile injury have been reported to date. To these we add 15 more cases. Missile TICAs are often seen on a secondary branch of the middle cerebral artery and are usually accompanied by a intracerebral hematoma (80%) or by an acute subdural hematoma (26%). Fourteen of our cases were secondary to shrapnel injuries and only one was secondary to a bullet. None of the injuries was through-and-through. TICAs may enlarge in time and, seemingly inoffensive, may rupture and lead to death. All seven TICAs studied histologically proved to be false aneurysms. TICAs are best treated through trapping and excision. The outcome depends on the patient's status and level of consciousness before surgery. Indications for angiography are discussed.
Cavernous Malformations and Capillary Telangiectasia: A Spectrum within a Single Pathological Entity
Authors: Rigamonti Daniele , Johnson Peter C. , Spetzler Robert F. , Hadley Mark N. , Drayer Burton P.
Published: April 2011

Cerebral vascular malformations have traditionally been divided into four categories: arteriovenous, venous, cavernous, and capillary telangiectases. A controversy exists about separating the latter two lesions into separate entities. Critics claim the distinction is arbitrary but have been unable to present convincing evidence linking the two types of lesions. We have reviewed the histories of 20 patients with cavernous malformations and have analyzed the clinical, radiographic, and surgical-autopsy data associated with these lesions. In some patients, multiple lesions, including cavernous malformations, capillary telangiectases, and transitional forms between the two, were identified. Based on this analysis, we conclude that capillary telangiectasia and cavernous malformations represent two pathological extremes within the same vascular malformation category and propose grouping them as a single cerebral entity called cerebral capillary malformations.
The Caspar Microsurgical Discectomy and Comparison with a Conventional Standard Lumbar Disc Procedure
Authors: Caspar Wolfhard , Campbell Bayard , Barbier Dragos D. , Kretschmmer Ralf , Gotfried Yechiel
Published: April 2011

The outcome in 119 patients who were operated on with a conventional standard lumbar discectomy procedure was retrospectively compared with that in 299 patients who were operated on with a microsurgical discectomy technique developed in Homburg/Saar, Federal Republic of Germany by the senior author (W.C.). All patients in this consecutive series had “virgin” lumbar radiculopathy evaluated and operated upon by two experienced surgeons at one institution. Determination of the final outcome was made objectively by an impartial third party using identical criteria for both groups, and with a patient self-evaluation form. The study looked at various pertinent aspects of the treatment course and at final outcome. The results in the microsurgical group were significantly favorable: fewer levels were explored; there was less operative blood loss and a decreased incidence of deep venous thrombosis, urinary tract infections, pulmonary emboli, and bladder catheterization; the time to full ambulation, discharge, and return to work was faster; and there was a decrease in change of occupation and a greater percentage of satisfactory final outcomes, as measured both objectively and subjectively. A description of the microsurgical technique used in this study, which differs significantly from existing microdiscectomy techniques, is presented. The authors conclude that the microsurgical discectomy technique presented in this study is a safe and effective approach to the treatment of lumbar radiculopathy.
The Transoral Approach for the Management of Intradural Lesions at the Craniovertebral Junction: Review of 7 Cases
Authors: Crockard Alan H. , Sen Chandra N.
Published: April 2011

The main difficulty in dealing with intradural lesions located ventrally in the region of the craniovertebral junction (CVJ) is related to their relative inaccessibility. Posterolateral approaches involve some manipulation of the brain stem and provide limited access because of the necessity of working between the cranial nerves. Even then, the view of the ventral midline and across is limited. The transoral approach, which has been widely used for the management of extradural lesions in this area, is also useful for the treatment of intradural lesions. It provides an unimpeded although somewhat restricted, view of the ventral aspect of the CVJ without the need for brain retraction. The cranial nerves and vertebral arteries are not interposed between the surgeon and the lesion. The risks of cerebrospinal fluid leakage and infection are greatly diminished by the use of fibrin adhesive and prolonged diversion of the cerebrospinal fluid. The use of this approach, together with its technical difficulties and results, in the management of seven purely intradural lesions located ventrally at the CVJ, is discussed.
Improved Access to Lesions of the Central Skull Base by Mobilization of the Zygoma: Experience with 54 Cases
Authors: Uttley D. , Archer D. J. , Marsh H. T. , Bell B. A.
Published: April 2011

Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it arc uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.
Orbitozygomatic Temporopolar Approach for a High Basilar Tip Aneurysm Associated with a Short Intracranial Internal Carotid Artery: A New Surgical Approach
Authors: Ikeda Kiyonobu , Yamashita Junkoh , Hashimoto Masaaki , Futami Kazuya
Published: April 2011

For two cases of a high basilar tip aneurysm accompanied by a short intracranial internal carotid artery, the orbitozygomatic temporopolar approach consisting of an en bloc fronto-orbitozygomatic temporal craniotomy and temporopolar approach was carried out. On angiograms, the height of the bifurcation of an elongated basilar artery and the length of the intracranial internal carotid artery from the interclinoid line between the anterior and posterior clinoid processes were 20 mm and 6 mm in Case 1, and 18 mm and 5 mm in Case 2. respectively. The skin flap was separated subfascially to preserve the frontotemporal branch of the facial nerve. The fronto-orbitozygomatic temporal bone flap was made, and a part of the basal bony structures of the orbital roof, the sphenoid ridge, and the temporal bone were removed. The basilar tip aneurysm could be seen and clipped easily by upward and oblique viewing from below through the wide operative space consisting of the less retracted internal carotid and middle cerebral arteries, the oculomotor nerve, the tentorial hiatus, and the emptied anterior temporal fossa obtained by partial division of the temporal bridging veins. The operative procedure is presented in detail and compared with other surgical approaches that have been described previously.
Direct Endovascular Thrombolytic Therapy for Dural Sinus Thrombosis
Authors: Barnwell Stanley L. , Higashida Randall T. , Halbach Van V. , Dowd Christopher F. , Hieshima Grant B.
Published: April 2011

Three patients, ages 51 to 71 years, sought treatment for symptomatic dural sinus thrombosis with occlusion and were treated by direct sinus perfusion with urokinase. All three patients had a dural arteriovenous fistula; one involved the inferior petrosal sinus and two involved the transverse sinus. Clinical findings included papilledema, diminished visual acuity, decreased mentation, and cranial nerve palsies. Diagnosis was made by cerebral arteriography and confirmed by sinus venography. All three patients were treated by a transjugular direct infusion of urokinase. In one patient, a transfemoral venous approach used initially was discontinued because of an infection. The period of continuous infusion for thrombolysis ranged between 4 and 10 days. In two patients, the clinical signs and symptoms improved with angiographic evidence of clot lysis and dural sinus recanalization. Angiography indicated that one patient had a partial resolution of a clot in the torcular herophili and transverse sinus but showed no clinical improvement. These preliminary results suggest that transjugular local infusion of thrombolytic agents can be an effective treatment for symptomatic, thrombosed dural sinuses. This selective lysis avoids thrombolytic effects that could aggravate or produce systemic hemorrhagic complications.
Abscess of the Sphenoid Sinus after Transsphenoidal Surgery
Authors: Nelson Paul B. , Hirsch Barry E. , De Vries Egbert J.
Published: April 2011

A case of a bacterial abscess developing in the sphenoid sinus 2 weeks after transsphenoidal surgery is presented. Although abscesses within the sella turcica have been reported as rare complications of transsphenoidal surgery, this is the first reported case of the postoperative formation of an abscess of the sphenoid sinus. The patient sought treatment for severe headaches, nausea and vomiting, and marked temperature elevation. A computed tomographic scan demonstrated soft tissue and air within the sphenoid sinus. A regimen of stress doses of hydrocortisone and antibiotics was prescribed, and the patient underwent transsphenoidal drainage of the sphenoid sinus. The sella turcica was not involved. Anaerobic cultures were positive for Fusobacterium necrophorum.
Interstitial Irradiation and Hyperthermia for the Treatment of Recurrent Malignant Brain Tumors
Authors: Sneed Penny K. , Stauffer Paul R. , Gutin Philip H. , Phillips Theodore L. , Suen Stuart , Weaver Keith A. , Lamb Sharon A. , Ham Brigid , Prados Michael D. , Larson David A. , Wara William M.
Published: April 2011

Between June 1987 and June 1989, 29 recurrent malignant gliomas or recurrent solitary brain metastases in 28 patients were treated in a Phase I study of interstitial irradiation and hyperthermia. Patient age ranged from 18 to 65 years, and the Karnofsky Performance Status scores ranged from 40 to 90%. There were 13 glioblastomas, 10 anaplastic astrocytomas. 3 melanomas, and 3 adenocarcinomas. Catheters were implanted stereotactically after computed tomography-based preplanning. Hyperthermia was administered before and after brachytherapy, using one to six 2450- or 915-MHz helical coil microwave antennas and one to three multisensor fiberoptic thermometry probes. The goal was to heat as much of the tumor as possible to 42.5±C for 30 minutes. Within 30 minutes after the first hyperthermia treatment, implant catheters were afterloaded with high-activity iodine-125 seeds delivering tumor doses of 32.6 to 61.0 Gy. Most patients had no sensation of heating. Complications included seizures in 5 patients, reversible neurological changes in 9 patients, a scalp burn in 1, and infections in 3. Of 28 evaluable 2-month follow-up scans, 11 showed definite improvement in the radiological appearance of the tumor, 4 were slightly improved, 7 were stable, and 6 showed tumor progression. Ten patients underwent reoperation for persistent tumor and/or necrosis. Eleven of 28 patients are alive 40 to 97 weeks after treatment. Thirteen patients died of a brain tumor, 2 died of extracranial melanoma metastases, 1 died of new brain melanoma metastases, and 1 died of a pulmonary embolus. The median survival was 55 weeks overall. Median survival has not yet been reached for the anaplastic astrocytoma subgroup. We conclude that interstitial brain hyperthermia using helical coil microwave antennas is technically feasible. The level of toxicity is acceptable, and the computed tomographic response rate is encouraging.
Definition of the Role of Contemporary Surgical Management in Cisternal and Parenchymatous Cysticercosis Cerebri
Authors: Couldwell William T. , Zee Chi-Shing , Apuzzo Michael L. J.
Published: April 2011

With increasing immigration from endemic regions, the incidence of neurocysticercosis in North America is rising. This retrospective study was undertaken to examine the role of surgery in those cases presenting with large cystic parenchymal and cisternal lesions in the current era of anthelminthic agents administered orally. A total of 237 patients presented with newly diagnosed neurocysticercosis to our institution over a recent 5-year period (mean age, 31.2 years). Among those who presented with cystic mass lesions predominantly affecting the brain parenchyma and cisternal spaces. 20 (8.4%; mean age, 40.2 years) with large cystic lesions subsequently underwent surgical intervention, either because of an emergent presentation or because they were refractory to medical management. Clinical presentation included increased intracranial pressure, focal neurological deficit, and seizure. Radiographic imaging (computed tomography and/or magnetic resonance imaging) demonstrated 12 cases with cisternal lesions, 7 with parenchymal lesions, and 1 involving both compartments. Based on imaging guidelines, 30 operative procedures (excluding shunt revisions) were performed (14 craniotomies, 8 cerebrospinal fluid diversions, 7 stereotactic procedures, and 1 burr hole drainage). Fifteen (75%) showed neurological or symptomatic improvement over a median follow-up period of 36.4 months. There were three surgery-related complications and no deaths.
Iatrogenic Saphenous Neuralgia: Successful Therapy with Neuroma Resection
Authors: Senegor Moris
Published: April 2011

We report the case of a patient with saphenous neuralgia secondary to iatrogenic trauma resulting from bypass surgery in the femoral-popliteal region. Early symptoms of this condition were medial calf and ankle pain, with no findings of motor and reflex abnormalities. Exploration of the thigh 2 years later revealed a neuroma of the nerve in the distal dissection site, medial to the knee. Resection of the neuroma alleviated this condition. It is noted that saphenous neuropathy is seen as a spontaneous entrapment syndrome as well as a complication of orthopedic and vascular procedures performed on the medial area of the knee. Saphenous neuralgia is often not recognized by neurosurgeons. If the condition is intractable, it does respond to surgical therapy.
Exposure of the Intracavernous Carotid Artery in Aneurysm Surgery
Authors: Ohmoto Takashi , Nagao Seigo , Mino Shogo , Ito Terukazu , Honma Yutaka , Fujiwara Takashi
Published: April 2011

The pterional intradural approach was used in five cases of large and giant carotid-ophthalmic aneurysms and in two cases of intracavernous aneurysms that arose from the anterior siphon knee in the cavernous sinus (CS) and extended into the carotid cistern. In four cases of large carotid-ophthalmic aneurysms removal of the anterior clinoid process and the roof of the optic canal gave easy access to the pericarotid ring. The anteromedial part of the pericarotid ring was dissected to expose the extradural portion of the internal carotid artery (ICA) proximal to the neck and to make enough room between the wall of the CS and the extradural portion of the ICA, thus allowing easy clipping of the neck. In one case of a giant carotid-ophthalmic aneurysm extending into the CS with an extradural origin of the ophthalmic artery and in two cases of an intracavernous aneurysm arising from the siphon knee, neck clipping was performed by opening the lateral wall and roof of the CS after removal of the optic strut. The opening of the lateral wall anterior to the 3rd nerve facilitated wide exposure of the anterior siphon knee. The horizontal portion of the intracavernous ICA as well as the whole aspect of the aneurysm could be exposed as a result of the extended opening of the cavernous roof anterior to the posterior clinoid process. Successful operative results were obtained in all seven patients. A visual field detect as an operative complication was noted in one patient. No disturbance of ocular movements was noted.
Peritumoral Blood Flow in Intracranial Meningiomas
Authors: Tatagiba Marcos , Mirzai Shahram , Samii Madjid
Published: April 2011

Blood flow was measured in intratumoral tissue, the cerebral hemispheres and particularly in the peritumoral area of 12 patients with intracranial meningiomas using the stable xenon-enhanced computed tomographic scan. Tumor blood flow frequently showed a heterogeneous pattern of enhancement with high flow at the tumor periphery and a central area of hypoperfusion. Blood flow values were on average 28% lower in the peritumoral area than in the ipsilateral cerebral hemisphere. In individual cases, blood flow values in the peritumoral edematous area were very low. These findings suggest that the hypodense area surrounding meningiomas does not solely represent vasogenic edema, but may actually represent tumor pressure ischemia.
Intraoperative Electrophysiological Monitoring of the Facial Nerve in the Presence of Damage to the Pre-Parotid Segment
Authors: Linskey Mark E. , Nuss Daniel W. , Krieger Don , Sekhar Laligam N.
Published: April 2011

A method is described for obtaining intraoperative monitoring of facial nerve function in patients who have previously lost facial nerve function distal to the pes anserinus or who have absent function because of trauma to the facial nerve in the pre-parotid segment during operative exposure.
Survival of Patients with Well-Differentiated Astrocytomas Diagnosed in The Era of Computed Tomography
Authors: Vertosick Frank T. , Selker Robert G. , Arena Vincent C.
Published: April 2011

We report 25 verified cases of well-differentiated cerebral astrocytomas in adults treated between 1978 and 1988. All patients were diagnosed by computed tomographic (CT); scans, with 5 undergoing a craniotomy for debulking and 20 undergoing a biopsy alone. The median survival for the entire group was 8.2 years, the longest survival yet reported for a series of patients with these tumors. A review of the literature suggests that the longer survival observed in more recent series is the result of the earlier diagnosis of tumors afforded by modern brain imaging. Twenty of our patients presented with seizures in the absence of any other focal findings and would probably not have had a biopsy in the era before CT scans until their tumors had progressed. Only 8% of our patients had papilledema at the time of presentation, in contrast to almost half of the patients with low-grade astrocytomas reported before 1975, supporting the hypothesis that patients in the CT era are diagnosed earlier. None of our patients died from progressive low-grade disease. One patient died from a squamous cell cancer, and 7 died as a consequence of their tumors dedifferentiating into a more malignant astrocytoma or glioblastoma multiforme, with a median time of approximately 5 years after the diagnosis. Our findings, together with the available data in the literature, suggest that death from a focal low-grade astrocytoma, in the absence of malignant degeneration, may be a rare event. Consequently, future therapeutic efforts should be targeted at preventing dediffer-entiation. The use of radiotherapy in this series of patients did not make a significant impact upon either the time to dedifferentiation or the time to death, but the numbers are small. Given the potential long-term detrimental effect of radiotherapy, the use of this treatment modality must be re-evaluated in the light of the earlier diagnosis and longer natural survival of the patient with an astrocytoma diagnosed in the CT era. Moreover, given the longer survival we observed in a patient population diagnosed predominantly by a biopsy alone, the necessity for radical surgery may also need to be reviewed. In view of the evolving nature of this patient population, much of the older literature on astrocytomas may have little relevance in advising and treating the “modern” patient with an astrocytoma.
Traumatic Atlantooccipital Dislocation with Survival
Authors: Papadopoulos Stephen M. , Dickman Curtis A. , Sonntag Volker K.H. , Rekate Harold L. , Spetzler Robert F.
Published: April 2011

Survival after traumatic atlantooccipital dislocation is rare. Only long-term survivors have been reported in the literature; however, improved prehospital care is likely responsible for the increase in the number of these patients seen at neurotrauma centers over the last decade. Associated severe and persistent neurological deficits are common in the few survivors. We report the case of a 10-year-old boy with traumatic atlantooccipital dislocation and a severe neurological injury. Low-field magnetic resonance imaging provided the additional diagnosis of an associated cervicomedullary epidural hematoma. The patient underwent emergency operative evacuation of the hematoma and an occipital-cervical fusion with internal fixation. He had a remarkable recovery in neurological function and achieved stable bony fusion 3 months postoperatively. With early recognition of this entity, improved neuroradiological imaging techniques, and aggressive treatment, patients may survive with significant neurological recovery.
Acute Atraumatic Subdural Hematoma Associated with Moyamoya Disease in an African-American
Authors: Oppenheim Jeffrey S. , Gennuso Rosemaria , Sacher Michael , Hollis Peter
Published: April 2011

A 57-year-old black woman with an atraumatic subdural hematoma was treated for congestive heart failure and was found to have moyamoya disease. The association of these two lesions is rare and has never been described in an African-American. High cerebral venous pressures and changes in cerebral perfusion caused by congestive heart failure and the loss of cerebrovascular autoregulation in moyamoya disease may explain the spontaneous occurrence of a subdural hematoma. Recommendations for management are discussed.
Symptomatic Chiari Malformation in Adults: A New Classification Based on Magnetic Resonance Imaging with Clinical and Prognostic Significance
Authors: Pillay Prem K. , Awad Issam A. , Little John R. , Hahn Joseph F.
Published: April 2011

Thirty-five consecutive adults with Chiari malformation and progressive symptoms underwent surgical treatment at a single institution over a 3-year period. All patients underwent magnetic resonance imaging scan before and after surgery. Images of the craniovertebral junction confirmed tonsillar herniation in all cases and allowed the definition of two anatomically distinct categories of the Chiari malformation in this age group. Twenty of the 35 patients had concomitant syringomyelia and were classified as Type A. The remaining 15 patients had evidence of frank herniation of the brain stem below the foramen magnum without evidence of syringomyelia and were labeled Type B. Type A patients had a predominant central cord symptomatology: Type B patients exhibited signs and symptoms of brain stem or cerebellar compression. The principal surgical procedure consisted of decompression of the foramen magnum, opening of the fourth ventricular outlet, and plugging of the obex. Significant improvement in preoperative symptoms and signs was observed in 9 of the 20 patients (45%) with syringomyelia (Type A), as compared to 13 of the 15 patients (87%) without syringomyelia (Type B). Postoperative reduction in syrinx volume was observed in 11 of the 20 patients with syringomyelia, including all 9 patients with excellent results. Magnetic resonance imaging has allowed a classification of the adult Chiari malformation in adults based on objective anatomic criteria, with clinical and prognostic relevance. The presence of syringomyelia implies a less favorable response to surgical intervention.
Conservative Treatment of Patients with Acoustic Tumors
Authors: Bederson Joshua B. , von Ammon Klaus , Wichmann Werner W. , Yasargil Gazi M.
Published: April 2011

Seventy of 178 patients with acoustic tumors initially were treated conservatively and have been followed up for an average of 26 ± 2 months. The tumor size was determined by the mean maximum anteroposterior and mediolateral diameters, using computed tomographic or magnetic resonance imaging scans obtained sequentially throughout the follow-up period. The average tumor growth was 1.6 ± 0.4 mm the 1st year, and 1.9 ± 1.0 mm the 2nd year (range, -2 to 17 mm/y): 4 tumors showed apparent regression, 28 (40%) had no detectable growth, and 37 (53%) exhibited growth (average, 3.8 ± 1.2 mm/y). Within individual patients, the tumor growth rate determined during the 1st year of follow-up was predictive of tumor growth rate during the following year. Rapid tumor growth or clinical deterioration in 9 of the 70 patients (13%) who initially were treated conservatively necessitated subsequent surgery an average of 14 ± 5 months after the patient was initially seen. This group had a larger initial tumor size (27.0 ± 3.4 mm vs. 21.3 ± 0.9 mm, P<0.05), and a faster 1-year growth rate (7.9 ± 2.3 mm/y vs. 1.3 ± 0.3 mm/y, P<0.05) than the 61 patients who did not require surgery. Two patients, however, experienced neurological deterioration that required surgery, even though there was no tumor growth. The high incidence of acoustic tumors with no detectable growth or apparent spontaneous regression must be taken into account when evaluating the indications for surgery and the efficacy of radiotherapy. Beacuse surgery carries some risk and acoustic tumors are generally slow growing, a trial of conservative treatment is possible in selected patients, provided serial radiological studies are obtained. Knowledge of the tumor growth rate established by these studies may be helpful in the treatment of individual patients.
Failed Back Surgery Syndrome: 5-Year Follow-Up after Spinal Cord Stimulator Implantation
Authors: North Richard B. , Ewend Matthew G. , Lawton Michael T. , Kidd David H. , Piantadosi Steven
Published: April 2011

Spinal cord stimulation, in use for more than 20 years, has evolved into an easily implemented technique, with percutaneous methods for electrode placement. We have reviewed our experience with this technique in treating “failed back surgery syndrome,” and have assessed patient and treatment characteristics as predictors of long-term outcome. A series of 50 patients with failed back surgery syndrome (averaging 3.1 previous operations), who underwent spinal cord stimulator implantation, was interviewed by impartial third parties, at mean follow-up intervals of 2.2 years and 5.0 years. Successful outcome (at least 50% sustained relief of pain and patient satisfaction with the result) was recorded in 53% of patients at 2.2 years and in 47% of patients at 5.0 years postoperatively. Ten of 40 patients who were disabled preoperatively returned to work. Improvements in activities of daily living were recorded in most patients for most activities; loss of function was rare. Most patients reduced or eliminated analgesic intake. Statistical analysis (including univariate and multivariate logistic regression) of patient characteristics as prognostic factors showed significant advantages for female patients and for those with programmable multi-contact implanted devices. These results, in patients with postsurgical lumbar arachnoid and epidural fibrosis and without surgically remediable lesions, compare favorably with the results in two separate series of patients with failed back surgery syndrome, in whom 1) surgical lesions were diagnosed and repeated operation performed; and 2) monoradicular pain syndromes were diagnosed and dorsal root ganglionectomies peroformed at our institution. This suggests the need for further assessment of selection criteria, critical analysis of treatment outcome, and prospective study of spinal cord stimulation and alternative approaches to failed back surgery syndrome.
Hypertrophic Spinal Pachymeningitis: Report of Two Cases and Review of the Literature
Authors: Ashkenazi E. , Constantini S. , Pappo O. , Gomori M. , Averbuch-Heller L. , Umansky F.
Published: April 2011

The cases of two patients with idiopathic pachymeningitis hypertrophica that caused progressive paraparesis are presented. Gadolinium-enhanced magnetic resonance imaging was used to demonstrate this pathological entity in one patient, and myelography was used in the other. Decompressive surgery led to significant neurological improvement. The etiology, diagnosis, and management of this disease is discussed, and the literature is reviewed. To our knowledge, this is the first report to describe the features of this rare pathological entity on magnetic resonance imaging.
Subependymoma with Rhabdomyosarcomatous Differentiation: Report of a Case and Literature Review
Authors: Tomlinson Frank H. , Scheithauer Bernd W. , Kelly Patrick J. , Forbes Glenn S.
Published: April 2011

A unique gliomesenchymal neoplasm, consisting of a subependymoma, a form of low-grade glioma, and a rhabdomyosarcoma, is described. It arose and recurred in the brain stem of a 52-year-old man. Immunohistochemical studies demonstrated the presence of a neuroectodermal marker S-100 protein within some sarcoma cells. The occurrence of this rare tumor supports the concept that striated muscle may derive from a neuroectodermal precursor lesion.
Cranioplasty, Vertebral Body Replacement, and Spinal Fusion with Tobramycin-impregnated Methylmethacrylate
Authors: Shapiro Scott A.
Published: April 2011

A prospective analysis of cranioplasty, vertebral body replacement, and spinal fusion using tobramycin-impregnated methylmethacrylate in 65 patients is presented. Cranioplastic methacrylate (1 packet) was mixed with 1.2 g of powdered tobramycin and placed into the desired location. The polymer was irrigated with bacitracin until it became solid. All patients received prophylactic medication with intravenously administered nafcillin and cephalosporin perioperatively and for 48 hours postoperatively. The follow-up time ranged from 7 to 57 months (mean, 32.2 months). Serum tobramycin levels remained below 0.5 μg/ml in all patients tested, regardless of the time interval. Blood urea nitrogen and creatinine levels remained within normal limits in all patients, and there has been no nephrotoxicity or ototoxicity. There has been 1 infection among the 65 patients (1%) to date. It occurred in a patient who had a previously treated local infection. Cranioplasty, vertebral body replacement, or spinal fusion with tobramycin-impregnated methylmethacrylate is safe and may reduce the incidence of infection.
Open Surgery Assisted by the Neuronavigator, a Stereotactic, Articulated, Sensitive Arm
Authors: Watanabe Eiju , Mayanagi Yoshiaki , Kosugi Yukio , Manaka Shinya , Takakura Kintomo
Published: April 2011

A new computed tomographic-stereotactic device that translates the operating point onto preoperative computed tomographic (CT) images, the Neuronavigator, has been developed. We have applied this system to various neurosurgical procedures to examine its usefulness. The system consists of a 6-joint sensing arm and a 16-bit personal computer. It projects the location of the arm tip onto a corresponding CT slice with a cursor that guides the surgeon toward the intracranial target during open surgery. The system also projects the location of the tip onto angiograms, and when used in conjunction with echography or a transcranial Doppler (TCD) flow meter, the surgeon's ability to navigate is enhanced. Sixty-eight patients underwent operation with the Neuronavigator. The navigation system worked as the core of a multimodal three-dimensional data base that proved to be useful during surgery. The maximum detection error was 2.5 mm, which was considered sufficient for open microsurgery. It also proved useful in designing the position of a craniotomy, in targeting deep-seated mass lesions, and in tracing the tumor edge, which had been identified on a CT scan. When the angiogram was combined with the navigator, it became easy to identify key vessels within a small operating field. The system was also combined with a TCD flow meter. This combination makes it possible to translate the measuring point of the TCD directly into CT coordinates, improving the precision of location of the TCD probe. The Neuronavigator combines various diagnostic images into one database and effectively guides the surgeon during surgery.
Anterior Transpetrosal-Transtentorial Approach for Sphenopetroclival Meningiomas: Surgical Method and Results in 10 Patients
Authors: Kawase Takeshi , Shiobara Ryuzo , Toya Shigeo
Published: April 2011

This report presents a new surgical method and the results in 10 patients with petroclival meningiomas extending into the parasellar region (sphenopetroclival meningiomas). Minimal but effective extradural resection of the anterior petrous bone via a middle fossa craniotomy offered a direct view of the clival area with preservation of the temporal bridging veins and cochlear organs. The dural incision was extended anteriorly to Meckel's cave, and in cases with invasion of the cavernous sinus, Parkinson's triangle was enlarged by mobilization of the trigeminal nerve. This approach offered an excellent view from the mid-clivus to the cavernous sinus. Extra-as well as intradural tumor masses and dural attachments could be cleared under direct view of the pontine surface. The risk of injury to the lower cranial nerve and of retraction damage to the temporal lobe and brain stem were kept minimal by this approach. Total tumor resection was achieved in 7 patients, with no resultant mortality. Eight patients had a satisfactory postsurgical course, extraocular paresis being their main complaint. The extent of tumor resection depended on the degree of tumor adhesion to the carotid artery, and operative morbidity on the degree of tumor invasion of the brain stem. Of the 3 patients in whom subtotal tumor removal was achieved, only one experienced regrowth of the tumor and underwent a second operation during the follow-up period (6 months-6 years).
Dissecting Aneurysms of the Posterior Inferior Cerebellar Artery
Authors: Yamaura Akira , Isobe Katsumi , Karasudani Hirohide , Tanaka Mikio , Komiya Hirokazu
Published: April 2011

The authors present three cases of dissecting aneurysms of the posterior inferior cerebellar artery (PICA). A literature search revealed only three previous cases. Analysis of these six cases showed a unique clinical picture. Three patients developed subarachnoid hemorrhage, and the other three had ischemia. All patients complained of occipital headache or neck pain, regardless of the initial symptoms. Heralding episodes were recorded in four cases. Angiography showed a characteristic fusiform dilatation of the PICA and a narrowing proximal to and distal to the lesion. Various surgical treatments were performed in five cases. Intraoperative observation showed a sausage-like swelling of the PICA or one of its branches with various discoloration depending on the age of the intramural clot. The outcomes were favorable.
Subarachnoid Hemorrhage from Multiple Neurofibromas of the Cauda Equina: Case Report
Authors: Bruni Patrizio , Esposito Stefano , Oddi Giuseppina , Hernandez Regulo , Martines Franca , Patricolo Angelo
Published: April 2011

The authors report a case of spinal subarachnoid hemorrhage caused by neurofibromas of the cauda equina. An examination of the literature revealing 13 similar cases and an analysis of this case showing three neurofibromas of the cauda equina prompted an hypothesis emphasizing the origin of bleeding and the difficulties associated with a correct diagnosis.
The Role of Radiosurgery in the Management of Chordoma and Chondrosarcoma of the Cranial Base
Authors: Kondziolka Douglas , Lunsford L. Dade , Flickinger John C.
Published: April 2011

Despite conventional multimodality treatment (surgery and fractionated radiation therapy), recurrence and clinical progression of cranial base chordomas and chondrosarcomas are common. The malignant behavior of these tumors is a result of their critical location, locally aggressive nature, and high recurrence rate. To explore the role of radiosurgery in the treatment of these skull base neoplasms, we assessed its use in four patients with chordoma and two with chondrosarcoma. In five of the patients, radiosurgery was used as adjuvant therapy for residual or recurrent tumors after surgical debulking, and in one patient with a chordoma, it was the primary treatment. No patient received fractionated external beam radiotherapy. All tumors were less than 30 mm in diameter and were treated with 20 Gy to the tumor margin. Skull base computed tomography and magnetic resonance images were essential to define the anatomic relationships between tumor and adjacent basal structures. During follow-up (mean, 22 mo; range, 8-36 mo), we found no progression of the treated tumor volume in any patient. Neurological deficits before treatment improved in three patients; the other three patients remained in stable neurological condition. Serial follow-up imaging studies demonstrated that two patients showed reduction in tumor size and four patients had no tumor growth. In one patient, a metastatic parietal lobe chondrosarcoma developed and was treated by microsurgery. Another patient showed tumor progression outside of the radiosurgical trcatment volume. Our results attest to the value of stereotactic radiosurgery as an adjuvant or primary treatment for selected patients with chordoma or chondrosarcoma and demonstrate its potential advantages over standard fractionated irradiation. Analysis of the long-term clinical and imaging effects after radiosurgery is warranted. (Neurosurgery 29:38-46, 1991)
Pituitary Microcirculation: Physiological Aspects and Clinical Implications. A Laser-Doppler Flow Study during Transsphenoidal Adenomectomy
Authors: Steinmeier Ralf , Fahlbusch Rudolf , Powers Alexandros D. , Dötterl Andreas , Buchfelder Michael
Published: April 2011

The anterior and posterior pituitary lobes (AL and PL, respectively) are assumed to differ in the type of vascular supply and structure of their microvascular networks. Animal experiments have shown that the pituitary microvascular flow differs between the two lobes, being extremely high in the PL and low in the AL. For technical reasons, it has hitherto not been possible to study pituitary microflow in humans. Laser-Doppler flowmetry (LDF) is now a well-established method for real-time monitoring of microcirculation, applicable also in humans. In a prospective clinical study, the microflow in the AL and PL was measured during transsphenoidal microsurgery in 52 patients with adenomas of different size, growth characteristics, and endocrinological activity. The mean microflow in the PL (177.7 ± 12.6 [flux]) was found to be about six times higher than that in the AL (27.4 ± 2.7 [flux]). No difference in the laser-Doppler fractional volume of the lobes could be detected (0.73 ± 0.006 [] vs. 0.77 ± 0.07 [], where [] designates the ratio of the alternating current output to the direct current output signals). Microflow within the pituitary lobes was influenced neither by the histological type nor the size of the adenoma. Additionally, LDF signal-averaging triggered by the electrocardiogram allowed detection of different characteristic pulsatile microvascular flow patterns in the AL and PL. Our findings provide strong physiological support for the idea that the angioarchitecture of the pituitary lobes differs. With this method, the AL and PL can be identified objectively during surgery. LDF might provide useful information concerning intraoperative surgical approach. (Neurosurgery 29:47-54, 1991)
Ossified Mucin-secreting Choroid Plexus Adenoma: Case Report
Authors: Duckett Serge , Osterholm Jewell , Schaefer Dale , Gonzales Carlos , Schwartzman Robert J.
Published: April 2011

This is the first report of a fully documented case of an ossified mucin-producing benign choroid plexus tumor. This was a chance finding in a man who complained only of posttraumatic low back discomfort. The ossification of the tumor appears to have been therapeutic. Mucin production may be a defense mechanism. (Neurosurgery 29:130-132. 1991)
Spontaneous Spinal Subdural Hematoma: Case Report and Review of the Literature
Authors: Calhoun Michael J. , Boop Frederick
Published: April 2011

We report the case of a pediatric patient with a spontaneous spinal subdural hematoma that was not associated with a coagulation abnormality. Six cases have been reported previously. The patient improved after surgical drainage. The possible causes of this rare problem are discussed. (Neurosurgery 29:133-134, 1991)
Inflammatory Pseudotumor of the Choroid Plexus in Sjögren's Disease
Authors: Chang Yuan , Horoupian Dikran S. , Lane Barton , Fross Robin D. , Smyth L.T. , Seiling Robert J.
Published: April 2011

We report an unusual case of inflammatory pseudotumor of the choroid plexus of the right lateral ventricle, manifesting as an intraventricular mass and causing unilateral hydrocephalus in a 48-year-old man who suffered from Sjögren's disease and subacute cutaneous lupus erythematosus. The lesion obliterated the normal choroidal architecture by a mixed chronic inflammatory process that was associated with reactive connective tissue changes. Immunohistochemical studies showed no light-chain restriction in the cells, and residual islands of transthyretin-positive epithelial cells were identified, implicating the choroid plexus origin of the mass.
Dissecting Aneurysm of the Posterior Cerebral Artery: Spontaneous Resolution
Authors: Maillo Angel , Diaz Pedro , Morales Francisco
Published: April 2011

Dissecting aneurysms of the intracranial arteries display vascular pathological features that appear sporadically, generally affecting young adults. The clinical features of this condition may involve both ischemic episodes and hemorrhages. Posterior circulation is affected less than the rest of the intracranial arteries, and it is extremely rare to find the posterior cerebral arteries only affected. Mortality is high in patients where the lesion is located in the posterior intracranial circulation, although dissecting aneurysms limited to the posterior cerebral arteries may, to a certain extent, be benign. We report the case of a young woman with ischemia in the territory of the posterior cerebral artery that occurred subsequent to a dissecting aneurysm that resolved spontaneously to a complete remission, both clinically and as demonstrated by angiography. A review of the literature is made, analyzing the pathogenic, clinical, angiographic, and therapeutic characteristics of such lesions.
Disc Herniation in Cervical Fracture Subluxation
Authors: Harrington Frederick J. , Likavec Matt J. , Smith Alison S.
Published: April 2011

Previous reports of computed tomographic scan with contrast myelography in cervical spinal cord injury have shown a rate of disc herniation of less than 5%. We hypothesized that injuries associated with forces adequate to cause bone or ligamentous injury in the region of the disc space could be associated with higher and more significant rates of disc herniation. Thirty-seven consecutive traumatic midcervical fracture subluxations were reviewed. Fracture subluxation was defined by fracture of the facet joints, pedicles, or vertebral bodies or more than 3.5 mm subluxation from C2-C3 to C7-T1. Reduction was achieved in 97% and was not associated with neurological deterioration. On the basis of plain films, tomograms, and plain computed tomographic scans, the injuries were classified as flexion dislocation, flexion compression, compression burst, or extension injuries. Twenty-five computed tomographic scans with contrast myelograms and one magnetic resonance imaging scan were obtained. All patients with partial neurological deficits were studied. A herniated disc was defined as that which deformed the thecal sac and/or nerve roots. Retrospectively, a neuroradiologist reviewed the studies for the presence of herniated disc. Disc herniation was seen at the level of injury in 9 (35%) patients and not seen in other patients. Forty-seven percent of the patients with partial deficits had herniated discs. Herniated discwas seen most frequently in flexion dislocation and flexion compression injuries. Three patients (20%) with partial deficits underwent discectomy. Patients with partial spinal cord injury and discectomy, on average, improved more than other patients with partial spinal cord injury. The authors conclude that: 1) herniated discs occur frequently in cervical fracture subluxation and are clinically significant; 2) disc herniation is associated with flexion dislocation and flexion compression injuries; 3) neuroimaging studies should be obtained in all patients with cervical fracture subluxation and neurological deficit to rule out compressive discs.
Missile Injuries to the Brain Treated by Simple Wound Closure: Results of a Protocol during the Lebanese Conflict
Authors: Taha Jamal M. , Saba Maurice I. , Brown Jeffrey A.
Published: April 2011

This is a prospective study of the treatment of penetrating missile injuries to the brain without intracranial surgery carried out at the American University of Beirut Medical Center between 1981 and 1988. Of 600 patients treated for missile injuries to the head. 32 satisfied the study criteria. There were 27 shrapnel and 5 bullet injuries. The mean patient age was 23 years (range, 3-51 years). Twenty patients had intracranial indriven bone fragments. Six patients had exposed brain tissue. The mean follow-up was 3.5 years (range, 1-7.5 years). The superficial entry wound was debrided and closed without drainage in the Emergency Room within a mean of 3 hours (range, 0.5-6 hours), and the patient received methicillin for 14 days. All patients survived and had no or improved neurological deficits. No leakage of the cerebrospinal fluid, infection, or seizures occurred in 31 patients. One patient with indriven bone fragments had leakage of the cerebrospinal fluid and developed seizures and a brain abscess 20 days after the injury. The management of penetrating missile injuries to the brain without intracranial surgery in a select patient population is a reasonable option. This treatment becomes important for a surgeon facing large numbers of casualties, or when operative personnel or resources are limited or unavailable.