bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving the prediction of outcome in severe acute closed head injury by using discriminant function analysis of normal auditory brainstem response latencies and amplitudes
Authors: Wilson Wayne J. , Penn Claire , Saffer David , Aghdasi Farzin
Published: May 2009

Object. The auditory brainstem response (ABR) is a useful addition to standard medical measures for predicting outcome in patients with severe acute closed head injury (ACHI). Limiting this success, however, is the poor predictive value of a so-called “normal” ABR. In this study the authors used discriminant function analysis (DFA) of ABR Wave I, III, and V latencies and amplitudes to improve the predictive accuracy of the normal ABR, both as a single measure and in combination with other standard medical measures.

Methods. The DFAs were conducted using the ABR and medical results in 68 patients with severe ACHI (30 who died [ACHI-died], and 38 who survived [ACHI-lived]) who presented with normal ABR responses in the neurosurgical intensive care unit of the authors' hospital in Johannesburg. All patients had undergone surgery to remove an intracranial hematoma.

Correct predictions of outcome by ABR DFA measures were 83% for the ACHI-died group (48% at ≥ 90% confidence level) and 87% for the ACHI-lived group (71% at ≥ 90% confidence level); by medical DFA measures the correct predictions were 83% for the ACHI-died group (96% at ≥ 90% confidence level) and 95% for the ACHI-lived group (94% at ≥ 90% confidence level); and by combined ABR and medical DFA measures correct predictions were 100% for the ACHI-died group (100% at ≥ 90% confidence level) and 97% for the ACHI-lived group (100% at ≥ 90% confidence level).

Conclusions. The DFA of ABR Wave I, III, and V latencies and amplitudes improved the predictive ability of normal ABR results to rates similar to those obtained using DFA for the medical measures, although at lower confidence levels. The DFA of the combined ABR and medical measures improved correct predictions to rates significantly higher than for either of the measures on its own.
Suboccipital and cervical chordomas: the value of aggressive treatment at first presentation of the disease
Authors: Carpentier Alexandre , Polivka Marc , Blanquet Alexandre , Lot Guillaume , George Bernard
Published: May 2009

Object. Chordoma is a locally invasive tumor with a high tendency for recurrence for which radical resection is generally recommended. To assess the benefits of aggressive treatment of chordomas, the authors compared results in patients treated aggressively at the first presentation of this disease with results in patients who were similarly treated, but after recurrence.

Methods. Among 36 patients with cervical chordomas who were treated at the authors' institution, 22 underwent primary aggressive treatment (Group A) and 14 were treated secondarily after tumor recurrence (Group B). Two cases were excluded from Group A because of unrelated early deaths and three from Group B because of insufficient pre- or postoperative data. Most tumors were located at the suboccipital level and only eight cases at a level below C-2. Radiotherapy and proton therapy were similarly conducted in both groups of patients.

The actuarial survival rates were 80 and 65% at 5 and 10 years, respectively, in Group A patients and 50 and 0% at 5 and 10 years, respectively, in Group B patients (p = 0.049, log-rank test). The actuarial recurrence-free rates were 70 and 35% at 5 and 10 years, respectively, in Group A and 0% at 3 years in Group B (p < 0.0001, log-rank test). The numbers of recurrences per year were 0.15 in Group A and 0.62 in Group B (p > 0.05). All other parameters that were analyzed (patient age, delay before diagnosis, clinical symptoms, chondroid type of lesion, and histological features) did not prove to influence prognosis in a statistically significant manner.

Conclusions. Aggressive therapy, combining as radical a resection as possible with radiotherapy, seems to improve the prognoses of suboccipital and cervical chordomas when applied at the patient's first presentation with the disease.
Use of diffusion-weighted magnetic resonance imaging in differentiating purulent brain processes from cystic brain tumors
Authors: Guzman Raphael , Barth Alain , Lövblad Karl-Olof , El-Koussy Marwan , Weis Joachim , Schroth Gerhard , Seiler Rolf W.
Published: May 2009

Object. Brain abscesses and other purulent brain processes represent potentially life-threatening conditions for which immediate correct diagnosis is necessary to administer treatment. Distinguishing between cystic brain tumors and abscesses is often difficult using conventional imaging methods. The authors' goal was to study the ability of diffusion-weighted (DW) magnetic resonance (MR) imaging to differentiate between these two pathologies in patients within the clinical setting.

Methods. Diffusion-weighted MR imaging studies and calculation of the apparent diffusion coefficient (ADC) values were completed in a consecutive series of 16 patients harboring surgically verified purulent brain processes. This study group included 11 patients with brain abscess (one patient had an additional subdural hematoma and another also had ventriculitis), two with subdural empyema, two with septic embolic disease, and one patient with ventriculitis. Data from these patients were compared with similar data obtained in 16 patients matched for age and sex, who harbored surgically verified neoplastic cystic brain tumors. In patients with brain abscess, subdural empyema, septic emboli, and ventriculitis, these lesions appeared hyperintense on DW MR images, whereas in patients with tumor, the lesion was visualized as a hypointense area. The ADC values calculated in patients with brain infections (mean 0.68 × 103 mm2/sec) were significantly lower than those measured in patients with neoplastic lesions (mean 1.63 × 103 mm2/sec; p < 0.05).

Conclusions. Diffusion-weighted MR imaging can be used to identify infectious brain lesions and can help to differentiate between brain abscess and cystic brain tumor, thus making it a strong additional imaging modality in the early diagnosis of central nervous system purulent brain processes.
Preoperative mapping of the supplementary motor area in patients harboring tumors in the medial frontal lobe
Authors: Nelson Lindsey , Lapsiwala Samir , Haughton Victor M. , Noyes Jane , Sadrzadeh Amir H. , Moritz Chad H. , Meyerand M. Elizabeth , Badie Behnam
Published: May 2009

Object. Injury to the supplementary motor area (SMA) is thought to be responsible for transient motor and speech deficits following resection of tumors involving the medial frontal lobe. Because direct intraoperative localization of SMA is difficult, the authors hypothesized that functional magnetic resonance (fMR) imaging might be useful in predicting the risk of postoperative deficits in patients who undergo resection of tumors in this region.

Methods. Twelve patients who had undergone fMR imaging mapping while performing speech and motor tasks prior to excision of their tumor, that is, based on anatomical landmarks involving the SMA, were included in this study. The distance between the edge of the tumor and the center of SMA activation was measured and was correlated with the risk of incurring postoperative neurological deficits.

In every patient, SMA activation was noted in the superior frontal gyrus on preoperative fMR imaging. Two speech and two motor deficits typical of SMA injury were observed in three of the 12 patients. The two speech deficits occurred in patients with tumors involving the dominant hemisphere, whereas one of the motor deficits occurred in a patient with a tumor in the nondominant hemisphere. The risk of developing a postoperative speech or motor deficit was 100% when the distance between the SMA and the tumor was 5 mm or less. When the distance between SMA activation and the lesion was greater than 5 mm, the risk of developing a motor or a speech deficit was 0% (p = 0.0007).

Conclusions. Early data from this study indicated that fMR imaging might be useful in localizing the SMA and in determining the risk of postoperative deficits in patients who undergo resection of tumors located in the medial frontal lobe.
Factors predictive of suboptimal seizure control following selective amygdalohippocampectomy
Authors: Abosch Aviva , Bernasconi Neda , Boling Warren , Jones-Gotman Marilyn , Poulin Nicole , Dubeau François , Andermann Frederick , Olivier André
Published: May 2009

Object. Selective amygdalohippocampectomy (SelAH) is used in the treatment of mesial temporal lobe epilepsy (MTLE). The goal of this study was to determine factors predictive of poor postoperative seizure control (Engel Class III or IV) following SelAH.

Methods. A retrospective study was conducted of 27 patients with poor seizure control postoperatively (Engel III/IV group), in comparison with 27 patients who were free from seizures after surgery (Engel I/II group). The results of electroencephalography, magnetic resonance (MR) imaging, and pathological studies were reviewed, and volumetric MR image analysis was used to compare the extent of the mesial structures that had been resected.

In 56% of patients in the Engel III/IV group, significant bitemporal abnormalities were displayed on preoperative EEG studies, compared with 24% of patients in the Engel I/II group (p < 0.05). An analysis of preoperative MR images disclosed five patients (19%) in the Engel III/IV group and no patient in the Engel I/II group with normal hippocampal volumes bilaterally. Thirteen patients in the Engel III/IV group subsequently underwent either extension of the SelAH (six cases) or a corticoamygdalohippocampectomy (seven patients). Three patients from the former and one patient from the latter subgroup subsequently became seizure free (four patients total [34%]). The remaining nine patients did not improve, despite the fact that they had undergone near-total resection of mesial structures.

Conclusions. The majority of patients receiving suboptimal seizure control following SelAH did not meet the criteria for unilateral MTLE, based on EEG, MR imaging, and/or histopathological studies. These patients were therefore unlikely to benefit from additional resection of mesial structures. With the benefits of modern imaging, and by strict adherence to selection criteria, SelAH can be predicted to yield excellent postoperative seizure control for nearly all patients with unilateral MTLE. There remains a subpopulation, however, that meets the criteria for MTLE, but does not become free from seizure following SelAH.
A new rat model of chronic cerebral hypoperfusion associated with arteriovenous malformations
Authors: Hai Jian , Ding Meixiu , Guo Zhilin , Wang Bingyu
Published: May 2009

Object. A new experimental model of chronic cerebral hypoperfusion was developed to study the effects of systemic arterial shunting and obstruction of the primary vessel that drains intracranial venous blood on cerebral perfusion pressure (CPP), as well as cerebral pathological changes during restoration of normal perfusion pressure.

Methods. Twenty-four Sprague—Dawley rats were randomly assigned to either a sham-operated group, an arteriovenous fistula (AVF) group, or a model group (eight rats each). The animal model was readied by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein (EJV) and the ispilateral common carotid artery (CCA), followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. Systemic mean arterial pressure (MAP), draining vein pressure (DVP), and CPP were monitored and compared among the three groups preoperatively, immediately postoperatively, and again 90 days later. Following occlusion of the fistula after a 90-day interval, blood—brain barrier (BBB) disruption and water content in the right cortical tissues of the middle cerebral artery territory were confirmed and also quantified with transmission electron microscopy.

Formation of a fistula resulted in significant decreases in MAP and CPP, and a significant increase in DVP in the AVF and model groups. Ninety days later, there were still significant increases in DVP and decreases in CPP in the model group compared with the other groups (p < 0.05). Damage to the BBB and brain edema were noted in animals in the model group during restoration of normal perfusion pressure by occlusion of the fistula. Electron microscopy studies revealed cerebral vasogenic edema and/or hemorrhage in various amounts, which correlated with absent astrocytic foot processes surrounding some cerebral capillaries.

Conclusions. The results demonstrated that an end-to-side anastomosis between the distal EJV and CCA can induce a decrease in CPP, whereas a further chronic state of cerebral hypoperfusion may be caused by venous outflow restriction, which is associated with perfusion pressure breakthrough. This animal model conforms to the basic hemodynamic characteristics of human cerebral arteriovenous malformations.
Fetal meningeal hemangiopericytoma
Authors: Cavalheiro Sergio , de Castro Sparapani Fábio Veiga , Moron Antonio Fernandes , da Silva Marcia Cristina , Stávale João Norberto
Published: May 2009

✓ The authors present the case of a 34-week-old fetus with a meningeal hemangiopericytoma that was diagnosed in utero by using abdominal magnetic resonance imaging. After birth, the neonate underwent transfontanelle ultrasonography and computerized tomography scanning of the head, which confirmed the presence of an extradural hyperdense lesion. Six hours after birth the neonate underwent a craniotomy, which resulted in complete resection of the mass. The postoperative period was uneventful and the newborn was discharged 7 days later. At 2-year follow-up examination there was no evidence of recurrence of the lesion. The authors have found no mention in the literature of this entity diagnosed in the prenatal period.
Wegener granulomatosis manifesting as meningitis
Authors: Yasuhara Takao , Fukuhara Toru , Nakagawa Minoru , Terai Yoshinori , Yoshino Kimihiro , Mizobuchi Koichi , Fujimoto Shunichiro
Published: May 2009

✓ The authors describe a unique presentation of Wegener granulomatosis (WG) manifesting predominantly as meningitis. Magnetic resonance imaging demonstrated diffuse meningeal enhancement, including the pia mater, in a 28-yearold man with meningitis. A diagnosis of atypical WG was based on the findings of a dural biopsy sample and an elevated cytoplasmic antineutrophil cytoplasmic antibody (cANCA) titer, although the patient did not have any of the lesions common to WG. Immunosuppressive therapy was quite effective. With treatment, the meningeal enhancement resolved and the cANCA titer normalized. Meningeal granulomatosis as the sole lesion in WG has never been reported in the literature. This atypical course of WG should be noted.
Ipsilateral hyperperfusion after neck clipping of a giant internal carotid artery aneurysm
Authors: Murakami Hideki , Inaba Makoto , Nakamura Akiyoshi , Ushioda Takakazu
Published: May 2009

✓ A 48-year-old woman exhibited hyperperfusion soon after undergoing a successful clip operation involving multiple clip placement for a giant internal carotid artery (ICA) aneurysm. Intraarterial digital subtraction angiography demonstrated a left paraclinoid giant aneurysm. Multiple clips were placed to obliterate the aneurysm during a 7minute temporary ICA occlusion. Intraoperative Doppler ultrasound flowmetry showed that the blood flow through the ICA distal to the aneurysm increased from 71.6 ml/minute before clipping to 123.3 ml/minute after. The patient exhibited right hemiparesis and motor aphasia after the operation. Postoperative imaging studies revealed an increase in perfusion and diffuse edema in the left cerebral cortex. The symptoms and diffuse brain edema gradually resolved. In this case, increase in blood flow through the ICA distal to the aneurysm may have played an important role in the circulatory disturbance.
Malignant squamous degeneration of a cerebellopontine angle epidermoid tumor
Authors: Link Michael J. , Cohen Paul L. , Breneman John C. , Tew John M.
Published: May 2009

✓ The authors present the case of a woman with a cerebellopontine angle (CPA) epidermoid cyst that degenerated into a squamous cell carcinoma. Malignant degeneration of an epidermoid cyst is an extremely rare occurrence. Malignant transformation must be considered in the differential diagnosis when new contrast enhancement on imaging studies and progressive neurological deficit are seen in a patient harboring an epidermoid cyst.

The patient initially presented with a 10-year history of left trigeminal neuralgia, subacute left-sided hearing loss, and with facial weakness of 3 weeks' duration. Initial magnetic resonance (MR) imaging revealed a left CPA mass, consistent with an epidermoid. There was faint contrast enhancement where the tumor was in contact with the lateral brainstem.

A subtotal resection was performed. Histopathological findings were consistent with an epidermoid tumor. One year after initial presentation, the patient's neurological deficit had increased, and follow-up MR imaging demonstrated a large contrast-enhancing tumor filling the left CPA and compressing the brainstem. At repeated surgery a squamous cell carcinoma arising from the previous epidermoid was found. The patient was subsequently treated with external-beam radiotherapy and stereotactic radiosurgery. Her tumor stabilized. Three years and 8 months after the patient's initial presentation, a new area of tumor developed at the torcular Herophili. The patient died shortly thereafter.

Malignant squamous degeneration is a rare cause of enhancement on MR images, as is progressive neurological deficit in a patient with an epidermoid. The combination of subtotal resection, external-beam radiotherapy, and stereotactic radiosurgery may be useful for local tumor control but the long-term prognosis is guarded.
Endovascular reconstruction of intracranial arteries by stent placement and combined techniques
Authors: Lylyk Pedro , Cohen José E. , Ceratto Rosana , Ferrario Angel , Miranda Carlos
Published: May 2009

Object. The authors investigated the feasibility, safety, and short-term outcome of stent treatment for intracranial aneurysms, stenoses, and dissections.

Methods. One hundred twenty-three consecutive patients with intracranial saccular, dissecting, and fusiform aneurysms, atherosclerotic lesions, and dissections were selected for intracranial stent implantation with or without adjunctive coil placement. One hundred eleven patients (mean age 47 years, range 3–73 years) underwent stent treatment; 12 patients (9.8%) were not treated. These 111 patients were divided into four groups: in Group 1 there were 62 patients with saccular aneurysms; Group 2 included nine patients (10 lesions) with dissecting or fusiform aneurysms; in Group 3 there were 36 patients with symptomatic intracranial atheromatous stenoses of more than 50%; and Group 4 included four patients with symptomatic intracranial dissections. All patients underwent computerized tomography scanning and/or magnetic resonance imaging and cerebral digital subtraction angiography preoperatively. Of the 72 aneurysms in Groups 1 and 2, 59 (82%) were treated with combined endovascular stent implantation and endosaccular coil placement. In 67 aneurysms (93%) we achieved complete or nearly complete obliteration. All patients with arterial narrowing achieved residual stenoses of less than 30% postangioplasty. One patient required repeated angioplasty. The morbidity rate in the series was 10.9% and the mortality rate was 6.3%.

Conclusions. These findings indicate that stent treatment is feasible and seems to be an effective modality for arterial reconstruction. This versatile tool allows the treatment of a wide variety of challenging intracranial lesions.
Preoperative magnetic source imaging for brain tumor surgery: a quantitative comparison with intraoperative sensory and motor mapping
Authors: Schiffbauer Hagen , Berger Mitchel S. , Ferrari Paul , Freudenstein Dirk , Rowley Howard A. , Roberts Timothy P. L.
Published: May 2009

Object. The aim of this study was to compare quantitatively the methods of preoperative magnetic source (MS) imaging and intraoperative electrophysiological cortical mapping (ECM) in the localization of sensorimotor cortex in patients with intraaxial brain tumors.

Methods. Preoperative magnetoencephalography (MEG) was performed while patients received painless tactile somatosensory stimulation of the lip, hand, and foot. The early somatosensory evoked field was modeled using a single equivalent current dipole approach to estimate the spatial source of the response. Three-dimensional magnetic resonance image volume data sets with fiducials were coregistered with the MEG recordings to form the MS image. These individualized functional brain maps were integrated into a neuronavigation system. Intraoperative mapping of somatosensory and/or motor cortex was performed and sites were compared.

In two subgroups of patients we compared intraoperative somatosensory and motor stimulation sites with MS imaging—based somatosensory localizations. Mediolateral projection of the MS imaging source localizations to the cortical surface reduced systematic intermodality discrepancies. The distance between two corresponding points determined using MS imaging and ECM was 12.5 ± 1.3 mm for somatosensory—somatosensory and 19 ± 1.3 mm for somatosensory—motor comparisons. The observed 6.5 mm increase in site separation was systematically demonstrated in the anteroposterior direction, as expected from actual anatomy. In fact, intraoperative sites at which stimulation evoked the same patient response exhibited a spatial variation of 10.7 ± 0.7 mm.

Conclusions. Preoperative MS imaging and intraoperative ECM show a favorable degree of quantitative correlation. Thus, MS imaging can be considered a valuable and accurate planning adjunct in the treatment of patients with intraaxial brain tumors.
Vision of the future: initial experience with intraoperative real-time high-resolution dynamic infrared imaging
Authors: Ecker Robert D. , Goerss Stephan J. , Meyer Fredric B. , Cohen-Gadol Aaron A. , Britton Jeffrey W. , Levine James A.
Published: May 2009

✓ High-resolution dynamic infrared (DIR) imaging provides intraoperative real-time physiological, anatomical, and pathological information; however, DIR imaging has rarely been used in neurosurgical patients. The authors report on their initial experience with intraoperative DIR imaging in 30 such patients.

A novel, long-wave (8–10 µm), narrow-band, focal-plane-array infrared photodetector was incorporated into a camera system with a temperature resolution of 0.006°C, providing 65,000 pixels/frame at a data acquisition rate of 200 frames/second. Intraoperative imaging of patients was performed before and after surgery. Infrared data were subsequently analyzed by examining absolute differences in cortical temperatures, changes in temperature over time, and infrared intensities at varying physiological frequencies.

Dynamic infrared imaging was applied in a variety of neurosurgical cases. After resection of an arteriovenous malformation, there was postoperative hyperperfusion of the surrounding brain parenchyma, which was consistent with a loss of autoregulation. Bypass patency and increased perfusion of adjacent brain were documented during two of three extracranial—intracranial bypasses. In seven of nine patients with epilepsy the results of DIR imaging corresponded to seizure foci that had been electrocorticographically mapped preoperatively. Dynamic infrared imaging demonstrated the functional cortex in four of nine patients undergoing awake resection and cortical stimulation. Finally, DIR imaging exhibited the distinct thermal footprints of 14 of 16 brain tumors.

Dynamic infrared imaging may prove to be a powerful adjunctive intraoperative diagnostic tool in the neurosurgical imaging armamentarium. Real-time assessment of cerebral vessel patency and cerebral perfusion are the most direct applications of this technology. Uses of this imaging modality in the localization of epileptic foci, identification of functional cortex during awake craniotomy, and determination of tumor border and intraoperative brain shift are avenues of inquiry that require further investigation.
Implantation of deep brain stimulation electrodes in unshaved patients
Authors: Miyagi Yasushi , Shima Fumio , Ishido Katsuya
Published: May 2009

✓ Although hair removal prior to neurosurgery may increase the risk of infection, the practice of shaving the patient's entire head is still common, particularly in implant surgery. The authors describe a technique for implanting a deep brain stimulation electrode without shaving the patient's hair and present a retrospective analysis of 261 implantations in 221 cases.
Determination of histopathological tumor grade in neuroepithelial brain tumors by using spectral pattern analysis of in vivo spectroscopic data
Authors: Herminghaus Sebastian , Dierks Thomas , Pilatus Ulrich , Möller-Hartmann Walter , Wittsack Jörg , Marquardt Gerhard , Labisch Christoph , Lanfermann Heinrich , Schlote Wolfgang , Zanella Friedhelm E.
Published: May 2009

Object. In this study, 1H magnetic resonance (MR) spectroscopy was prospectively tested as a reliable method for presurgical grading of neuroepithelial brain tumors.

Methods. Using a database of tumor spectra obtained in patients with histologically confirmed diagnoses, 94 consecutive untreated patients were studied using single-voxel 1H spectroscopy (point-resolved spectroscopy; TE 135 msec, TR 1500 msec). A total of 90 tumor spectra obtained in patients with diagnostic 1H MR spectroscopy examinations were analyzed using commercially available software (MRUI/VARPRO) and classified using linear discriminant analysis as World Health Organization (WHO) Grade I/II, WHO Grade III, or WHO Grade IV lesions. In all cases, the classification results were matched with histopathological diagnoses that were made according to the WHO classification criteria after serial stereotactic biopsy procedures or open surgery. Histopathological studies revealed 30 Grade I/II tumors, 29 Grade III tumors, and 31 Grade IV tumors. The reliability of the histological diagnoses was validated considering a minimum postsurgical follow-up period of 12 months (range 12–37 months). Classifications based on spectroscopic data yielded 31 tumors in Grade I/II, 32 in Grade III, and 27 in Grade IV. Incorrect classifications included two Grade II tumors, one of which was identified as Grade III and one as Grade IV; two Grade III tumors identified as Grade II; two Grade III lesions identified as Grade IV; and six Grade IV tumors identified as Grade III. Furthermore, one glioblastoma (WHO Grade IV) was classified as WHO Grade I/II. This represents an overall success rate of 86%, and a 95% success rate in differentiating low-grade from high-grade tumors.

Conclusions. The authors conclude that in vivo 1H MR spectroscopy is a reliable technique for grading neuroepithelial brain tumors.
Surgical management of spinal cord hemangioblastomas in patients with von Hippel—Lindau disease
Authors: Lonser Russell R. , Weil Robert J. , Wanebo John E. , Devroom Hetty L. , Oldfield Edward H.
Published: May 2009

Object. Von Hippel—Lindau (VHL) disease is an autosomal-dominant disorder frequently associated with hemangioblastomas of the spinal cord. Because of the slow progression, protean nature, and high frequency of multiple spinal hemangioblastomas associated with VHL disease, the surgical management of these lesions is complex. Because prior reports have not identified the factors that predict which patients with spinal cord hemangioblastomas need surgery or what outcomes of this procedure should be expected, the authors have reviewed a series of patients with VHL disease who underwent resection of spinal hemangioblastomas at a single institution to identify features that might guide surgical management of these patients.

Methods. Forty-four consecutive patients with VHL disease (26 men and 18 women) who underwent 55 operations with resection of 86 spinal cord hemangioblastomas (mean age at surgery 34 years; range 20–58 years) at the National Institutes of Health were included in this study (mean clinical follow up 44 months). Patient examination, review of hospital charts, operative findings, and magnetic resonance imaging studies were used to analyze surgical management and its outcome. To evaluate the clinical course, clinical grades were assigned to patients before and after surgery. Preoperative neurological status, tumor size, and tumor location were predictive of postoperative outcome. Patients with no or minimal preoperative neurological dysfunction, with lesions smaller than 500 mm3, and with dorsal lesions were more likely to have no or minimal neurological impairment. Syrinx resolution was the result of tumor removal and was not influenced by whether the syrinx cavity was entered.

Conclusions. Spinal cord hemangioblastomas can be safely removed in the majority of patients with VHL disease. Generally in these patients, hemangioblastomas of the spinal cord should be removed when they produce symptoms or signs.
Comparison of anterior and posterior surgical approaches in the treatment of ventral spinal hemangioblastomas in patients with von Hippel—Lindau disease
Authors: Pluta Ryszard M. , Iuliano Brian , Devroom Hetty L. , Nguyen Tung , Oldfield Edward H.
Published: May 2009

Object. Von Hippel—Lindau (VHL) disease is an autosomal-dominant neoplastic syndrome with manifestations in multiple organs, which is evoked by the deletion or mutation of a tumor suppressor gene on chromosome 3p25. Spinal hemangioblastomas (40% of VHL disease—associated lesions of the central nervous system) arise predominantly in the posterior aspect of the spinal cord and are often associated with an intraspinal cyst. Rarely, the tumor develops in the anterior aspect of the spinal cord. Ventral spinal hemangioblastomas are a surgical challenge because of difficult access and because vessels feeding the tumor originate from the anterior spinal artery.

The goal of this study was to clarify whether an anterior or posterior surgical approach is better for management of hemangioblastomas of the ventral spinal cord.

Methods. The authors performed a retrospective analysis of clinical outcomes and findings on magnetic resonance (MR) imaging studies in eight patients (two women and six men with a mean age of 34 ± 15 years) who underwent resection of ventral spinal hemangioblastomas (nine tumors: five cervical and four thoracic). Two surgical approaches were used to resect these tumors. A posterior approach was selected to treat five patients (laminectomy and posterior myelotomy in four patients and the posterolateral approach in one patient); an anterior approach (corpectomy and arthrodesis) was selected to treat the remaining three patients.

Immediately after surgery, the ability to ambulate remained unchanged in patients in whom an anterior approach had been performed, but deteriorated significantly in patients in whom a posterior approach had been used, because of motor weakness (four of five patients) and/or proprioceptive sensory loss (three of five patients). This difference in ambulation, despite significant improvements over time among patients in the posterior access group, remained significant 6 months after surgery. In all cases, MR images revealed complete resection of the tumor and in five patients significant or complete resolution of the intramedullary cyst was demonstrated (present in six of eight patients).

Conclusions. The outcomes of these eight patients with hemangioblastomas of the ventral spinal cord indicate that both immediate and long-term results are better when an anterior approach is selected for resection.
The safety and utility of recombinant human bone morphogenetic protein-2 for cranial procedures in a nonhuman primate model
Authors: Sheehan Jason P. , Sheehan Jonas M. , Seeherman Howard , Quigg Mark , Helm Gregory A.
Published: May 2009

Object. The goal of this study was to evaluate the safety and efficacy of recombinant human bone morphogenetic protein 2 (rhBMP-2) in cranial applications.

Methods. Critical-sized calvarial defects were created bilaterally in four rhesus monkeys, and bilateral rectangular bone flaps were created in six others. Control and rhBMP-2—treated sides were randomly chosen for each animal, and an absorbable collagen sponge was used to deliver the growth factor. Over a 6-month period postoperatively, the animals were serially evaluated for bone healing and adverse BMP-related consequences by using the following methods: computerized tomography (CT) scanning, magnetic resonance (MR) imaging, electroencephalography, histological investigations, and cerebrospinal fluid (CSF) analysis.

The critical-sized defects for the rhBMP-2—treated and control sides attained 71 ± 12% and 28 ± 11% closure, respectively (four animals; p = 0.04). The CT scans demonstrated that the bone flaps treated with rhBMP-2 had complete osteointegration in five of six animals, whereas scans of the untreated bone flaps demonstrated uniformly poor osteointegration with the intact skull. Histological analysis confirmed well-formed bridges of bone on the rhBMP-2—treated sides. No epileptogenic activity was detected in any of the animals, and MR imaging revealed no evidence of adverse effects on the brain parenchyma. Meningitic irritation was not found on postoperative CSF sample analysis.

Conclusions. Treatment of bone flaps and critical-sized cranial defects with rhBMP-2 leads to improved bone formation and osteointegration in nonhuman primates. Initial evaluation of rhBMP-2 appears to indicate a good safety profile for use in cranial procedures in primates.
Feasibility of using the potassium titanyl phosphate laser with micromanipulators in robotic neurosurgery: a preliminary study in the rat
Authors: Goto Tetsuya , Hongo Kazuhiro , Koyama Jun-ichi , Kobayashi Shigeaki
Published: May 2009

Object. Robotic surgery can be used as a novel technology in ultramicrosurgery. A microscopic-manipulator (micromanipulator) system, which has a rigid neuroendoscope and three guiding manipulators, was developed in Japan for less invasive telerobotic neurosurgery. To apply this system in a clinical setting, it is necessary to confirm that it is capable of performing various surgical procedures including cutting, coagulation, and bleeding control. The authors chose the potassium titanyl phosphate (KTP) laser for such procedures. The aim of this paper was to evaluate the feasibility of this system mounted with the KTP laser.

Methods. A prototypical micromanipulator system was tested in rats. Two kinds of in vivo experiments were performed using the KTP laser: coagulation and biopsy. The coagulated lesions were precisely aligned and their maximum depths were proportional to the energy applied during the coagulation experiment. The diagnosable specimens were obtained during the biopsy experiment. The micromanipulator system was able to perform all surgical procedures accurately. There was no complication relating to the use of the micromanipulator system such as brain injury or uncontrollable bleeding.

Conclusions. The results from this study proved that this system works precisely and safely and will become a new neurosurgical tool in managing lesions that are difficult to treat using conventional microsurgery or neuroendoscopic surgery.
Characterization of the levels of expression of retinoic acid receptors, galectin-3, macrophage migration inhibiting factor, and p53 in 51 adamantinomatous craniopharyngiomas
Authors: Lefranc Florence , Chevalier Catherine , Vinchon Mathieu , Dhellemmes Patrick , Schüring Max-Peter , Kaltner Herbert , Brotchi Jacques , Ruchoux Marie-Magdeleine , Gabius Hans-Joachim , Salmon Isabelle , Kiss Robert
Published: May 2009

Object. Craniopharyngiomas are histopathologically defined as benign tumors that can behave very aggressively at the clinical level. They can originate from different types of embryonal epithelial tissue in which correct spatiotemporal regulation has been disrupted at the effector production level. The goal of this study was to determine the efficacy of using selected biological markers to distinguish between recurring and nonrecurring craniopharyngiomas.

Methods. The authors used computer-assisted microscopy to determine quantitatively the immunohistochemical levels of expression of selected markers, including retinoic acid receptors (RARs), as response elements to retinoic acid in a series of 51 adamantinomatous craniopharyngiomas.

These tumors may also originate as the result of physiological defects in the apoptosis-mediated elimination of embryological remnants of epithelial tissue. Galectin-3, p53, and the macrophage migration inhibiting factor (MIF) are known to play crucial roles in these processes. The authors quantitatively determined the levels of expression of these substances in this series of 51 craniopharyngiomas. The data show that all craniopharyngiomas were immunoreactive for RARα, whereas their immunoreactivity for RARβ and RARγ varied dramatically from one case to another. Craniopharyngiomas with low levels of RARβ and high levels of RARγ are more likely to recur than those with higher levels of RARβ and lower levels of RARγ. Rapidly recurring craniopharyngiomas also show significantly lower levels of expression of galectin-3 and MIF than nonrecurring or slowly recurring cases. Few tumors exhibited p53 immunopositivity.

Conclusions. The data indicate that even in the so-called adamantinomatous group of craniopharyngiomas, several subgroups with different clinical behavior patterns can be identified on the basis of differentiation markers relating mainly to the presence or absence of RARβ and RARγ.
Capillary hemangioma of the cavernous sinus
Authors: Tsao May N. , Schwartz Michael L. , Bernstein Mark , Halliday William C. , Lightstone Alex W. , Hamilton Mark G. , Jaywant Satish , Laperriere Normand
Published: May 2009

✓ Capillary hemangiomas are rare benign vascular tumors that tend to occur in children. Whereas the majority of hemangiomas may regress spontaneously, those associated with functional sequelae or severe symptoms may require treatment. Two patients with capillary hemangiomas of the cavernous sinus that caused neurological symptoms were treated with fractionated stereotactic radiation therapy. Both hemangiomas had shown a progressive increase in size during observation before radiation therapy; both tumors regressed after radiotherapy. Up to the time of the last follow-up evaluation both patients experienced symptomatic relief after radiation. One patient's tumor remains in complete remission and the second tumor continues to demonstrate minor residual contrast enhancement without progression.

The authors conclude that fractionated stereotactic radiation therapy is a useful treatment modality in the management of symptomatic capillary hemangiomas when these tumors arise in regions of the brain or skull base in which a complete resection cannot be accomplished.
Barotrauma as a possible cause of aneurysmal subarachnoid hemorrhage
Authors: Reichardt Kristin A. , Nabavi Arya , Barth Harald , Mehdorn H. Maximillian , Blömer Ulrike
Published: May 2009

✓The authors report the case of a 47-year-old man who suffered a diving accident. After regaining consciousness he experienced severe headache. He was initially treated for barotrauma, but the persistent headache led to diagnostic imaging that revealed an aneurysmal subarachnoid hemorrhage. To the authors' knowledge, this is the first report of a ruptured brain aneurysm associated with barotrauma.
Development of multiple cerebral arteriovenous malformations documented in an adult by serial angiography
Authors: Miyasaka Yoshio , Nakahara Kuniaki , Takagi Hiroshi , Hagiwara Hiroyuki
Published: May 2009

✓ A 50-year-old woman with a parietal intracerebral hematoma was initially treated by hematoma evacuation. Initial preoperative and follow-up angiograms obtained 6 months later demonstrated no pial arteriovenous malformations (AVMs). She suffered a subarachnoid hemorrhage 8 years later. Results of follow-up cerebral angiography revealed the development of previously undetected multiple cerebral AVMs. This appears to be the first reported case of the development of multiple cerebral AVMs in an adult, demonstrated on serial angiography.
Recovery from mild concussion in high school athletes
Authors: Lovell Mark R. , Collins Michael W. , Iverson Grant L. , Field Melvin , Maroon Joseph C. , Cantu Robert , Podell Kenneth , Powell John W. , Belza Mark , Fu Freddie H.
Published: May 2009

Object. A computerized neuropsychological test battery was conducted to evaluate memory dysfunction and self-reporting of symptoms in a group of high school athletes who had suffered concussion.

Methods. Neuropsychological performance prior to and following concussion was compared with the test performance of an age-matched control group. Potentially important diagnostic markers of concussion severity are discussed and linked to recovery within the 1st week of injury.

Conclusions. High school athletes who had suffered mild concussion demonstrated significant declines in memory processes relative to a noninjured control group. Statistically significant differences between preseason and postinjury memory test results were still evident in the concussion group at 4 and 7 days postinjury. Self-reported neurological symptoms such as headache, dizziness, and nausea resolved by Day 4. Duration of on-field mental status changes such as retrograde amnesia and posttraumatic confusion was related to the presence of memory impairment at 36 hours and 4 and 7 days post-injury and was also related to slower resolution of self-reported symptoms. The results of this study suggest that caution should be exercised in returning high school athletes to the playing field following concussion. On-field mental status changes appear to have prognostic utility and should be taken into account when making return-to-play decisions following concussion. Athletes who exhibit on-field mental status changes for more than 5 minutes have longer-lasting postconcussion symptoms and memory decline.
Apolipoprotein E polymorphism and outcome after closed traumatic brain injury: influence of ethnic and regional differences
Authors: Nathoo Narendra , Chetty Runjan , van Dellen James R. , Connolly Catherine , Naidoo Richard
Published: May 2009

Object. The presence of the apolipoprotein E-ϵ4 (APOE-ϵ4) allele is reported to be associated with poor outcome after traumatic brain injury (TBI). This study was performed to determine if the presence of the APOE-ϵ4 allele influenced outcome in a cohort of black patients with TBI who had homogeneous neuropathological findings.

Methods. Venous blood was collected at the time of admission to determine the APOE genotype in black Zulu-speaking patients who presented with traumatic cerebral contusions. The frequency of the APOE-ϵ4 allele's appearance was correlated with outcome at a minimum of 6 months of follow up. Univariate and multivariate analyses were performed to determine independent risk factors and to control for confounding factors.

In 110 black Zulu-speaking patients with traumatic cerebral contusions, genotypes for APOE were analyzed. Eleven of 45 (24.4%) with the APOE-ϵ4 allele experienced a poor outcome, compared with 10 (15.4%) of 65 without this allele (p = 0.34). Both patients with homozygous APOE-ϵ4 alleles experienced a good outcome (Glasgow Outcome Score 5). Univariate and multivariate analysis revealed no significant relationship in patients with the APOE-ϵ4 allele with regard to age, admission Glasgow Comas Scale score, contusion volume, type of neurosurgical management, and outcome. The risk of a poor outcome was, however, greater in patients with the APOE-ϵ4 allele (relative risk 1.59; 95% confidence interval 0.74–3.42).

Conclusions. The authors recorded no relationship between APOE-ϵ4 allele status and outcome after TBI in black patients. Given the high regional susceptibility to the APOE gene, further studies, possibly even community-based investigations and studies conducted in other geographic areas, are probably warranted.
Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries
Authors: Tung Thomas H. , Novak Christine B. , Mackinnon Susan E.
Published: May 2009

Object. In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve.

Methods. The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG).

The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+ in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient.

Conclusions. The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.
Growth pattern and rate in residual nonfunctioning pituitary adenomas: correlations among tumor volume doubling time, patient age, and MIB-1 index
Authors: Tanaka Yuichiro , Hongo Kazuhiro , Tada Tsuyoshi , Sakai Keiichi , Kakizawa Yukinari , Kobayashi Shigeaki
Published: May 2009

Object. Surgical cure can be achieved in pituitary adenomas when they are completely removed. It is controversial whether postoperative radiation therapy should be given to prevent recurrence, and whether an early reoperation should be performed for residual adenomas, because we have little information about the natural history of postoperative residual adenomas.

Methods. The residual tumor volume was serially measured in 40 nonfunctioning pituitary adenomas (NFPAs) and the tumor volume doubling time (TVDT) was calculated. Correlations between the patients' age, tumor volume, log TVDT, and MIB-1 index were examined. Other factors including the patient's sex, cavernous sinus (CS) invasion by the tumor, or presence of an intratumoral cyst were analyzed to assess their influence on the TVDT. Values are expressed as the means ± standard deviations.

Thirty-eight adenomas increased in volume and two decreased during a follow-up period ranging from 4 to 141 months (mean 52.5 months). Exponentially linear tumor growth was observed in the 38 growing adenomas regardless of the residual tumor volume, with the TVDT ranging from 506 to 5378 days (mean 1836 days). The patients' age was 57.1 ± 15.7 years (range 15–79 years), the tumor volume at the beginning of the magnetic resonance imaging observation period was 2.5 ± 2.2 cm3 (range 0.07–14.5 cm3), and the MIB-1 index was 0.73 ± 0.68% (range 0.1–2.9%). There was a correlation between the log TVDT and patient age (R = 0.73), an inverse correlation between the log TVDT and MIB-1 index (r = −0.49), and an inverse correlation between the MIB-1 index and patient age (r = −0.61). A significant difference (p = 0.0001) was noted between the TVDT (1106 days) in the 19 patients younger than 61 years of age and the TVDT (2566 days) in the 19 patients who were 61 years of age or older. There was also a significant difference (p = 0.0002) between the age (50.8 ± 15.3 years) of the patients with rapidly growing tumors (TVDT < 1836 days, 24 patients) and the age (69.1 ± 7.6 years) of the patients with slowly growing tumors (TVDT > 1836 days, 14 patients). Other factors including the patients' sex, CS invasion, and intratumoral cyst formation did not affect the TVDT of residual NFPAs.

Conclusions. The tumor growth rate of residual NFPAs is strongly influenced by the patient's age. The TVDT in elderly patients is much longer than that previously reported. Treatment strategies that take into consideration the natural history of residual adenomas should be established especially in the elderly population.