bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracranial-Intracranial Vein Graft Bypass for Giant Intracranial Aneurysm Surgery for Pediatric Patients: Two Technical Case Reports
Authors: Zhang Y. Jonathan , Barrow Daniel L. , Day Arthur L.
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Herein we describe two cases of extracranial-intracranial vein graft bypasses for the treatment of giant intracranial aneurysms in prepubertal pediatric patients. One patient is, we think, the youngest patient reported in the literature to have been successfully treated in such a manner, with a good long-term outcome. Such grafts seem to enlarge longitudinally during the growth spurt, making such techniques reasonable long-term therapeutic options for the management of complex intracranial aneurysms in pediatric patients.

CLINICAL PRESENTATION:

Patient 1, a 13-year-old boy, presented with headaches and rapidly progressive right cavernous sinus syndrome. Computed tomography and cerebral angiography revealed a giant, fusiform, right intracavernous internal carotid artery aneurysm. Patient 2, a 23-month-old girl, was discovered to harbor an asymptomatic, recurrent, giant, fusiform, left M1 middle cerebral artery aneurysm 1 year after presenting with seizures related to subarachnoid hemorrhage from the aneurysm, for which she had been treated with clipping and an M2-M2 anastomosis.

INTERVENTION:

Both patients underwent craniotomies, with sacrifice of the proximal parent vessel (the distal cervical internal carotid artery and the proximal middle cerebral artery, respectively), combined with cerebral revascularization through extracranial-intracranial saphenous vein bypass grafts. Both patients experienced excellent long-term clinical outcomes, have undergone significant growth, and exhibit excellent long-term graft patency and aneurysm obliteration.

CONCLUSION:

These two cases highlight the safety and efficacy of extracranial-intracranial vein graft bypasses among prepubertal pediatric patients. The indications for bypass procedures to treat giant intracranial aneurysms are discussed, and the technical aspects of maximizing vein bypass graft patency are reviewed.
Microvascular Decompression to Treat Hemifacial Spasm: Long-term Results for a Consecutive Series of 143 Patients
Authors: Samii Madjid , Günther Thomas , Iaconetta Giorgio , Muehling Michael , Vorkapic Peter , Samii Amir
Published: July 2004

OBJECTIVE:

The concept of neurovascular decompression for the treatment of hemifacial spasm is now widely accepted. In this study, we report our long-term results for 145 cases treated with this procedure.

METHODS:

The results of 145 microvascular decompressions to treat hemifacial spasm (performed between 1980 and 1998) among 143 patients (62.2% female patients and 37.8% male patients; mean age, 54.5 yr) are presented. The onset of symptoms was typical in 95.9% of cases and atypical in 4.1%. Platysma muscle involvement was observed for 24.5% of patients, with a higher incidence among female patients (74.3%). Patients were monitored with annual questionnaires. Twenty-six patients were lost to follow-up monitoring, and 117 are still undergoing follow-up monitoring, with an average period of 9.6 years (range, 1–17.6 yr).

RESULTS:

At discharge, 69 patients (59%) were spasm-free and 48 patients (41%) experienced further spasm. At 6 months, the number of spasm-free patients had increased to 108 (92.3%), whereas only 9 patients (7.7%) complained of hemifacial spasm; 44 patients were spasm-free at an average time of 15 weeks. In follow-up examinations (average period, 9.4 yr), 106 patients were spasm-free. Seven patients experienced only temporary relief, with recurrence after 4.5 years. Two patients were spasm-free after 4 or 6 weeks, and the recurrence of spasm was observed 1 year later. Two patients were never completely spasm-free. Among the patients who did not undergo previous surgery elsewhere, only two experienced recurrence.

CONCLUSION:

Deafness was the main postoperative complication (8.3%); most of those cases (66%) occurred before the routine use of intraoperative evoked potential monitoring. Analysis of our series demonstrates that this surgical procedure involves very low risk, is well tolerated by elderly patients, is associated with very low recurrence rates, and is a definitive treatment for more than 90% of cases.
Role of Postoperative Magnetic Resonance Imaging after Microvascular Decompression of the Facial Nerve for the Treatment of Hemifacial Spasm
Authors: Chang Jin Woo , Chang Jong Hee , Choi Jae Young , Kim Dong Ik , Park Yong Gou , Chung Sang Sup
Published: July 2004

OBJECTIVE:

This study was performed to investigate the role of postoperative three-dimensional short-range magnetic resonance angiography in the prediction of clinical outcomes after microvascular decompression (MVD) for the treatment of hemifacial spasm.

METHODS:

We examined pre- and postoperative magnetic resonance imaging scans obtained between March 1999 and May 2000 for 122 patients with hemifacial spasm, to evaluate the degree of detachment of the vascular contact and changes in the positions of offending vessels. The degree of vascular decompression of the facial nerve root was classified into three groups, i.e., contact, partial decompression, or complete decompression. Contact was defined as unresolved compression, as indicated by postoperative three-dimensional short-range magnetic resonance angiography. Partial decompression was defined as incompletely resolved compression; vascular indentation of the facial nerve was improved, but contact with the facial nerve remained. Complete decompression was defined as completely resolved compression. These findings were compared with the surgical findings and clinical outcomes.

RESULTS:

Of 122 patients with MVD, complete decompression of offending vessels at the root entry zone of the facial nerve was observed for 106 patients (86.9%), partial decompression was observed for 10 patients (8.2%), and contact with offending vessels was observed for 6 patients (4.9%) by using postoperative three-dimensional short-range magnetic resonance angiography. Our study demonstrated that the types of offending vessels affected neither the degree of decompression of the root entry zone of the facial nerve nor surgical outcomes (P > 0.05). Also, there was no significant relationship between the degree of decompression and improvement of symptoms (P > 0.05). Furthermore, there was no significant relationship between the degree of decompression and the timing of symptomatic improvement (P > 0.05).

CONCLUSION:

Our data suggest that MVD of the facial nerve alone may not be sufficient to resolve symptoms for all patients with hemifacial spasm. Therefore, unknown factors in addition to vascular compression may cause symptoms in certain cases, and it may be necessary to remove those factors, simultaneously with MVD, to obtain symptom resolution.
Diffusion-weighted Magnetic Resonance Imaging in Patients with Subarachnoid Hemorrhage
Authors: Hadeishi Hiromu , Suzuki Akifumi , Yasui Nobuyuki , Hatazawa Jun , Shimosegawa Eku
Published: July 2004

OBJECTIVE:

To evaluate the occurrence and distribution of direct brain injury caused by acute subarachnoid hemorrhage (SAH) by the use of magnetic resonance imaging.

METHODS:

Computed tomography and magnetic resonance imaging, including diffusion-weighted imaging (DWI), were performed in 32 patients with SAH by use of a 1.5-T whole-body superconductive scanner equipped with an echo planar imaging system. In all cases, computed tomographic and magnetic resonance imaging scans were obtained at the time of admission, before angiography and surgical intervention.

RESULTS:

No abnormalities were revealed by DWI in any of the low-grade SAH patients. However, five (71%) of seven patients diagnosed as having poor-grade SAH (World Federation of Neurosurgical Societies Grades 4 and 5) displayed multiple, patchy focal abnormalities on DWI. Computed tomographic scans obtained at admission failed to clearly demonstrate all of the damaged areas of the brain that were visualized by DWI. These lesions were located in supratentorial cerebral parenchyma, but not in the thalamus, basal ganglia, or cerebellar hemisphere. These multiple widespread lesions exhibiting laminar involvement of the cerebral cortex were not associated with the site of the ruptured aneurysm.

CONCLUSION:

DWI revealed widespread multifocal lesions in the cerebral cortex of acute poor-grade SAH patients. DWI provides accurate images of all areas of brain damage directly attributable to SAH.
Aneurysm Originating from the Fenestration of the Posterior Cerebral Artery: Case Report
Authors: Iwashita Tomomi , Tanaka Yuichiro , Hongo Kazuhiro , Koyama Jun-ichi , Koyama Toru , Nitta Junpei
Published: July 2004

OBJECTIVE AND IMPORTANCE:

A rare case of an aneurysm arising at the fenestration of the P2 segment of the posterior cerebral artery is reported.

CLINICAL PRESENTATION:

A 37-year-old man presented with severe headache and disturbance of consciousness. Computed tomographic scanning showed diffuse subarachnoid hemorrhage. Cerebral angiography revealed an aneurysm at the fenestration of the P2 segment of the right posterior cerebral artery. The aneurysm was located at the middle portion of the lower trunk of the fenestration. An unruptured arteriovenous malformation was incidentally found in the right thalamus.

INTERVENTION:

A right frontotemporal craniotomy with orbitozygomatic osteotomy was made, and the aneurysm was successfully clipped. One year after the operation, gamma knife surgery was performed for the right thalamic arteriovenous malformation.

CONCLUSION:

This is the first reported case of an aneurysm originating from the middle portion of a fenestrated posterior cerebral artery.
Interactive Use of Cerebral Angiography and Magnetoencephalography in Arteriovenous Malformations: Technical Note
Authors: Kamiryo Toshifumi , Cappell Joshua , Kronberg Eugene , Woo Henry H. , Jafar Jafar J. , Llinás Rodolfo R. , Nelson Peter K.
Published: July 2004

OBJECTIVE:

To minimize the risks associated with treating cortical cerebral arteriovenous malformations (AVMs), we developed a technique combining functional imaging and cerebral angiography. The functional loci obtained by performing magnetoencephalography (MEG) are projected onto stereoscopic pairs of a stereotactically derived digital subtraction angiogram. The result is a simultaneous three-dimensional perspective of the angioarchitecture of an AVM and its relationship to the sensorimotor cortex.

METHODS:

Eight patients underwent multimodality brain imaging, including magnetic resonance imaging, functional mapping via MEG, and stereotactic angiography using a modified Compass fiducial system (Compass International, Rochester, MN). The coordinates derived by performing MEG were superimposed onto stereotactic, stereoscopic, angiographic pairs using custom-made distortion correction and coordinate transfer software.

RESULTS:

The magnetoencephalographic angiogram allowed simultaneous viewing of the angioarchitecture of the AVM nidus, the feeding vessels, and the draining veins and their relationship to the normal cerebral vasculature and functional cortex. This imaging technique was particularly valuable in identifying en passant vessels that supplied functional cortex and was used during the treatment of these lesions.

CONCLUSION:

The techniques of MEG and cerebral angiography were combined to provide simultaneous viewing of both modalities in a three-dimensional perspective. This technique can aid in risk stratification in the management of patients with cerebral AVMs. In addition, this technique can facilitate the selective targeting of vessels, thus potentially reducing the risks associated with embolization of these formidable lesions.
Intrinsic Spinal Cord Tumor Resection
Authors: Brotchi Jacques
Published: July 2004

SPINAL CORD TUMORS are more frequently detected than in the past, because of progress in neuroradiology. Many neurosurgeons must now decide how to treat such lesions. The recent neurosurgical literature contains many case reports, few series, and different strategies. This article describes the surgical method I have developed in a period of 15 years, with Georges Fischer in Lyon, on the basis of experience with more than 260 patients and 300 operations. The standard treatment is complete resection whenever possible, but we must learn when and where to stop to preserve the quality of life. I have several useful strategies, which are explained in this report. For gliomas (ependymomas and astrocytomas), I favor a midline approach; for most vascular tumors (such as hemangioblastomas and cavernomas), however, I prefer to proceed from the point at which the lesion is observed through the microscope and to dissect the lesion in one piece. Meticulous nonbleeding surgery and experience are the keys to success.
Surgical Indications and Microsurgical Anatomy of the Transchoroidal Fissure Approach for Lesions in and around the Ambient Cistern
Authors: Ikeda Kiyonobu , Shoin Katsuo , Mohri Masanao , Kijima Tamotsu , Someya Shigeru , Yamashita Junkoh
Published: July 2004

OBJECTIVE:

Opening the temporal part of the choroidal fissure (CF) makes it possible to expose the crural cistern, the ambient cistern, and the medial temporal lobe. We examined the microsurgical anatomy and the surgical indications for use of the trans-CF approach.

METHODS:

The microsurgical anatomy encountered in the trans-CF approach for lesions in and around the ambient cistern was studied in three cadavers. On the basis of these cadaveric studies, the trans-CF approach was used during surgery in three live patients with such lesions.

RESULTS:

The angiographic “plexal point,” which indicates the entrance of the anterior choroidal artery as it enters the temporal horn of the lateral ventricle, was thought to be a key anatomic landmark of the trans-CF approach. A cortical incision for entry into the temporal horn should be made in the inferior temporal gyrus to minimize the potential damage to the optic radiations and to the speech centers. After the CF is opened posteriorly to the plexal point between the tenia fimbria and the choroid plexus, the posterior cerebral artery (PCA) in the ambient cistern can be observed with minimal caudal retraction of the hippocampus. In this study, surgical procedures using the trans-CF approach were successfully performed on patients with high-positioned P2 aneurysms whose PCA ran close to the plexal point or higher, whose medial temporal arteriovenous malformations were fed mainly by the PCA, and whose tentorial hiatus meningiomas protruded into the temporal horn through the CF, with no resulting postoperative visual or memory disturbances.

CONCLUSION:

The trans-CF approach is especially useful in surgery for lesions in and around the ambient cistern.
Cranial Base Approaches for the Surgical Treatment of Aggressive Posterior Fossa Dural Arteriovenous Fistulae with Leptomeningeal Drainage: Report of Four Technical Cases
Authors: Kattner Keith A. , Roth Toni C. , Giannotta Steven L.
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Dural arteriovenous fistulae (DAVFs) with leptomeningeal drainage have an aggressive natural history. Urgent treatment is necessary to arrest neurological deterioration and to prevent the risk of intracranial hemorrhage. In many patients, a primary endovascular approach is the most appropriate and most successful treatment available. In some circumstances, however, surgical intervention is required for complete obliteration. Posterior fossa DAVFs are generally deep-seated and difficult to gain access to with standard surgical approaches. The advent of cranial base surgery allows 360-degree access to the draining venous complex or sinus via extradural bone removal.

CLINICAL PRESENTATION:

Four patients with posterior fossa DAVFs presented to the neurosurgical service at our institutions. One DAVF was located at the craniocervical junction, and three were tentorial DAVFs of the superior petrosal sinus. All four patients were treated surgically with extradural bone removal.

INTERVENTION:

Postoperative angiography documented complete obliteration of all four DAVFs. All patients had normal recoveries, with the exception of one patient who experienced persistent temporal lobe seizure activity as a result of the presenting hematoma. One patient died of unrelated causes 2 years after surgery. One postoperative temporal lobe hematoma required evacuation.

CONCLUSION:

Recent advances in cranial base techniques have allowed the successful obliteration of aggressive posterior fossa DAVFs with acceptable morbidity. The use of these techniques should be considered in selected patients who cannot be treated with endovascular approaches.
Risk of Hemorrhage from Unsecured, Unruptured Aneurysms during and after Hypertensive Hypervolemic Therapy
Authors: Hoh Brian L. , Carter Bob S. , Ogilvy Christopher S.
Published: July 2004

OBJECTIVE

Hypertensive hypervolemic therapy for vasospasm is widely practiced. It is not clear, however, whether the use of hypertension and hypervolemia as a treatment for vasospasm risks hemorrhage from an unsecured, unruptured aneurysm.

METHODS

From 1991 to 2000, the neurovascular unit at the Massachusetts General Hospital treated 1908 aneurysms, of which 966 were ruptured. Forty patients with ruptured aneurysms had unsecured, unruptured aneurysms and underwent hypertensive hypervolemic therapy for vasospasm. Hypertension was induced by intravenously administered phenylephrine, norepinephrine, and/or dopamine, and hypervolemia was achieved by intravenously administered crystalloid and colloid solutions. The 24-hour mean arterial systolic blood pressure (SBP) and the 24-hour mean central venous pressure were calculated on the basis of hourly measurements during hypertensive hypervolemic treatment.

RESULTS

The 40 study patients harbored 124 aneurysms, of which 51 aneurysms were treated (clipping, 37; coiling, 14) by the time hypertensive hypervolemic therapy began, leaving 73 unsecured aneurysms at risk. The mean size of the unsecured aneurysms was 4.45 mm. Nineteen patients were treated with mild hypertension (SBP, 140–180 mm Hg), 12 patients were treated with moderate hypertension (SBP, 180–200 mm Hg), and 9 patients were treated with severe hypertension (SBP, >200 mm Hg). The 24-hour mean SBP readings were 166.81 ± 8.19, 187.57 ± 5.79, and 204.01 ± 3.75 mm Hg for the mild, moderate, and severe hypertension groups, respectively. The mean central venous pressure was 10.43 ± 3.89 mm Hg. The mean course of hypertensive hypervolemic therapy was 7.25 days, and therapy began on mean post-subarachnoid hemorrhage Day 6.73. Twenty-eight aneurysms were eventually treated in later procedures (clipping, 25; coiling, 3). The mean interval to treatment was 6.93 months. In a treatment and follow-up period of 121.75 aneurysm-years of risk, there was no instance of hemorrhage.

CONCLUSION

Hypertension and hypervolemia do not seem to increase the risk of hemorrhage from unsecured, unruptured aneurysms in the acute setting or in their short-term natural history.
Relationship between Severity of Lumbar Disc Disease and Disability Scores in Sciatica Patients
Authors: Porchet François , Wietlisbach Vincent , Burnand Bernard , Daeppen Karine , Villemure Jean-Guy , Vader John-Paul
Published: July 2004

OBJECTIVE

To study the association between the clinical examination and the radiological assessment of lumbar disc disease in patients with sciatica.

METHODS

The study included 394 consecutive sciatica patients. The patients’ disabilities were evaluated by a visual analog pain scale, the Prolo functional-economic rating scale, the modified Roland-Morris disability questionnaire, and the health-related quality of life short form (SF-36) questionnaire. Radiological imaging findings were independently classified according to the Modic criteria into five groups of increasing severity of disc disease. Stepwise multivariate logistic regression was used to determine which scores were significant independent predictors of a severe disc disease (extrusion or sequestration).

RESULTS

Of these patients, 9.6% had no disc disease, 3.3% had a bulging, 11.4% had a protrusion, 68.5% had an extrusion, and 7.1% had a disc sequestration. Statistically significant positive linear associations with the severity of disc disease were found for the leg pain scale, the Roland-Morris and Prolo disability scales, and the SF-36 scores related to physical functioning, physical role, and bodily pain (all P < 0.005). A poor (<5) Prolo score (odds ratio, 2.91; 95% confidence interval, 1.74–4.87), a higher leg pain score (odds ratio, 1.16 per centimeter increase; 95% confidence interval, 1.07–1.27), and a lower low back pain score (odds ratio, 0.90 per centimeter decrease; 95% confidence interval, 0.82–0.98) were retained in the multivariate logistic model as independent predictors of severe disc disease.

CONCLUSION

The positive correlation between disability status and imaging findings validates both assessment methods. Routine use of disability scores brings a useful contribution to the assessment of sciatica patients.
Cerebellar Hemorrhage after Spinal Surgery: Report of Two Cases and Literature Review
Authors: Friedman Jonathan A. , Ecker Robert D. , Piepgras David G. , Duke Derek A.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Cerebellar hemorrhage remote from the site of surgery may complicate neurosurgical procedures. We describe our experience with two cases of cerebellar hemorrhage after spinal surgery and review the three cases previously reported in the literature to determine whether these cases provide insight regarding the pathogenesis of remote cerebellar hemorrhage.

CLINICAL PRESENTATION

One of our patients developed cerebellar hemorrhage in the vermis and right hemisphere after transpedicular removal of a partially intradural T9–T10 herniated disc with the patient in the prone position. The other patient developed cerebellar hemorrhage in the vermis and bilateral hemispheres after L3–S1 decompression and instrumentation with the patient in the prone position, during which the dura was inadvertently opened.

INTERVENTION

The first patient was treated conservatively and had mild residual dysarthria and gait ataxia 2 months after surgery. The second patient underwent exploration and revision of the lumbar wound with primary dural repair. The cerebellar hemorrhage was treated conservatively, and the patient had mild dysarthria and ataxia 1 month after surgery.

CONCLUSION

Cerebellar hemorrhage must be considered in patients with unexplained neurological deterioration after spinal surgery. Dural opening with loss of cerebrospinal fluid has occurred in every reported case of cerebellar hemorrhage complicating a spinal procedure, supporting the hypothesis that loss of cerebrospinal fluid is central to the pathogenesis of this condition. Because remote cerebellar hemorrhage can occur after procedures with the patient in the supine, sitting, and prone positions, patient positioning seems unlikely to play a causative role in its occurrence.
Bilateral Multiple Cervical Root Avulsions without Skeletal or Ligamentous Damage Resulting from Blast Injury: Case Report
Authors: Morenski John David , Avellino Anthony M. , Elliott J. Paul , Winn H. Richard
Published: July 2004

OBJECTIVE AND IMPORTANCE

We describe a unique case of multiple bilateral cervical root injuries without ligamentous or bony injury secondary to a sandblast accident.

CLINICAL PRESENTATION

A 19-year-old man sustained a sandblast injury to his face, neck, chest, and upper extremities, with immediate loss of motor and sensory function occurring in both of his upper extremities. Cervical spine x-rays, computed tomography, and magnetic resonance imaging demonstrated no fracture, soft tissue abnormality, or malalignment. The restriction of deficits to the patient's upper extremities suggested a central cervical spinal cord injury, bilateral brachial injuries, or a conversion disorder.

INTERVENTION

Cervical computed tomographic myelography revealed multiple bilateral nerve root injuries.

CONCLUSION

This case report is unique in the literature in that it describes a patient with multiple cervical nerve root injuries secondary to sandblast injury without ligamentous or bony injury. Although magnetic resonance imaging remains the diagnostic modality of choice in patients with acute spinal cord injury, it is deficient in demonstrating cervical root injury in the acute setting. In this setting, computed tomographic myelography is superior.
Dissecting Aneurysms of the Bilateral Vertebral Arteries with Subarachnoid Hemorrhage: Report of Three Cases
Authors: Otawara Yasunari , Ogasawara Kuniaki , Ogawa Akira , Kogure Tetsuo
Published: July 2004

OBJECTIVE AND IMPORTANCE

Treatment of one side in cases of dissecting aneurysms of the bilateral vertebral arteries (VAs) with subarachnoid hemorrhage may result in dissection or rupture on the contralateral side.

CLINICAL PRESENTATION

Three patients presented with dissecting aneurysms of the bilateral VAs with subarachnoid hemorrhage.

INTERVENTION

Two patients underwent trapping of the ruptured VA, with side-to-side anastomosis between the bilateral posteroinferior cerebellar arteries. One patient underwent resection of the ruptured VA, with interposition of a saphenous vein graft. Two patients died as a result of rupture of the contralateral VA dissecting aneurysm after surgery. One patient demonstrated development of an unruptured dissecting aneurysm in the contralateral VA 1 month after surgery.

CONCLUSION

Surgical intervention to treat dissecting aneurysms of the bilateral VAs on one side carries the risk of rupture of the contralateral lesion. Increased hemodynamic stress may be important in the development and rupture of dissections in the contralateral VA.
Transsphenoidal Surgery for Cushing's Disease: Endocrinological Follow-up Monitoring of 82 Patients
Authors: Shimon Ilan , Ram Zvi , Cohen Zvi R. , Hadani Moshe
Published: July 2004

OBJECTIVE

Transsphenoidal surgery is the preferred treatment modality for adrenocorticotropic hormone-secreting pituitary adenomas. In the past 2 decades, several institutions in the United States and Europe have reported remission rates of 70 to 85% after transsphenoidal surgery for treatment of Cushing's disease. We analyzed our postoperative results for a large cohort of patients with Cushing's disease.

METHODS

Eighty-two patients with adrenocorticotropic hormone-secreting adenomas (79 microadenomas and 3 macroadenomas) underwent transsphenoidal surgery between 1990 and 2000. Seventy-seven patients were surgically treated for the first time, and 13 patients underwent reoperations (5 had undergone the first operation elsewhere) because of previous surgical failure (10 patients) or recurrence (3 patients). The mean postoperative follow-up period was 4.2 ± 2.8 years. Biochemical remission was defined as postoperative normalization of elevated 24-hour urinary free cortisol secretion and suppression of morning cortisol levels with 1 mg of dexamethasone.

RESULTS

Remission was achieved for 78% of all patients after one operation and for 62% of patients who underwent a second operation. The recurrence rate was 5%. Ten patients did not exhibit a visible tumor on magnetic resonance imaging scans, and the other patients were divided according to adenoma size (2–5 or 6–10 mm). Remission rates were similar for the three groups of patients (78–80%). Pituitary tumor stained for adrenocorticotropic hormone was detected in 78% of resected pituitary tissue specimens obtained from patients who achieved remission, compared with 53% from patients who experienced surgical failure (P = 0.06).

CONCLUSION

Our series demonstrates the efficacy of transsphenoidal surgery for Cushing's disease resulting from pituitary microadenomas. Microadenoma size had no effect on the remission rate. Reoperations are indicated after initial surgical failures.
Long-term Control of Hydrocephalus via Endoscopic Third Ventriculostomy in Children with Tectal Plate Gliomas
Authors: Wellons John C. , Tubbs R. Shane , Banks Jason T. , Grabb Brenda , Blount Jeffrey P. , Oakes W. Jerry , Grabb Paul A.
Published: July 2004

OBJECTIVE

We report the control of hydrocephalus in children with presumed tectal plate gliomas by the use of endoscopic third ventriculostomy (ETV).

METHODS

The hospital records, office charts, and imaging studies from children who underwent ETV at the Children's Hospital of Alabama were reviewed. Thirteen children with the diagnosis of tectal plate glioma and hydrocephalus were identified. ETV was the primary therapy instituted for all but one of these children. Successful treatment outcome was defined as shunt freedom, improvement in symptoms, and reduced ventricular size.

RESULTS

Thirteen children underwent a total of 15 ETVs, and all children were shunt-free at their most recent follow-up examinations. One child underwent successful secondary ETV, one child underwent shunt removal concomitant with the initial ETV, and one child underwent shunt removal concomitant with secondary ETV. Symptoms and signs resolved in all patients. All postoperative cranial imaging studies revealed normal or reduced ventricular size as compared with preoperative cranial imaging scans. The median follow-up period was 31 months.

CONCLUSION

In our surgical experience, ETV has been uniformly successful in the management of hydrocephalus caused by tectal plate gliomas in children. ETV should be considered the treatment of choice for hydrocephalus in pediatric patients with tectal plate gliomas.
Transsphenoidal Microsurgery
Authors: Ciric Ivan , Rosenblatt Sami , Zhao Jin-Chen
Published: July 2004

TRANSSPHENOIDAL MICROSURGERY IS a well-established neurosurgical procedure that has become the standard of care in the management of the majority of pituitary tumors and a select group of other sellar lesions. The safety of the procedure depends on the surgeon's adherence to certain anatomic concepts. Foremost among these concepts is the necessity of preserving the integrity of the arachnoid membrane covering the tumor dome and avoiding vascular injuries in the cavernous sinus. The objective of this article is to demonstrate the sequential steps of a transsphenoidal microsurgical procedure for the removal of a pituitary tumor in light of the anatomic concepts discussed, with the goal of preventing complications and achieving the best possible outcome.
Ventriculostomy-related Infections: A Critical Review of the Literature
Authors: Lozier Alan P. , Sciacca Robert R. , Romagnoli Mario F. , Connolly E. Sander
Published: July 2004

OBJECTIVE

To provide a critical evaluation of the published literature describing risk factors for ventriculostomy-related infections (VRIs) and the efficacy of prophylactic catheter exchange.

METHODS

A MEDLINE literature search was performed, and data were extracted from studies published from 1941 through 2001.

RESULTS

Published criteria for diagnosing VRIs are highly variable. Intraventricular hemorrhage, subarachnoid hemorrhage, cranial fracture with cerebrospinal fluid leak, craniotomy, systemic infections, and catheter irrigation all predispose patients to the development of VRIs. Extended duration of catheterization is correlated with an increasing risk of cerebrospinal fluid infections during the first 10 days of catheterization. Prophylactic catheter exchange does not modify the risk of developing later VRIs in retrospective studies.

CONCLUSION

Categorizing suspected cerebrospinal fluid infections as contaminants, colonization, suspected or confirmed VRIs, or ventriculitis more accurately describes the patient's clinical condition and may indicate different management strategies. A prospective, randomized clinical trial is required to further evaluate the efficacy of prophylactic catheter exchange in limiting the incidence of VRIs during prolonged catheterization. Although prophylactic catheter exchange remains a practice option, the available data suggest that this procedure is not currently justified.
The Role of Radiosurgery for the Treatment of Pineal Parenchymal Tumors
Authors: Hasegawa Toshinori , Kondziolka Douglas , Hadjipanayis Constantinos G. , Flickinger John C. , Lunsford L. Dade
Published: July 2004

OBJECTIVE

Radiosurgery is an appealing alternative management strategy for selected patients with biopsy-proved pineal parenchymal tumors. The purpose of this report was to clarify its role in conjunction with other surgical, radiation, and medical approaches.

METHODS

We retrospectively evaluated 16 patients who had undergone radiosurgery as the primary or adjuvant treatment for pineal parenchymal tumors. Ten patients (62.5%) had pineocytomas, two (12.5%) had mixed pineocytoma and pineoblastoma, and four (25%) had pineoblastomas. The mean marginal dose was 15 Gy, and the mean tumor volume was 5.0 cm3. The mean follow-up periods from the time of diagnosis or the time of radiosurgery were 61 and 52 months, respectively.

RESULTS

The overall actuarial 2- and 5-year survival rates after diagnosis were 75.0 and 66.7%, respectively. In 14 patients who were evaluated with imaging, 4 (29%) demonstrated complete remission, 8 (57%) had partial remission, 2 (14%) had no change, and no patient had local progression. The local tumor control rate (complete remission, partial remission, or no change) was 100%. Five patients died during follow-up. One patient with a pineocytoma and three patients with pineoblastomas died secondary to leptomeningeal or extracranial spread tumor. No cause of death was established for one patient. Two patients developed adverse radiation effects after radiosurgery.

CONCLUSION

Our initial experience suggests that stereotactic radiosurgery is a valuable primary management modality for patients with pineocytomas. As adjuvant therapy, radiosurgery may be used to boost local tumor dose during multimodality management of malignant pineal parenchymal tumors.
Management of Intracranial Vertebral Artery Dissections Initially Presenting without Subarachnoid Hemorrhage
Authors: Naito Isao , Iwai Tomoyuki , Sasaki Tomio
Published: July 2004

OBJECTIVE

The clinical and angiographic follow-up results for intracranial vertebral artery (VA) dissections that initially presented without subarachnoid hemorrhage (SAH) were retrospectively investigated, to clarify their management.

METHODS

Twenty-one patients with VA dissections that initially presented without SAH were studied. Initial angiography revealed aneurysmal dilation in 11 cases (typical pearl-and-string sign in 8 cases, aneurysmal dilation only in 2, and aneurysmal dilation with double-lumen sign in 1), occlusion in 7, double-lumen sign in 2, and string-like stenosis in 1. Nine patients (six with pearl-and-string sign, one with occlusion with aneurysmal dilations, and two with double-lumen sign), including three patients who experienced subsequent SAH, underwent endovascular proximal parent artery occlusion. The other 12 patients were treated conservatively. All patients were monitored with magnetic resonance angiography or digital subtraction angiography.

RESULTS

Three patients experienced subsequent SAH, 1 day (two patients) or 51 months after onset. Follow-up angiographic assessments of the 20 patients demonstrated complete resolution in five cases, reduction of aneurysmal dilation in one case, and partial recanalization in one case. However, enlargement or formation of an aneurysmal dilation was recognized in four cases and progression of dissection was observed in one case. Eighteen patients experienced good recoveries, and three patients demonstrated moderate disabilities as a result of the initial ischemic insult.

CONCLUSION

The risk of bleeding from unruptured VA dissections is higher than previously considered. Therefore, endovascular treatment should be considered for patients with VA dissections with relatively large or growing aneurysmal dilations.
Evaluation of Vasospasm after Subarachnoid Hemorrhage by Use of Multislice Computed Tomographic Angiography
Authors: Otawara Yasunari , Ogasawara Kuniaki , Ogawa Akira , Sasaki Makoto , Takahashi Kei
Published: July 2004

OBJECTIVE

Multislice computed tomographic angiography (CTA) can provide clearer vascular images, even of the peripheral arteries, than conventional CTA. Multislice CTA was compared with digital subtraction angiography (DSA) for the detection of cerebral vasospasm in patients with acute aneurysmal subarachnoid hemorrhage (SAH) to analyze whether multislice CTA can replace DSA in the detection of vasospasm after SAH.

METHODS

Within 72 hours after the onset of symptoms, multislice CTA and DSA were performed in 20 patients with SAH. Multislice CTA and DSA were repeated on Day 7 to assess cerebral vasospasm. Regions of interest were established in the proximal and distal segments of the anterior and middle cerebral arteries on both multislice CTA and DSA images, and the agreement between the severity of vasospasm on multislice CTA and DSA images was statistically compared. The multislice Aquilon computed tomography system (Toshiba, Inc., Tokyo, Japan) used the following parameters: 1 mm collimation and 3.5 mm per rotation table increment (pitch, 3.5).

RESULTS

The degree of vasospasm as revealed by multislice CTA correlated significantly with the degree of vasospasm revealed by DSA (P < 0.0001). The agreement between the severity of vasospasm on multislice images obtained via CTA and DSA in the overall, proximal, and distal segments of the cerebral arteries was 91.6, 90.8, and 92.3%, respectively.

CONCLUSION

Multislice CTA can detect angiographic vasospasm after SAH with accuracy equal to that of DSA.
Increased Expression of Phosphorylated c-Jun Amino-terminal Kinase and Phosphorylated c-Jun in Human Cerebral Aneurysms: Role of the c-Jun Amino-terminal Kinase/c-Jun Pathway in Apoptosis of Vascular Walls
Authors: Takagi Yasushi , Ishikawa Masatsune , Nozaki Kazuhiko , Yoshimura Shinichi , Hashimoto Nobuo
Published: July 2004

OBJECTIVE

Vascular remodeling via apoptotic mechanisms is an important factor in vascular diseases. c-Jun amino-terminal kinase (JNK) is a member of the mitogen-activated protein kinase family and initiates apoptosis mainly via phosphorylation of the c-Jun transcription factor. We performed this study to clarify the roles of the JNK/c-Jun pathway and apoptosis in the pathogenesis of cerebral aneurysms.

METHODS

Cerebral aneurysms from 12 patients and control vessels from 5 patients were studied. We analyzed the expression of phosphorylated JNK and phosphorylated c-Jun in cerebral aneurysms by using immunohistochemical methods.

RESULTS

Immunoreactivity for phosphorylated JNK and phosphorylated c-Jun was increased in the vascular walls of the cerebral aneurysms studied. Immunoreactivity for single-stranded deoxyribonucleic acid (a marker of deoxyribonucleic acid damage) was also increased in aneurysmal tissue, compared with control vessels, and was colocalized with that for phosphorylated JNK and phosphorylated c-Jun in smooth muscle cells.

CONCLUSION

These observations may lead to better understanding of the role of the JNK/c-Jun pathway in the development of cerebral aneurysms and to new strategies for treatment.
Optic Nerve Arteriovenous Malformation Causing Optic Apoplexy: Case Report
Authors: Muragaki Yoshihiro , Ujiie Hiroshi , Ohno Masayuki , Kubo Osami , Hori Tomokatsu
Published: July 2004

OBJECTIVE AND IMPORTANCE

Vascular malformations in the optic pathway are rare. Only one case of pathologically confirmed arteriovenous malformation (AVM) of the optic nerve has been reported previously. We document the case of a patient with an optic nerve AVM who presented with optic apoplexy that was diagnosed with the use of magnetic resonance imaging.

CLINICAL PRESENTATION

A 15-year-old girl developed left visual disturbance of sudden onset while playing badminton. A magnetic resonance imaging scan disclosed left optic nerve swelling and intraoptical hemorrhage, although an angiogram did not reveal abnormal vessels.

INTERVENTION

The patient underwent total removal of the hematoma and tangles of the abnormal vessels in the left optic nerve, which was diagnosed pathologically as an AVM. The patient recovered visual acuity, but the left visual field defect remained unchanged.

CONCLUSION

Along with cavernous malformations and optic gliomas, AVMs can be a rare cause of optic nerve apoplexy. T2-weighted magnetic resonance imaging is useful in rendering the diagnosis of an optic nerve AVM, observed as a mass lesion consisting of serpiginous, tangled, low-intensity bands. Early surgical treatment is recommended to obtain a rapid recovery.
Intrasellar Pleomorphic Xanthoastrocytoma: Case Report
Authors: Arita Kazunori , Kurisu Kaoru , Tominaga Atsushi , Sugiyama Kazuhiko , Sumida Masayuki , Hirose Takanori
Published: July 2004

OBJECTIVE AND IMPORTANCE

A patient with a primary intrasellar pleomorphic xanthoastrocytoma is described.

CLINICAL PRESENTATION

A 78-year-old woman experienced slowly progressing bilateral visual disturbance. Analysis of magnetic resonance imaging scans indicated a well-enhanced tumor occupying intra- and suprasellar spaces with displacement of the pituitary gland anteriorly.

INTERVENTION

Partial resection of the tumor via the transsphenoidal route brought about improvement of the patient's visual disturbance. The tumor was conspicuously pleomorphic and composed of plump to spindle-shaped large and bizarre cells with single or multiple nuclei and lipid-laden foamy cytoplasm. The neoplastic cells were positive for glial fibrillary acidic protein, S-100 protein, and vimentin. The MIB-1 antibody labeling index was very low (<1%)

CONCLUSION

Pleomorphic xanthoastrocytoma should be included in the differential diagnosis of tumors arising in the posterior hypophysis.
Three-dimensional Contrast Medium-enhanced Computed Tomographic Cisternography for Preoperative Evaluation of Surgical Anatomy of Intradural Paraclinoid Aneurysms of the Internal Carotid Artery: Technical Note
Authors: Ito Kiyoshi , Hongo Kazuhiro , Kakizawa Yukinari , Kobayashi Shigeaki
Published: July 2004

OBJECTIVE AND IMPORTANCE

Precise preoperative evaluation is especially important when internal carotid artery aneurysms in the paraclinoid region are clipped, because these vascular structures are located in close proximity to various important structures such as the optic nerve and anterior clinoid process. We report a new method for “simultaneously” describing the interrelationships among the aneurysm, internal carotid artery, optic nerve, and bony structures with three-dimensional contrast medium-enhanced computed tomographic (3-D CMECT) cisternography.

METHODS

Informed consent was obtained from the patient. An 8-ml injection of iotrolan (Isovist; Schering, Berlin, Germany) (240 mg I/ml) was administered into the lumbar intrathecal space. A computed tomographic scan of the head was obtained 2 hours later with a multislice Asteion computed tomographic scanner (Toshiba, Inc., Tokyo, Japan). An Alatoview workstation (Silicon Graphics, Mountain View, CA) was used to reconstruct the three-dimensional images.

RESULTS

These images, as generated by 3-D CMECT cisternography, were found to accurately demonstrate the interrelationships of the internal carotid artery, aneurysm, and surrounding structures preoperatively. The findings obtained from these images proved to be quite similar to the intraoperative findings. 3-D CMECT cisternography clarified whether the paraclinoid aneurysm was intradural or extradural.

CONCLUSION

3-D CMECT cisternography was found to provide a useful means for preoperative evaluation of lesions in the paraclinoid area.
Management of Intracranial Infectious Aneurysms: A Series of 16 Cases
Authors: Phuong Loi K. , Link Michael , Wijdicks Eelco
Published: July 2004

OBJECTIVE

The purpose of this study was to better define the management of intracranial infectious aneurysms.

METHODS

We present a retrospective review of the management of 16 patients with intracranial infectious aneurysms. The mean follow-up period was 86 months.

RESULTS

None of the patients had a rehemorrhage during antibiotic treatment. The mortality and long-term outcome from ruptured intracranial infectious aneurysms may be better than previously thought. There was no significant difference in long-term outcome between patients with single or multiple infectious aneurysms or between patients who underwent surgical resection and those who were treated only with antibiotics.

CONCLUSION

Operative treatment should be pursued for patients with ruptured infectious aneurysms. Patients with unruptured intracranial infectious aneurysms should be observed during antibiotic therapy and followed up with cerebral angiography. Surgical resection should be considered if the aneurysm enlarges and the patient's general medical condition allows general anesthesia to be tolerated.
Radiosurgical Treatment of Cavernous Sinus Meningiomas: Experience with 122 Treated Patients
Authors: Nicolato Antonio , Foroni Roberto , Alessandrini Franco , Bricolo Albino , Gerosa Massimo
Published: July 2004

OBJECTIVE

To evaluate the efficacy of gamma knife (GK) radiosurgery, in terms of neurological improvement and tumor growth control (TGC), for a large series of patients with cavernous sinus meningiomas.

METHODS

Between February 1993 and January 2002, 156 patients with cavernous sinus meningiomas (35 male and 121 female patients; mean age, 56.1 yr) were treated with GK radiosurgery in our department. GK radiosurgery was used as a first-choice treatment for 75 of 156 patients and as postoperative adjuvant therapy for 81 of 156 patients (all with Grade I meningiomas). Eligibility criteria for radiosurgery were as follows: symptomatic meningiomas and/or documented tumor progression on magnetic resonance imaging scans, conditions of high operative risk, patient refusal of microsurgery or reoperation, tumor volume of <20 cm3, and location no less than 2 mm from the optic pathways.

RESULTS

Follow-up data for at least 12 months were available for 122 patients (median follow-up period, 48.9 mo). Clinical conditions were improved or stable for 118 of 122 patients (97%). Neurological recovery was observed for 78.5% of patients treated with GK radiosurgery alone and for 60.5% of patients treated with adjuvant therapy (P < 0.05). Adequate TGC was documented for 119 of 122 tumors (97.5%), with shrinkage/disappearance in 75 of 122 cases (61.5%) and no variation in volume in 44 of 122 cases (36%); the overall actuarial progression-free survival rate at 5 years was 96.5%. Tumor size regression was observed for 80% of patients with follow-up periods of more than 30 months, compared with 43.5% of patients with follow-up periods of less than 30 months (P < 0.0002). Radiosurgical sequelae were transient in 4 of 122 cases (3.0%) and permanent in 1 case (1%).

CONCLUSION

For the follow-up periods in our series (median, >4 yr), GK radiosurgery seems to be both safe (permanent morbidity rate, 1%) and effective (97% neurological improvement/stability, 97.5% overall TGC, and 96.5% actuarial TGC at 5 yr). GK radiosurgery might be considered a first-choice treatment for selected patients with cavernous sinus meningiomas.