bluuebunny/crossref_metadata_2025 huggingface dataset:
Morphometric Analysis of Reticular and Elastin Fibers in the Cerebral Arteries of Patients with Intracranial Aneurysms
Authors: Chyatte Douglas , Reilly Jeffrey , Tilson David M.
Published: April 2011

Elastin and reticular fibers were identified using standard histological stains in middle cerebral arteries taken from patients who had died from aneurysmal subarachnoid hemorrhage and control patients who did not have cerebral aneurysms, Examination of cerebral arteries from normal individuals revealed a dense network of fine reticular fibers in the arterial media that were uniformly distributed. Computerized morphometric analysis indicated that reticular fibers in the arterial media of cerebral arteries were significantly decreased in patients with aneurysms. In addition, these fibers were irregularly distributed and shortened when compared to those seen in control arteries. In both patients with aneurysms and control patients, elastin fibers were limited almost exclusively to the internal elastin lamina. No differences were observed in the appearance or content of elastin fibers in control patients and patients with aneurysm. Although other explanations cannot be excluded, these observations are consistent with the hypothesis that “intrinsic“ abnormalities in the walls of cerebral arteries lead to conditions that favor the formation and rupture of cerebral aneurysms.
An Unusual Cause for Trigeminal Neuralgia: Contralateral Meningioma of the Posterior Fossa
Authors: Haddad Fuad S. , Taha Jamal M.
Published: April 2011

Twenty cases of facial neuralgia associated with tumors of the contralateral posterior fossa were collected from the world literature. Only four of these conform to the description of typical trigeminal neuralgia. We report on a fifth such case with a critical review of the literature. Subtotal excision of the tumor improves the pain and may convert a carbamazepine-resistant neuralgia into a responsive one. Total excision is often followed by a cure. Faced with such a case, the tumor should always be excised first, as this usually cures the neuralgia. Surgical treatment of the neuralgia in the presence of the tumor may be followed by disastrous results. An alternative hypothesis to the pathogenesis of the contralateral neuralgia is presented.
Multiple Meningiomas of the Fourth Ventricle in Infancy: Case Report
Authors: Díaz Pedro , Maillo Angel , Morales Francisco , Gómez-Moreta Juan A. , Hernández Javier
Published: April 2011

Meningiomas are uncommon tumors in infancy. Intraventricular meningiomas do occur more frequently in infancy than in adulthood, although the establishment and growth of such tumors in the fourth ventricle is exceptional in children. The occurrence of multiple meningiomas is currently estimated to be less than 8%. We present the case of a girl who displayed two meningiomas in the fourth ventricle. Five years later, the child had four more meningiomas detected and extirpated from the same site. Eighteen months later, a new tumor appeared in the lower third of the clivus; after resection this was found to be another meningioma. The presence in a child of the repeated occurrence of multiple meningiomas, both in the fourth ventricle and in other areas of the posterior fossa, have led the authors to consider that the case is both curious and rare. Twelve similar cases of meningiomas developing exclusively in the fourth ventricle have been published; of these, only 3 occurred during infancy. A discussion is offered concerning the etiology and pathogenesis of these tumors, in which the possibility of unknown neuro-oncogenic factors that might induce meningiomas is postulated.
Evaluation of Posttraumatic Cerebral Blood Flow Velocities by Transcranial Doppler Ultrasonography
Authors: Weber Marcel , Grolimund Peter , Seiler Rolf W.
Published: April 2011

Thirty-five patients were admitted to the hospital with Glasgow coma scale scores of 4 to 7 after severe, blunt head injury. Blood flow velocities of the middle cerebral artery (MCA) and the ipsilateral internal carotid artery (ICA), high in the neck, were recorded noninvasively by Doppler ultrasonography. Serial examinations were begun within 48 hours of trauma and continued until the patient either died or was discharged. Spasm of the MCA was assumed if the ratio of the velocity of blood flow in the MCA (VMCA) to the velocity of blood flow in the ICA (VICA) exceeded 3 (normal value, 1.7 ± 0.4). In cases of severe MCA spasm, this ratio is higher because of increased flow velocity in the MCA and reduced flow in the ICA due to increased cerebrovascular resistance. Higher MCA velocities with VMCA/VICAabove 3, consistent with MCA spasm, were found in 14 of the 35 patients (40%). The increase began as early as 48 hours after injury, reached a maximum between Days 5 and 7, and lasted until 2 weeks after injury. There was a significant correlation between the occurrence of vasospasm and the quantity of cisternal or intracerebral blood seen on a computed tomographic scan. No correlation was found with the age of the patients, the Glasgow coma scale score at admission, the intracranial pressure, or the functional outcome 6 months after injury. The occurrence of a secondary infarction in a patient with severe MCA spasm suggests that, at least in some cases, spasm may influence the prognosis.
Epidural Peg Electrodes for the Presurgical Evaluation of Intractable Epilepsy
Authors: Barnett Gene H. , Burgess Richard C. , Award Issam A. , Skipper George J. , Edwards Christopher R. , Luders Hans
Published: April 2011

A new electrode design for the extradural recording of electrical brain activity is described. Epidural peg electrodes are implantable mushroom-shaped composites of Silastic clastomer and a stainless steel or platinum disc. These electrodes are useful for the preoperative mapping of seizure foci in some patients who have cranial defects or severe muscle artifacts on scalp recordings. They are also used for canvassing wide areas of cortex to determine whether a seizure is focal in origin, arises diffusely from a hemisphere, or has a bilateral origin. Advantages of epidural peg electrodes over screw and other types of epidural electrodes include low risk of infection or hemorrhage and improved patient comfort.
Subacute Pituitary Apoplexy: Clinical and Magnetic Resonance Imaging Characteristics
Authors: Glick Roberta P. , Tiesi James A.
Published: April 2011

Between 1987 and 1988, we utilized magnetic resonance imaging (MRI) in the diagnosis of seven cases of “subacute” pituitary apoplexy. that is, intra-adenomatous pituitary hemorrhage associated with clinical symptoms atypical of acute pituitary apoplexy. These symptoms lasted longer than 24 hours and included visual changes in four patients, headache in five, and seizures, endocrine dysfunction, and oculomotor palsy in one each. Estimates of the ages of the hemorrhages were also possible based on characteristics on the MRI scan and ranged from 48 hours to more than 14 days. Four of our seven patients underwent transsphenoidal decompression at which time the presence of intratumoral hemorrhage was confirmed. The remaining three patients have been followed as outpatients with serial MRI examinations and have shown improvement in clinical symptoms and stabilization of the radiological picture. From our series of patients, it is now apparent that the MRI scan is an invaluable tool in identifying this subacute form of intra-adenomatous pituitary hemorrhage and has proven especially useful as a means of therapeutic planning and follow-up care in patients presenting with symptoms not typical of classic pituitary apoplexy.
Radiofrequency Cingulotomy for Intractable Cancer Pain Using Stereotaxis Guided by Magnetic Resonance Imaging
Authors: Hassenbusch Samuel J. , Pillay Prem K. , Barnett Gene H.
Published: April 2011

This study presents a new and simplified method of creating cingulate gyrus lesions by using stereotaxis guided by magnetic resonance imaging (MRI). Previous methods have utilized ventriculogram-guided stereotaxis requiring indirect cingulate gyrus localization and general anesthesia. With the present technique a BRW stereotactic frame was applied with the patient under local anesthesia. An MRI scan was performed using a T1 signal (TR, 600 ms; TE, 30 ms) in the coronal plane with 5-mm thick sections spaced every 6 mm. The coronal slice 24 mm posterior to the anterior tip of lateral ventricle was identified. The center of each (right and left) cingulate gyrus was identified as a target area, and appropriate coordinates were determined. Approach parameters were calculated for the right and left gyri using an azimuth of 45° and 315°, respectively, and a declination of 45°. A radiofrequency electrode was stereotactically placed so that the electrode tip was at a target point which was the center of the cingulate gyrus. A radiofrequency lesion (75°, 60 seconds) was made in each hemisphere's cingulate gyrus. Four patients with intractable terminal cancer pain have been initially treated in this manner. The lesions were well-localized on postoperative MRI scans. There have been no complications except for perilesional edema for 10 days in 1 patient (treated with longer radiofrequency settings that have subsequently been modified). Short-term pain relief in cancer patients was dramatic: morphine (intravenous 14 to 40 mg/h or oral 60 mg every 4 hours) preprocedure to oral oxycodone (1 to 2 tablets q4-6h) or oral morphine (4 to 8 mg every 4 to 6 hours) postprocedure. The use of MRI-guided stereotaxis to make cingulate gyrus lesions is an improvement that potentially allows the routine creation of these lesions as a standard cancer pain treatment. The technique is simple, uses local anesthesia, and appears to be effective and safe.
Chondromatosis of the Choroid Plexus: Case Report
Authors: Valdueza Jose Manuel , Freckmann Niels , Herrmann Hans-Dietrich
Published: April 2011

We report the case of a patient with successful total removal of a previously undescribed intracranial tumor arising in the right lateral ventricle (probably of metaplastic origin). The histopathological examination revealed benign chondromatosis of the choroid plexus. The pathogenesis of this lesion, with special reference to synovial chondromatosis and to the differential diagnosis of solid neoplastic chondromas, their clinical features, and computed tomographic and magnetic resonance imaging findings, is presented and discussed.
Isolated Growth Hormone Deficiency Associated with a Giant Arteriovenous Varix
Authors: Martin Neil A. , Macagba-Crain Carol Lynn , Geffner Mitchell , Peacock Warwick
Published: April 2011

A 6.5-year-old girl with short stature (height age, 3 years; bone age, 1.75 years) had isolated growth hormone deficiency. Preoperative computed tomography and magnetic resonance imaging demonstrated a large, well-demarcated, homogeneous mass above the dorsum sellae with a density consistent with flowing blood. Vertebral angiography showed a giant intracranial varix caused by an arteriovenous fistula that originated at the apex of the basilar artery. At operation, an aneurysm clip was placed at the origin of the fistula, and occlusion of the fistula was confirmed by intraoperative digital subtraction angiography. There were no permanent neurological sequelae. Despite shrinkage of the varix, demonstrated by follow-up computed tomography, growth hormone deficiency persisted postoperatively. Biosynthetic growth hormone therapy was initiated 6.5 months after surgery and resulted in a height increment of 8.2 cm after 9 months of treatment.
Posterior Interosseous Nerve Palsies
Authors: Cravens George , Kline David G.
Published: April 2011

One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings included weak wrist extension with a radial drift, inability to extend the fingers, paralysis of thumb extension, and weak thumb abduction. Causes included entrapment at the arcade of Froshe (14 patients), laceration (6 patients), fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women was 2:1, and the right arm was involved twice as often as the left. Preoperative evaluation included physical examination, electrophysiological testing (electromyogram/nerve conduction velocity), and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5, and 7 had obtained Grade 5/5. At operation, 23 nerves were found to be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and. not unexpectedly, transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis, and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture, and 3 required graft repair. A large ganglion cyst involving the posterior interosseous nerve was also resected.
Repair of Isolated Axillary Nerve Lesions after Infraclavicular Brachial Plexus Injuries: Case Reports
Authors: Friedman Allan H. , Nunley James A. , Urbaniak James R. , Goldner Richard D.
Published: April 2011

Stretch injuries of the infraclavicular brachial plexus have a much better prognosis for spontaneous recovery than do their supraclavicular counterparts. We present three patients with stretch injuries of the infraclavicular brachial plexus who had spontaneous restoration of function in all muscles except the deltoid. Decreased shoulder abduction was a serious handicap to these individuals. At surgical exploration, each patient had an isolated, complete axillary nerve disruption at the quadrilateral space. Deltoid muscle function was restored in all three patients by repair of the axillary nerve with sural nerve grafts across the quadrilateral space.
Xenon-enhanced Computed Tomographic Measurement of Cerebral Blood Flow in Patients with Chronic Subdural Hematomas
Authors: Tanaka Akira , Yoshinaga Shinya , Kimura Masato
Published: April 2011

We compared clinical symptoms with extent of brain shift on computed tomographic (CT) scans and quantitative and three-dimensional measurements of cerebral blood flow (CBF) on xenon-enhanced CT scans in 10 patients with chronic subdural hematomas. Five patients had only headache and minimal or no brain shift on a CT scan. The other five had hemiparesis and/or mental disturbance in addition to headache and moderate or severe brain shift on a CT scan. The mean hemispheric CBF decreased about 7% in patients with headache and about 35% in patients with hemiparesis and/or mental disturbance. It decreased also on the side without the hematoma. The CBF reduction was always more pronounced in the putamen and thalamus than in the cortex. On the contrary, the cortex CBF was mostly preserved or even elevated in both groups of patients. We speculate that CBF reduction in patients with a chronic subdural hematoma occurs initially in central cerebral areas like the basal ganglia and thalamus, and then extends to the entire hemisphere including the cortex as brain compression and displacement progress. Central cerebral area involvement might be more responsible for clinical symptoms than the cortex.
Shunt for Bypass Graft of the Cavernous Carotid Artery: An Anatomical and Technical Study
Authors: Al-Mefty Ossama , Khalil Nabil , Elwany Mohammed Nagy , Smith Robert R.
Published: April 2011

During direct surgery of neoplastic and vascular lesions of the cavernous sinus, the intracavernous carotid artery may be injured beyond repair, or its total isolation may be necessary for surgical management of these lesions. The newly developed procedure of a saphenous vein graft bypass of the cavernous carotid artery allows re-establishment of carotid circulation. Patients with poor collateral circulation are at high risk for ischemic complications induced by the prolonged temporary occlusion required to perform the bypass graft. Optimal management of these patients is to perform the venous bypass graft for permanent vascularization while maintaining carotid cerebral circulation through an intraoperative shunt. We studied this procedure in cadavers, and three shunt types were evaluated: the external intrapetrous-supraclinoid shunt (Type A), the internal intrapetrous-supraclinoid shunt (Type B), and the neck internal carotid-supraclinoid shunt (Type C). Anatomical landmarks, techniques, distances, caliber, and materials used are presented. The rationale and candidates for such a procedure are discussed. The specifications of an optimal balloon shunt are presented, and the three procedures are compared.
Entrapment Neuropathy of the Meidan Nerve at the Level of the Ligament of Struthers
Authors: Bilge Turgay , Yalaman Okan , Bilge Semra , Çokneşeli Baki , Barut Şeref
Published: April 2011

The presence of a supracondylar process and Struthers' ligament is a rare congenital anomaly that may cause compression of either the median nerve, the brachial artery, or both. The authors present a case in which the supracondylar process and Struthers' ligament compressed both the median nerve and the brachial artery. This case is unusual, in that the symptoms of compression of the brachial artery increased—namely, the pulse intensity decreased and the pain increased with elbow flexion.
Pretreatment Neuropsychological Status and Associated Factors in Children with Primary Brain Tumors
Authors: Brookshire Bonnie , Copeland Donna R. , Moore Bartlett D. , Ater Joann
Published: April 2011

We report on the neuropsychological status of 31 children with primary brain tumors who underwent assessment before receiving therapy. Overall, the children performed within normal limits in all test areas. The exception was the group with anterior hemispheric tumors who demonstrated deficits in executive cognitive functions. Also, when compared according to tumor type, children with midline tumors and hydrocephalus performed more poorly than others on measures of intelligence, executive abilities, visual-motor skills, and fine-motor functions. Although one-half to two-thirds of the children with supratentorial midline and infratentorial tumors had cranial nerve, oculomotor, or cerebellar deficits, only the latter were associated with specific neuropsychological deficits (poorer performance on fine-motor and visual-motor tests). Age did not appear to be a factor in these children's neuropsychological test performances.
Endovascular Coil Embolization of Unusual Posterior Inferior Cerebellar Artery Aneurysms
Authors: Dowd Christopher F. , Halbach Van V. , Higashida Randall T. , Barnwell Stanley L. , Hieshima Grant B.
Published: April 2011

Three patients underwent transarterial platinum coil embolization of unusual posterior inferior cerebellar artery aneurysms. In one case, a giant, bilobed, partially thrombosed aneurysm exhibited marked mass effect on the adjacent medulla. In the second case, diffuse severe cerebral vasospasm, 3 days after subarachnoid hemorrhage, rendered transvascular treatment of the aneurysm difficult. Increasing vertigo and nausea caused by mass effect from an aneurysm previously coated with methyl methacrylate warranted treatment in the third case. Indications for transvascular coil treatment included relative surgical inaccessibility to the aneurysm, and, in our case, inability to perform transarterial detachable balloon therapy. The aneurysms were obliterated by endovascular coil embolization in each case. In the patient with vasospasm, aneurysm treatment followed angioplasty of the major affected cerebral vessels, resulting in significant neurological improvement within 24 hours. Two patients were neurologically intact at the time of discharge, and the third displayed persistent cerebellar signs despite a marked decrease in vertigo and nausea. Reports of transvascular coil embolization of intracranial aneurysms are very rare. Our experience with these patients demonstrates that this technique can be successfully utilized in selected cases.
Observations on the Pathophysiology of Nelson's Syndrome: A Report of Three Cases
Authors: Buchfelder Michael , Fahlbusch Rudolf , Thierauf Paul , Muüller Otto A.
Published: April 2011

Nelson's syndrome is generally regarded as an unusual sequela of primary bilateral adrenalectomy when performed for Cushing's disease. It is classically defined by cutaneous hyperpigmentation, considerably elevated adrenocorticotropic hormone (ACTH) levels, and an enlarged sella turcica. In this report, we present three cases initially treated by transsphenoidal sellar exploration for Cushing's disease. In two of these cases, remission of hypercortisolism did not occur after the initial pituitary exploration. A microadenomectomy was performed in one case and, in the other, no microadenoma was found. In both, Nelson's syndrome occurred after adrenalectomy. A second transsphenoidal operation and radiotherapy were required to control tumor growth. In another case, transsphenoidal adenomectomy of an ACTH-secreting tumor initially led to a remission of hypercortisolism for 4 years, but recurrent Cushing's disease necessitated adrenalectomy, and again Nelson's syndrome occurred. The documentation of a pre-existing ACTH-secreting basophilic pituitary microadenoma before adrenalectomy, as seen in two of our cases, has not been previously reported, and these observations of “non-classical” courses have major implications for the pathophysiology of Nelson's syndrome.
Juvenile Intervertebral Disc Calcification: Recognition, Management, and Pathogenesis
Authors: Dias Mark S. , Pang Dachling
Published: April 2011

Juvenile intervertebral disc calcification is an uncommon disorder of childhood, characterized by calcification of the nucleus pulposus of one or more intervertebral discs. Calcification may remain dormant or subsequently become symptomatic. The symptoms include fever, malaise, and neck pain and are associated with an elevated erythrocyte sedimentation rate and, occasionally, leukocytosis. Although disc protrusion occurs in 38% of patients, neurological signs are distinctly uncommon. We report the case of a patient with a herniated T2-T3 calcified intervertebral disc and compressive myelopathy. Juvenile intervertebral disc calcification is generally a self-limiting disease that seldom requires an operation. The symptoms are transient, and resorption of the disc calcification is the rule once symptoms occur. Neither the cause of the disc calcification nor the trigger for the onset of symptoms is known. An inflammatory response within the disc appears to give rise to clinical symptoms and is associated with eventual resorption of the disc calcification.
Chemotherapy of Brain Metastases from Lung Carcinoma: A Controlled Randomized Study
Authors: Ushio Yukitaka , Arita Norio , Hayakawa Toru , Mogami Heitaro , Hasegawa Hiroshi , Bitoh Shoji , Oku Yuzuru , Ikeda Hiroya , Kanai Nobuhiro , Kanoh Mitsuaki , Akagi Katsuhito , Nakagawa Hidemitsu
Published: April 2011

A controlled randomized study was carried out to evaluate the effects of chemotherapy in patients with brain metastases from lung carcinoma. One hundred patients were randomly divided into three groups at the time of diagnosis or after surgery for metastases. Group A received radiotherapy alone; Group B received radiotherapy and chloroethylnitrosoureas (methyl-CCNU, 100-120 mg/m2, or ACNU 80-100 mg/m2, every 6-8 weeks), and Group C received radiotherapy and a combination of chloroethylnitrosoureas and tegafur (300 mg/m2. daily). Of the 100 patients, 88 could be evaluated. The reduction rates of the tumors of the patients in whom tumor was not surgically removed or not totally removed were compared. Complete resolution of the tumor was noted in 29, 69, and 63% of the patients in Groups A, B, and C, respectively, Tumor regression of ⩾50% was seen in 36, 69. and 74% of the patients in Groups A, B, and C, respectively. The difference in the response rates of Groups A and C was statistically signficiant (P<0.05). Median survival after the start of treatment for brain metastasis was 27, 30.5, and 29 weeks in Groups A, B, and C, respectively. There was 1 long-term survivor (more than 5 years) in Group A, 3 in Group B, and 1 in Group C. The main cause of death was deterioration attributable to the primary lesion or systemic metastasis, and no statistical difference was noted in survival time among the groups. Our results indicate that combination chemotherapy with chloroethylnitrosoureas and tegafur has an additive effect on radiotherapy in reducing or eliminating brain metastases from lung carcinoma, and that brain metastasis is well controlled by multidisciplinary treatment including chemotherapy.
Isolated Trigeminal Sensory Loss Secondary to a Distal Anterior Inferior Cerebellar Artery Aneurysm: Case Report
Authors: Zager Eric L.
Published: April 2011

A previously healthy 25-year-old woman suddenly developed right-sided facial numbness and a headache. The neurological examination was within normal limits with the exception of meningismus and right-sided facial sensory loss. A computed tomographic scan and a magnetic resonance imaging study demonstrated an acute hematoma in the right cerebellopontine angle. A 4-vessel cerebral angiogram revealed no abnormalities. Posterior fossa exploration disclosed a large, partially thrombosed, fusiform anterior inferior cerebellar artery aneurysm, which indented the pons at the trigeminal root entry zone. The aneurysm was excised, and the patient made an excellent recovery. She was left with a persistent trigeminal sensory deficit. Anterior inferior cerebellar artery aneurysms are rare lesions that generally present with a cerebellopontine angle syndrome: occasionally, facial sensory loss is also a feature. Isolated trigeminal sensorv findings, as illustrated in this case, are extremely unusual in posterior fossa vascular lesions.
Lymphocytic Hypophysitis with Involvement of the Cavernous Sinus and Hypothalamus
Authors: Nussbaum Charles E. , Shige-Hisa Okawara , Jacobs Laurence S.
Published: April 2011

Two cases of lymphocytic hypophysitis are reported, in which hypothalamic involvement causing diabetes insipidus was a prominent clinical feature. In one case, a man had clinical and radiological evidence of the involvement of the cavernous sinus. This represents the second reported case of a man with lymphocytic hypophysitis. A transsphenoidal biopsy established the diagnosis in both cases. Neither the involvement of the cavernous sinus nor permanent diabetes insipidus has been reported previously. A review of the literature is provided.
Management of Intraoperative Rupture of Aneurysm without Hypotension
Authors: Giannotta Steven L. , Oppenheimer Jeffrey H. , Levy Michael L. , Zelman Vladimir
Published: April 2011

A retrospective analysis was performed on all aneurysms operated on by one of us (SLG); from July 1980 to October 1988 to determine the factors that govern outcome from the intraoperative rupture of aneurysms. A total of 276 consecutive surgical procedures for 317 intracranial aneurysms produced 41 perioperative or intraoperative ruptures for analysis. Five cases were pre-exposure ruptures, 3 of which occurred during anesthetic induction. Four of these patients died, and 1 made a good recovery. Of the remaining 36 cases, outcome was analyzed in terms of the adjuncts used to deal with the intraoperative rupture. There was no statistically significant difference in outcome between those cases in which tamponade was used to control hemorrhage versus temporary clipping; however, those cases in which hypotension was used did less well than those in which it was not used. From October 1986 to October 1988, 108 operations for 132 aneurysms were performed without the use of induced hypotension. There were 16 intraoperative ruptures (14.8%);. All 16 of these patients made a good recovery. In the group before 1986, of which there were 20 intraoperative ruptures (of 168 operations, 11.9%);, 11 of those 20 patients suffered a permanent deficit or died. We conclude that hypotension may not be a necessary adjunct to the management of intraoperative rupture of aneurysms.
Delayed Hearing Loss after Surgery for Acoustic Neurinomas: Clinical and Electrophysiological Observations
Authors: Strauss Christian , Fahlbusch Rudolf , Romstöck Johann , Schramm Johannes , Watanabe Eiju , Taniguchi Makoto , Berg Michael
Published: April 2011

In a series of 26 patients with medium-sized and large acoustic neurinomas and documented hearing before surgery, 7 patients had preservation of hearing initially after the procedure but then developed delayed hearing loss. The most prominent intraoperative electrophysiological finding in these cases was a gradual deterioration of brain stem auditory evoked potentials (BAEP);, especially of Wave V. Four additional patients with a similar gradual intraoperative loss of BAEP and severe postoperative hearing deterioration received vasoactive treatment after surgery (low-molecular weight dextran);. In all 4 patients, including 1 patient with documented total deafness after surgery, hearing was preserved. Initial preservation of cochlear nerve function after the removal of an acoustic neurinoma does not guarantee postoperative hearing. Intraoperative BAEP help to identify patients at risk for delayed postoperative hearing loss. The pathophysiological mechanism can be attributed to disturbances of the microcirculation in endoneurial vasa nervorum caused by the mechanical manipulation of the cochlear nerve.
The Prognostic Significance of Postoperative Residual Tumor in Ependymoma
Authors: Healey Elizabeth A. , Barnes Patrick D. , Kupsky William J. , Scott Michael R. , Sallan Stephen E. , Black Peter McL. , Tarbell Nancy J.
Published: April 2011

Between 1970 and 1989, 29 patients with intracranial ependymomas were evaluated and treated at the Children's Hospital in Boston. With a median follow-up of 82 months, the actuarial survival rates at 5 and 10 years were 61 ± 10% and 46 ± 12%, respectively. Anaplastic histological findings were uncommon (2 of 29). Initial postoperative radiotherapy was given to 25 patients, with a median tumor dose of 5360 cGy. With a median time to recurrence of 22 months, local failure (within 2 cm of original enhancing mass) was the predominant pattern of relapse (15 of 16 failures). The presence of radiographic residual disease seen on postoperative magnetic resonance imaging or computed tomographic scans was the most important prognostic variable for patients with intracranial ependymoma. Analysis of the 19 patients who underwent postoperative imaging revealed a 75 ± 15% 5-year freedom from progressive disease for 9 patients with no residual disease. as compared with 0% freedom from progressive disease for the 10 patients with gross residual disease (P = 0.03). In contrast, the surgical assessment of residual disease was not significant (P = 0.4). Age at presentation was also a significant prognostic factor. The overall actuarial survival rate at 12 years for infants 24 months or younger at diagnosis was 0%, as compared with 62 ± 13% for older patients (P = 0.03). For non-anaplastic ependymomas, complete surgical resection followed by local-field, high-dose (>54 Gy) radiotherapy appears to offer the greatest chance for long-term survival. Because of the markedly reduced survival rate for patients with radiologically apparent postoperative disease, maximal surgical resection and novel therapeutic endeavors appear warranted for this high-risk group. Future protocols should use postoperative imaging, not operative reports, to stratify patients with ependymoma.
Telecanthal Approach for Meningiomas in the Ethmoid and Sphenoid Sinuses
Authors: Fujitsu Kazuhiko , Saijoh Masakuni , Aoki Fumihiko , Sakata Katsumi , Fujii Satoshi , Mochimatsu Yasuhiko , Kuwabara Takeo
Published: April 2011

In three cases involving meningiomas in the ethmoid and sphenoid sinuses, transbasal spreading of the interocular distance (telecanthal approach) was used for tumor removal and reconstruction of the skull base. This telecanthal approach involves 1) bilateral en bloc removal of the superior lateral rim of the orbit, the nasal bone, and the posterior lateral wall of the orbit; 2) detachment of the medial canthal ligaments; and 3) spreading of the interocular distance. This approach provides a wide working space beneath the anterior half of the midline skull base, and needs neither a facial incision nor significant retraction of the brain. The surgical technique and its modification are described. The discussion focuses not only on comparisons with other techniques, but on the indications for this approach. Meningiomas originating in the paranasal sinuses are rare; a brief review of the literature concerning the clinicopathological features and pathogenesis is also given.
Operative Approach to the Frontal Skull Base: Extensive Transbasal Approach
Authors: Kawakami Katsuhiro , Yamanouchi Yasuo , Kawamura Yasuo , Matsumura Hiroshi
Published: April 2011

An operative technique called the extensive transbasal approach is reported with the operative results of 11 cases. This is an operative mode in which en bloc osteotomy of the orbital roofs and frontal sinus is performed after ordinary bifrontal craniotomy. Through this approach, a far wider operative space than that afforded by conventional operative techniques is possible, and reconstruction of the frontal base can be made securely. We consider this approach of major clinical value.
The Clinical Importance of the Inferolateral Trunk of the Internal Carotid Artery
Authors: Capo H. , Kupersmith M. J. , Berenstein A. , Choi I. S. , Diamond G. A.
Published: April 2011

The inferolateral trunk (ILT) of the internal carotid artery (ICA) is a branch that arises inferiorly from the C4 segment of the cavernous ICA. It provides blood supply to the 3rd, 4th, and 6th cranial nerves, as well as to the gasserian ganglion. The ILT anastomoses to branches of the internal maxillary artery, providing collateral circulation between the external carotid artery and the ICA systems. Retinal and cerebral emboli can arise from the external carotid artery system and travel via the ILT to the ICA. Cranial nerve palsies may result after occlusion of the ILT. We present the cases of four patients who had iatrogenic neurological dysfunction subsequent to intravascular procedures that involved the ILT. These cases provide further clinical confirmation of the importance of this blood vessel. A 5th case involving iatrogenic occlusion of the ILT and no neurological deficit is also presented, demonstrating that the ILT is not the sole blood supply of the cranial nerves in the cavernous sinus.
Primary Intrasellar Coccidioidomycosis Simulating a Pituitary Adenoma
Authors: Scanarini M. , Rotilio A. , Rigobello L. , Pomes A. , Parenti A. , Alessio L.
Published: April 2011

The case of a 68-year-old woman who had relatively acute, unilateral ophthalmoplegia is reported. Radiological studies indicated a mass lesion involving the pituitary gland and left cavernous sinus. Pathological tissue obtained by the transsphenoidal approach revealed the presence of a Coccidioides granuloma. This pathological entity should be considered when evaluating patients with a pituitary mass and ophthalmoplegia.
Vascularized Omentum Graft for the Reconstruction of the Skull Base after Removal of a Nasoethmoidal Tumor with Intracranial Extension: Case Report
Authors: Yamaki Toshiaki , Uede Teiji , Tano-oka Atsushi , Asakura Kohji , Tanabe Sumiyoshi , Hashi Kazuo
Published: April 2011

A 16-year-old boy with rhabdomyosarcoma occupying the nasal cavities and the ethmoid sinus with intracranial extension underwent transcranial surgery. The intradural tumor was resected first with the affected dura of the anterior skull base, and the dural defect was repaired with fascia harvested from the sheath of the rectus abdominis muscle. The remaining tumor contiguous to the nasal cavities was completely extirpated. The cranial cavity was then exposed to the opened nasal cavities, where a revascularized omental graft was used to separate these compartments. Lyophilized dura was placed beforehand beneath the omental graft, as a roof to the nasal cavity, and was removed 3 weeks later through the nostril. A bony skull base repair was performed over the omentum using the inner table of the bone flap. Subcutaneous fat from the abdomen was placed on the bone graft for fixation and as an additional seal for the dural defect. Reconstruction of the anterior skull base with a vascularized omental transfer provides an efficient barrier to the nasal cavity. It also serves as an excellent supporting structure for regeneration of the mucosal epithelium of the nasal cavities.
Aneurysm of the Distal Anterior Inferior Cerebellar Artery Unrelated to the Cerebellopontine Angle: Case Report
Authors: Oana Katsumaro , Murakami Toshiharu , Beppu Takaaki , Yamaura Akira , Kanaya Haruyuki
Published: April 2011

This is a case report of an unusual aneurysm of the distal anterior inferior cerebellar artery. A 44-year-old woman had a severe frontal headache and vomiting of sudden onset. On the day after admission, the patient began to demonstrate nuchal rigidity and difficulty with upward gaze bilaterally. There were no complaints at this time suggestive of a syndrome of the cerebellopontine angle. A computed tomographic scan revealed an intraventricular hemorrhage of the 3rd and 4th ventricles; however, multiple attempts at four-vessel angiography were required before an aneurysm could be demon-strated. On the 28th hospital day, a suboccipital craniectomy using the retromastoid approach in the lateral position was performed. A saccular aneurysm with a surrounding hematoma in the distal anterior inferior cerebellar artery was found and clipped. The operative findings revealed that the aneurysm was unrelated to the cerebellopontine angle. After surgery, the patient had an uneventful recovery and complete resolution of symptoms.
Extramedullary Hematopoiesis in Cerebellar Hemangioblastoma
Authors: Zec Natasa , Cera Peter , Towfighi Javad
Published: April 2011

Extramedullary hematopoiesis and paraneoplastic erythrocytosis are uncommon in cerebellar hemangioblastoma, and their concomitant occurrence has not been reported. In a study of 26 cases of hemangioblastoma, we found extramedullary hematopoiesis in 4 tumors; one was associated with erythrocytosis. The significance of this association and the possible histogenetic origin of extramedullary hematopoiesis in cerebellar hemangioblastoma are discussed. (Neurosurgery 29:34-37, 1991)
Intracranial Fibromatosis
Authors: Mitchell Andrew , Scheithauer Bernd W. , Ebersold Michael J. , Forbes Glenn S.
Published: April 2011

Fibromatoses are uncommon infiltrative lesions affecting musculoaponeurotic structures, most often of the limbs and trunk. Lesions involving the cranial cavity are rare and require the same aggressive surgical management as elsewhere in the body. This case illustrates their clinical and neuroradiological features and underscores the necessity for aggressive resection to avoid recurrence. The literature is reviewed. (Neurosurgery 29:123-126, 1991)
Cyst of the Ligamentum Flavum: Report of Six Cases
Authors: Vernet Olivier , Fankhauser Heinz , Schnyder Pierre , Déruaz Jean-Pierre
Published: April 2011

Six cases of cyst of the ligamentum flavum with compression of a lumbar nerve root are reported. All patients exhibited recurrent back pain and sciatica. Investigation included computed tomography, myelography, or both. The correct diagnosis was reached before operation in only half the patients. High-resolution computed tomography performed in the four last patients outlined the cystic lesion with its low-density center. Surgical excision was performed in all patients. Microscopic examination showed a dense fibrous cyst arising from the ligamentum flavum. The lumen contained myxoid or necrotic material, but no epithelial lining. Cysts of the ligamentum flavum must be considered in the differential diagnosis of causes of sciatica. A firm radiological diagnosis may, at present, still require myelography combined with high-resolution computed tomography. Differentiation from synovial or ganglion cysts of the spine is discussed.
Neuropsychological Sequelae of Arteriovenous Malformations
Authors: Mahalick David M. , Ruff Ronald M. , Hoi Sang U
Published: April 2011

A total of 24 patients harboring arteriovenous malformations (AVMs) in either the dominant hemisphere (n = 12) or the nondominant hemisphere (n = 12) were examined neuropsychologically. When compared with 24 matched normal control subjects, the AVM patients demonstrated differential degrees of impairment in verbal or visuospatial processing, depending on whether the lesion involved the dominant or nondominant hemisphere. As predicted, most compelling were the findings of cognitive deficit associated with the hemisphere contralateral to the AVM relative to matched normal control subjects. Evidence of higher cortical dysfunction contralateral to the residing AVM is discussed in the context of cerebrovascular steal.
Surgical Treatment of Intractable Epilepsy Associated with Schizencephaly
Authors: Leblanc Richard , Tampieri Donatella , Robitaille Yves , Feindel William , Andermann Frederick
Published: April 2011

With the advent of magnetic resonance imaging, there has been an increased recognition of schizencephaly during life, especially in epileptic patients. We report our experience with the assessment and treatment of three patients with medically intractable seizures associated with this condition. The three men were aged 24 to 37 years. Two had delayed developmental milestones and hemiparesis or hemiplegia. One had normal development and a normal neurological examination. Seizures began between the ages of 15 and 19 years and lasted for 5 to 22 years before surgery. All had partial simple or generalized seizures with predominant electroencephalographic and electrocorticographic epileptic activity localized to temporal and frontal lobes on the side of the lesion. Neuropsychological assessment indicated widespread dysfunction maximal at the areas of predominant electroencephalographic abnormality. Magnetic resonance imaging demonstrated anterior parasagittal, parietal, and Rolandic cerebral clefts, with ventricular diverticuli, gray matter heterotopia, polymicrogyria, and a true agenesis of the corpus callosum in individual patients. The patients underwent temporal (one patient) and frontotemporal (two patients) lobectomies without additional neurological deficits or neuropsychological deterioration. Postoperative follow-up showed reduction in seizure frequency. We conclude that the surgical treatment of epilepsy is well tolerated in such patients, and their seizures can be alleviated by resection of epileptogenic areas.
Chordoma in Early Childhood: A Clinicopathological Study
Authors: Kaneko Yoichi , Sato Yuji , Iwaki Toru , Shin Ryong-Woon , Tateishi Jun , Fukui Masashi
Published: April 2011

A case of clival chordoma in a 4-year-old girl is presented. The tumor regrew rapidly after it was partially removed, and the patient died after a clinical course of 11 months. An autopsy revealed a massive clival mass and widespread metastases in the dura mater, skull bone, bilateral lungs, liver, sternum, left humerus, and vertebrae. Pathological findings showed that the tumor cells were poorly differentiated, with a rare, but typical, physaliphorous appearance. The presence of epithelial differentiation proteins, mitochondria surrounded by rough endoplasmic reticulum, and desmosomes was demonstrated in the tumor cells both immunohistochemically and ultrastructurally. Thus, the tumor was diagnosed as a chordoma. The literature pertaining to intracranial chordoma in early childhood is reviewed. Rapid growth and distant metastases may occur in chordomas at a young age.
Accessory Nerve Neurinoma Manifesting with Typical Jugular Foramen Syndrome
Authors: Iwasaki Kouiti , Kondo Akinori
Published: April 2011

A case of neurinoma arising from the accessory nerve is reported. The tumor was small and located entirely within the jugular foramen: the patient sought treatment for a jugular foramen syndrome. The lesion was visualized only on magnetic resonance imaging, and surgery confirmed that it originated from a cranial root of the accessory nerve. There have been no previous reports of a small, accessory neurinoma that is confined entirely to the jugular foramen, appearing with a typical jugular foramen syndrome.
Optimum Position for an Antisiphon Device in a Cerebrospinal Fluid Shunt System
Authors: Tokoro Kazuhiko , Chiba Yasuhiro
Published: April 2011

The effects on shunt flow from the position of an antisiphon device (ASD) and from changes in posture in hydrocephalic patients were examined. Fifty patients with hydrocephalus (including 36 with normal pressure hydrocephalus) were investigated, using quantitative radionuclide shuntography (99mtechnetium-pertcchnetate) in the supine, sitting, and standing positions. The types of shunt valve used were as follows: Mishler dual chamber low pressure without ASD (16 cases), with ASD 40 cm below the level of the foramen of Monro (three cases), and with ASD 10 cm below the level of the foramen of Monro (12 cases); low pressure with integral ASD (14 cases); and medium pressure with integral ASD (five cases). In patients with a low pressure valve without ASD, shunt flow was least in the supine position (0.0011 ml/min) but increased significantly in the sitting position (0.4381 ml/min, P < 0.001) because of the siphon effect. Conversely, in patients with a low pressure valve with integral ASD, shunt flow was maximal in the supine position (0.1056 ml/min) and decreased significantly in the sitting position (0.0017 ml/min, P < 0.001), indicating overfunction of the ASD. Intracranial pressure (ICP) in the supine position increased significantly compared with patients with a low pressure valve without ASD (93.6 and 20.7 mm H2O. respectively, P < 0.01). Intermediate values for shunt flow in the supine and sitting positions (0.0279 and 0.0896 ml/min, respectively) and for ICP (55.8 mm H2O) were obtained with patients with a low pressure valve with the ASD 10 cm below the level of the foramen of Monro P < 0.05). Shunt flow in the supine position correlated negatively with the log of the shunt flow in the sitting position (P < 0.025). Shunt flow in the sitting position correlated positively with the distance between the ASD and the level of the foramen of Monro (P < 0.01). ICP in the supine position correlated negatively with the distance between the ASD and the level of the foramen of Monro (P < 0.025). Shunt flow and ICP are significantly affected by the position of the ASD and the patient's posture. The optimum position for the ASD appears to be 10 cm downstream; the resulting hydrostatic column helps initiate flow when the patient assumes the sitting and standing positions.