bluuebunny/crossref_metadata_2025 huggingface dataset:
Functional Activity within Brain Tumors: A Magnetic Source Imaging Study
Authors: Schiffbauer Hagen , Ferrari Paul , Rowley Howard A. , Berger Mitchel S. , Roberts Timothy P.L.
Published: July 2004

OBJECTIVE

To determine whether low-grade gliomas contain functional cortical activity more often than high-grade gliomas within radiologically defined abnormal tissue.

METHODS

Patients with intra-axial cerebral lesions located in the vicinity of eloquent brain cortex preoperatively underwent magnetic source imaging. A dual 37-channel biomagnetometer was used to perform the imaging. Evoked magnetic fields were analyzed using the single-equivalent dipole representation to ascertain the neuronal source. Stimuli included painless tactile somatosensory stimulation of fingers, toes, and lips and auditory presentation of pure sinusoidal tones.

RESULTS

A retrospective analysis of 106 nonconsecutively treated patients, who had undergone preoperative magnetic source imaging between February 1996 and December 1999, revealed that 24.5% of the patients had been at risk for neurological deficits, because functionally active tissue was located within or at the border of the tumor. Functional activity was found within the radiologically defined lesion in 18% of Grade 2 tumors, in 17% of Grade 3 tumors, and in 8% of Grade 4 tumors.

CONCLUSION

The results confirm that, regardless of tumor grade, intra-axial brain tumors may involve or directly border on functional cortex. The degree of involvement of functionally viable cortex appeared greater for low-grade tumors than for high-grade lesions. On the other hand, high-grade lesions were more likely to be associated with functional cortex at their margins or within peritumoral edema. To safely maximize tumor resection, preoperative functional imaging and intraoperative electrophysiological mapping of the cerebral cortex and the white matter tracts are deemed necessary.
A Review of Size and Location of Ruptured Intracranial Aneurysms
Authors: Forget Thomas R. , Benitez Ronald , Veznedaroglu Erol , Sharan Ashwini , Mitchell William , Silva Marco , Rosenwasser Robert H.
Published: July 2004

OBJECTIVE

To review our experience and examine the size at which aneurysms ruptured in our patient population.

METHODS

Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed.

RESULTS

Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture.

CONCLUSION

We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone.
Remote Cerebellar Hemorrhage after Supratentorial Surgery
Authors: Friedman Jonathan A. , Piepgras David G. , Duke Derek A. , McClelland Robyn L. , Bechtle Perry S. , Maher Cormac O. , Morita Akio , Perkins William J. , Parisi Joseph E. , Brown Robert D.
Published: July 2004

OBJECTIVE

Remote cerebellar hemorrhage (RCH) is an infrequent and poorly understood complication of supratentorial neurosurgical procedures. We retrospectively compared 42 patients who experienced RCH with a case-matched control cohort, to delineate risk factors associated with the occurrence of this complication.

METHODS

Between 1988 and 2000, 42 patients experienced RCH after supratentorial neurosurgical procedures at our institution. Diagnoses were made on the basis of postoperative computed tomographic or magnetic resonance imaging findings in all cases. The medical records for these patients were reviewed and compared with those for a control cohort of 43 patients, matched for age, sex, surgical lesion, and type of craniotomy, who were treated during the same period.

RESULTS

RCH most commonly occurred after frontotemporal craniotomies for unruptured aneurysm repair or temporal lobectomy and was frequently an incidental finding on postoperative computed tomographic scans. However, some cases of RCH were associated with significant morbidity, and two patients died. Preoperative aspirin use and elevated intraoperative systolic blood pressure were significantly associated with RCH (P = 0.026 and P = 0.036, respectively). Pathological findings for two cases demonstrated hemorrhagic infarctions in both.

CONCLUSION

RCH most commonly follows supratentorial neurosurgical procedures, performed with the patient in the supine position, that involve opening of cerebrospinal fluid cisterns or the ventricular system (such as unruptured aneurysm repair or temporal lobectomy). Preoperative aspirin use and moderately elevated intraoperative systolic blood pressure are potentially modifiable risk factors associated with the development of RCH. Although RCH can cause death or major morbidity, most cases are asymptomatic or exhibit a benign course. Cerebellar “sag” as a result of cerebrospinal fluid hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, is the most likely pathophysiological cause of RCH.
Hemifacial Spasm: Intraoperative Electromyographic Monitoring as a Guide for Microvascular Decompression
Authors: Mooij Jan Jakob A. , Mustafa Mustafa K. , van Weerden Tom W.
Published: July 2004

OBJECTIVE

Microvascular decompression is the logical and well-accepted treatment of choice for hemifacial spasm (HFS). In experienced hands, good to excellent results can be obtained. However, sometimes the exact site of the vascular compression is unclear. The aim of this study was to analyze whether intraoperative monitoring by stimulated electromyography of the facial nerve may help to improve the results of vascular decompression for HFS.

METHODS

In a series of 74 patients operated for HFS, the impact of intraoperative facial nerve monitoring on the surgical procedure was analyzed by use of the clinical and operative patient records. The role of this type of monitoring, with assessment of the so-called abnormal muscle response, was broken down into four categories: a guiding, a confirming, an indirect confirming, or an inconclusive role. The relationship between abnormal muscle response monitoring results and final surgical outcome was analyzed.

RESULTS

The overall cure rate was 87.8%, including patients who had previously undergone unsuccessful operations. Complications were minor, and hearing impairment was found in 2.7% of patients. A guiding role of intraoperative monitoring was apparent in 33.8% of patients, and a confirming role was demonstrated in 52.7% of patients, which resulted in a positive contribution of approximately 87% for intraoperative facial monitoring in microvascular decompression for HFS. In patients defined as guiding cases, the cure rate was 92%.

CONCLUSION

This study demonstrates the applicability and usefulness of intraoperative facial nerve monitoring in microvascular decompression operations for HFS.
Inferior Temporal Sulcus as a Site of Corticotomy: Magnetic Resonance Imaging Analysis of Individual Sulcus Patterns
Authors: Miyagi Yasushi , Shima Fumio , Ishido Katsuya , Araki Takehisa , Kamikaseda Kazufumi
Published: July 2004

OBJECTIVE

Transcortical approaches to the inferior horn often result in quadrant hemianopsia attributable to the injury to the optic radiation. The inferior temporal sulcus (ITS) has received little attention as an entrance point for the transsulcal approach. We used the method of detecting the ITS with magnetic resonance imaging (MRI) scans and investigated the sulcus pattern of ITS, its incidence rate, and the availability of the ITS to the corticotomy for selective amygdalohippocampectomy.

METHODS

The sulcus patterns of the ITS of 100 temporal lobes in 50 healthy individuals were classified according to the number of interruptions by gyral bridges, and the localization of the ITS was characterized in relation to the outer surface by means of the surface anatomy scan of MRI.

RESULTS

Most of the ITS was interrupted by one to three gyral bridges (0 bridges, 8%; one bridge, 27%: two bridges, 37%; three bridges, 20%; more than four bridges or no apparent ITS, 8%). When the ITS was present, it was located 15 mm above the orbitotragus line at a point 20 mm anterior to the tragus. The number of gyral bridges was significantly larger in the left temporal lobes than in the right temporal lobes, regardless of the sex of the subject.

CONCLUSION

The ITS was clearly identified in 72% of the temporal lobes by the oblique sagittal view of MRI scans; thus, in such cases, the ITS was considered to be a candidate for an entrance point of a small temporal corticotomy. The preoperative observation of the ITS in relation to the orbitotragus line by means of MRI may improve the planning of the transsulcal approaches to deeply seated mesial temporal lesions, such as hippocampal sclerosis.
Coadministration of Methylprednisolone with Hypertonic Saline Solution Improves Overall Neurological Function and Survival Rates in a Chronic Model of Spinal Cord Injury
Authors: Legos Jeffrey J. , Gritman Kurt R. , Tuma Ronald F. , Young William F.
Published: July 2004

OBJECTIVE

We previously demonstrated that administration of 7.5% hypertonic saline (HS) significantly improved spinal cord blood flow and neurological outcomes after spinal cord injury. The aim of this study was to determine whether hypertonicity would enhance the effects of methylprednisolone (MP), further improving neurological function.

METHODS

Rat spinal cords were compressed for 10 minutes with 50 g of weight, and neurological function was assessed for 28 days, using the Basso-Beattie-Bresnahan locomotor rating scale. The control group received an intravenous injection of isotonic saline (IS) (5 ml/kg). Group 1 received an intravenous injection of 7.5% HS (5 ml/kg). Group 2 received an intravenous injection of MP (30 mg/kg) and IS (5 ml/kg). Group 3 received an intravenous injection of MP (30 mg/kg) administered with 7.5% HS (5 ml/kg).

RESULTS

At 24 hours after spinal cord injury, the combination of MP plus HS provided significant (P < 0.01) neurological improvements, compared with all other treatment groups. At 10 days after injury, the animals that had received MP plus HS exhibited significantly (P < 0.01) higher Basso-Beattie-Bresnahan scores, compared with the MP plus IS and control groups. The median survival time was significantly (P < 0.01) increased for the MP plus HS group (28 d), compared with the MP plus IS group (16 d). Because of the dramatic decrease in survival rates at 28 days after injury, there was a significant (P < 0.01) difference in neurological function only between the MP plus HS group and the control group.

CONCLUSION

The results indicate that the administration of HS may enhance the delivery of MP and prevent immunosuppression, leading to improvements in overall neurological function and survival rates after spinal cord injury.
Cervical Sympathetic Schwannoma: Case Report
Authors: Rosner Michael , Fisher Winfield , Mulligan Lisa
Published: July 2004

OBJECTIVE AND IMPORTANCE

Approximately 20 to 27% of neck masses in the parapharyngeal space may be benign nerve sheath tumors. Cervical sympathetic chain schwannomas or vagal nerve schwannomas are most common. We report a patient with a cervical sympathetic chain schwannoma.

CLINICAL PRESENTATION

The patient was a 47-year-old Caucasian man with a 7-month history of a painless, enlarging right neck mass. No hoarseness or Horner's syndrome was found preoperatively. Formal head and neck examination in the otolaryngology department revealed no vocal cord dysfunction.

INTERVENTION

By use of a standard right carotid incision, a tumor was identified growing from the cervical sympathetic chain posterior to the carotid bifurcation. A gross total resection was performed and a section of the cervical sympathetic chain was sacrificed.

CONCLUSION

Cervical sympathetic chain schwannomas are unusual tumors that require microneurosurgical resection for cure. We discuss the differential diagnosis, evaluation, surgical management, and pathological characteristics of such tumors and review the literature.
Meralgia Paresthetica Occurring 40 Years after Iliac Bone Graft Harvesting: Case Report
Authors: Yamamoto Tetsuji , Nagira Keiko , Kurosaka Masahiro
Published: July 2004

OBJECTIVE AND IMPORTANCE

Meralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve. We describe an unusual case in which meralgia paresthetica occurred many years after iliac bone graft harvesting.

CLINICAL PRESENTATION

An 81-year-old man presented with a 1-year history of pain, dysesthesia, and hypesthesia in the anterolateral aspect of the right thigh. This patient had undergone iliac bone grafting when he sustained a calcaneal fracture 40 years previously. Radiographs and computed tomographic scans of the pelvis revealed a bony excrescence in the anterosuperior iliac spine.

INTERVENTION

The patient underwent neurolysis of the lateral femoral cutaneous nerve and excision of the bony excrescence. At surgery, the nerve was densely adherent to the bony excrescence.

CONCLUSION

The etiology of meralgia paresthetica in this patient is considered to be heterotopic ossification on the anterosuperior iliac spine and pubic symphysis degeneration. A significant relationship between pubic symphysis degeneration with increasing age and meralgia paresthetica has been reported. One should be aware of meralgia paresthetica as a late complication of iliac bone graft harvesting.
Combined Encephaloduroarteriosynangiosis and Bifrontal Encephalogaleo(periosteal)synangiosis in Pediatric Moyamoya Disease
Authors: Kim Seung-Ki , Wang Kyu-Chang , Kim In-One , Lee Dong Soo , Cho Byung-Kyu
Published: July 2004

OBJECTIVE

We compared the surgical results of simple encephaloduroarteriosynangiosis (EDAS) and EDAS with bifrontal encephalogaleo(periosteal)synangiosis for the treatment of pediatric moyamoya disease.

METHODS

Data for 159 children (up to 15 yr of age, 76 boys and 83 girls) who underwent indirect revascularization procedures for the treatment of moyamoya disease between 1987 and 1998 were retrospectively reviewed. Group A patients underwent simple EDAS (n = 67). Group B patients underwent EDAS with bifrontal encephalogaleo(periosteal)synangiosis (n = 92). The surgical results for each group were compared, in terms of clinical outcomes, neuroimaging changes, extent of revascularization evident on angiograms, and hemodynamic changes evident on single-photon emission computed tomographic scans. The average follow-up periods were 45 months for Group A and 22 months for Group B.

RESULTS

The overall clinical outcomes and neuroimaging changes tended to be better for Group B. In terms of single-photon emission computed tomographic changes of the whole brain after surgery, Group B patients exhibited more favorable outcomes than did Group A patients (62 versus 36%, P = 0.003). The surgical results for the anterior cerebral artery territory were significantly better for Group B than for Group A, with respect to outcomes of anterior cerebral artery symptoms (81 versus 40%, P = 0.015), revascularization on angiograms (79 versus 16%, P < 0.001), and hemodynamic changes on single-photon emission computed tomographic scans (70 versus 52%, P = 0.002). The incidences of postoperative infarctions were not significantly different between the two groups.

CONCLUSION

EDAS with bifrontal encephalogaleo(periosteal)synangiosis is a more effective surgical modality for the treatment of pediatric moyamoya disease, compared with simple EDAS, because it covers both the middle cerebral artery and anterior cerebral artery territories of the brain.
Dandy-Walker Complex and Syringomyelia in an Adult: Case Report and Discussion
Authors: Hammond Christopher J. , Chitnavis Bhupal , Penny Christopher C. , Strong Anthony J.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Syringomyelia in association with the Dandy-Walker complex is rare and only 17 cases have been reported, mostly as autopsy findings or incidental reports in series for other conditions. We present a further case report and discuss the possible pathogenetic mechanisms of syrinx formation in the presence of the Dandy-Walker complex. We emphasize the role of foramen magnum obstruction and alteration in cerebrospinal fluid flow dynamics in syrinx formation. The therapeutic importance of disimpaction of the foramen magnum is stressed.

CLINICAL PRESENTATION

A 39-year-old man presented with headache. As a child, he had had cystoperitoneal and ventriculoperitoneal shunts inserted for hydrocephalus in association with the Dandy-Walker complex. On examination, the patient had limited upgaze but was otherwise normal. Magnetic resonance imaging revealed a large cervicothoracic syrinx and a Dandy-Walker cyst obstructing the foramen magnum.

INTERVENTION

The cystoperitoneal shunt was revised. The patient's headaches resolved, and follow-up imaging demonstrated resolution of the syrinx and disimpaction of the foramen magnum.

CONCLUSION

Disimpaction of the foramen magnum can resolve syringomyelia in patients with the Dandy-Walker complex. This can be achieved by a shunt procedure or by formal foramen magnum decompression. The rarity of the association between the Dandy-Walker complex and syringomyelia prevents firm conclusions from being made regarding the best management strategy for this condition.
Internal Carotid-Inferior Petrosal Sinus Fistula Complicating Foramen Ovale Telemetry: Successful Treatment with Detachable Coils: Case Report and Review
Authors: Marshman Laurence A.G. , Connor Steven , Polkey Charles E.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Iatrogenic internal carotid artery-cavernous sinus fistula complicating percutaneous foramen ovale (FO) instrumentation (e.g., retrogasserian rhizotomy for trigeminal neuralgia) has been reported in only four patients to date. To our knowledge, no case of fistula has previously been reported either to complicate FO telemetry or to involve the inferior petrosal sinus (IPS); moreover, most patients have presented within 48 hours. We present a case of internal carotid artery-IPS fistula that complicated FO telemetry in which the clinical syndrome was delayed by 4 weeks.

CLINICAL PRESENTATION

Four weeks after undergoing bilateral FO telemetry during Phase 2 investigations for surgery for epilepsy, a 37-year-old man suddenly developed a painful bilateral pupil-sparing oculomotor palsy, poor visual acuity, proptosis, conjunctival suffusion, and an audible bruit over the right frontotemporal region.

INTERVENTION

Cerebral angiography demonstrated a high-flow arteriovenous fistula between the junction of the petrous and laceral portions of the right internal carotid artery and right IPS, with rapid filling of both cavernous sinuses. Successful obliteration was obtained with Guglielmi detachable coils, followed by complete resolution of the bilateral ocular abnormality.

CONCLUSION

This is the first reported case of iatrogenic fistula formation to either involve the IPS or to complicate FO telemetry. In addition, symptomatology was anomalously delayed. This case highlights the importance of noting FO anatomic asymmetries before FO instrumentation and of routinely inquiring for “swooshing” noises after electrode withdrawal.
Intravascular Graft Stent Treatment of a Ruptured Fusiform Dissecting Aneurysm of the Intracranial Vertebral Artery: Technical Case Report
Authors: Chiaradio Juan Carlos , Guzman Luis , Padilla Lucio , Chiaradio Maria Paula
Published: July 2004

OBJECTIVE AND IMPORTANCE

An innovative stenting technique to treat a difficult case of a fusiform aneurysm of the intracranial vertebral artery (VA), with restoration of the vessel lumen, is described.

CLINICAL PRESENTATION

A 58-year-old patient experienced sudden pain in the upper cervical spine, followed by a severe headache. He underwent computed tomographic evaluation, which demonstrated subarachnoid hemorrhage in the prepontine cistern. A fusiform aneurysm of the distal right VA and critical stenosis of the left VA were detected in digital subtraction angiograms. The patient experienced a new subarachnoid hemorrhaging episode, and urgent endovascular treatment was planned.

INTERVENTION

The patient underwent angioplastic and stenting procedures in the left VA, with good results. Forty-eight hours later, an endovascular procedure was performed to treat the right VA aneurysm. We decided to use a graft stent (Jostent graft stent; Jomed, Conroe, TX) instead of a balloon to preserve the arterial lumen. The complete procedure was well tolerated by the patient, and he was discharged, without symptoms, 48 hours later.

CONCLUSION

The patient was discharged, without neurological deficits, 48 hours after completion of the endovascular procedure, with clopidogrel (75 mg/d) and aspirin (325 mg/d) therapy. This treatment was discontinued after 4 weeks. According to our search of the medical literature, this is the first clinical case in which an intracranial fusiform aneurysm was permanently sealed with a graft stent.
Repair of a Tear at the Base of a Blister-like Aneurysm with Suturing and an Encircling Clip: Technical Note
Authors: Yanaka Kiyoyuki , Meguro Kotoo , Nose Tadao
Published: July 2004

OBJECTIVE

An aneurysm can produce large defects in the parent vessel if the aneurysm tears at the neck of the vessel. The authors present a technique to repair a tear at the base of a blister-like aneurysm encountered during microsurgical clipping of an anterior wall aneurysm of the internal carotid artery.

METHODS

The repair technique involved suturing and covering the aneurysm with an encircling aneurysm clip. A large tear had destroyed the vessel's tubular structure, and repair was not sufficient using an encircling clip alone. Two microsuture stitches were placed on the tear, so that a split artery re-formed a tubular structure. The lesion was then covered with Surgicel (Ethicon, Inc., Somerville, NJ) and fibrin glue. When the Surgicel and fibrin glue were applied, the temporary clip on the distal internal carotid artery was removed for a moment, allowing retrograde blood flow to provide the counterforce necessary to maintain the vessel's tubular structure. An encircling clip was then applied to cover the entire circumference of the lesion.

RESULTS

This method required only a short occlusion time for arterial repair, thus helping avoid ischemic complications. The patient awoke with transient hemiparesis, but recovery was prompt.

CONCLUSION

This technique is useful for repairing an aneurysmal tear at its base, especially if the tear is large.
Surgical Simulation Software for Insertion of Pedicle Screws
Authors: Eftekhar Behzad , Ghodsi Mohammad , Ketabchi Ebrahim , Rasaee Saman
Published: July 2004

OBJECTIVE

As the first step toward finding noninvasive alternatives to the traditional methods of surgical training, we have developed a small, stand-alone computer program that simulates insertion of pedicle screws in different spinal vertebrae (T10–L5).

METHODS

We used Delphi 5.0 and DirectX 7.0 extension for Microsoft Windows. This is a stand-alone and portable program.

RESULTS

The program can run on most personal computers. It provides the trainee with visual feedback during practice of the technique. At present, it uses predefined three-dimensional images of the vertebrae, but we are attempting to adapt the program to three-dimensional objects based on real computed tomographic scans of the patients. The program can be downloaded at no cost from the web site: www.tums.ac.ir/downloads

CONCLUSION

As a preliminary work, it requires further development, particularly toward better visual, auditory, and even proprioceptive feedback and use of the individual patient's data.
Anterior Cervical Plating Enhances Arthrodesis after Discectomy and Fusion with Cortical Allograft
Authors: Kaiser Michael G. , Haid Regis W. , Subach Brian R. , Barnes Bryan , Rodts Gerald E.
Published: July 2004

OBJECTIVE

Anterior plate fixation has gained widespread acceptance for the treatment of cervical spondylosis, theoretically enhancing the rate of arthrodesis. There are few studies comparing fusion rates after anterior cervical discectomy and fusion (ACDF) with and without a plate. The purpose of this study was to evaluate the efficacy of anterior cervical plating for fusion enhancement after one- and two-level ACDF with cortical allograft.

METHODS

A retrospective review was performed with 251 patients who underwent one- or two-level ACDF with cortical allograft and plate stabilization between 1993 and 1999. An independent surgeon reviewer determined fusion status and complications. A successful fusion was defined by the absence of lucency around the graft, evidence of bridging bone between the endplate and the graft, and the absence of movement on dynamic imaging scans. Follow-up data, ranging from 9 months to 3.6 years, were available for 233 patients. A control group of 289 patients who underwent ACDF without plating was described in a previously published report by the senior author (RWH). Therefore, a total of 540 patients were evaluated for determination of the efficacy of anterior cervical plating with cortical allograft bone. Statistical significance was determined by χ2 test.

RESULTS

The fusion rates for one- and two-level ACDF with anterior fixation were 96 and 91%, respectively, compared with 90 and 72% for one- and two-level ACDF without anterior fixation. The observed increases in fusion rates for both one- and two-level procedures proved to be statistically significant (P < 0.05). There were no recorded infectious, neurological, or graft-related complications among the cohort treated with anterior cervical plating. Compared with the results for the cohort treated without anterior cervical plates, there was a statistically significant decrease in the graft-related complication rate with the application of plates (P < 0.001). Two patients who received plates were noted to have adjacent-segment degenerative changes that required surgical intervention. No hardware fractures were noted; however, one patient was noted to have a single displaced screw, without clinical consequences.

CONCLUSION

The use of anterior cervical plating after one- and two-level ACDF with allograft cortical bone significantly enhanced arthrodesis. The improved fusion rate and negligible complication rate associated with anterior cervical plating are compelling factors justifying its use in the treatment of cervical spondylosis.
Follow-up Angiography of Intracranial Aneurysms Treated with Endovascular Placement of Guglielmi Detachable Coils
Authors: Thornton John , Debrun Gerard M. , Aletich Victor A. , Bashir Qasim , Charbel Fady T. , Ausman James
Published: July 2004

OBJECTIVE

The success of endovascular treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs) is dependent on the long-term exclusion of the aneurysm from the circulation. We reviewed our experience with the long-term angiographic follow-up monitoring of aneurysms that had been treated with GDCs.

METHODS

All patients whose aneurysms had been treated with GDCs between January 1995 and August 1999 and who subsequently underwent follow-up angiography at 6 months or more were included in this study. We reviewed all of the angiographic findings, to determine the percentage of aneurysm occlusion on the initial angiograms and on the last available follow-up angiograms. The categories of aneurysm occlusion used were 100%, ≥95%, and less than 95% occlusion.

RESULTS

One hundred thirty patients with 141 aneurysms underwent 143 endovascular coiling procedures and subsequently underwent angiographic follow-up monitoring of 6 months or more. There were 102 female and 28 male patients. The mean angiographic follow-up period was 16.7 months (range, 6–62 mo). The initial rates of occlusion were 100% for 56 aneurysms (39%), ≥95% for 65 aneurysms (46%), and less than 95% for 22 aneurysms (15%). Recurrence of one aneurysm (1.8%) was observed. Of the 87 aneurysms that were incompletely occluded initially, there was progressive thrombosis in 40 (46%), stable neck remnants in 23 (26%), and enlargement of the residual neck in 24 (28%). The final occlusion rates, determined on the last available angiograms, were 100% for 88 aneurysms (61%), ≥95% for 31 aneurysms (22%), and less than 95% for 24 aneurysms (17%). No patient experienced repeat or new subarachnoid hemorrhage more than 6 months after the initial treatment.

CONCLUSION

Late angiographic follow-up monitoring of aneurysms that have been treated with GDCs demonstrates the durability of the treatment. Aneurysms with large residual neck remnants were subjected to further treatment, whereas aneurysms with small residual neck remnants remain under observation.
Traumatic Subarachnoid Hemorrhage: Demographic and Clinical Study of 750 Patients from the European Brain Injury Consortium Survey of Head Injuries
Authors: Servadei Franco , Murray Gordon D. , Teasdale Graham M. , Dearden Mark , Iannotti Fausto , Lapierre Françoise , Maas Andrew J.R. , Karimi Abbi , Ohman Juha , Persson Lennart , Stocchetti Nino , Trojanowski Tomasz , Unterberg Andy
Published: July 2004

OBJECTIVE

Previous reports identified the presence of traumatic subarachnoid hemorrhage (tSAH) on admission computed tomographic (CT) scans as an independent prognostic factor in worsening outcomes. The mechanism underlying the link between tSAH and prognosis has not been clarified. The aim of this study was to investigate the association between CT evidence of tSAH and outcomes after moderate or severe head injuries.

METHODS

In a survey organized by the European Brain Injury Consortium, data on initial severity, treatment, and subsequent outcomes were prospectively collected for 1005 patients with moderate or severe head injuries who were admitted to one of the 67 European neurosurgical units during a 3-month period in 1995. The CT findings were classified according to the Traumatic Coma Data Bank classification system, and the presence or absence of tSAH was recorded separately in the initial CT scan forms.

RESULTS

Complete data on early clinical features, CT findings, and outcomes at 6 months were available for 750 patients, of whom 41% exhibited evidence of tSAH on admission CT scans. There was a strong, highly statistically significant association between the presence of tSAH and poor outcomes. In fact, 41% of patients without tSAH achieved the level of good recovery, whereas only 15% of patients with tSAH achieved this outcome. Patients with tSAH were significantly older (median age, 43 yr; standard deviation, 21.1 yr) than those without tSAH (median age, 32 yr; standard deviation, 19.5 yr), and there was a significant tendency for patients with tSAH to exhibit lower Glasgow Coma Scale scores at the time of admission. A logistic regression analysis of favorable/unfavorable outcomes demonstrated that there was still a very strong association between tSAH and outcomes after simultaneous adjustment for age, Glasgow Coma Scale Motor Scores, and admission CT findings (odds ratio, 2.49; 95% confidence interval, 1.74–3.55;P < 0.001). Comparison of the time courses for 164 patients with early (within 14 d after injury) deaths demonstrated very similar patterns, with an early peak and a subsequent decline; there was no evidence of a delayed increase in mortality rates for either group of patients (with or without tSAH).

CONCLUSION

These findings for an unselected series of patients confirm previous reports of the adverse prognostic significance of tSAH. The data support the view that death among patients with tSAH is related to the severity of the initial mechanical damage, rather than to the effects of delayed vasospasm and secondary ischemic brain damage.
Cerebral Revascularization for Aneurysms and Tumors
Authors: Sekhar Laligam N. , Kalavakonda Chandrasekar
Published: July 2004

OBJECTIVE

To discuss the indications, techniques, pitfalls, complication avoidance, and management of cerebral revascularization techniques for the treatment of aneurysms and cranial base tumors.

METHODS

The indications for cerebral revascularization procedures included microsurgical occlusion of a parent vessel during the treatment of aneurysms and occlusion of a major vessel during the treatment of basal tumors. The techniques discussed include arterial patch grafting, end-to-end anastomosis, side-to-side anastomosis, arterial interposition grafting, and extracranial-to-intracranial bypass grafting, using radial artery grafts or saphenous vein grafts.

RESULTS

During the 15-year period between 1985 and 2000, the senior author performed 24 radial artery grafts, 105 saphenous vein grafts, and 8 other revascularization procedures, among 50 patients with aneurysms and 83 patients with cranial base tumors. The overall patency rate was 95.6%. Twenty-three patients experienced a cerebral infarction; among those patients, 17 (12.5%) exhibited symptoms but the majority demonstrated considerable recovery during the follow-up period. One hundred one patients recovered to an excellent (Glasgow Outcome Scale score of 5) or good (Glasgow Outcome Scale score of 4) condition. Fifteen patients died as a result of recurrence or progression of tumors during the follow-up period. There were five perioperative deaths. For the last 35 patients, the surgical mortality rate was 0%, with all patients returning to an excellent or good condition.

CONCLUSION

Although highly specialized, these sophisticated cerebral revascularization techniques should be learned and practiced by all neurosurgeons who wish to microsurgically treat intracranial aneurysms or cranial base tumors.
Hemihypoglossal Nerve Transfer in Brachial Plexus Repair: Technique and Results
Authors: Ferraresi Stefano , Garozzo Debora , Ravenni Roberta , Dainese Rinaldo , De Grandis Domenico , Buffatti Paolo
Published: July 2004

OBJECTIVE

In multiple avulsions of the brachial plexus, the search for extraplexal donor nerves in the hope of achieving motor neurotization is a major goal. We explored the possibility of using the hypoglossal nerve as a transfer point to reanimate muscles in the upper limb.

METHODS

The hypoglossal nerve was used as a donor nerve for neurotization in seven patients with avulsive injuries of the brachial plexus. The surgical technique—an end-to-side microsuture using approximately half of the nerve fascicles—is basically the same as that used in the hypoglossal nerve-facial nerve jump graft, which is a well-known technique in facial nerve reanimation. The recipient nerves were the suprascapular (two patients), the musculocutaneous (one patient), the posterior division of the upper trunk (two patients), and the medial contribution to the median nerve (two patients).

RESULTS

In spite of a connection documented by electromyography and selective activation in three of seven patients, the functional results in our patients were extremely disappointing: no patient had an outcome better than M1 in the reinnervated muscles.

CONCLUSION

This technique was of no help to the patients and thus has been abandoned at our institution.
Fluorodeoxyglucose and Methionine Uptake in Lhermitte-Duclos Disease: Case Report
Authors: Pirotte Benoit , Goldman Serge , Baleriaux Danielle , Brotchi Jacques
Published: July 2004

OBJECTIVE AND IMPORTANCE

Lhermitte-Duclos disease (LDD) represents a focally indolent dysplastic growth of the cerebellar cortex. The 106 cases reported previously in the literature show an extremely slow evolution, and the operative indications and techniques for this disease entity are still controversial. The authors present the first case of LDD studied with positron emission tomography using the labeled tracers [18F]2-fluoro-2-deoxy-d-glucose ([18F]FDG) and 11C-labeled methionine ([11C]Met) to study the glucose and protein metabolism of the lesion.

CLINICAL PRESENTATION

A 40-year-old woman suddenly became unconscious then completely recovered 5 minutes later. Magnetic resonance imaging of her brain showed a well-delineated 10 × 5-cm abnormal area with enlarged cerebellar folia, which led to the diagnosis of LDD.

TECHNIQUE

On positron emission tomographic scans, [18F]FDG and [11C]Met uptake in the normal cerebral and cerebellar cortex appeared higher than normal, reaching levels found in patients with primary malignant brain tumors. Moreover, the uptake of both tracers was heterogeneous, in contrast to the homogeneous uptake visualized on magnetic resonance imaging scans. The areas of greatest [11C]Met and [18F]FDG uptake were discordant. Some areas of greater than normal [18F]FDG uptake corresponded to areas of moderate or low [11C]Met uptake. Because of the important mass effect in the posterior fossa, total surgical resection was performed. A histological examination confirmed the diagnosis of LDD.

CONCLUSION

This first reported metabolic study of LDD supports the view that LDD is an active and evolving disease. These data should prompt reevaluation of the indications for surgery in patients with this disease as well as the timing of surgery.
Construction of a New Posterior Communicating Artery in a Patient with Poor Posterior Fossa Circulation: Technical Case Report
Authors: Tulleken Cornelis A.F. , Streefkerk Henk Johan N. , van der Zwan Albert
Published: July 2004

OBJECTIVE AND IMPORTANCE

The carotid and the vertebrobasilar circulation were connected, effectively creating a new posterior communicating artery (PComA). The excimer laser-assisted nonocclusive anastomosis technique is a new anastomosis technique whereby formerly untreatable patients may be treated with an intracranial artery-to-intracranial artery bypass procedure. This report is the first one in which an angiographically proved patent internal carotid artery-posterior cerebral artery segment P1 bypass is presented.

CLINICAL PRESENTATION

Our patient presented with repeated episodes of vertebrobasilar ischemia because of vertebral artery occlusion and stenosis.

INTERVENTION

An internal carotid artery-posterior cerebral artery segment P1 bypass procedure was performed. Because the patient experienced transient ischemia in the left cerebral hemisphere at the end of postoperative angiography procedure, no radiological intervention was performed, and the patient refused to undergo a new radiological intervention at a later stage.

TECHNIQUES

Both anastomoses were made using the excimer laser-assisted nonocclusive anastomosis technique.

CONCLUSION

Intraoperative flowmetry was performed using an ultrasound flowmeter, which disclosed blood flow of 35 ml/min through the bypass. We hope that this new PComA suffices to protect the patient from infarction in the territory of the vertebrobasilar circulation.
Persistent Iliac Crest Donor Site Pain: Independent Outcome Assessment
Authors: Heary Robert F. , Schlenk Richard P. , Sacchieri Theresa A. , Barone Dean , Brotea Cristian
Published: July 2004

OBJECTIVE:

This study objectively defines the incidence of donor site pain in an independent outcome analysis. In addition, this study identifies the significant discrepancies that are observed when independent outcome assessment results are compared with the incidences determined by review of the operating surgeon's documented findings.

METHODS:

A review of patients who underwent iliac bone graft harvesting by a single neurosurgeon was conducted. The presence of iliac crest donor site pain, at a time remote from surgery, as determined by specific questioning and recorded in the neurosurgeon's written evaluation was compared with independent assessment findings obtained in structured telephone questionnaire interviews. During a 4-year period, 105 patients met the inclusion criteria. Both the operating surgeon's and independent interviewer's follow-up evaluations were completed for all study patients. Pain was classified into three categories, i.e., no pain, acceptable pain, or unacceptable pain. Patients were also asked to assess the severity of their donor site pain by using a visual analog scale. Statistical analyses comparing the incidences of iliac crest donor site pain in the operating surgeon's evaluations and the independent assessments were performed.

RESULTS:

When evaluated at a time remote from surgery, the true incidence of iliac crest donor site pain after graft harvest procedures (34%) was significantly greater than previously appreciated by the neurosurgeon (8%). Although occasional or mild pain was observed for 31% of patients, only 3% of all patients experienced unacceptable pain.

CONCLUSION:

Independent outcome assessment values should be provided to patients in preoperative discussions regarding donor site morbidity. Objective outcome analysis, based on independent observations, is crucial for the most accurate interpretation of perceptions of iliac crest donor site pain.
Intraventricular Infusion of Vascular Endothelial Growth Factor Promotes Cerebral Angiogenesis with Minimal Brain Edema
Authors: Harrigan Mark R. , Ennis Steven R. , Masada Tetsuya , Keep Richard F.
Published: July 2004

OBJECTIVE:

Therapeutic cerebral angiogenesis, i.e., using angiogenic factors to enhance collateral vessel formation within the central nervous system, is a potential method for cerebral revascularization. Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen that also increases capillary permeability, particularly in ischemic tissue. The purpose of this study was to assess the angiogenic and capillary permeability effects of chronic intraventricular infusion of exogenous VEGF in nonischemic brain tissue, because many patients with impaired cerebrovascular reserve do not exhibit chronic cerebral ischemia.

METHODS:

Recombinant human VEGF165 was infused into the right lateral ventricle of rats at a rate of 1 μl/h for 7 days, at concentrations of 1 to 25 μg/ml, with osmotic minipumps. Control animals received vehicle only. Vessels were identified in laminin immunohistochemical analyses. Capillary permeability and brain edema were assessed with Evans blue extravasation, [3H]inulin permeability, and brain water content measurements.

RESULTS:

Vessel density was dose-dependently increased by VEGF165 infusions, with significant increases occurring in animals treated with 5 or 25 μg/ml, compared with control animals (P < 0.01). Significant enlargement of the lateral ventricles was observed for the highest-dose group but not for animals treated with other doses. Capillary permeability was assessed in animals treated with a dose of 5 μg/ml. An increase in capillary permeability in the diencephalon was identified with Evans blue extravasation and [3H]inulin permeability assessments; however, the brain water content was not significantly increased.

CONCLUSION:

Chronic intraventricular infusions of VEGF165 increased vascular density in a dose-dependent manner. There seems to be a therapeutic window, because infusion of VEGF165 at a concentration of 5 μg/ml resulted in a significant increase in vessel density with minimal associated brain edema and no ventriculomegaly.
De Novo Development of a Cavernous Malformation of the Brain: Significance of Factors with Paracrine and Endocrine Activity: Case Report
Authors: Lüdemann Wolf , Ellerkamp Verena , Stan Alexandru C. , Hussein Sami
Published: July 2004

OBJECTIVE AND IMPORTANCE:

De novo development of cavernous malformations is poorly documented in the literature.

CLINICAL PRESENTATION:

We report the case of a 37-year old woman with de novo growth of a cavernous malformation of the brain. The patient presented with a 12-month history of nonspecific headaches and paresthesias after two pregnancies. After computed tomographic scanning of the cranium, a cavernous malformation located parieto-occipitally within the right brain hemisphere was diagnosed. Control magnetic resonance imaging scans obtained 12 years earlier did not reveal a similar lesion.

INTERVENTION:

Surgery was performed, and the specimen was analyzed histopathologically.

CONCLUSION:

Immunohistochemistry demonstrated lack of expression of pituitary hormones as well as of androgen, estrogen, and progesterone hormone receptors. However, strong expression of both basic fibroblast growth factor and CD44 was detected in surrounding tissue, and expression of CD44 was noted within the matrix of the cavernous malformation.
New Trends in Neuromodulation for the Management of Neuropathic Pain
Authors: Aló Kenneth M. , Holsheimer Jan
Published: July 2004

SINCE ITS FIRST application in 1967, the methodology and technology of spinal cord stimulation for the management of chronic, intractable pain have evolved continuously. Despite these developments and improved knowledge of the effects of spinal anatomy and epidural contact configuration on paresthesia coverage, the clinical results of spinal cord stimulation—particularly the long-term effects—are still unsatisfactory in many patients. This dissatisfaction has come primarily from the failure of single-electrode configurations to provide consistent paresthesia coverage of the entire painful area. Therefore, new approaches were developed during the late 1990s that attempted to selectively cover one or more dermatomes with paresthesia as well as to provide sequential stimulation of different anatomic sites. These approaches have been applied both intraspinally and extraspinally by stimulating either the spinal nerves or the dorsal columns. To target parts of the latter, different methods have been developed and tested using either two-dimensional contact configurations or electronic field steering. These developments hold promise for improving long-term outcomes as well as increasing the number of pain conditions that can be treated with neuromodulation therapy. In this review, the history, theoretical basis, and evolution of these methodologies, as well as the ways in which they represent new trends in neuromodulation, are discussed.