bluuebunny/crossref_metadata_2025 huggingface dataset:
Neurophysiological criteria for intraoperative prediction of pure motor hemiplegia during aneurysm surgery
Authors: Szelényi Andrea , de Camargo Adauri Bueno , Flamm Eugene , Deletis Vedran
Published: May 2009

✓ The value of motor evoked potentials (MEPs) as an intraoperative neurophysiological monitoring tool for detecting selective subcortical ischemia of the motor pathways during intracerebral aneurysm repair is described and the use of such measures to predict postoperative motor status is discussed.

The authors present the case of a 64-year-old woman in whom there was an incidental finding of two right middle cerebral artery (MCA) aneurysms. During the aneurysm clipping procedure, an intraoperative MEP loss in the left abductor pollicis brevis and tibial anterior muscles occurred during an attempt at permanent clip placement. There were no concurrent changes in somatosensory evoked potentials. Postoperatively, the patient demonstrated a left hemiplegia with intact sensation. A computerized tomography scan revealed an infarct in the anterior division of the MCA territory, including the posterior limb of the internal capsule.

In this patient, intraoperative neurophysiological monitoring with MEPs has been shown to be a sensitive tool for indicating subcortical ischemia affecting selective motor pathways in the internal capsule. Therefore, intraoperative loss of MEPs can be used to predict postoperative motor deficits.
Stereotactic radiotherapy for the treatment of lymphocytic hypophysitis
Authors: Selch Michael T. , DeSalles Antonio A. F. , Kelly Daniel F. , Frighetto Leonardo , Vinters Harry V. , Cabatan-Awang Cynthia , Wallace Robert E. , Solberg Timothy D.
Published: May 2009

✓ Lymphocytic hypophysitis is a rare inflammatory disorder of the pituitary gland. Standard therapy consists of transsphenoidal resection or oral administration of corticosteroid medications. Two patients with symptomatic lymphocytic hypophysitis, which recurred after standard therapy, were treated with low-dose stereotactic radiotherapy. On imaging studies both lesions demonstrated a response to radiation and each patient experienced relief of symptoms. There has been no adverse sequela of the radiation treatment.

The authors conclude that stereotactic radiotherapy represents an effective, noninvasive treatment option for patients with lymphocytic hypophysitis, particularly if the disease is recurrent after surgery or resistant to corticosteroid medications.
Fluorescence-guided resection of glioblastoma multiforme by using high-dose fluorescein sodium
Authors: Shinoda Jun , Yano Hirohito , Yoshimura Shin-Ichi , Okumura Ayumi , Kaku Yasuhiko , Iwama Toru , Sakai Noboru
Published: May 2009

✓ The authors have recently performed a fluorescence-guided tumor resection procedure by using high-dose fluorescein sodium without any special surgical microscopes for the intraoperative visualization of glioblastoma multiforme (GBM), and they report on the actual procedure and clinicopathological findings.

Thirty-two patients with GBMs underwent tumor resection during which this fluorescence-guided procedure was used. Fluorescein sodium (20 mg/kg) was intravenously injected after dural opening at the craniotomy site. The tumor was stained almost homogeneously yellow and the color was intense enough to be readily perceived for resection. The center of the solid lesion was stained a deep yellow and surrounded by a transition zone that was faintly stained. The colored lesion was clearly distinguishable from the unstained zone outside the GBM, particularly in the white matter. Both the deeply and faintly stained regions included endothelial proliferation and dense tumor cells. In the unstained region, less dense tumor cells were consistently revealed; however, no endothelial proliferation could be seen. Grosstotal resection (GTR) was successful in 84.4% of the patients who received an injection of fluorescein sodium, which accounted for 100% of those in whom all the visible yellow color (both the deeply and faintly stained regions) was judged to have been resected during operation. Gross-total resection was performed in 100% of the patients who underwent the fluorescence-guided procedure and assigned to Stage I, a GBM stage in which, as a therapeutic policy, the tumor should be resected as radically as possible. The GTR rates in patients who received fluorescein sodium were significantly higher than those in patients who did not (73 patients with GBMs who underwent tumor resection without the fluorescence-guided procedure). Although the extent of surgery was revealed to be one of the significant and independent prognostic factors for GBM, the fluorescein sodium—guided resection procedure was not a significant or independent prognostic factor in this series.

This surgical procedure does not require any special surgical microscopic equipment and is simple, safe, useful, readily accomplished, and universally available for resection of GBMs. Its efficacy simplifies the surgical procedure of navigating the stained lesion from the unstained area to achieve GTR of GBMs, which can be demonstrated on magnetic resonance images.
A device for cooling localized regions of human cerebral cortex
Authors: Bakken Hans E. , Kawasaki Hiroto , Oya Hiroyuki , Greenlee Jeremy D. W. , Howard Matthew A.
Published: May 2009

✓ Neurosurgeons use invasive mapping methods during surgery to understand the functional neuroanatomy of patients. Electrical stimulation methods are used routinely for the temporary disruption of focal regions of cerebral cortex so that the surgeon may infer the functional role of the brain site being stimulated. Although it is an efficient and useful method, modes of electrical stimulation mapping have significant limitations. Neuroscientists use focal cooling to effect a more controlled disruption of cortical functions in experimental animals, and in this report, the authors describe their experience using a device to achieve this same objective in patients undergoing neurosurgery. The cooling probe consists of a stainless steel chamber with thermocouples and electroencephalography (EEG) recording contacts. Active cooling is achieved by infusing chilled saline into the chamber when the cooling probe is positioned on the pial surface. Experiments were performed in 18 patients. Temperature gradient measurements indicate that the entire thickness of gray matter under the probe is cooled to temperatures that disrupt local synaptic activity. Statistically significant changes in spontaneous and stimulusevoked EEG activity were consistently observed during cooling, providing clear evidence of reversible disruption of physiological functions. Preliminary findings during functional mapping of the Broca area demonstrated qualitative differences between the temporary neurological deficits induced by cooling and those caused by electrical stimulation. These findings indicate the safety and utility of the cooling probe as a neurosurgical research tool. Additional rigorously designed studies should be undertaken to correlate the effects of cooling, electrical stimulation, and focal lesioning.
Factors associated with the development of vasospasm after planned surgical treatment of aneurysmal subarachnoid hemorrhage
Authors: Macdonald R. Loch , Rosengart Axel , Huo Dezheng , Karrison Theodore
Published: May 2009

Object. The goal of this study was to determine factors associated with the development of symptomatic vasospasm among patients with aneurysmal subarachnoid hemorrhage (SAH) who participated in the randomized, double-blind, placebo-controlled trials of tirilazad between 1991 and 1997.

Methods. Data obtained from 3567 patients entered into trials of tirilazad were analyzed using uni- and multivariate logistic regression to determine factors that predict the development of symptomatic vasospasm. Symptomatic vasospasm was defined by clinical criteria accompanied by laboratory- and radiologically determined exclusion of other causes of neurological deterioration. Transcranial Doppler ultrasonographic and/or angiographic confirmation was not required. In these patients, the aneurysms were scheduled to be treated surgically, and no patient undergoing endovascular treatment was included. A multivariate analysis showed that factors significantly associated with vasospasm were age 40 to 59 years, history of hypertension, worse neurological grade, thicker blood clot on the cranial computerized tomography (CT) scan obtained on hospital admission, larger aneurysm size, presence of intraventricular hemorrhage (IVH), prophylactic use of induced hypertension, and not participating in the first European tirilazad study.

Conclusions. Symptomatic vasospasm was associated with the amount of SAH on the CT scan, the presence of IVH, and the patient's neurological grade. The association with patient age may reflect alterations in vessel reactivity associated with age. A history of hypertension may render the brain more susceptible to symptoms from vasospasm. The explanation for the relationships with aneurysm size, use of prophylactic induced hypertension, and the particular study is unclear.
Long-term motor effect of unilateral pallidal stimulation in 26 patients with advanced Parkinson disease
Authors: Visser-Vandewalle Veerle , van der Linden Chris , Temel Yasin , Nieman Fred , Celik Halime , Beuls Emile
Published: May 2009

Object. The aim of this study was to evaluate the long-term effects of unilateral pallidal stimulation on motor function in selected patients with advanced Parkinson disease (PD).

Methods. The authors enrolled 26 patients with idiopathic PD in whom there was an asymmetric distribution of symptoms and, despite optimal pharmocological treatment, severe response fluctuations and/or dyskinesias. After the patient had received a local anesthetic agent, a quadripolar electrode (Medtronic model 3387) was implanted at the side opposite the side affected or, if both sides were affected, the side contralateral to the more affected side. No serious complications occurred. After 3 months, the total Unified PD Rating Scale (UPDRS) Part III score decreased by 50.7% while patients were in the off-medication state (from 26.5 ± 9.2 to 13.1 ± 6.1) and by 55.4% while they were in the on-medication state (from 10.6 ± 6.3 to 4.7 ± 4.4). Only during the on state was the contralateral effect clearly more pronounced. The UPDRS Part IVa score decreased by 75% (from 3.7 ± 2.5 to 0.9 ± 1.1) and the UPDRS Part IVb score by 54.7% (from 3.3 ± 1.3 to 1.5 ± 1.3).

At long-term follow-up review (32.7 ± 10.7 months), there was an 8.3% increase in the UPDRS Part III score while patients were in the off state (from 26.5 ± 9.2 to 28.7 ± 7.6) and a 40.2% increase in this score while patients were in the on state (from 10.6 ± 6.3 to 14.9 ± 5.1). The UPDRS Part IVa score decreased by 28.1% (from 3.7 ± 2.5 to 2.7 ± 2.3) and the UPDRS Part IVb score increased by 3.5% (from 3.3 ± 1.3 to 3.4 ± 1.6).

Conclusions. Based on these unsatisfactory results at long-term review, the authors conclude that unilateral pallidal stimulation is not an effective treatment option for patients with advanced PD.
Selective opening of the blood—brain barrier by a nitric oxide donor and long-term survival in rats with C6 gliomas
Authors: Weyerbrock Astrid , Walbridge Stuart , Pluta Ryszard M. , Saavedra Joseph E. , Keefer Larry K. , Oldfield Edward H.
Published: May 2009

Object. The response of brain tumors to systemic chemotherapy is limited by the blood—tumor barrier (BTB). Nitric oxide (NO) has been implicated in the regulation of vascular permeability and blood flow. The authors evaluated the effects of exogenous NO, which was released from a short-acting NO donor (Proli/NO), and those of NO metabolites on the capillary permeability of tumors and normal brain tissue by using quantitative autoradiography in a C6 glioma model in rats.

Methods. The Proli/NO was infused at a wide dose range (10−2 to 10−12 M) either intravenously or into the internal carotid artery (ICA) and demonstrated substantial tumor-selective increases in blood-brain barrier (BBB) permeability in response to various-sized tracers ([14C]aminoisobutyric acid, [14C]sucrose, [14C]dextran). Internal carotid artery or intravenous administration of sodium nitrite had a comparable effect on BTB permeability. The NO effect on microvascular permeability could be obtained without causing hemodynamic side effects. The effect of NO on the efficacy of carboplatin chemotherapy was investigated in intracerebral C6 gliomas. Simultaneous intravenous infusions of Proli/NO (10−6 M) and carboplatin (20 mg/kg) led to long-term survival in 40% of rats harboring intracerebral C6 gliomas compared with control animals receiving ICA or intravenous infusions of carboplatin, Proli/NO, or vehicle alone. No residual tumor was demonstrated on histological or magnetic resonance imaging studies performed in rats treated with Proli/NO and carboplatin, and no toxicity was observed.

Conclusions. This new approach demonstrated the in vivo efficacy and safety of NO and nitrite in enhancing the delivery of systemically delivered radiolabeled tracers and carboplatin into rat gliomas. The NO-induced tumor-selective BBB disruption and intravenous carboplatin chemotherapy may be more efficacious than current chemotherapy strategies against brain tumors.
Transcriptional expression of survivin and its splice variants in brain tumors in humans
Authors: Yamada Yoshitaka , Kuroiwa Toshihiko , Nakagawa Toshimasa , Kajimoto Yoshinaga , Dohi Takehiko , Azuma Haruhito , Tsuji Motomu , Kami Kazuhiro , Miyatake Shin-Ichi
Published: May 2009

Object. Survivin, one of the apoptosis inhibitor proteins, has been detected in most cancers in humans. In addition, two splice variants (survivin-2B and survivin-ΔEx3) have been identified. The authors investigated the transcription levels of survivin messenger (m)RNA and its splice variants in nine tumor cell lines, including gliomas, and in 25 brain tumor samples, by performing quantitative reverse transcription-polymerase chain reaction. The correlation between transcript expression levels and pathological findings were also analyzed.

Methods. Transcription levels were measured using primer pairs specific for survivin and either of its splice variants and were normalized to the glyceraldehyde 6-phosphate dehydrogenase. Among the tumor cell lines tested, glioblastoma cell lines showed the highest levels of survivin expression. Among brain tumor samples studied, survivin was preferentially expressed in malignant brain tumors and gliomas. The relative expression level of survivin-ΔEx3/survivin was significantly higher in malignant than in benign brain tumor samples. Expression patterns were dominant for survivin-ΔEx3 in malignant brain tumors and dominant for survivin-2B in benign ones. A significant linear correlation between survivin mRNA expression and MIB-1 labeling index was demonstrated in all brain tumor samples.

Conclusions. The authors' results indicate that quantifying the levels of survivin and its splice variants is useful for the prediction of the cell biological malignancy of gliomas, independent of their pathological features.
Induction of an antitumor immunological response by an intratumoral injection of dendritic cells pulsed with genetically engineered Semliki Forest virus to produce interleukin-18 combined with the systemic administration of interleukin-12
Authors: Yamanaka Ryuya , Tsuchiya Naoto , Yajima Naoki , Honma Junpei , Hasegawa Hitoshi , Tanaka Ryuichi , Ramsey Jay , Blaese R. Michael , Xanthopoulos Kleanthis G.
Published: May 2009

Object. The aim of this study was to investigate further immunogene treatment of malignant brain tumor to improve its therapeutic efficacy.

Methods. Intratumoral dendritic cells pulsed with Semliki Forest virus (SFV)—interleukin-18 (IL-18) and/or systemic IL-12 were injected into mice bearing the B16 brain tumor. To study the immune mechanisms involved in tumor regression, we monitored the growth of implanted B16 brain tumor cells in T cell—depleted mice and IFNγ-neutralized mice. To analyze the protective immunity created by tumor inoculation, B16 cells were injected into the left thighs of mice that had received an inoculation, and tumor growth was monitored.

The local delivery of dendritic cells pulsed with IL-18 bound by SFV combined with the systemic administration of IL-12 enhanced the induction of the T helper type 1 response from tumor-specific CD4+ and CD8+ T cells and natural killer cells as well as antitumor immunity. Interferon-γ is partly responsible for this IL-18—mediated antitumor immunity. Furthermore, the protective immunity is mediated mainly by CD8+ T cells.

Conclusions. Immunogene therapy that combines the local administration of dendritic cells pulsed with IL-18 bound by SFV and the systemic administration of IL-12 may be an excellent candidate for the development of a new treatment protocol. A self-replicating SFV system may therefore open a novel approach for the treatment of malignant brain tumor.
Attenuation of cerebellar tremor with implantation of an intrathecal baclofen pump: the role of γ-aminobutyric acidergic pathways in cerebellar tremor
Authors: Weiss Nirit , North Richard B. , Ohara Shinji , Lenz Frederick A.
Published: May 2009

✓ The authors present the case of a 49-year-old woman with disabling bilateral upper-extremity cerebellar tremor that resolved unexpectedly after placement of an intrathecal baclofen pump for lower-extremity spasticity. The tremor amplitude decreased nearly linearly with increasing intrathecal baclofen dosage, and disappeared completely at a dose of 250 µg/day. In this report the authors demonstrate the role of the γ-aminobutyric acidergic system in the pathogenesis of cerebellar tremor, and these findings may lead to a new treatment modality for patients disabled by this manifestation of their disease.
Transient dystonia following magnetic resonance imaging in a patient with deep brain stimulation electrodes for the treatment of Parkinson disease
Authors: Spiegel Jörg , Fuss Gerhard , Backens Martin , Reith Wolfgang , Magnus Tim , Becker Georg , Moringlane Jean-Richard , Dillmann Ulrich
Published: May 2009

✓ Data from previous studies have shown that magnetic resonance (MR) imaging of the head can be performed safely in patients with deep brain stimulators. The authors report on a 73-year-old patient with bilaterally implanted deep brain electrodes for the treatment of Parkinson disease, who exhibited dystonic and partially ballistic movements of the left leg immediately after an MR imaging session. Such dystonic or ballistic movements had not been previously observed in this patient. In the following months, this focal movement disorder resolved completely. This case demonstrates the possible risks of MR imaging in patients with deep brain stimulators.
Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states
Authors: Cross DeWitte T. , Tirschwell David L. , Clark Mary Ann , Tuden Dan , Derdeyn Colin P. , Moran Christopher J. , Dacey Ralph G.
Published: May 2009

Object. The goal of this study was to determine whether a hospital's volume of subarachnoid hemorrhage (SAH) cases affects mortality rates in patients with SAH. For certain serious illnesses and surgical procedures, outcome has been associated with hospital case volume. Subarachnoid hemorrhage, usually resulting from a ruptured cerebral aneurysm, yields a high mortality rate. There has been no multistate study of a diverse set of hospitals to determine whether in-hospital mortality rates are influenced by hospital volume of SAH cases.

Methods. The authors conducted an analysis of a retrospective, administrative database of 16,399 hospitalizations for SAH (9290 admitted through emergency departments). These hospitalizations were from acute-care hospitals in 18 states representing 58% of the US population. Both univariate and multivariate analyses were used to assess the case volume—mortality rate relationship. The authors used patient age, sex, Medicaid status, hospital region, data source year, hospital case volume quartile, and a comorbidity index in multivariate generalized estimating equations to model the relationship between hospital volume and mortality rates after SAH.

Patients with SAH who were treated in hospitals in which low volumes of patients with SAH are admitted through the emergency department had 1.4 times the odds of dying in the hospital (95% confidence interval 1.2–1.6) as patients admitted to high-volume hospitals after controlling for patient age, sex, Medicaid status, hospital region, database year, and comorbid conditions.

Conclusions. Patients with a diagnosis of SAH on their discharge records who initially presented through the emergency department of a hospital with a high volume of SAH cases had significantly lower mortality rates. Concentrating care for this disease in high-volume SAH treatment centers may improve overall survival.
Self-assessed quality of life after acoustic neuroma surgery
Authors: Betchen Simone A. , Walsh Jane , Post Kalmon D.
Published: May 2009

Object. The aim of this study was to determine if factors such as postoperative hearing, facial function, headaches, or other factors have an impact on self-assessed quality of life (QOL) after acoustic neuroma surgery.

Methods. The SF-36 and seven additional questions on the impact of surgery on the QOL were sent to 135 consecutive patients who had undergone acoustic neuroma surgery. The Spearman rho correlations were calculated for each of the eight categories of the SF-36 (general health, physical functioning, physical role limitations, emotional role limitations, mental health, energy/vitality, pain, social functioning). The results were correlated with patients' sex, age, persistent headache, years since surgery, postoperative hearing level, and facial function.

The response rate was 74.8%. The transformed scores of the eight categories of the SF-36 were lower than age-matched healthy controls in approximately half of the categories. The strongest trend toward lower scores with statistical significance in two categories was persistent headaches. Some categories demonstrated trends toward lower scores with females or age older than 55 years. Postoperative hearing and facial functioning, and time since surgery showed no statistically significant impact on QOL measured by the SF-36. Responses to the additional questions indicate that hearing, facial function, and headache influenced people's feelings about surgery and had an impact on their return to work.

Conclusions. The QOL scores are not consistently lower than population normative values compared with different normative studies. The strongest correlation was between the presence of persistent headache and QOL. Other correlations were not consistent in all categories, and few were statistically significant. These trends in some categories do not explain the difference seen between patients after acoustic neuroma surgery in this study and normal populations in other studies.
Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus
Authors: Govender Soma T. , Nathoo Narendra , van Dellen James R.
Published: May 2009

Object. Staphylococcus species are the most common organisms responsible for infection following implantable cerebrospinal fluid (CSF) diversionary procedures. The role of an antibiotic-impregnated shunt (AIS) system in the prevention of shunt infection has remained unclear because no human clinical trial has been reported on thus far. In this study, the authors assess an AIS system with respect to its prevention of shunt infection.

Methods. Patients were prospectively randomized into groups to evaluate the efficacy of an AIS system against an identical control shunt system. The data accrued were subjected to a detailed statistical analysis. Logistic regression analysis was performed to determine the independent association between outcome and predictor variables. Shunt function analysis was also performed to compare the average time to infection between the two groups.

One hundred ten patients were recruited; 60 received control shunt systems and 50 received AIS systems. Thirteen shunt infections were recorded (10 in the control group and three in the AIS group). Nine (69%) of 13 infections occurred within 2 months after shunt implantation (eight of 10 in the control group and one of three in the AIS group). Apart from one patient in whom no organism was identified, a total of 14 organisms (12 patients) were cultured from either the CSF (nine) or the shunt apparatus (three). Staphylococcus species accounted for the majority of shunt infections (83%): all 10 control shunts were found to have a positive culture of staphylococci, whereas none of the AISs had any staphylococci (p = 0.038).

Conclusions. The AIS afforded antistaphylococcal protection, especially during the early postoperative period when most shunt infections are known to occur and throughout the follow-up period (median 9 months). The AIS system represents another important tool to enable the neurosurgeon to prevent shunt infections.
Surgery for Parkinson disease in the United States, 1996 to 2000: practice patterns, short-term outcomes, and hospital charges in a nationwide sample
Authors: Eskandar Emad N. , Flaherty Alice , Cosgrove G. Rees , Shinobu Leslie A. , Barker Fred G.
Published: May 2009

Object. The surgical treatment of Parkinson disease (PD) has undergone a dramatic shift, from stereotactic ablative procedures toward deep brain stimulaion (DBS). The authors studied this process by investigating practice patterns, mortality and morbidity rates, and hospital charges as reflected in the records of a representative sample of US hospitals between 1996 and 2000.

Methods. The authors conducted a retrospective cohort study by using the Nationwide Inpatient Sample database; 1761 operations at 71 hospitals were studied. Projected to the US population, there were 1650 inpatient procedures performed for PD per year (pallidotomies, thalamotomies, and DBS), with no significant change in the annual number of procedures during the study period. The in-hospital mortality rate was 0.2%, discharge other than to home was 8.1%, and the rate of neurological complications was 1.8%, with no significant differences between procedures. In multivariate analyses, hospitals with larger annual caseloads had lower mortality rates (p = 0.002) and better outcomes at hospital discharge (p = 0.007).

Placement of deep brain stimulators comprised 0% of operations in 1996 and 88% in 2000. Factors predicting placement of these devices in analyses adjusted for year of surgery included younger age, Caucasian race, private insurance, residence in higher-income areas, hospital teaching status, and smaller annual hospital caseload. In multivariate analysis, total hospital charges were 2.2 times higher for DBS (median $36,000 compared with $12,000, p < 0.001), whereas charges were lower at higher-volume hospitals (p < 0.001).

Conclusions. Surgical treatment of PD in the US changed significantly between 1996 and 2000. Larger-volume hospitals had superior short-term outcomes and lower charges. Future studies should address long-term functional end points, cost/benefit comparisons, and inequities in access to care.
Efficient reinnervation of hindlimb muscles by thoracic motor neurons after nerve cross-anastomosis in rats
Authors: Liu Song , Damhieu Phong , Devanze Pauline , Saïd Gérard , Heard Jean Michel , Tadié Marc
Published: May 2009

Object. Peripheral motor axons can regenerate through motor endoneurial tubes of foreign nerves to reinnervate different target muscles. This regenerative capacity has been brought to clinical applications for restorative surgery after nerve or root injury. In this study the authors explore the extent to which nerve cross-anastomosis between lower intercostal nerves and lumbar ventral roots would be effective in inducing reinnervation of paralyzed hindlimb muscles after spinal cord hemisection at the thoracolumbar boundary in rats.

Methods. The proximal extremities of sectioned intercostal nerves T10–12 were surgically connected to the distal extremities of sectioned ipsilateral lumbar ventral roots L3–5, respectively. Motor activity reappeared 2 months postsurgery; however, locomotion was not restored and inappropriate motor patterns persisted at 9 months postsurgery. At that time, data from electrophysiological and histological studies and horseradish peroxidase retrograde labeling demonstrated efficient regrowth of thoracic motor neuron axons that reached hindlimb muscles. They also revealed a persistent maturation defect of regrown fibers, as shown by size heterogeneity and presumable extensive axonal branching. These features are consistent with reduced neural activity subsequent to continuing inappropriate motor patterns.

Conclusions. These results indicate that cross-anastomosis of intercostal nerves with lumbar ventral roots allows efficient reinnervation of paralyzed hindlimb muscles after spinal cord hemisection in rats. Stimulating the reorganization of the neuronal circuitry in the central nervous system by locomotion training or other methods would presumably result in both functional and anatomical improvements. This experimental setting provides a convenient animal model to investigate these processes.
Prognostic significance of annexin VII expression in glioblastomas multiforme in humans
Authors: Hung Kuo-Sheng , Howng Shen-Long
Published: May 2009

Object. Glioblastoma multiforme (GBM) is the most common and lethal primary brain tumor in adults. It is nearly uniformly fatal, with a median survival time of approximately 1 year, despite modern treatment modalities. Nevertheless, a range of survival times exists around this median. Efforts to understand why some patients live longer or shorter than the average may provide insight into the biology of these neoplasms. The annexin VII (ANX7) gene is located on the human chromosome 10q21, a site long hypothesized to harbor tumor suppressor genes associated with prostate and other cancers. To test whether ANX7 expression might be a predictor for GBMs, we examined ANX7 expression, p53 accumulation, and the MIB-1 labeling index in a retrospective series of 99 GBMs.

Methods. In all 99 cases, the patient's age, Karnofsky Performance Scale (KPS) score before surgery, extent of surgery, tumor location, and immunohistochemical features were analyzed using univariate and multivariate analyses to identify whether any significance exists among ANX7 expression, p53 accumulation, the MIB-1 labeling index, and survival time. Kaplan—Meier analyses demonstrated that a higher KPS score before surgery (< 0.0001), total tumor excision (p = 0.0072), young patient age (p = 0.03), and ANX7 expression (p = 0.0006) correlated with longer survival. Multivariate Cox regression analyses demonstrated that ANX7 expression was the strongest predictor of outcome (p < 0.0001), independent of all other variables. In addition, ANX7 expression correlated with higher MIB-1 immunostaining, but did not correlate with p53 accumulation. Moreover, a significant positive correlation was observed between p53 and MIB-1 staining.

Conclusions. These findings indicate that a higher KPS score before surgery, total tumor excision, young patient age, and ANX7 expression correlate with longer survival in patients with GBMs. Multivariate Cox regression analyses demonstrated that ANX7 expression was the strongest predictor of outcome (p < 0.0001) and was independent of all other variables.
Metastatic melanoma of the pituitary gland
Authors: Leung Gilberto Ka Kit , Chow Wing Sun , Tan Kathryn Choon Beng , Fan Yiu Wah , Lam Karen Siu Ling
Published: May 2009

✓ The authors report on the clinical features and imaging studies in a case of metastatic melanoma of the pituitary gland. Cerebral metastatic melanoma and pituitary metastasis from any source are commonly associated with systemic metastasis, whereas pituitary metastatic melanoma without widespread disease dissemination is distinctly rare. This 46-year-old man presented with diabetes insipidus and anterior pituitary dysfunction 5 years after he underwent resection of a cutaneous malignant melanoma of the neck. Magnetic resonance imaging demonstrated the presence of melanin within a sellar tumor mass. Transsphenoidal resection was performed and histopathological examination of tumor material confirmed metastatic melanoma. Postoperative [18F]fluorodeoxyglucose—positron emission tomography revealed no other focus of hypermetabolism in the patient's body.
Modifications to the orbitozygomatic approach
Authors: Lemole G. Michael , Henn Jeffrey S. , Zabramski Joseph M. , Spetzler Robert F.
Published: May 2009

✓ The orbitozygomatic craniotomy is one of the workhorse approaches of skull base surgery, providing wide, multidirectional access to the anterior and middle cranial fossae as well as the basilar apex. Complete removal of the orbitozygomatic bar increases the angles of exposure, decreases the working depth of the surgical field, and minimizes brain retraction. In many cases, however, only a portion of the exposure provided by the full orbitozygomatic approach is needed. Tailoring the extent of the bone resection to the specific lesion being treated can help lower approach-related morbidity while maintaining its advantages. The authors describe the technical details of the supraorbital and subtemporal modified orbitozygomatic approaches and discuss the surgical indications for their use.

Modifications to the orbitozygomatic approach are an example of the ongoing adaptation of skull base procedures to general neurosurgical practice.
Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage
Authors: Hamada Jun-ichiro , Kai Yutaka , Morioka Motohiro , Yano Shigetoshi , Todaka Tatemi , Ushio Yukitaka
Published: May 2009

Object. The goal of this study was to implement an algorithm for and assess the multimodal (endovascular and microsurgical) treatment of patients with ruptured dissecting aneurysms of the vertebral artery (VA) during the acute stage.

Methods. During a 4-year period, the authors treated 19 ruptured dissecting aneurysms of the VA during the acute stage, within 3 days after the hemorrhage. Factors guiding management decisions were tolerance of the test occlusion and the site of the dissection. The algorithm takes into account these factors to select among treatment options, that is, trapping of the VA with Guglielmi Detachable Coils (GDCs); trapping of the VA and revascularization of the posterior inferior cerebellar artery (PICA); trapping of the VA and VA—posterior cerebral artery (PCA) anastomosis; and trapping of the VA, VA—PCA anastomosis, and revascularization of the PICA. Of the 15 aneurysms without PICA involvement, 14 were treated by trapping of the VA with GDCs and one by trapping of the VA and a VA—PCA bypass. The other four aneurysms with PICA involvement were treated by VA trapping and PICA revascularization. There was no episode of recurrent hemorrhage or ischemia during the posttreatment follow-up period. Although lateral medullary syndrome developed as a permanent complication in one patient, a good recovery was made by the other 18 patients by 6 months after the ictus.

Conclusions. The factors that determine the appropriate treatment for ruptured dissecting aneurysms of the VA are tolerance of a test occlusion and the site of dissection. Favorable patient outcomes can be achieved when this algorithm is used.
Delayed hemorrhage following resection of an arteriovenous malformation in the brain
Authors: morgan Michael K. , Winder Mark , Little Nicholas S. , Finfer Simon , Ritson Elizabeth
Published: May 2009

Object. Between 1989 and 2002 the authors treated 416 cases of angiographically confirmed arteriovenous malformations (AVMs) of the brain.

Methods. Three hundred fifty-five patients underwent resection of an AVM; 2% died and 12% experienced a permanent morbidity (1.7% experienced a deterioration of modified Rankin Scale [mRS] score of 3–5). Patient outcomes in this series were based on the Spetzler—Martin grade. For patients with Grade I and II AVMs the rate of permanent morbidity was 1% and the rate of mortality was 0.5%. For patients with Grade III AVMs the morbidity rate was 18.9% (2.7% experienced a deterioration of mRS score of 3–5) and the mortality rate was 2.7%. For patients with Grade IV and V AVMs the morbidity rate was 25.6% (5.1% experienced a deterioration of mRS score of 3–5) and the mortality rate was 7.7%. No patient with a Spetzler—Martin Grade I or II lesion had a worsened outcome due to delayed hemorrhage, whereas 3.6% of patients with a Grade III and 12.8% of patients with Grade IV and V AVMs experienced delayed hemorrhage that led to a permanent downgrade in function.

With the introduction of an aggressive postoperative blood pressure protocol (for AVMs with grades > II and sizes > 3.5 cm in diameter) the incidence of delayed postoperative hemorrhage leading to mortality or permanent morbidity decreased from 4.4 to 1%. This difference was significant. Neither case selection nor complications other than delayed hemorrhage changed between these two periods.

Conclusions. In selected cases an aggressive postoperative blood pressure protocol is likely to reduce delayed hemorrhage following AVM resection.
Delineating gray and white matter involvement in brain lesions: three-dimensional alignment of functional magnetic resonance imaging and diffusion-tensor imaging
Authors: Hendler Talma , Pianka Pazit , Sigal Michal , Kafri Michal , Ben-Bashat Dafna , Constantini Shlomi , Graif Moshe , Fried Itzhak , Assaf Yaniv
Published: May 2009

Object. The role of functional magnetic resonance (fMR) imaging has become increasingly important in the presurgical mapping of gray matter. Neurosurgical interventions often involve fiber bundles that connect critical functional areas. Recently, diffusion-tensor (DT) imaging has enabled the visualization of fiber bundle direction and integrity, thus providing the ability to delineate clearly white matter from gray matter tissue. The main objective of this study was to improve the presurgical assessment of critical functionality in the vicinity of brain lesions by combining DT and fMR imaging methodologies.

Methods. Twenty patients with various space-occupying brain lesions underwent imaging for presurgical evaluation of motor and/or somatosensory functions. The authors focus on five patients with diverse space-occupying brain lesions. Diffusion tensor—based fiber tracking and fMR imaging activation maps were superimposed in three dimensions to visualize pyramidal tracts corresponding to motor and somatosensory regional activation.

Conclusions. The combination of DT and fMR imaging for presurgical functional brain mapping provides valuable information that cannot be extracted using either method alone. The validity and sensitivity of noninvasive functional mapping for surgical guidance could be improved by considering results obtained with both methods. Furthermore, the use of three-dimensional visualization seems crucial and unique for viewing and understanding the complicated spatial relationship among the lesion, gray matter activation, and white matter fiber bundles.
Microsurgical anatomy of the great cerebral vein of Galen and its tributaries
Authors: Chaynes Patrick
Published: May 2009

Object. The deep cerebral veins may pose a major obstacle in operative approaches to deep-seated lesions, especially in the pineal region where multiple veins converge on the great cerebral vein of Galen. Because undesirable sequelae may occur from such surgery, the number of veins and branches to be sacrificed during these approaches should kept to a minimum. The purpose of this study was to examine venous drainage into the vein of Galen with a view to surgical approaches. If a vein hampering surgical access must be sacrificed, it can therefore be selected according to the smallest draining territory.

Methods. The deep cerebral veins and their surrounding neural structures were examined in 50 cerebral hemispheres from 25 adult cadavers in which the arteries and veins had been perfused with red and blue silicone, respectively. Special consideration was given to the size and location of drainage of the vein of Galen and its tributaries.

Conclusions. When a surgeon approaches the pineal region, several veins may hamper the access route. From posterior to anterior, these include the following: the superior vermian and the precentral or superior cerebellar veins, which drain into the posteroinferior aspect of the vein of Galen; and the tectal and pineal veins, which drain into its anterosuperior aspect. The internal occipital vein is the main vessel draining into the lateral aspect of the vein of Galen. It may be joined by the posterior pericallosal vein, and in that case has an extensive territory. To avoid intraoperative venous infarction, it is important to use angiography to determine the venous organization before surgery and to estimate the permeability and size of the branches of the deep venous system.
Inhibition of DNA repair for sensitizing resistant glioma cells to temozolomide
Authors: Kanzawa Takao , Bedwell Joshua , Kondo Yasuko , Kondo Seiji , Germano Isabelle M.
Published: May 2009

Object. Temozolomide (TMZ) is a DNA alkylating agent currently used as adjuvant treatment for anaplastic astrocytomas. Its use in managing glioblastoma multiforme has been halted because of the lack of therapeutic effects due to cell resistance. Note that O6-alkylguanine—DNA alkyltranferase (AGT) is a DNA repair enzyme that limits the efficacy of TMZ. In this study the authors investigated the ability of O6-benzylguanine (BG), an AGT inhibitor, to sensitize a glioblastoma cell line resistant to TMZ.

Methods. The effects of TMZ alone (100 µg) and after exposure to BG (50 µg) were assessed in two glioblastoma cell lines, U373-MG and T98G, respectively, sensitive and resistant to TMZ. Cell viability was assessed using trypan blue; cell cycle analysis by fluorescence-activated cell sorter; and apoptosis and autophagy by terminal deoxynucleotidyl transferase—mediated deoxyuridine triphosphate nick-end labeling (TUNEL) and acridine orange staining, respectively. Furthermore, the involvement of an autophagy marker, microtubule-associated light chain 3 (LC3), was assessed. Temozolomide suppressed the growth of and caused cell cycle arrest in the G2—M phase of U373-MG cells but not T98G cells. Exposure to BG prior to TMZ resulted in a significant decrease in cell viability as well as cell cycle arrest in the G2—M phase in T98G cells (p < 0.05). Although apoptosis was not detected on TUNEL staining, programmed cell death Type II (autophagy) was detected after exposure to BG and TMZ in T98G cells.

Conclusions. These results indicate that inhibition of AGT by BG can render previously resistant glioma cells sensitive to TMZ treatment. The mechanism of cell demise following BG-TMZ treatment seems to be autophagy and not apoptosis. Combination therapy involving TMZ and an AGT inhibitor may be an effective strategy to treat resistant gliomas.
Repetitive transcranial magnetic stimulation for protection against delayed neuronal death induced by transient ischemia
Authors: Fujiki Minoru , Kobayashi Hidenori , Abe Tatsuya , Kamida Tohru
Published: May 2009

Object. Data in the present study demonstrate that repetitive transcranial magnetic stimulation (rTMS) induces ischemic tolerance against delayed neuronal death (DND) of hippocampal neurons following an otherwise lethal ischemic insult.

Methods. Various regimens of rTMS were delivered to adult gerbils at various times prior to an episode of ischemia induced by transient (5-minute) bilateral common carotid artery (CCA) occlusion. The extent of DND in the CA1 region of the hippocampus was assessed quantitatively 7 days after the transient ischemic episode.

When rTMS was delivered 2 to 5 days prior to bilateral CCA occlusion, DND was substantially attenuated; delivery of rTMS 12 to 24 hours prior to occlusion induced partial tolerance. In the group of animals that had received stimulation 2 days prior to occlusion, neuron density in the CA1 sector was significantly higher (three gerbils, 210.33, 86.01% of normal) than in the group that experienced ischemia only (three gerbils, 10.66, 4.36% of normal). A similar degree of neuron sparing occurred when stimulation was delivered 3, 4, or 5 days prior to occlusion. Note that rTMS was effective when it was delivered at frequencies of 25 and 50 Hz. Stimulation at 25 Hz for 128 seconds (3200 pulses) was more effective than stimulation at 50 Hz for 64 seconds (3200 pulses) or 128 seconds (6400 pulses), however.

Conclusions. Noninvasive rTMS represents an important tool for exploring the mechanisms of ischemic tolerance and preventing ischemic neuronal damage.
Healing of a brain abscess by secondary intention
Authors: Georgius Peter , Yu Xavier K. , Rosenfeld Jeffrey V. , D'Urso Paul S.
Published: May 2009

✓✓ A cerebral abscess developed in this 33-year-old man after a compound, comminuted skull fracture of the left temporoparietal region. This lesion failed to respond to standard management, which included subtotal excision and drainage. This case presented the unusual opportunity to externalize a cerebral abscess that had failed to respond to standard surgical treatment. The cerebral abscess healed rapidly by secondary intention. This may be a safe and effective option for an abscess that is walled off by granulation tissue and situated close to the cortical surface.
Surgical innovation or surgical evolution: an ethical and practical guide to handling novel neurosurgical procedures
Authors: Bernstein Mark , Bampoe Joseph
Published: May 2009

Object. Surgical innovation is an important driver of improvements in technique and technology, which ultimately translates into improvements in patients' outcomes. Nevertheless, patients may face new risks of morbidity and mortality when surgical innovation is used, and well-intentioned surgical “experimentation” on patients must be regulated and monitored. In this paper the authors examine the challenges of defining surgical innovation and briefly review the literature on this challenging subject.

Methods. Using examples from the field of neurosurgery and in part from the personal experience of the senior author, the authors develop a model of levels of experimental acuity of surgical procedures and offer recommendations on how these procedures would best be regulated.

Conclusions. The authors propose guidelines for determining the need for regulation of innovation. The potential role of institutional review boards in this process is highlighted.