bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of antihypertension agents for the suppression of arterial pulse pressure waveforms in patients with intracranial aneurysms
Authors: Turner Carole L. , Wilkinson Ian B. , Kirkpatrick Peter J.
Published: January 2008

Object

Patients with intracranial aneurysms tend toward raised blood pressure and abnormal pulse pressure profiles. The authors have investigated the influence of three antihypertension agents on blood pressure and pulse pressure waveforms in patients with known intracranial aneurysms, with a view to assessing the potential benefits of longterm antihypertension therapy on the progression of unruptured intracranial aneurysms.

Methods

Nineteen patients with a mean age of 56 years (range 38–76 years) were recruited for this study. All patients had confirmed intracranial aneurysms. A double-blind, randomized, crossover study was performed using perindopril, irbesartan, isosorbide mononitrate, and a placebo. Blood pressure and pulse pressure waveforms were assessed at the end of each 4-week treatment period.

Perindopril and irbesartan were well tolerated. For all measured parameters except heart rate (p = 0.03), no significant difference between baseline and placebo was identified. Each drug when compared with placebo reduced peripheral arterial blood pressure. Perindopril significantly decreased mean blood pressure by 10 mm Hg (p = 0.004), irbesartan by 9 mm Hg (p = 0.004), and isosorbide mononitrate by 13 mm Hg (p = 0.005).

The administration of each drug effected a significant reduction in the carotid artery augmentation index (AIX) compared with baseline values (perindopril p = 0.01, irbesartan p = 0.0002, and isosorbide mononitrate p = 0.03). There was also a significant difference in the AIX between irbesartan and the placebo (p = 0.05). Compared with the placebo, there was a significant difference in AIX (adjusted for heart rate) following the administration of irbesartan (p = 0.003) and isosorbide mononitrate (p = 0.01), but not with perindopril (p = 0.17).

Conclusions

Irbesartan appears to be the most effective treatment for the combined suppression of blood pressure and AIX in patients with intracranial aneurysms and has a high degree of patient tolerance.
Modification of glucose metabolism in brain tumors by using cervical spinal cord stimulation
Authors: Clavo Bernardino , Robaina Francisco , Montz Ricardo , Domper Marta , Caramés Miguel Á. , Morera Jesús , Pinar Beatriz , Hernández María A. , Santullano Victoria , Carreras José Luis
Published: January 2008

Object

In previous studies the authors have shown potential increases in locoregional blood flow and oxygenation in tumors by using electrical cervical spinal cord stimulation (SCS). In the present report they demonstrate the effect of cervical SCS on brain tumor metabolism, as assessed using [18F]fluorodeoxyglucose–positron emission tomography (FDG-PET).

Methods

Cervical devices were inserted in 11 patients who had high-grade gliomas, six of which had recurred. While the SCS device was deactivated, each patient underwent an initial FDG-PET study to clarify the clinical status. A second FDG-PET study was performed later the same day while the stimulation device was activated to determine the effect of cervical SCS on glucose metabolism.

All 11 patients were evaluable for this PET study. Basal glucose metabolism was higher in the tumor than in the peritumoral areas (p = 0.048). There was a significant increase in glucose uptake during cervical SCS in both the tumor (p = 0.035) and the peritumoral (p = 0.001) areas, with measured increases of 43 and 38%, respectively. The estimated potential maximal residual activity of the first FDG dose’s contribution to the activity on the second scan was 18.5 ± 1% or less.

Conclusions

This PET study is the first in which is described the effect of cervical SCS on glucose metabolism in brain tumors and supports previous study data indicating a modification of locoregional blood flow and oxygenation by cervical SCS. These results open up new approaches to modifying the effect of radiochemotherapy in the treatment of malignant brain tumors.
Preoperative endovascular brain mapping for intraoperative volumetric image guidance: preliminary concept and feasibility in animal models
Authors: Mericle Robert A. , Richter Erich O. , Eskioglu Eric , Watkins Courtney , Prokai Laszlo , Batich Christopher , Santra Swadeshmukul
Published: January 2008

Object

The authors describe a novel concept for brain mapping in which an endovascular approach is used, and they demonstrate its feasibility in animal models. The purpose of endovascular brain mapping is to delineate clearly the nonfunctional brain parenchyma when a craniotomy is performed for resection. The nonfunctional brain will be stained with sharp visual margins, differentiating it from the functional, nonstained brain. The authors list four essential criteria for developing an ideal endovascular mapping agent, and they describe seven potential approaches for accomplishing a successful endovascular brain map.

Methods

Four Sprague–Dawley rats and one New Zealand white rabbit were used to determine initial feasibility of the procedure. The animals were anesthetized, and the internal carotid artery was catheterized. Four potential brain mapping agents were infused into the right hemisphere of the five animals. Afterward, the brains were removed and each was analyzed both grossly and histologically.

Fluorescein and FD&C Green No. 3 provided good visual clarity and margins, but required blood–brain barrier (BBB) manipulation. Tantalum particles enabled avoidance of BBB manipulation, but provided inadequate visual clarity, probably because of their size. A Sudan black “cocktail” provided excellent clarity and margins despite remaining in the brain capillaries.

Conclusions

This is a novel application of the endovascular approach, and has broad potential for clinical neurosurgical brain mapping. The animal models in this study establish the feasibility of the procedure. However, further study is required to demonstrate safety, minimize toxicity, investigate stain durability, and improve the characteristics of potential mapping agents. The authors are planning to conduct future studies for identification of mapping agents that do not require BBB manipulation or vascular occlusion.
Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma
Authors: Litvack Zachary N. , Hunt Matthew A. , Weinstein Jason S. , West G. Alexander
Published: January 2008

✓ In this case report, the authors describe a 33-year-old man who presented with headache due to the presence of 12 nail-gun nails impacted in his cranium and cerebral parenchyma. The authors also review the relevant literature regarding penetrating brain injury.

The patient's physical examination revealed a Glasgow Coma Scale score of 15 and impairment of abduction of the right eye and abduction of the jaw producing dysarthria; the remaining results of the neurological examination were normal. Both x-ray films and computerized tomography (CT) scans of the head revealed the presence of 12 nails, the majority of which were located intracranially. A scattering artifact limited the ability of CT scanning to demonstrate any intracranial hemorrhage. Angiography did not demonstrate any evidence of traumatic vascular injury. After general anesthesia had been induced in the patient, the nails were removed in the operating room. Following removal of the final nail, a small left temporal craniotomy was performed to control hemorrhage from a tear in the left middle meningeal artery. Despite the development of a postoperative insular hematoma, the patient was discharged home with minimal deficits.

This patient is the only known survivor of the largest number of foreign objects (12) to penetrate the skull intentionally. Overall, self-inflicted nail-gun injuries are less common than accidental discharges. A review of the literature, however, suggests that for penetrating brain injury, self-infliction is the more common mechanism. For those patients who survive such an injury, clinical decision making must focus on preventing further cortical or vascular damage. A rational management strategy should permit these patients to be discharged with no additional injury.
Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening
Authors: Liu James K. , Couldwell William T.
Published: January 2008

Object

The authors report their experience with pituitary apoplexy and evaluate the clinical significance of sphenoid sinus mucosal thickening found on magnetic resonance (MR) imaging.

Methods

The cases of 28 patients (19 males and nine females) with pituitary apoplexy were reviewed retrospectively. The mean age of the patients was 50 years (range 16–83 years), and the mean follow-up duration was 32 months (range 1–104 months). Admission MR imaging demonstrated hemorrhage or infarction in a pituitary tumor in each patient. A clinical grading scale for apoplexy was devised as follows: Grade I, presence of acute headache and/or endocrine abnormality (12 patients); Grade II, presence of the foregoing symptoms as well as cranial nerve deficit (visual and/or oculomotor; 15 patients); and Grade III, presence of all of these symptoms and a decreased level of consciousness (one patient).

Twenty-five patients (89%) underwent early transsphenoidal resection within 9 days (80% within 72 hours) of diagnosis. Headaches and oculomotor paresis resolved completely in 100%, visual function resolved completely in 44% and partially in 56%, and hypopituitarism was reversed in 25%. Twelve patients (43%) required long-term hormone replacement therapy. Two of the three patients who were treated conservatively had prolactin-secreting adenomas, which were treated with dopamine agonist therapy. Thickening of sphenoid sinus mucosa was present in 22 patients (79%). Fifty percent of patients in Grade I and 100% of those in Grades II and III, including all those with persistent hypopituitarism and residual visual deficits, had thickened sphenoid sinus mucosa on MR imaging. Patients with thickened sphenoid sinus mucosa had larger tumors that compressed the optic chiasm or cavernous sinus, and these individuals also had a higher rate of cranial nerve deficits at presentation than those without mucosal thickening (73% compared with 0%). Patients with thickened mucosa had a higher rate of hypopituitarism and subsequent long-term hormone replacement therapy than those without thickened mucosa (55% compared with 17%).

Conclusions

Thickened sphenoid sinus mucosa may correlate with higher grades of pituitary apoplexy and worse neurological and endocrinological outcomes.
Mechanics of acute subdural hematomas resulting from bridging vein rupture
Authors: Depreitere Bart , Van Lierde Carl , Sloten Jos Vander , Van Audekercke Remy , Van Der Perre Georges , Plets Christiaan , Goffin Jan
Published: January 2008

Object

Based on data from primate experiments it is known that rotational acceleration in the sagittal plane and in a forward direction is most likely to produce acute subdural hematomas due to bridging vein rupture. For protection against these lesions, knowledge of rotational acceleration tolerance levels in humans is required. In the present study the authors analyze human tolerance levels for bridging vein rupture by performing head impact tests in cadavers.

Methods

Ten unembalmed cadavers were subjected to 18 occipital impacts producing head rotation in the sagittal plane with varying rotational acceleration magnitudes and pulse durations. Rotational acceleration was calculated from the linear acceleration histories recorded by three uniaxial accelerometers mounted on the side of the head. Bridging vein ruptures were detected by injecting contrast dye into the superior sagittal sinus under fluoroscopy and by autopsy procedures. Bridging vein ruptures were produced in six head impact tests: one test with a pulse duration of 5.2 msec and a peak rotational acceleration of 13,411 rad/second2; three tests with a pulse duration between 7 and 8 msec and a peak rotational acceleration of 12,558, 10,607, and 8567 rad/second2; and two tests with a pulse duration longer than 10 msec and a peak rotational acceleration as low as 5267 rad/second2.

Conclusions

This is the only cadaveric study of bridging vein rupture focused on short pulse durations, which are usually associated with falls. The data suggest a tolerance level of approximately 10,000 rad/second2 for pulse durations shorter than 10 msec, which seems to decrease for longer pulse durations.
An accelerated senescence response to radiation in wild-type p53 glioblastoma multiforme cells
Authors: Quick Quincy A. , Gewirtz David A.
Published: January 2008

Object

Radiotherapy is one of the few treatment options available for glioblastoma multiforme (GBM); however, the basis for its overall ineffectiveness in GBM is not fully understood. The present study was designed to explore the nature of the response to ionizing radiation in GBM cells to gain insight into the basis for the general failure of radiotherapy in the treatment of this disease.

Methods

The response to fractionated radiotherapy was examined in GBM cell lines with differing p53 status. A viable cell number was determined during an 8-day period; accelerated senescence was based on β-galactosidase staining and cell morphology; apoptosis was evaluated by the terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling assay and fluorescence-activated cell-sorter analysis, whereas the expression of cell-cycle regulatory proteins was monitored by Western blot analysis.

Based on clonogenic survival, the wild-type p53 U87 cells and mutant p53 T98 cells demonstrated essentially identical sensitivity to fractionated radiotherapy; however, neither cell line underwent apoptosis, and the primary response to irradiation was growth arrest. The wild-type p53 GBM cells showed clear evidence of accelerated senescence in response to irradiation. In contrast, senescence was not evident in mutant p53 GBM cells or GBM cells in which p53 function was abrogated by the viral E6 protein. The T98 (mutant p53) cells demonstrated a relatively robust proliferative recovery whereas both the rate and extent of recovery were attenuated in the wild-type p53 U87 cells.

Conclusions

Both accelerated senescence and conventional growth arrest are likely to represent alternative responses to apoptosis in irradiated GBM cells.
Sarcomatous transformation of clival chordoma after charged-particle radiotherapy
Authors: Hara Takayuki , Kawahara Nobutaka , Tsuboi Koji , Shibahara Junji , Ushiku Tetsuo , Kirino Takaaki
Published: January 2008

✓ Skull base chordomas containing a sarcomatous component are extremely rare. Here the authors report two new cases in which a recurrent tumor with a sarcomatous component appeared after the patient had undergone charged-particle radiotherapy. Histological examinations performed in Case 1 revealed some retention of epithelial features in the sarcomatous component, whereas no such regions were observed in Case 2. Both patients had rapidly deteriorating clinical courses and died within 6 months after diagnosis of the recurrent tumor. The authors discuss the significance of the histological subtypes of these tumors for long-term prognosis and their pathogenetic mechanisms in relation to radiotherapy. Although these sarcomatous transformations are rare in conventional chordomas, a careful histological examination and thorough follow-up imaging studies are crucial when treating patients with such lesions.
Diagnostic method for differentiating external hydrocephalus from simple subdural hygroma
Authors: Huh Pil-Woo , Yoo Do-Sung , Cho Kyung-Suok , Park Chun-Kun , Kang Seok-Gu , Park Young-Sup , Kim Dal-Soo , Kim Moon-Chan
Published: January 2008

Object

The various terms used to describe subdural fluid collection—“external hydrocephalus,” “subdural hygroma,” “subdural effusion,” “benign subdural collection,” and “extraventricular obstructive hydrocephalus”—reflect the confusion surrounding the diagnoses of these diseases. Differentiating external hydrocephalus from simple subdural hygroma may be difficult, but the former appears to be a distinct clinical entity separate from the latter. In this report, the authors present a diagnostic method for differentiating external hydrocephalus from simple subdural hygroma, based on their clinical experience in treating subdural fluid collection after mild head trauma.

Methods

Twenty patients with subdural fluid collection after mild head trauma were included in this study. Ventricle size was measured using a modified frontal horn index (mFHI); that is, the largest width of the frontal horns divided by the bicortical distance in the same plane, instead of the inner table distance. Bur hole trephination was performed on the appearance of a subdural fluid collection thicker than 15 mm on computed tomography (CT), persistent (longer than 4 weeks) or increasing in size, and accompanied by neurological symptoms (confusion or memory impairment). During the procedure, subdural pressure was measured using a manometer before opening the dura mater. Subdural pressure varied among the patients, ranging from 3 to 27.5 cm H2O. Four patients with a subdural pressure greater than 15 cm H2O had hydrocephalus after surgery (p < 0.05). Hydrocephalus developed in a pediatric patient (2 years old) with a subdural pressure of 12 cm H2O. All of the patients in whom hydrocephalus developed after bur hole trephination had had enlarged ventricles (mFHI > 33%) on preoperative CT scans.

Conclusions

Monitoring subdural pressure may be a valuable tool for differentiating subdural hygroma from external hydrocephalus in patients with mild head trauma. Additionally, the mFHI reflects the nature of the subdural collection more accurately than the standard frontal horn index.
Progesterone and estrogen receptors: opposing prognostic indicators in meningiomas
Authors: Pravdenkova Svetlana , Al-Mefty Ossama , Sawyer Jeffrey , Husain Muhammad
Published: January 2008

Object

The preponderance of progesterone receptors (PRs) and the scarcity of estrogen receptors (ERs) in meningiomas are well known. The expression of PRs may relate to tumor grade and recurrence. Cytogenetic abnormalities are associated with aggressive behavior, recurrence, and progression. In this study, the authors focus on the prognostic implications of hormone receptors in meningiomas to help determine the clinical and biological aggressiveness of tumors and their correlations with cytogenetic abnormalities.

Methods

Two hundred thirty-nine patients with meningiomas were separated into three groups. Group 1 (PR-positive group) comprised patients whose meningiomas displayed expression of PRs alone. Group 2 (receptor-negative group) included patients whose lesions did not have receptors for either progesterone or estrogen. Group 3 (ER-positive group) included patients whose tumors displayed expression of ERs. Clinical and histological findings, proliferative indices, tumor recurrence, and cytogenetic findings were analyzed by performing the Fisher exact test.

Compared with the receptor-negative (Group 2) and ER-positive (Group 3) groups, the PR-positive group (Group 1) had a statistically significant lower proliferative index and a smaller number of patients in whom there were aggressive histopathological findings or changes in karyotype. In Groups 1, 2, and 3, the percentages of cases with aggressive histopathological findings were 10, 31, and 33%, respectively; the percentages of cases with chromosomal abnormalities were 50, 84, and 86%, respectively; and the percentages of cases in which there initially was no residual tumor but recurrence was documented were 5, 30, and 27%, respectively. A statistically significant increase in the involvement of chromosomes 14 and 22 was identified in receptor-negative and ER-positive de novo meningiomas, when compared with the PR-positive group. Abnormalities on chromosome 19 were statistically significantly higher in receptor-negative meningiomas than in PR-positive tumors.

Conclusions

The expression of the PR alone in meningiomas signals a favorable clinical and biological outcome. A lack of receptors or the presence of ERs in meningiomas correlates with an accumulation of qualitative and quantitative karyotype abnormalities, a higher proportional involvement of chromosomes 14 and 22 in de novo tumors, and an increasing potential for aggressive clinical behavior, progression, and recurrence of these lesions. Sex hormone receptor status should routinely be studied for its prognostic value, especially in female patients, and should be taken into account in tumor grading. The initial receptor status of a tumor may change in progression or recurrence of tumor.
Metastases to hemangioblastomas in von Hippel–Lindau disease
Authors: Jarrell S. Taylor , Vortmeyer Alexander O. , Linehan W. Marston , Oldfield Edward H. , Lonser Russell R.
Published: January 2008

Object

Patients with hereditary cancer syndromes may be at increased risk for the development of tumor-to-tumor metastases. To gain insight into the biological nature of these lesions in the central nervous system (CNS), to determine their prevalence in a familial neoplasia syndrome, and to better define their management, the authors retrospectively examined a series of cases in which metastatic lesions developed within hemangioblastomas in patients with von Hippel–Lindau (VHL) disease.

Methods

The study included all cases of VHL disease in which patients underwent resection of a CNS hemangioblastoma that contained a metastasis or were found at autopsy to have a metastasis to a hemangioblastoma between January 2002 and December 2005 at the National Institute of Neurological Disorders and Stroke (NINDS). Clinical, histopathological, imaging, and surgical and/or autopsy findings were analyzed.

Metastasis to a CNS hemangioblastoma was found in six resected tumors (8% of all hemangioblastomas resected from patients with VHL disease at the NINDS during the study period) from six patients (five women, one man; mean age at surgery 42.5 years). The primary site of metastatic disease was the kidney in five patients (renal cell carcinoma) and the pancreas in one (a pancreatic neuroendocrine tumor). Only one patient had systemic metastases at the time of resection of the hemangioblastoma containing the metastasis. Neurologically, all patients had remained at baseline or were improved at last clinical follow-up examination (mean follow-up duration 16.5 months, range 3–40 months). In all cases, postoperative imaging revealed that the hemangioblastoma resection was complete, and there was no evidence of recurrence in any of the patients at the last follow up. Two patients (including one who was also in the surgical group) were found at autopsy to have CNS metastases exclusively to spinal hemangioblastomas.

Conclusions

Hemangioblastomas are an early and preferred site for metastasis in VHL disease. Emerging histopathological techniques may lead to recognition of an increasing number of cases of tumor-to-hemangioblastoma metastasis. Management of cases involving tumor-to-hemangioblastoma metastases in VHL disease should be based on the histological characteristics of the primary tumor, extent of the primary disease, and completeness of the resection.
Three-tesla magnetic resonance imaging of the ventrolateral thalamus: a correlative anatomical description
Authors: Mercado Rodrigo , Mandat Tomasz , Wayne Moore G. R. , Li David , MacKay Alex , Honey Christopher R.
Published: January 2008

Object

Surgery for tremor targets the ventrolateral nuclei of the thalamus. An initial radiological estimation of this target can be further refined through intraoperative physiological confirmation. Direct visualization of these nuclei has not yet been described. The improved signal-to-noise ratio associated with 3-tesla (3T) magnetic resonance (MR) imaging makes increased spatial resolution possible, which may aid in the identification of subtle morphological features. This study was conducted to describe the anatomy of the nuclei and fiber projections within the ventral thalamus by using 3T MR imaging.

Methods

Using a commercially available 3T MR unit, the authors obtained images of a formalin-fixed, paraffin-embedded brain. Slices with a 2-mm thickness and 0.2-mm gap were obtained parallel to the anterior commissure–posterior commissure (AC–PC) line. The brain was then sectioned through the cerebral hemispheres to obtain tissue slices encompassing the same levels. Adjacent 10-μm paraffin sections from the middle of each level were stained with Luxol fast blue and cresyl violet. The MR image and histological sections at the level of the AC–PC line were then compared in detail. In a separate study, the human thalamus was scanned in vivo using 3T and 1.5T MR imaging for anatomical comparison.

Conclusions

The anatomy of the nuclei and fiber projections within the ventrolateral thalamus in humans can be described using 3T MR imaging. The findings were reproducible in vivo with 3T but not 1.5T MR imaging. Additional studies are needed to confirm the accuracy of this observation for clinical purposes.
Phase II study of nimustine, carboplatin, vincristine, and interferon-β with radiotherapy for glioblastoma multiforme: experience of the Kyoto Neuro-Oncology Group
Authors: Aoki Tomokazu , Takahashi Jun A. , Ueba Tetsuya , Oya Natsuo , Hiraoka Masahiro , Matsui Kunihiko , Fukui Tsugiya , Nakashima Yasuaki , Ishikawa Masatsune , Hashimoto Nobuo
Published: January 2008

Object

This Phase II study was performed to determine the safety, tolerability, and efficacy of combining nimustine (ACNU)–carboplatin-vincristine-Interferon-β (IFNβ) chemotherapy.

Methods

Ninety-seven patients with Karnofsky Performance Scale scores of 50 or greater were enrolled in the study. Nimustine (60 mg/m2), carboplatin (110 mg/m2), vincristine (0.6 mg/m2), and IFNβ (10 μg) were administered on Day 1 concomitant with radiotherapy (63 Gy); vincristine (0.6 mg/m2) and IFNβ (10 μg) on Days 8 and 15; and IFNβ alone (10 μg) three times per week throughout the course of radiotherapy. Fifty-six days after radiotherapy ended, the time schedule for chemotherapy was reset and ACNU, carboplatin, vincristine, and IFNβ were again administered on the new Day 1 and vincristine and IFNβ on the new Days 8 and 15. This course was repeated every 56 days. Instances of nonhematological toxicity were rare and mild. During the course of radiotherapy, the percentages of patients who experienced Grade 3 toxicity were 14% with neurocytopenia and 7% with thrombocytopenia. Seven percent of all adjuvant chemotherapy cycles following radiotherapy were associated with Grade 3 toxicity, as manifested in neurocytopenia or thrombocytopenia. No instance of Grade 4 toxicity was observed. The median duration of progression-free survival was 10 months (95% confidence interval [CI] 8–12 months) and the median duration of overall survival was 16 months (95% CI 13–20 months).

Conclusions

The combination of ACNU-carboplatin-vincristine-IFNβ chemotherapy and radiotherapy is safe and well tolerated, and may prolong survival in patients with glioblastoma multiforme.
Recurrent late cerebral necrosis with aggressive characteristics after radiosurgical treatment of an arteriovenous malformation
Authors: Chen H. Isaac , Burnett Mark G. , Huse Jason T. , Lustig Robert A. , Bagley Linda J. , Zager Eric L.
Published: January 2008

✓Late cerebral radiation necrosis usually occurs within 3 years of stereotactic radiosurgery. The authors report on a case of recurrent radiation necrosis with rapid clinical deterioration and imaging findings resembling those of a malignant glioma. This 68-year-old man, who had a history of a left posterior temporal and thalamic arteriovenous malformation (AVM) treated with linear accelerator radiosurgery 13 years before presentation and complicated by radiation necrosis 11 years before presentation, exhibited new-onset mixed aphasia, right hemiparesis, and right hemineglect. Imaging studies demonstrated hemorrhage and an enlarging, heterogeneously enhancing mass in the region of the previously treated AVM. The patient was treated medically with corticosteroid agents, and stabilized temporarily. Unfortunately, his condition worsened precipitously soon thereafter, requiring the placement of a shunt for relief of obstructive hydrocephalus. Further surgical intervention was offered, but the patient’s family opted for hospice care instead. The patient died 10 weeks after initially presenting to the authors’ institution, and the results of an autopsy demonstrated radiation necrosis.

Symptomatic radiation necrosis can occur more than a decade after stereotactic radiosurgery, necessitating patient follow up during a longer period of time than currently practiced. Furthermore, there is a need for more careful reporting on the natural history of such cases to clarify the pathogenesis of very late and recurrent radiation necrosis after radiosurgery and to define patient groups with a higher risk for these entities.
Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses
Authors: Sindou Marc P. , Alvernia Jorge E.
Published: January 2008

Object

Radical removal of meningiomas involving the major dural sinuses remains controversial. In particular, whether the fragment invading the sinus must be resected and whether the venous system must be reconstructed continue to be issues of debate. In this paper the authors studied the effects, in terms of tumor recurrence rate as well as morbidity and mortality rates, of complete lesion removal including the invaded portion of the sinus and the consequences of restoring or not restoring the venous circulation.

Methods

The study consisted of 100 consecutive patients who had undergone surgery for meningiomas originating at the superior sagittal sinus in 92, the transverse sinus in five, and the confluence of sinuses in three. A simplified classification scheme based on the degree of sinus involvement was applied: Type I, lesion attachment to the outer surface of the sinus wall; Type II, tumor fragment inside the lateral recess; Type III, invasion of the ipsilateral wall; Type IV, invasion of the lateral wall and roof; and Types V and VI, complete sinus occlusion with or without one wall free, respectively. Lesions with Type I invasion were treated by peeling the outer layer of the sinus wall. In cases of sinus invasion Types II to VI, two strategies were used: a nonreconstructive (coagulation of the residual fragment or global resection) and a reconstructive one (suture, patch, or bypass). Gross-total tumor removal was achieved in 93% of cases, and sinus reconstruction was attempted in 45 (65%) of the 69 cases with wall and lumen invasion. The recurrence rate in the study overall was 4%, with a follow-up period from 3 to 23 years (mean 8 years). The mortality rate was 3%, all cases due to brain swelling after en bloc resection of a Type VI meningioma without venous restoration. Eight patients—seven of whom harbored a lesion in the middle third portion of the superior sagittal sinus—had permanent neurological aggravation, likely due to local venous infarction. Six of these patients had not undergone a venous repair procedure.

Conclusions

The relatively low recurrence rate in the present study (4%) favors attempts at complete tumor removal, including the portion invading the sinus. The subgroup of patients without venous reconstruction displayed statistically significant clinical deterioration after surgery compared with the other subgroups (p = 0.02). According to this result, venous flow restoration seems justified when not too risky.
Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system
Authors: Auguste Kurtis I. , McDermott Michael W.
Published: January 2008

Object

When complicated by infection, craniotomy bone flaps are commonly removed, discarded, and delayed cranioplasty is performed. This treatment paradigm is costly, carries the risks associated with additional surgery, and may cause cosmetic deformities. The authors present their experience with an indwelling antibiotic irrigation system used for the sterilization and salvage of infected bone flaps as an alternative to their removal and replacement.

Methods

The authors retrospectively reviewed the medical records for 12 patients with bone flap infections following craniotomy who received treatment with the wash-in, wash-out indwelling antibiotic irrigation system. Infected flaps were removed and scrubbed with povidone–iodine solution and soaked in 1.5% hydrogen peroxide while the wound was debrided. The bone flaps were returned to the skull and the irrigation system was installed. Antibiotic medication was infused through the system for a mean of 5 days. Intravenous antibiotic therapy was continued for 2 weeks and oral antibiotics for 3 months postoperatively. Wound checks were performed at clinic follow-up visits, and there was a mean follow-up period of 13 months. Eleven of the 12 patients who had undergone placement of the bone flap irrigation system experienced complete resolution of the infection. In five patients there was involvement of the nasal sinus cavities, and in four there was a history of radiation treatment. In the one patient whose infection recurred, there was both involvement of the nasal sinuses and a history of extensive radiation treatment.

Conclusions

Infected bone flaps can be salvaged, thus avoiding the cost, risk, and possible disfigurement associated with flap removal and delayed cranioplasty. Although prior radiation treatment and involvement of the nasal sinuses may interfere with wound healing and clearance of the infection, these factors should not preclude the use of irrigation with antibiotic agents for bone flap salvage.
Reliability of cobalt–chromium alloy aneurysm clips after long-term implantations in patients with cerebral aneurysms
Authors: Otawara Yasunari , Endo Miguel M. , Ogasawara Kuniaki , Kubo Yoshitaka , Ogawa Akira , Watanabe Kouichi
Published: January 2008

Object

Aneurysm clip reliability after long-term implantation in vivo has not been examined. In this study the authors evaluated the mechanical properties and surface elemental composition of Co-Cr alloy aneurysm clips implanted for more than 10 years in patients with cerebral aneurysms.

Methods

Five aneurysm clips implanted for ruptured or unruptured intracranial aneurysms were retrieved and examined. New aneurysm clips were applied to the regrown aneurysms. The implantation period ranged from 11 to 20 years. Four new and unused aneurysm clips were also examined as controls. The mechanical properties of the clips were tested by measuring their closing force and bending strength. The surface elemental composition of the aneurysm clips was evaluated using x-ray photoelectron spectroscopy. The closing force of the retrieved clips exceeded the minimum force requirement at the time of manufacture. The bending strength was similar between the retrieved and control clips. Chromium oxide was the predominant constituent on the surface of all clips, and its concentration on the retrieved clips was higher than that on the control clips.

Conclusions

Data in the present study demonstrated that Co-Cr alloy aneurysm clips retain their mechanical properties in vivo for a long time, which indicates the reliability of these clips.
Magnesium infusion for vasospasm prophylaxis after subarachnoid hemorrhage
Authors: Stippler Martina , Crago Elizabeth , Levy Elad I. , Kerr Mary E. , Yonas Howard , Horowitz Michael B. , Kassam Amin
Published: January 2008

Object

Despite the application of current standard therapies, vasospasm continues to result in death or major disability in patients treated for ruptured aneurysms. The authors investigated the effectiveness of continous MgSO4 infusion for vasospasm prophylaxis.

Methods

Seventy-six adults (mean age 54.6 years; 71% women; 92% Caucasian) were included in this comparative matched-cohort study of patients with aneurysmal subarachnoid hemorrhage on the basis of computed tomography (CT) findings. Thirty-eight patients who received continuous MgSO4 infusion were matched for age, race, sex, treatment option, Fisher grade, and Hunt and Hess grade to 38 historical control individuals who did not receive MgSO4 infusion. Twelve grams of MgSO4 in 500 ml normal saline was given intravenously daily for 12 days if the patient presented within 48 hours of aneurysm rupture. Vasospasm was diagnosed on the basis of digital substraction angiography, CT angiography, and transcranial Doppler ultrasonography, and evidence of neurological deterioration.

Symptomatic vasospasm was present at a significantly lower frequency in patients who received MgSO4 infusion (18%) compared with patients who did not receive MgSO4 (42%) (p = 0.025). There was no significant difference in mortality rate at discharge (p = 0.328). A trend toward improved outcome as measured by the modifed Rankin Scale (p = 0.084), but not the Glasgow Outcome Scale (p = 1.0), was seen in the MgSO4-treated group.

Conclusions

Analysis of the results suggests that MgSO4 infusion may have a role in cerebral vasospasm prophylaxis if therapy is initiated within 48 hours of aneurysm rupture.
Evaluation of particulate systems supporting tumor cell fractions in a preventive vaccination against intracranial rat glioma
Authors: Sapin Anne , Clavreul Anne , Garcion Emmanuel , Benoit Jean-Pierre , Menei Philippe
Published: January 2008

Object

Irradiated autologous tumor cells are commonly used as a source of antigens in antiglioma vaccinations to activate the immune system. As cell number is often a limiting factor in these cells’ preparation, the aim of the present study was to find a means that can lower the amount of cells required. Among strategies currently developed, adjuvant particulate systems offer a promising means to improve the antitumor immune response. In this study, the authors were interested in evaluating the role of particulate systems containing biodegradable microspheres that carry tumor cell fractions on their surfaces in the induction of a protective immunity in the 9L/Fischer 344 rat glioma model. The efficiency of these particulate systems was compared to that of irradiated 9L cells.

Methods

Particulate systems composed of poly(d,l-lactide-co-glycolide) (PLGA) microspheres that support 9L cell fractions on their surfaces (cell lysates or plasma membranes) or irradiated 9L cells alone were injected subcutaneously into the flanks of syngeneic Fischer 344 rats. Eighteen days later, the rats were intracranially injected with nonirradiated 9L cells. A study of survival in these animals and an analysis of the resulting immune response were then conducted.

For the same amount of protein (50 μg) injected, irradiated 9L cells provided long-term survival in 30% of animals, whereas 9L plasma membranes adsorbed onto PLGA microspheres provided long-term survival in 10% of animals and cell lysates adsorbed onto microspheres provided long-term survival in 0%. Accordingly, particulate systems induced a lower T helper cell Type 1 (Th1) peripheral immune response than irradiated 9L cells. However, greater secretion of Th1 cytokines was observed when particulate systems were used than when cell fractions separated from microspheres were used, indicating the adjuvant property of these particulate systems.

Conclusions

Particulate systems have adjuvant properties but are still less efficient than irradiated whole tumor cells for vaccinations. Encapsulation of an activating molecule in the microsphere will be the next developmental step in the search for efficient antiglioma vaccinations.
Postoperative dural sinus thrombosis in a patient in a hypercoagulable state
Authors: Lega Bradley C. , Yoshor Daniel
Published: January 2008

✓ Spontaneous cerebral venous sinus thrombosis is a rare problem that may be encountered in patients with underlying thrombophilic disorders. It has also been reported as a postoperative complication following suboccipital, transpetrosal, and transcallosal approaches. The authors report on a 67-year-old man with two prior episodes of lower-extremity deep venous thrombosis who underwent transcallosal resection of a colloid cyst and in whom sagittal sinus thrombosis developed 2 weeks thereafter. Results of a subsequent hematological workup revealed both a factor V Leiden mutation and the presence of antiphospholipid antibodies, two thrombophilic risk factors that likely contributed to the development of delayed postoperative sinus thrombosis. Although the safety of low-molecular-weight heparin (LMWH) after craniotomy has not been established in a randomized, controlled study, there is sufficient evidence to justify its use for prophylactic anticoagulation therapy in patients at high risk for postoperative cerebral venous thrombosis. The authors propose using LMWH prophylaxis in patients with thrombophilic disorders who undergo neurosurgical procedures in proximity to dural sinuses in an effort to prevent catastrophic venous infarction.
Stereotactic radiosurgery as adjuvant treatment for residual solitary fibrous tumor
Authors: Nakahara Kuniaki , Yamada Masaru , Shimizu Satoru , Fujii Kiyotaka
Published: January 2008

✓ This 50-year-old woman presented with headache and visual disturbance. Neuroimaging results demonstrated a well-demarcated tumor attached to the falx cerebri near the transverse sinus, and the lesion was subtotally removed. Based on histological and immunohistochemical evaluation, a solitary fibrous tumor (SFT) was diagnosed. During the next 32 months, the size of the residual tumor increased slightly at the transverse sinus. Stereotactic radiosurgery (SRS) was performed as an adjuvant treatment. Over the course of the next 4 years the tumor decreased in size. The authors suggest that SRS constitutes good adjuvant treatment for regrowing residual SFTs not amenable to reoperation.
Shunts in normal-pressure hydrocephalus: do we place too many or too few?
Authors: Stein Sherman C. , Burnett Mark G. , Sonnad Seema S.
Published: January 2008

Object

The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts.

Methods

Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics.

Conclusions

In summary, many more patients with suspected NPH should be considered for shunt insertion.
Screening tests for normal-pressure hydrocephalus: sensitivity, specificity, and cost
Authors: Burnett Mark G. , Sonnad Seema S. , Stein Sherman C.
Published: January 2008

Object

Many tests have been proposed to help choose candidates for shunt insertion in cases of suspected normal-pressure hydrocephalus (NPH). It is unclear what sensitivity and specificity a prospective test must have to improve outcomes, compared with the results of automatic shunt insertion.

Methods

The authors adapted the decision analysis model used in a companion article to allow for application of a screening test. Using the reported sensitivities and specificities of several such tests, they evaluated the effects such tests would have on the expected outcome of an average 65-year-old patient with moderate dementia. They also evaluated the cost-effectiveness of a theoretical screening test with superior sensitivity and specificity.

Conclusions

Although external lumbar drainage comes quite close, none of the screening tests reported to date have sufficient sensitivity and specificity to improve expected outcome in an average candidate, compared with the results of automatic shunt placement in cases of suspected NPH. In addition, even a theoretically improved test would need to be considerably less expensive than prolonged lumbar drainage to be cost-effective in clinical practice.
The role of recombinant activated factor VII in neurosurgery: hope or hype?
Authors: Hawryluk Gregory W. J. , Cusimano Michael D.
Published: January 2008

✓ Recombinant activated factor VII (rFVIIa) is a relatively new pharmaceutical agent developed for use in patients with hemophilia in whom inhibitors to clotting factors VIII or IX have developed. Use of this drug has become common in recent years because of its efficacy and safety in patients with coagulation disorders as well as in patients who are at high risk for thromboembolism, even when other means of establishing hemostasis have failed. The use of rFVIIa in neurosurgery has lagged behind its use in other fields, although there is a growing body of literature on such uses. In this article the authors review the history and science of rFVIIa as well as dosing and safety information. Various uses pertinent to the neurosurgeon are reviewed, including the treatment of patients with coagulation disorders, those suffering trauma, and those with perioperative hemorrhage, intracerebral hemorrhage, or subarachnoid hemorrhage. Based on their review of the uses of rFVIIa, the authors conclude that rFVIIa is a safe and effective agent with the potential to revolutionize the treatment of neurosurgical patients with hemorrhage. Cost is a major impediment to the widespread use of rFVIIa, and there is some evidence that its use in the neurosurgical population may be subject to higher risk than in other populations studied thus far. Although further study is needed to better delineate the safety and efficacy of the drug in many nonlicensed uses, it is clear that rFVIIa is an agent with tremendous promise.
Quantitation of the lower subscapular nerve for potential use in neurotization procedures
Authors: Tubbs R. Shane , Khoury Charles A. , Salter E. George , Acakpo-Satchivi Leslie , Wellons John C. , Blount Jeffrey P. , Oakes W. Jerry
Published: January 2008

Object

New information regarding nerve branches of the brachial plexus can be useful to the surgeon performing neurotization procedures following patient injury. Nerves in the vicinity of the axillae have been commonly used for neural grafting procedures, with the exception of the lower subscapular nerve (LSN).

Methods

The authors dissected and measured the LSN in 47 upper extremities (left and right sides) obtained in 27 adult cadavers, and determined distances between the LSN and surrounding nerves to help quantify it for possible use in neurotization procedures.

The mean diameter of the LSN was 2.3 mm. The mean length of the LSN from its origin at the posterior cord until it branched to the subscapularis muscle was 3.5 cm, and the mean distance from this branch until its termination in the teres major muscle was 6 cm. Therefore, the mean length of the entire LSN from the posterior cord to the teres major was 9.5 cm.

When the LSN was mobilized to explore its possible use in neurotization, it reached the entrance site of the musculocutaneous nerve into the coracobrachialis muscle in all but three sides and was within 1.5 cm from this point in these three. In the other specimens, the mean length of the LSN distal to this site of the musculocutaneous nerve was 2 cm. The mobilized LSN reached the axillary nerve trunk as it entered the quadrangular space in all specimens. The mean length of the LSN distal to this point on the axillary nerve was 2.5 cm. Furthermore, on all but one side the LSN was found within the confines of an anatomical triangle previously described by the authors.

Conclusions

The authors hope that these data will prove useful to the surgeon for both identifying the LSN and planning for potential neurotization procedures of the brachial plexus.