bluuebunny/crossref_metadata_2025 huggingface dataset:
Variability in lesion location after microelectrode-guided pallidotomy for Parkinson's disease: anatomical, physiological, and technical factors that determine lesion distribution
Authors: Gross Robert E. , Lombardi Wendy J. , Hutchison William D. , Narula Soni , Saint-Cyr Jean A. , Dostrovsky Jonathan O. , Tasker Ronald R. , Lang Anthony E. , Lozano Andres M.
Published: May 2009

Object. To understand the factors that determine the distribution of lesions after microelectrode-guided pallidotomy for Parkinson's disease, the authors quantitatively characterized lesion location in a cohort of patients who were prospectively followed to determine the effects of pallidotomy on clinical outcome.

Methods. Thirty-three patients underwent volumetric magnetic resonance (MR) imaging after surgery to allow quantitative lesion localization in relation to conventional intraventricular landmarks and, alternatively, more anatomically relevant landmarks. The validity of the method was verified in a cohort of postpallidotomy patients who underwent concurrent volumetric and stereotactic MR imaging in an external head frame. Lesions were distributed over a considerable distance in the anteroposterior (8.8 mm) and mediolateral (8.7 mm) dimensions in relation to the anterior commissure and wall of the third ventricle, respectively. Less variation was seen in lesion location in the dorsoventral dimension (4.8 mm) in relation to the intercommissural plane.

Conclusions. Lesion distribution was not random: lesion locations in the anteroposterior and mediolateral dimensions were highly correlated, such that lesions were distributed from anteromedial to posterolateral, parallel to the border of the globus pallidus internus with the obliquely oriented internal capsule. The factors that led to variability in lesion location were variation in third ventricle width and the oblique anteromedial-to-posterolateral course of the internal capsule. This demonstration of variability of lesion location in a cohort of patients who experienced excellent clinical benefits and minimal postoperative complications emphasizes the importance of anatomical variations in determining lesion position and the need for physiological corroboration for correct lesion placement.
Stereotactic pallidotomy in a child with Hallervorden—Spatz disease
Authors: Justesen Chad R. , Penn Richard D. , Kroin Jeffrey S. , Egel Robert T.
Published: May 2009

✓ The authors present a case of Hallervorden—Spatz disease (HSD) in a 10-year-old boy treated with stereotactic pallidotomy for control of severe dystonia. Hallervorden—Spatz disease is a rare type of neuraxonal dystrophy that can be familial or sporadic. This is the first case of HSD reported in the literature in which a pallidotomy was performed. The patient had progressively worsening dystonias and spasms that prevented useful function of his entire right side and eventually threatened his respiratory ability. Pre- and postoperative magnetic resonance images are presented along with electrophysiological recordings made in the globus pallidus at the time of surgery. Functional improvement in the use of the patient's limbs and relief from the painful dystonia were observed. Stereotactic pallidotomy should be considered as a potential treatment in the management of HSD.
Late complications of Silastic duraplasty: low-virulence infections
Authors: Ekseth Kåre , Bostr∞m Sverre
Published: May 2009

✓ The authors describe three patients with expanding hemorrhagic mass lesions who presented 13 to 18 years after undergoing Silastic duraplasty. In all patients, results of bacteriological cultures of the masses obtained intraoperatively were positive, revealing low-virulence bacteria. Two of the patients were treated with antibiotic drugs and made a good recovery. The third did not receive antibiotic medications initially and later developed an epidural empyema that necessitated reoperation, but subsequently made a complete recovery. Vascularized neomembranes are generally agreed to be causes of the expanding masses, but the possibility that patients could be harboring chronic infections must be considered. Thus, on removal of duraplasty materials a complete bacteriological culture should be obtained, and if it is positive the proper antibiotic therapy should be administered. Furthermore, the creation of a registry of patients who have received implants is advocated to facilitate tracking of implanted material in case of complications.
Intracranial Castleman's disease of solitary form
Authors: Hashimoto Hiroyuki , Iida Jun-ichi , Hironaka Yasuo , Sakaki Toshisuke
Published: May 2009

✓ This 62-year-old woman presented with clumsiness in her right hand. Magnetic resonance imaging demonstrated a small lesion mimicking a meningioma, which had arisen from the tentorium and contained notable edema.

Full recovery was achieved by total removal of the lesion, which was diagnosed as a lymphoid mass resembling giant lymph node hyperplasia on histological examination. The lack of notable findings on whole-body and laboratory studies was compatible with a rare case of intracranial Castleman's disease of solitary form. The authors document clinical, neuroradiological, and pathological features of this rare disease.
Resolution of central pain after embolization of an arteriovenous malformation
Authors: Fukuhara Toru , McKhann Guy M. , Santiago Paul , Eskridge Joseph M. , Loeser John D. , Winn H. Richard
Published: May 2009

✓ The authors describe a patient with right-sided central pain resulting from a left parietal arteriovenous malformation (AVM). The AVM was treated with staged embolization and stereotactic radiosurgery, and its obliteration was documented on follow-up angiographic studies. Surprisingly, the patient noted complete resolution of her pain syndrome after embolization, which is an extremely rare result. Central pain and its proposed mechanisms are discussed.
Thalamic stimulation and functional magnetic resonance imaging: localization of cortical and subcortical activation with implanted electrodes
Authors: Rezai Ali R. , Lozano Andres M. , Crawley Adrian P. , Joy Michael L. G. , Davis Karen D. , Kwan Chun L. , Dostrovsky Jonathan O. , Tasker Ronald R. , Mikulis David J.
Published: May 2009

✓ The utility of functional magnetic resonance (fMR) imaging in patients with implanted thalamic electrodes has not yet been determined. The aim of this study was to establish the safety of performing fMR imaging in patients with thalamic deep brain stimulators and to determine the value of fMR imaging in detecting cortical and subcortical activity during stimulation.

Functional MR imaging was performed in three patients suffering from chronic pain and two patients with essential tremor. Two of the three patients with pain had undergone electrode implantation in the thalamic sensory ventralis caudalis (Vc) nucleus and the other had undergone electrode implantation in both the Vc and the periventricular gray (PVG) matter. Patients with tremor underwent electrode implantation in the ventralis intermedius (Vim) nucleus. Functional MR imaging was performed during stimulation by using a pulse generator connected to a transcutaneous extension lead. Clinically, Vc stimulation evoked paresthesias in the contralateral body, PVG stimulation evoked a sensation of diffuse internal body warmth, and Vim stimulation caused tremor arrest.

Functional images were acquired using a 1.5-tesla MR imaging system. The Vc stimulation at intensities provoking paresthesias resulted in activation of the primary somatosensory cortex (SI). Stimulation at subthreshold intensities failed to activate the SI. Additional stimulation-coupled activation was observed in the thalamus, the secondary somatosensory cortex (SII), and the insula. In contrast, stimulation of the PVG electrode did not evoke paresthesias or activate the SI, but resulted in medial thalamic and cingulate cortex activation. Stimulation in the Vim resulted in thalamic, basal ganglia, and SI activation.

An evaluation of the safety of the procedure indicated that significant current could be induced within the electrode if a faulty connecting cable (defective insulation) came in contact with the patient. Simple precautions, such as inspection of wires for fraying and prevention of their contact with the patient, enabled the procedure to be conducted safely. Clinical safety was further corroborated by performing 86 MR studies in patients in whom electrodes had been implanted with no adverse clinical effects.

This is the first report of the use of fMR imaging during stimulation with implanted thalamic electrodes. The authors' findings demonstrate that fMR imaging can safely detect the activation of cortical and subcortical neuronal pathways during stimulation and that stimulation does not interfere with imaging. This approach offers great potential for understanding the mechanisms of action of deep brain stimulation and those underlying pain and tremor generation.
Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding
Authors: Byrne James V. , Sohn Min-Joo , Molyneux Andrew J.
Published: May 2009

Object. During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding.

Methods. Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography.

Conclusions. Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.
A simple relationship between radiological arteriovenous malformation hemodynamics and clinical presentation: a prospective, blinded analysis of 31 cases
Authors: Norris John S. , Valiante Taufik A. , Wallace M. Christopher , Willinsky Robert A. , Montanera Walter J. , terBrugge Karel G. , Tymianski Michael
Published: May 2009

Object. The authors sought to establish prospectively whether there is a simple relationship between radiological features of brain arteriovenous malformation (AVM) hemodynamics and a patient's clinical presentation.

Methods. Thirty-one consecutive patients with AVMs underwent cerebral angiography at 3.8 frames/second during each standardized injection of contrast material. Contrast dilution curves were derived from the image sequences by using regions of interest (ROIs) traced on arteries feeding and veins draining the AVM nidus. Angiographic parameters were then analyzed in a blinded fashion. These parameters included the times required to reach the peak contrast density, the contrast decay time, and fractions thereof, in the ROI for each vessel. The authors determined whether these parameters, the arteriovenous transit time, and/or AVM size were related to patients' presentation with hemorrhage (11 patients), seizure (11 patients), or other clinical symptoms (nine patients). Statistically significant results were found only in analyses of arterial phase times to reach peak contrast density. Analyses of venous parameters, AVM size, and nidus transit time showed trends but no statistical significance. Arterial filling with contrast material was significantly slower in patients presenting with hemorrhage (mean 50%, 80%, and 100% of time to peak ± standard error [SE] = 1.19 ± 0.13, 1.97 ± 0.18, and 3.04 ± 0.34 seconds, respectively) compared with patients presenting with seizures (mean 50%, 80%, and 100% of time to peak ± SE = 0.80 ± 0.12, 1.32 ± 0.18, and 1.95 ± 0.29 seconds, respectively) according to analysis of variance (p < 0.05) and post-hoc t-tests (p < 0.05) for each parameter. Patients who presented with other symptoms had intermediate arterial filling times.

Conclusions. These simple hemodynamic parameters, which can be obtained without added risk to the patient, may help identify a subset of individuals in whom AVMs pose a higher risk of future hemorrhage and who may therefore warrant more expeditious treatment.
Topographic anatomy of the insular region
Authors: Türe Uğur , Yaşargil Dianne C. H. , Al-Mefty Ossama , Yaşargil M. Gazi
Published: May 2009

Object. The insula is one of the paralimbic structures and constitutes the invaginated portion of the cerebral cortex, forming the base of the sylvian fissure. The authors provide a detailed anatomical study of the insular region to assist in the process of conceptualizing a reliable surgical approach to allow for a successful course of surgery.

Methods. The topographic anatomy of the insular region was studied in 25 formalin-fixed brain specimens (50 hemispheres). The periinsular sulci (anterior, superior, and inferior) define the limits of the frontoorbital, frontoparietal, and temporal opercula, respectively. The opercula cover and enclose the insula. The limen insula is located in the depths of the sylvian fissure and constitutes the anterobasal portion of the insula. A central insular sulcus divides the insula into two portions, the anterior insula (larger) and the posterior insula (smaller). The anterior insula is composed of three principal short insular gyri (anterior, middle, and posterior) as well as the accessory and transverse insular gyri. All five gyri converge at the insular apex, which represents the most superficial aspect of the insula. The posterior insula is composed of the anterior and posterior long insular gyri and the postcentral insular sulcus, which separates them. The anterior insula was found to be connected exclusively to the frontal lobe, whereas the posterior insula was connected to both the parietal and temporal lobes. Opercular gyri and sulci were observed to interdigitate within the opercula and to interdigitate the gyri and sulci of the insula. Using the fiber dissection technique, various unique anatomical features and relationships of the insula were determined.

Conclusions. The topographic anatomy of the insular region is described in this article, and a practical terminology for gyral and sulcal patterns of surgical significance is presented. This study clarifies and supplements the information presently available to help develop a more coherent surgical concept.
Complex right hemisphere developmental venous anomaly associated with multiple facial hemangiomas
Authors: Aagaard Beverly D. L. , Song Joon K. , Eskridge Joseph M. , Mayberg Marc R.
Published: May 2009

✓ Complex developmental venous anomalies (DVAs) represent variations of normal cerebral venous drainage and consist of dilation of the superficial and/or deep venous system. These rare anomalies can occur unilaterally or bilaterally, supratentorially or infratentorially, focally or they can affect the entire hemisphere. Some DVAs are associated with cervicofacial venous malformations or facial lymphatic malformations. Anomalies of this type are generally clinically silent, and cerebral dysfunction is usually absent. Symptoms, when they occur, are most commonly headache or mild seizure disorders. The angiographic findings are striking, with well-formed but enlarged transcerebral medullary and deep and/or superficial cortical veins. Opacification of these venous structures occurs within the same time frame as a normal angiographic venous phase.

The authors report the case of a 33-year-old man in whom a large inoperable arteriovenous malformation had been previously diagnosed and who presented with seizures. Repeated magnetic resonance imaging and angiography demonstrated abnormally dilated transcerebral, superficial, and deep venous structures involving the entire right hemisphere with no identifiable nidus. Additionally, multiple bilateral benign facial hemangiomas were present in this patient.

It is important to recognize this rare venous appearance as a developmental variant and not mistake it for an arteriovenous malformation or a partially thrombosed vein of Galen malformation. Because these venous anomalies are extreme variants of the normal venous system, hemorrhage rarely, if ever, occurs and the patient can be reassured that no interventional or surgical therapy is necessary or warranted.
Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils
Authors: Solander Sten , Ulhoa Alexandre , Viñuela Fernando , Duckwiler Gary R. , Gobin Y. Pierre , Martin Neil A. , Frazee John G. , Guglielmi Guido
Published: May 2009

Object. The purpose of this paper is to present the authors' experience with Guglielmi detachable coil (GDC) embolization of multiple intracranial aneurysms and to evaluate the results of this therapy in single-stage procedures.

Methods. Clinical and angiographic evaluations were performed in 38 consecutive patients with multiple intracranial aneurysms treated by GDC embolization between March 1990 and October 1997. Twenty-nine patients presented with subarachnoid hemorrhage (SAH), four with mass effect, and five were asymptomatic. These 38 patients harbored 101 aneurysms, 79 of which were treated with GDCs, 14 by surgical clipping, and eight were left untreated. Of the GDC-treated lesions, a complete endovascular occlusion was achieved in 55 aneurysms (70%), and 24 (30%) presented neck remnants. Twenty-five patients (66%) underwent GDC embolization of more than one aneurysm in the first session. Eighteen (86%) of 21 patients with acute SAH underwent treatment for all aneurysms within 3 days after admission (15 of 21 in one session). Follow-up angiographic studies in 30 patients demonstrated an unchanged or improved result in 94% of the aneurysms (59 lesions) and coil compaction in 6% (four lesions). The overall clinical outcome was excellent in 34 patients (89%), good in one (3%), fair in one (3%), and death in two (5%).

Conclusions. Endovascular treatment of multiple intracranial aneurysms, regardless of their location, with GDCs was performed safely in one session, even during the acute phase of SAH. Treatment of all aneurysms in one session protected the patient from rebleeding and eliminated the risk of mistakenly treating only the unruptured aneurysms.
Lack of correlation between neuronal hyperexcitability and electrocorticographic responsiveness in epileptogenic human neocortex
Authors: Telfeian Albert E. , Spencer Dennis D. , Williamson Anne
Published: May 2009

Object. The purpose of this study was to determine whether intrinsic neuronal properties and synaptic responses differed between interictally active and inactive tissue removed in neocortical resections from patients undergoing surgical treatment for epilepsy.

Methods. Whole-cell patch recordings were performed in layer 2 or 3 and layer 5 pyramidal cells in neocortical slices obtained from tissue surgically removed from patients for the treatment of medically intractable seizures. Synaptic responses to stimulation at the layer 6—white matter border were used to classify cells as nonbursting if they responded with only a single action potential for all above-threshold stimuli (80%). These responses were usually followed by biphasic inhibitory postsynaptic potentials (IPSPs). Cells were classified as bursting if they fired at least three action potentials in response to synaptic stimulation (20%). These cells typically showed no IPSPs and responded in either an all-or-nothing or graded fashion. Approximately twice as many cells at layer 2 or 3 (29%) than cells at layer 5 (14%) fired synaptic bursts. Synaptic bursting was not associated with an alteration in a cell's response properties to γ-aminobutyric acid. It was notable that, in tissue samples determined by electrocorticography (ECoG) to be either interictally active or not active, the proportion of cells that burst was exactly the same in both groups (24%). We found no cells with intrinsic burst firing.

Conclusions. We conclude that synaptic bursting was characteristic of a small proportion of cells from epileptic tissue; however, this did not correlate with interictal spikes on ECoG.
Successful cerebral artery stent placement for total occlusion of the vertebrobasilar artery in a patient suffering from acute stroke
Authors: Mori Takahisa , Kazita Ken , Seike Masato , Nojima Yuji , Mori Koreaki
Published: May 2009

✓ A 64-year-old man suffering from crescendo brainstem symptoms due to acute total occlusion of the vertebrobasilar artery was successfully treated by cerebral artery stent placement. The total occlusion of a long segment of the vertebrobasilar artery was completely recanalized by implanting two flexible, balloon-expandable coronary stents. The patient's clinical outcome 30 days later was favorable. No complications occurred during or after the procedure. This therapeutic option may prove to be a useful means to revascularize an acute total occlusion of the vertebrobasilar artery.
Benefit of bilateral pallidotomy in the treatment of generalized dystonia
Authors: Lin Juei-Jueng , Lin Ging-Yau , Shih Chunhsi , Lin Shinn-Zong , Chang Dar-Cheng , Lee Chan-Chian
Published: May 2009

✓ This 29-year-old man with cerebral palsy complicated by generalized dystonia was treated by simultaneous bilateral posteroventral pallidotomy. Postoperatively, there was slow, but steady, improvement in the patient's dystonia and disability. However, the improvement in abnormal movements was only prominent for cervical dystonia and oromandibular dyskinesia. The patient's Burke-Fahn-Marsden dystonia scores were 51 preoperatively and 37, 33.5 and 33.5, at 3, 6, and 12 months postoperatively, respectively, demonstrating a maximum improvement of 34%. These results suggest that pallidotomy can be an alternative therapy for those patients suffering from intractable generalized dystonia.
Anatomical and functional connectivity of the transected ulnar nerve after intercostal neurotization in cats
Authors: Isla Alberto , Bejarano Bartolomé , Morales Carmen , Conde Concepción Pérez , Avendaño Carlos
Published: May 2009

Object. Acute transfer of three intercostal nerves to the ulnar nerve was performed in cats for histological and clinical evaluation of a distal muscle reinnervation.

Methods. Infraclavicular intercostal-ulnar communications were created after dividing the motor branches of the upper intercostal nerves in 14 adult cats. Reinnervation of distal forelimb muscles in the ulnar territory was assessed by electromyographic (EMG) studies and motor function rating each month until 18 months postsurgery. In five of these treated animals, and in four controls, horseradish peroxidase (HRP) was applied to the ulnar or intercostal nerves to study the amount and distribution of retrograde motor neuron labeling in the spinal cord. Also, samples of reinnervated muscles and neurotized ulnar nerves were processed to assess regeneration.

Simple ulnar transection without reconstruction led to permanent atrophy of ulnar muscles, lack of recovery according to EMG or clinical studies, and disappearance of the ulnar motor neuron pool. In contrast, ulnar neurotization with the intercostal nerves led to a high rate of functional recovery, which began 5 months postsurgery, and progressed from muscle activity synchronized with ventilatory movements to spontaneous movements that were independent of respiration. This recovery was accompanied by substantial retrograde labeling of intercostal motor neurons after HRP application in the ulnar nerve. Cell counts showed that practically the whole motor neuron pool of the involved intercostal nerves contributed to reinnervation of the transected ulnar nerve.

Conclusions. These findings demonstrate that the use of intercostal nerves to neurotize long brachial plexus nerves can achieve long-lasting and successful reinnervation of distal forelimb muscles.
Mitogen-activated protein kinase mediation of hemolysate-induced contraction in rabbit basilar artery
Authors: Zubkov Alexander Y. , Ogihara Kotaro , Tumu Phani , Patlolla Anita , Lewis Adam I. , Parent Andrew D. , Zhang John
Published: May 2009

Object. Mitogen-activated protein kinase (MAPK) is an important signaling factor in vascular proliferation and contraction, which are the two features of cerebral vasospasm that follow subarachnoid hemorrhage. The authors studied the possible involvement of MAPK in hemolysate-induced signal transduction and contraction in rabbit basilar artery (BA).

Methods. Isometric tension was used to record the contractile response of rabbit BA to hemolysate, and Western blots were obtained using antibodies for MAPK.

The following results are reported. 1) Hemolysate produced a concentration-dependent contraction of rabbit BA; however, preincubation of arteries with the MAPK kinase (MEK) inhibitor PD-98059 markedly reduced this contraction. The administration of PD-98059 also relaxed, in a concentration-dependent fashion, the sustained contraction induced by 10% hemolysate. 2) The Janus tyrosine kinase 2 inhibitor AG-490, preincubated with arterial rings, reduced the contractile response to hemolysate but failed to relax the sustained contraction induced by this agent. The Src-tyrosine kinase inhibitor damnacanthal and the phosphatidylinositol 3—kinase inhibitor wortmannin failed to reduce hemolysate-induced contraction. 3) Hemolysate produced a time-dependent elevation of MAPK immunoreactivity as seen on Western blots of rabbit BA. The MAPK was enhanced 1 minute after hemolysate exposure and the effect reached maximum levels at 5 minutes. The immunoreactivity of MAPK decayed slowly over time, but the level of this kinase was still higher than the basal level, even at 2 hours after exposure to hemolysate. Preincubation of arteries with the MEK inhibitor PD-98059 abolished the effect of hemolysate on MAPK immunoreactivity.

Conclusions. Hemolysate produced contraction of rabbit BA, possibly by activation of MAPK, and therefore MAPK inhibitors may be useful in the treatment of cerebral vasospasm.
Endoscopic ventriculocystocisternostomy of a quadrigeminal cistern arachnoid cyst
Authors: Hayashi Nakamasa , Endo Shunro , Tsukamoto Eiji , Hohnoki Shuji , Masuoka Toru , Takaku Akira
Published: May 2009

✓ The authors present the case of an elderly patient with a quadrigeminal arachnoid cyst who was successfully treated with endoscopic fenestration through the posterior wall of the third ventricle via the anterior horn of the lateral ventricle. This 71-year-old man suffered from progressive gait instability and disorientation. Radiological examination revealed hydrocephalus caused by a quadrigeminal arachnoid cyst. The patient underwent endoscopic fenestration of the quadrigeminal cistern arachnoid cyst and third ventriculostomy via one burr hole placed at the coronal suture. This method is less invasive and is effective for quadrigeminal cistern arachnoid cyst and accompanying hydrocephalus.
Sporadic unifocal infantile myofibromatosis involving the skull
Authors: Detwiler Paul W. , Porter Randall W. , Coons Stephen W. , Spetzler Robert F. , Carrion Carlos A. , Rekate Harold L.
Published: May 2009

✓ Infantile myofibromatosis involving the skull is a benign disease if there is a solitary lesion. However, the multifocal form with skull involvement may portend a lethal course in the 1st year of life if there is involvement of the heart, lungs, or gastrointestinal tract. The authors report the case of a 3-year-old boy with an enlarging left parietal skull lesion that had been present since infancy. Increasing pain and the need to obtain tissue for diagnosis led to resection of the lesion by means of a small craniectomy. Further evaluation revealed no other lesions. A distinctly rare disease is presented, and the need for staging in children younger than 2 years of age is suggested to rule out cardiac, pulmonary, or gastrointestinal involvement.
Surgical treatment of multiple neurofibromas of the ulnar nerve in segmental neurofibromatosis
Authors: González-Darder José M. , Pesudo-Martínez José V.
Published: May 2009

✓ The case of an 18-year-old man with numerous neurofibromas along his left ulnar nerve is described. The patient had a painful mass in the medial third of the internal aspect of his left forearm, and two additional symptomatic painful masses were identified during clinical examination: one in the distal portion of the retroepitroclear groove and another near the Guyon tunnel in the wrist. The main symptom was neurogenic pain; however, sensory and motor disturbances were also present. No other stigma of neurofibromatosis (NF) was found, and no cases of NF were known in the patient's family. During surgery many neurofibromas were found; the three painful neurofibromas and some of the other larger lesions were microsurgically excised. The patient's symptoms fit the criteria for segmental NF or NF5. This is a very rare form of NF characterized by lesions located in a particular area of the body.
Treatment of postoperative subgaleal cerebrospinal fluid fistulas by using fibrin sealant
Authors: Menovsky Tomas , de Vries Joost , Bloss Heinz-Georg
Published: May 2009

✓ The authors describe a simple technique by which a postoperative subgaleal cerebrospinal fluid fistula is treated by local tapping and injection of fibrin sealant through the same needle.
Experience with a programmable valve shunt system
Authors: Yamashita Nobuko , Kamiya Ken , Yamada Kazuo
Published: May 2009

Object. The goal of this study was to clarify the efficacy of the Codman Hakim programmable valve. Clinical data obtained in 179 patients with hydrocephalus or other intracranial fluid—accumulating diseases were analyzed.

Methods. Shunt placement operations were effective in 168 patients, approximately one half (50.6%) of whose devices required reprogramming of opening pressure postoperatively. This was a significantly larger number of shunts than the authors had thought would need reprogramming. Extremely narrowed ventricles observed on computerized tomography scans, as well as clinical symptoms related to inadequate or excessive cerebrospinal fluid drainage, improved in patients after shunt reprogramming. Shunt reprogramming frequently was necessary in patients with posthemorrhagic acute hydrocephalus; the programmable valve proved particularly beneficial for such patients. Subdural effusion and arachnoid cyst also proved to be good indications for use of the valve. Twelve patients (7%) suffered complications postoperatively. The most common complication was valve obstruction, which occurred in five patients, most of whom had brain tumors.

Conclusions. The programmable valve was beneficial for the treatment of hydrocephalus and other intracranial fluid—accumulating diseases. It is important to be careful in selecting patients for treatment with the programmable valve, because complications involving the valve seem more likely in brain tumor cases. The valve proved to be poorly resistant to magnetic fields; therefore, it is essential to confirm opening pressure after every magnetic resonance imaging examination. The authors recommend that an identification system for patients be developed so that medical personnel will be aware of the presence of the valve and the previous setting of opening pressure.
Functional neuronavigation with magnetoencephalography: outcome in 50 patients with lesions around the motor cortex
Authors: Ganslandt Oliver , Fahlbusch Rudolf , Nimsky Christopher , Kober Helmut , Möller Martin , Steinmeier Ralf , Romstöck Johann , Vieth Jürgen
Published: May 2009

Object. The authors conducted a study to evaluate the clinical outcome in 50 patients with lesions around the motor cortex who underwent surgery in which functional neuronavigation was performed.

Methods. The sensorimotor cortex was identified in all patients with the use of magnetoencephalography (MEG). The MEG-source localizations were superimposed onto a three-dimensional magnetic resonance image and the image data set was implemented into a neuronavigation system. Based on this setup, the surgeon chose the best surgical strategy. During surgery, the pre- and postcentral gyri were identified by neuronavigation and, in addition, the central sulcus was localized using intraoperative recording of somatosensory evoked potentials. In all cases MEG localizations of the sensory or motor cortex were correct. In 30% of the patients preoperative paresis improved, in 66% no additional deficits occurred, and in only 4% (two patients) deterioration of neurological function occurred. In one of these patients the deterioration was not related to the procedure.

Conclusions. The method of incorporating functional data into neuronavigation systems is a promising tool that can be used in more radical surgery to lessen morbidity around eloquent brain areas.
Human arachnoid villi response to subarachnoid hemorrhage: possible relationship to chronic hydrocephalus
Authors: Massicotte Eric M. , Del Bigio Marc R.
Published: May 2009

Object. The origin of chronic communicating hydrocephalus following subarachnoid hemorrhage (SAH) is not well understood. Fibrosis of the arachnoid villi has been suggested as the cause for obstruction of cerebrospinal fluid (CSF) flow, but this is not well supported in the literature. The goal of this study was to determine the relationship between blood, inflammation, and cellular proliferation in arachnoid villi after SAH.

Methods. Arachnoid villi from 50 adult patients were sampled at autopsy. All specimens were subjected to a variety of histochemical and immunohistochemical stains. The 23 cases of SAH consisted of patients in whom an autopsy was performed 12 hours to 34 years post-SAH. Fifteen cases were identified as moderate-to-severe SAH, with varying degrees of hydrocephalus. In comparison with 27 age-matched non-SAH controls, the authors observed blood and inflammation within the arachnoid villi during the 1st week after SAH. Greater mitotic activity was also noted among arachnoid cap cells. The patient with chronic SAH presented with ventriculomegaly 2 months post-SAH and exhibited remarkable arachnoid cap cell accumulation.

Conclusions. The authors postulate that proliferation of arachnoidal cells, triggered by the inflammatory reaction or blood clotting products, could result in obstruction of CSF flow through arachnoid villi into the venous sinuses. This does not exclude the possibility that SAH causes generalized fibrosis in the subarachnoid space.
Falcotentorial plasmacytoma
Authors: Vaicys Ceslovas , Schulder Michael , Wolansky Leo J. , Fromowitz Frank B.
Published: May 2009

✓ Intracranial solitary plasmacytomas are extremely rare tumors and are often misdiagnosed preoperatively. The authors report the successful treatment of a patient who harbored such a tumor involving both the falx and tentorium; this is the second case reported. A 59-year-old woman suffered from a seizure disorder due to a falcotentorial lesion, which had been identified 3 years earlier and was thought at the time to be an en plaque meningioma. Most recently, the patient presented with symptoms of increased intracranial pressure and hemiparesis. Computerized tomography and magnetic resonance imaging of her head revealed progressive growth of the tumor. The patient underwent partial resection of the tumor and chemo- and radiation therapies. Intracranial plasmacytomas must always be included in a differential diagnosis because potential complete cure can be achieved using fairly conservative treatment modalities.
Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing's disease
Authors: Semple Patrick L. , Laws Edward R.
Published: May 2009

Object. Transsphenoidal surgery is the usual treatment of choice for adrenocorticotropic hormone—secreting pituitary adenomas associated with Cushing's disease. In this paper the authors investigate the complications of transsphenoidal surgery in the treatment of a contemporary series of patients with Cushing's disease.

Methods. Between January 1992 and December 1997, 105 patients with Cushing's disease underwent transsphenoidal surgery at the University of Virginia Health Sciences Center. A retrospective analysis of the complications was conducted, and the mortality rate was found to be 0.9% and permanent morbidity was 1.8%. The overall number of complications was 14 (13.3%), which included seven complications directly related to surgery; one instance of permanent diabetes insipidus; one syndrome of inappropriate secretion of antidiuretic hormone; and five medical complications (four patients developed deep vein thrombosis and one developed pneumonia).

Conclusions. Transsphenoidal surgery for Cushing's disease has a higher complication rate than that for pituitary adenomas in general. This is primarily related to a greater number of medical complications, most notably deep vein thrombosis, resulting from the generally debilitated state of most patients with Cushing's disease. In view of the high incidence of deep vein thrombosis in these patients, prophylaxis for thromboembolism during the perioperative period is recommended.
Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients
Authors: Taniguchi Masaaki , Takimoto Hiroshi , Yoshimine Toshiki , Shimada Nobumitsu , Miyao Yasuyoshi , Hirata Masayuki , Maruno Motohiko , Kato Amami , Kohmura Eiji , Hayakawa Toru
Published: May 2009

Object. To enhance visual confirmation of regional anatomy, endoscopy was introduced during microsurgery for cerebral aneurysms. The risks and benefits are analyzed in the present study.

Methods. The endoscopic technique was used during microsurgery for 54 aneurysms in 48 patients. Forty-three aneurysms were located in the anterior circulation and 11 were in the posterior circulation. Thirty-eight aneurysms (70.4%) had not ruptured. All ruptured aneurysms in the present series produced Hunt and Hess Grade I or II subarachnoid hemorrhage.

After initial exposure achieved with the aid of a microscope, the rigid endoscope was introduced to confirm the regional anatomy, including the aneurysm neck and adjacent structures. The necks of 43 aneurysms were clipped using microscopic control or simultaneous microscopic/endoscopic control. After clipping, the positions of the clip and nearby structures were inspected using the endoscope.

Use of the neuroendoscope provided useful information that further clarified the regional anatomy in 44 cases (81.5%) either before or after neck clipping. In nine cases (16.7%), these details were available only with the use of the endoscope. In five cases (9.3%), the surgeons reapplied the clip on the basis of endoscopic information obtained after the initial clipping. There were two cases in which surgical complications were possibly related to the endoscopic procedures (one patient with asymptomatic cerebral contusion and another with transient oculomotor palsy).

Conclusions. It is the authors' impression that the use of the endoscope in the microsurgical management of cerebral aneurysms enhanced the safety and reliability of the surgery. However, there is a prerequisite for the surgeon to be familiar with this instrumentation and fully prepared for the risks and inconveniences of endoscopic procedures.
Antisense oligonucleotide—induced inhibition of adrenocorticotropic hormone release from cultured human corticotrophs
Authors: Frankel Bruce , Longo Sharon L. , Rodziewicz Gerard S. , Hodge Charles J.
Published: May 2009

Object. Available therapies for Cushing's disease are often inadequate or involve the risk of significant morbidity. Accordingly, the need arises for the development of novel treatments, especially for cases caused by corticotroph hyperplasia, a condition difficult to treat using standard therapies. In this study, the authors investigated the use of phosphorothioate antisense oligonucleotides as a potential treatment for Cushing's disease.

Methods. Corticotrophs, obtained from a patient with Cushing's disease in whom pathological findings showed multifocal areas of corticotroph adenoma and hyperplasia, were grown in tissue culture. By assessing cell viability and using immunoradiometric assay techniques, it was determined that these cells grew autonomously and secreted adrenocorticotropic hormone (ACTH) in vitro. A fully phosphorothioated antisense oligonucleotide was constructed to be complementary to the first 25 bp of the region coding for ACTH in exon 3 of the proopiomelanocortin precursor. After incubation of the corticotrophs with liposome-coated phosphorothioate antisense oligonucleotides, a greater than 90% decrease in ACTH release was noted on Days 3 and 6, compared with nonsense-treated controls (p < 0.05).

Conclusions. Antisense oligonucleotides may prove to be a useful adjunct in treating Cushing's disease by targeting one of its fundamental problems, ACTH hypersecretion.
Recurrent intracranial Masson's vegetant intravascular hemangioendothelioma
Authors: Avellino Anthony M. , Grant Gerald A. , Harris A. Basil , Wallace Sharon K. , Shaw Cheng-Mei
Published: May 2009

✓ In the central nervous system, recurrence of intracranial Masson's vegetant intravascular hemangioendothelioma (MVIH) is rare. To the authors' knowledge, only three recurrent intracranial cases have been reported.

The authors report the case of a 75-year-old woman with a recurrent left-sided cerebellopontine angle and middle cranial fossa MVIH. When the patient was 62 years of age, she underwent preoperative embolization and subtotal resection of the intracranial lesion followed by postoperative radiotherapy. She was well and free from disease until 9 years postoperatively when she became symptomatic. At 71 years of age, the patient again underwent preoperative embolization and near-gross-total resection of the lesion. Follow-up imaging performed 15 months later revealed tumor recurrence, and she underwent stereotactic gamma knife radiosurgery. At a 2.75-year follow-up review, the patient's imaging studies revealed stable residual tumor.

This case report is unique in that it documents the clinical and pathological features, surgical and postoperative treatment, and long-term follow-up review of a patient with recurrent intracranial MVIH and suggests that this unusual vascular lesion is a slow-growing benign tumor rather than a reactive process. Because the pathological composition of the lesion may resemble an angiosarcoma, understanding this benign vascular neoplasm is crucial so that an erroneous diagnosis of malignancy is not made and unnecessary adjuvant therapy is not given.
Congenital intraorbital optic nerve cyst
Authors: Kim Kyoung Mee , Kang Seok Jin , Kim Dal Soo , Chi Je G. , Kim Sun Moo
Published: May 2009

✓ Congenital cystic lesions of the optic nerve are exceedingly rare; only one case is reported in the world literature. The authors describe a case of congenital simple glial cyst in the intraorbital portion of the optic nerve with a brief review of the literature and comment on its histogenesis.

A 45-day-old male infant was admitted to the hospital because of progressive proptosis and hypotropia in the left eye, which had been present since birth. Magnetic resonance imaging of the left orbit revealed an ovoid, well-demarcated, homogeneous cystic mass in the intraconal retrobulbar area. The mass compressed the left eyeball with downward and lateral displacement. The wall of the cystic mass was very thin, and a needle puncture of the cyst released clear, colorless, watery fluid. The cystic wall was lined by loose astroglial nerve fibers with some scattered glial cells.
Pineal epidermoid cysts: diagnosis and management
Authors: Konovalov Alexander Nikolaevich , Spallone Aldo , Pitzkhelauri David Ilich
Published: May 2009

Object. The results of surgical treatment of epidermoid cysts of the pineal region in six cases are presented.

Methods. Six patients with pineal epidermoid cysts underwent surgery at the Institute of Neurosurgery “N. N. Burdenko,” in Moscow, during the period 1976 to 1995. The duration of the patients' preadmission clinical history varied from 6 months to 2 years (average 1.4 years). Headache, diplopia, and vertigo were the most frequently occurring symptoms. Neurological examination demonstrated papilledema, impaired pupillary reaction, ataxia, and long-pathways deficit; Parinaud's syndrome was found in only one case. Computerized tomography and magnetic resonance imaging constituted the primary diagnostic tools. Surgery was performed using either an infratentorial—supracerebellar approach (two cases) or an occipital—transtentorial approach (four cases).

Conclusions. Surgical results can be excellent if a removal, as extensive as possible, is performed using either the supracerebellar or occipital—transtentorial approach.
Expression of the JAK and STAT superfamilies in human meningiomas
Authors: Magrassi Lorenzo , De-Fraja Claudio , Conti Luciano , Butti Giorgio , Infuso Lodovico , Govoni Stefano , Cattaneo Elena
Published: May 2009

Object. The goal of this study was to investigate whether the janus kinase/signal transducer and activator of transcription (JAK/STAT) signal transduction pathway is present and active in meningiomas. The results of these investigations are important for all meningioma therapies that, similar to interferon-α-2B (IFNα-2B), depend on activation of this pathway for their effect. The authors were interested in evaluating the importance, if any, of the JAK/STAT pathway in the biology and therapy for these tumors.

Methods. Total proteins were extracted from 17 meningioma samples and the levels of JAKs and STATs were determined by using Western blot analysis. Levels of these proteins in meningiomas were compared with those found in normal dura. The JAKs and STATs (with the exception of Jak3 and Tyk2) were present both in the dura and in the meningiomas studied. In tumors JAK and STAT levels were always significantly higher than those found in normal dura. Differences in relative levels were found when meningiomas were subdivided according to the current neuropathological criteria and the highest levels were found in transitional meningiomas. The authors also investigated, using tyrosine-phosphorylated Stat1 and Stat3 antibodies, whether STATs were activated in meningiomas and normal dura in vivo. Their results indicate that both Stat1 and Stat3 are phosphorylated in vivo in meningiomas and in the dura. Furthermore, in vitro experiments in which two independent short-term cultures obtained from freshly dissected meningioma samples were used indicated that Stat1 and Stat3 are phosphorylated in response to treatment with IFNα-2B. Exposure of meningioma cells to IFNα-2B leads to nuclear translocation of tyrosine-phosphorylated Stat1 and Stat3, as demonstrated by immunocytochemical analysis.

Conclusions. The results of this study indicate that the JAK and STAT families of proteins are important effectors in brain tumors and support the idea that the effects of IFNα in vivo are direct and not mediated by the immune system. This suggests a role for modulation of STAT transcription factors in inhibiting meningioma cell proliferation.
Meningioma recurrence at a different site masquerading as a subdural hematoma
Authors: Timothy Jake , Lafuente David , Chakrabarty Arundhati , Saxena Amar , Marks Paul
Published: May 2009

✓ It is unusual for a meningioma to recur at a distant site. It is more unusual for a meningioma to present as a subdural hematoma. The authors report a unique case in which both of these events occurred in the same patient during a 4-year period. The authors discuss the pathogenesis of these rare events with regard to meningiomas.