bluuebunny/crossref_metadata_2025 huggingface dataset:
Evidence for telomerase involvement in the angiogenesis of astrocytic tumors: expression of human telomerase reverse transcriptase messenger RNA by vascular endothelial cells
Authors: Pallini Roberto , Pierconti Francesco , Falchetti Maria Laura , D'Arcangelo Daniela , Fernandez Eduardo , Maira Giulio , D'Ambrosio Ettore , Larocca Luigi Maria
Published: May 2009

Object. Evidence from recent in vitro studies indicates that reactivation of telomerase, the enzyme that synthesizes the telomere ends of chromosomes, is a crucial event in the unlimited clonal expansion of endothelial cells that precedes the neoplastic conversion of these cells. It is known that high-grade gliomas express telomerase and that, in these neoplasms, proliferating endothelial cells may undergo transformational changes with development of sarcomatous components within the primitive tumor. To assess whether telomerase is involved in the endothelial cell proliferation that characterizes brain tumor angiogenesis, the authors investigated at the single-cell level the expression of messenger (m)RNA for the human telomerase catalytic subunit human telomerase reverse transcriptase (hTERT) by vascular cells of astrocytic tumors.

Methods. The in situ hybridization (ISH) method was performed by processing histological sections with specific riboprobes for hTERT and for c-myc, an oncogene that is known to upregulate hTERT. Results of the ISH studies were compared with proliferative activity, as estimated by Ki-67 immunostaining. The expression of hTERT mRNA by vascular endothelial cells was related to the histological grade of the tumor because it was detected in five (29%) of 17 low-grade astrocytomas, nine (56%) of 16 anaplastic astrocytomas, and 19 (100%) of 19 glioblastomas multiforme (GBMs). Expression of c-myc mRNA was strictly correlated with that of hTERT mRNA. In low-grade astrocytomas and anaplastic astrocytomas, a dissociation was noted between hTERT mRNA expression and the proliferation rate of endothelial cells. Conversely, GBMs displayed a significant correlation between the level of hTERT mRNA expression and endothelial cell proliferation. Data from an in vitro assay in which human umbilical vein endothelial cells were stimulated to proliferate by adding vascular endothelial growth factor and an ISH study of newly formed vessels surrounding brain infarcts confirmed that expression of hTERT mRNA does not merely reflect the proliferative status of endothelial cells but represents a specific feature of brain tumor neovascularization.

Conclusions. The results of this study are consistent with a role of telomerase in the angiogenesis of astrocytic tumors. Expression of hTERT mRNA by tumor vascular cells is an early event during the progression of astrocytic tumors, which precedes endothelial cell proliferation and may represent a first sign of dedifferentiation. Other than elucidating the mechanisms of tumor angiogenesis, these results encourage research on antitelomerase drugs for the treatment of malignant gliomas.
Molecular determinants of glioma cell migration and invasion
Authors: Wild-Bode Christine , Weller Michael , Wick Wolfgang
Published: May 2009

Object. Migration and invasion are important prerequisites for the infiltrative and destructive growth patterns of malignant gliomas. Infiltrative growth prevents complete tumor resection and causes significant neurological morbidity and mortality.

Methods. The authors assessed the expression of matrix metalloproteinases (MMPs) at messenger RNA and protein levels, MMP-2 and MMP-9 activities, and expression levels of a panel of anti- and proapoptotic proteins of the BCL-2 family. They then correlated their findings with αVβ3 integrin expression and the migratory and invasive potentials in 12 human malignant glioma cell lines.

Multiple MMPs were expressed by most cell lines. The levels of MMP-2 and MMP-3 and the activities of MMP-2 and MMP-9 correlated with tumor cell invasion. Migration and invasion were also correlated. Although the expression levels of αVβ3 integrin did not predict migration or invasion, a neutralizing αVβ3 integrin antibody inhibited migration and invasion selectively in cell lines that contained a high level of αVβ3 integrin expression, thus indicating the important role of αVβ3 integrin for migration and invasion in this subset of cell lines. An expression pattern of BCL-2 family proteins that favor resistance to apoptosis was associated with enhanced migration, invasion, and MMP activity. Wild-type p53 cell lines migrated farther than mutant p53 cell lines.

Conclusions. Activities of MMP-2 and MMP-9 are the best predictors of glioma cell invasion. The αVβ3 integrin mediates migration and invasion in a subset of glioma cell lines, but these processes do not depend on αVβ3 integrin expression. Antiapoptotic BCL-2 family protein expression is a predictor of efficient migration and invasion.
Sagittal suture as an external landmark for the superior sagittal sinus
Authors: Tubbs R. Shane , Salter George , Elton Scott , Grabb Paul A. , Oakes W. Jerry
Published: May 2009

Object. Historically, the sagittal suture has been used as an external landmark to indicate the middle portion of the superior sagittal sinus (SSS). The goal of this study was to verify this relationship.

Methods. The authors examined 30 adult cadavers to reveal the location of the SSS with respect to the sagittal suture. Their findings demonstrated that the SSS is deviated to the right of the sagittal suture in the majority of observed specimens, although the maximum displacement to the right side was never more than 11 mm.

Conclusions. This information should be useful to the neurosurgeon who must be aware of the SSS and its relationship with superficial skull landmarks.
An unusual presentation of neurotuberculosis: subdural empyema
Authors: Çayli Süleyman R. , Önal ÇAğatay , Koçak Ayhan , Onmusş S. Hale , Tekiner Ayhan
Published: May 2009

✓ Tuberculosis continues to be a major public health concern, especially in developing countries. Many types of neurotuberculosis have been described, but there is only one previously reported case of subdural empyema caused by tuberculous bacilli. A 1-year-old boy who had been treated for pulmonary tuberculosis was referred to the authors' institution with a diagnosis of right frontoparietal extraaxial abscess formation. Computerized tomography and magnetic resonance imaging revealed an extraaxial abscess with no evidence of calvarial infection. A craniotomy was performed to drain the pus, which was located subdurally. A polymerase chain reaction test yielded positive results, and histopathological examination revealed caseation. Antituberculous treatment was started after a diagnosis of subdural empyema with related neurotuberculosis had been made. At the end of a 12-month course of medical therapy, the patient was well with no evidence of tuberculosis.
Serum cortisol response to transsphenoidal surgery for Cushing disease
Authors: Simmons Nathan E. , Alden Tord D. , Thorner Michael O. , Laws Edward R.
Published: May 2009

Object. Transsphenoidal surgery remains the optimal treatment for Cushing disease, but the definitions of surgical cure and failure remain debatable. In this study the authors evaluated serum cortisol levels in patients before and after they underwent transsphenoidal surgery to elucidate the patterns of cortisol decrease and the optimal time and criteria for determining surgically induced remission.

Methods. Twenty-seven patients were evaluated throughout an 8-month period. Serum cortisol levels were obtained before surgery and at 6-hour intervals postoperatively. No exogenous steroid medications were administered until after cortisol sampling was discontinued, following diagnosis of remission.

Twenty-one (78%) of 27 cases were labeled initial surgically induced remissions. Twenty-two (81%) of 27 cases were deemed surgically induced remissions at follow-up examination. Following surgery, initial remissions and failures demonstrated divergent patterns of cortisol levels. No patient whose condition was deemed an initial surgically induced remission has experienced definitive relapse of disease since discharge. One patient whose condition was initially deemed a surgical failure, eventually was found to exhibit surgically induced remission without further intervention.

Conclusions. Given such findings, exogenous steroid medications do not appear to be required for patients until after the determination of remission. During the 1st postoperative day, there is a time period during which serum cortisol values significantly differ between the categories of surgically induced remissions and surgical failures. Surgically induced remissions were identified when postoperative values of cortisol were lower than preoperative midnight levels and when absolute values of cortisol were less than 10 µg/dl. In a small proportion of patients remission on a delayed basis may also be demonstrated. These data allow for a simple and rapid determination of postoperative remission in patients undergoing transsphenoidal surgery for Cushing disease.
Identification of novel regions of allelic loss in ependymomas by high-resolution allelotyping with 384 microsatellite markers
Authors: Tong Carol Yuen-kwan , Zheng Ping-pin , Pang Jesse Chung-sean , Poon Wai-sang , Chang Alexander R. , Ng Ho-keung
Published: May 2009

Object. Ependymomas are rare glial neoplasms; little is known about the molecular pathogenesis of this tumor entity. In a previous study the authors found multiple genomic imbalances in ependymomas resected in 20 adults and eight children, including loss of chromosomes 1p, 6, 16, 17, 19q, 20q, and 22q, as well as gain of chromosomes 4q, 5q, 7q, 9q, and 12q on comparative genomic hybridization. The aim of this study was to map in more detail the commonly affected regions in ependymomas.

Methods. A comprehensive allelotype analysis of 16 ependymomas was conducted using 384 microsatellite markers that span the 22 autosomes. Based on this high-resolution loss of heterozygosity analysis, multiple overlapping deletion regions were identified as follows: 6q25.2–27, 16p12–13.1, 16q22.3–24.1, 17q22–24, 19q12–13.2, 20q13.2–13.3, and 22q13.1–13.3.

Conclusions. These data confirmed previous reports that loss of chromosomes 17 and 22 were common in ependymomas. Moreover, the authors were able to identify loss of chromosomes 13, 16, 19, and 20 as novel findings in ependymomas. It is believed that potential tumor suppressor genes that reside in these commonly deleted regions may contribute to the molecular tumorigenesis of ependymomas.
Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization
Authors: Hoh Brian L. , Putman Christopher M. , Budzik Ronald F. , Carter Bob S. , Ogilvy Christopher S.
Published: May 2009

Object. Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels, are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the “inflow zone,” the site most vulnerable to aneurysm growth and rupture, is used.

Methods. From 1991 to 1999 the combined neurosurgical—neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0–5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies—surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively.

Conclusions. Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.
Efficacy of controlled-release papaverine pellets in preventing symptomatic cerebral vasospasm
Authors: Dalbasti Tayfun , Karabiyikoglu Murat , Ozdamar Nurcan , Oktar Nezih , Cagli Sedat
Published: May 2009

Object. Vasospasm as a complication of subarachnoid hemorrhage is a major concern in clinical practice. The systemic drugs in current use are of limited value. Topical, intrathecal, or intraarterial papaverine administered during surgical or angiographic procedures is a potent vasodilating drug; however, hypotension limits its systemic application. Local application of papaverine in a biodegradable controlled- or sustained-release matrix is proposed for vasospasm prophylaxis to be used in patients scheduled for aneurysm surgery.

Methods. Controlled-release papaverine (PapaCR) drug pellets were prepared using the biodegradable aliphatic polyester poly(DL-lactide-co-glycolide) as the carrier matrix. In vitro tests were performed to determine drug kinetics. One hundred seventeen patients, 73 assigned to the control group and 44 assigned to the PapaCR-treated group, participated in this study. Patients who were deemed to be at high risk for the development of vasospasm were selected to participate in the study. During aneurysm surgery, drug pellets were placed in cisterns over arterial segments. In two patients, cerebrospinal fluid was sampled every 6 hours for the first 5 days through a lumbar catheter that had been inserted at the beginning of aneurysm surgery. The incidence of clinical vasospasm and Glasgow Outcome Scale scores in the patients were evaluated statistically.

The results of in vitro studies showed that effective local concentrations of papaverine could be maintained for more than 10 days. The first-degree drug-release profile was demonstrated using this design. In clinical studies no adverse effects due to the drug were seen. The PapaCR effectively prevented development of clinical vasospasm, and outcome scores were significantly better in patients in the treated group.

Conclusions. Local application of controlled- or sustained-release papaverine can be safely used in preventing vasospasm.
Sensory ganglionectomy: theory, technical aspects, and clinical experience
Authors: Wilkinson Harold A. , Chan Andy S.
Published: May 2009

Object. Sensory ganglionectomy offers theoretical advantages over rhizotomy but remains controversial because reported success rates vary widely. The authors sought to add to the available data on this subject and to review technical aspects of the surgery.

Methods. This retrospective chart review included 19 patients, in whom 22 operations were performed and 35 sensory ganglia were resected between May 1995 and May 1999. The eight women and 11 men ranged in age from 27 to 75 years (median age 40 years, average age 42.3 years). All patients had undergone extensive therapy and a mean of 2.4 previous operations (median three, range zero—eight operations) for their pain, all without long-term pain relief. Duration of symptoms varied, from 1 month (for the cancer patient) to 15 years (mean 5.9, median 4 years). Preoperatively, all patients underwent diagnostic selective nerve root blocks, which temporarily relieved their targeted pain. The duration of follow up averaged 22 months (median 13, range 1.5 [to death of the cancer patient]—58 months). Before undergoing the first ganglionectomy, nearly all patients rated their targeted pain as 8 to 10 (average 9.6, median 10) on an analog (0–10) pain scale.

At 6 months all patients rated their ganglionectomy-specific pain as an average of 4.5 (median 4, range 0–8), and pain reduction of 50% or more was achieved in 74%. At 1 year or more the 13 patients available for study rated their pain as an average of 4.3 (median 4.5, range 0–9). There were no severe complications, residual pain was never worse than presurgical pain, and no patient experienced significant or lasting new motor deficits.

Conclusions. Dorsal root ganglionectomy has a useful role in the treatment of a variety of refractory pain states, especially those involving radicular pain.
Reliability of intraoperative electrophysiological monitoring in selective posterior rhizotomy
Authors: Mittal Sandeep , Farmer Jean-Pierre , Poulin Chantal , Silver Kenneth
Published: May 2009

Object. Selective posterior rhizotomy is a well-established treatment for spasticity associated with cerebral palsy. At most medical centers, responses of dorsal rootlets to electrical stimulation are used to determine ablation sites; however, there has been some controversy regarding the reliability of intraoperative stimulation. The authors analyzed data obtained from the McGill Rhizotomy Database to determine whether motor responses to dorsal root stimulation were reproducible.

Methods. A series of 77 patients underwent selective dorsal rhizotomy at a single medical center. The dorsal roots from L-2 to S-2 were stimulated to determine the threshold amplitude. The roots were then stimulated at 2 to 4 times the highest threshold with a 1-second 50-Hz train. A second stimulation run of the entire dorsal root was performed before it was divided into rootlets. Rootlets were individually stimulated and sectioned according to the extent of abnormal electrophysiological propagation. Motor responses were recorded by electromyography and were also assessed by a physiotherapist, and grades of 0 to 4+ were assigned. The difference in grades between the first and second stimulation trains was determined for 752 roots.

Statistical analysis demonstrated a clear consistency in motor responses between the two stimulation runs, both in the electromyographic readings and the physiotherapist's assessment. More than 93% of dorsal roots had either no change or a difference of only one grade between the two trials. Furthermore, the vast majority of dorsal roots assigned a grade of 4+ at the first trial maintained the same maximally abnormal electrophysiological response during the second stimulation run.

Conclusions. This study indicates that currently used techniques are reproducible and reliable for selection of abnormal rootlets. Intraoperative electrophysiological stimulation can be valuable in achieving a balance between elimination of spasticity and preservation of underlying strength.
Ventriculopleural shunt obstruction and positive-pressure ventilation
Authors: Chiang Veronica L. , Torbey Michel , Rigamonti Daniele , Williams Michael A.
Published: May 2009

✓ The authors report an unusual case of a patient with low-pressure hydrocephalus and a ventriculopleural shunt, in whom routine respiratory management performed using positive-pressure ventilation caused shunt obstruction and coma. While the patient received positive-pressure ventilation with external cerebrospinal fluid (CSF) drainage at subatmospheric pressure, the ventricles returned to normal size and the coma rapidly reversed. After the authors' recognition of the effect of positive-pressure ventilation on intrapleural pressure and ventriculopleural shunt function, and the subsequent removal of positive-pressure ventilation, CSF flow through the shunt resumed and the patient's coma resolved.
Obstructive hydrocephalus caused by intraventricular collapse of malacotic brain
Authors: Nakaguchi Hiroshi , Miyamoto Mario
Published: May 2009

✓ The authors present the case of a 68-year-old man who experienced acute obstructive hydrocephalus after having suffered an infarction in the occipital lobe. Histopathological and serial neuroimaging examinations revealed that portions of a large disintegrating occipital infarct had entered the lateral ventricle and obstructed the passage of cerebrospinal fluid (CSF). Ventricular drainage was performed for 2 weeks until the patient's hydrocephalus resolved. The CSF initially contained a high concentration of protein (1070 mg/dl), a high leukocyte count of 115 cells/mm3, and a rich fibrinous exudate.

Findings in the present case indicate that collapse of a periventricular ischemic lesion into the ventricles may sometimes occur not only after cerebral hemorrhage but also after cerebral infarction.
Inflammatory pseudotumor of the median nerve
Authors: Pérez-López Carlos , Gutiérrez Manuel , Isla Alberto
Published: May 2009

✓ The authors report the presence of an inflammatory pseudotumor of the median nerve in a young woman who presented with a sensorimotor deficit in the median nerve area. Magnetic resonance (MR) images revealed a fusiform mass in the nerve, and the patient underwent surgery for a suspected peripheral nerve—sheath tumor. Her clinical condition improved slowly and notably. Histological study revealed a heterogeneous lymphoid infiltration with mononuclear cells, lymphocytes (mostly T cells), and plasmocytoid cells. Because of the unknown significance of this infiltration, the patient was examined to exclude the possible diagnosis of a systemic tumoral process. All the studies yielded negative results and no systemic disease was found. Later, control MR imaging revealed no tumoral remains, and electromyography demonstrated progressive improvement of median nerve function. The follow-up period has been 8 years. The cause of the lesion is unknown. The differential diagnosis includes benign and malignant peripheral nerve—sheath tumors, lymphoma, and all tumorlike lesions of peripheral nerves.
Delayed appearance of carbon granulomas of the scalp after use of carbon fiber pins for refixation of a stereotactic head frame
Authors: McCormick William E. , Barnett Gene H. , Peereboom David M. , Stevens Glen H. J. , Biscotti Charles V.
Published: May 2009

✓ The authors present a case involving the formation of several carbon granulomas in the scalp of a woman 7 years after she underwent craniotomy. Her operation had included the use of carbon fiber pins for refixation of a stereotactic head frame. Carbon granulomas have been noted in multiple organs following surgical or traumatic carbon deposition, but have not been reported in association with neurosurgical carbon fiber pins used for head fixation. The lesions in this case arose a few months after initiation of chemotherapy for the patient's brain tumor. The relationship of carbon and cutaneous granuloma formation to adjuvant therapies and treatment strategies is discussed.
Malignant transformation of a gangliocytoma/ganglioglioma into a glioblastoma multiforme: a molecular genetic analysis
Authors: Hayashi Yutaka , Iwato Masayuki , Hasegawa Mitsuhiro , Tachibana Osamu , von Deimling Andreas , Yamashita Junkoh
Published: May 2009

✓ A gangliocytoma/ganglioglioma with no atypical or malignant features was subtotally resected from the right temporal lobe of a 16-year-old woman. A second resection was performed 8 years later to treat a locally recurrent lesion with increased cellularity that was diagnosed as a World Health Organization Grade II ganglioglioma on the basis of neuropathological examination. Molecular analysis of the recurrent tumor revealed a TP53 gene mutation, but no amplification of the epidermal growth factor receptor (EGFR) gene. Radiotherapy (60 Gy) was administered after the second resection. The patient returned 1 year later with a second focal recurrence. The specimen obtained during the third resection of tumor exhibited exclusively astrocytic differentiation, cellular pleomorphism with multinucleated cells, high mitotic activity, and endothelial proliferation. Therefore, the tumor was diagnosed to be a glioblastoma multiforme (GBM). Molecular analysis of tumor DNA from the second recurrent tumor demonstrated the presence of the TP53 mutation, which previously had been observed in the first recurrent tumor, but again no evidence of EGFR amplification. Findings demonstrate that the presence of TP53 mutation in progressed gangliogliomas should be interpreted as a progression-associated mutation rather than a consequence of treatment. This is the first report to indicate that the molecular pathways of gangliocytomas/gangliogliomas progressing to become GBMs may parallel those of diffuse astrocytomas progressing to become GBMs.
A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival
Authors: Lacroix Michel , Abi-Said Dima , Fourney Daryl R. , Gokaslan Ziya L. , Shi Weiming , DeMonte Franco , Lang Frederick F. , McCutcheon Ian E. , Hassenbusch Samuel J. , Holland Eric , Hess Kenneth , Michael Christopher , Miller Daniel , Sawaya Raymond
Published: May 2009

Object. The extent of tumor resection that should be undertaken in patients with glioblastoma multiforme (GBM) remains controversial. The purpose of this study was to identify significant independent predictors of survival in these patients and to determine whether the extent of resection was associated with increased survival time.

Methods. The authors retrospectively analyzed 416 consecutive patients with histologically proven GBM who underwent tumor resection at the authors' institution between June 1993 and June 1999. Volumetric data and other tumor characteristics identified on magnetic resonance (MR) imaging were collected prospectively.

Conclusions. Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4–14.6 months), compared with 8.8 months (95% CI 7.4–10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1–3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4–5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.
Long-term outcome after gamma knife surgery for secondary trigeminal neuralgia
Authors: Régis Jean , Metellus Philippe , Dufour Henry , Roche Pierre-Hughes , Muracciole Xavier , Pellet William , Grisoli Francois , Peragut Jean-Claude
Published: May 2009

Object. This study was directed to evaluate the potential role of gamma knife surgery (GKS) in the treatment of secondary trigeminal neuralgia (TN). The authors have identified three anatomicoclinical types of secondary TN requiring different radiosurgical approaches.

Methods. Pain control was retrospectively analyzed in a population of patients harboring tumors of the middle or posterior fossa that involved the trigeminal nerve pathway. This series included 53 patients (39 women and 14 men) treated using GKS between July 1992 and June 1997. The median follow-up period was 55 months. Treatment strategies differed according to lesion type, topography, and size, as well as visibility of the fifth cranial nerve in the prepontine cistern. Three different treatment groups were established. When the primary goal was treatment of the lesion (Group IV, 46 patients) we obtained pain cessation in 79.5% of cases. In some patients in whom GKS was not indicated for treatment of the lesion, TN was treated by targeting the fifth nerve directly in the prepontine cistern if visible (Group II, three patients) or in the part of the lesion including this nerve if the nerve root could not be identified (Group III, four patients). No deaths and no radiosurgically induced adverse effects were observed, but in two cases there was slight hypesthesia (Group IV). The neuropathic component of the facial pain appeared to be poorly sensitive to radiosurgery. At the last follow-up examination, six patients (13.3%) exhibited recurrent pain, which was complete in four cases (8.8%) and partial in two (4.4%).

Conclusions. The results of GKS regarding facial pain control are very similar to those achieved by microsurgery according to series published in the literature. Nevertheless, the low rate of morbidity and the greater comfort afforded the patient render GKS safer and thus more attractive.
Subthalamic nucleus stimulation for Parkinson disease: benefits observed in levodopa-intolerant patients
Authors: Katayama Yoichi , Kasai Masahiko , Oshima Hideki , Fukaya Chikashi , Yamamoto Takamitsu , Ogawa Katsuhiko , Mizutani Tomohiko
Published: May 2009

Object. A blinded evaluation of the effects of subthalamic nucleus (STN) stimulation was performed in levodopaintolerant patients with Parkinson disease (PD). These patients (Group I, seven patients) were moderately or severely disabled (Hoehn and Yahr Stages III–V during the off period), but were receiving only a small dose of medication (levodopa-equivalent dose [LED] 0–400 mg/day) because they suffered unbearable side effects. The results were analyzed in comparison with those obtained in patients with advanced PD (Group II, seven patients) who were severely disabled (Hoehn and Yahr Stages IV and V during the off period), but were treated with a large dose of medication (500–990 mg/day).

Methods. The patients were evaluated twice at 6 to 8 months after surgery. To determine the actual benefits afforded by STN stimulation to their overall daily activities, the patients were maintained on their medication regimen with optimal doses and schedules. Stimulation was turned off overnight for at least 12 hours. It was turned on in the morning (or remained turned off), and each patient's best and worst scores on the Unified Parkinson's Disease Rating Scale during waking daytime activity were recorded as on- and off-period scores, respectively. The order of assessment with respect to whether stimulation was occurring was determined randomly.

The STN stimulation markedly improved daily activity and total motor scores in Group I patients. The percentage time of immobility (Hoehn and Yahr Stages IV and V) became 0% in patients who were intermittently immobile while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, akinesia, and gait subscores. The STN stimulation produced less marked but still noticeable improvements in the daily activity and total motor scores in Group II patients. The percentage time of immobility as well as the LED was reduced in patients who displayed intermittent immobility with pronounced motor fluctuations while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, and dyskinesia subscores in these patients. In contrast, STN stimulation did not improve the overall daily activities at all in patients who had become unresponsive to a tolerable dose of levodopa and were continuously immobile, even though these patients' tremor and rigidity subscores were still improved by stimulation.

Conclusions. Consistent with earlier findings, the great benefit of STN stimulation in levodopa-intolerant patients is that STN stimulation can reduce the level of required levodopa medication. This suggests that STN stimulation could be a therapeutic option for patients with less-advanced PD by allowing levodopa medication to be maintained at as low a dose as possible, and to prevent adverse reactions to the continued use of large-dose levodopa.
Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases
Authors: Vinchon Matthieu , Noulé Nathalie , Soto-Ares Gustavo , Dhellemmes Patrick
Published: May 2009

Object. Subduroperitoneal drainage (SDPD) is commonly used in the treatment of infantile subdural hematomas (SDHs). Few studies have focused on this technique and most series have included SDHs of various origins in children of different ages. The surgical procedure is not standardized and results achieved using this technique have not been well documented.

The authors reviewed their cases of traumatic SDH treated with SDPD in infants (< 2 years of age). Their standard technique includes bilateral SDPD whenever the SDH is bilateral, placement of a free shunt, and systematic removal of the drainage unit after a few months.

Methods. The authors performed SDPD in 244 infants with traumatic SDH. The patients' SDHs were controlled by SDPD in 241 cases, and 78.9% of the patients recovered to live a normal life. Complications of SDPD occurred in 38 patients (15.6%): obstruction in 22 cases (9%), infection in eight cases (3.28%), and internal hydrocephalus in eight cases (3.28%). Early complications could be ascribed to surgical technique, delayed complications were associated with the severity of the initial clinical presentation, and late complications were time dependent and unrelated to initial clinical severity. Poor clinical outcome was correlated to the severity of the initial presentation, but not to complications of surgery.

Conclusions. Because of its efficacy and low complication rate, SDPD is the procedure of choice when subdural taps fail to control SDH. The authors prefer bilateral drainage because of the low rate of complications. Drains should be systematically removed after a few months to prevent long-term complications.
Role of dural fenestrations in acute subdural hematoma
Authors: Guilburd Joseph N. , Sviri Gil E.
Published: May 2009

Object. Patients with acute subdural hematomas (ASDHs) have higher mortality and lower functional recovery rates compared with those of other head-injured patients. Early surgical decompression and active intensive care treatment represent, so far, the best way to assist these patients. Paradoxically, one of the factors contributing to poor outcomes in cases of ASDHs could be rapid surgical decompression, owing to the severe extrusion of the brain through the craniotomy defect in response to acute brain swelling. To avoid the deleterious consequences of abrupt decompression of the subdural space with disruption of brain tissue, the authors have adopted a new surgical technique for evacuation of ASDHs. This procedure consists of creating multiple fenestrations of the dura (MFD) in a meshlike fashion and removing clots through the small dural openings that are left open, avoiding the creation of a wide dural opening and the disruption of and additional damage to brain tissue.

Methods. Thirty-one patients (26 male and five female patients with a mean age of 32.5 years) harboring ASDHs were treated using this method. On admission there were 16 patients (51.5%) with Glasgow Coma Scale (GCS) scores of 3 to 5, 11 patients (35.5%) with GCS scores of 6 to 8, and four patients (12.9%) with GCS scores of 9 to 12. Postoperative computerized tomography scans of the brain revealed evacuation of more than 80% of the hematoma in 29 of 31 patients. The overall mortality rate in this group was 51.6%.

Conclusions. This preliminary report of a new surgical approach for patients who have sustained ASDHs should be considered to avoid abrupt disruption of the brain and to allow the gradual and gentle release of subdural clots. This is especially important in cases in which there are severe midline shifts and a tight brain. Further clinical studies should be conducted in a more selected series to estimate the impact of this new procedure on morbidity and mortality rates.
Neural regeneration along longitudinal polyglactin sutures across short and extended defects in the rat sciatic nerve
Authors: Scherman Peter , Lundborg Göran , Kanje Martin , Dahlin Lars B.
Published: May 2009

Object. The authors have previously shown that longitudinal sutures without artificial tube support regeneration across a 7-mm gap in the rat sciatic nerve. In the present study, the authors compared this new approach with the use of autologous nerve grafts across short defects and examined whether the approach could be used to support regeneration across extended gaps and whether the interposition of a short nerve segment (the stepping-stone procedure) was applicable in this model.

Methods. Longitudinal sutures were used to bridge 7- and 15-mm gaps in the rat sciatic nerve. Contralateral comparisons were made to nerve autografts in the 7-mm group and to sutures plus a short interposed nerve segment in the 15-mm group. Regeneration was evaluated at 2, 4, and 12 weeks by using immunocytochemical analysis for Schwann cells, neurofilament protein, and macrophages and at 12 weeks also by using histological examination, including morphometry in the distal tibial trunk and tetanic force measurements in the gastrocnemius muscle.

Conclusions. The authors found that the results of regeneration after repair with longitudinal polyglactin sutures across short defects were not significantly different from those produced by the use of autologous nerve grafts. Regeneration, although poor, occurred along sutures across extended gaps and was significantly enhanced by an interposed nerve segment acting as a Schwann cell resource in this model.
Segmental myoclonus as the sole manifestation of a choroid plexus papilloma in the posterior fossa
Authors: Chroni Elisabeth , Paschalis Christos , Konstantinou Dimitris , Maraziotis Theodoros , Bonas Michalis , Papapetropoulos Thodoros
Published: May 2009

✓ The authors describe the case of a 22-year-old woman with involuntary contractions of the sternocleidomastoid and trapezius muscles that resulted in turning movements of the head. The jerks displayed the clinical and neurophysiological characteristics of segmental myoclonus (SM) restricted to muscles supplied bilaterally by the first four cervical segments. Magnetic resonance imaging disclosed a tumor in the midline above the cisterna magna that was later histologically proven to be a choroid plexus papilloma. The patient's involuntary movements did not extend to other muscle groups or, in particular, to the palate, as one might have expected in the case of brainstem lesions. Myoclonus was the sole clinical manifestation of the tumor in this patient; other signs and symptoms invariably reported in other cases of posterior fossa papilloma, such as increased intracranial pressure or cranial nerve palsies, were absent. Release from suprasegmental control is suggested as a possible pathophysiological mechanism in this case of SM.
Associated arteriovenous malformation of the orbit and brain: a case of Wyburn-Mason syndrome without retinal involvement
Authors: Ponce Francisco A. , Han Patrick P. , Spetzler Robert F. , Canady Alexa , Feiz-Erfan Iman
Published: May 2009

✓ Wyburn-Mason syndrome is a rare condition associated with multiple cerebral arteriovenous malformations. The disease, also called retinoencephalofacial angiomatosis, includes lesions of the retina, brain, and skin. This disorder stems from a vascular dysgenesis of the embryological anterior plexus early in the gestational period when the primitive vascular mesoderm is shared by the involved structures. The timing of the insult to the embryonic tissue determines which structures are affected. Extensions of the lesions vary widely but cutaneous lesions are unusual. Among reports in the literature, only three cases appear to have manifested without retinal involvement. The authors report the fourth case of Wyburn-Mason syndrome in which there was no retinal involvement and the first to involve neither the retina nor the face.
No ordinary time, no ordinary men: the relationship between Harvey Cushing and Franklin D. Roosevelt, 1928–1939
Authors: Rovit Richard L. , Couldwell William T.
Published: May 2009

✓ The authors elucidate the strong personal relationship that developed between Dr. Harvey Cushing and Franklin Delano Roosevelt (FDR) from 1928 to 1939, as manifested in their frequent letters to each other. The relationship was initiated by the marriage of their children. Through his correspondence with FDR, Cushing was able to affect several medical issues of the period. The relationship of these two individuals is set within the historical, social, and political contexts of the times.
Intraoperative magnetic resonance imaging during transsphenoidal surgery
Authors: Fahlbusch Rudolf , Ganslandt Oliver , Buchfelder Michael , Schott Werner , Nimsky Christopher
Published: May 2009

Object. The aim of this study was to evaluate whether intraoperative magnetic resonance (MR) imaging can increase the efficacy of transsphenoidal microsurgery, primarily in non—hormone-secreting intra- and suprasellar pituitary macroadenomas.

Methods. Intraoperative imaging was performed using a 0.2-tesla MR imager, which was located in a specially designed operating room. The patient was placed supine on the sliding table of the MR imager, with the head placed near the 5-gauss line. A standard flexible coil was placed around the patient's forehead. Microsurgery was performed using MR-compatible instruments. Image acquisition was started after the sliding table had been moved into the center of the magnet. Coronal and sagittal T1-weighted images each required over 8 minutes to acquire, and T2-weighted images were obtained optionally. To assess the reliability of intraoperative evaluation of tumor resection, the intraoperative findings were compared with those on conventional postoperative 1.5-tesla MR images, which were obtained 2 to 3 months after surgery.

Among 44 patients with large intra- and suprasellar pituitary adenomas that were mainly hormonally inactive, intraoperative MR imaging allowed an ultra-early evaluation of tumor resection in 73% of cases; such an evaluation is normally only possible 2 to 3 months after surgery. A second intraoperative examination of 24 patients for suspected tumor remnants led to additional resection in 15 patients (34%).

Conclusions. Intraoperative MR imaging undoubtedly offers the option of a second look within the same surgical procedure, if incomplete tumor resection is suspected. Thus, the rate of procedures during which complete tumor removal is achieved can be improved. Furthermore, additional treatments for those patients in whom tumor removal was incomplete can be planned at an early stage, namely just after surgery.
Relationship of aneurysmal subarachnoid hemorrhage to changes in atmospheric pressure: results of a prospective study
Authors: Buxton Neil , Liu Clarence , Dasic Davor , Moody Paula , Hope D. Terence
Published: May 2009

Object. The purpose of this study was to evaluate the relationship between atmospheric pressure and subarachnoid hemorrhage (SAH) in a region in the English Midlands.

Methods. All patients with angiographically proven SAH for the calendar year 1998 were analyzed. A geographical allocation was made based on the patients' origin within the region. The events were then compared with the data available for the local atmospheric pressures. One hundred nine patients had an SAH during the time period studied. The median atmospheric pressure recorded was 1014.5 millibars. Atmospheric pressure was modestly correlated with the number of SAHs per day (Spearman's rank correlation, r = 0.33; p < 0.0001); the daily change in atmospheric pressure also correlated mildly (r = 0.34, p < 0.0001). No other statistically significant association was found.

Conclusions. The authors have shown a relationship between high atmospheric pressure and increased incidence of SAH. The underlying reason for this remains obscure.
Continuous monitoring of regional cerebral blood flow during temporary arterial occlusion in aneurysm surgery
Authors: Thomé Claudius , Vajkoczy Peter , Horn Peter , Bauhuf Christian , Hübner Ulrich , Schmiedek Peter
Published: May 2009

Object. Temporary arterial occlusion (TAO) during aneurysm surgery carries the risk of ischemic sequelae. Because monitoring of regional cerebral blood flow (rCBF) may limit neurological damage, the authors evaluated a novel thermal diffusion (TD) microprobe for use in the continuous and quantitative assessment of rCBF during TAO.

Methods. Following subcortical implantation of the device at a depth of 20 mm in the middle cerebral artery or anterior cerebral artery territory, rCBF was continuously monitored by TD microprobe (TD-rCBF) throughout surgery in 20 patients harboring anterior circulation aneurysms; 46 occlusive episodes were recorded. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance.

The mean subcortical TD-rCBF decreased from 27.8 ± 8.4 ml/100 g/min at baseline to 13.7 ± 11.1 ml/100 g/min (p < 0.0001) during TAO. The TD microprobe showed an immediate exponential decline of TD-rCBF on clip placement. On average, 50% of the total decrease was reached after 12 seconds, thus rapidly indicating the severity of hypoperfusion. Following clip removal, TD-rCBF returned to baseline levels after an average interval of 32 seconds, and subsequently demonstrated a transient hyperperfusion to 41.4 ± 18.3 ml/100 g/min (p < 0.001). The occurrence of postoperative infarction (15%) and the extent of postischemic hyperperfusion correlated with the depth of occlusion-induced ischemia.

Conclusions. The new TD microprobe provides a sensitive, continuous, and real-time assessment of intraoperative rCBF during TAO. Occlusion-induced ischemia is reliably detected within the 1st minute after clip application. In the future, this may enable the surgeon to alter the surgical strategy early after TAO to prevent ischemic brain injury.
New pain following cordotomy: clinical features, mechanisms, and clinical importance
Authors: Nagaro Takumi , Adachi Naoto , Tabo Etsuo , Kimura Shigeo , Arai Tatsuru , Dote Kentaro
Published: May 2009

Object. The clinical features, possible causes, and contributing factors associated with novel spontaneous pain following unilateral cordotomy were investigated to clarify the mechanism and clinical importance of this pain.

Methods. Forty-five patients who underwent cordotomy for severe unilateral cancer pain were included in this study. New pain occurred in 33 (73.3%) of 45 patients. Pathological conditions of tissue demonstrated on imaging corresponded to new pain in eight patients, referred pain in five, and neither of these in 15 patients. New pain was centered opposite the site of the original pain in a mirror-image location in 28 patients and rostral to the original pain in five patients. It was temporary in seven patients, weaker than the original pain in 25, and as severe as the original pain in one patient. The incidence of moderate or severe pain was significantly higher in patients with confirmed tissue disease (six of eight patients) than in those without (six of 20 patients). An important contributing factor to the occurrence of new pain was the achievement of analgesia by performing the cordotomy.

Conclusions. The present results indicate that new pain occurs frequently after unilateral cordotomy. Nonetheless, cordotomy may still be indicated for unilateral uncontrollable pain because new pain, when present, was weaker and more easily controlled than the original pain in nearly all cases. The authors speculate that new pain may represent a type of referred pain from the original painful area or may arise from sensitization of contralateral spinal nociceptive circuits due to metastasis or tumor infiltration, and that new pain is potentiated by the interruption of descending inhibitory pathways.