bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Treatment of Intracavernous Neoplasms: A Four-Year Experience
Authors: Sekhar Laligam N. , Sen Chandra N. , Jho Hae Dong , Janecka Ivo P.
Published: May 2010

Forty-two patients with neoplasms involving the cavernous sinus had operations between 1983 and 1987. The lesions included 25 benign tumors (e.g., meningioma, neurilemoma) and 17 malignant tumors (e.g., chondrosarcoma, adenoid cystic carcinoma). The cavernous sinus was entered by inferior, anterolateral, or medial extradural approaches or by superior or lateral intradural approaches. The intracavernous internal carotid artery was managed by dissecting tumor away from it or by occlusion and excision with or without direct vein graft reconstruction, based on the results of a preoperative balloon occlusion test. Cranial nerves III, IV, V, and VI usually were dissected from tumor, but in 3 cases of tumor invasion, the excised nerve segment was reconstructed by direct suture or with a sural nerve interposition graft. Twenty-one of the benign tumors and 8 of the malignant tumors were excised totally and the remainder subtotally. On follow-up ranging from 3 to 48 months, one subtotally excised meningioma recurred and was treated with reexcision and adjuvant radiation therapy. Two “totally” excised malignant tumors recurred outside the cavernous sinus at the margins of excision. There was no operative mortality or permanent cerebral morbidity. Postoperatively, the ocular and neurological function of most patients was similar to the preoperative status; in some, it was significantly improved. Thirteen additional patients with intracavernous neoplasms also were evaluated during the same period and followed without operation. The early follow-up information regarding these patients is provided.
Effects of Hydrocephalus and Surgical Decompression on Cortical Norepinephrine Levels in Neonatal Cats
Authors: Lovely Thomas J. , McAllister James P. , Miller David W. , Lamperti Albert A. , Wolfson Barbara J.
Published: May 2010

Norepinephrine (NE) changes during hydrocephalus, and the effects of surgical decompression on these changes, were studied using a new model of neonatal hydrocephalus. Kittens 4 to 10 days old received intracisternal injections of a sterile solution of 25% kaolin. Control kittens were injected similarly with sterile injectable saline. Ultrasonography was used to follow the progression of ventriculomegaly and the initial effects of the shunts. A subgroup of hydrocephalic animals was shunted using a cerebrospinal fluid lumbar-peritoneal catheter. Hydrocephalic animals were killed at approximately 25 days of age (16-21 days after kaolin injection). Surgical decompression was performed at 12, 16, and 17 days after kaolin injection; these animals were killed 30 days after the shunts were inserted. Control animals were killed at 29 and 53 days of age, to correlate with the ages of the hydrocephalic and shunted animals, respectively. Cortical samples equivalent to Brodmann's areas 4, 22, and 17 were measured for NE using high-performance liquid chromatography. Hydrocephalus caused NE levels to decrease significantly in all cortical areas. These alterations followed a rostrocaudal gradient in severity, with mean reductions of 65.8, 83.9, and 95.8% in areas 4, 22, and 17, respectively. Partial recovery occurred in animals that received shunts 16 and 17 days after kaolin injection, such that NE reductions of 75.7, 56.2, and 81.6% were noted in areas 4, 22, and 17, respectively. Shunting at 12 days after kaolin injection produced complete recovery in areas 4 and 22, with only a 67.7% decrease in area 17. These results suggest that the projection fibers from the locus ceruleus are damaged by the direct effects of hydrocephalus. Axotomy or neuropraxia of these fibers could result in decreases in NE throughout the cerebral cortex. In addition, there appears to be a period of time during which surgical decompression will allow neuropraxic fibers to recover with partial restoration of NE levels. Earlier insertion of a shunt appears to allow for more recovery than later decompression.
Angiographic Follow-up Study of Cerebral Arteriovenous Malformations with Reference to Their Enlargement and Regression
Authors: Minakawa Takashi , Tanaka Ryuichi , Koike Tetsuo , Takeuchi Shigekazu , Sasaki Osamu
Published: May 2010

Twenty patients with cerebral arteriovenous malformations (AVMs) were followed up by angiography. Of the 20 AVMs, 16 were nontreated and the remaining 4 were residual. The follow-up periods between the two examinations were from 5 to 28 years, with a median interval of 15 years. At follow-up, the size of the AVM had increased in 4 patients (20%), decreased in 4 (20%), totally regressed in 4 (20%), and was unchanged in 8 (40%). In cases of enlarged AVMs, the patients were all young: from 0 to 11 years old at first angiography and from 6 to 30 at second angiography. The decrease or total regression of the AVM occurred in older patients (over 30 years old at second angiography), and the AVMs were relatively small and fed by single or a few feeders. The patient's age and the size of AVM should be considered when operative indications are discussed.
Improvement of Cortical Perfusion, Intracellular pH, and Electrocorticography by Nimodipine During Transient Focal Cerebral Ischemia
Authors: Tally Philip W. , Sundt Thoralf M. , Anderson Robert E.
Published: May 2010

The alterations in metabolism and cerebral blood flow that occur following transient focal ischemia were studied in rabbits anesthetized with halothane and subjected to transient occlusion of an M2 segment of the middle cerebral artery (MCA). The parameters measured included intracellular brain pH and focal cortical blood flow (fCBF)—assessed by the umbelliferone technique—electrocorticograms, and cortical microcirculatory changes. A gradient of ischemia developed in the cortex between the patent and occluded vessels. Cortical sites with moderate and severely diminished flow were examined as a function of time before and after occlusion. Mean preocclusion fCBF was 50.8 ± 2.1 ml/100 g/min, and brain pH was 6.99 ± 0.04. Following occlusion, fCBF fell to 14.6 ± 2.3 ml/100 g/min, with an intracellular pH of 6.53 ± 0.03 in sites of severe ischemia in the territory of the occluded vessel. Sites between the patent and occluded branches revealed moderate changes in fCBF and intracellular pH of 26.7 ± 3.6 ml/100 g/min and 6.74 ± 0.03 ml/100 g/min, respectively. Sites adjacent to the patent M2 branch remained similar to baseline. Pretreatment intravenously with nimodipine, a dihydropyridine class of Ca2+ channel antagonist, improved flow in the territory of the occluded segment of the middle cerebral artery to 30.6 ± 2.2 ml/100 g/min, while maintaining the brain pH at 6.83 ± 0.03. Similarly, at sites intermediate between the patent and occluded M2 segments of the MCA, cortical blood flow remained at 53.5 ± 4.0 ml/100 g/min, and the pH at 6.95 ± 0.04, in 10 animals pretreated with nimodopine. This effect was apparently achieved by blocking the secondary, ischemia-induced vasoconstriction known to occur in areas of focal incomplete ischemia.

The diphenylalkylamine class Ca2+ channel blockers was examined using verapamil. This was found to be without significant effect. The vehicle carrying nimodopine was also without effect. To authenticate further the reliability of MCA occlusion, a separate group of animals was examined with cautery occlusion of the M2 segment of the MCA. Nimodopine had an effect in this group of animals identical to that caused by occlusion of the vessel with a clip. Visual inspection of the cortex in control and treated animals revealed a marked difference in the development of cortical pallor and microcirculatory changes. We conclude that nimodopine protects the conducting vessels against the secondary vasoconstriction known to occur in areas of focal incomplete ischemia, and thus increases collateral flow. This agent may have the potential for brain protection in areas of incomplete focal ischemia from occlusion of a single major vessel.
Stereotactic Drainage of Aspergillus Brain Abscess with Long-Term Survival: Case Report and Review
Authors: Goodman Michael L. , Coffey Robert J.
Published: May 2010

Aspergillus species are second only to Cryptococcus neoformans as the most common cause of fungal infections of the central nervous system in immunocompromised patients. Survival following treatment of Aspergillus brain abscess has been reported only 4 times. In each case, craniotomy was performed for abscess drainage. We present a case of long-term survival following stereotactic drainage of a bilateral Aspergillus brain abscess. In all reported cases, including the present one, histological examination of the abscess contents established the correct diagnosis. Amphotericin B was used in combination with operation in 4 of the 5 cases of long-term survival.
Familial Cavernous Angioma of the Brain Stem Dominantly Inherited in Hispanics
Authors: Bicknell Joseph M.
Published: May 2010

A 23-year-old Hispanic woman whose mother had died of a brain hemorrhage developed signs and symptoms of a brain stem lesion. These gradually progressed over the next 30 years. Her computed tomographic and magnetic resonance imaging scans show features typical of a cavernous angioma in the brain stem. Her daughter had a transient right hemiparesis at age 25, and at age 28 noted periorbital pain with twitching of the forehead and jaw. The daughter's computed tomographic and magnetic resonance imaging scans likewise suggest cavernous angioma of the brain stem. There has been only one other report of familial cavernous angioma of the brain stem, and that also involved a Hispanic family. Hispanics have a known predisposition to familial cavernous angioma, and this diagnosis should be considered when more than one person in a family develops brain stem symptoms.
Intrasellar Balloon Inflation for Treatment of Symptomatic Empty Sella Syndrome
Authors: Cybulski George R. , Stone James L. , Geremia Glenn , Anson John
Published: May 2010

Intrasellar extradural placement of a detachable vascular balloon via a transsphenoidal approach was performed successfully in a patient with primary empty sella syndrome, relieving headache and visual field defect. This technique offers an alternative approach to other methods of treating symptomatic empty sella syndrome that require packing of the sella with fat, muscle, cartilage, or bone.
Granulocytic Sarcoma Presenting as an Epidural Mass with Cord Compression
Authors: Ripp Daniel J. , Davis James W. , Rengachary Setti S. , Lotuaco Luisa G. , Watanabe Itaru S.
Published: May 2010

Granulocytic sarcoma (GS) usually occurs during the course of, or as a presenting sign of myelogenous leukemia. Rarely it is found before peripheral blood or bone marrow evidence of leukemia is present. We describe a man who presented with low back pain and lower extremity weakness. He had spinal cord compression due to GS without evidence of leukemia. Only four such instances have been previously reported. Such aleukemic presentations of GS are frequently misdiagnosed. The chloroacetate esterase stain and electron microscopy are useful in demonstrating the myeloid origin of GS cells. GS lesions are probably best treated by localized radiation therapy and systemic chemotherapy.
Radiation-Associated Atheromatous Disease of the Cervical Carotid Artery: Report of Seven Cases and Review of the Literature
Authors: Atkinson John L. D. , Sundt Thoralf M. , Dale Allan J. D. , Cascino Terrence L. , Nichols Douglas A.
Published: May 2010

The natural history of postirradiation extracranial cerebrovascular disease is uncertain. Previous reported cases spanning 20 years of carotid surgery are difficult to evaluate, because patients may sometimes have unspecified symptoms, physical examinations, postoperative results, and follow-up. Also, the evolution of carotid surgery over the past two decades makes it impossible to compare earlier operative technique with the state-of-the-art technique of today. Our series of 7 patients underwent 9 carotid endarterectomies with an average follow-up period of 46 months. The number of patients is small, and although technically this is a more difficult operation, we feel the results are favorable and may be comparable with endarterectomy procedures in nonirradiated patients. These patients should be approached as if radiation changes are not a major factor when they are considered for reconstructive arterial surgery.
Intraoperative Measurement of Adrenocorticotropic Hormone in Peripituitary Blood in Cushing's Disease
Authors: Lüdecke Dieter K.
Published: May 2010

A new method of intraoperative measurement of adrenocorticotropic hormone for the localization of microadenomas in Cushing's disease is described and, in 21 cases, compared with preoperative bilateral sampling of the inferior petrosal sinus. By intraoperative measurement of adrenocorticotropic hormone in peripituitary venous blood, it was possible to determine a gradient for adrenocorticotropic hormone in 14 of 19 patients with surgically proven adenomas. In 4 of 6 patients in whom a false positive bilateral sample from the inferior petrosal sinus directed the surgeon to the wrong side of the pituitary, the localization could be correctly determined by intraoperative radioimmunoassay of adrenocorticotropic hormone.
Control of Intractable Spasticity with Intrathecal Morphine Sulfate
Authors: Erickson Donald L. , Lo Jo , Michaelson Margi
Published: May 2010

Three years ago we reported our preliminary results regarding treatment of intractable spasticity with use of intrathecal morphine. This paper is a follow-up report of 12 patients who underwent implantation of a pump or reservoir for delivery of intrathecal morphine sulfate for control of spasticity. Our primary concern initially was that patients would ultimately become drug tolerant and lose the beneficial effect of the morphine. Only one of these 12 patients has developed drug tolerance. The longest follow-up period has been 4.3 years, and this patient has maintained excellent control of his spasticity with a stable dose of 2 mg of morphine daily.
Does Intraoperative Monitoring of Auditory Evoked Potentials Reduce Incidence of Hearing Loss as a Complication of Microvascular Decompression of Cranial Nerves?
Authors: Møller Aage R. , Møller Margareta B.
Published: May 2010

During a 14-month period, 129 individuals underwent 140 operations for microvascular decompression to relieve hemifacial spasm, disabling positional vertigo, tinnitus, or trigeminal neuralgia at our institution. Seven patients were operated upon twice on the same side and 4 were operated upon on both sides at different times. In each case, the brainstem auditory evoked potentials were monitored intraoperatively by the same neurophysiologist. In 75 of these operations, compound action potentials were also recorded from the exposed 8th nerve. Comparison of speech discrimination scores before the operation and at the time fo discharge showed that at discharge, discrimination had decreased in 7 patients by 15% or more and increased in 4 patients by 15% or more, in 2 patients by as much as 52%. Essentially similar results were obtained when preoperative speech discrimination scores were compared with results obtained from the 87 patients who returned for a follow-up visit between 3 and 6 months after discharge. Only one patient lost hearing (during a second operation to relieve hemifacial spasm). Another patient (also operated upon to relieve hemifacial spasm) suffered noticeable hearing loss postoperatively, but had recovered nearly normal hearing by 4 months after the operation. Nine patients had an average elevation of the hearing threshold for pure tones in the speech frequency range (500 to 2000 Hz) of 11 dB or more at 4 to 5 days after the operation; 8 of these had fluid in their middle ears that most likely contributed to the hearing loss. Threshold elevations occurred at 4000 Hz and 8000 Hz in 19 and 29 ears, respectively.
Upward Transtentorial Herniation: A Complication of Postoperative Edema at the Cervicomedullary Junction
Authors: Spiegelmann Roberto , Hadani Moshe , Ram Zvi , Faibel Meir , Shacked Itzhack
Published: May 2010

Local edema at the operative bed developed a few hours after uneventful subtotal removal of a lesion occupying the lower medulla and upper cervical cord. The patient experienced apnea, quadriplegia, and circulatory collapse followed by acute respiratory insufficiency. Hydrocephalus secondary to aqueductal occlusion occurred on the 3rd postoperative day. A computerized tomographic scan was compatible with upward transtentorial herniation. The association of this phenomenon with an intra-axial lesion at the cervicomedullary junction has not been previously documented. The pathophysiological mechanisms implicated in this complication are discussed.
Acute Effect of the Nd:YAG Laser on the Cerebral Arteriovenous Malformation: A Histological Study
Authors: Zuccarello Mario , Mandybur Thaddeus I. , Tew John M. , Tobler William D.
Published: May 2010

The acute effect of Nd:YAG laser beam on cerebral arteriovenous malformations (AVMs) was examined. Histological examination of the specimens after treatment with the Nd:YAG laser revealed that the most prominent effect of the laser was shrinkage of the collagen of the vessels of the AVM, which led to laser-induced narrowing of blood vessels. The brain tissue confined to the resected AVM did not contain any histological evidence of acute damage. The resection of 10 cases of AVMs was safely accomplished with no morbidity or increased neurological deficits attributable to the laser technique.
Use of Intraoperative Ultrasonography to Improve the Diagnostic Accuracy of Exploratory Burr Holes in Patients with Traumatic Tentorial Herniation
Authors: Andrews Brian T. , Bederson Joshua B. , Pitts Lawrence H.
Published: May 2010

Seventeen head-injured patients with signs of brain stem compression at admission underwent emergency bilateral burrhole exploration before computerized tomographic (CT) scanning. After exploration of the epidural and subdural spaces, real-time ultrasonography was performed intraoperatively to identify intraaxial hematomas. Epidural or subdural hematomas were identified surgically in 11 patients (65%) and immediately evacuated through a craniotomy; in 2 patients, bilateral subdural hematomas were removed. Ultrasonography showed no evidence of intracerebral mass lesions in 14 (82%) of the 17 patients, demonstrated extensive contusions of the temporal lobe in 2 patients (prompting partial lobectomy in both cases), and revealed a small intraparenchymal hematoma deep within the dominant hemisphere, which was not removed, in 1 patient. The sensitivity of ultrasound images for identifying intraparenchymal lesions was evaluated postoperatively by CT or autopsy. In 15 patients (88%), the results of ultrasonography were confirmed. In 2 (12%), CT scans showed small but significant lesions at the frontal pole missed by ultrasonography; one patient had a residual subdural hematoma, and the other a small intraparenchymal hemorrhage. These results confirm that patients with clinical evidence of brain stem compression soon after head injury often have extraaxial hematomas that can be readily identified by burr-hole exploration. Although intraparenchymal hematomas are rare immediately after head injury, they can ususally be identified by intraoperative ultrasonography. This simple technique can reduce the risk of missing intractranial hematomas during emergency burr-hole exploration and improve intraoperative decision making in this population of severely head-injured patients.
Evaluation of Recombinant Tissue Plasminogen Activator in Embolic Stroke
Authors: Chehrazi B. Barry , Seibert J. Anthony , Kissel Phillip , Hein Larry , Brock John M.
Published: May 2010

In an effort to determine the value of tissue-type plasminogen activator (TPA) in the treatment of embolic stroke, 17 rabbits were subjected to a model of embolic stroke in which 2-hour-old, tin-impregnated, autologous clots were embolized to the bifurcation of the internal carotid artery at the circle of Willis via retrograde injection into the cannulated external carotid artery. High-resolution digital subtraction radiography was used to localize clots intracranially at the carotid bifurcation. Circulation through the internal carotid artery and intracranial vessels was monitored with serial digital subtraction angiography before and after embolization and during treatment. Disappearance of the tin marker on the digital subtraction radiograph indicated dissolution of clot and was associated with reestablishment of circulation on the digital subtration angiogram. Experimental animals were treated with human-specific recombinant TPA 30 minutes, 2 hours, or 4 hours after clot embolization. TPA was administered as an intravenous bolus of 0.5 mg/kg followed by an infusion of 1 mg/kg/h for 2 hours. Digital subtraction angiograms were performed every 30 minutes. All clots dissolved, and cerebral circulation was reestablished within 120 minutes of treatment. In control animals treated with saline, embolized clots were stable, and the internal carotid artery remained occluded. At the completion of each study, the animal was perfused with freshly prepared, buffered 2,3,5-triphenyltetrazolium chloride (TTC) for demarcation of cerebral infarction. Control animals demonstrated infarction of 50 ± 3.6% of the ipsilateral cerebral hemisphere, with an infarct weight of 2.1 ± 0.2 g. The weight of cerebral infarction, as defined by the failure of tissue to stain with TTC, was reduced significantly in TPA-treated animals (P < 0.01). Treatment begun 30 minutes after clot embolization resulted in the most pronounced reduction in cerebral infarction. No intracerebral bleeding was observed. Results indicate that treatment with TPA is effective in dissolving embolic clots and reestablishing intracranial circulation. For best protection against cerebral infarction, however, treatment should be started as soon as possible.
Stereotactic Management of Cystic Gliomas of the Brain Stem
Authors: Hood Terry W. , McKeever Paul E.
Published: May 2010

Although cystic gliomas of the brain stem can be readily aspirated using a stereotactic technique, they will frequently recur, resulting in progressive neurological deficit. Since standard neurosurgical approaches to cystic gliomas of the cerebral hemispheres and cerebellum are difficult to apply to brain stem lesions, modification of these techniques are necessary to provide cyst control with minimal morbidity and mortality. This report, based upon 12 procedures performed on 10 patients with gliomas of the mesencephalon, pons, and medulla, details an approach using aspiration, stereotactically placed cyst catheters, and/or intracavitary irradiation with colloidal chromium phosphorus-32 in addition to external radiation therapy and chemotherapy. Cyst control without mortality or permanent morbidity was obtained in all patients using this multimodality approach.
Outcome of Laminectomy for Civilian Gunshot Injuries of the Terminal Spinal Cord and Cauda Equina: Review of 88 Cases
Authors: Cybulski George R. , Stone James L. , Kant Ravi
Published: May 2010

Case records of 88 patients with low-velocity gunshot injuries of the terminal spinal cord and cauda equina treated by laminectomy at Cook County Hospital between 1969 and 1987 were reviewed. Sixty-one patients were operated upon within 72 hours of injury, 29 of whom (47.5%) experienced neurological improvement or pain relief. Twenty-seven patients were operated upon at a later time for associated injuries, 13 of whom (48.1%) experienced neurological improvement or pain relief. When laminectomy was delayed for more than 2 weeks, either arachnoid adhesions (15%) or occult abscesses (17%) were observed. From this review as well as from the literature, it appears that the timing of laminectomy for gunshot injuries of the thoracolumbar and lumbosacral spine is not essential to neurological recovery. It appears, however, that adequate debridement of these injuries, performed as soon as the patient is stable from any associated injuries, may help to mitigate the late sequelae of arachnoiditis, infection, and pain syndromes in the lower extremities.
Endocrine Function in Patients with Large Pituitary Tumors Treated with Operative Decompression and Radiation Therapy
Authors: Nelson Paul B. , Goodman Michael L. , Flickenger John C. , Richardson Donald W. , Robinson Alan G.
Published: May 2010

Large pituitary tumors are still a common problem. Thirty consecutive patients underwent operative decompression and radiation therapy for large sellar and suprasellar tumors. They were studied prospectively in terms of their endocrine outcome. Ten of the patients had panhypopituitarism both before and after treatment. The other 20 patients had partial hormonal deficits prior to treatment. Ten (50%) of the 20 patients who had partial preoperative deficits went on to develop delayed onset of worsening in their endocrine function; 9 of the 10 developed panhypopituitarism, and 1 patient developed decreased thyroid function. The mean time from surgery until the onset of delayed worsening in endocrine function was 26.1 months. The mean age of those patients who developed delayed onset of worsening in pituitary function was significantly higher than that of those who did not develop further hormonal loss (40.5 ± 3.1 years versus 52.0 ± 4.1 years, P < 0.05). None of the 10 patients with delayed onset of worsening in pituitary function had anatomical evidence by computed tomographic scan of tumor recurrence. Delayed onset radiation effect is the most likely cause of the late onset of worsening in endocrine function.
Normal Perfusion Pressure Breakthrough Complicating Surgery for the Vein of Galen Malformation: Report of Three Cases
Authors: Morgan Michael K. , Johnston Ian H. , Sundt Thoralf M.
Published: May 2010

Three cases are described of infants who developed malignant brain swelling (and in one case hemorrhage) after surgery for vein of Galen malformations. The cause for the brain swelling was felt to be due to hyperperfusion, or the “normal perfusion pressure breakthrough” syndrome. Although well-described for cerebral parenchymal arteriovenous malformations, cases of this complication occurring in vein of Galen malformations have not previously been reported. It is concluded from these cases that infants with large arteriovenous shunts, as attested by cardiac failure and cerebral atrophy, have an increased risk of developing this complication.
Atypical Monoclonal Plasma Cell Hyperplasia of the Central Nervous System: Precursor of Plasmacytoma with Evolutionary Considerations
Authors: Weidenheim Karen M. , Campbell Wallace G. , Goldman H. Warren
Published: May 2010

Hematopoietic proliferations rich in plasma cells rarely occur within the central nervous system without the involvement of other organ systems. Depending on their histological pattern and cellular composition, several different terms, including plasmacytoma, plasma cell granuloma, hyalinizing plasmacytic granulomatosis, and inflammatory meningioma, are used for these lesions. We report a left temporal dural lesion composed of plasma cells, lymphocytes, histiocytes, and rare eosinophils with hyaline changes and a suggestion of follicle formation, which stained predominantly for IgG and kappa light chains. This lesion arose in an otherwise healthy 52-year-old woman. Free kappa light chains without a monoclonal peak were found in the urine. We are aware of only two other heterogeneous, predominantly plasmacytic, solitary dural lesions that were found to be monoclonal on immunohistochemical examination. The label atypical monoclonal plasma cell hyperplasia appears to suit the morphological characteristics of our lesion. We suggest that a spectrum of solitary plasmacytic lesions may occur within the central nervous system and that atypical plasma cell hyperplasias have the potential to evolve into plasmacytoma. The preneoplastic nature of this lesion and its potential for evolution to malignant myeloma should be considered when planning treatment and lifelong follow-up for patients.
Simultaneous Presentation of Glioblastoma Multiforme in Siblings Two and Five Years Old: Case Report
Authors: Duhaime A. C. , Bunin G. , Sutton L. , Rorke L. B. , Packer R. J.
Published: May 2010

Histologically identical cases of glioblastoma multiforme in two siblings are presented. The diagnoses were made within 2 months of each other. Current knowledge of familial brain tumors is reviewed.
Vascular Abnormalities in the Neck Associated with Intracranial Aneurysms
Authors: George B. , Mourier K. L. , Gelbert F. , Reizine D. , Raggueneau J. L.
Published: May 2010

In 102 cases of ruptured intracranial aneurysms, the cervical as well as the cranial areas were explored by angiography. Loops in the course of the cervical vessels were present in 28 patients; features of fibromuscular dysplasia were present in 31 patients; and in 50 patients, no abnormalities were observed. In 7 patients, both cervical anomalies were present. Loops were associated with single aneurysms (95%), located primarily on the anterior communicating artery (76%), predominantly in men (M/F = 1.6). Aneurysms with fibromuscular dysplasia affected women more than men (F/M = 7), were frequently multiple (58%), and were located mainly on the intracranial part of the internal carotid and vertebral arteries (51%). These data suggest new concepts of aneurysm formation from inherited diseases and should permit the detection of some aneurysms before rupture.
Redundant Nerve Roots of the Cauda Equina: Clinical Aspects and Consideration of Pathogenesis
Authors: Suzuki Kazuhiro , Ishida Yoshihiro , Ohmori Kazuo , Sakai Hisashi , Hashizume Yoshio
Published: May 2010

In order to investigate the clinical significance of redundant nerve roots of the cauda equina (RNR) and their pathogenesis, the following studies were performed: 1) examination of 1,256 myleograms of patients with lumbar disease; 2) clinical analysis of 55 patients with RNR and 75 without RNR; 3) electrophysiological examination of 9 patients with RNR; and 4) anatomical and histopathological examination of 6 autopsy cases. RNR were found in 42% of patients with severely constricted spinal canals. In comparing patients with RNR and those without RNR, RNR were found in older patients, these patients exhibited a longer period from the onset of the symptoms to the time of myelographic manifestation, and they caused more severe signs and symptoms. The spatial distribution of redundant nerve roots and the extent of degeneration of nerve fibers in redundant nerve roots indicated the close causal relationship between RNR and constriction of the spinal canal. As the pathogenesis of RNR, the authors suggest a squeezing force from the constricted spinal canal acting on the nerve roots.
The Infant Whiplash-Shake Injury Syndrome: A Clinical and Pathological Studya
Authors: Hadley Mark N. , Sonntag Volker K. H. , Rekate Harold L. , Murphy Alan
Published: May 2010

The cases of 13 infants (median age, 3 months) who sustained nonaccidental trauma were reviewed. All presented with profound neurological impairment, seizures, retinal hemorrhages, and intracranial subarachnoid and/or subdural hemorrhages. Of 8 infants who died, autopsy was performed on 6. No patient had a skull fracture, and only one had an extracalvarial contusion. Five of the 6 patients on whom autopsy was performed had injuries at the cervicomedullary junction consisting of sub- or epidural hematomas of the cervical spinal cord with proximal spinal cord contusions. The authors conclude that direct cranial trauma is not an essential element of the injury mechanism in young patients who sustain severe whiplash-shake injuries. In addition to the classic injuries reported to occur with the shaken-baby syndrome, hemorrhages and contusions of the high cervical spinal cord may contribute to morbidity and mortality.
Clinical Course and Surgical Prognosis of 33 Cases of Intracranial Epidermoid Tumors
Authors: Yamakawa Kenta , Shitara Nobuyuki , Genka Shigeru , Manaka Shinya , Takakura Kintomo
Published: May 2010

Thirty-three cases of intracranial epidermoid tumors treated during the past 25 years were analyzed with regard to clinical manifestations, recurrence rates related to the extent of surgery, and long-term survival rates. Epidermoid tumors caused various symptoms, especially in the cerebellopontine angle (15 cases), of which a transient remission of symptoms was observed in 4 cases (23.5%). The average time from initial symptoms to surgery was much shorter in suprasellar region and third ventricular locations (average of 11 months) than in other locations (average of 7 years). In 28 patients (84.9%), the tumor was removed totally or subtotally. Most of the patients could lead an independent and useful life after operation (93.1%). Among the 29 patients in a long-term follow-up survey, seven tumors recurred after an average interval of 8 years and 10 months (from the first to second operation) and 12 years and 6 months (from the second to third operation). Patients with recurrent tumors were successfully treated, and excellent functional prognosis was observed even after the second or third operation. The 20-year survival rate was 92.8% (Kaplan-Meier method).
Bilateral Germ Cell Tumors Involving the Basal Ganglia and Thalamus
Authors: Kobayashi Tatsuya , Yoshida Jun , Kida Yoshihisa
Published: May 2010

Two cases of a human chorionic gonadotropin-producing germ cell tumor originating bilaterally in the basal ganglia and thalamus are reported. The biological behavior and clinical characteristics were similar to those of unilateral germinomas involving the basal ganglia and thalamus. Common clinical features were slowly progressive unilateral pyramidal signs and bilateral and/or unilateral extrapyramidal signs which occurred either concomitantly or sequentially. Bilateral symmetrical lesions were demonstrated by computed tomography and/or magnetic resonance imaging at an early stage of illness. Serum and cerebrospinal fluid human chorionic gonadotropin levels were elevated (116 and 141 mIU/ml, respectively) but decreased and remained within normal limits after radiation therapy alone. Radiosensitivity was confirmed by repeated computed tomographic scans and tumor marker measurements. Multiple concomitant germ cell tumors is a rare, but interesting lesion, especially considering its pathogenesis and oncogenesis.
Superior Sagittal Sinus Infection with Petriellidium boydii: Case Report
Authors: Fessler Richard G. , Brown Frederick D.
Published: May 2010

A case of infection of the superior sagittal sinus with Petriellidium boydii is reported. This relatively common fungal pathogen rarely invades the central nervous system. Immunological compromise and poor personal hygiene seem to be common attributes shared by this patient and the 4 previous patients reported to have suffered invasion of the central nervous system by this organism. This report is unique in that it is the first demonstrating apparent hematogenous dissemination of this organism to the central nervous system.
Microsurgical DREZ-otomy for the Treatment of Spasticity and Pain in the Lower Limbs
Authors: Sindou Marc , Jeanmonod Daniel
Published: May 2010

The authors report on a series of 53 bedridden patients suffering from harmful spasticity in one (6) or both (47) lower limbs, who were treated with microsurgical DREZ-otomy. Surgery was performed to treat fixed abnormal postures in flexion in 49 patients and hyperextension in 3, and, additionally, to treat pain in 37 patients. Microsurgical DREZ-otomy was introduced in 1972, on the basis of anatomical studies of the human dorsal root entry zone (DREZ) showing a topographical segregation of the afferent fibers according to their size and functional destinations. It consists of a 2 mm deep microsurgical lesion directed at a 45° angle in the posterolateral sulcus and penetrating the dorsal root entry zone in its ventrolateral aspect, at the level of all the rootlets considered involved in spasticity (and pain). It destroys mainly the lateral (nociceptive) and central (myotatic) afferent fibers as well as the facilitatory medial part of the Lissauer tract, while sparing most of the medial (lemniscal) fibers, the suppressor lateral part of the Lissauer tract, and more or less of the dorsal horn (DH). The postoperative results were evaluated after a mean follow-up period of 3 years and 4 months. Both spasticity and spasms were significantly decreased or suppressed in 75% and 88.2% of the patients, respectively. When present, pain was relieved without abolition of sensation in 91.6%. These benefits-combined with complementary orthopedic surgery in 23 patients-resulted in either disappearance or marked reduction of the abnormal postures in 85.3% of the patients and of articular limitations in 96.8%. Mid-to-severe complications occurred in 25 patients and precipitated or were responsible for death in 5. This is explained by the fact that the general and neurological conditions of most of the patients-especially those affected by multiple sclerosis-were precarious. MDT has, however, enabled a majority of these severely disabled patients to sit and lie comfortably, and has allowed them to reach a significantly improved quality of life.
Prognostic Factors in Well-Differentiated Cerebral Astrocytomas in the Adult
Authors: Soffietti Riccardo , Chioò Adriano , Giordana Maria Teresa , Vasario Ezio , Schiffer Davide
Published: May 2010

Eighty-five “well-differentiated” astrocytomas in adults (age, >18 years), operated on between 1950 and 1982, were retrospectively reviewed. The pilocytic variant was not included. Twenty-four clinical and 8 histological factors were analyzed to investigate their importance in predicting length of survival. Multivariate analysis showed that the following variables were correlated with survival time (P < 0.01): extent of surgical removal, altered consciousness during preoperative examination, focal deficit as presenting symptom, performance status (Karnofsky rating) after surgery, and vessel size in the surgical specimen. Total removal of the tumor was related to a higher 5-year survival rate (51%) than subtotal removal (23.5%), and none of the patients with partial removal survived more than 5 years. Postoperative radiotherapy (40-55 Gy) improved only the 1- and 3-year survival rates. Based on the significant factors provided by multivariate analysis, a score was developed to detect subgroups with different prognoses. Median survival time ranged from 383 days for patients with a score >2.5 to 1,533 days for those with a score <0.5; no patient with a score >1.5 survived more than 10 years. The percentage of recurring astrocytomas that showed anaplastic areas in the second biopsy specimen was 79%. Total surgical removal is the most important factor in the management of well-differentiated astrocytomas, whereas the efficacy of postoperative radiotherapy still needs to be confirmed by prospective and randomized studies. The rationale for treating incompletely resected astrocytomas with radiation therapy could lie in the high incidence of malignant transformation.
Colloid Cysts: Experience with the Management of 84 Cases Since the Introduction of Computed Tomography
Authors: Camacho Arturo , Abernathey Chad D. , Kelly Patrick J. , Laws Edward R.
Published: May 2010

A retrospective review of colloid cysts diagnosed from 1974 to 1986 emphasizes the presenting symptoms of these lesions, their surgical management, and the contribution of modern imaging techniques to their diagnosis and therapy. In this 12-year period, 84 patients (45 men and 39 women) had a colloid cyst diagnosed. The patients' mean age was 46 years (range, 7-82 years). Surgery was performed in 55 patients, 7 of whom had undergone prior surgery elsewhere. The surgical approaches used were transfrontal-transventricular, transcallosal, computer-assisted stereotactic aspiration and resection by stereotactic craniotomy, and shunting of cerebrospinal fluid without removal of the lesion. There was no operative mortality, but complications occurred in 15 patients (27%). Preoperative imaging showed hydrocephalus in 93% of the patients: severe in 43%, moderate in 36%, and mild in 14%. In the surgically treated group, the most common presenting symptoms were headache, change in mental status, ataxia, nausea and vomiting, visual disturbance, emotional lability/inappropriate affect, depersonalization, and hypersomnolence. Twenty-four patients for whom surgery was not recommended are being followed up closely. Most of these patients had normal ventricles. The symptoms in this group included headache, anxiety/nervousness, ataxia, memory impairment, visual disturbance, and seizures. Five autopsy cases of patients with colloid cysts were available during this period and were reviewed. Direct removal of colloid cysts can be accomplished with low morbidity and mortality, avoiding the frequent revisions and complications related to shunt procedures. There is a subgroup of colloid cysts that can be operated upon electively or followed up closely with serial imaging studies.
Ultrastructural Microvascular Response to Boron Neutron Capture Therapy in an Experimental Model
Authors: Goodman Joseph H. , McGregor John M. , Clendenon Nancy R. , Gahbauer Reinhard A. , Fairchild Ralph G. , Barth Rolf F. , Soloway A. H.
Published: May 2010

A CD 344 rat glioma model currently used to investigate boron neutron capture therapy (BNCT) was used to demonstrate an increased survival rate after thermal neutron irradiation enhanced by administration of 10B-enriched polyhedral borane, Na2B12H11SH. To investigate the possible effects of BNCT on normal and tumor microvasculature, we subjected animals to sublethal neutron irradiation with and without intravenous injection of 50 mg/kg of enriched 10B and performed histological and ultrastructural analyses. In the rats that did not undergo tumor transplantation, minimal detectable morphological changes in the microvasculature of the central nervous system were observed after treatment, both in the immediate posttreatment phase and at 10 months. Light microscopy of cerebral cortex and caudate nucleus showed normal cytoarchitecture with no evidence of vessel occlusion, hyalinization, thickening, or reactive gliosis. Electron microscopy demonstrated that the junctional complexes of the endothelial cells, the basal lamina, and the perivascular glia were comparable in both treated and control animals. In those animals examined at 18 months, pathological membrane-bound clusters of electron-dense vesicles were seen in pericytes. In the rats implanted with gliomas, vascular proliferation with evidence of breakdown of the blood-brain barrier and vasogenic edema occurred. In the irradiated animals, we noted increased peritumoral edema 3 days after treatment. At seven days, both increased peritumoral edema and necrosis were noted in the rats treated with BNCT. These observations show that the normal microvasculature of the central nervous system tolerates BNCT at the treatment parameters used in our experimental model; the progressive edema and necrosis found in the peritumoral region after BNCT indicate a pathological endothelial response.
Noninvasive Motor Evoked Potential Monitoring During Neurosurgical Operations on the Spinal Cord
Authors: Zentner Josef
Published: May 2010

We present the results of monitoring descending pathways with motor evoked potentials (MEP) in 50 patients during neurosurgical operations on the spinal cord. The electromyographic responses of the anterior tibial muscles were recorded. In addition, in 24 patients responses of the thenar muscles after transcranial electrical stimulation of the motor cortex were recorded. Usually, the averages of 5 to 15 signals were evaluated. Although potentials were obtained preoperatively in all 50 patients, during neuroleptanesthesia intraoperative recording from the anterior tibial muscles was possible in 43 patients (86%) and from the thenar muscles in 21 patients (87.5%). Amplitudes were superior to latencies as evaluation criteria for intraoperative changes in potentials. On the basis of acceptable changes in amplitudes of up to 50% at the end of the operation, 16 recordings from the thenar muscles (76.2%) and 35 from the anterior tibial muscles (81.4%) correlated correctly with the postoperative neurological status; there were false positive results in 5 (23.8%) and 8 (18.6%) patients, respectively. We did not observe false negative findings. Postoperative neurological complications coincided in every case with permanent reduction in amplitudes of more than 50% of the base lines or with intraoperative loss of potentials as observed in 3 and 1 patient, respectively. MEP monitoring during neurosurgical operations on the spinal cord is a sensitive method for early detection of impending neurological complications. Major problems are the influence of anesthesia and the definition of acceptable limits for changes in amplitudes.
Failure of Autologous Fat Grafts to Prevent Postoperative Epidural Fibrosis in Surgery of the Lumbar Spine
Authors: Martin-Ferrer Secundino
Published: May 2010

In three cases of lumbar disc herniation, autologous fat grafts were inserted over the dura mater and the exposed nerve roots during surgery with the aim of preventing postoperative epidural fibrosis. A second operation had to be performed in two of these cases as a result of the radiographic appearance of excessive scar formation in the epidural and adjacent regions of the nerve root giving rise to symptoms. In the third patient, myelographic studies revealed the development of this type of hypertrophic scarring; however, the patient refused a further operation. The hypertrophic epidural scarring occurred in these three cases despite the presence of autologous fat grafts. Histopathological examination of the fat removed from the two patients who were operated on a second time showed a fibrotic infiltration into the fat graft.
Prolactin-Secreting Adenomas: Surgical Results and Long-Term Follow-up
Authors: Maira Giulio , Anile Carmelo , De Marinis Laura , Barbarino Antonino
Published: May 2010

Transsphenoidal surgery is an efficacious treatment for patients with prolactin (PRL)-secreting adenomas, even if disrupted pituitary-hypothalamic relationships may persist and/or a recurrence of the PRL-secreting tumor can occur. In this paper, we analyze the long-term follow-up of 119 consecutively treated women who underwent transsphenoidal microsurgery for PRL-secreting adenomas. Apparent total removal of the tumor was achieved in 98 patients who had enclosed tumors (58 with Grade-I tumors and 40 with Grade II). In the remaining patients, the removal was considered partial. Persistent normal basal PRL levels were achieved in 61 patients who had apparent total removal of the adenoma (44 with Grade I tumors and 17 with Grade II). Of the remaining 37 patients in whom surgical removal of the adenomatous tissue was thought to be total, 30 had persistent nonevolutive, high PRL levels ranging from 21 to 196 ng/ml, without clinical and radiological signs of tumor regrowth, and 7 with PRL levels ranging from 56 to 560 ng/ml had a recurrence of the PRL-secreting tumor. These data seem to indicate that a slightly elevated postsurgical PRL value does not imply that tumoral tissue is still present. Nontumoral conditions (i.e., a secondary empty sella) could induce functional hyperprolactinemia.
Subarachnoid Hemorrhage from Intraspinal Intradural Vertebral Artery Aneurysm: Case Report and Review of the Literature
Authors: Barnett Gene H.
Published: May 2010

A patient with subarachnoid hemorrhage (SAH) due to rupture of a saccular aneurysm arising at the origin of the intradural intraspinal vertebral artery is presented. This case shows that aneurysms at this site may be a rare cause of SAH and reinforces need for 4-vessel angiography after SAH.