bluuebunny/crossref_metadata_2025 huggingface dataset:
PET of malignant cerebral tumors after interstitial brachytherapy
Authors: Valk Peter E. , Budinger Thomas F. , Levin Victor A. , Silver Pamela , Gutin Philip H. , Doyle Werner K.
Published: May 2009

✓ Positron emission tomography (PET) with rubidium-82 (82Rb) and fluorine-18-fluorodeoxyglucose (18F-FDG) was used to diagnose active tumor recurrence and to differentiate this from radiation injury after interstitial irradiation of malignant gliomas. Patients were studied when they presented with radiological or clinical deterioration after an initial period of posttreatment stabilization. Forty studies were performed in 34 patients. The 82Rb was used as a blood-brain barrier tracer to localize the lesion. Uptake of 18F-FDG by the lesion was then compared to uptake by adjacent brain in order to make a diagnosis of active tumor recurrence (higher or equal lesion uptake) or no active tumor (lower uptake). Radiation injury was diagnosed by the exclusion of active tumor. A retrospective clinical diagnosis was established in 38 cases by following the patients' progress for 8 to 142 weeks after the PET study. In two cases, no follow-up diagnosis could be determined. The PET results agreed with the follow-up diagnosis in 15 of 17 cases of active tumor and 17 of 21 cases of radiation injury. Histological examination of surgically resected tissue obtained after the PET study was performed in 18 patients (nine with tumor regrowth and nine with radiation injury). This showed apparently viable tumor as well as necrosis in all cases, regardless of eventual clinical outcome. Some cells from the irradiated volume may appear morphologically intact, but have little or no metabolic or clinical activity. The functional nature of the PET-FDG technique allows diagnosis of tumor activity, which cannot be demonstrated by anatomic imaging studies or by histological examination. The addition of a blood-brain barrier tracer to the 18F-FDG study aids in differentiating normal brain uptake from tumor activity and improves the accuracy of the technique.
Choroid plexus papillomas: long-term follow-up results in a surgically treated series
Authors: McGirr Stephen J. , Ebersold Michael J. , Scheithauer Bernd W. , Quast Lynn M. , Shaw Edward G.
Published: May 2009

✓ The medical records and histological specimens from 26 patients with choroid plexus papillomas operated on at one institution were reviewed retrospectively. Four patients died perioperatively, and 21 of the remaining 22 patients were followed through March, 1986; the patient lost to follow-up review was last seen 14 years postoperatively. Of the 14 patients who underwent gross total removal of their tumor, one had a recurrence at 11 years postoperatively and two died in the perioperative period. Of the 12 patients who underwent subtotal removal of their tumor, two died in the perioperative period. The two patients who did not have radiation therapy postoperatively are free of apparent disease at 6 and 8 years after their operation. Eight patients underwent radiation therapy after subtotal removal of their tumor; four of these remain alive and well, and four have died of progressive disease.

The role of irradiation in the treatment of subtotally resected lesion remains controversial, but this therapy is thought to be indicated for recurrent disease after a surgical excision that is as complete as possible. Histopathologically, the presence of occasional mitotic figures, microscopic infiltration, ependymal differentiation, or mild to moderate atypia was not correlated with likelihood of complete resectability or tendency to recurrence.
Brain abscesses in neonates
Authors: Renier Dominique , Flandin Cécile , Hirsch Elizabeth , Hirsch Jean-François
Published: May 2009

✓ Since the introduction of ultrasonography and computerized tomography (CT) scanning, brain abscesses are found more frequently in cases of neonatal meningitis and septicemia, particularly when the offending pathogen isProteus. Thirty cases of brain abscess in neonates are reported, 27 of which were caused byProteusspecies infections. Twenty infants had meningitis and 13 had septicemia. Most of the abscesses were enormous, and multiple abscesses were observed in 17 cases. The frontal region was involved in 22 cases (12 unilaterally and 10 bilaterally). The ventricles were enlarged on the first CT scan in 13 cases.

The abscesses were treated by aspiration and antibiotics in 25 cases, and by antibiotics alone in five. A shunt for hydrocephalus was necessary in 14 infants. Four infants died, three from the initial illness and one from a shunt complication. Sixteen children have seizures. Subsequent intelligence quotient (IQ) testing was performed in 22 children: eight (36%) have an IQ at or above 80 and eight have an IQ of less than 60. In the 17 children followed for more than 2 years, the proportion with an IQ at or above 80 fell to 24% (four cases). The absence of initial seizures, sterile cerebrospinal fluid, normal ventricles on CT scans, and early aspiration of the abscess seem to be factors portending a better prognosis in terms of epilepsy and mental sequelae.
The widened transcochlear approach to jugular foramen tumors
Authors: Pellet William , Cannoni Maurice , Pech André
Published: May 2009

✓ The authors describe a widened transcochlear approach for large tumors of the jugular foramen with intrapetrous, intracranial, and infratemporal extensions. This approach complements the transcochlear and infratemporal approaches by enlarging the route of access to the region with disinsertion of the sternocleido-mastoid, digastric, and stylohyoid muscles, by removing petrous bone in order to displace the facial nerve, by resection of the auditory canal, and by subluxation of the temporomandibular joint and zygomatic process. The use of this approach is described in seven patients.
Transoral-transpharyngeal approach to the anterior craniocervical junction
Authors: Menezes Arnold H. , VanGilder John C.
Published: May 2009

✓ The anterior transoral-transpharyngeal operation to correct ventral irreducible compression of the cervicomedullary junction was utilized in 72 individuals. The patients' ages ranged from 6 to 82 years, and 29 were children. The pathology encountered was primary basilar invagination, rheumatoid irreducible cranial settling, secondary basilar invagination due to migration of odontoid fracture fragments, dystopic os odontoideum, granulation masses, clivus chordoma, osteoblastoma, and chondroma of the atlas. Fifteen patients had associated Chiari malformation with basilar invagination. Fifty-two patients required subsequent atlantoaxial or occipitocervical fusion. Neurological improvement was the rule. There were two deaths within 30 days of surgery: one from myocardial infarction 4 weeks after surgery and one from Gram-negative septicemia of urinary tract origin. There was one pharyngeal wound infection. The ventral transoral approach provides a safe, rapid, and effective means for decompression of the abnormal craniovertebral junction.
Neuronal changes in fetal cortex transplanted to ischemic adult rat cortex
Authors: Mampalam Thomas J. , Gonzalez Manuel F. , Weinstein Philip , Sharp Frank R.
Published: May 2009

✓ Fetal cortex from 16- and 17-day-old embryonic rats was transplanted into the parietal cortex of 12 adult rats rendered ischemic by temporary intraluminal occlusion of the middle cerebral artery. Ischemic injury in the host cortex adjacent to all nine surviving transplants was demonstrated with hematoxylin and eosin and cresyl violet stains. Nicotidamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemical studies revealed a normal number of NADPH-d-positive neurons, whereas acetylcholinesterase (AChE) staining revealed many more AChE-positive neurons in the transplants compared to the host parietal cortex. This could be due to: 1) selective survival of AChE neurons in the transplants compared to the host cortex; 2) increased expression of AChE in transplanted neurons; 3) induction of AChE in normally AChE-negative neurons; or 4) decreased transport of the AChE enzyme from the perikarya to fibers in surviving transplanted neurons. Many fibers positive for AChE and NADPH-d crossed between the host and transplant, although fiber density in the transplants was less than in normal host cortex. These results should encourage future investigation of whether similar transplants improve neurological function following experimental stroke.
Effects of neuropeptide Y, calcitonin gene-related peptide, substance P, and capsaicin on cerebral arteries in man and animals
Authors: Mejia Juan Armando , Pernow John , von Holst Hans , Rudehill Anders , Lundberg Jan M.
Published: May 2009

✓ The smooth-muscle tone of pial, middle, and anterior cerebral arteries from humans, cats, and pigs, respectively, was studiedin vitrowith respect to the effects of capsaicin and various peptides which are present in local perivascular nerves. Neuropeptide Y (NPY) caused concentration-dependent, potent contractions of the cerebral vessels both in the presence and in the absence of endothelium. In contrast to the response to noradrenaline (NA) and K+, the NPY effect was not altered by changes in the extracellular Ca++concentration. The relaxant action of the calcium antagonist nifedipine on NPY-evoked contraction of cerebral arteries was not inhibited by a Ca++-deficient medium or by a high-Ca++medium. Calcitonin gene-related peptide (CGRP), substance P (SP), and capsaicin caused relaxation of precontracted cerebral arteries with an intact endothelium. Calcitonin gene-related peptide was the most potent dilatory agent, and removal of the endothelium did not change the CGRP response. In contrast, the ability of SP to cause relaxation was abolished after removal of the endothelium. Capsaicin, which activates sensory nerves, induced long-lasting relaxation in both the presence and absence of endothelium. In conclusion, in contrast to earlier reported data, the contractile effect of NPY seems to be largely independent of extracellular Ca++, while NA- and K+-induced contractions are dependent on extracellular Ca++. The present results suggest that the relaxant effect of nifedipine on cerebral blood vessels may involve actions other than inhibition of Ca++influx. The relaxant effect of capsaicin is likely to be induced by release of CGRP rather than SP. The potent effects of these peptides on human pial arteries suggest that neuropeptides may be involved in the control of cerebral blood flow in man.
Pial arteriolar vessel diameter and CO2 reactivity during prolonged hyperventilation in the rabbit
Authors: Muizelaar J. Paul , van der Poel Henk G. , Li Zhongchao , Kontos Hermes A. , Levasseur Joseph E.
Published: May 2009

✓ Hyperventilation reduces intracranial pressure (ICP) acutely through vasoconstriction, but its long-term effect on vessel diameter is unknown. In seven rabbits with a cranial window implanted 3 weeks earlier, the effect of prolonged hyperventilation on vessel diameter was studied. Anesthesia was maintained for 54 hours with a pentobarbital drip (1 mg/kg/hr). The pH, CO2, and HCO3− levels were measured in arterial blood and cisterna magna cerebrospinal fluid (CSF). The diameter of 31 pial arterioles was measured with an image splitter. After baseline measurements, pCO2 was reduced from 38 to 25 mm Hg and allowed to return to 38 mm Hg for 10 minutes every 4 hours.

There was an initial vasoconstriction of 13%, which progressively diminished by 3% every 4 hours. Thus, by the 20th hour, vessel diameters at a pCO2 of 25 mm Hg had returned to slightly above baseline values obtained at a pCO2 of 38 mm Hg. The temporary return of pCO2 to 38 mm Hg every 4 hours caused vasodilation: 12% at 4 hours, gradually increasing to 16% at 52 hours. Thus, at 52 hours, the vessel diameters were 105% of baseline at a pCO2 of 25 mm Hg and increased to 122% at a pCO2 of 38 mm Hg. Arterial pH had returned to baseline at 20 hours, and CSF pH had returned at 24 hours. Bicarbonate in blood and CSF remained decreased throughout the experiments. In three control experiments during which normocapnia was maintained, vessel diameter and pH and bicarbonate levels remained unaltered over the same period. The CO2 reactivity, tested by brief periods of hyperventilation every 4 hours, also did not change.

These results indicate that hyperventilation is effective in reducing cerebral blood volume for less than 24 hours and that it should be used only during actual ICP elevations. If used preventively, its effect may have worn off by the time ICP starts to rise for other reasons, and further decreases in pCO2 cannot be obtained. Moreover, the reduction in buffer capacity with lower bicarbonate renders the vessels more sensitive to changes in PaCO2. This could lead to more pronounced elevations in ICP during transient rises in PaCO2, such as during endotracheal suctioning in head-injured patients.
Myelopathy due to epidural varicose veins of the cervicothoracic junction
Authors: Dickman Curtis A. , Zabramski Joseph M. , Sonntag Volker K. H. , Coons Stephen
Published: May 2009

✓ A 30-year-old man presented with a subacute course of myelopathic signs and symptoms. Magnetic resonance imaging demonstrated an epidural mass lesion of the spinal canal at the cervicothoracic junction causing compression of the spinal cord. Laminectomy with resection of this lesion revealed a large varix with acute and chronic thrombus. Postoperatively, an improvement in neurological function occurred. Spinal epidural varicosities have been reported as an etiological factor in lumbar and sacral radiculopathies. This is the first reported case of spinal cord compression in association with spinal epidural varices. The diagnosis, pathophysiology, and management of this disorder are presented.
Positional oculogyric crises
Authors: Heimburger Robert F.
Published: May 2009

✓ A young woman with a cystic glioma in the region of the posterior third ventricle is presented. Each time she turned to the supine position she developed immediate, forceful, conjugate upward gaze (oculogyric crises) and an inability to talk. If she turned to either side, she was alert and oriented, and could talk and lie comfortably. After stereotaxic removal of the cystic fluid, this phenomenon disappeared and did not return, even when the cyst refilled.
Quality of survival of patients with brain gliomas treated with postoperative CCNU and radiation therapy
Authors: Trojanowski Tomasz , Pęszyński Jerzy , Turowski Krzysztof , Markiewicz Piotr , Gościński Igor , Bielawski Adam , Bendarzewska Barbara , Szymona Jacek , Dąbrowska Aleksandra , Łopatkiewicz Janina , Czochra Tadeusz , Jeziernicka Barbara , Basińska Grażyna , Koźniewska Halina
Published: May 2009

✓ This prospective randomized clinical trial compared the effectiveness of combined treatment with CCNU and radiation therapy to the use of radiation therapy alone for the postoperative management of supratentorial brain gliomas (67% anaplastic) in 198 patients. The results were evaluated with the aid of a specially developed weighted neuropsychological test battery providing single-value estimation of “life quality” of patients, as well as with a clinical performance scale. Based on these methods, it was established that patients improved within 6 months following therapy. This improvement was maintained in surviving patients during the 2-year follow-up period. The patients led a relatively normal life, but when their condition deteriorated their decline was rapid. The median survival time of patients treated with radiotherapy did not differ significantly from that of patients receiving chemotherapy in addition. Nor did the analysis of life quality and of changes in clinical performance show any benefit in supplementing surgery and radiation therapy with CCNU chemotherapy at the dosage used.
Primary optic nerve sheath meningiomas
Authors: Clark W. Craig , Theofilos Charles S. , Fleming James C.
Published: May 2009

✓ Between 1979 and 1987 the authors treated nine cases of primary optic nerve sheath meningioma. The definitive treatment for these lesions is surgical resection, although no single best plan for optimal management has been determined. The data indicate that only small anterior tumors may be removed with preservation of useful vision. With posterior circumferential tumors, there have been no cases of tumor removal with preservation of vision. A management strategy directed toward preservation of vision is discussed.
Multiple intracranial meningiomas
Authors: Domenicucci Maurizio , Santoro Antonio , D'Osvaldo Daniel H. , Delfini Roberto , Cantore Gianpaolo P. , Guidetti Beniamino
Published: May 2009

✓ The authors report 14 cases of multiple intracranial meningiomas representing 1.1% of all meningiomas operated on at their hospital in the past 35 years. Differentiation of multiple meningiomas, especially from meningiomatosis, must be strict. Since the introduction of computerized tomography scanning, the frequency of these cases has risen from 0.58% to 4.5% in the authors' meningioma series. Despite the multiplicity of sites, multiple meningiomas do not differ in prognosis from benign solitary meningiomas.
Neurosurgical management of acute atlas-axis combination fractures
Authors: Dickman Curtis A. , Hadley Mark N. , Browner Carol , Sonntag Volker K. H.
Published: May 2009

✓ Combination atlas-axis fractures occur relatively frequently and have a higher incidence of neurological morbidity than isolated C-1 or isolated C-2 injuries. Patients with combination C1–2 fracture-subluxation injuries should be studied with thin-section computerized tomography. Appropriate treatment is determined by the type of axis fracture present and includes surgical and nonsurgical strategies. An experience with 25 patients with combination C1–2 fractures is presented, and management and follow-up guidelines are reviewed.
Malignant astrocytomas of the spinal cord
Authors: Cohen Alan R. , Wisoff Jeffrey H. , Allen Jeffrey C. , Epstein Fred
Published: May 2009

✓ The authors review their experience with the operative management of 19 consecutive cases of malignant astrocytoma of the spinal cord. There was a male to female ratio of 1.1:1, and the median age of the population was 14 years (range 1 to 32 years). The median duration of symptoms prior to definitive diagnosis was 7 weeks. Radical excision was carried out in all cases, with 18 patients (95%) receiving radiotherapy and 10 patients (53%) receiving chemotherapy as well.

To date, 15 (79%) of the 19 patients in this series have died, with a median survival period of 6 months following surgery. No patient improved after operation. Hydrocephalus was present in 11 patients (58%), seven of whom underwent ventricular shunting procedures. Dissemination of disease was found in 11 patients (58%). Extraneural metastases did not occur in the absence of a ventricular shunt. The authors conclude that malignant astrocytomas of the spinal cord are heralded by a short history followed by rapid neurological deterioration and usually death. The rationale for operation is discussed, and an aggressive approach utilizing adjuvant therapy directed at the entire neuraxis is suggested.
Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study
Authors: Öhman Juha , Heiskanen Olli
Published: May 2009

✓ A total of 216 patients with a ruptured aneurysm of the anterior part of the circle of Willis were enrolled into this prospective randomized study of timing of the operation after aneurysmal subarachnoid hemorrhage (SAH). Only patients in clinical Grades I to III (according to the classification of Hunt and Hess) who were admitted and randomly assigned to a treatment group within 72 hours after the SAH were included in the trial. The patients were randomly assigned to one of three operation groups: acute surgery (AS: 0 to 3 days after the SAH; day of SAH = Day 0), intermediate surgery (IS: 4 to 7 days after the SAH), or late surgery (LS: 8 days to an indefinite time after the SAH). Three patients (4.3%) in the IS group and six patients (8.6%) in the LS group died before surgery was undertaken. At 3 months post-SAH, 65 patients (91.5%) from the AS group were classified as independent compared to 55 (78.6%) from the IS group and 56 (80.0%) from the LS group. The management mortality rate in the AS group was 5.6% compared to 12.9% in the LS group.

Of the 216 patients enrolled in the timing study, 159 were randomly assigned to an independent double-blind placebo-controlled trial of nimodipine in Grade I to III patients. A total of 79 patients received nimodipine and 80 placebo. When the nimodipine group and the no-nimodipine group (the 80 placebo-treated patients plus the 52 patients who were not entered into the nimodipine trial) were analyzed separately, a significant difference was seen in the outcome of the no-nimodipine group (dependent AS vs. dependent IS, p = 0.01). Nimodipine treatment was associated with a significant reduction of delayed ischemic deterioration (all operation groups combined, nimodipine vs. no nimodipine p = 0.01; LS with nimodipine vs. LS with no nimodipine, p = 0.03).
Plasmin-α2-plasmin inhibitor complex and α2-plasmin inhibitor in chronic subdural hematoma
Authors: Saito Kenichi , Ito Haruhide , Hasegawa Takeshi , Yamamoto Shinjiro
Published: May 2009

✓ Levels of the plasmin-α2-plasmin inhibitor complex (PLN-A2PI complex) and α2-plasmin inhibitor (A2PI) were determined by enzyme-linked immunosorbent assay (ELISA) with monoclonal antibodies in 59 patients with 66 chronic subdural hematomas (SDH's). Normal concentrations of the PLN-A2PI complex and A2PI in plasma are below 0.8 µg/ml and 60.5 ± 16.1 µg/ml, respectively (mean ± 2 standard deviations). The hematoma fluid contained high concentrations of the PLN-A2PI complex (4.58 ± 2.60 µg/ml) and low concentrations of A2PI (10.32 ± 4.81 µg/ml), while both values in the plasma of 12 patients with chronic SDH's were within the normal range. This represents local hyperfibrinolytic activity in the hematoma.

Stuporous or comatose patients had higher PLN-A2PI complex levels than did the alert and the drowsy or disoriented patients. The layering type of hematoma as seen on computerized tomography scans showed the highest PLN-A2PI complex levels among five types of hematoma. In the fluid drained postoperatively from the subdural cavities of chronic SDH's, both the PLN-A2PI complex and A2PI levels decreased gradually in healing cases. In two patients with hematoma reaccumulation after surgery, both levels increased. The postoperative increase of the PLN-A2PI complex represents the recurrence of intermittent cycles of fibrinolysis, bleeding, coagulation, and hemostasis in the subdural space.
Tumor-infiltrating lymphocytes and histocompatibility antigens in primary intracranial germinomas
Authors: Saito Takafumi , Tanaka Ryuichi , Kouno Mituo , Washiyama Kazuo , Abe Satoshi , Kumanishi Toshiro
Published: May 2009

✓ Subpopulations of tumor-infiltrating lymphocytes (TIL's) and the major histocompatibility complex (MHC) antigens of neoplastic cells were examined in three intracranial germinomas by an immunohistochemical method using monoclonal antibodies. About 70% to 80% of TIL's were T lymphocytes which were either infiltrating diffusely or in clusters, whereas 20% to 30% of TIL's were B lymphocytes which tend to cluster in tumor tissues. Examination of T lymphocyte phenotypes revealed both the cytotoxic/suppressor and helper/inducer T lymphocytes, as in other tumors. However, the existence of a considerable number of B lymphocytes in the TIL population was uncommon and seemed to be a characteristic feature of the intracranial germinoma, which might suggest a difference of host immune response to this neoplasm as compared to other tumors.

On examination of the MHC antigens, no MHC class I or II antigens in the neoplastic cells were stained, while positive staining for both antigens was seen in the TIL and stroma tissues. From these findings, it was suggested that the degree of TIL infiltration might not be correlated with the expression of MHC antigens in neoplastic cells in cases of primary intracranial germinoma.
The effect of interleukin-2 on the blood-brain barrier in the 9L gliosarcoma rat model
Authors: Alexander Joseph T. , Saris Stephen C. , Oldfield Edward H.
Published: May 2009

✓ Carbon-14-labeled aminoisobutyric acid was used to determine local blood-to-tissue transfer constants in 22 Fischer rats with intracerebral 9L gliosarcomas that received either high-dose parenteral interleukin-2 (IL-2) or a control injection. In tumor and peritumoral tissue, the transfer constants in the IL-2-treated animals (89.6 ± 14.6 and 35.8 ± 6.0, respectively, mean ± standard error of the mean) were larger (p < 0.05) than in control animals (61.4 ± 6.4 and 14.6 ± 2.2, respectively). In contrast, in normal frontal and occipital tissue contralateral to the tumor-bearing hemisphere, there was no significant difference between the transfer constants in IL-2-treated and control animals. Furthermore, treatment of animals with IL-2 excipient caused no change in permeability as compared to animals treated with Hanks' balanced salt solution.

Parenteral injection of IL-2 increases blood-brain barrier disruption in tumor-bearing rat brain but does not increase the vascular permeability of normal brain. Methods to prevent this increased tumor vessel permeability are required before parenteral IL-2 can be used safely for the treatment of primary or metastatic brain tumors.
Foramen magnum decompression in an infant with homozygous achondroplasia
Authors: Moskowitz Nathan , Carson Benjamin , Kopits Steven , Levitt Roy , Hart Graeme
Published: May 2009

✓ Homozygous achondroplasia is a rare yet distinct clinical entity. Most infants succumb to an early death as a result of respiratory compromise due to upper airway obstruction, thoracic cage deformity, and/or cervicomedullary compression. The successful cervicomedullary decompression of a 16-week-old infant with homozygous achondroplasia is described. This report suggests that homozygous achondroplasia is not universally fatal and that these infants are potentially viable if managed by aggressive respiratory and surgical measures.
Preoperative diagnosis of Lhermitte-Duclos disease by magnetic resonance imaging
Authors: Carter John E. , Merren Michael D. , Swann Karl W.
Published: May 2009

✓ Lhermitte-Duclos disease is a benign, presumably hamartomatous lesion of the cerebellum which presents clinically as a mass lesion. Pathologically, it consists of thickening of both the molecular and granular cell layers of the cerebral cortex which enlarges the folia but allows for preservation of the gyral pattern of the cerebellar cortex. Preoperative diagnosis with computerized tomography and other studies has not been possible, and even at surgery the diagnosis may be missed because of the preservation of the gyral pattern. The sensitivity of magnetic resonance imaging allows recognition of the cortical nature of the mass lesion, and especially the gyral pattern within the mass lesion, providing a diagnostic image which is unlikely to be confused with any other pathological process in the cerebellum. Preoperative diagnosis of Lhermitte-Duclos disease allows surgeons to plan an appropriate decompressive procedure.
Cranial vault growth in craniosynostosis
Authors: Delashaw Johnny B. , Persing John A. , Broaddus William C. , Jane John A.
Published: May 2009

✓ Skull growth after single suture closure was described in 1851 by Virchow, who noted that growth in the plane perpendicular to a fused suture was restricted. However, this observation failed to predict compensatory growth patterns that produce many of the deformities recognized as features of individual syndromes. The deformities resulting from premature closure of a coronal, sagittal, metopic, or lambdoid suture can be predicted on the basis of the following observations: 1) cranial vault bones that are prematurely fused secondary to single suture closure act as a single bone plate with decreased growth potential; 2) asymmetrical bone deposition occurs mainly at perimeter sutures, with increased bone deposition directed away from the bone plate; 3) sutures adjacent to the prematurely fused suture compensate in growth more than those sutures not contiguous with the closed suture; and 4) enhanced symmetrical bone deposition occurs along both sides of a non-perimeter suture that is a continuation of the prematurely closed suture. These observations regarding growth in craniosynostosis are illustrated with clinical material in this report.
Civilian gunshot wounds to the brachial plexus
Authors: Kline David G.
Published: May 2009

✓ Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia.

Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found “blown apart” and required repair, usually by grafting.

The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.
Stereotaxic suboccipital transcerebellar biopsy of pontine mass lesions
Authors: Abernathey Chad D. , Camacho Arturo , Kelly Patrick J.
Published: May 2009

✓ Twenty-six patients (16 male and 10 female) ranging in age from 5 to 68 years underwent suboccipital transcerebellar stereotaxic biopsy of mass lesions situated in the pons. Stereotaxic computerized tomography, magnetic resonance imaging, and angiographic data were obtained while the patient was positioned in an inverted custom stereotaxic head frame. The patients were then placed under general endotracheal anesthesia and positioned prone. Optimal trajectory planning utilized a transcerebellar route directed through the middle cerebellar peduncle, with target and entry points calculated to avoid vascular structures. No complications were encountered in the perioperative period when this technique was used. Histological diagnosis of the lesions revealed: astrocytomas in 14 patients, oligodendroglioma in one, ependymoma in one, arteriovenous malformations in two, radionecrosis in one, cryptococcal abscess in one, demyelinating disease in three, and infarctions in three. No consistent correlation could be made between radiographic characteristics and histological diagnoses.

Empiric treatment of brain-stem lesions without tissue diagnosis based upon the radiological and clinical findings may result in inappropriate therapy administration. Alternatively, open operative procedures to obtain tissue require a visible surface abnormality to guide biopsy, and carry the risks of a major surgical procedure in already compromised patients. For these reasons the authors consider a suboccipital transcerebellar stereotaxic biopsy to be the diagnostic procedure of choice in the assessment of pontine mass lesions.
Carotid cave aneurysms of the internal carotid artery
Authors: Kobayashi Shigeaki , Kyoshima Kazuhiko , Gibo Hirohiko , Hegde Sathyaranjandas A. , Takemae Toshiki , Sugita Kenichiro
Published: May 2009

✓ In a series of 32 surgical cases of carotid-ophthalmic artery aneurysm, seven of the lesions were located in the “carotid cave.” This special type of aneurysm is usually small and projects medially on the anteroposterior view of the angiogram. At surgery, it is located intradurally at the dural penetration of the internal carotid artery (ICA) on the ventromedial side, appears to be buried in the dural pouch (carotid cave), and is often difficult to find, dissect, and clip. The aneurysm extends into the cavernous sinus space, and the parent ICA penetrates the dural ring obliquely. An ipsilateral pterional approach was used in all 32 cases, and ring clips were used exclusively because the aneurysms were located ventromedially. Clipping was successful in five cases. All patients returned to their preoperative occupation, although vision worsened postoperatively in two cases. The technical steps required for successful obliteration of this aneurysm are summarized as follows: 1) exposure of the cervical ICA; 2) unroofing of the optic canal and removal of the anterior clinoid process; 3) exploration of the ICA around the dural ring and opening of the cavernous sinus; 4) direct retraction of the ICA and optic nerve; and 5) application of multiple ring clips to conform to the natural curvature of the carotid artery; a curved-blade ring clip is especially useful. The relevant topographic anatomy is discussed.
Acidophil stem-cell pituitary adenoma in a prepubescent female
Authors: Marks Warren A. , Brumback Roger A. , Schaefer G. Brad , Pendleton Bruce D. , Farris Bradley K. , Culbertson Jan L.
Published: May 2009

✓ Acidophil stem-cell pituitary adenomas account for less than 5% of pituitary tumors. Only 15 cases have previously been reported, with a mean age of occurrence of 38.7 years. A case of this unusual tumor is reported in a prepubertal girl. Clinical symptoms included prominent behavioral disturbance with associated headache and visual disturbance. There was marked elevation of serum growth hormone concentration without clinical features of growth hormone excess, suggesting that this tumor has the capacity to excrete biologically inactive hormones. The clinical and pathological features of this unusual invasive pituitary tumor are reviewed; the age spectrum for this neoplasm must be expanded to include prepubertal children.
Intracranial chondroma in a patient with Ollier's disease
Authors: Traflet Robert F. , Babaria Ashok R. , Barolat Giancarlo , Doan H. T. , Gonzalez Carlos , Mishkin Mark M.
Published: May 2009

✓ A case is presented in which a solitary chondroma arose from the clivus of a patient with Ollier's disease. These tumors are rare. The diagnostic value of computerized tomography and magnetic resonance imaging is discussed.
Localization of brain tumors with a simple scalp-mounted fiducial device
Authors: Hirschberg Henry
Published: May 2009

✓ A method is described for marking the site of a tumor on the scalp based on information from computerized tomography (CT) scans. The technique employs a syrinx-shaped array of radiopaque catheters of varying length taped to the patient's scalp for visualization on the CT scan. Fiducial markings on the CT images allow the transfer of the tumor's location directly onto the scalp. The device can be placed anywhere on the scalp, including in a parasagittal position.
The management of “asymptomatic” epidural hematomas
Authors: Knuckey Neville W. , Gelbard Steven , Epstein Mel H.
Published: May 2009

✓ Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma.

Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol.

It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.
Microsurgical reoperation following lumbar disc surgery
Authors: Ebeling Uwe , Kalbarcyk H. , Reulen H. J.
Published: May 2009

✓ Ninety-two patients who underwent microsurgical reoperation for persistent or new complaints following initial lumbar intervertebral disc surgery were evaluated retrospectively. Sixty percent of all pain relapses occurred within 1 year following the first operation; thereafter, the probability of a relapse declined steadily and was as low as 0.1% per year between 5 and 20 years. The results of microsurgical reoperation in terms of pain relief and working capability were considered “excellent” in 22% of patients, “good” in 30%, and “satisfactory” in 29%. Thus, 81% of the patients could be considered as treated successfully and in 19% the result was not successful.

The most common intraoperative findings were: a true recurrence at the same level in 43% of cases, a new herniation at another level in 15%, and a small recurrent fragment embedded in epidural fibrosis in 23%. Five percent of patients had severe epidural fibrosis as the only pathology. In 15%, reoperation was performed within 1 month to treat persisting pain, and either a missed disc fragment, an inadequately decompressed lateral recess, or an unrecognized second-level disc protrusion was found.

The clinical outcome is affected predominantly by the intraoperative pathology and the time interval between the first and second operation. An excellent or good outcome was usually achieved in patients with a recurrence of pain after 1 year resulting from a true recurrent disc or a new herniation at another level. In contrast, very unfavorable results were noted with most reoperations performed during the 1st year when extensive epidural fibrosis (or fibrosis with a small recurrence) was present.
One-stage posterolateral decompression and stabilization for primary and metastatic vertebral tumors in the thoracic and lumbar spine
Authors: Shaw Brian , Mansfield Frederick L. , Borges Lawrence
Published: May 2009

✓ During the past decade, anterior approaches to the spine have been shown to be much more effective than laminectomy for the relief of pain and neurological deficits due to vertebral metastases. Laminectomy has failed because it does not allow adequate decompression of epidural lesions anterior to the thecal sac. In an effort to combine the advantages of the posterior approach with an adequate decompression, a one-stage posterolateral decompression-stabilization procedure was performed on nine patients with thoracolumbar spine tumors. The approach has been used for decompression and stabilization after thoracolumbar burst fractures. Marked lasting improvement was seen in all six patients with preoperative neurological deficits and in four patients with severe back pain and/or radiculopathy. Three nonambulators and two marginal ambulators could walk postoperatively without assistance. Of five patients who were working preoperatively, four returned full-time to their prior occupations. Three patients had serious complications, including one early postoperative death. No patient deteriorated neurologically due to the procedure. Although the series is small, it demonstrates that adequate one-stage decompression-stabilization of spinal epidural lesions is possible via the posterolateral approach and should be considered in certain cases as an alternative to the anterior approach.
Tic douloureux caused by primitive trigeminal artery or its variant
Authors: Morita Akio , Fukushima Takanori , Miyazaki Shinichiro , Shimizu Tsuneo , Atsuchi Masayuki
Published: May 2009

✓ Primitive trigeminal artery (PTA) is an extremely rare cause of tic douloureux. None of the reports on PTA variant, which is an anomalous cerebellar artery arising from the internal carotid artery without anastomosis to the basilar artery, has suggested the possibility of this vessel causing tic douloureux. Eight cases of tic douloureux are reported in which a PTA or PTA variant was found during microvascular decompression (MVD). These cases were derived from a series of 1257 patients treated with MVD for tic douloureux. In one patient, the neuralgia was caused by a combination of vessels: a PTA, the superior cerebellar artery, and the anterior inferior cerebellar artery. In the other seven cases, a PTA variant was compressing the root entry zone of the trigeminal nerve. All eight patients gained excellent pain relief after MVD of the root entry zone. The significance of PTA's and PTA variants as the cause of tic douloureux and the effectiveness of MVD in the management of such cases are discussed.
Cerebral aneurysms in childhood and adolescence
Authors: Meyer Fredric B. , Sundt Thoralf M. , Fode Nicolee C. , Morgan Michael K. , Forbes Glen S. , Mellinger James F.
Published: May 2009

✓ In this study, 24 aneurysms occurring in 23 patients under the age of 18 years (mean 12 years) are analyzed. The male:female ratio was 2.8:1, and the youngest patient was 3 months old. Mycotic lesions and those associated with other vascular malformations were excluded. Forty-two percent of the aneurysms were located in the posterior circulation, and 54% were giant aneurysms. Presenting symptoms included subarachnoid hemorrhage in 13 and mass effect in 11. Several of these aneurysms were documented to rapidly increase in size over a 3-month to 2-year period of observation. All aneurysms were surgically treated: direct clipping was performed in 14; trapping with bypass in four; trapping alone in four; and direct excision with end-to-end anastomosis in two. The postoperative results were excellent in 21 aneurysms (87%), good in two (8%), and poor in one. The pathogenesis of cerebral aneurysms is reviewed.
Studies on embryonic transplants to the transected spinal cord of adult rats
Authors: Pallini Roberto , Fernandez Eduardo , Gangitano Carlo , Del Fà Aurora , Olivieri-Sangiacomo Corrado , Sbriccoli Alessandro
Published: May 2009

✓ Spinal cord tissue was obtained from 13- and 14-day embryonic rats and homologously grafted to the completely transected spinal cord of adult rats. Eight and 12 weeks after grafting, clinical, electrophysiological, histological, and neuroanatomical studies were performed. Motor performance of the hosts was assessed by the inclined-plane test. The conduction of nerve impulses across the lesion-transplantation site was evaluated by recording the spinal corticomotor and somatosensory evoked potentials. The survival, growth, differentiation, and parenchymal integration of the graft were documented histologically on semi-thin sections. The axonal interactions between the host spinal cord and the graft as well as the posttraumatic retrograde degeneration of corticospinal axons were investigated using the horseradish peroxidase (HRP) technique.

Clinical and electrophysiological assessments did not demonstrate any functional activity of the graft. On histological examination, grafted neurons showed a survival rate of 55%. Such neurons exhibited a limited degree of growth and differentiation. The extent of parenchymal integration between the host spinal cord and the graft varied considerably among different specimens and in the various regions of every specimen. The HRP investigations demonstrated that some axonal interactions between the host spinal cord and the graft had occurred. Regenerated axons arising from both the spinal cord and the dorsal root ganglia of the host entered the graft and elongated in it. Also, axons from the grafted neurons were able to grow for some distance in the host spinal cord. The phenomenon of the posttraumatic retrograde degeneration of corticospinal axons was not affected by this embryonic tissue grafting.
Pleomorphic xanthoastrocytoma
Authors: Whittle Ian R. , Gordon Alex , Misra Basant K. , Shaw John F. , Steers A. James W.
Published: May 2009

✓ Four cases of pleomorphic xanthoastrocytoma (PXA), a low-grade leptomeningeal glioma with a reported favorable prognosis affecting young patients, are reported together with a discussion and review of management and prognosis. A literature review has confirmed a favorable prognosis in at least 50% of patients with this disorder. Seventeen of 35 reported patients are still alive and often seizure-free for a mean period of 7.4 years (range 2 to 18 years) after diagnosis. Five patients have died within 2 years and four between 9 and 25 years after diagnosis of PXA. In some cases in which death followed shortly after diagnosis, there may have been histological confusion between PXA and a malignant glioma with heavily lipidized tumor cells. Nonetheless, transformation of PXA into a malignant astrocytoma or glioblastoma with eventual death may occur many years after initial diagnosis. From the currently reported cases it does not appear possible on clinicopathological grounds to predict which patients will have a favorable prognosis. Optimal management of PXA seems to be primary surgical resection with later surgery for residual or recurrent tumor. The role of radiotherapy in the management of PXA is at this time uncertain.
Intracranial fibro-osseous lesion
Authors: Garen Paul D. , Powers James M. , King J. Stovall , Perot Phanor L.
Published: May 2009

✓ A rare tumor closely associated with the trigeminal ganglion produced a syndrome of atypical facial pain in a 44-year-old man. Two previous reports have designated similar tumors as “fibro-osseous lesions.” The distinctive morphological appearance is illustrated and possible histogenesis discussed.
Neuropsychological deficit and emotional disturbance in head-injured patients
Authors: Bornstein Robert A. , Miller Harry B. , van Schoor J. Tinnie
Published: May 2009

✓ The relationship between neuropsychological deficit and emotional disturbance was examined in a sample of 124 patients who sustained work-related head injuries. Most injuries met criteria for minor head injury. Since all patients were receiving compensation, the relationship between emotional disturbance and neuro-behavioral deficit does not appear to be related to compensation or litigation factors. There was a positive relationship between degree of neurobehavioral and emotional abnormality. This was not due to the interval between injury and examination, and did not appear to be related to duration of unconsciousness or amnesia, or to the presence of skull fracture or posttraumatic seizures. The findings are discussed in relation to previous research and to their implications regarding posttraumatic emotional adjustment.