bluuebunny/crossref_metadata_2025 huggingface dataset:
Writing, calculating, and finger recognition in the region of the angular gyrus: a cortical stimulation study of Gerstmann syndrome
Authors: Roux Franck-Emmanuel , Boetto Sergio , Sacko Oumar , Chollet François , Trémoulet Michel
Published: May 2009

Object. In an attempt to gain a better understanding of the cerebral functions represented in the angular gyrus and to spare them during surgery, the authors studied patients with brain tumors located close to the angular gyrus and mapped cortical sites by using electrostimulation.

Methods. Before undergoing tumor removal, six right-handed patients (five with left and one with right hemisphere tumors) were studied using cortical mapping with the aid of calculating, writing, finger-recognition, and color-naming tasks in addition to standard reading and object-naming tasks (for a total of 36 brain mapping studies). Strict conditions of functional site validation were applied to include only those cortical sites that produced repetitive interferences in the function tested. Preoperatively, four of the patients exhibited discrete symptoms related to Gerstmann syndrome while performing very specific tasks, whereas the other two patients presented with no symptoms of the syndrome. No patient had significant language or apraxic deficits.

Distinct or shared cortical sites producing interferences in calculating, finger recognition, and writing were repeatedly found in the angular gyrus. Object- or color-naming sites and reading-interference sites were also found in or close to the angular gyrus; although frequently demonstrated, these latter results were variable and unpredictable in the group of patients studied. Finger agnosia and acalculia sites were also found elsewhere, such as in the supramarginal gyrus or close to the intraparietal sulcus. Mechanisms involved in acalculia, agraphia, or finger agnosia (either complete interferences or hesitations) during stimulation were various, from an aphasia-like form (for instance, the patient did not understand the numbers or words given for calculating or writing tasks) to an apparently pure interference in the function tested (patients understood the numbers, but were unable to perform a simple addition).

Conclusions. Symptoms of Gerstmann syndrome can be found during direct brain mapping in the angular gyrus region. In this series of patients, sites producing interferences in writing, calculating, and finger recognition were demonstrated in the angular gyrus, which may or may not have been associated with object-naming, color-naming, or reading sites.
Sympathetic mechanisms in cerebral blood flow alterations induced by spinal cord stimulation
Authors: Patel Sachin , Huang Dah-Luen , Sagher Oren
Published: May 2009

Object. Cervical spinal cord stimulation (SCS) has been found to augment cerebral blood flow (CBF) in a number of animal models, although the mechanisms underlying the cerebrovascular effects of SCS are poorly described. In this study, the authors examined the role of sympathetic tone in CBF alterations induced by SCS in rats.

Methods. Spinal cord stimulation was performed at three intervals while CBF was monitored with laser Doppler flowmetry (LDF). Either hexamethonium (5, 10, or 20 mg/kg), prazosin (0.25, 0.5, or 1 mg/kg), idazoxan (0.5, 1, or 2 mg/kg), propranolol (1, 2, or 4 mg/kg), or vehicle was administered intravenously before the second stimulation. Changes in LDF values due to SCS were recorded as the percentage of change from baseline values and were analyzed. In vehicle-treated animals, SCS increased LDF values by 60.5 ± 1.8% over baseline, whereas both high-dose hexamethonium and prazosin completely abolished the SCS-induced increases in LDF values. On the other hand, LDF values increased by 50.9 ± 4% and 61.4 ± 4% after SCS in the presence of idazoxan or propranolol, respectively. Administration of sympathetic nervous system blockers resulted in a variable degree of systemic hypotension as well. Nevertheless, induced hypotension without sympathetic blockade had only a minimal effect on SCS-induced augmentation of LDF values (48 ± 1.4% over baseline).

Conclusions. Sympathetic tone plays a major role in SCS-induced increases in CBF. This effect seems to be mediated primarily by α1-adrenergic receptors. Systemic hypotension alone cannot explain the effects of sympathetic blockade on the SCS response. Clinical use of SCS in the treatment of cerebral ischemia should take α1-adrenergic receptor sympathetic tone into account.
Effect of ipsilateral subthalamic nucleus lesioning in a rat parkinsonian model: study of behavior correlated with neuronal activity in the pedunculopontine nucleus
Authors: Jeon Mi Fa , Ha Yoon , Cho Yoon Hee , Lee Bae Hwan , Park Yong Gou , Chang Jin Woo
Published: May 2009

Object. The purpose of this study was to investigate the spontaneous behavioral changes and the alteration of neuronal activities in the pedunculopontine nucleus (PPN) after ipsilateral subthalamic nucleus (STN) lesioning by kainic acid in a rat parkinsonian model created by lesioning with 6-hydroxydopamine (6-OHDA).

Methods. Assumptions about the mechanisms mediating the effects of lesioning of the nigrostriatal dopaminergic pathway by 6-OHDA and the effects of STN lesioning were examined behaviorally by means of apomorphine-induced rotational behavior and forepaw-adjusting steps. The authors subsequently investigated the alteration of neuronal activities in the PPN to compare them with the behavioral changes in rat parkinsonian models.

Conclusions. The results demonstrated that STN lesioning induced behavioral improvement in rat parkinsonian models. This result, which confirms previously held assumptions, may account for the therapeutic effect of STN stimulation in Parkinson disease. The alteration of the neuronal activities in the PPN units also indicates that the PPN units are responsible for the improvement in motor symptoms observed after STN lesioning in rat parkinsonian models.
Treatment of intracerebral hematomas caused by aneurysm rupture: coil placement followed by clot evacuation
Authors: Niemann David B. , Wills Andrew D. , Maartens Nicholas F. , Kerr Richard S. C. , Byrne James V. , Molyneux Andrew J.
Published: May 2009

Object. The aim of this study was to evaluate the efficacy of a treatment combination of coil embolization and clot evacuation in patients presenting with an intracerebral hematoma (ICH) caused by the rupture of an aneurysm.

Methods. Twenty-seven patients were prospectively recruited in this study between 1996 and 2000. Endovascular treatment of the putative ruptured aneurysm was performed as soon as practical after diagnosis and before surgical evacuation of the ICH. The Glasgow Outcome Scale (GOS) was used during follow up.

Despite admission World Federation of Neurosurgical Societies grades of IV or V in 25 patients (92%), 13 (48%) recovered well with GOS scores of 1 or 2, whereas six patients (21%) died.

Conclusions. The combined result of a favorable outcome in 48% of the patients and a mortality rate of 21% indicates that this treatment may be a valuable alternative for this patient group and warrants further study.
Sex steroid hormone exposures and risk for meningioma
Authors: Jhawar Balraj S. , Fuchs Charlie S. , Colditz Graham A. , Stampfer Meir J.
Published: May 2009

Object. The goal of this study was to investigate the risk of meningioma in relation to exogenous and endogenous sex hormones.

Methods. The study participants were female registered nurses from 11 US states who were between 30 and 55 years of age when they enrolled in the Nurses' Health Study cohort. These women completed biennial questionnaires between 1976 and 1996. All participants were free from cancer and other major medical illness at the onset of the study. The primary endpoint was meningioma as self-reported in biennial and supplemental questionnaires.

During 1,213,522 person-years of follow-up review, 125 cases of meningioma were confirmed. After adjusting for age and body mass index (BMI), compared with postmenopausal women who had never used postmenopausal hormones, the relative risk (RR) for premenopausal women was 2.48 (95% confidence interval [CI] 1.29–4.77; p = 0.01) and the RR for postmenopausal women who received hormone therapy was 1.86 (95% CI 1.07–3.24; p = 0.03). The authors found no excess risk associated with past hormone use. In models that additionally controlled for hormone use and menopausal status, the authors found that, compared with women whose menarche occurred before they were 12 years of age, the RR for women whose menarche occurred at ages 12 through 14 years was 1.29 (95% CI 0.86–1.92; p = 0.21) and the RR for women whose menarche occurred after age 14 years was 1.97 (95% CI 1.06–3.66; p = 0.03). The authors also observed a tendency, albeit nonsignificant, for increased risk of meningioma in parous as opposed to nulliparous women (multivariate RR = 2.39, 95% CI 0.76–7.53; p = 0.14). A trend toward an increasing risk of meningioma with increasing BMI was also noted (p for trend = 0.06). No association was found for past or current use of oral contraceptives.

Conclusions. The risk for meningiomas was increased among women exposed to either endogenous or exogenous sex hormones. An unexpected relationship with increasing age at menarche was also noted; this remains unexplained.
Outcomes after cerebral aneurysm clip occlusion in the United States: the need for evidence-based hospital referral
Authors: Cowan John A. , Dimick Justin B. , Wainess Reid M. , Upchurch Gilbert R. , Thompson B. Gregory
Published: May 2009

Object. In an age of multimodality and multidisciplinary treatment of cerebral aneurysms, patient outcomes have improved significantly. For a number of complex surgical procedures, hospitals with high case volumes yield superior outcomes. The effect of hospital volume on the mortality rate after emergency and elective cerebral aneurysm clip occlusion in a nationally representative sample of patients is unknown.

Methods. Using clinical data derived from the Nationwide Inpatient Sample for the years from 1995 through 1999, 12,023 patients who underwent clip occlusion of a cerebral aneurysm (International Classification of Diseases, Ninth Revision, Clinical Modification code 3951) were included. Patient age, comorbid conditions, nature of admission, and diagnosis of subarachnoid hemorrhage were abstracted. Hospital case volume was grouped into quartiles. Unadjusted and case-mix adjusted analyses were performed.

The mean patient age was 53.2 ± 13.5 years. The overall crude postoperative mortality rates for emergency and elective aneurysm clip occlusion were 12.2 and 6.6%, respectively. Very low volume hospitals demonstrated higher mortality rates than very high volume hospitals for both emergency (14.7 compared with 8.9%, p < 0.001) and elective (9.4 compared with 4.5%, p < 0.001) aneurysm surgery. Patient-specific predictors of death in the multivariate model were renal disease (odds ratio [OR] 3.32, p < 0.042); age (> 60 years, OR 2.36, p < 0.001; 51–60 years, OR 1.63, p < 0.001; 40–50 years, OR 1.25, p = 0.047); chronic obstructive pulmonary disease (present, OR 1.52, p < 0.001); and nature of admission (emergency, OR 1.18, p = 0.03). Provider-specific predictors of death included very low volume (OR 1.59, p < 0.001); low-volume (OR 1.37, p = 0.001); and high-volume (OR 1.45, p < 0.001) hospitals compared with very high volume hospitals.

Conclusions. A significant volume—outcome effect exists for surgical treatment of cerebral aneurysms in the US. Factors influencing this effect should be investigated to guide future healthcare policy and evidence-based referral. Whenever possible, healthcare practitioners should refer patients to centers in which superior outcomes are consistently demonstrated.
Urgent endovascular treatment of acute symptomatic occlusion of the cervical internal carotid artery
Authors: Wang Huan , Lanzino Giuseppe , Fraser Kenneth , Tracy Patrick , Wang David
Published: May 2009

Object. The prognosis of patients with acute symptomatic cervical internal carotid artery (ICA) occlusion is generally considered to be poor. Traditionally, such patients are not considered eligible for urgent thrombolytic/endovascular treatment. Since 1998, an aggressive therapeutic approach with endovascular treatment has been adopted at the authors' institution. In this report they assess whether aggressive treatment of ICA occlusion is appropriate.

Methods. The clinical characteristics and outcome of six consecutive patients treated urgently with an endovascular approach between 1998 and 2001 are reviewed and summarized.

Recanalization was accomplished in all patients. At a mean follow-up period of 8 months (range 2–14 months), five of six patients had good or excellent outcomes (modified Rankin Scale [mRS] Score 0–1) and one had a poor outcome (mRS Score 4).

Conclusions. With recent advancements in thrombolytic and endovascular treatments, an aggressive endovascular approach in patients with acute symptomatic cervical ICA occlusion may be successful. Further clinical data are required to determine the optimal endovascular approach in these patients.
Asymmetry of pressure autoregulation after traumatic brain injury
Authors: Schmidt Eric A. , Czosnyka Marek , Steiner Luzius A. , Balestreri Marcella , Smielewski Piotr , Piechnik Stefan K. , Matta Basil F. , Pickard John D.
Published: May 2009

Object. The aim of this study was to assess the asymmetry of autoregulation between the left and right sides of the brain by using bilateral transcranial Doppler ultrasonography in a cohort of patients with head injuries.

Methods. Ninety-six patients with head injuries comprised the study population. All significant intracranial mass lesions were promptly removed. The patients were given medications to induce sedation and paralysis, and artificial ventilation. Arterial blood pressure (ABP) and intracranial pressure (ICP) were monitored in an invasive manner. A strategy based on the patient's cerebral perfusion pressure (CPP = ABP − ICP) was applied: CPP was maintained at a level higher than 70 mm Hg and ICP at a level lower than 25 mm Hg. The left and right middle cerebral arteries were insonated daily, and bilateral flow velocities (FVs) were recorded. The correlation coefficient between the CPP and FV, termed Mx, was calculated and time-averaged over each recording period on both sides. An Mx close to 1 signified that slow fluctuations in CPP produced synchronized slow changes in FV, indicating a defective autoregulation. An Mx close to 0 indicated preserved autoregulation. Computerized tomography scans in all patients were reviewed; the side on which the major brain lesion was located was noted and the extent of the midline shift was determined. Outcome was measured 6 months after discharge. The left—right difference in the Mx between the hemispheres was significantly higher in patients who died than in those who survived (0.16 ± 0.04 compared with 0.08 ± 0.01; p = 0.04). The left—right difference in the Mx was correlated with a midline shift (r = −0.42; p = 0.03). Autoregulation was worse on the side of the brain where the lesion was located (p < 0.035).

Conclusions. The left—right difference in autoregulation is significantly associated with a fatal outcome. Autoregulation in the brain is worse on the side ipsilateral to the lesion and on the side of expansion in cases in which there is a midline shift.
Clinical application of robotic telemanipulation system in neurosurgery
Authors: Goto Tetsuya , Hongo Kazuhiro , Kakizawa Yukinari , Muraoka Hisashi , Miyairi Yosuke , Tanaka Yuichiro , Kobayashi Shigeaki
Published: May 2009

✓ The NeuRobot is a telecontrolled microscopic micromanipulator system designed for neurosurgical procedures. The unit houses a three-dimensional endoscope and three robot arms that the surgeon operates without direct contact with the patient. The authors have successfully performed robotics-assisted neurosurgical procedures by using the NeuRobot in a 54-year-old man who had a recurrent atypical meningioma. Following the usual preparation of craniotomy and opening of the dura mater, a portion of the tumor was removed using the NeuRobot with the aid of microscopic observation. No complication related to the use of the NeuRobot was encountered and the patient's postoperative course was uneventful. Although various kinds of robots have been developed for use in neurosurgery in recent years, a robotic telemanipulation system capable of performing several surgical tasks has not previously been introduced to clinical neurosurgery. This is the first case report in which neurosurgical manipulation by a robotics system is described.
Hemangiopericytoma of the confluence of sinuses and the transverse sinuses
Authors: Collignon Frederic P. , Cohen-Gadol Aaron A. , Piepgras David G.
Published: May 2009

✓✓ The authors describe the case of a 38-year-old man with progressive headache and blurred vision related to a hemangiopericytoma located exclusively in the confluence of sinuses (CoS) and in the transverse sinuses bilaterally. They believe this is the first report in which a hemangiopericytoma of the dural sinuses has been described without any intradural component. Although the diagnosis was not suspected preoperatively, a gross-total resection of the tumor with restoration of sinus patency was achieved to relieve the symptoms. This diagnosis should be included in the preoperative differential diagnosis of a tumor of the CoS. Successful resection can be achieved in these cases.
Intracranial follicular dendritic cell sarcoma
Authors: Hasselblatt Martin , Sepehrnia Abolghassem , von Falkenhausen Marcus , Paulus Werner
Published: May 2009

✓✓ Intracranial occurrence of follicular dendritic cell (FDC) sarcoma, a rare tumor derived from dendritic cells of the lymphoid follicle, has not yet been described. Therefore, the case of a 53-year-old man presenting with an intracranial mass invading the clivus is reported. The diagnosis of FDC sarcoma was confirmed by immunohistochemical staining for dendritic cell markers, that is, CD21, CD23, and CD35. Due to some similarities with meningioma, intracranial FDC sarcoma might be an underdiagnosed disease.
Chronic bilateral thalamic stimulation: a new therapeutic approach in intractable Tourette syndrome
Authors: Visser-Vandewalle Veerle , Temel Yasin , Boon Peter , Vreeling Fred , Colle Henry , Hoogland Govert , Groenewegen Henk J. , van der Linden Chris
Published: May 2009

✓✓ Based on the results of thalamotomies described by Hassler in 1970, the authors performed bilateral thalamic highfrequency stimulation (HFS) in three patients with intractable Tourette syndrome (TS). In this report they describe the long-term effects.

Three male patients (42, 28, and 45 years of age) had manifested motor and vocal tics since early childhood. The diagnosis of TS was made according to the criteria of the Tourette Syndrome Classification Study Group. Any drug or alternative treatment had been either ineffective or only temporarily effective in all three patients. There was no serious comorbidity. The target for stimulation was chosen at the level of the centromedian nucleus, substantia periventricularis, and nucleus ventrooralis internus. After 2 weeks of test stimulation, the pulse generators were implanted. After a follow-up period of 5 years in the patient in Case 1, 1 year in the patient in Case 2, and 8 months in the patient in Case 3, all major motor and vocal tics had disappeared and no serious complications had occurred. When stimulation was applied at the voltage necessary to achieve an optimal result on the tics, a slight sedative effect was noted in all three patients. In the patients in Cases 1 and 3 there were stimulation-induced changes in sexual behavior.

Chronic thalamic HFS may be an effective and safe treatment for medically intractable TS in adult patients. Unwanted stimulation-induced side effects may occur.
Treatment of aneurysms with wires and electricity. A historical overview
Authors: Siddique Khawar , Alvernia Jorge , Fraser Kenneth , Lanzino Giuseppe
Published: May 2009

✓✓ Endovascular treatment of aneurysms has only recently become an accepted therapeutic modality. Nonetheless, treatment of aneurysms with the aid of various foreign bodies such as needle and wire insertion with or without electrical current has been reported since the first half of the 19th century. In 1832 Phillips induced clot formation in the femoral and carotid arteries of dogs by leaving needles in the arteries for variable lengths of time. Simultaneously, in France, Velpeau had proposed using “l'acupuncture des arteres dans le traitement des anevrismes.” Later, Phillips and Pelrequin connected the offending needles to a source of electrical current in an attempt to increase thrombus formation and aneurysm occlusion. Subsequently, Moore introduced the concept of packing the aneurysm with wire inserted through a needle transfixed to the vessel wall. To this method, Corradi added electrical current. Widely known as the Moore—Corradi technique, it was used in ensuing years with variable success. The early phase of endovascular aneurysm treatment culminated when Blakemore and Moore treated a case of symptomatic cavernous sinus aneurysm by passing wire through the patient's orbit. These pioneering cases combined with technological advances in the diagnosis of intracranial aneurysms paved the way for further refinements in coil embolization of aneurysms.
Delayed neurological deficits detected by an ischemic pattern in the extracellular cerebral metabolites in patients with aneurysmal subarachnoid hemorrhage
Authors: Skjøth-Rasmussen Jane , Schulz Mette , Kristensen Soren Risom , Bjerre Per
Published: May 2009

Object. In the treatment of patients with aneurysmal subarachnoid hemorrhage (SAH), early occlusion of the aneurysm is necessary as well as monitoring and treatment of complications following the primary bleeding episode. Monitoring with microdialysis has been studied for its ability to indicate and predict the occurrence of delayed ischemic neurological deficits (DINDs) in patients with SAH.

Methods. In 42 patients with aneurysmal SAH microdialysis monitoring of metabolites was performed using a 0.3-µl/minute perfusion flow over several days, and the results were correlated to clinical events and to brain infarction observed on computerized tomography scans. The microdialysis probe was inserted into the territory of the parent artery of the aneurysm. The authors defined an ischemic pattern as increases in the lactate/glucose (L/G) and lactate/pyruvate (L/P) ratios that were greater than 20% followed by a 20% increase in glycerol concentration.

This ischemic pattern was found in 17 of 18 patients who experienced a DIND and in three of 24 patients who did not experience a delayed clinical deterioration. The ischemic pattern preceded the occurrence of a DIND by a mean interval of 11 hours. Maximum L/G and L/P ratios did not correlate with the presence of DIND or outcome, and there was no association between the glycerol level and subsequent brain infarction.

Conclusions. Microdialysis monitoring of the cerebral metabolism in patients with SAH may predict with high sensitivity and specificity the occurrence of a DIND. Whether an earlier diagnosis results in better treatment of DINDs and, therefore, in overall better outcomes remains to be proven, as it is linked to an efficacious treatment of cerebral vasospasm.
Inflammation markers and risk factors for recurrence in 35 patients with a posttraumatic chronic subdural hematoma: a prospective study
Authors: Frati Alessandro , Salvati Maurizio , Mainiero Fabrizio , Ippoliti Flora , Rocchi Giovanni , Raco Antonino , Caroli Emanuela , Cantore Giampaolo , Delfini Roberto
Published: May 2009

Object. To evaluate the role of local inflammation in the pathogenesis and postoperative recurrence of chronic subdural hematoma (CSDH), the authors conducted an investigation in a selected group of patients who could clearly recall a traumatic event and who did not have other risk factors for CSDH. Inflammation was analyzed by measuring the concentration of the proinflammatory and inflammatory cytokines interleukin (IL)-6 and IL-8. The authors also investigated the possible relationship between high levels of local inflammation that were measured and recurrence of the CSDH.

Methods. A prospective study was performed between 1999 and 2001. Thirty-five patients who could clearly recall a traumatic event that had occurred at least 3 weeks previously and who did not have risk factors for CSDH were enrolled. All patients were surgically treated by burr hole irrigation plus external drainage.

The concentration of inflammatory cytokines was very high in the lesion, whereas it was normal in serum. In five cases in which recurrence occurred, concentrations of both IL-6 and IL-8 were significantly increased (p < 0.01) in comparison with cases without a recurrence. In a layering hematoma, the IL-6 and IL-8 concentrations were significantly higher (p < 0.05). Layering CSDHs were also significantly correlated with recurrence. Trabecular hematoma had the lowest cytokine levels and the longest median interval between trauma and clinical onset. The interval from trauma did not significantly influence recurrence, although it did differ significantly between the trabecular and layering CSDH groups. Concentrations of IL-6 and IL-8 in the CSDHs did not differ significantly in relation to either the age of the hematoma (measured as the interval from trauma) or the age of the patient.

Conclusions. Brain trauma causes the onset of an inflammatory process within the dural border cell layer; high levels of inflammatory cytokines were significantly correlated with recurrence and layering CSDH. A prolonged postoperative antiinflammatory medicine given as prophylaxis may help prevent the recurrence of a CSDH.
Errors in compliance with federal rules and regulations relating to healthcare benefits programs: the University of Washington Department of Neurological Surgery experience
Authors: Winn H. Richard
Published: May 2009

✓ This article details the errors in compliance with federal rules and regulations relating to the healthcare benefits programs at the University of Washington Department of Neurological Surgery from 1996 through 2002. University faculty members, regardless of the organization to which they belong, will be identified by the federal government as the individual responsible in healthcare finance inquiries. A full understanding of all regulations and an active compliance program are necessary to avoid problems, including criminal prosecution.
Superior semicircular canal dehiscence syndrome
Authors: Ramsey Mitchell J. , McKenna Michael J. , Barker Fred G.
Published: May 2009

✓ The authors present the case of a man who had superior semicircular canal dehiscence syndrome in addition to chronic otitis media. This case is atypical because the patient coincidentally had middle ear and mastoid disease, which previously had been treated surgically. The prior ear surgery delayed the diagnosis of superior semicircular canal dehiscence syndrome and increased the complexity of the repair of the superior semicircular canal dehiscence.

Superior semicircular canal dehiscence syndrome is a recently recognized syndrome resulting in acute or chronic vestibular symptoms. The diagnosis is made using history, vestibular examination, and computerized tomography studies. Neurosurgeons should be aware that patients with superior semicircular canal dehiscence syndrome who experience disabling chronic or acute vestibular symptoms can be treated using a joint neurosurgical—otological procedure through the middle cranial fossa.
Direct repair of a blisterlike aneurysm on the internal carotid artery with vascular closure staple clips
Authors: Yanagisawa Toshiharu , Mizoi Kazuo , Sugawara Taku , Suzuki Akira , Ohta Tohru , Higashiyama Naoki , Takahashi Masataka , Sasajima Toshio , Kinouchi Hiroyuki
Published: May 2009

✓ Vascular closure staple clips made of titanium were originally developed for microvascular anastomosis. Clinical applications for these clips include arteriotomy closure for carotid endarterectomy, extracranial—intracranial bypass, and dural closure. This is the first report in which vascular closure staple clips have been used successfully for direct repair of a tear on the internal carotid artery (ICA). This report involves a 65-year-old man who presented with sudden onset of headache. Admission computerized tomography scans demonstrated a diffuse and thick subarachnoid hemorrhage in the basal cisterns. Cerebral angiograms demonstrated a broad-based, small bulge on the superomedial wall of the left ICA. Intraoperatively, an extremely thin-walled aneurysm was seen on the segment of the ICA at the C-2 vertebral level. The aneurysm ruptured abruptly, although no surgical manipulation was being performed on the aneurysm itself. After temporary clips were applied on the vessel, a large tear of the ICA was repaired with vascular closure staple clips. Reconstruction with the vascular closure staple clips required only a short period of temporary occlusion of the ICA. Postoperative angiograms revealed reduction of the aneurysm bulge and good patency of the ICA. The postoperative course was uneventful, and the patient has been free of symptoms. The vascular closure staple clipping procedure is useful for urgent repair of an aneurysm tear. This method is a new treatment option for these fragile aneurysms in cases in which other options, such as encircling clips or bypass procedures, may have drawbacks or be impossible.
Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial
Authors: Cruz Julio , Minoja Giulio , Okuchi Kazuo , Facco Enrico
Published: May 2009

Object. The authors evaluated long-term clinical outcomes in selected acutely comatose patients with severe diffuse brain swelling and recent clinical signs of impending brain death who received a novel high-dose mannitol treatment compared with those who received conventional-dose mannitol in the emergency room.

Methods. Forty-four adult patients with traumatic, nonmissile-inflicted, acute, severe diffuse brain swelling were prospectively and randomly evaluated. All patients were selected based on the presence of recent clinical signs of impending brain death on the first emergency room evaluation. These signs included bilateral abnormal pupillary widening and lack of motor responses to painful stimulation (Glasgow Coma Scale score of 3). The study group (23 patients) received ultra-early and fast intravenous high-dose mannitol treatment (∼1.4 g/kg), whereas the control group (21 patients) received half that dose (∼0.7 g/kg).

Ultra-early improvement of bilateral abnormal pupillary widening was significantly more frequent in the high-dose mannitol group than in the conventional-dose group (p < 0.02). High-dose mannitol treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (p < 0.02); the best rate of favorable outcomes was 43.5%, compared with only 9.5% in the conventional-dose mannitol group. The two groups of patients were well matched with respect to all emergency room and head computerized tomography findings, as well as the timing of initial mannitol treatment (∼80–90 minutes after the first evaluation at the scene of the injury).

Comparative evaluation of bilateral pupillary widening between the scene of the injury and the emergency room showed no significant differences between groups, whereas mannitol dose dependence was statistically significant (p < 0.05), insofar as early pupillary improvement in the emergency room was concerned.

Conclusions. Ultra-early high-dose mannitol administration in the emergency room is the first known treatment strategy significantly to reverse recent clinical signs of impending brain death, and also to contribute directly to improved long-term clinical outcomes for these patients who have previously been considered unsalvageable.
Surgical removal of corpus callosum infiltrated by low-grade glioma: functional outcome and oncological considerations
Authors: Duffau Hugues , Khalil Ihab , Gatignol Peggy , Denvil Dominique , Capelle Laurent
Published: May 2009

Object. Although still controversial, many authors currently advocate extensive resection in the treatment of low-grade gliomas (LGGs). Because these tumors usually migrate along white matter pathways, the corpus callosum is often invaded. Nevertheless, there is evidently no specific study featuring resection of the corpus callosum infiltrated by glioma, despite abundant literature concerning callosotomy in epilepsy surgery or transcallosal ventricular approaches. The aim of this paper was to analyze functional outcome following removal of corpus callosum invaded by LGG and to analyze the impact of this callosectomy on the quality of resection.

Methods. Between 1996 and 2002, a total of 32 patients harboring an LGG involving part of the corpus callosum and having no or only a mild preoperative deficit underwent surgery aided by intraoperative electrical mapping to preserve eloquent structures identified on stimulation and to perform the most extensive resection possible.

Preoperatively, no clinical response was elicited on stimulation of the corpus callosum; thus, the part of this structure that was invaded by LGG was removed. Despite immediate postoperative neurological worsening, all patients but one recovered within 3 months and returned to a normal socioprofessional life. The additional callosectomy allowed for nine total resections, 18 subtotal resections, and five partial resections. Furthermore, only two cases of contralateral hemispherical migration occurred during a median follow up of 3 years.

Conclusions. Resection of the corpus callosum infiltrated by glioma improves the quality of tumor removal without increasing the risk of sequelae.
Effect of human albumin administration on clinical outcome and hospital cost in patients with subarachnoid hemorrhage
Authors: Suarez Jose I. , Shannon Larry , Zaidat Osama O. , Suri Muhammad F. , Singh Grwant , Lynch Gwendolyn , Selman Warren R.
Published: May 2009

Object.Human albumin is used to induce hypervolemia (central venous pressure [CVP] > 8 mm Hg) after subarachnoid hemorrhage (SAH). Unfortunately, human albumin may increase the mortality rate in critically ill patients; because of this, its use became restricted in the authors' hospital in May 1999. The goal of this study was to determine the effect of human albumin on outcome and cost in patients with SAH before and after this restriction was put into place.

Methods.All patients with aneurysmal SAH who were admitted to the authors' institution between May 1998 and May 2000 were studied. Basic demographic information, dosage of human albumin given, length of stay, and the incidence of in-hospital deaths and complications were collected. The authors obtained Glasgow Outcome Scale (GOS) scores at 3 months after SAH (good outcome, GOS ≥ 4). Data were analyzed using t-test and chi-square analysis. Logistic regression was used to identify independent associations between use of human albumin and outcome.

The authors studied 140 patients: 63 who were admitted between May 1998 and May 1999 (Group 1) and 77 treated between June 1999 and May 2000 (Group 2). Two subgroups of patients were further analyzed. Group 1 patients who received human albumin (albumin subgroup, 37 patients) and Group 2 patients who would have received albumin under the old protocol (that is, those who failed to achieve CVP > 8 mm Hg after normal saline administration; nonalbumin subgroup, 47 patients). Patients in the nonalbumin subgroup were more likely to be male (38% compared with 16%), to experience hypertension (55% compared with 30%), to suffer from hypomagnesemia (49% compared with 5.4%), and to have hydrocephalus (47% compared with 27%). There was a trend for these patients to have more vasospasm (28% compared with 19%, p = 0.2). Patients in the albumin subgroup were more likely to have a good outcome at 3 months.

Conclusions.Administration of human albumin after SAH may improve clinical outcome and reduce hospital cost.
Outcome after subarachnoid hemorrhage from a very small aneurysm: a case-control series
Authors: Taylor Christopher L. , Steele Debra , Kopitnik Thomas A. , Samson Duke S. , Purdy Phillip D.
Published: May 2009

Object. A case-control analysis of patients with SAH was performed to compare risk factors and outcomes at 6 months posthemorrhage in patients with a very small aneurysm compared with those with a larger aneurysm.

Methods. All patients with SAH who were treated between January 1998 and December 1999 were studied. A very small aneurysm was defined as “equal to or less than 5 mm in diameter.” Clinical data and treatment summaries were maintained in an electronic database. The Glasgow Outcome Scale (GOS) score was determined by an independent registrar.

One hundred twenty-seven patients were treated. A very small aneurysm was the cause of SAH in 42 patients (33%), whereas 85 (67%) had aneurysms larger than 5 mm (mean diameter 11 mm). There were no differences in demographic variables or medical comorbidities between the two groups. Thick SAH (Fisher Grade 3 or 4) was more common in patients with a very small aneurysm than in those with a larger aneurysm (p = 0.028). One hundred eight patients underwent microsurgery (85%), 15 underwent coil embolization (12%), and four (3%) required both procedures. Vasospasm occurred in nine patients (21%) with very small aneurysms compared with 14 (16%) with larger aneurysms (p = 0.62). Shunt-dependent hydrocephalus occurred in nine patients (21%) with very small aneurysms and in 19 (22%) with larger aneurysms (p = 1). The mean GOS score for both groups was 4 (moderately disabled) at 6 months.

Conclusions. Small aneurysms produce thick SAH more often than larger aneurysms. There is no difference in outcome after SAH between patients with a very small aneurysm and those with a larger aneurysm.
Extended middle fossa approach: quantitative analysis of petroclival exposure and surgical freedom as a function of successive temporal bone removal by using frameless stereotaxy
Authors: Hsu Frank P. K. , Anderson Gregory J. , Dogan Aclan , Finizio Joseph , Noguchi Akio , Liu Kenneth C. , McMenomey Sean O. , Delashaw Johnny B.
Published: May 2009

Object. Conventional wisdom regarding skull base surgery says that more extensive bone removal equals greater exposure. Few researchers have quantitatively examined this assertion, however. In this study the authors used a frameless stereotactic system to measure quantitatively the area of petroclival exposure and surgical freedom for manipulation of instruments with successive steps of temporal bone removal.

Methods. With the aid of high-power magnification and a high-speed drill, 12 cadaveric specimens were dissected in four predetermined, successive bone removal steps: 1) removal of the Kawase triangle; 2) removal of the Glasscock triangle; 3) removal of the cochlea together with skeletonization of the anterior internal auditory canal; and 4) inferior displacement of the zygoma.

Step 1 offered 62 ± 43 mm2 of exposed petroclival area, with 84 ± 69 mm2 of surgical freedom; Step 2, 61 ± 22 and 76 ± 58 mm2; Step 3, 128 ± 47 and 109 ± 87 mm2; and Step 4, 135 ± 38 and 102 ± 69 mm2, respectively.

Conclusions. The middle fossa approach provided a means surgically to expose the petroclival area. When examined quantitatively by using a frameless stereotactic device, the authors determined that the removal of the cochlea and skeletonization of the anterior internal auditory canal (Step 3) provided the most significant increase in both exposure and surgical freedom. Removal of the zygoma improved neither exposure nor surgical freedom.
Dorcas Hager Padget: neuroembryologist and neurosurgical illustrator trained at Johns Hopkins
Authors: Kretzer Ryan M. , Crosby Ranice W. , Rini David A. , Tamargo Rafael J.
Published: May 2009

✓ Dorcas Hager Padget was a pioneer in the fields of neurosurgical illustration and neuroembryology who practiced during the early 20th century at The Johns Hopkins University. Without a college degree, she trained as a medical illustrator in the Johns Hopkins School of Medicine's Department of Art as Applied to Medicine under Max Brödel. She began her career working for Walter Dandy as his medical artist, gaining worldwide recognition for her neurosurgical illustrations. With Dandy's encouragement, Hager Padget undertook her own scientific research, studying neurodevelopment and aneurysm formation in the circle of Willis by using human embryos from the world-renowned Carnegie Collection. She made lasting contributions to the field of neuroembryology, publishing the first major work on neurodevelopment of the cerebral arterial and venous systems. Following Dandy's death in 1946, Hager Padget began a full-time career as a scientific researcher, first at the Department of Embryology at the Carnegie Institution of Washington in Baltimore and later at the University of Maryland School of Medicine. She continued to make contributions to the field of congenital malformations of the brain and spine, coining the term “neuroschisis” to describe a possible mechanism of neural tube damage leading to the creation of a myelomeningocele. The authors describe Dorcas Hager Padget's contributions to neurosurgical illustration and neuroembryology, as well as her remarkable career.
Evaluation of the response of metastatic brain tumors to stereotactic radiosurgery by proton magnetic resonance spectroscopy, 201TlCl single-photon emission computerized tomography, and gadolinium-enhanced magnetic resonance imaging
Authors: Kimura Teruo , Sako Kazuhiro , Tanaka Kunio , Gotoh Takumi , Yoshida Hiroshi , Aburano Tamio , Tanaka Tatsuya , Arai Hiroyuki , Nakada Tsutomu
Published: May 2009

Object. The goal of this study was to investigate the usefulness of proton (1H) magnetic resonance (MR) spectroscopy to evaluate the response of metastatic brain tumors to stereotactic radiosurgery (SRS) in comparison with Gd-enhanced MR imaging and single-photon emission computerized tomography with administration of thallium-201 chloride (201TlCl-SPECT).

Methods. Forty patients with a total of 47 metastatic brain tumors were evaluated. The primary lesion was identified in all cases. Stereotactic radiosurgery was effective in 37 lesions. All patients were examined using Gd-enhanced MR imaging before and after SRS. Thalium-201 chloride was administered to 27 patients with 34 tumors and SPECT images were obtained. Proton MR spectroscopy was performed in 36 patients who harbored 43 tumors. On Gd-enhanced MR images, a decrease in the volume of the Gd-enhanced lesion and a change in the enhanced effect in the lesion after treatment were recognized as showing the effectiveness of SRS between 1 and 3 months or more (mean 8.54 ± 3.58 weeks). In 201TlCl-SPECT studies, the ratio of lesion to normal brain decreased from 2 weeks to 2 months (mean 5.03 ± 2.77 weeks) after radiosurgery. On 1H-MR spectroscopy images a high choline (Cho) peak and a lipiddominant (Lip) peak were observed in 25 lesions and a high Cho peak and a lactate-dominant (Lac) peak were observed in 12 lesions before SRS. A decrease in the Cho peak, a disappearance of the Lac peak, and an increase in the Lip peak were observed between 1 week and 1 month (mean 2.76 ± 1.62 weeks) after treatment.

Conclusions. Based on histopathological findings obtained at autopsy or at surgery, we assume that a high Cho peak may be observed in viable tumor tissue and a Lip peak in areas of necrosis. The results indicate that 1H-MR spectroscopy is potentially a more sensitive tool in evaluating the response to SRS than 201TlCl-SPECT or Gd-enhanced MR imaging and that it can be used earlier for this purpose than those other imaging methods.
Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia
Authors: Brisman Ronald
Published: May 2009

Object. The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years.

Methods. Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4–4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan—Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6 , 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0–10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001).

Conclusions. Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.
A rare case of primary sellar melanoma
Authors: Tüttenberg Jochen , Fink Wolfram , Back Walter , Wenz Frederik , Schadendorf Dirk , Thomé Claudius
Published: May 2009

✓ The authors report on the case of a 37-year-old woman in whom a primary sellar malignant melanoma mimicking a hemorrhagic pituitary macroadenoma was treated. This entity is exceedingly rare; only five cases are described in the literature. The patient presented with rapid deterioration of vision within a 2-week period. After an ophthalmological diagnosis of chiasmal syndrome was made, magnetic resonance (MR) imaging of the head revealed an intra- and suprasellar mass that was elevating and compressing the optic chiasm. Because of the signal heterogeneity of the lesion a hemorrhagic pituitary macroadenoma was assumed; the lesion was transsphenoidally resected. Histological examination of the specimen showed a malignant melanocytic tumor with immunopositivity for S100 protein and HMB-45. Despite extensive staging no other primary melanotic tumor was found. Thus, a primary sellar melanoma was diagnosed. Postoperative MR images demonstrated no residual tumor. For adjuvant therapy the region around the sella turcica received 40.4 Gy stereotactically guided radiation. A 24-month follow-up examination revealed no tumor recurrence.

This represents the sixth case of such a lesion reported in the literature, the third case evaluated using MR imaging, and the first case with a progression-free survival of 24 months. Thus, the authors advocate that management of primary sellar melanoma should include gross-total removal and postoperative stereotactic radiotherapy.