bluuebunny/crossref_metadata_2025 huggingface dataset:
Motor cortex stimulation
Authors: Brown Jeffrey A.
Published: January 2008

In 1991 Tsubokawa and colleagues first published their landmark results from a series in which epidural motor cortex stimulation (MCS) was used in the treatment of eight patients with central and neuropathic pain. In ensuing studies authors have elaborated on the indications, technique, hypotheical mechanisms, and beneficial results of this treatment. Epidural MCS is effective for trigeminal neuropathy, lateral medullary and thalamic infarction, anesthesia dolorosa, postherpetic neuralgia, spinal cord injury, and limb stump pain. Postoperative outcomes are better when patients present with only mild or absent motor weakness in the region of pain and when there is pain in the trigeminal region. It is hypothesized that MCS is effective because it increases regional cerebral blood flow in the ipsilateral ventrolateral thalamus in which corticothalamic connections from the motor and premotor areas predominate. The extent of pain alleviation also correlates with the increase of blood flow in the cingulate gyrus. This suggests that stimulation reduces the suffering experienced by a patient with chronic pain. Procedure-related morbidity has included epidural hematoma, subdural effusion, gradual diminution of benefit, and painful stimulation. Although of concern, treatment-induced chronic seizure disorders have not occurred as a complication or in animal models of chronic cortical stimulation. Stimulation-induced pain relief occurs within minutes. There are no associated paresthesias or muscle contractions that confirm function. Pain relief may last for hours after electrical stimulation is discontinued. Motor cortex stimulation is an established therapy for the treatment of complex central and neuropathic pain syndromes that have proved refractory to medical treatment.
Influence of early posttraumatic hypothermia therapy on local cerebral blood flow and glucose metabolism after fluid-percussion brain injury
Authors: Zhao Weizhao , Alonso Ofelia F. , Loor Judith Y. , Busto Raul , Ginsberg Myron D.
Published: January 2008

Object

Using autoradiographic image averaging, the authors recently described prominent foci of marked glucose metabolism-greater-than-blood-flow uncoupling in the acutely traumatized rat brain. Because hypothermia is known to ameliorate injury in this and other injury models, the authors designed the present study to assess the effects of post-traumatic therapeutic hypothermia on the local cerebral metabolic rate of glucose (LCMRglu) and local cerebral blood flow (LCBF) following moderate parasagittal fluid-percussion head injury (FPI) in rats.

Methods

Either cranial hypothermia (30°C) or normothermia (37°C) was induced for 3 hours in matched groups of rats immediately after FPI; LCMRglu and LCBF were assessed 3 hours after concluding these temperature manipulations.

In rats subjected to FPI, regardless of whether normothermia or hypothermia ensued, LCBF was reduced relative to the sham-injury groups. In addition, when FPI was followed by hypothermia (FPI–30°C group), the subsequent LCBF was significantly lower (35–38% on average) than in FPI–37°C rats. Statistical mapping of LCBF difference imaging data revealed confluent cortical and subcortical zones of significantly reduced LCBF (largely ipsilateral to the prior injury) in FPI–30°C rats relative to the FPI–37°C group. Local glucose utilization was reduced in both hemispheres of FPI–37°C rats relative to the sham-injury group and was lower in the right (traumatized) hemisphere than in the left. However, LCMRglu values were largely unaffected by temperature manipulation in either the FPI or sham-injury groups. The LCMRglu/LCBF ratio was nearly doubled in FPI–30°C rats relative to the FPI–37°C group, in a diffuse and bihemispheric fashion. Linear regression analysis comparing LCMRglu and LCBF revealed that the FPI–37°C and FPI–30°C data sets were completely nonoverlapping, whereas the two sham-injury data sets were intermixed.

Conclusions

Despite its proven neuroprotective efficacy, early posttraumatic hypothermia (30°C for 3 hours) nonetheless induces a moderate decline in cerebral perfusion without the (anticipated) improvement in cerebral glucose utilization, so that a state of mild metabolism-greater-than-blood-flow dissociation is perpetuated.
Management of metastatic tumors of the spine: strategies and operative indications
Authors: Steinmetz Michael P. , Mekhail Anis , Benzel Edward C.
Published: January 2008

The spinal column is the most frequent site of bone metastasis in the body. Spine surgeons are often involved in the care of these patients only after nonoperative management has failed. Because surgery has been viewed as no better than radiotherapy in the treatment of metastasis of the spine, it has only been used as a salvage approach. These views are based on a body of literature in which laminectomy combined with radiotherapy was compared with radiotherapy alone. Anterior approaches to the spine are now popular and familiar to most surgeons. These approaches allow direct access to the metastatic lesion, reconstruction of the anterior vertebral column, and the placement of anterior instrumentation. Outcomes are frequently much better when this combined treatment is used instead of radiotherapy alone. In selected patients, surgery may be desired as first-line therapy before radio- or chemotherapy has been initiated.

The controversy surrounding surgery for metastatic spinal disease is reviewed. Treatment strategies, both operative and nonoperative, are presented. Indications and strategies for surgery are also presented, and the supporting literature is reviewed.
The use of carbon fiber cages in anterior cervical interbody fusion
Authors: Salame Khalil , Ouaknine Georges E. R. , Razon Nissim , Rochkind Semion
Published: January 2008

Object

Cage devices were introduced in spinal fusion to overcome the shortcomings of autograft, allograft, and biocompatible implants. The aim of this study was to assess the short-term results of anterior cervical discectomy and fusion (ACDF) in which an interbody carbon fiber cage (CFC) and local osteophyte–derived bone graft were implanted.

Methods

A retrospective review was conducted of 100 consecutive patients treated by ACDF in which a CFC was packed with bone fragments obtained from osteophytes at the surgical site. Plain radiographs with dynamic lateral views obtained 1 year postoperatively were used to assess bone fusion, alignment of the cervical spine, and stability. Dynamic radiographs were also obtained at last follow up to determine whether loss of cervical alignment or collapse at the fused disc had occurred.

The mean follow-up period was 25 months. In all cases the cervical lordosis was maintained or corrected to different extents and disc height was restored. Solid fusion was achieved in 98% of the cases. There were no cage-related complications and no cases of cage failure.

Conclusions

The authors conclude that application of the CFC for ACDF is safe, effective, and technically feasible. Osteophytes resected during surgery may be a good alternative material for bone grafting in cage-assisted cervical interbody fusion.
Prospective controlled study of rectangular titanium cage fusion compared with iliac crest autograft fusion in anterior cervical discectomy
Authors: Zevgaridis Dimitris , Thomé Claudius , Krauss Joachim K.
Published: January 2008

Object

The complications of autogenous bone grafting compel spine surgeons to seek alternative methods for cervical spinal fusion. This prospective study was conducted to evaluate the safety and efficacy of using rectangular titanium cage fusion compared with the widely performed iliac crest autograft fusion.

Methods

A total of 36 patients with cervical disc disease in whom an anterior approach was indicated for discectomy were included in this prospective controlled study. The first 18 consecutive patients received iliac crest autograft; the next 18 consecutive patients received rectangular titanium cages. The intergroup demographic and clinical data were comparable. All patients attended follow up for 1 year. According to Odom criteria, 15 (83%) of 18 patients in both groups experienced good to excellent functional recovery. According to the Patient Satisfaction Index, 17 (94%) of 18 patients in both groups were satisfied. The evaluation of neck pain and arm pain did not indicate statistically significant differences between either group. Fusion was present after 1 year in 16 (89%) of 18 patients who received iliac crest autografts and in 15 (83%) of 18 patients who received rectangular titanium cages. In the autograft group, a pseudarthrosis was present in one patient and marked hip pain was observed in three patients. In the cage group, there was one case of temporary vocal cord paresis but no implant-related complications.

Conclusions

The authors conclude that the use of titanium cages in anterior cervical discectomy constitutes a safe and efficient alternative to iliac crest bone autograft.
Current diagnosis and treatment of oligodendroglioma
Authors: Engelhard Herbert H.
Published: January 2008

Object

The strategies used to diagnose and treat oligodendroglial tumors have changed significantly over the past decade. The purpose of this paper is to review the topic of oligodendroglioma, emphasizing the new developments.

Methods

Information was obtained by conducting a Medline search in which the term oligodendroglioma was used. Recent editions of standard textbooks were also studied.

Because of tools such as magnetic resonance imaging, oligodendrogliomas are being diagnosed earlier, and they are being recognized more frequently histologically than in the past. Seizures are common in these patients. Functional mapping and image-guided surgery may now allow for a safer and more complete resection, especially when tumors are located in difficult areas. Genetic analysis and positron emission tomography may provide data that supplement the standard diagnostic tools. Unlike other low-grade gliomas, patients in whom residual or recurrent oligodendroglioma (World Health Organization Grade II) is present may respond to chemotherapy. Although postoperative radiotherapy prolongs survival of the patient, increasingly this therapeutic modality is being delayed until tumor recurrence, especially if a gross-total tumor resection has been achieved. Oligodendrogliomas are the first type of brain tumor for which “molecular” characterization gives important information. The most significant finding is that allelic losses on chromosomes 1p and 19q indicate a favorable response to chemotherapy.

Conclusions

Whereas surgery continues to be the primary treatment for oligodendroglioma, the scheme for postoperative therapy has shifted, primarily because of the lesion's relative chemosensitivity. Molecular characterization of oligodendrogliomas may become a standard practice in the near future.
Weapons of mass destruction: biological
Authors: Moquin Ross R. , Moquin Mary E.
Published: January 2008

Humans are susceptible to microbial infections from many sources. Biological warfare is the use of microbial forms of life to diminish the capabilities, disrupt the organization, and terrorize the noncombatant population of an adversary. This form of warfare has been used throughout history and has gained renewed interest with the current use of asymmetrical warfare. The civilized world has condemned its use by the implementation of treaties specifically against it. This is a brief review of some of the more easily used biological agents such as anthrax, plague, tularemia, Q fever, and smallpox. Each agent's biology, infectious route, and disease course will be discussed. Possible delivery systems and signs of outbreak will also be reviewed. There are few real neurosurgery-related implications in biological warfare. Neurosurgeons, as members and leaders of the healthcare community, must have the ability to recognize and initiate treatment when biological agents have been deployed. If there is widespread use of these inhumane agents, the neurosurgical community will not be able to practice the surgical art for which we have trained. New knowledge must be acquired so that we can best serve our patients and communities during times of extreme need.
Molecular mechanisms involved in development of cerebral vasospasm
Authors: Tani Eiichi
Published: January 2008

Object

Although the agents responsible for production of vasospasm have not yet been clearly identified, the author reviews the molecular mechanisms involved in development of vasospasm mainly based on the experimental data in a canine two-hemorrhage model.

Methods

The blood products after subarachnoid hemorrhage most likely stimulate many cell membrane receptors, such as G protein–coupled receptors and receptor tyrosine kinases, to activate the tyrosine kinase pathway of the vascular smooth muscle cells. The activation of the tyrosine kinase pathway is associated with continuous elevation of intracellular Ca++ levels and activation of μ-calpain; the former may result mainly not from Ca++ release but from Ca++ influx from outside the cells. The increased intracellular Ca++ concentrations stimulate Ca++/calmodulin (CaM)–dependent myosin light chain kinase to phosphorylate myosin light chain continuously during vasospasm. A topical application of genistein, ethylene-glycol-bis(β-aminoethylether) N,N'-tetraacetic acid, or various L-type Ca++ channel blockers likely induces reversal of vasospasm as a result of a decrease in intracellular Ca++ levels. The blood products also activate the rho/rho-associated kinase pathway during vasospasm most likely via G protein–coupled receptors, and the activated rho-associated kinase inhibits myosin phosphatase through phosphorylation at its myosin-binding subunit to induce Ca++-independent development of vasospasm. The enhanced generation of arachidonic acid during vasospasm may also contribute to inhibition of myosin phosphatase, at least in part, through the rho/rho-associated kinase pathway. The activity of myosin phosphatase in vasospam can also be inhibited by activated protein kinase C independently of the rho/rho-associated kinase pathway, but the inhibition may play a minor and transient role in contractile regulation. The protein levels of thin filament–associated proteins, calponin and caldesmon, are progressively decreased in vasospasm, whereas their phosphorylation levels are increased. Both changes probably contribute to the enhancement of smooth muscle contractility. Contractile and cytoskeletal proteins appear to be degraded in vasospasm by proteolysis with activated μ-calpain, suggesting that the intracellular devices responsible for smooth-muscle contraction are severely degraded in vasospasm.

Conclusions

It remains to be determined the extent to which Ca++-dependent and -independent contractile regulations, proteolysis and phosphorylation of thin filament–associated proteins, and degradation of contractile and cytoskeletal proteins are involved in the development of vasospasm.
What is a “fair salary” for a surgical subspecialist?
Authors: Wohns Richard N. W.
Published: January 2008

The author presents a net present value model by which a “fair salary” for surgical subspecialists is justified. Neurosurgical practitioners are used as an example, based on assumed fair salary for family physicians.
Decision analysis to estimate cost effectiveness in neurosurgery
Authors: Stein Sherman C. , Burnett Mark G.
Published: January 2008

Medical decisions often depend, in part, on cost-effectiveness concerns. Decision analysis is frequently used to help resolve these questions. Unfortunately, this technique has received little attention in neurosurgery. Using an example of moderate head injury, the authors illustrate the utility of this powerful tool in estimating the cost effectiveness of neurosurgical management options.
Socioeconomic issues of United States military neurosurgery
Authors: Moquin Ross R. , Ecklund James M.
Published: January 2008

Although the practice of neurosurgery in the United States (US) Armed Forces is in many ways similar to the civilian practice of neurosurgery, there are many differences as well. The unique challenges, duties, and opportunities US military neurosurgeons are given, both in peacetime and in times of conflict, are discussed, as are pathways for entering into service. The advantages of military service for neurosurgeons include sponsored training, decreased direct exposure to tort actions, little involvement with third-party payers, significant opportunities for travel, and military-specific experiences. The most appealing aspect of military practice is serving fellow members of the US Armed Forces. Disadvantages include the extreme gap between the military and civilian pay scales, lack of support personnel, and in some areas low surgery-related case volume. The greatest concern faced by the military neurosurgical community is the failure to retain experienced neurosurgeons after their obligated service time has been completed, for which several possible solutions are described. It is hoped that future changes will make the practice of military neurosurgery attractive enough so that it will be seen as a career in itself and not an obligation to endure before starting practice in the “real world.”
Skull base reconstruction after anterior subcranial tumor resection
Authors: Fliss Dan M. , Gil Ziv , Spektor Sergey , Leider-Trejo Leonor , Abergel Avraham , Khafif Avi , Amir Aharon , Gur Eyal , Cohen Jacob T.
Published: January 2008

Object

The goal of this study was to demonstrate the efficacy of a simple and reliable technique for anterior skull base and craniofacial reconstruction in patients who have undergone excision of tumors via the subcranial approach.

Methods

There were 63 patients who had undergone 71 anterior skull base resections of tumors via the aforementioned approach. Twenty-nine cases (41%) involved malignant tumors and 42 (59%) involved benign tumors. Reconstruction of the anterior skull base was performed by a single team who used double-layer fascial graft. Limited dural defects were reconstructed using the temporalis fascia, whereas large anterior skull base defects were reconstructed using a fascia lata sheath. Reconstruction was achieved without the support of bone graft or titanium mesh and without pericranial, galeal, or free flaps. Pericranial flap wrapping of the frontonasoorbital segment was performed to prevent osteoradionecrosis if postoperative radiotherapy was planned. The incidence of cerebrospinal fluid (CSF) leakage, intracranial infection, and tension pneumocephalus was 5.6%. Histopathological examination of fascia lata grafts obtained in patients who had undergone a second procedure demonstrated integration of vascularized fibrous tissue to the graft, as well as local proliferation of a newly formed vascular layer embedding the fascial sheath.

Conclusions

The use of a double-layer fascial graft alone was adequate for prevention of CSF leakage, meningitis, tension pneumocephalus, and brain herniation. The double-layer fascial flap provided a simple and reliable means for anterior skull base reconstruction after en bloc resection of both malignant and benign tumors.
Misdiagnosis of olfactory neuroblastoma
Authors: Cohen Zvi R. , Marmor Eric , Fuller Gregory N. , Demonte Franco
Published: January 2008

Object

Olfactory neuroblastoma (ON) is a rare neoplasm arising from the olfactory epithelium and found in the upper nasal cavity. The authors studied the frequency with which ON is misdiagnosed with other tumors of the paranasal sinuses such as neuroendocrine carcinoma (NEC), pituitary adenoma, melanoma, lymphoma, and sinonasal undifferentiated carcinoma (SNUC). Based on the belief that misdiagnosis commonly occurs, they emphasized the importance of establishing the correct diagnosis, because the treatment regimens and prognosis of these tumor types are often significantly different.

Methods

Twelve consecutive patients in whom ON was diagnosed were referred to the Department of Neuro-surgery at the M. D. Anderson Cancer Center between January 1998 and March 2000.

Demographic data were collected, physical findings and mode of treatments were documented, and neuroimaging studies were assessed. Pathologists at the authors' institute reviewed the histological specimens. Only in two of 12 patients was the diagnosis of ON confirmed. Lesions in 10 patients were misdiagnosed; there were two cases of mel-anoma, three cases of NEC, three cases of pituitary adenoma, and two cases of SNUC. Eight of 10 patients in whom lesions were misdiagnosed required significant alteration in the initially proposed treatment plan.

Conclusions

Neurosurgeons should be acutely aware of the variety of neoplasms that occur in the paranasal region. The correct diagnosis should be ensured before initiating treatment to provide the optimum therapy and spare the patients from needless and potentially toxic treatment.
Perioperative management of complex skull base surgery: the anesthesiologist's point of view
Authors: Jellish W. Scott , Murdoch John , Leonetti John P.
Published: January 2008

The anesthetic management of complex skull base surgical procedures provides unique problems and concerns for the neuroanesthesiologist. Positioning to access the skull base could put the patient at risk for peripheral nerve injury and some of the positions may increase the risk for air emboli. In addition, tumor pathology and involvement with vital structures could increase the chances for substantive blood loss, destruction of associated nerves or vessels, and may require temporary occlusion of the carotid artery necessitating intraoperative neuroprotection. Neurophysiological monitors may also be used to safeguard nerve function and anesthetic techniques must be adjusted to accommodate their use. Finally, postoperative morbidity may be affected by surgical approach to the skull base and the anesthesiologist should be aware of which approach may produce a greater incidence of pain, nausea, and vomiting in the postoperative period.

The authors discuss the anesthetic concerns and management for complex cranial base surgery. Different approaches will be discussed and comparisons of perioperative parameters between these approaches will be made with data provided by retrospective chart review of more than 600 skull base procedures performed at the authors' institution over the last 10 years. This information should help guide decision making concerning anesthetic management for these skull base procedures.
Management of malignant tumors of the anterior and anterolateral skull base
Authors: Origitano Thomas C. , Petruzzelli Guy J. , Vandevender Darl , Emami Bahman
Published: January 2008

Object

Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior–anterolateral cranial base resections for malignant disease.

Methods

The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed.

Conclusions

Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.
Intramedullary spinal cysticercosis
Authors: Sheehan Jason P. , Sheehan Jonas , Lopes M. Beatriz , Jane John A.
Published: January 2008

Cysticercosis is the most common parasitic infection of the central nervous system. It infrequently affects the spine, but when it does, it can present with symptoms similar to other more common spinal diseases. The authors present a case of isolated intramedullary cysticercosis of the cervical spine and review the literature.
Reconstruction of the superior sagittal sinus with silicone tubing
Authors: Ma Jingjian , Song Tianqiang , Hu Wang , Muhumuza Michael Edgar , Zhao Wenping , Yang Shuyuan , Bai Jingwen , Yang Haixian
Published: January 2008

Object

The authors conducted a study to develop a safe and effective intracranial venous sinus reconstruction for extensive clinical use.

Methods

After resecting the superior sagittal sinus (SSS), it was reconstructed in eight dogs by performing either a tube-insertion technique or end-to-end anastomosis procedure, in both of which a thin-walled silicone tube was used for repair. The patency of the SSS reconstruction was observed on digital subtraction angiography and transcranial Doppler ultrasonography, preoperatively and at 1, 2, 4, and 8 weeks postoperatively. Histological and ultrastructural changes were observed using light and electron microscopy.

In five dogs the reconstructed SSS was patent, in one it was narrowed, in one it was completely occluded at the proximal site of the anastomosis, and one dog escaped from the laboratory 1 week postoperatively. The authors found no evidence of any additional neurological deficits, signs of toxicity, or side effects. Histological and ultrastructural studies generally showed vascular endothelial proliferation. No thrombosis occurred in the inner surface, at the site of anastomosis, or in the lumen of silicone tube nor in the sagittal sinus at up to 8 weeks postoperatively.

Conclusions

The use of a thin-walled silicone tube as an artificial substitute for intracranial dural venous sinus reconstruction seems to be a valuable technique. The silicone tubes were found to have good biological compatibility, nonthrombogenic effects, and a high patency rate. The method was found to be simple and effective as well as practicable in the clinic for the short term (8 weeks). The authors emphasize that Phase I clinical trials involving silicone tube–assisted SSS reconstruction require further research.
Surgical treatment of cerebral cysticercosis: long-term results and prognostic factors
Authors: Colli Benedicto O. , Carlotti Carlos G. , Assirati João A. , Machado Hélio R. , Valença Marcelo , Amato Marcelo C. M.
Published: January 2008

Object

Cysticercosis is the most frequent parasitosis of the central nervous system. Although anticysticercal drugs have proven efficient in some cases, many patients with NCC require palliative, occasionally curative, surgical procedures. The authors analyzed the data and prognostic factors obtained during the follow-up period (range 1–255 months, median 38 months) in 160 patients with cerebral cysticercosis who underwent surgical treatment.

Methods

Different surgical approaches were indicated to control increased intracranial pressure (ICP) in most patients, and some patients had undergone decompressive surgery for local brain lesions. Most patients required more than one surgical procedure. Statistical analysis was performed using the Fisher exact, the log-rank, and the Kruskall–Wallis tests. Survival curves were calculated according the Kaplan–Meier method. The removal of a giant cyst from the parenchyma or cisterns for relief of increased ICP and for chiasm/optic nerve decompression improved most symptoms in patients. The removal of ventricular cysts was effective in the control of increased ICP in most patients. Patients with a ventricular cyst and ependymitis/arachnoiditis required placement of a ventriculoperitoneal (VP) shunt after the cyst was removed. This therapy effectively controlled increased ICP. Patients younger than 40 years of age at the time of treatment and male patients had worse outcomes. The outcome in patients who underwent VP shunt surgery or shunt surgery combined with reservoir implantation was worse than that in those who underwent cyst removal alone. Shunt-related infection was the most frequent complication, and the global mortality rate during the follow-up period was 21.2%. Although both complications were more frequent in the first 2 postoperative years, they occurred at any time.

Conclusions

Long-term prognosis in patients with cerebral cysticercosis who required surgery was not good. Cysts located in the basal cisterns and patient age younger than 40 years were poor prognostic factors.
Intraventricular neurocysticercosis: 18 consecutive patients and review of the literature
Authors: Cuetter Albert C. , Andrews Russell J.
Published: January 2008

Object

The prognosis for intraventricular neurocysticercosis (IVNCC) is poorer than that for parenchymal NCC, making prompt diagnosis and treatment especially important. Although active, viable intraventricular cysts produce no reaction in the host; they can cause noncommunicating hydrocephalus, the onset of which is frequently abrupt. With the death of the larva comes a local granulomatous ependymitis, generalized ventriculitis, and meningoencephalitis. The authors report on 18 patients with IVNCC (accrued from a larger case series of 62 patients with NCC treated over an 11-year period), detailing clinical presentation, neuroimaging findings, treatment, and outcome.

Methods

All patients presented with hydrocephalus and/or meningitis. The most valuable diagnostic tests were magnetic resonance imaging of the brain and EITB of serum and/or cerebrospinal fluid. Treatment included albenda-zole and steroid therapy in all cases, and when necessary in cases requiring urgent or emergency ventriculostomy and/or surgical removal of the obstructing cyst (followed by shunt placement if indicated).

Conclusions

An extensive review of the literature on IVNCC has been prepared, with the goal of providing the reader with the information necessary to diagnose and treat this complex and potentially fatal disease in a timely and effective manner.
Endoscopic removal of cisternal neurocysticercal cysts
Authors: Gravori Tooraj , Steineke Thomas , Bergsneider Marvin
Published: January 2008

The authors report the use of neuroendoscopy for the treatment of cisternal neurocysticercosis. The utilization of the endoscope is meant to provide a safe and minimally invasive procedure for the removal of symptomatic cysts, minimizing morbidity and mortality relating to the natural history of the disease, as well as possibly avoiding a more extensive standard open craniotomy.

A retrospective review of three cases of cisternal cysticercosis was performed. The presenting signs and symptoms, neuroimaging findings, endoscopic treatment, and outcomes are presented. The technical aspect of the endoscopic resection is described, with visual support provided by intraoperative video. Cerebrospinal fluid shunt placement was avoided in one patient in whom complete resection of the cyst was required. In one patient there were extensive inter-hemispheric and premesencephalic cisternal cysts, some of which could not be removed because of their multiplicity and extensive adhesions. Despite the intraoperative rupture of cysts, there were no cases of arachnoiditis or ventriculitis postoperatively.

The minimally invasive endoscopic resection of cisternal cysticercosis is possible and effective in selected patients. Although the most appropriate treatment of cisternal cysticercosis remains a controversial issue, endoscopic resection should be considered as a primary treatment in symptomatic patients in cases that are amenable to endoscopic intervention.
Outcome measures for clinical trials in neurotrauma
Authors: Bullock M. Ross , Merchant Randall E. , Choi Sung C. , Gilman Charlotte B. , Kreutzer Jeffrey S. , Marmarou Anthony , Teasdale Graham M.
Published: January 2008

Under the auspices of the American Brain Injury Consortium and the Joint Section of Neurotrauma and Critical Care of the American Association of Neurological Surgeons, the authors have reviewed and formulated opinions based on the evidence on protocol design and the outcome measures used for clinical trials in patients with a severe or moderate traumatic brain injury (TBI). First, in view of the heterogeneity of the population under study, the authors suggest that block randomization and stratification should always be used in the design of neurotrauma trials. Second, although the Glasgow Outcome Scale (GOS) remains the most widely used and accepted instrument for TBI trials, the authors believe the eight-point expanded scale that has recently been designed will ultimately provide greater discrimination, and narrower categories and will ultimately prove superior for detecting more subtle changes in outcome. Furthermore, the authors recommend, in view of the profound cognitive impairment in survivors of TBI, that neuropsychological tests be explored further as an adjunct to the GOS. Future research should focus on the development of more sensitive and specific surrogate outcome measures such as magnetic resonance imaging, neurochemical, neuropsychological, and quality of life measures in order to detect a neuroprotective effect in patients with TBI.
Lumbar disc disease: the natural history
Authors: Baldwin Nevan G.
Published: January 2008

Symptomatic lumbar disc disease represents a major cost to societies providing modern care for these conditions. The impact of any treatment cannot be assessed without an understanding of the natural history of the disease process. The majority of individuals with degenerative disc disease are asymptomatic. Although the natural history of sciatica is associated with a good overall prognosis, that of discogenic low-back pain is less promising. For patients with symptomatic lumbar disc herniations, the results of discectomy are better than those predicted by the natural history of the disease process.
Prevalence of intracranial aneurysms in first-degree relatives of patients with aneurysms
Authors: Wang Marjorie C. , Rubinstein David , Kindt Glenn W. , Breeze Robert E.
Published: January 2008

Object

A familial predisposition toward cerebral aneurysms has been previously described in patients with two or more affected family members. In the present study the familial incidence of unruptured intracranial aneurysms was studied in 96 patients with at least one first-degree relative (parent, sibling, or child) in whom a cerebral aneurysm was diagnosed.

Methods

All patients were between 20 and 70 years of age and underwent three-dimensional fast–spin echo magnetic resonance imaging. Sixty-one patients (63.5%) were women. The majority of patients (84%) were caucasian and the remainder were Hispanic (13%) or African-American (3%). No patient suffered a medical condition (excluding hypertension and smoking) known to be associated with cerebral aneurysm formation.

In four patients at least one aneurysm was found (two harbored multiple aneurysms). Three of the four patients were women. Two of the patients were siblings. The estimated prevalence in first-degree relatives was 4.2% (95% confidence interval 1.2–10.1). Of note, the mean age in the current study population was 39 years. The authors of recent metaanalyses have suggested that the prevalence of nonfamilial aneurysms is approximately 2%, despite earlier reports in which higher figures were cited.

Conclusions

The authors conclude that first-degree relatives of patients with aneurysms are at higher risk for harboring an intracranial aneurysm.
Intracranial ependymoma
Authors: Maksoud Yaser A. , Hahn Yoon S. , Engelhard Herbert H.
Published: January 2008

Object

An intracranial ependymoma is a relatively rare but very interesting variety of glioma. In this paper, the authors compiled a review of the pathological features, imaging characteristics, and treatment strategies related to this brain tumor.

Methods

A Medline search was conducted using the term “ependymoma.” The bibliographies of papers obtained were also checked for articles and chapters that could provide additional understanding of this tumor. Malignant ependy-momas and ependymomas of the spinal cord (including myxopapillary ependymomas) were excluded from this review.

Conclusions

The posterior fossa is the most frequent site for an intracranial ependymoma. Children are frequently affected. Most authors recommend resecting as much of the tumor as is safely possible. Microscopically, ependymal tumors show both epithelial and glial features. Glial fibrillary acidic protein immunohistochemistry, therefore, helps in identifying ependymomas. Because ependymomas often recur despite surgical intervention, radiotherapy and/or radio-surgery may also play an important role in their treatment. The use of chemotherapy in the treatment of these tumors, especially in the very young, is still being studied.
How to create vectorial templates for stereotactic functional surgery with Microsoft PowerPoint
Authors: Ferrández-Sempere Diego , Eiras-Ajuria José
Published: January 2008

The use of scalable templates representing the basal ganglia, as an aid in electrophysiological mapping, is a common practice among stereotactic functional neurosurgeons. The authors describe the procedure to create vectorial templates, based on the Atlas For Stereotaxy of the Human Brain by Schaltenbrand and Wahren, using inexpensive commercially available vectorial software.
Utility of preoperative functional magnetic resonance imaging for identifying language cortices in patients with vascular malformations
Authors: Pouratian Nader , Bookheimer Susan Y. , Rex David E. , Martin Neil A. , Toga Arthur W.
Published: January 2008

Object

The goal of this study was to evaluate the utility of preoperative functional magnetic resonance (fMR) imaging in the prediction of whether a given cortical area would be deemed essential for language processing by electro-cortical stimulation mapping (ESM).

Methods

The authors studied patients with vascular malformations, specifically arteriovenous malformations (AVMs) and cavernous angiomas, in whom blood-flow patterns are not normal and in whom a perfusion-dependent mapping signal may be questionable. Ten patients were studied (seven harboring AVMs and three with cavernous angiomas). The authors used a battery of linguistic tasks, including visual object naming, word generation, auditory responsive naming, visual responsive naming, and sentence comprehension, to identify brain regions that were consistently activated across expression and comprehension linguistic tasks. In a comparison of ESM and fMR imaging activations, the authors varied the matching criteria (overlapping activations, adjacent activations, and deep activations) and the radii of influence of ESM (2.5, 5, and 10 mm) to determine the effects of these factors on the sensitivity and specificity of fMR imaging. The sensitivity and specificity of fMR imaging were dependent on the task, lobe, and matching criterion. For the population studied, the sensitivity and specificity of fMR imaging activations during expressive linguistic tasks were found to be up to 100 and 66.7%, respectively, in the frontal lobe, and during comprehension linguistic tasks up to 96.2 and 69.8%, respectively, in the temporal and parietal lobes. The sensitivity and specificity of each disease population (patients with AVMs and those with cavernous angiomas) and of individuals were consistent with those values reported for the entire population studied.

Conclusions

The authors conclude that preoperative fMR imaging is a highly sensitive preoperative planning tool for the identification of which cortical areas are essential for language and that this imaging modality may play a future role in presurgical planning for patients with vascular malformations.
Role of cell therapy in Parkinson disease
Authors: Lindvall Olle , Hagell Peter
Published: January 2008

Clinical studies involving intrastriatal transplantation of embryonic mesencephalic tissue in patients with Parkinson disease (PD) have provided proof-of-principle for the cell replacement strategy in this disorder. The grafted dopaminergic neurons can reinnervate the denervated striatum, restore regulated dopamine release and movement-related frontal cortical activation, and produce significant symptomatic relief. In the most successful cases, patients have been able to withdraw from levodopa treatment after undergoing transplantation and resume an independent life. There are, however, several problems linked to the use of primary embryonic tissue: 1) lack of sufficient amounts of tissue for transplantation in a large number of patients; 2) variability of functional outcome (major improvement in some and modest if any clinical benefit in others); and 3) occurrence of troublesome dyskinesias in a significant proportion of patients after transplantation. Thus, neural transplantation is still at an experimental stage in the treatment of PD. For the development of a clinically useful cell therapy we need to define better criteria for patient selection and how graft placement should be optimized in each individual. Most importantly, we need to generate large numbers of viable dopamine neurons in preparations that are standardized and quality controlled. Stem cells could be useful as an unlimited source of dopamine neurons. Thus far, neurons with at least some dopaminergic characteristics have been generated from stem cells. In most cases, however, their survival after grafting in animals has been poor, and it is also unclear if they function as normal dopamine neurons. Several scientific issues need to be addressed before stem cell-based therapies can be tested in PD patients.
Use of osteogenic protein–1 in spinal fusion: literature review and preliminary results in a prospective series of high-risk cases
Authors: Govender Preneshlin V. , Rampersaud Yoga R. , Rickards Lynda , Fehlings Michael G.
Published: January 2008

Object

The safety and effectiveness of osteogenic protein (OP)–1 putty (recombinant human bone morphogenetic protein–7) in promoting fusion in complex spinal cases was studied in nine cases.

Methods

The authors prospectively evaluated nine patients requiring spinal fusion in whom there were medical risk factors that would inhibit osseous fusion. Intraoperatively the OP-1 putty mixed with autologous bone was placed at the fusion site. Outcome measurement instruments were used to provide information on patient demographics, comorbidities, and pain. The Short Form (SF)–36 questionnaire and Oswestry Disability Index (ODI) were administered pre- and postoperatively. All patients underwent routine radiography of the surgery site during follow-up examination.

The age of the five women and four men ranged from 21 to 74 years (mean height 1.6 m, mean weight 76.7 kg). Risk factors included mucopolysaccharide syndrome, adrenal insufficiency, rheumatoid arthritis with chronic corticosteroid use, morbid obesity, and heavy smoking. Surgery, which consisted of five cervical and four lumbar procedures, including intradural surgery in three patients, was uneventful in all cases without perioperative complication. The follow-up period ranged from 1 to 15 months (mean 5.22 months). The ODI score changed from severe disability (mean 46.89) pre-operatively to minimal and moderate disability (mean 34.56) postoperatively. The SF-36 survey showed overall improved mental and physical health scores. Fusion was present in all patients with greater than 3 months follow up.

Conclusions

The OP-1 putty appears to be safe and effective in promoting spinal arthrodesis in patients in whom adverse medical risk factors exist.
A minimally invasive approach for posterior lumbar interbody fusion
Authors: Salerni Anthony A.
Published: January 2008

Object

Despite the technical innovations that posterior approaches for lumbar fusion have undergone, the goal of a significant reduction in the extent of dissection has remained elusive. Because extensive muscular dissection is related to both acute and chronic pain, a reproducible minimally invasive posterior approach to lumbar interbody fusion would have significant clinical value. The technical aspects of a minimally invasive approach to posterior lumbar inter-body fusion (μPLIF) with fixation involving tools developed for videoscopic discectomy will be described.

Methods

The technical description of this μPLIF procedure is based on experience gained in the first 38 cases. Outcomes categorized using a modified Macnab criteria are reported for 13 patients in whom 1 year or more of follow-up data were available.

All procedures were completed. The section of anulus fibrosus that was exposed provided access for a thorough discectomy and endplate preparation. Outcome in 11 of the 13 patients in whom outcome data were available was excellent or good. Six of these patients returned to work between 3 and 12 weeks postoperatively. Two patients suffered complications related to insertion of the interbody device.

Conclusions

This procedure involves a reproducible technique that results in a construct that is radiographically identical to that which could be expected from any standard open procedure. The minimized muscular dissection results in a tremendous improvement in postoperative mobility. All complications in this series were related to the placement of femoral cortical allograft implants. The use of a modified cement restrictor should eliminate the risk of interbody device placement.
Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice
Authors: Malone David G. , Baldwin Nevan G. , Tomecek Frank J. , Boxell Christopher M. , Gaede Steven E. , Covington Christopher G. , Kugler Kenyon K.
Published: January 2008

Object

The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature.

Methods

During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence.

Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown–Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region.

Conclusions

Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.