bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Spontaneous Cerebellar Hematomas: A Prospective Treatment Protocol
Authors: Kirollos Ramez W. , Tyagi Atul K. , Ross Stuart A. , van Hille Philip T. , Marks Paul V.
Published: July 2004

OBJECTIVE

To identify easily applicable guidelines for the surgical and conservative management of spontaneous cerebellar hematomas.

METHODS

A treatment protocol was developed and prospectively applied for the management of 50 consecutive cases of cerebellar hematomas. The appearance of the fourth ventricle, adjacent to the hematoma, on computed tomographic scans was divided into three grades (normal, compressed, or completely effaced). The degree of fourth ventricular compression was correlated with the size and volume of the hematoma and the presenting Glasgow Coma Scale (GCS) score. The hematoma was surgically evacuated for all patients with Grade III compression and for patients with Grade II compression when the GCS score deteriorated in the absence of untreated hydrocephalus. Patients with Grade I or II compression were initially treated with only ventricular drainage in the presence of hydrocephalus and clinical deterioration.

RESULTS

The degree of fourth ventricular compression was classified as Grade I in 6 cases, Grade II in 26, and Grade III in 18. The degree of fourth ventricular compression was significantly correlated with the volume of the hematoma (rs = 0.67, P < 0.0001), hydrocephalus (rs = 0.44, P = 0.001), the preoperative GCS score (rs = 0.43, P = 0.001), the maximal diameter of the hematoma (rs = 0.43, P = 0.001), and a midline location of the hematoma (χ2 = 6.84, P < 0.009). Acute deterioration in GCS scores occurred for 6 (43%) of 14 patients with Grade III ventricular compression who were conscious at presentation. Thirteen patients with Grade I or II ventricular compression and stable GCS scores of more than 13 were treated conservatively. Nine patients were treated with ventricular drainage only, and 28 underwent posterior fossa craniectomy and evacuation of the hematoma with ventricular drainage. The mortality rate at 3 months was 40%. None of the patients with Grade III fourth ventricular compression and GCS scores of less than 8 at the time of treatment experienced good outcomes. Overall, 15 (60%) of 25 patients with hematomas with maximal diameters of more than 3 cm and Grade I or II compression did not require clot evacuation.

CONCLUSION

Conscious patients with Grade III fourth ventricular compression should undergo urgent clot evacuation before deterioration. Surgical evacuation of the clot may not be required for large hematomas (>3 cm) if the fourth ventricle is not totally obliterated at the level of the clot.
Surgical Pathology of Spinal Schwannomas: A Light and Electron Microscopic Analysis of Tumor Capsules
Authors: Hasegawa Mitsuhiro , Fujisawa Hironori , Hayashi Yutaka , Tachibana Osamu , Kida Shinya , Yamashita Junkoh
Published: July 2004

OBJECTIVE

Although spinal schwannomas are often encountered, the pathology of the tumor capsule has not been reported. In this study, we describe the ultrastructural pathology of the tumor capsule of spinal schwannomas.

METHODS

In 18 patients who underwent total removal of spinal schwannomas (C2–conus), the tumor capsule was collected and examined by light and electron microscopy.

RESULTS

The thickness of the tumor capsule ranged from 15 to 800 μm (mostly 30–100 μm) and was composed of three layers from the surface to the center: 1) a thinly stretched nerve tissue layer; 2) a fibrous layer of fibrocytes, abundant collagen fibers, and tumor vessels; and 3) a thin transitional layer intermingled with fibrous components and tumor cells. The thickness of each layer varied in different regions of the surface. There was no clear separation between the tumor capsule and the neoplastic tissue, even on the electron microscopic level. A number of nerve fibers ran through the fibrous layer and beneath the capsule as well as in the nerve tissue layer.

CONCLUSION

Compared with vestibular schwannomas, which have been reported to be covered by an extremely thin layer (3–5 μm) of connective tissue, spinal schwannomas were well encapsulated. The capsule was composed of three distinct components; however, the cleavage between thin capsule and tumor cells was indistinct, and the thickness of the axon-containing capsule varied from site to site. Therefore, resection of the nerve of tumor origin, rather than enucleation, would be justified to avoid tumor recurrence. Surgeons should be aware of this pathology when performing the procedure.
Can Diffusion- and Perfusion-weighted Magnetic Resonance Imaging Evaluate the Efficacy of Acute Thrombolysis in Patients with Internal Carotid Artery or Middle Cerebral Artery Occlusion?
Authors: Uno Masaaki , Harada Masafumi , Yoneda Kazuhide , Matsubara Shunji , Satoh Koichi , Nagahiro Shinji
Published: July 2004

OBJECTIVE

The value of combined diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) for detecting ischemic lesions of patients with acute ischemic injury was analyzed. Combined pre- and posttreatment DWI and PWI studies were used to assess the efficacy of intra-arterial thrombolysis.

METHODS

Intra-arterial thrombolysis was performed within 6 hours of onset in 10 patients who presented with acute middle cerebral artery or internal carotid artery occlusion. DWI and PWI obtained before and after treatment were studied. The final T2-weighted magnetic resonance scans were obtained 1 month after onset. Thrombolysis resulted in recanalization in seven patients. The mismatch ratio percentage ([initial PWI − initial DWI/initial PWI] × 100) and the rescued ratio percentage ([initial PWI − final T2/initial PWI] × 100) were calculated. The National Institutes of Health Stroke Scale (NIHSS) was used for neurological assessment of stroke severity at admission and at 1 month after onset.

RESULTS

In all patients, the mismatch ratio was greater than 60% (mean ± standard deviation, 81.7 ± 16.7%) and was significantly correlated with initial NIHSS score (−0.74;P = 0.03), and the rescued ratio was significantly correlated with the NIHSS score 1 month after the insult (r = −0.83;P = 0.01). In patients who exhibited recanalization of the occluded artery (n = 7), the mean rescued ratio was 89.6 ± 12.8% (range, 63–100%). In addition, the lesion volume on posttreatment DWI scans and final T2-weighted magnetic resonance images was not enlarged; on posttreatment PWI scans, it was significantly decreased. The NHISS score at 1 month after the insult (2.3 ± 2.1) was markedly improved as compared with the initial NHISS score (10.7 ± 3.9).

CONCLUSION

In a small number of patients who presented with internal carotid artery or middle cerebral artery occlusion, the DWI/PWI mismatch ratio correlated with the initial neurological severity. The rescued ratio may be an objective indicator of the efficacy of treatment.
Gamma Knife Stereotactic Radiosurgery for Patients with Glioblastoma Multiforme
Authors: Nwokedi Emmanuel C. , DiBiase Steven J. , Jabbour Salma , Herman Joseph , Amin Pradip , Chin Lawrence S.
Published: July 2004

OBJECTIVE

Stereotactic radiosurgery (SRS) has become an effective therapeutic modality for the treatment of patients with glioblastoma multiforme (GBM). This retrospective review evaluates the impact of SRS delivered on a gamma knife (GK) unit as an adjuvant therapy in the management of patients with GBM.

METHODS

Between August 1993 and December 1998, 82 patients with pathologically confirmed GBM received external beam radiotherapy (EBRT) at the University of Maryland Medical Center. Of these 82 patients, 64 with a minimum follow-up duration of at least 1 month are the focus of this analysis. Of the 64 assessable patients, 33 patients were treated with EBRT alone (Group 1), and 31 patients received both EBRT plus a GK-SRS boost (Group 2). GK-SRS was administered to most patients within 6 weeks of the completion of EBRT. The median EBRT dose was 59.7 Gy (range, 28–70.2 Gy), and the median GK-SRS dose to the prescription volume was 17.1 Gy (range, 10–28 Gy). The median age of the study population was 50.4 years, and the median pretreatment Karnofsky performance status was 80. Patient-, tumor-, and treatment-related variables were analyzed by Cox regression analysis, and survival curves were generated by the Kaplan-Meier product limit.

RESULTS

Median overall survival for the entire cohort was 16 months, and the actuarial survival rate at 1, 2, and 3 years were 67, 40, and 26%, respectively. When comparing age, Karnofsky performance status, extent of resection, and tumor volume, no statistical differences where discovered between Group 1 versus Group 2. When comparing the overall survival of Group 1 versus Group 2, the median survival was 13 months versus 25 months, respectively (P = 0.034). Age, Karnofsky performance status, and the addition of GK-SRS were all found to be significant predictors of overall survival via Cox regression analysis. No acute Grade 3 or Grade 4 toxicity was encountered.

CONCLUSION

The addition of a GK-SRS boost in conjunction with surgery and EBRT significantly improved the overall survival time in this retrospective series of patients with GBM. A prospective, randomized validation of the benefit of SRS awaits the results of the recently completed Radiation Therapy Oncology Group's trial RTOG 93-05.
Laminoplasty with Preservation of Posterior Cervical Elements: Surgical Technique
Authors: Tani Satoshi , Isoshima Akira , Nagashima Yasuhiro , Tomohiko Numoto Robert , Abe Toshiaki
Published: July 2004

OBJECTIVE

We have developed a modified laminoplasty procedure that preserves the posterior cervical elements, and we have used it to treat multilevel cervical canal stenosis, with or without spondylotic changes, in 30 patients.

METHODS

In this procedure, the posterior bony elements, such as the spinous processes, are not completely detached from the ligaments and musculature and are repositioned in the midline, to maintain normal cervical anatomic relationships. Thirty patients (mean age, 55.2 yr) were registered and evaluated in this study, with a mean follow-up period of 18.1 months, between November 1995 and October 2000. The rates of bony union of the reconstructed laminae and alignment of the cervical spine were assessed by using computed tomographic scans and lateral radiographs.

RESULTS

All patients except one noted some improvement in sensation, motor function, or both. Changes in spinal curvature were noted for two patients for whom a kyphotic deformity had developed before surgery (because of S-shaped or straight curvature). The average decrease in the range of motion was 7.26 degrees. Estimated rates of bony fusion at the sites of the gutters, spacers, and spinous processes were 94.6, 62.3, and 86.6%, respectively. A stable bony arch was assumed to be achieved with bony fusion at the gutters on the hinge side, as well as the spinous processes, approximately 6 months after surgery.

CONCLUSION

Our new technique of cervical laminoplasty preserves the posterior musculature and bony elements. This new procedure also helps maintain correct spinal alignment.
Thoracoscopic Microdiscectomy
Authors: Oskouian Rod J. , Johnson J. Patrick , Regan John J.
Published: July 2004

THE THORACOSCOPIC APPROACH for the microsurgical removal of herniated thoracic discs is described, and perioperative management is also discussed. The microsurgical techniques used for decompression of the spinal canal in the thoracic spine are presented in detail. The diagnostic imaging, surgical positioning, approach, port placement, localization of the thoracic level, exposure of the surgical field, excision of the rib head, exposure with removal of the herniated disc, and postoperative management are outlined. Surgical and operative “pearls” in thoracoscopic spinal surgery for removing herniated thoracic discs when possible are described and illustrated.
Human Endothelin Subtype A Receptor Enhancement during Tissue Culture via de Novo Transcription
Authors: Hansen-Schwartz Jacob , Nordström Carl-Henrik , Edvinsson Lars
Published: July 2004

OBJECTIVE

Endothelin (ET) has, since its discovery, increasingly been considered a key player in the pathophysiological processes of cerebral vasospasm in the course of subarachnoid hemorrhage, although it remains unclear how ET is involved. We present data that indicate an inherent capacity of human cerebral arteries to change their sensitivity to ET.

METHODS

Human cerebral arteries were obtained from patients undergoing intracranial tumor surgery. The vessels were divided into segments and subjected to organ culture for 48 hours. The vessels were then examined by using in vitro pharmacological methods and molecular biological techniques.

RESULTS

After organ culture of the cerebral arteries, both the sensitivity to and potency of ET were enhanced (maximal response, 152 ± 9%; −log (50% effective concentration), 10.3 ± 0.3), in comparison with data for fresh cerebral arteries. Contractions were inhibited by both FR139317 (a specific ETA receptor antagonist) and bosentan (a mixed ETA and ETB receptor antagonist), in a manner indicating the sole presence of contractile ETA receptors. An inconsistent dilative response to the selective ETB receptor agonist sarafotoxin 6c was observed; the response was preserved in some segments and abolished in others, and potentiation of the precontraction was observed in yet other segments. No isolated contractile response to sarafotoxin 6c was observed, however. In reverse transcription-polymerase chain reaction assays, both ETA and ETB receptor messenger ribonucleic acid was detected.

CONCLUSION

These results demonstrate that human cerebral arteries are capable of enhancing the function of ETA receptors.
Recurrent Torticollis Caused by Dissecting Vertebral Artery Aneurysm in a Pediatric Patient: Results of Endovascular Treatment by Use of Coil Embolization: Case Report
Authors: Grosso Salvatore , Mostardini Rosa , Venturi Carlo , Bracco Sandra , Casasco Alfredo , Berardi Rosario , Balestri Paolo
Published: July 2004

OBJECTIVE AND IMPORTANCE

Torticollis is a symptom that can be related to different pathological mechanisms ranging from simple to life-threatening conditions. We report a child with recurrent torticollis caused by an intracranial dissecting vertebral artery aneurysm. This is a very rare condition in childhood, and it was resolved successfully with endovascular treatment.

CLINICAL PRESENTATION

The patient was a 10-year-old boy with a 4-year history of left recurrent torticollis, followed by hemiparesis, dysarthria, dysmetria, and tremor. Brain magnetic resonance imaging and digital angiography detected a dissecting aneurysm involving the fourth segment of the left vertebral artery.

INTERVENTION

The patient underwent endovascular treatment. Coil embolization, followed by histoacryl injection into the lesion, provided complete obliteration of the aneurysmal sac.

CONCLUSION

The patient's postoperative course was characterized by a dramatic disappearance of symptoms and signs within a few hours of the intervention. No relapses of symptoms occurred during a follow-up period of 18 months. This is the first report of a child in whom recurrent torticollis was related to a dissecting vertebral artery aneurysm. Although long-term results of vertebral artery coil embolization remain to be elucidated, the method seems reliable and effective in treatment of these vascular lesions in pediatric patients.
Cerebellopontine Angle Epidermoids Presenting with Cranial Nerve Hyperactive Dysfunction: Pathogenesis and Long-term Surgical Results in 30 Patients
Authors: Kobata Hitoshi , Kondo Akinori , Iwasaki Koichi
Published: July 2004

OBJECTIVE

To provide the characteristics and long-term surgical results of patients who present with cerebellopontine angle epidermoids and trigeminal neuralgia (TN) or hemifacial spasm.

METHODS

A total of 30 patients (23 women, 7 men) who presented with cerebellopontine angle epidermoids and TN (28 patients) or hemifacial spasm (2 patients) between 1982 and 1995 were reviewed, with emphasis being placed on the clinical manifestations, the mechanisms of symptom development, the long-term follow-up results, and the anatomic relationship between the tumor and the surrounding neurovascular structures.

RESULTS

The average age of the patients was 37.8 years at symptom onset and 49.3 years at the time of the operation. The tumor-nerve relationships were classified into four types: complete encasement of the nerve by the tumor, compression and distortion of the nerve by the tumor, compression of the nerve by an artery located on the opposite side of the unilateral tumor, and compression of the nerve by an artery on the same side of the tumor. Total resection was achieved in 17 patients (56.7%). Microvascular decompression of the respective cranial nerve was achieved in nine cases of direct arterial compression in addition to tumor removal. The symptom was relieved completely in all cases. In an average follow-up period of 11.5 years, three patients developed recurrent symptoms: two experienced tumor regrowth, and one had arachnoid adhesion.

CONCLUSION

Hyperactive dysfunction of the cranial nerves, especially TN, may be the initial and only symptom that patients with cerebellopontine angle epidermoids experience. The occurrence of TN at a younger age was characteristic of TN patients with epidermoids, in contrast to patients with TN due to a vascular cause. The symptom is elicited by compression of the nerve by the tumor per se, by an artery that is displaced to the nerve, or by both. Careful resection of the tumor, whose capsule occasionally is strongly adherent to the neurovascular structures, is necessary, and microvascular decompression to straighten the neuraxis should be performed in some cases to achieve a complete, permanent cure of symptoms with a low rate of recurrence.
Hyperbaric Oxygen Treatment of Postoperative Neurosurgical Infections
Authors: Larsson Agneta , Engström Mats , Uusijärvi Johan , Kihlström Lars , Lind Folke , Mathiesen Tiit
Published: July 2004

OBJECTIVE

To evaluate the clinical usefulness of hyperbaric oxygen (HBO) therapy for neurosurgical infections after craniotomy or laminectomy.

METHODS

The study involved review of medical records, office visits, and telephone contacts for 39 consecutive patients who were referred in 1996 to 2000. Infection control and healing without removal of bone flaps or foreign material, with a minimum of 6 months of follow-up monitoring, were considered to represent success.

RESULTS

Successful results were achieved for 27 of 36 patients, with a mean follow-up period of 27 months (range, 6–58 mo). One patient discontinued HBO therapy because of claustrophobia, and two could not be evaluated because of death resulting from tumor recurrence. In Group 1 (uncomplicated cranial wound infections), 12 of 15 patients achieved healing with retention of bone flaps. In Group 2 (complicated cranial wound infections, with risk factors such as malignancy, radiation injury, repeated surgery, or implants), all except one infection resolved; three of four bone flaps and three of six acrylic cranioplasties could be retained. In Group 3 (spinal wound infections), all infections resolved, five of seven without removal of fixation systems. There were no major side effects of HBO treatment.

CONCLUSION

HBO treatment is an alternative to standard surgical removal of infected bone flaps and is particularly useful in complex situations. It can improve outcomes, reduce the need for reoperations, and allow infection control without mandatory removal of foreign material. HBO therapy is a safe, powerful treatment for postoperative cranial and spinal wound infections, it seems cost-effective, and it should be included in the neurosurgical armamentarium.
Timing of Aneurysm Surgery in Subarachnoid Hemorrhage: A Systematic Review of the Literature
Authors: de Gans Koen , Nieuwkamp Dennis J. , Rinkel Gabriël J.E. , Algra Ale
Published: July 2004

OBJECTIVE

Many practitioners favor early operation after aneurysmal rupture, but sound data supporting this practice are lacking. A systematic review was conducted to compare early aneurysm surgery (Days 0–3), intermediate surgery (Days 4–7), and late surgery (more than 7 d after subarachnoid hemorrhage).

METHODS

We performed a MEDLINE search of the literature published between January 1974 and December 1998 and an additional manual search of selected journal titles from January 1998 to December 1998. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of the follow-up period. Risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated; patients planned for late surgery were used as the reference.

RESULTS

Identified were 1 randomized clinical trial and 268 observational studies, of which only 10 studies (assessing a total of 1814 patients) fulfilled a set of minimum requirements for methodological quality. In the trial, the RR of poor outcome was 0.42 (95% CI, 0.17–1.04) for patients planned for early surgery and 1.07 (95% CI, 0.56–2.05) for intermediate surgery. In analyses with data from the 11 included studies, the RR of poor outcome for patients in good clinical condition at admission was 0.41 (95% CI, 0.34–0.51) for early surgery and 0.47 (95% CI, 0.32–0.69) for intermediate surgery. For patients in poor clinical condition at admission, the RR of poor outcome was 0.84 (95% CI, 0.67–1.05) for early surgery and 0.54 (95% CI, 0.24–1.22) for intermediate surgery. Adjustment of the RRs for year of publication, study design, and aneurysm location yielded essentially the same results, as did a sensitivity analysis after exclusion of the data from the randomized trial.

CONCLUSION

This meta-analysis suggests that both early and intermediate surgical treatment improve outcome after aneurysmal subarachnoid hemorrhage—in particular for patients in good clinical condition at admission. However, this impression is derived only from an indirect comparison between different cohorts of patients. Sound evidence on the best timing of surgery is still lacking. Observational studies with better methods—and ideally a new randomized trial—are needed.
Histological Findings in Coil-packed Experimental Aneurysms 3 Months after Embolization
Authors: Böcher-Schwarz Hans G. , Ringel Kurt , Bohl Jürgen , Filippi Ronald , Kempski Oliver , Perneczky Axel
Published: July 2004

OBJECTIVE

Knowledge regarding tissue reactions within coil-packed aneurysms is poor. The purpose of this study was to analyze histological changes in a chronic experimental bifurcation aneurysm model that might explain the protective effect of Guglielmi detachable coils.

METHODS

The aneurysms were produced by means of a venous graft pouch at a surgically created bifurcation of the carotid artery in the neck of rabbits. After 3 weeks, embolization with Guglielmi detachable coils was performed in the treatment group but not in the control group (seven rabbits each). At the time of embolization, six of seven treated aneurysms were completely occluded according to radiological criteria. Twelve weeks later, all aneurysms were explanted after final angiography. Histological examinations were performed with coils in situ.

RESULTS

Six of seven embolized aneurysms demonstrated complete occlusion in final angiography. But gross pathology revealed that all specimens had differently sized open cavities between the coils. In only two cases, these spaces were very small and the aneurysmal sacs were filled with coils and tissue by more than 90%. Light microscopy demonstrated intraluminal granulation tissue and strong chronic inflammatory wall thickening with numerous foreign body cells at the interface between coils and tissue. Coils were partially incorporated into the aneurysmal wall, sometimes close to the surface and occasionally even outside the wall within the surrounding tissue.

CONCLUSION

The protective effect of Guglielmi detachable coil treatment in our chronic experimental bifurcation aneurysms results from formation of intraluminal granulation tissue and wall thickening attributable to chronic inflammation.
Castleman's Disease and Spinal Cord Compression: Case Report
Authors: Kachur Edward , Ang Lee-Cyn , Megyesi Joseph F.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Castleman's disease is a rare lymphoproliferative disorder most often found in the mediastinum. Localized forms are usually benign, whereas multicentric forms may be aggressive . We report a patient with Castleman's disease who presented with spinal cord compression, and we review previously published cases of Castleman's disease involving the central nervous system. To our knowledge, this is only the second case of Castleman's disease presenting as a spinal epidural mass with cord compression.

CLINICAL PRESENTATION

A 44-year-old otherwise healthy woman presented acutely with difficulty walking. Examination revealed mild myelopathy in her legs. Magnetic resonance imaging revealed a posterior epidural mass compressing the thoracic spinal cord at T3–T5.

INTERVENTION

Thoracic laminectomy and gross total resection of the lesion were performed. Pathological examination of the lesion identified the hyaline-vascular type of Castleman's disease. The patient's symptoms resolved postoperatively.

CONCLUSION

Castleman's disease presenting as a spinal epidural mass lesion with cord compression is rare. Surgical treatment can result in an excellent outcome.
Postoperative Edema after Vascular Access Causing Nerve Compression Secondary to the Presence of a Perineuronal Lipoma: Case Report
Authors: Goldstein Lawrence J. , Helfend Lisa K. , Kordestani Rouzbeh K.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Median nerve neuropathy can be clinically devastating to a patient. It can be caused by compression of the median nerve anywhere along its course. We present the case of delayed median nerve neuropathy after the placement of a vascular graft in the arm.

CLINICAL PRESENTATION

An arm shunt was placed in the nondominant upper extremity in a 60-year-old man with end-stage renal disease. Twelve hours postoperatively, the patient developed neurapraxia in the median nerve distribution in the hand.

INTERVENTION

Exploration of the arm revealed a lipoma coursing along and deep to the median nerve. Resection of the lipoma decompressed the nerve.

CONCLUSION

In this patient, median nerve neuropathy was caused by a lipoma and postoperative swelling from placement of the vascular graft. The swelling that occurred after the shunt placement unmasked subclinical compression of the nerve by a lipoma deep to the median nerve. To our knowledge, this report is unique in documenting damage to the median nerve after vascular graft placement as a result of an occult mass.
Use of Intraventricular Tissue Plasminogen Activator and Guglielmi Detachable Coiling for the Acute Treatment of Casted Ventricles from Cerebral Aneurysm Hemorrhage: Two Technical Case Reports
Authors: Azmi-Ghadimi Hooman , Heary Robert F. , Farkas Jeffrey E. , Hunt C. David
Published: July 2004

OBJECTIVE AND IMPORTANCE

We report two cases of massive intraventricular hemorrhage resulting from subarachnoid hemorrhage. Both patients had experienced a ruptured cerebral aneurysm and were initially moribund. The patients were treated with Guglielmi detachable coiling and then administration of intraventricular tissue plasminogen activator (tPA). Rapid clot resolution was demonstrated radiographically in both. Both patients survived and had a meaningful functional neurological recovery. These are the first reported cases of the acute use of intraventricular tPA after Guglielmi detachable coiling treatment for ruptured cerebral aneurysm.

CLINICAL PRESENTATION

A 59-year-old woman and a 44-year-old man presented with high-grade subarachnoid hemorrhage. Both had had extensive casting of their ventricular systems with blood.

INTERVENTION

The patients were treated with Guglielmi detachable coiling thrombosis of the aneurysm and then intraventricular administration of tPA for dissolution of blood clots. Both patients survived; one is able to carry out activities of daily living with moderate assistance, and the other is able to communicate with his family.

CONCLUSION

This is a novel method to manage patients with high-grade aneurysms with massive intraventricular blood clots. The tPA reduced the mass effect of the blood clot, possibly helping to improve the neurological grade; in addition, the administration of tPA helped keep the external ventricular drains functional, enabling treatment of the acute hydrocephalus. The safety of administering tPA after endovascular thrombosis was demonstrated in these two patients. Further investigation is required to determine the applicability of this approach on a broader scale.
Reoperation for Acute Hemispheric Stroke after Carotid Endarterectomy: Is There Any Value?
Authors: Findlay J. Max , Marchak B. Elaine
Published: July 2004

OBJECTIVE:

Because the clinical benefit of urgent investigation and carotid rerepair for acute stroke complicating carotid endarterectomy (CEA) is uncertain, the results of this approach were examined in a large series of patients.

METHODS:

In a consecutive series of 700 CEAs, 24 patients (3.4%) had a postoperative stroke. Thirteen of these 24 patients experienced major hemispheric deficits (hemiplegia with or without aphasia, forced eye deviation, and decreased consciousness) that prompted either immediate surgical reexploration or cerebral angiography with reoperation on the basis of angiogram results; these 13 patients are the subject of this report. Neurological improvement was attributed to carotid reopening when affected muscle strength increased to antigravity power within 6 hours of reoperation.

RESULTS:

Of the 13 patients with severe postoperative deficits, 5 (38%) had the deficits when they awakened, 7 deficits occurred within 12 hours of surgery, and the only intracerebral hemorrhage in this series occurred 8 days after surgery. Five patients underwent urgent reoperation without angiography, and carotid occlusions were found and repaired in two patients. In another patient, the carotid was patent, and an intra-arterial injection of tissue plasminogen activator (20 mg) was given. In the seven patients who underwent cerebral angiography as the first step, two carotid occlusions and one residual stenosis with thrombus were found and repaired on an urgent basis. Surgical reopening of occluded arteries was followed by improvement in two of four patients, and early improvement was noted in one patient with a stenosis correction as well as in the patient who received intraoperative tissue plasminogen activator. Four patients who underwent urgent reoperation did not demonstrate a benefit soon after surgery. Two patients died, two were left with major deficits and five with moderate deficits, and four patients eventually had good recovery at a minimum of 6 months of follow-up.

CONCLUSION:

In this series, approximately one-half of hemispheric strokes complicating CEA had an underlying correctable lesion (occlusion or stenosis), and these patients typically had delayed-onset strokes. Approximately one-half of these patients improved early as a result of reopening, although computed tomography revealed new infarcts in most of them. Urgent carotid repair may benefit a minority of selected patients who have a major stroke after CEA.
Repeat Radiosurgery for Refractory Trigeminal Neuralgia
Authors: Hasegawa Toshinori , Kondziolka Douglas , Spiro Richard , Flickinger John C. , Lunsford L. Dade
Published: July 2004

OBJECTIVE:

Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied.

METHODS:

Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment.

RESULTS:

After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure.

CONCLUSION:

Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.
Pure Subdural Hematomas: A Postmortem Analysis of Their Form and Bleeding Points
Authors: Maxeiner Helmut , Wolff Michael
Published: July 2004

OBJECTIVE:

Although the literature concerning subdural hematomas (SDHs) is vast, few data are available as to the sources and related clinical differences of SDHs. Pure SDHs of arterial versus venous origin should be compared in terms of cause, size, space-occupying effect, and form.

METHODS:

We analyzed data from 46 patients who died as a result of pure SDHs. Twenty-three SDHs resulted from bridging vein ruptures and 23 from torn cortical arteries. We performed a morphometric analysis of the intracranial situation on the horizontal plane at the level of the greatest fronto-occipital diameter. We included in our analysis the clinical one-dimensional parameters (e.g., hematoma thickness, midline shift); the areas of the hemispheres, the SDHs, and their displacement; and the hematoma volume.

RESULTS:

Most of the investigated postmortem characteristics of both types of hematomas were similar, with the exception of the form and the midline shift. SDHs resulting from arterial ruptures (which are generally located in the temporoparietal region) differ in form from those caused by bridging vein ruptures (which typically rupture in the frontoparietal parasagittal region).

CONCLUSION:

The form difference allows the probable rupture site to be estimated; this observation might prove useful for clinical purposes.
Efficacy of the Morphine-Adcon-L Compound in the Management of Postoperative Pain after Lumbar Microdiscectomy
Authors: Mastronardi Luciano , Pappagallo Marco , Puzzilli Fabrizio , Tatta Carlo
Published: July 2004

OBJECTIVE:

Epidural analgesia is a pharmacological technique for operative and postoperative pain control. It has been used with lumbar microdiscectomy to facilitate management of surgical pain, shorten patient recovery time, and increase patient satisfaction with the procedure and the hospital stay. Adcon-L (Gliatech, Inc., Cleveland, OH) (adhesion control in a barrier gel) has been demonstrated to act as a barrier to the development of epidural fibrosis after lumbar procedures, minimizing the formation of fibrotic scar and improving the long-term outcome. In this study, we used Adcon-L as a vehicle to administer 1 mg of morphine epidurally to patients who underwent lumbar microdiscectomy. Our objective was to evaluate the safety and analgesic efficacy of this compound .

METHODS:

A randomized, controlled, double-blind study was conducted in 100 patients. Patients were randomized to two groups: the morphine-Adcon-L (M-ADL) group (n = 51 patients) or the Adcon-L control group (n = 49 patients). Outcome measures included: 1) a visual analog scale to assess the intensity of spontaneous low back and radicular pain, 2) a straight leg-raising maneuver to assess the degree of leg elevation in relation to evoked sciatic pain, 3) postoperative time to comfortable walking, 4) duration of postoperative hospitalization, 5) required amount of postoperative analgesics, and 6) postoperative work time loss.

RESULTS:

No intraoperative or postoperative complications were observed. No clinically relevant adverse events, such as urinary retention, respiratory disturbances, or wound infections were reported in the M-ADL group. At the time of hospital discharge, results were as follows: 1) the M-ADL group had significantly lower pain intensity scores (mean value of postoperative visual analog scale, 12.3 mm ± 0.9 in the M-ADL group versus 24.7 mm ± 11.5 in the control group [P < 0.0001]); 2) the M-ADL group consumed significantly less analgesics: 57.4% of M-ADL patients versus 95.9% of controls received analgesics in the hospital, and 23.5% of M-ADL patients versus 55.1% of controls used analgesics at home (P < 0.0001); 3) the M-ADL group had significantly shorter hospital stays (1.37 ± 0.07 d versus 2.53 ± 0.12 d in the control group [P < 0.0001]); 4) the M-ADL group had a significantly higher degree of symptomatic leg elevation in the straight leg raising (mean postoperative straight leg-raising test, 64.41 degrees ± 1.59 versus 57.77 degrees ± 1.85 in the controls [P = 0.02]); and 5) the M-ADL group lost significantly less postoperative work time (21.67 ± 0.92 d versus 29.47 ± 1.18 d in the control group). In addition, at 1 year of follow-up, there was no clinical evidence of late-onset neurological complications.

CONCLUSION:

The epidural application of the compound M-ADL after lumbar microdiscectomy was found to be safe and effective, and it significantly improved postoperative pain control and return to function.
Bilateral Metachronous Germinoma of the Basal Ganglia Occurring Long after Total Removal of a Mature Pineal Teratoma: Case Report
Authors: Sugimoto Keiji , Nakahara Ichiro , Nishikawa Michio
Published: July 2004

OBJECTIVE AND IMPORTANCE:

We report the extremely rare occurrence of a second germ cell tumor at a different site and with different histological types long after total removal of a mature pineal teratoma.

CLINICAL PRESENTATION:

A 10-year-old boy who presented with headache and vomiting was admitted to our hospital. Neuroradiological studies revealed a tumor in the pineal region. The tumor was totally removed. Histologically, the tumor proved to be a mature teratoma. The patient's postoperative course was uneventful. The patient received no adjuvant therapy and was followed in the outpatient clinic. Three years later, he was readmitted with transient left upper limb weakness and vomiting. Neuroradiological studies showed a tumor in the bilateral basal ganglia.

INTERVENTION:

The second tumor, which was located in the right basal ganglion, was partially removed for biopsy. Histologically, the tumor proved to be a germinoma. The patient received three cycles of combination chemotherapy consisting of carboplatin and etoposide with radiotherapy. After the second course of chemotherapy, magnetic resonance imaging studies revealed no evidence of the tumor.

CONCLUSION:

The second tumor was considered to be a de novo metachronous neoplasm rather than a recurrence of the original mature teratoma. We think that if primordial germ cell groups exist along the midline of the brain, more than two primordial germ cell groups could give rise to metachronous neoplasms at different sites and with different histological types.
Suprasellar Adrenocorticotropic Hormone-secreting Ectopic Pituitary Adenoma: Case Report and Literature Review
Authors: Hou Lewis , Harshbarger Todd , Herrick Maie K. , Tse Victor
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Functional ectopic pituitary adenomas are rare and can be misdiagnosed as extensions of pituitary adenomas when they are located in the vicinity of the normal gland. In this report, we present a case of an ectopic adrenocorticotropic hormone-secreting suprasellar pituitary adenoma that caused Cushing's disease. A literature review of previously reported ectopic pituitary adenomas is included to illustrate the diverse clinical manifestations of this disease entity.

CLINICAL PRESENTATION:

An 11-year-old boy was noted to have hirsutism, a buffalo hump, and unexplained weight gain consistent with Cushing's syndrome. Laboratory investigations revealed that the boy had elevated adrenocorticotropic hormone and serum cortisol levels unsuppressed by dexamethasone. Magnetic resonance imaging scans were suggestive of a pituitary adenoma with suprasellar extension.

INTERVENTION:

The initial transsphenoidal approach failed to achieve complete surgical resection. A repeat operation in which the pterional approach was used revealed a suprasellar pituitary adenoma without association with intrasellar contents. The patient's cushingoid symptoms improved significantly 3 months after surgery.

CONCLUSION:

Ectopic pituitary adenomas should be considered in the differential diagnosis for all patients with Cushing's syndrome. Furthermore, surgical approaches should be chosen carefully once the diagnosis of ectopic pituitary adenoma is made.
Cerebellopontine Angle Lipomas: Report of Four Cases and Review of the Literature
Authors: Tankéré Frédéric , Vitte Elizabeth , Martin-Duverneuil Nadine , Soudant Jacques
Published: July 2004

OBJECTIVE:

To define the management of internal acoustic meatus and cerebellopontine angle (CPA) lipomas according to their clinical, histological, and surgical characteristics.

METHODS:

We report four new cases of CPA lipomas diagnosed in the Department of Otorhinolaryngology–Head and Neck Surgery of Hôpital Pitié-Salpêtrière and review 94 cases reported previously in the literature.

RESULTS:

Lipomas represented 0.14% of CPA and internal acoustic meatus tumors. Localization was on the left side in 59.9%, on the right side in 37%, and bilateral in 3.1% of the patients. The diagnosis was confirmed radiologically in 33 of 98 patients, surgically in 60 patients, and by autopsy in 5 patients. The most frequent associated symptoms were of cochleovestibular origin, such as hearing loss (62.2%), dizziness (43.3%), and unilateral tinnitus (42.2%). Other associated symptoms involved the facial nerve (9%) or the trigeminal nerve (14.4%). Complete resection was performed in only 32.8% of the patients with frequent cranial nerve involvement. Frequent cranial nerve involvement was seen in 95.4% of all patients. After surgery, patient symptomatology was unchanged in 9.2% of the patients, and 50% were improved; however, new postoperative deficits occurred in two-thirds of the patients. Overall, 72.2% of the patients experienced new postoperative deficits such as hearing loss (64.8%). Preservation of hearing was possible in only 26% of the patients. Only 18% of patients were improved after surgery without any new postoperative deficits.

CONCLUSION:

Preoperative diagnosis of internal acoustic meatus/CPA lipomas is based on magnetic resonance imaging. The aim of surgery in these cases is not tumor removal but cranial nerve decompression or vestibular transection, and surgery is performed only in patients with disabling and uncontrolled symptoms.
Ectopic Recurrence of Craniopharyngioma after an Interhemispheric Transcallosal Approach: Case Report
Authors: Liu Jeannette M. , Garonzik Ira M. , Eberhart Charles G. , Sampath Prakash , Brem Henry
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Ectopic recurrence of a craniopharyngioma is a rare postoperative complication. We present a case of a craniopharyngioma that ectopically recurred along the tract of a previous surgical route.

CLINICAL PRESENTATION:

A 73-year-old female patient presented 8 years earlier with a suprasellar craniopharyngioma. She underwent a right frontal craniotomy, with an interhemispheric transcallosal approach, for total microsurgical resection of the tumor. No postoperative radiotherapy was administered. Four years after surgery, magnetic resonance imaging studies revealed a well-circumscribed, heterogeneously enhancing, parasagittal mass with significant vasogenic edema in the right frontal lobe. Enlargement of the lesion was noted in subsequent radiological evaluations until 8 years after surgery, when the patient experienced a significant decline in neurocognitive status and the mass was surgically resected.

INTERVENTION:

Gross total resection of a histologically confirmed craniopharyngioma was achieved.

CONCLUSION:

To our knowledge, only eight previous case reports described the ectopic recurrence of a craniopharyngioma. Transplantation of tumor cells along the tract of a previous surgical route in six cases and dissemination in cerebrospinal fluid in two cases are presumed to be the primary mechanisms by which these ectopic recurrences occurred. The results of our literature review led us to conclude that total surgical resection, combined with careful inspection and irrigation of the surgical field, is the optimal treatment for preventing ectopic recurrences. Furthermore, it is recommended that, after primary craniopharyngioma resection, patients undergo long-term clinical and radiological follow-up monitoring for the rare development of an ectopically recurring tumor.
Treatment of an Iatrogenic Petrous Carotid Artery Pseudoaneurysm with a Symbiot Covered Stent: Technical Case Report
Authors: Alexander Michael J. , Smith Tony P. , Tucci Debara L.
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Surgery involving the middle ear or the temporal bone may cause an injury to the petrous carotid artery resulting in a pseudoaneurysm. Conventional treatment of such pseudoaneurysms has ranged from carotid occlusion to conservative management. The use of a balloon-expandable stent and/or Guglielmi detachable coils may be effective in a partially healed pseudoaneurysm. This report details the case of an acute petrous carotid pseudoaneurysm after a myringotomy procedure that was effectively treated with an expanded polytetrafluoroethylene-covered stent.

CLINICAL PRESENTATION:

During a right myringotomy procedure, pulsatile blood was encountered in a 42-year-old woman with a history of repeated ear infections and bilateral middle ear ventilation tube placement. The blood was adequately tamponaded with gauze packing. Computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and cerebral angiography revealed a 6-mm right petrous carotid pseudoaneurysm.

INTERVENTION/TECHNIQUE:

An 8-French guide catheter was positioned via a transfemoral approach into the cervical right internal carotid artery, and the patient was systemically heparinized. A 4- × 31-mm Symbiot covered stent (Boston Scientific/Scimed, Maple Grove, MN) was passed over a Choice PT exchange wire (Boston Scientific/Scimed) to cover the neck of the pseudoaneurysm, obliterating the pseudoaneurysm. The patient was given aspirin and clopidogrel after stenting, and ear exploration was possible later the same day. Follow-up computed tomographic angiography performed 6 weeks later verified patency of the stent.

CONCLUSION:

The use of an expanded polytetrafluoroethylene-covered stent may effectively treat intracranial internal carotid artery pseudoaneurysms in an acute setting. This treatment allows preservation of the parent artery and immediate treatment by reconstruction of the incompetent arterial wall to prevent potentially life-threatening hemorrhagic complications.