bluuebunny/crossref_metadata_2025 huggingface dataset:
Worries and concerns of patients with multiple sclerosis: development of an assessment scale
Authors: Thornton E W , Tedman S , Rigby S , Bashforth H , Young C
Published: April 2006

This study examined the nature of worry in adult patients with multiple sclerosis (MS) in the UK. A measure of worry in MS was developed and the relationship between worry and standard scale measures of anxiety and depression was examined. Thirty-nine patients with MS and 40 controls completed the new worry scale (WQMS) that was psychometrically evaluated, together with the Penn State Worry Questionnaire (PSWQ), the Hospital Anxiety and Depression Scale (HAD) and a previously developed scale to assess self-efficacy in MS (SESMS). The scores for both anxiety ( t=2.34; p<0.05) and depression ( t=5.52; p<0.01) were higher in MS patients than controls, as was the new scale for worry - the WQMS. A factor analysis (explaining 65.73% of the variance) suggests that the worries of patients may be dichotomized into those concerned with the physical effects of the disease and those relating to the impact on social interaction, family relationships and daily activity in the home and/or work. Worry in patients with MS was associated with a decreased sense of being able to produce positive activities or effect positive outcomes (low self-efficacy). The questionnaire provides a framework for investigation in clinic of specific concerns and level of worry they engender.
The macrophage in MS: just a scavenger after all? Pathology and pathogenesis of the acute MS lesion
Authors: Barnett M H , Henderson A PD , Prineas J W
Published: April 2006

Advances in the neuropathology of multiple sclerosis (MS) have contributed greatly to our understanding of the mechanisms of tissue injury in the condition. Particular interest has focussed on the active MS lesion, defined by macrophage activity in the presence of partially demyelinated axons. This has led to the prevailing consensus that a T-cell dependent, macrophage-mediated, autoimmune attack on constituents in the normal myelin sheath underlies the disease. This hypothesis, which has been largely supported by comparisons with the animal model, experimental allergic encephalomyelitis, has recently been questioned by an analysis of the pathological events preceding myelin phagocytosis in nascent MS lesions. The prephagocytic changes in evolving lesions examined shortly after the onset of an MS relapse raise the possibility that oligodendrocyte cell death and associated changes within the myelin sheath initiate local macrophage scavenger activity, with subsequent amplification of the inflammatory response. The presence of such lesions in patients with a spectrum of pathological changes in nearby or distant active phagocytic plaques suggests that pathological heterogeneity in MS is largely due to evolution of lesional pathology, rather than pathogenic heterogeneity.
Antiphospholipid Antibodies Syndrome Associated with Hyperhomocysteinemia Related to MTHFR Gene C677T and A1298C Heterozygous Mutations in a Young Man with Idiopathic Hypoparathyroidism (DiGeorge Syndrome)
Authors: Nucera Carmelo , Vaccaro Mario , Moleti Mariacarla , Priolo Carmen , Tortorella Gaetano , Angioni Adriano , Ientile Riccardo , Violi Maria Antonia , Loda Massimo , Trimarchi Francesco , Vermiglio Francesco
Published: April 2006

Context: Antiphospholipid syndrome (APS, or Hughes’ syndrome) is a systemic autoimmune disorder characterized by antiphospholipid antibody positivity, which may lead to arterial and/or venous thrombosis. Hyperhomocysteinemia (HHcy), variously associated with 5,10-methylene tetrahydrofolate reductase (MTHFR) gene point mutations, is also implicated in thromboembolic events. The association of APS and HHcy has already been described but has never been reported in patients with DiGeorge syndrome (DGS), the most common contiguous-gene deletion syndrome (22q11.2) in humans, whose phenotype conversely includes bleeding disorders.

Data Acquisition: In this report, we present the case of a 19-yr-old patient with a past medical history of learning disability and obesity affected with idiopathic hypoparathyroidism, metabolic syndrome, and diffuse vasculitis disorders. He was referred to our endocrinology clinic for the management of severe hypocalcemia. At the time of presentation he had been taking antiepileptic drugs for 2 wk and displayed facial dysmorphism (short neck, micrognathia, a small mouth, hypoplastic nasal alae, eye hypertelorism, and low-set simple ears). DGS was suspected and confirmed by both fluorescence in situ hybridization analysis and single nucleotide polymorphism-array analysis, which revealed contiguous gene microdeletion of the chromosome 22q11.2 in the minimal DiGeorge critical region, specifically at the gene locus D22S75 (N25).

Conclusions: APS, revealed by anti-β-2-glycoprotein and anti-prothrombin antibodies positivity, and moderate HHcy related to heterozygous C677T and A1298C point mutations of the MTHFR gene were identified as a possible cause of thrombotic disorder responsible for the widespread presence of cutaneous and cerebral lesions.
Free Fatty Acids Are Independently Associated with All-Cause and Cardiovascular Mortality in Subjects with Coronary Artery Disease
Authors: Pilz Stefan , Scharnagl Hubert , Tiran Beate , Seelhorst Ursula , Wellnitz Britta , Boehm Bernhard O. , Schaefer Jürgen R. , März Winfried
Published: April 2006

Context: Free fatty acids (FFAs) are associated with several cardiovascular risk factors and exert harmful effects on the myocardium.

Objective: The aim of our study was to elucidate the relationship between FFAs and mortality in subjects who underwent coronary angiography.

Design, Setting, and Participants: Ludwigshafen Risk and Cardiovascular Health is a prospective cohort study of Caucasians who had undergone coronary angiography at baseline (1997–2000). During a median time of follow-up of 5.38 yr, 513 deaths had occurred among 3315 study participants with measured FFAs.

Main Outcome Measure: Hazard ratios for mortality according to FFA levels were measured.

Results: At the fourth quartile of FFAs, fully adjusted hazard ratios for death from any cause and cardiovascular causes were 1.58 (P = 0.002) and 1.83 (P = 0.001), respectively. In persons with angiographic coronary artery disease (CAD), stable CAD, and unstable CAD, the predictive value of FFAs was similar to that in the entire cohort, but the association did not attain statistical significance in persons without CAD analyzed separately. FFA levels were not related to the presence of angiographic CAD but were elevated in subjects with unstable CAD, compared with probands with stable CAD. Furthermore, FFAs increased with the severity of heart failure and were positively correlated with N-terminal pro-B-type natriuretic peptide (P < 0.001).

Conclusions: FFA levels independently predict all-cause and cardiovascular mortality in subjects with angiographic CAD. A possible diagnostic use of FFAs warrants further studies, but our results may underline the importance of therapeutic approaches to influence FFA metabolism.
Combined Anterior and Anterolateral Approaches to the Cranial Base:Complication Analysis, Avoidance, and Management
Authors: Origitano Thomas C. , Petruzzelli Guy J. , Leonetti John P. , Vandevender Darl
Published: April 2006

Objective:

During the past decade, applications of anterior and anterolateral cranial approaches for both benign and malignant pathologies have expanded in frequency and application. Complications associated with these procedures impact significantly on patient outcome. The primary aim of this study is to detail the strategies for complication management and avoidance developed from experience with 120 patients who underwent anterior and anterolateral cranial base procedures during the past 14 years.

Methods:

Between July 1990 and February 2004, 62 male and 58 female patients underwent 120 combined (neurological surgery and otolaryngology joint participation) anterior and anterolateral cranial base procedures. Fifty-four percent had malignant pathology, and 46% had benign pathology. The approaches taken were transfacial (10%), extended subfrontal (33%), lateral craniofacial (23%), and anterior craniofacial (35%). Thirty-day morbidity and mortality were analyzed.

Results:

Twenty (17%) patients experienced at least one complication. Malignancy and reoperation, regardless of histology, appeared to affect the complication rate. A decline in complications occurred with experience, in part because of changes in management that reflected the complication experience (25% in Patients 0–31, 18% in Patients 32–70, 10% in Patients 71–120). Methodology is detailed for avoidance and management of retraction injury, infection, tension pneumocephalus, cerebrospinal fluid leak, pericranial flap failure, free flap sizing, dural banding, intracranial hypotension, and cerebrovascular events. Individual patient analysis, complications timing, and strategy for management are discussed.

Conclusion:

Improved patient outcomes for anterior and anterolateral cranial base surgery are, in part, directly related to the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.
Dual Electrode Thalamic Deep Brain Stimulation For The Treatment Of Posttraumatic And Multiple Sclerosis Tremor
Authors: Foote Kelly D. , Seignourel Paul , Fernandez Hubert H. , Romrell Janet , Whidden Elaine , Jacobson Charles , Rodriguez Ramon L. , Okun Michael S.
Published: April 2006

Objective:

To report the results of ventralis intermedius nucleus/ventralis oralis posterior nucleus (VIM) plus ventralis oralis anterior (VOA)/ventralis oralis posterior (VOP) thalamic deep brain stimulation (DBS) for the treatment of posttraumatic and multiple sclerosis tremor.

Objective:

The treatment of posttraumatic tremor and multiple sclerosis tremor, by either medication or surgery, has proven difficult. Lesions and DBS have had mixed and somewhat disappointing results. Previously, we reported the use of two DBS electrodes (one at the VIM/VOP border and one at the VOA/VOP border) as effective for the treatment of posttraumatic tremor in a single patient. In this study, we report the results of this technique on four patients.

Methods:

Four patients with either posttraumatic tremor (n = 3) or multiple sclerosis tremor (n = 1) underwent placement of two DBS electrodes (one at the VIM/VOP border and one at the VOA/VOP border). Patients underwent preoperative testing and testing at a minimum of 6 months after implantation in four conditions: On VIM DBS/On VOA/VOP DBS; On VIM DBS/Off VOA VOP DBS (5 h DBS washout); Off VIM DBS/Off VOA/VOP DBS (12 h overnight washout); and Off VIM DBS/On VOA/ VOP DBS (5 h DBS washout).

Results:

Each of the patients showed improvements in all four conditions when compared with the baseline. All of the improvements were maintained with chronic DBS, without tremor rebound. An analysis was performed to determine whether each condition was associated with symptom reduction (percentage change). The percentage reduction was significant for each condition and measure, despite the small number of participants. For the total tremor rating scale score, the Off VIM/Off VOA/VOP condition yielded less symptom reduction than the On VIM condition or the On VOA/VOP condition. The On VIM and On VOA/VOP conditions did not differ significantly from each other in terms of contralateral upper extremity symptoms or total clinical score. Activation of both the VIM and VOA/VOP electrodes was associated with the greatest symptom reduction.

Conclusion:

Tremors, such as those examined in this study, that are refractory to medications and have a poor response to VIM DBS monotherapy, may respond favorably to VIM plus VOA/VOP DBS. Two electrodes may be better than one for the treatment of certain disorders; however, more study will be required to confirm this hypothesis.
The Extended Retrosigmoid Approach:An Alternative To Radical Cranial Base Approaches For Posterior Fossa Lesions
Authors: Quiñones-Hinojosa Alfredo , Chang Edward F. , Lawton Michael T.
Published: April 2006

Objective:

The extended retrosigmoid approach is presented as a simple and safe modification of the traditional retrosigmoid approach, with increased exposure resulting from a limited mastoidectomy and skeletonization of the sigmoid sinus.

Methods:

Patients with posterior fossa vascular lesions treated with the extended retrosigmoid approach between 1997 and 2003 were reviewed. A detailed description of the surgical approach, as well as case illustrations, is provided. We present a video narrated by the senior author in which a description of the technique is offered.

Results:

Thirty-eight patients underwent this approach to manage 40 lesions, including 15 dural arteriovenous fistulae, 9 arteriovenous malformations, 10 cavernous malformations, and 6 aneurysms. The extended retrosigmoid approach differs from the traditional approach with its C-shaped skin incision, posterior mastoidectomy, and extensive dissection of the sigmoid sinus, craniotomy rather than craniectomy, and anterior mobilization of the sinus with the dural flap.

Conclusion:

The application of the extended retrosigmoid approach to a series of complex lesions in the posterior fossa demonstrates its applicability as an alternative to radical cranial base approaches. The extended retrosigmoid approach requires a fundamental change in the management of the sigmoid sinus. The neurosurgeon must be familiar with petrous bone anatomy, experienced dissecting through bone using a high-speed drill, and comfortable working directly over a major venous sinus. The technical modifications of the extended retrosigmoid approach can be incorporated into the neurosurgical repertoire and will enhance exposure of the cerebellopontine angle and deep vascular structures, thereby minimizing the need for brain retraction and other transpetrous approaches.
Anterolateral Approach To The V1 Segment Of The Vertebral Artery
Authors: Bruneau Michaël , Cornelius Jan Frédérick , George Bernard
Published: April 2006

Objective:

We describe the normal anatomy, variations, and the surgical technique to expose and control the V1 segment of the vertebral artery (VA).

Methods:

The VA V1 segment extends classically from the subclavian artery to the C6 transverse foramen. It courses obliquely upwards and posteriorly in the cervical fat tissue, at a distance of 5 to 10 mm from the C7 vertebral body. Along its course, the VA V1 segment is crossed by the inferior thyroid artery, the thoracic duct, and the sympathetic chain. For neurosurgeons, the safest approach is to expose the distal part of the V1 segment at the C6 transverse foramen level through an antero-lateral approach. Otherwise, direct exposure of the subclavian artery requires vascular surgery expertise.

Results:

Surgical exposure of the VA V1 segment can be indicated on approaching the C6–C7 intervertebral disc space for degenerative disease or on treating tumoral processes in its vicinity. With developments of endovascular techniques, revascularization procedures are more rarely indicated nowadays.

Conclusion:

Perfect knowledge of the anatomy and of the surgical technique permits a safe exposure and control of the VA V1 segment.
Video-Assisted Thoracoscopic Dissection Of The Brachial Plexus:Cadaveric Study And Illustrative Case
Authors: Morgan Chad J. , Lyons Jefferson , Ling Benjamin C. , Maher P. Colby , Bohinski Robert J. , Keller Jeffrey T. , Howington John A. , Kuntz Charles
Published: April 2006

Objective:

Standard surgical approaches to the brachial plexus require an open operative technique with extensive soft tissue dissection. A transthoracic endoscopic approach using video-assisted thoracoscopic surgery (VATS) was studied as an alternative direct operative corridor to the proximal inferior brachial plexus.

Methods:

VATS was used in cadaveric dissections to study the anatomic details of the brachial plexus at the thoracic apex. After placement of standard thoracoscopic ports, the thoracic apex was systematically dissected. The limitations of the VATS approach were defined before and after removal of the first rib. The technique was applied in a 22-year-old man with neurofibromatosis who presented with a large neurofibroma of the left T1 nerve root.

Results:

The cadaveric study demonstrated that VATS allowed for a direct cephalad approach to the inferior brachial plexus. The C8 and T1 nerve roots as well as the lower trunk of the brachial plexus were safely identified and dissected. Removal of the first rib provided exposure of the entire lower trunk and proximal divisions. After the fundamental steps to the dissection were identified, the patient underwent a successful gross total resection of a left T1 neurofibroma with VATS.

Conclusion:

VATS provided an alternative surgical corridor to the proximal inferior brachial plexus and obviated the need for the extensive soft tissue dissection associated with the anterior supraclavicular and posterior subscapular approaches.
Microsurgical Anatomy Of The Oculomotor Cistern
Authors: Martins Carolina , Yasuda Alexandre , Campero Alvaro , Rhoton Albert L.
Published: April 2006

Objective:

To define the characteristics of the arachnoidal sleeve and cistern that accompany the oculomotor nerve through the cavernous sinus roof.

Methods:

Forty cavernous sinuses were examined using 3 to 40x magnification. Information was obtained about the size of the oculomotor cistern and its relationship to the roof of the cavernous sinus and anterior clinoid process.

Results:

An arachnoidal sleeve and cistern, referred to as the oculomotor cistern, accompanied the oculomotor nerve into the roof of all the cavernous sinuses examined. The oculomotor cistern extends from the oculomotor porus, where the nerve enters the roof of the cavernous sinus, to the area below the tip or the adjacent part of the lower margin of the anterior clinoid process. From the porus, the nerve passes forward and downward to the depth of the cistern where it becomes incorporated into the fibrous lateral wall of the cavernous sinus. The width of the cistern was maximal at the oculomotor porus averaged 5.5 mm (range, 3.0–9.2 mm), and tapered slightly towards the midpoint and deep end of the cistern. The cistern's average length was 6.5 mm (range, 3.0–11.0 mm). The oculomotor nerve usually coursed closer to the anterior than the posterior wall of the cistern at the level of the oculomotor porus.

Conclusion:

The oculomotor cistern, an arachnoidal and dural cuff, accompanies the oculomotor nerve through the cavernous sinus roof to the area just below or anterior to the lower edge of the tip of the anterior clinoid process. The segment of the nerve inside the oculomotor cistern is interposed between its free portion in the interpeduncular cistern and the part of its course where it is incorporated into the fibrous lateral wall of the cavernous sinus. The cistern can be opened to aid in the exposure and mobilization of the nerve in dealing with pathology in the area.
Surgical Anatomy Of Dural Defects In Spontaneous Spinal Cerebrospinal Fluid Leaks
Authors: Cohen-Gadol Aaron A. , Mokri Bahram , Piepgras David G. , Meyer Fredric B. , Atkinson John L.D.
Published: April 2006

Objective:

Spontaneous intracranial hypotension is typically caused by a spontaneous spinal cerebrospinal fluid (CSF) leak. The configuration of the related dural defects can be complex. We describe our experience with the surgical anatomy of these defects.

Methods:

Thirteen consecutive patients with spontaneous spinal CSF leaks who underwent surgical exploration at Mayo Clinic between 1994 and 2003 were studied. All patients' records, imaging studies, detailed intraoperative findings, and outcomes were reviewed.

Results:

There were four men and nine women with an average age of 40 years (range, 12–62 yr). Preoperative imaging studies revealed a single site of CSF leak in eight patients, two sites in three patients, and multiple sites in two patients. Intraoperatively, the exact site of leakage could not be found in four patients. Among the other nine patients, primary closure of a meningeal diverticulum was achieved in one patient. Significant regional attenuation of the dura prevented primary repair of the leak site in eight patients. Muscle, fibrin glue, and Gelfoam (Upjohn Co., Kalamazoo, MI) soaked in patient's own blood were commonly used to pack the epidural space in an attempt to seal the site of the leak. Ligation of two nonappendicular nerve roots allowed closure of the leak in one of these patients. Postoperatively, resolution of symptoms occurred in eight patients, significant improvement was noted in three patients, and only transient resolution in two. The mean duration of follow-up was 20.5 months.

Conclusion:

Surgery for closure of spontaneous spinal CSF leaks may not be straightforward. Even when extradural CSF leakage is discovered preoperatively by imaging studies, it may not always be possible to identify the exact site of the leakage intraoperatively. Furthermore, the anatomy of the dural defects may be complex and not amenable to primary closure. In such cases, the use of adjuvant techniques during surgical exploration may be effective.
Intra/Extra-Aneurysmal Stent Placement For Management Of Complex And Wide-Necked-Bifurcation Aneurysms:Eight Cases Using The Waffle Cone Technique
Authors: Horowitz Michael , Levy Elad , Sauvageau Eric , Genevro Julie , Guterman Lee R. , Hanel Ricardo , Wehman Christopher , Gupta Rishi , Jovin Tudor
Published: April 2006

Objective:

To describe a novel application of the Neuroform stent (Boston Scientific-Target, Fremont, CA) for the management of eight wide-necked aneurysms.

Methods:

All patients were treated using a single Neuroform stent placed partially into the aneurysm and into the afferent artery. The portion of the stent protruding into the aneurysm fundus provided neck support for the subsequent successful coiling.

Conclusion:

The Neuroform stent is a versatile device that can be used in a variety of ways to assist in the coiling of wide-necked aneurysms. The technique described here may be used for bifurcation aneurysms in lieu of using two stents in a Y configuration.
Intraoperative Magnetic Resonance Imaging-guided neurosurgery at 3-T
Authors: Truwit Charles L. , Hall Walter A.
Published: April 2006

Objective:

Between 1997 and 2004, more than 700 neurosurgical procedures were performed in a 1.5-T magnetic resonance-guided therapy suite. During this period, the concept of high-field intraoperative magnetic resonance imaging (MRI) was validated, as was a new surgical guidance tool, the Navigus (Image-guided Neurologics, Melbourne, FL), and its methodology, prospective stereotaxy. Clinical protocols were refined to optimize surgical techniques. That implementation, the “Minnesota suite, ” has recently been revised, and a new suite with a 3-T MRI scanner has been developed.

Methods:

On the basis of experience at the initial 1.5-T suite, a new suite was designed to house a 3-T MRI scanner with wide surgical access at the rear of the scanner (opposite the patient couch). Use of electrocautery, a fiberoptic headlamp, a power drill, and MRI-compatible neurosurgical cutlery was anticipated by inclusion of waveguides and radiofrequency filter panels that penetrate the MRI suite's radiofrequency shield. An MRI-compatible head holder was adapted for use on the scanner table. A few items exhibiting limited ferromagnetism were used within the magnetic field, taking strict precautions.

Results:

During the initial procedures (all magnetic resonance-guided neurobiopsies), the new suite functioned as anticipated. Although metallic artifact related to titanium needles is more challenging at 3 T than at 1.5 T, it can be contained even at 3 T. Similar to 1.5 T, such artifact is best contained when the device is oriented along B0, the main magnetic field. Surgical needles, disposable scalpels, and disposable razors, despite being minimally ferromagnetic, were easily controlled by the surgeon.

Conclusion:

An intraoperative magnetic resonance-guided neurosurgical theater has been developed with a 3-T MRI scanner. Intraoperative imaging is feasible at this field strength, and concerns regarding specific absorption rate can be allayed. Infection control procedures can be designed to permit neurosurgery within this environment. Despite the increase in magnetic field strength, safety can be maintained.
Anterior Cervical Discectomy and Corpectomy
Authors: Perez-Cruet Mick J. , Samartzis Dino , Fessler Richard G.
Published: April 2006

Objective:

The objective of this review article is to describe the authors' operative technique for performing anterior cervical corpectomy and fusion.

Methods:

The authors reviewed their operative technique and experience to clearly detail the general methods utilized to safely and effectively perform anterior cervical corpectomy and fusion. Specific nuances peculiar to the authors' technique were identified and highlighted.

Results:

The operative technique for anterior cervical corpectomy, including nuances for enhancing ease or outcome of surgery, is described in detail. Drawings and photographs are included where appropriate to highlight specific aspects of the procedural technique.

Conclusion:

Anterior cervical corpectomy and fusion is a well known technique that proceeds in a consistent and logical sequence of maneuvers. Specific technical nuances at various points enhance the ease and safety of the technique, as well as the completeness of the eventual result.
Increased Cell Opening and Prolapse of Struts of a Neuroform Stent in Curved Vasculature:Value of Angiographic Computed Tomography: Technical Case Report
Authors: Benndorf Goetz , Claus Benjamin , Strother Charles M. , Chang Lee , Klucznik Richard P.
Published: April 2006

Objective and Importance:

To describe the use of a new imaging tool, angiographic computed tomography, for visualization of cell opening and strut prolapse of a Neuroform 2 stent (Boston Scientific/Target, Fremont, CA) placed in curved vasculature for treatment of a basilar tip aneurysm.

Clinical Presentation:

A 46-year-old woman presented with an unruptured 8-mm basilar tip aneurysm with a wide patulous neck.

Intervention:

A 4 × 20-mm Neuroform 2 stent was placed across the aneurysm neck. Angiographic computed tomographic scanning was performed using a flat detector biplane angiographic system with new commercially available software (Dyna-CT; Siemens Medical Solution, Forchheim, Germany) and the following parameters: 20-second acquisition, 0.4-degree increment, 512 matrix in projections, 220-degree total angle, 20 degree/s, and approximately 15 to 30 frames/s, for a total of 538 projections. Image postprocessing was performed to correct scattered radiation, beam hardening, and ring artifacts on a commercially available workstation (Leonardo, Siemens Medical Solutions, Erlangen, Germany). The aneurysm was coiled in a second session, using bare platinum coils without clinical sequelae.

Conclusion:

Increased opening of cells and prolapsing of struts of an open cell design stent can occur after placement in a curved vessel across an aneurysm orifice. Angiographic computed tomography is a new imaging tool that provides visualization of intracranial stents that is superior to digital subtraction angiogram or nonsubtracted images. It will enhance our understanding of stent behavior in clinical practice and improve the efficacy and safety of intracranial stent placement. Further in vitro and in vivo imaging studies of intracranial stents are necessary to assess the value of this promising new technique.
Simultaneous Image-guided and Endoscopic Navigation without Rigid Cranial Fixation: Application in Infants:Technical Case Report
Authors: Mangano Francesco T. , Limbrick David D. , Leonard Jeffrey R. , Sung Park Tae , Smyth Matthew D.
Published: April 2006

Objective and Importance:

Infants and young children demonstrate a variety of intraventricular and periventricular lesions. Endoscopy has proven useful in the treatment of many of these lesions, but its benefit is limited if it is applied to complex loculated cysts or if the disease is concealed by normal ependymal boundaries. In adults and older children, endoscopy can be augmented by the simultaneous use of frameless stereotaxy, but this combined modality has not been possible in infants and young children without rigid cranial fixation. We describe a method of achieving simultaneous stereotactic and endoscopic navigation in infants and young children by using a pinless, frameless stereotactic assembly.

Clinical Presentation:

The first patient was a 6-week-old boy with macroceph-aly and a bulging fontanelle. Computed tomographic and magnetic resonance imaging revealed a complex arachnoid cyst and obstructive hydrocephalus. The second patient was a 7-month-old, ex-premature (27-wk gestational age) boy who developed posthemorrhagic hydrocephalus. He underwent multiple shunt revisions, one of which was complicated by enterococcal ventriculitis. Despite bilateral ventriculoperitoneal shunts, he developed increasing head circumference, listlessness, and irritability. Imaging revealed an enlarged, multiloculated, and asymmetric ventricular system.

Intervention:

Simultaneous image-guided and endoscopic neuronavigation was implemented in both patients. Before the procedure, a cranial reference arc was secured to the outer table of the cranium through a small incision adjacent to the operative field. After the stereotactic apparatus was registered, the software was used to plan a trajectory for the approach. A burr hole was then made, and a rigid 6-mm endoscope was inserted for direct visualization. Once advanced past the endoscopic port tip, the electromagnetic coil stylet was used to stereotactically track position and identify areas for fenestration, biopsy, and catheter insertion.

Conclusion:

Endoscopic views of complex hydrocephalus and arachnoid cysts alone are often difficult to interpret. Simultaneous image-guided and endoscopic neuronavigation may be advantageous in the management of complex cases that are anatomically related to the ventricular system in infants for whom rigid cranial fixation could lead to increased procedure-related morbidity.
Surgical Management of Distal Coil Migration and Arterial Perforation after Attempted Coil Embolization of a Ruptured Ophthalmic Artery Aneurysm:Technical Case Report
Authors: Deshmukh Vivek R. , Klopfenstein Jeffrey , Albuquerque Felipe C. , Kim Louis J. , Spetzler Robert F.
Published: April 2006

Objective and Importance:

Distal coil migration is a rare but hazardous complication of aneurysm coil embolization. Various microsnare devices have been developed to address this problem. We describe the surgical management of a case in which microsnare retrieval failed.

Clinical Presentation:

A 34-year-old woman presented with subarachnoid hemorrhage. Magnetic resonance imaging, computed tomography angiography, and conventional angiography showed an approximately 2.5-mm ophthalmic artery aneurysm. Using balloon remodeling, a 2 × 4-cm coil was deployed into the aneurysm fundus. While the coil pusher was being removed after deployment, the microcatheter advanced abruptly into the aneurysm. The coil mass was dislodged and migrated into the angular branch of the middle cerebral artery. Contrast extravasation was noted during attempted retrieval with a microsnare device.

Technique:

Computed tomographic scans showed a subarachnoid hemorrhage in the territory of the left frontotemporal operculum. A left modified orbitozygomatic approach was performed. The coil mass was removed from the angular artery and a thromboembolectomy was performed. The artery was repaired and the pseudoaneurysm was clip ligated. The ophthalmic artery aneurysm was clip ligated. The patient recovered without deficits.

Conclusion:

Distal coil migration and arterial perforation can be treated surgically with a good clinical outcome.
Quantification And Comparison Of Telovelar And Transvermian Approaches To The Fourth Ventricle
Authors: Deshmukh Vivek R. , Figueiredo Eberval Gadelha , Deshmukh Puspha , Crawford Neil R. , Preul Mark C. , Spetzler Robert F.
Published: April 2006

Objective:

To quantify the exposure to the fourth ventricle obtained with the telovelar and transvermian approaches.

Methods:

The telovelar, with and without C1 posterior arch removal, and transvermian approaches were performed on six cadaveric heads. The area of surgical exposure was calculated from triangles formed by defined anatomic points. A robotic microscope was used to determine the “angle of approach” for the same points.

Results:

The maximal allowable vertical angle of attack to the obex of the fourth ventricle was significantly greater with the telovelar approach than with the transvermian approach (P < 0.002), but there was no difference at the rostral fourth ventricle. The maximal allowable horizontal angle of attack at the level of the obex, Luschka, and rostral fourth ventricle was significantly greater with the telovelar than with the transvermian approach (P < 0.001). Removal of the C1 posterior arch with the telovelar approach significantly increased the vertical angle of approach to the obex (P < 0.001) and rostral aspect of the fourth ventricle (P = 0.005) compared with the telovelar alone. The telovelar approach with C1 arch removal offered a larger working area than the transvermian approach (P < 0.001).

Conclusion:

Except for the vertical angle to the rostral aspect of the fourth ventricle, the telovelar approach provides greater angle of exposure in all planes than the transvermian approach. Removal of the C1 posterior arch obviates this sole advantage of the transvermian approach. The telovelar approach offers a corridor through noneloquent arachnoid planes and a safe and capacious working environment.
Minimally Invasive Atlantoaxial Fixation with a Polyaxial Screw-rod Construct: Technical Case Report
Authors: Joseffer Seth S. , Post Nicholas , Cooper Paul R. , Frempong-Boadu Anthony K.
Published: April 2006

Objective and Importance:

Posterior C1–C2 fusion with polyaxial screw and rod fixation has become an accepted means of atlanto-axial stabilization. We describe a novel technique for minimally invasive placement of C1 lateral mass screws and C2 pedicle screws for polyaxial screw-rod stabilization.

Clinical Presentation:

The patient presented with a history of chronic neck pain, as well as a 6-month history of weakness and paresthesias involving her left hand. An Os Odontoideum was present on computed tomographic imaging of the cervical spine. Significant instability was noted on flexion-extension imaging, and magnetic resonance imaging demonstrated mild T2 signal change within the spinal cord.

Technique:

Under fluoroscopic guidance, serial dilators were passed through a 2.5 cm paramedian skin incision to allow placement of an expandable tubular retractor. The exposure was centered on the C2 lateral mass. After expansion of the retractor and further subperiosteal dissection, the C1 and C2 lateral masses were visible permitting placement of a polyaxial screw rod construct. This procedure was carried out bilaterally.

Conclusion:

Placement of C1 lateral mass and C2 pedicle screws using minimally invasive techniques is technically feasible.
Two-stage Operation for Resection of Spinal Cord Astrocytomas:Technical Case Report of Three Cases
Authors: Hida Kazutoshi , Iwasaki Yoshinobu , Seki Toshitaka , Yano Shunsuke
Published: April 2006

Objective and Importance:

Surgery for excision of intramedullary spinal cord tumors without increasing neurological deficit is one of the more difficult operations in spinal surgery. In particular, infiltrating astrocytomas without a clear cleavage between the tumor and normal spinal cord parenchyma are difficult to remove totally without producing additional neurological impairment. In this study, we describe a two-stage resection facilitating total resection of intramedullary tumors.

Clinical Presentation:

Three cases of spinal cord astrocytomas were treated using a two-staged method.

Technique:

The first surgery included myelotomy, biopsy and duroplasty. A thin expanded polytetrafluoroethylene sheet was placed between the dorsal surface of the spinal cord and dura mater to prevent adhesions. Two or 3 weeks after surgery, a second surgery was performed to remove the now exophytic tumor.

Results:

Magnetic resonance imaging scans showed exophytic extrusion of the tumor in all three cases before the second operation. In each patient, we were able to carry out gross total removal of the tumors without additional neurological deficit except for transient joint position sense loss in one case. All three patients remain neurologically stable without evidence of tumor recurrence more than 3 years after surgery.

Conclusion:

A two-stage operation may enhance the surgeon's ability to completely resect extensive low-grade spinal cord astrocytomas and, at the same time preserve neurological function.
Subpectoral Implantation of the Vagus Nerve Stimulator
Authors: Bauman Joel A. , Ridgway Emily B. , Devinsky Orrin , Doyle Werner K.
Published: April 2006

Objective:

To report the technique of subpectoral (SP) implantation of the vagus nerve stimulator (VNS) generator.

Methods:

We retrospectively reviewed and compared demographics and complications from patients receiving either subcutaneous (SQ; n = 107) or SP (n = 138) VNS implants, performed by one surgeon (WKD) between 1999 and 2003. Selection of implant location was made during the preoperative surgeon-patient consultation on the basis of surgeon recommendation and patient preference.

Results:

The standard VNS generator implantation is performed within a SQ pocket in the left infraclavicular region of the chest. We have modified this technique by placing the generator into a deeper pocket SP, beneath the pectoralis major muscle, while tunneling the electrodes SQ in the usual fashion. The SP group was substantially younger (median age 19 yr) compared with the SQ group (median age 29 yr). At an average follow-up of 52 months for SQ implants and 28.4 months for SP implants, there were 2.9% infections per patient in the SQ group and 2.5% infections per patient in the SP group. There were three cases of excessive generator mobility in the SQ group; no cases occurred in the SP group.

Conclusion:

The SP implantation technique provides an attractive alternative to SQ VNS implantation. With increased soft tissue coverage, we provide improved cosmesis, increased wound durability to tampering and trauma, and a comparable infection rate with the SQ group.
Double Reimplantation Technique to Reconstruct Arterial Bifurcations with Giant Aneurysms
Authors: Lawton Michael T. , Quiñones-Hinojosa Alfredo
Published: April 2006

Objective:

To introduce the double implantation technique, a variation of standard radial artery or saphenous vein bypass that can be used to reconstruct arterial bifurcations in the management of giant aneurysms with complex branch arteries.

Methods:

This technique was applied in two patients with giant aneurysms. A 74-year-old woman presented with a ruptured thrombotic middle cerebral artery aneurysm, and a 24-year-old man presented with an enlarging infectious aneurysm of the distal anterior cerebral artery (ACA).

Results:

In the first case, a saphenous vein graft was anastomosed end-to-end to the external carotid artery. The temporal M2 middle cerebral artery trunk was disconnected from the aneurysm and reimplanted onto the graft with an end-to-side anastomosis. The graft was anastomosed end-to-side to the frontal M2 middle cerebral artery trunk, and the aneurysm was trapped. Similarly, in the second case, a radial artery graft was connected to a proximal ACA branch (anterior internal frontal artery) and to the distal pericallosal artery, with reimplantation of the callosomarginal artery onto the graft. The aneurysm was occluded proximally with a clip.

Conclusion:

The combination of two arterial reimplantations onto a bypass graft connected to a proximal donor artery (3 anastomoses overall) reconstructs an arterial bifurcation and enables the exclusion of a giant aneurysm. Ischemia times are minimized by completing the proximal anastomosis first, successively reimplanting efferent arterial trunks distally, and restoring cerebral perfusion to reimplanted arteries while other anastomoses are performed. This technique may be indicated when critical efferent arteries require revascularization, conventional donor arteries are diminutive, the aneurysm has ruptured, or intraluminal thrombus requires debulking.
Anterior Supraclavicular Approach to the Brachial Plexus
Authors: Tender Gabriel C. , Kline David G.
Published: April 2006

The anterior supraclavicular approach to the brachial plexus is commonly indicated in patients with traumatic injuries, tumors, or entrapment of the brachial plexus elements. We describe the anatomy and operative technique of this approach, which has been used by the senior author (DGK) for the past 30 years.
Single-Stage Thoracolumbar Vertebrectomy With Circumferential Reconstruction And Arthrodesis: Surgical Technique And Results In 15 Patients
Authors: Snell Brian E. , Nasr Fadi F. , Wolfla Christopher E.
Published: April 2006

Objective:

Circumferential reconstruction and arthrodesis can be necessary after thoracolumbar vertebrectomy. The authors describe a technique for single-stage tho-racolumbar vertebrectomy with circumferential reconstruction and arthrodesis. The surgical results using this technique are reviewed.

Methods:

Fifteen patients ranging from 14 to 75 years of age underwent single-stage thoracolumbar vertebrectomy with circumferential reconstruction and arthrodesis. The vertebrectomy was performed through a posterior midline approach. Anterior column reconstruction was performed with expandable or nonexpandable cages. Anterior and posterolateral arthrodeses used autograft. Posterior segmental instrumentation was used in all cases.

Results:

Fifteen procedures have been performed to date, 4 for tumor and 11 for fracture. The range of treated levels was T4 to L2 (7 thoracic spine and 8 lumbar spine levels). One patient was incomplete preoperatively (Frankel Grade C) and improved to being intact postoperatively (Frankel Grade E), another improved from Frankel Grade C to Frankel Grade D. All other patients were neurologically unchanged postopera-tively. Mean operative time was 4.0 hours. Average blood loss was 1100 ml. Average number of levels fused was 5.8 (range 4–9). There were four complications: one delayed transient neurological deficit after deformity correction, one infection, one postoperative myocardial infarction, and one hardware failure. All patients were treated and had a good recovery.

Conclusion:

The authors present a method for thoracolumbar vertebrectomy, circumferential reconstruction, and arthrodesis performed in a single stage, solely via a posterior approach. This is an alternative to anterior (i.e., thoracoabdominal and retroperitoneal) and lateral (i.e., lateral extracavitary) approaches that can be used for circumferential reconstruction and arthrodesis. Potential advantages and pitfalls are discussed.
Surgical Applications To Arteriovenous Malformations Involving The Brainstem
Authors: Nozaki Kazuhiko , Hashimoto Nobuo , Kikuta Ken-ichiro , Takagi Yasushi , Kikuchi Haruhiko
Published: April 2006

Objective:

To evaluate possible applications of microsurgical extirpation to arteriovenous malformations (AVMs) involving the brainstem.

Methods:

We retrospectively reviewed clinical records of 25 patients with AVMs involving brainstems who were admitted to our institute from 1984 to 2004. We defined a brainstem AVM as an AVM in which some part was located within the brainstem. The main location of the nidus was classified into ventral midbrain (n = 3), dorsal midbrain (n = 10), pons (n = 5), cerebellopontine angle (n = 6), and medulla oblongata (n = 1). Bleeding risks from the AVMs were calculated, and applied treatment modalities, respectability, and clinical outcomes were analyzed.

Results:

The annual bleeding and rebleeding risks of brainstem AVMs were 15.1 and 14.2%, respectively. Total resection was successfully performed in 0 out of 3, 6 out of 10,2 out of 5,6 out of 6, and 0 out of 1 in each of the groups, respectively. Stereotactic radiosurgery was applied as a main treatment modality in three patients (two ventral midbrain AVMs and one pontine AVM), and after microsurgery in one patient with a medulla oblongata AVM. Microsurgery-related permanent neurological complications were observed in five patients (one postoperative bleeding, one hemiparesis, three hearing deterioration, one abducens nerve palsy). During a follow-up period of 8 years (range, 8 mo-15 yr), one patient with an untreated pontine AVM died owing to hemorrhage and one patient with a subtotally resected dorsal midbrain AVM died owing to an unknown etiology 4 years later.

Conclusion:

Surgical resection can be applied with considerable, but acceptable, morbidity and mortality in some groups of brainstem AVMs with hemorrhagic presentation, particularly dorsal midbrain and cerebellopontine angle types, in which most parts of the nidus located sub- or extrapially.
One-Piece Versus Two-Piece Orbitozygomatic Craniotomy:Quantitative And Qualitative Considerations
Authors: Tanriover Necmettin , Ulm Arthur J. , Rhoton Albert L. , Kawashima Masatou , Yoshioka Nobutaka , Lewis Stephen B.
Published: April 2006

Objective:

The orbitozygomatic (OZ) craniotomy minimizes brain retraction and improves cranial base exposure by providing a multidirectional view, increased operative angles and working space. The two main variations of the approach include the one-piece and the two-piece types. The microsurgical anatomy of the one- and two-piece OZ craniotomies are presented with the goal of comparing the extent of orbital roof removal between these two craniotomies and the effect of orbital roof removal on operative exposure.

Methods:

Ten two-piece and 11 one-piece OZ craniotomies were performed in a stepwise manner simulating the approaches on formalin fixed specimens. The orbital surface area removed above the frontozygomatic suture extending medially over the orbital roof was measured from each bone flap. The two-sided unpaired t test using STATA 7.0 software was used to compare the amount of orbital roof removed using the two approaches.

Results:

The two-piece OZ craniotomy allowed for the removal of a larger portion of the roof and lateral wall of the orbitthan the one-piece. The total orbitotomy, including the orbital roof plus the part of the lateral wall above the frontozygomatic suture, had an average surface area of 996 ± 229 mm2 for the two piece and 372 ± 103 mm2 for the one-piece. The orbital roof made up 27 ± 18% of the orbital osteotomy for the one-piece craniotomies and 67 ± 10% of the osteotomy for the two-piece craniotomies (P<0.001).

Conclusion:

The two-piece OZ craniotomy allows for more extensive orbital roof removal and better visualization of the basal frontal lobe. Therefore, the two-piece may result in a lower incidence of enophtalmus and poor cosmetic outcomes, particularly if the remaining orbital roof must be removed piecemeal during the one-piece OZ craniotomy in order to obtain satisfactory exposure.
Stereoselective Photochemical Cyclization of 3-O-Benzyl-6-deoxy-1,2-O-isopropylidene-α-d-xylo-hexofuranos-5-ulose Derivatives
Authors: Araki Younosuke , Arai Yoshifusa , Endo Tadatoshi , Ishido Yoshiharu
Published: April 2006

Photoirradiation of a solution of 3-O-benzyl-6-deoxy-1,2-O-isopropylidene-α-d-xylo-hexofuranos-5-ulose in benzene for 92 h gave (6S)-3,6-anhydro-1,2-O-isopropylidene-5-c-methyl-6-c-phenyl-α-d-gluco- and -β-l-idofuranose in 54% and 11% yield, respectively. Related photocyclizations and solvent effects in the reactions were also described.
Periselectivities in Thermal Addition of Tropone to Allenic Esters
Authors: Gandhi R P , Ishar M P S
Published: April 2006

Unlike the reactions of tropone with tetraethylallenetetracarboxylic ester and phenylsulphonylpropa-1,2-diene reported in the literature (which yield 2+8 cycloadducts), thermal additions involving tropone and ethyl penta-2,3-dienoate, ethyl hexa-2,3-dienoate and ethyl 4-methylhexa-2,3-dienoate occur predominantly in a 2+4 manner. The reactions are of mechanistic significance.