bluuebunny/crossref_metadata_2025 huggingface dataset:
Correlation between venous stump pressure and brain damage after cortical vein occlusion: an experimental study
Authors: Yoshimoto Yuhei , Endo Masaru , Mori Takashi , Wakai Susumu
Published: June 2009

✓ A canine model of cortical vein occlusion was used to evaluate whether data obtained from monitoring venous stump pressure could help predict cerebral infarction after venous obstruction. Following bilateral parasagittal craniotomy, the cortical vein in each hemisphere was temporarily occluded and the increase in pressure was directly measured. Permanent venous obstruction was subsequently produced, and parenchymal brain damage 24 hours later was classified as: Stage 0, no parenchymal damage; Stage I, mild edema; Stage II, moderate parenchymal edema and/or ischemic changes in neurons; and Stage III, moderate-to-severe hemorrhage. The histological stages correlated closely with the rise in venous pressure: mean pressure increases (± standard deviation) were 5.5 ± 2.9 mm Hg in hemispheres graded as Stage 0 (12 hemispheres), 7.7 ± 3.2 mm Hg in those graded as Stage I (five), 11.2 ± 4.1 mm Hg in those classed as Stage II (five), and 16.4 ± 5 in those categorized as Stage III (seven). There were significant differences between Stages 0 and II (p < 0.01) and between Stages 0 and III (p < 0.001). Disruption of the blood-brain barrier as indicated by extravasation of Evans blue dye correlated well with the pressure increment. These results may indicate the threshold for injury after cortical venous occlusion. Venous stump pressure measurements obtained during a test occlusion may be a useful adjunct in predicting brain damage and may be helpful for intraoperative vessel selection for venous resection.
Evaluation of the transient hyperemic response test in head-injured patients
Authors: Smielewski Piotr , Czosnyka Marek , Kirkpatrick Peter , Pickard John D.
Published: June 2009

✓ The transient hyperemic response test has been shown to provide an index of cerebral autoregulation in healthy individuals and in patients who have suffered a subarachnoid hemorrhage. In this study, the test was applied to patients who had received a severe head injury, and the value of the test was assessed by comparing its result with the individual's clinical condition (Glasgow Coma Scale [GCS] score), cerebral perfusion pressure (CPP), transcranial Doppler wave form—derived index for cerebral autoregulation (relationship between the CPP and the middle cerebral artery flow velocity), and outcome (Glasgow Outcome Scale [GOS] score).

Forty-seven patients, aged 16 to 63 years, with head injuries were included in the study. Signals of intracranial pressure, arterial blood pressure, flow velocity, and cortical microcirculatory flux were digitized and recorded for a period of 30 minutes using special computer software. Two carotid compressions were performed at the beginning of each recording. The transient hyperemic response ratio (THRR: the ratio of the hyperemic flow velocity recorded after carotid release and the precompression baseline flow velocity) was calculated, as was the correlation coefficient Sx used to describe the relationship between slow fluctuations in the systolic flow velocity and CPP throughout the period of recording.

No significant changes in CPP were found during compression. There was a significant correlation between the THRR and the Sx (r = 0.49, p < 0.0001). The hyperemic response proved to be lower in patients who exhibited a poor clinical grade at presentation (GCS scores < 6, p = 0.01) and lower in patients achieving a poor outcome (GOS scores of 3, 4, and 5, p = 0.003). Loss of postcompression hyperemia occurred when the CPP fell below 50 mm Hg.

The carotid compression test provides a simple index of cerebral autoregulation that is relevant to the clinical condition and outcome of the severely head injured patient.
Intravenous insulin-like growth factor-I (IGF-I) in moderate-to-severe head injury: a Phase II safety and efficacy trial
Authors: Hatton Jimmi , Rapp Robert P. , Kudsk Kenneth A. , Brown Rex O. , Luer Mark S. , Bukar Julie G. , Chen Sharon A. , McClain Craig J. , Gesundheit Neil , Dempsey Robert J. , Young Byron
Published: June 2009

✓ The purpose of this study was to determine the effect of insulin-like growth factor-I (IGF-I) on the catabolic state and clinical outcome of head-injured patients. Thirty-three patients between the ages of 18 and 59 years with isolated traumatic head injury and Glasgow Coma Scale (GCS) scores of 4 to 10 were randomized to one of two groups. All patients received standard neurosurgical intensive care plus aggressive nutritional support; the patients in the treatment group also received intravenous therapy with continuous IGF-I (0.01 mg/kg/hour).

During the 14-day dosing period, the control patients lost weight, whereas treated patients gained weight despite a significantly higher measured energy expenditure and lower caloric intake (p = 0.02). Daily glucose concentrations and nitrogen outputs were greater in control patients (p = 0.03) throughout the study period. During Week 1, only treated patients achieved positive nitrogen balance. Fifteen of 17 treated and 13 of 16 control patients survived the 1st week. No deaths occurred in patients whose serum IGF-I concentrations were higher than 350 ng/ml. Dichotomized Glasgow Outcome Scale scores for patients with baseline GCS scores of 5 to 7 improved from poor to good for eight of 12 treated patients but for only three of 11 control patients (p = 0.06). Eight of 11 treated patients with serum IGF-I concentrations that were at least 350 ng/ml achieved moderate-to-good outcome scores at 6 months, compared to only one of five patients with lower concentrations (p < 0.05). These findings indicate that pharmacological concentrations of IGF-I may improve clinical outcome and nitrogen utilization in patients with moderate-to-severe head injury.
Hydroxyurea for treatment of unresectable and recurrent meningiomas. I. Inhibition of primary human meningioma cells in culture and in meningioma transplants by induction of the apoptotic pathway
Authors: Schrell Uwe M. H. , Rittig Michael G. , Anders Marc , Kiesewetter Franklin , Marschalek Rolf , Koch Uwe H. , Fahlbusch Rudolf
Published: June 2009

✓ Meningiomas, which invade intracranial bone structures and the adjacent connective tissue, are frequently unresectable because of their aggressive and recalcitrant growth behavior. They have a high recurrence rate, and in approximately 10% of these tumors there is an increased risk of malignancy. Significant morbidity and mortality rates associated with recurrent meningiomas demand nonsurgical approaches. To date, adjuvant hormonal treatment has not proven beneficial. The anticancer drug hydroxyurea was therefore tested for its potential use in the treatment of meningiomas.

Early-passaged cell cultures were established from 20 different meningiomas. The addition of 5 × 10−4 and 10−3 M hydroxyurea over a period of 5 to 9 days resulted in a remarkable decrease in cell proliferation and even blocked tumor cell growth when compared with untreated cells. A significant arrest of meningioma cell growth in the S phase of the cell cycle was revealed on DNA flow cytometry.

Electron micrographs of hydroxyurea-treated tumor cells showed ultrastructural features consistent with apoptosis, and light microscopy demonstrated DNA fragmentation by in situ DNA strand break labeling. Short-term treatment of meningioma cell cultures with hydroxyurea for 24 to 48 hours resulted in discrete oligonucleosomal fragments (DNA ladder), another characteristic sign of apoptosis. In addition to the in vitro studies, tissue from five different meningiomas was transplanted into nude mice followed by treatment with 0.5 mg/g body weight hydroxyurea over 15 days. In situ DNA strand break labeling demonstrated DNA fragmentation in distinct regions with different tumor cell densities in all hydroxyurea-treated meningioma transplants.

These data provide evidence that hydroxyurea is a powerful inhibitor of meningioma cell growth, most likely by causing apoptosis in the tumor cells. Thus, hydroxyurea may be a suitable chemotherapeutic agent for the long-term treatment of unresectable or semi- to malignant meningiomas, or for preventing recurrent growth of meningiomas after resection.
Effects of intraluminal or extraluminal endothelin on perfused rabbit basilar arteries
Authors: Kazuki Shuji , Ohta Tomio , Ogawa Ryusuke , Tsuji Masao , Tamura Yoji , Yoshizaki Yasushi , Takase Takashi
Published: June 2009

✓ The authors investigated selective intra- and extraluminal effects of endothelin (ET) on perfused basilar and extracranial arteries and also studied the interaction between ET and extraluminal oxyhemoglobin (oxyHb). The basilar, mesenteric, and femoral arteries were isolated from 23 Japanese White rabbits. After isolation of the intra- and extraluminal sides of the preparation, 3 × 10−10 to 3 × 10−8 mol/L of ET was administered intra- or extraluminally. After extraluminal pretreatment with 10−5 mol/L oxyHb, 10−5 mol/L NG-monomethyl-l-arginine (l-NMMA), or 10−6 mol/L indomethacin, 10−10 to 10−8 mol/L of ET was administered intra- or extraluminally. Arterial contraction was evaluated by measuring the increase in the perfusion pressure gradient with a differential pressure gauge. Both intra- and extraluminal ET (10−9 to 3 × 10−8 mol/L) showed potent and dose-dependent vasoconstricting effects on basilar arteries (p < 0.01). The effect of ET on the basilar arteries was significantly greater than on the femoral or mesenteric arteries (both p < 0.01). The effect of intraluminal ET was enhanced by extraluminal oxyHb (p < 0.05) and l-NMMA (p < 0.01), but not by extraluminal indomethacin. Extraluminal oxyHb did not potentiate the contraction induced by extraluminal ET. These results indicate that the sensitivity of the basilar artery to intraluminal ET is greater than that of the femoral or mesenteric artery. Endothelin may act as a potent vasoconstrictor intra- as well as extraluminally under conditions such as subarachnoid hemorrhage in which oxyHb is present in the extraluminal space and endothelium-derived relaxing factors are inhibited.
Epstein—Barr virus—associated dural leiomyosarcoma in a man infected with human immunodeficiency virus
Authors: Morgello Susan , Kotsianti Angeliki , Gumprecht Jeffrey P. , Moore Frank
Published: June 2009

✓ A 35-year-old man infected with human immunodeficiency virus presented with cervical myelopathy of 2 months duration. Clinical and radiographic evaluation revealed a discrete, subdural mass at C-6. At surgery, the mass proved to have a dural attachment and thus clinically, radiographically, and grossly, it resembled meningioma. Histopathological analysis revealed a leiomyosarcoma that stained diffusely for muscle-specific actin. Electron microscopy revealed basal lamina surrounding the tumor cells and intracytoplasmic bundles of myofilaments. Epstein—Barr virus (EBV) was demonstrated within tumor cell nuclei by in situ hybridization for EBER1 messenger RNA and immunohistochemical staining for EBNA2 protein. Epstein—Barr virus latent membrane protein (LMP1) was not detected. This is the first documentation of an EBV-associated smooth-muscle tumor of the dura, and the first demonstration that tumors in this location contain EBV in an unusual form of latency not seen in lymphoid cell lines. With increasing numbers of individuals being afflicted with long-term immunosuppression, EBV-associated dural leiomyoma and leiomyosarcoma may be encountered more frequently in the future.
Lymphoplasmacyte-rich meningioma with clinical resemblance to inflammatory pseudotumor
Authors: Yamaki Toshiaki , Ikeda Tatsuru , Sakamoto Yasuo , Ohtaki Masafumi , Hashi Kazuo
Published: June 2009

✓ Two cases of lymphoplasmacyte-rich meningioma manifesting clinical and radiological characteristics unusual for a meningioma are reported. The patient in Case 1 was a 22-year-old man with a 9-year history of bilateral visual disturbances and recent dyspnea. An en plaque skull base mass, which was partially resected, was found at surgery to extend down from the planum sphenoidale into the spinal canal to C-5. Seven years later most of the residual mass in the spinal canal had disappeared, although a localized round tumor recurred at C2–3. The patient in Case 2 was a 24-year-old woman with an original diagnosis of clival meningioma, which recurred as multiple skull base lesions that spontaneously regressed in 10 months. These two cases and others reported in the literature indicate that lymphoplasmacyte-rich meningiomas may manifest peculiar biological behavior more typical of intracranial granulomas than of meningiomas.
Prospective study of zero drift in fiberoptic pressure monitors used in clinical practice
Authors: Bavetta Seb , Norris John S. , Wyatt Michelle , Sutcliffe John C. , Hamlyn Peter J.
Published: June 2009

✓ One hundred and one fiberoptic pressure transducers (59 subdural and 42 ventricular) were studied in 86 patients (some in whom more than one device had been inserted). Only four complications occurred: two transient cerebrospinal fluid leaks after removal and two clinically insignificant intracerebral hematomas. No intracranial infections could be attributed to the devices. Technical problems occurred 23 times, with 11 devices ceasing to function before removal, seven becoming displaced, and five microventricular catheters failing to enter the ventricles. Zero-drift readings were obtained for 83 devices at the time of removal (median 66 hours after insertion, range 2 hours–13 days). There was a clear negative bias in the readings (median −3), with a wide range of values (−12 to +14 mm Hg; interquartile range −6 to −1) that was apparent even in the first 3 days of use. There was no important relationship between zero drift and any recorded variable. It is concluded that zero drift of fiberoptic pressure transducers is a significant problem and that undue reliance should not be placed on intracranial pressure readings from these devices in isolation from other clinical and radiological information.
Management of postoperative infections after spinal instrumentation
Authors: Levi Allan D. O. , Dickman Curtis A. , Sonntag Volker K. H.
Published: June 2009

✓ The authors retrospectively reviewed 452 consecutively treated patients who underwent a spinal instrumentation procedure at a single institution to establish which patients and which surgical approaches might be associated with an increased risk of developing deep wound infections and to determine the efficacy with which the institution's current treatment strategy eradicates these infections. Wound infections occurred in 17 patients (10 men and seven women) with spinal instrumentation (incidence 3.8%). All infections occurred after posterior spinal instrumentation procedures (7.2%); there were no infections after anterior instrumentation procedures regardless of the level. Each patient was assigned an infection risk factor (RF) score depending on the number of RFs identified in an individual patient preoperatively. The mean RF score of patients who developed infections was 2.18, whereas the mean RF score for a procedure-matched, infection-free control group was 0.71. The mean number of days from surgery to clinical presentation was 27.6 days (range 4–120 days), and the mean increase in hospitalization time for the subset of patients who developed infections was 16.6 days. The most common organism isolated from wound cultures wasStaphylococcus aureus(nine of 17 cases). Of the 17 patients, five had infections involving multiple organisms. All patients were infection free at a minimum of 8 months follow-up review. The current treatment regimen advocated at this institution consists of operative debridement of the infected wound, a course of intravenous followed by oral antibiotic medications, insertion of an antibiotic-containing irrigation—suction system for a mean of 5 days, and maintenance of the instrumentation system within the infected wound.
Multifocal noninfectious granulomatous encephalitis in a child
Authors: Lasner Todd M. , Sutton Leslie N. , Rorke Lucy B.
Published: June 2009

✓ This 9-year-old boy presented with a multifocal, apparently noninfectious granulomatous process involving the central nervous system. Despite gross-total excision of the large left temporal lesion, it recurred after surgery. Serological studies and cultures failed to demonstrate an infectious agent, and histopathological investigation showed a nonspecific granulomatous process without vasculitis. The patient underwent a second craniotomy and was given corticosteroid therapy. There has been no recurrence during 3 years of follow-up review, the last year of which included no course of steroid medications. The case is presented as a noninfectious idiopathic granulomatous encephalitis that is responsive to surgery and corticosteroid therapy. To the authors' knowledge, it is the first reported case of its kind.
Selective cochlear neurotomy in the cerebellopontine cistern using electrophysiological monitoring in a patient with intractable tinnitus
Authors: Ryu Hiroshi , Yamamoto Seiji , Sugiyama Kenji , Uemura Kenichi
Published: June 2009

✓ Selective cochlear neurotomy for intractable tinnitus is quite difficult to perform because there is no way to approach the cochlear nerve without interfering with other neural structures. The authors successfully performed selective cochlear neurotomy in the cerebellopontine cistern in a patient with persistent intractable high-pitched tinnitus, but with normal hearing and vestibular functions, by monitoring cochlear nerve compound action potentials and auditory brainstem responses. The procedure is a very simple and safe technique for the treatment of intractable tinnitus. Although this destructive procedure is the last choice of treatment, it can be justified in patients who have poor hearing and severe tinnitus in spite of normal vestibular functions. The procedure may also be applied in some rare cases such as that of the present patient whose quality of life was markedly reduced because loud tinnitis prevented him from hearing anything with the affected ear even though his hearing and vestibular functions were normal.
Direct brainstem recording of auditory evoked potentials during vestibular schwannoma resection: nuclear BAEP recording
Authors: Matthies Cordula , Samii Madjid
Published: June 2009

✓ The usefulness of intraoperative monitoring in cerebellopontine angle surgery should be improved by obtaining faster and stronger brainstem auditory evoked potential (BAEP) responses. A new technique of direct recording at the brainstem has been developed, which is applicable to all tumor sizes. By placing a retractor with electrodes attached to its tip at the cerebellomedullary junction, the authors have recorded BAEP amplitudes that are 10 times greater than those recorded using the conventional technique. Only small sampling numbers (64–256 recordings) are required and are obtained in 5 to 15 seconds. The technique has been applied successfully in 34 patients who underwent vestibular schwannoma resections. It has also been tested in patients with intrameatal—extrameatal meningiomas and in those with vascular compressive disorders; there have been no false results. The advantages of this new technique are: 1) identification of BAEP components is easier and faster; 2) reliable BAEP responses are obtained in some cases in which conventional BAEP responses are lost or severely deformed; and 3) BAEP response deterioration and improvement are recognized earlier than would occur using the conventional technique. This last advantage provides the surgeon with a useful warning at a stage of surgery at which BAEP changes are still temporary and can be reversed. This method is different from other trials of intradural BAEP recordings in three respects: its use is not limited to particular tumor sizes; there is no interference with the surgical process; and, most important, the obtained responses correlate well with those of conventional BAEP responses, probably because the recording site is in the vicinity of the anterior cochlear nucleus. In conclusion, the chances of useful monitoring feedback with adequate adaptation of the microsurgical strategy are improved considerably.
Ventriculofemoroatrial shunt: a viable alternative for the treatment of hydrocephalus
Authors: Philips Matthew F. , Schwartz Steven B. , Soutter Alexander D. , Sutton Leslie N.
Published: June 2009

✓ Children with shunted hydrocephalus often have a myriad of other medical conditions. When these concomitant problems involve the pleura, peritoneum, and/or the venous system, placement of the distal catheter may prove to be problematic. This report presents preliminary results in three hydrocephalic children following ventriculofemoroatrial shunt placement. The peritoneal and pleural cavities in each of these children were compromised and there was no vascular access into the superior vena cava due to intercurrent disease. An alternative technique for ventriculoperitoneal shunt placement was performed via the femoral vein. Fluoroscopic guidance was used to confirm the intraatrial position of the distal end of the shunt catheter. Follow-up review to date shows no complications. This newly described technique provides a feasible alternative to distal shunt catheter placement in patients in whom more traditional sites are unavailable.
A cost-effectiveness analysis of anterior temporal lobectomy for intractable temporal lobe epilepsy
Authors: King Joseph T. , Sperling Michael R. , Justice Amy C. , O'Connor Michael J.
Published: June 2009

✓ Patients with medically intractable temporal lobe epilepsy are potential candidates for anterior temporal lobectomy (ATL), in which epileptogenic temporal lobe tissue is localized and surgically removed. This surgical approach can eliminate or drastically reduce seizures in the majority of patients. The authors used a decision-analysis model to examine the cost-effectiveness of a surgical evaluation and treatment protocol for medically intractable temporal lobe epilepsy. This model compared a cohort treated with the new protocol with a continuation of their immediate preoperative medical management and projected these differences over the patient's lifetime. The Markov model incorporated postoperative seizure status, patient quality of life, death from surgical and natural causes, discounting, and the direct medical costs associated with outpatient evaluation, hospitalization, surgery, antiepileptic drugs, and lifetime outpatient treatment. The intent-to-treat analysis included patients who underwent evaluation but were not eligible for ATL. Sensitivity analyses were also performed on the variables in the model.

Data from the baseline model indicated that evaluation for ATL provided an average of 1.1 additional quality-adjusted life years (QALYs) compared with continued medical management, at an additional cost of $29,800. Combining the clinical and economic outcomes yielded a cost-effectiveness ratio of $27,200 per QALY. This value is comparable to other accepted medical or surgical interventions, such as total knee arthroplasty ($16,700/QALY) or coronary artery balloon angioplasty ($40,800/QALY). Sensitivity analyses demonstrate that the results are critically dependent on postoperative seizure status and improvement in quality of life. Although further work is necessary to quantify the improvement in quality of life after epilepsy surgery better, the present data indicate that ATL for treatment of intractable temporal lobe epilepsy is a cost-effective use of medical resources.
Outpatient surgical treatment of cervical radiculopathy
Authors: Tomaras Christopher R. , Blacklock J. Bob , Parker Warren D. , Harper Richard L.
Published: June 2009

✓ A series of 200 patients who underwent outpatient surgical treatment for cervical radiculopathy is presented. The patients were selected on the basis of their willingness to undergo surgery in the outpatient setting and the absence of serious underlying medical conditions. All operations were performed using general anesthetic techniques with limited posterior dissections. A laminoforaminotomy was performed at each affected level, which had been determined by preoperative imaging and clinical examination. After being observed for several hours, the patients were discharged if they met specific criteria. No patient required subsequent hospital admission in the immediate postoperative period. Follow-up review in 183 patients ranged from 3 to 43 months, with a mean of 19 months. In cases in which Workers' Compensation claims were not involved, 92.8% of patients reported an excellent or good outcome and returned to work or comparable duties at a mean of 2.9 weeks. In cases in which Workers' Compensation claims were involved, 77.8% of patients reported excellent or good outcome and returned to work at a mean of 7.6 weeks postoperatively. Two patients whose cases involved Workers' Compensation claims did not return to work. There were seven patients (3.8%) who had a poor outcome. Two of these patients underwent a second posterior procedure and reported a good outcome at the time of follow-up review. The results of this study show that outpatient surgical treatment of cervical radiculopathy can be safely provided in selected patients with outcomes similar to the inpatient surgical management of these individuals.
Endoscopic microscopic transpedicular thoracic discectomy
Authors: Jho Hae-Dong
Published: June 2009

✓ In an effort to make thoracic discectomy simple and less invasive while using direct visualization, a 70°-angled lens endoscope has been adopted to visualize the ventral aspect of the spinal cord dura mater during microsurgical thoracic discectomy via a transpedicular approach. The patient is positioned in a 60° forwardly inclined lateral position with the side of the lesion facing upward. After radiographic corroboration of the correct level, a transpedicular approach is made using a 1.5-cm-diameter tubular retractor through a 2-cm-long paramedian transverse skin incision. With the aid of an operating microscope, the ipsilateral facet joint, including the upper portion of the pedicle, is removed using a high-speed drill, thus exposing the neural foramen, intervertebral disc, and upper portion of the pedicle leading to the vertebral bodies. When the herniated disc and bone spur have been removed laterally in relation to the spinal cord, creating a cavity under the operating microscope, a 4-mm-diameter rigid endoscope with a 70°-angled lens is mounted to an endoscope holder so that the ventral aspect of the spinal cord dura mater can be visualized directly. With the aid of direct endoscopic visualization, the disc and bone spur, which compress the spinal cord anteriorly, are pushed away toward a cavity created at the intervertebral space and are removed using a downward-biting long-armed curette. Patients with myelopathy are kept overnight in the hospital; however, those with radiculopathy are discharged home on the same day as their operation. The surgical technique and two illustrative cases are reported.
Hemostasis and fibrinolysis activation after subarachnoid hemorrhage
Authors: Peltonen Seija , Juvela Seppo , Kaste Markku , Lassila Riitta
Published: June 2009

✓ The authors assessed hemostasis and fibrinolysis serially: on admission and on the 1st and 7th days after surgery for subarachnoid hemorrhage (SAH), examining the complications of aneurysm rupture and its surgical repair. Of 32 patients, 25 with SAH were compared with seven control patients who underwent surgery for an unruptured intracranial aneurysm. On admission, patients with SAH had higher thrombin-antithrombin III complex (TAT) levels (13.3 ± 3.8 vs. 3.8 ± 0.6 ng/ml, p = 0.01), fibrin degradation product, D-dimer levels (1310 ± 220 vs. 556 ± 89 ng/ml, p = 0.0001), and leukocyte counts (14.6 ± 0.7 vs. 10.6 ± 1.8 × 109 cells/L, p < 0.05) than did control patients. Postoperative D-dimer values (p = 0.007) remained higher in the SAH group. Furthermore, admission D-dimer levels were higher in the patients in poor clinical condition than in those in good condition (2017 ± 377 vs. 934 ± 208 ng/ml, p = 0.007), and D-dimer levels were associated with the outcome at 3 months after admission. Additionally, thrombin generation and fibrinolytic markers measured on admission were related to clinical grade, amount of subarachnoid blood seen on computerized tomography (CT) scanning, and patient fatality. Patients with hypodense lesions verified on follow-up CT scanning or with persistent neurological deficits at 3 months had higher prothrombin fragments 1 and 2, TAT, D-dimer, and plasminogen activator inhibitor-1 values on the 1st day postoperatively than did patients without such lesions. In short, in patients with SAH, activation of coagulation and fibrinolysis was strongly associated with clinical state, patient fatality, and outcome at 3 months, and postoperatively this activation correlated with the development of brain infarction.
Management of primary intracranial germinomas: diagnostic surgery or radical resection?
Authors: Sawamura Yutaka , de Tribolet Nicolas , Ishii Nobuaki , Abe Hiroshi
Published: June 2009

✓ Because intracranial germinomas are readily curable with radiation and chemotherapy or radiation therapy alone, the role of radical surgery has become debatable. This study assesses the optimum degree of surgical resection for intracranial germinomas.

Twenty-nine patients who underwent surgery for germinoma were retrospectively analyzed (male/female ratio 27:2, median age 18 years). Among these 29 patients there were 10 solitary pineal, seven solitary neurohypophyseal/hypothalamic, and 12 multifocal or disseminated tumors. Biopsy samples were obtained in 16 patients (stereotactically in eight, transsphenoidally in four, and via frontotemporal craniotomy in four). Partial resection was attained in five patients (via a frontotemporal approach in three and occipitotranstentorially in two). Gross-total resection was achieved via an occipitotranstentorial route in eight patients with pineal masses. After surgery, 10 patients were treated with radiotherapy alone, and 19 received radiation and chemotherapy; complete remission was achieved in all 29 patients. The overall tumor-free survival rate was 100% at a median follow-up period of 42 months. There was no significant difference in outcome related to the extent of surgical resection. Postoperative neurological improvement was seen in only two patients, whereas transient postoperative complications, mainly upgaze palsy, were observed in six. One patient experienced a slight hemiparesis, bringing the surgical morbidity rate to 3% (one of 29).

It is concluded that radical resection of intracranial germinomas offers no benefit over biopsy. The primary goal of surgery should be to obtain a sufficient volume of tumor tissue for histological examination. If there is strong evidence of germinoma on radiological studies, biopsy samples should be obtained. When a perioperative histological diagnosis of pure germinoma is made during craniotomy, no risk should be taken in continuing the resection.
Surgical management and seizure outcome in patients with tuberous sclerosis
Authors: Avellino Anthony M. , Berger Mitchel S. , Rostomily Robert C. , Shaw C. M. , Ojemann George A.
Published: June 2009

✓ The authors report the results obtained in 11 patients with tuberous sclerosis (TS) who underwent cortical resection surgery for medically intractable epilepsy. Patients' ages at time of surgery ranged from 3 to 46 years (mean 19.6 years). Preoperative epileptiform electroencephalographic abnormalities were focal spike wave discharges in six patients (55%), multifocal in four patients (36%), and generalized in one patient (9%). In the multifocal and generalized groups, all patients (45%) were evaluated by means of subdural grid and strip electrode recordings, whereas electrophysiological localization in the remaining patients was derived from ictal and interictal scalp recordings. The seizure foci were found to be extratemporal in six patients (55%) and temporal in five patients (45%). Surgical intervention consisted of craniotomy and seizure foci resection guided by electrocorticographic monitoring and functional mapping in five awake (45%) and six asleep (55%) patients. Neuropathological examination of the resected seizure foci revealed cortical tubers in eight patients and diffuse gliosis in three patients. Follow up ranged from 8 to 127 months (mean 35 months). Six patients (55%) were seizure free, half of whom were not receiving antiepileptic drugs (AEDs); three patients (27%) had a greater than 70% reduction in seizure frequency, although they required AEDs; one patient (9%) had a 50% temporary reduction in seizure frequency during the initial 6-month postoperative period; and one patient (9%) was lost to follow-up study. From this small but adequately followed patient population with TS, the authors conclude that cortical resection of seizure foci tailored to electrocorticographic findings and functional mapping is encouraging for this difficult to manage patient population with medically intractable epilepsy.
Papillary adenoma of endolymphatic sac origin: a temporal bone tumor in von Hippel—Lindau disease
Authors: Ouallet Jean-Christophe , Marsot-Dupuch Kathlyn , Van Effenterre Remy , Kujas Michele , Tubiana Jean-Michel
Published: June 2009

✓ This report describes a patient with von Hippel—Lindau disease who presented with an 8-year history of a slow-growing, locally invasive vascularized lesion of the temporal bone involving the cerebellopontine angle. The mass, studied by computerized tomography scanning and magnetic resonance imaging techniques, was partly cystic in appearance. After removal of the mass, pathological studies confirmed a papillary cystic tumor with characteristics that have been described in tumors with an endolymphatic sac origin. These rare neoplasms constitute a distinct pathological entity and deserve wider recognition.
Spondyloptotic fracture of the cervical spine in a pregnant, anemic Jehovah's Witness: technical and ethical considerations
Authors: Feigenbaum Frank , Sulmasy Daniel P. , Pellegrino Edmund D. , Henderson Fraser C.
Published: June 2009

✓ The authors present the case of a 15-year-old Jehovah's Witness with a hematocrit level of 19% who was 4 months pregnant and had a two-level spondyloptotic cervical spine fracture. The patient was transferred to Georgetown University Medical Center with C-5 quadriplegia 3 weeks after having been injured in an automobile collision.

The neurosurgical issues in this case included addressing a rare cervical spine injury, assessing and treating a vertebral artery injury, and performing surgery on a pregnant minor with severe anemia who held strong Jehovah's Witness beliefs. An ethics consultation was convened to determine the validity of a pregnant minor's refusal to undergo transfusion on the grounds of her religious beliefs.

This case illustrates the potential benefits of thorough technical and ethical evaluations and reveals how they may contribute to the delivery of care in complex neurosurgical cases.

To the authors' knowledge, this is the first two-level spondyloptotic cervical spine fracture dislocation to be reported in the literature. The added complexities of the case, given that the patient was an anemic, adolescent, pregnant Jehovah's Witness who refused blood transfusion, also appear to be unprecedented.
Hemostasis activation in patients undergoing brain tumor surgery
Authors: Vukovich Thomas C. , Gabriel Adelheid , Schaefer Bruno , Veitl Mario , Matula Christian , Spiss Christian K.
Published: June 2009

✓ Patients undergoing brain tumor surgery are at high risk for the occurrence of a thromboembolic event. To identify a laboratory marker suitable for risk estimation the authors studied the perioperative time pattern of routine coagulation parameters and the specific hemostasis activation marker D-dimer in 28 consecutive patients at high risk (11 patients with glioma and eight patients with meningioma) and low risk (nine patients with metastases) for thromboembolism, as previously reported. As is typical during major surgery, most of the routine parameters declined, probably because of hemodilution, and recovered postoperatively to values higher than baseline, probably because of an acute-phase reaction. On Days 2 and 7 after surgery no difference in the routine parameters was recorded between patients at high (meningioma and glioma) and low risk (metastasis). The level of D-dimer was elevated at baseline in patients with metastasis, indicating a hemostatic hyperactivity that is usual in cancer patients. During surgery a marked increase in D-dimer levels occurred in patients with meningioma and glioma (pre- and postoperative median 90/2000 and 100/1020 ng/ml, respectively), but the increase was less pronounced in patients with metastasis (320/660 ng/ml). Postoperatively, D-dimer declined in patients with metastases to lower than preoperative levels (Day 7, 270 ng/ml); in patients with meningioma or glioma, however, D-dimer levels remained elevated until Day 7 (450 and 200 ng/ml, respectively). These results indicate that levels of Ddimer correlate with the reported high risk for thromboembolism in patients with meningioma and glioma, and D-dimer should be evaluated for its use in estimating individual risk and the efficiency of its use in the control of prophylactic treatment.
Increased choline signal coinciding with malignant degeneration of cerebral gliomas: a serial proton magnetic resonance spectroscopy imaging study
Authors: Tedeschi Gioacchino , Lundbom Nina , Raman Ramesh , Bonavita Simona , Duyn Jeff H. , Alger Jeffrey R. , Chiro Giovanni Di
Published: June 2009

✓ The authors tested the hypothesis that proton magnetic resonance spectroscopy (1H-MRS) imaging can be used as a supportive diagnostic tool to differentiate clinically stable brain tumors from those progressing as a result of low- to high-grade malignant transformation or posttherapeutic recurrence. Twenty-seven patients with cerebral gliomas verified on histological examination were studied repeatedly with 1H-MRS imaging over a period of 3.5 years. At the time of each 1H-MRS imaging study, clinical examination, MR imaging, positron emission tomography with 18F-fluorodeoxyglucose, and biopsy findings (when available) were used to categorize each patient as having either stable or progressive disease. Measures of the percentage changes in the choline (Cho) 1H-MRS imaging signal intensity between studies, which were obtained without knowledge of the clinical categorization, allowed the investigators to segregate the groups with a high degree of statistical significance. All progressive cases showed a Cho signal increase between studies of more than 45%, whereas all stable cases showed an elevation of less than 35%, no change, or even a decreased signal. The authors conclude that increased Cho levels coincide with malignant degeneration of cerebral gliomas and therefore may possibly be used as a supportive indicator of progression of these neoplasms.
Cranial base approaches to posterior circulation aneurysms
Authors: Day J. Diaz , Fukushima Takanori , Giannotta Steven L.
Published: June 2009

✓ Aneurysms arising from the posterior circulation, especially when they are large and complex, continue to present a technical challenge. The development of cranial base strategies and principles has added to surgical management options. The authors used one of four cranial base approaches for the treatment of 30 patients with large and/or complex aneurysms arising from the vertebrobasilar circulation. These approaches included the extradural temporopolar, combined petrosal, retrolabyrinthine—transsigmoid, and the extreme-lateral inferior transtubercular exposure. The indications, technique, and results of each approach in this series are discussed, and a management paradigm is suggested for such aneurysms.
Effect of delayed albumin hemodilution on infarction volume and brain edema after transient middle cerebral artery occlusion in rats
Authors: Belayev Ludmila , Busto Raul , Zhao Weizhao , Clemens James A. , Ginsberg Myron D.
Published: June 2009

✓ The authors examined the effect of delayed high-concentration albumin therapy on ischemic injury in a highly reproducible model of middle cerebral artery (MCA) occlusion in rats. Male Sprague—Dawley rats weighing 270 to 320 g were anesthetized with halothane and subjected to 120 minutes of temporary MCA occlusion induced by means of a poly-l-lysine—coated intraluminal nylon suture inserted retrograde via the external carotid artery into the internal carotid artery and MCA. The agent (20% human serum albumin [HSA]) or control solution (sodium chloride 0.9%) was administered intravenously at a dosage of 1% of body weight immediately after suture removal following a 2-hour period of MCA occlusion. The animals' neurological status was evaluated during MCA occlusion (at 60 minutes) and daily for 3 days thereafter. The brains were perfusion-fixed, and infarct volumes and brain edema were determined. The HSA significantly improved the neurological score compared with saline at 24 hours after MCA occlusion. The rats treated with HSA also had significantly reduced total infarct volume (by 34%) and brain edema (by 81%) compared with saline-treated rats. There was a strong correlation between hematocrit level and brain edema (p < 0.01), and between total infarct volume or brain edema and neurological score at 24, 48, and 72 hours postinjury (p < 0.0002).

These results strongly support the beneficial effect of delayed albumin therapy in transient focal ischemia and indicate its possible usefulness in treating patients with acute ischemic stroke.
Attenuation of brain injury and reduction of neuron-specific enolase by nicardipine in systemic circulation following focal ischemia and reperfusion in a rat model
Authors: Kittaka Mamoru , Giannotta Steven L. , Zelman Vladimir , Correale Jorge D. , DeGiorgio Christopher M. , Weiss Martin H. , Zlokovic Berislav V.
Published: June 2009

✓ reversible middle cerebral artery occlusion was performed in rats to determine whether nicardipine, a dihydropyridine voltage-sensitive Ca++channel (VSCC) antagonist, exerts neuroprotective effects when administered 10 minutes following an ischemic insult, and if it does, whether this is due to its vasodilatory action and effect on cerebral blood flow (CBF) or to direct blockade of Ca++entry into ischemic brain cells. An increase in the intracellular calcium, [Ca++]i, plays a major role in neuronal injury during cerebral ischemia. Although a large amount of Ca++enters neurons through the VSCC during ischemia, inconsistent neuroprotective effects have been reported with the antagonists of the VSCC. An intraperitoneal injection of nicardipine (1.2 mg/kg) was administered to rats 10 minutes after the onset of ischemia, and 8, 16, and 24 hours after occlusion. Cortical CBF was determined by laser-Doppler flowmetry. Neurological and neuropathological examinations were performed after 72 hours. Neuron-specific enolase, a specific marker for the incidence of neuronal injury, was measured in plasma. The CBF and other physiological parameters were not affected by nicardipine during occlusion or reperfusion. However, nicardipine treatment significantly improved motor neurological outcome by 29%, and the infarction and edema volume in the pallium as well as the edema volume in the striatum were significantly reduced by 27%, 37%, and 52%, respectively. Nicardipine also reduced the neuron-specific enolase plasma levels by 50%, 42%, and 59% at 24, 48, and 72 hours after the occlusion, respectively. It is concluded that nicardipine may attenuate focal ischemic brain injury by exerting direct neuroprotective and antiedematous effects that do not depend on CBF.
Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience
Authors: Duke Bryan J. , Ryu Robert K. , Coldwell Douglas M. , Brega Kerry E.
Published: June 2009

✓ Identification of blunt carotid injury prior to the development of ischemic symptoms requires aggressive screening of patients at risk. The treatment of these lesions has centered around long-term anticoagulation therapy. However, studies have revealed that many of these lesions persist despite medical treatment, as does the risk of distal embolization. The authors present a series of six patients who were successfully treated by means of endovascular stent placement for nonpenetrating carotid injuries. In the authors' experience this treatment requires only temporary anticoagulation therapy, results in immediate reconstruction of the injured vessel, obliterates pseudoaneurysms, and prevents distal embolization.
Spinal cord stimulator activation by an antitheft device
Authors: Eisenberg Elon , Waisbrod Hanan
Published: June 2009

✓ The authors present a case in which electrical injury to the central nervous system resulted from uncontrolled activation of a cervical spinal cord stimulation device by an antitheft device. The injury resulted in long-term neurological sequelae.
Modified Tafel Equation for Electroless Metal Deposition
Authors: Gorker Lev , Dimitrov Vasili
Published: June 2009

The concept of the Dynamic Electrical Double Layer (DEDL) is the physicochemical basis for electrochemical processes that proceed without an external source of current (electroless processes). The most characteristic feature of such processes is that they proceed only in an oscillation regime, with the anodic processes of electrode charging and the cathodic processes of its discharging alternating periodically at maximum values of the stationary electrode potential (the phenomenon of overpotential).

The DEDL model enables full account to be taken of this specific feature (adsorption and a heterogeneous chemical reaction at the anodic stage of the process and subsequent deposition of the metal in the cathodic stage) and the process to be described from a unified standpoint. In the framework of the DEDL model, the autocatalytic process of metal coating deposition depending on process conditions is described by modified Nernst or Tafel equations, which enable direct computation of both the values of the oscillating stationary electrode potential and of the characteristics of metal deposition (thickness and weight of the coating) by the kinetic dependence of “electrode potential vs time”.

It is demonstrated that both the modified Tafel equation for exchange current density (oscillation regime of the stationary electrode potential in electroless processes) and its classical interpretation for systems with constant values of the stationary electrode potential are particular cases of the Volmer – Butler equation.
1,10-Phenanthroline-Catalysed Cr(Vi) Oxidation of D-Sorbitol and D-Mannitol in Aqueous Micellar Media
Authors: Bayen Ruhidas , Das Asim K.
Published: June 2009

Chromic acid oxidation of two polyols (D-sorbitol and D-mannitol) to their corresponding aldohexoses in the presence of phenanthroline (phen) involves as the active oxidant, a Cr(VI)-phen complex formed in a rapid pre-equilibrium step. The observed micellar effect (rate acceleration by an anionic surfactant and rate retardation by a cationic surfactant) conforms with the proposed reaction mechanism.