bluuebunny/crossref_metadata_2025 huggingface dataset:
Brain Biopsy in Tuberculoma: The Risks and Benefits
Authors: Bouchama A. , Al-Kawi M. Zuheir , Kanaan I. , Coates R. , Jallu A. , Rahm B. , Siqueira E. B.
Published: April 2011

In developing countries, 5 to 8% of the space-occupying lesions of the central nervous system are tuberculomas. Diagnosis can be difficult in the absence of extracranial tuberculosis; computed tomography is suggestive only. To assess the value of brain biopsies in tuberculomas, the records of 15 patients aged 6 to 80 years were reviewed. Histological confirmation was obtained in 15 patients, and acid-fast bacilli were cultured from 12 patients. Intracranial hypertension was the principal sign in 11 patients; other neurological signs were related to the location of the tuberculoma. One patient had evidence of extracranial tuberculosis. Biopsy-related complications consisted of an epidural hematoma in 1 patient and hydrocephalus in another; both required additional surgery. One case of tuberculous meningitis was probably related to surgery and poor drug compliance. There was no postoperative mortality. Thirteen patients (2 were lost to follow-up) were cured after an average of 16 months of antituberculous therapy. It was concluded that the brain biopsy is useful in diagnosing tuberculoma but that there is some associated risk.
Results of Transsphenoidal Extirpation of Craniopharyngiomas and Rathke's Cysts
Authors: Landolt Alex M. , Zachmann Milo
Published: April 2011

Fourteen patients undergoing transsphenoidal extirpation of craniopharyngiomas or Rathke's cysts underwent endocrinological evaluation before and after surgery. One patient died during the procedure because of uncontrollable arterial bleeding. The other patients were followed for up to 16 years (average, 8.5 years). One patient had recurrence of tumor 12 years after surgery. Another patient, the only one operated on because of a recurrent craniopharyngioma after previous radiation therapy, died 2 years after the transsphenoidal operation. No patient recovered pituitary functions that had been lost before surgery. One patient, who had an isolated growth hormone deficiency, and another, who had panhypopituitarism with sustained antidiuretic hormone secretion, had no change postoperatively from their preoperative endocrine status. The other 11 patients lost pituitary function and required pharmacological replacement of one to four pituitary hormones.
Cervical Spine Diastematomyelia in Adulthood
Authors: Rawanduzy Ahmed , Murali Raj
Published: April 2011

Adult cervical diastematomyelia is a rare malformation and is usually associated with posterior element anomalics. A case of isolated cervical diastematomyelia, which was initially thought to be a herniated cervical disc. is described. Diagnosis and surgical management are discussed.
New Aneurysm Clip Appliers for “Key-Hole” Neurosurgery
Authors: Solomon Robert A. , Fukushima Takanori
Published: April 2011

A new set of aneurysm clip appliers has been developed to overcome many of the obstacles to safe clipping of complex intracranial aneurysms. The applier set consists of six units, each one delivering clips at a different specified angle to the applier shaft. These appliers have been independently tested on over 250 aneurysm operations and found to be of great utility.
Second Operation after the Failure of Previous Resection for Epilepsy
Authors: Awad Issam A. , Nayel Mohamad H. , Lüders Hans
Published: April 2011

We present our surgical experience with second operations in 15 patients with recurrent intractable partial seizures after resection for epilepsy. The interval from the first operation until the first recurrence of seizures ranged from 1 day to 7 months (mean, 62 days);. The interval between the first and second operations ranged from 3 months to 12 years (mean, 38 months);. Detailed video-electroencephalographic interictal and ictal recording was performed in all patients (invasive electrodes were used in 11 patients);. Ictal onset was shown to be remote from the zone of previous resection in 3 of 15 cases (all 3 extratemporal and in the ipsilateral hemisphere);. Recurrent seizures arose from the area of previous extratemporal resection in 2 of 15 patients, and from the area of previous temporal resection in 10 of 15 patients. Both cases of extratemporal recurrences and 3 of the 10 cases of temporal lobe recurrences in the area of previous resection were associated with residual unresected structural lesion. Of the 10 patients with local temporal recurrence, 6 had proven epileptogenicity in the residual mesial structures, and 4 had residual epileptogenicity in the unresected lateral temporal lobe. The patients have been monitored for 8 to 82 months (mean, 18 months); after the second operation: 7 patients (47%); have remained seizure-free and another 5 (33%); have achieved a reduction in seizure frequency of more than 90%. There was no mortality or significant morbidity in this series. We conclude that the extent and distribution of residual epileptogenicity after failed epilepsy surgery are highly variable. Recurrent intractable seizures usually (but not always); arise from the area of previous resection, and reflect residual structural lesions or epileptogenic foci. Individualized second operations can be safe and effective, and may provide selected patients with “failed cases” another chance at seizure control. Patient selection and the technical aspects of remapping and second operations are discussed.
The Thalamogeniculate Perforators of the Posterior Cerebral Artery: The Microsurgical Anatomy
Authors: Milisavljević Milan M. , Marinković Slobodan V. , Gibo Hirohiko , Puškaš Laslo F.
Published: April 2011

The thalamogeniculate (TG); arteries of 30 forebrain hemispheres were examined. These vessels varied from 2 to 12 in number (mean, 5.7);, and from 70 to 580 μm in caliber (mean, 345.8 μm);. The average caliber of all the TG vessels per posterior cerebral artery ranged from 700 to 3400 μm (mean, 1972 μm);. The TG arteries most often originated as individual vessels; however, in 26.67% of the hemispheres examined they shared a common site of origin, and 33.33% of the hemispheres they arose from common stems. The common stems ranged from 320 to 800 μm in diameter (mean, 583 μm);. The TG branches arose from the crural or ambient (P2); segment of the posterior cerebral artery in 80% of the hemispheres, from the P2 and the quadrigeminal (P3); segment in 20%, from both the distal segment of the posterior cerebral artery and the common temporal artery (13.33%);, or from the distal segment and either the calcarine (3.33%); or parieto-occipital artery (3.33%);. The TG arteries usually penetrated the medial geniculate body (100%);, pulvinar thalami (80%);, brachium of the superior colliculus (53.33%);, or lateral geniculate body (13.33%);. The collateral branches of the TG arteries were noted to reach the medial geniculate body (76.67%);, pulvinar (70%);, brachium of the superior colliculus (40%);, crus cerebri (40%);, and lateral geniculate body (6.67%);. The anastomoses were present in 66.67%, usually between the TG vessels and the medial posterior choroidal artery (33.33%);, or the mesencephalothalamic artery (26.67%);. They ranged in number from 1 to 3 (mean, 1.2);, and in caliber from 90 to 400 μm (mean, 197 μm);. In spite of the anastomoses, the TG arteries must be spared during surgery within the ambient cistern.
Progressive Deterioration of Auditory Evoked Potentials after Excision of an Acoustic Neurinoma: Case Report
Authors: Sekiya Tetsuji , Iwabuchi Takashi , Takiguchi Masahiro , Ichijo Hiroaki , Sasaki Hitoshi
Published: April 2011

The authors report the case of a 17-year-old girl who underwent excision of bilateral neurinomas of the cerebellopontine angle. Although her auditory evoked potentials were well maintained during the operation, they deteriorated gradually and progressively for the following 2 months. This seemed to reflect degeneration of the cochlear nerve fibers initiated by operative manipulation in the cerebellopontine angle in a patient who had no hearing when she awoke from surgery.
Intracranial Arteriovenous Fistula Manifesting as Progressive Neurological Deterioration in an Infant: Case Report
Authors: Aoki Nobuhiko , Sakai Tatsuo , Oikawa Akihiro
Published: April 2011

This 1-year-old male infant had been diagnosed with cerebral degenerative disease because he developed psychomotor regression, and brain atrophy was demonstrated on computed tomography. He underwent magnetic resonance imaging, which suggested a cerebrovascular malformation. Cerebral angiography disclosed an arteriovenous fistula, fed by an anterior cerebral artery and directly draining into a cortical vein. The occlusion of the feeding artery was followed by a satisfactory recovery. The mechanism of the neurological symptoms in this patient is thought to be caused by a steal phenomenon and compression of the brain stem by venous engorgement in the posterior fossa.
Posterior Fossa Ependymomas: Report of 30 Cases and Review of the Literature
Authors: Lyons Mark K. , Kelly Patrick J.
Published: April 2011

Thirty patients with histologically confirmed posterior fossa ependymomas operated on between January 1976 and December 1988 were reviewed. The median age was 44 years (range, 1-69 yr). There were 7 children (aged 5 yr or younger) and 23 adults (aged 16 yr or older). There were 18 female patients and 12 male patients. Headache, nausea and vomiting, and disequilibrium were the most frequent symptoms. The most common findings were ataxia and nystagmus. Gross total resection was performed in 8 patients (27%), subtotal resection in 21 patients (70%), and biopsy in only 1 patient (3%), Tumors were low grade in 73% and high grade in 27%. Twenty-seven patients underwent posterior fossa radiotherapy (median dose, 5400 cGy). Fourteen patients also underwent spinal irradiation (median dose, 3520 cGy). Age was the only significant prognostic factor identified (P <0.01). The 5-year survival rates were 76% for adults and 14% for children. All 14 patients who died had recurrent or residual tumor at the primary site. This review suggests that in patients with primary posterior fossa ependymomas the following is true: 1) the young patient (5 yr old or younger) has a poor prognosis: 2) there was a trend toward a better 5-year survival rate with a gross total resection; 3) if recurrence occurs, it will be at the primary intracranial site; and 4) symptomatic spinal seeding does not occur frequently.
Cervical Spondylotic Myelopathy: Treatment with Posterior Decompression and Luque Rectangle Bone Fusion
Authors: Maurer Paul Kurt , Ellenbogen Richard G. , Ecklund James , Simonds Gary R. , van Dam Bruce , Ondra Stephen L.
Published: April 2011

Cervical spondylotic myelopathy appears to result from a combination of factors. The two major components are 1) compressive forces resulting from narrowing of the spinal canal, and 2) dynamic forces owing to mobility of the cervical spine. There is substantial evidence to suggest that the repetitive trauma to the spinal cord that is sustained with movement in a spondylotic canal may be a major cause of progressive myelopathy. Utilization of extensive anterior procedures that remove the diseased ventral features as well as eliminate the dynamic forces owing to the accompanying fusion have grown in popularity. Cervical laminectomy enlarges the spinal canal, but does not reduce the dynamic forces affecting the spinal cord, and may actually increase cervical mobility, leading to a perpetuation of the myelopathy. The authors propose the combination of posterior decompression and Luque rectangle bone fusion to deal with both the compressive and the dynamic factors that lead to cervical spondylotic myelopathy. Ten patients who had advanced myelopathy underwent the combined procedures. Nine of the 10 experienced significant neurological improvement, and the 10th has had no progression. The combination of posterior decompression and Luque rectangle bone fusion may offer a simple, safe, and effective alternative treatment for cervical spondylotic myelopathy.
Use of Intrathecally Administered Morphine in the Treatment of Postoperative Pain after Lumbar Spinal Surgery: A Prospective, Double-Blind, Placebo-Controlled Study
Authors: Ross Donald A. , Drasner Kenneth , Weinstein Philip R. , Flaherty John F. , Barbaro Nicholas M.
Published: April 2011

Improved control of postoperative pain is now known to reduce the incidence of morbidity. Although spinally administered narcotics have found a clear role in chest and abdominal surgery, their role in lumbar spinal surgery is debated. We conducted a prospective, double-blind, randomized, placebo-controlled trial of intrathecally administered morphine sulfate after lumbar spinal surgery in 56 patients. Patients received 0, 0.125, 0.25, or 0.5 mg of intrathecally administered morphine during extradural lumbar spinal operations, and the effects on postoperative analog pain scores, narcotic consumption, complications, and length of hospitalization were assessed. As compared with systemic narcotic administration, intrathecally administered morphine provided superior analgesia in a dose-dependent fashion without an increase in narcotic side effects. Consumption of parenteral narcotics on the first postoperative day and over the total hospitalization period decreased in correlation with increasing doses of intrathecally administered morphine. Mean length of hospitalization was significantly decreased, as compared with the control group, in patients receiving 0.25 or 0.5 mg of intrathecally administered morphine. When proper precautions are observed, intrathecally administered morphine can improve the postoperative care of patients undergoing lumbar spinal surgery.
Giant Pseudoaneurysm of the Extracranial Vertebral Artery Successfully Treated Using Intraoperative Balloon Catheters
Authors: Hanakita Junya , Suwa Hideyuki , Nishihara Kiyoshi , Iihara Koji , Sakaida Hiroshi
Published: April 2011

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.
Positron Emission Tomography of Pituitary Macroadenomas: Hormone Production and Effects of Therapies
Authors: Francavilla Thomas L. , Miletich Robert S. , De Michele Dominic , Patronas Nicholas J. , Oldfield Edward H. , Weintraub Bruce D. , Di Chiro Giovanni
Published: April 2011

Positron emission tomography with [18F]fluorodeoxyglucose (FDG) was carried out in 24 patients with pituitary macro-adenomas (32 studies) to assess the glucose utilization of these tumors in vivo. The adenoma metabolic index, which is the ratio of FDG uptake of tumor to a whole brain slice, was calculated. Comparisons were made between tumor uptake of FDG and hormone secretion and response to therapies. In each positron emission tomography study, the macroadenoma could be easily identified visually as an area of increased FDG uptake near the region of the sella. FDG uptakes were highest for nonfunctional adenomas, and the prolactin, growth hormone, and thyroid-stimulating hormone-producing groups displayed similar levels of glucose metabolism. The adenoma metabolic index for all tumors averaged 1.3, ranging from 0.3 for a thyroid-stimulating hormone adenoma to 3.5 for a nonfunctional tumor. Tumors did not exhibit metabolic rates that could characterize the type of hormone produced. Recurrent macroadenomas displayed metabolism similar to tumors not operated on, whereas irradiated adenomas showed lower glucose uptake than nonir-radiated tumors. Drug therapy with bromocriptine or the long-acting somatostatin analogue octreotide also decreased the glucose utilization of the tumor. There was no correlation between the amount of hormone produced and the adenoma metabolic index when a group of tumors was analyzed. Patients scanned more than once, however, demonstrated changes in hormone levels that changed or did not change in parallel with tumor metabolism. Thus, positron emission tomography offers the potential capability for predicting and defining the growth of pituitary adenomas. This may be of particular value when plasma hormone assays and conventional imaging techniques prove inadequate for monitoring patient response to therapy.
The Mermaid Malformation: Cloacal Exstrophy and Occult Spinal Dysraphism
Authors: Cohen Alan R.
Published: April 2011

Five infants with cloacal exstrophy underwent neurological evaluation and radiographic examination of the caudal spine shortly after birth. Each was found to have occult spinal dysraphism. Four had terminal myelocystoceles, and one had a lipomyelomeningocele. Pathological anatomy was confirmed during surgery for the release of the tethered spinal cords. The striking association between cloacal exstrophy and occult spinal dysraphism suggests a common developmental defect in the caudal pole of the embryo. A hypothesis is offered to explain this association. Terminal myelocystocele and lipomyelomeningocele appear to be part of a continuum of lesions associated with skin-covered spina bifida.
Transoral Decompression Evaluated by Cine-Mode Magnetic Resonance Imaging: A Case of Basilar Impression Accompanied by Chiari Malformation
Authors: Tominaga Teiji , Koshu Keiji , Ogawa Akira , Yoshimoto Takashi
Published: April 2011

Cine-mode magnetic resonance imaging provides simultaneous images of cerebrospinal fluid flow dynamics. A patient with a basilar impression accompanied by a Chiari malformation and von Recklinghausen's disease who underwent transoral decompression is reported. Preoperative cine-mode magnetic resonance imaging visualized an associated obstruction of cerebrospinal fluid pulsatile flow at the level of the foramen magnum. Tonsilar herniation (Chiari I malformation) and hydrocephalus were also present. Postoperatively, the obstruction of cerebrospinal fluid flow was resolved concomitant with the correction of the cervicomedullary angulation. On the basis of observations made by magnetic resonance imaging, the surgical treatment of basilar impression accompanied by Chiari malformation is briefly discussed.
Arachnoid Cyst of the Cerebellopontine Angle Manifesting as Contralateral Trigeminal Neuralgia: Case Report
Authors: Babu Ramesh , Murali Raj
Published: April 2011

A case of an arachnoid cyst in the cerebellopontine angle manifesting as contralateral trigeminal neuralgia is presented. Decompression and excision of the lesion resulted in total relief of symptoms. The possible causes of contralateral trigeminal neuralgia are briefly reviewed, and the surgical treatment of this entity is discussed.
Transoral Crossbow Injury to the Cervical Spine: An Unusual Case of Penetrating Cervical Spine Injury
Authors: Salvino Christopher K. , Origitano T. C. , Dries David J. , Shea John F. , Springhorn Mary , Miller Charles J.
Published: April 2011

The complexity of missile injuries to the cervical spine has increased as the technology that causes these injuries has become more sophisticated. Management requires adaptation of conventional neurosurgical approaches to the cervical spine in an effort to limit neurological deficit and establish stability. We report an unusual case of a 19-year-old man who suffered transoral penetration of the cervical spine by an arrow released by a crossbow at close range.
Successful Management of an Adult Lightning Victim Using Intracranial Pressure Monitoring
Authors: Lehman L. B.
Published: April 2011

Serious central nervous system injuries after lightning strikes are fortunately rare. Optimal neurological and neurosurgical management has not been firmly established. We describe the successful neurological resuscitation and critical care management using intracranial pressure monitoring of an adult who sustained a lightning strike. The role of intracranial pressure monitoring in this setting is discussed.
Civilian Craniocerebral Gunshot Wounds
Authors: Benzel Edward C. , Day William T. , Kesterson Lee , Willis Brian K. , Kessler Charles W. , Modling Denise , Hadden Theresa A.
Published: April 2011

Experience with 120 patients who incurred a gunshot wound to the head with dural penetration is presented. All of the patients were managed by a standard resuscitation protocol and assigned a clinical grade based on their level of consciousness both at the time of presentation and at 2 to 4 months after injury. Fifty patients (42%) underwent surgery. Twenty-eight patients (23%) had a good recovery, 19 (16%) were moderately disabled, 6 (5%) were severely disabled, and 67 (56%) died. All patients who were alert and awake with a normal or near normal neurological examination at the time of admission survived with a good outcome. All but 4 patients who were comatose at the time of admission died. Nine patients, however, who were not comatose at the time of admission died from potentially preventable causes. In 3 of these patients, a more aggressive diagnostic approach (including cerebral angiography) may have altered their ultimate outcome. An expeditious approach to the trauma victim with a comprehensive management scheme after injury may have altered the course in the remainder of these patients. (Neurosurgery 29:67-72, 1991)
Ossifying Fibroma in the Sylvian Fissure: Case Report
Authors: Kamei Yoshifumi , Kanno Tetsuo , Abe Masato
Published: April 2011

A rare case of an ossifying fibroma that developed in the sylvian fissure is reported here. During surgery, branches of the middle cerebral artery were encased in osseous tumor. The encased branches were divided and reanastomosed after the mass was removed. Postoperative angiograms demonstrated patency of the anastomosed arteries and a postoperative magnetic resonance imaging scan revealed no infarction distal to the arterial anastomoses. The authors recommend division and anastomosis of the encased arteries rather than partial removal of tumor from around the encased arteries, resulting in residual tumor being left behind. (Neurosurgery 29:120-123, 1991)
Transfalcine Approach to a Callosomarginal Artery Aneurysm
Authors: Ellenbogen Richard G. , Scott Michael R.
Published: April 2011

We describe a transfalcine approach to clipping and subsequently excising an expanding mycotic callosomarginal aneurysm. The patient had a devastating dominant (left) hemispheric spontaneous intracranial hemorrhage and was neurologically improving at the time of surgery nearly 2 months later. To avoid retracting the left hemisphere, we approached this left callosomarginal aneurysm from the nondominant side through the falx. The approach was straightforward, and the result was satisfactory. (Neurosurgery 29:140-143, 1991)
Association of Hypovolemia after Subarachnoid Hemorrhage with Computed Tomographic Scan Evidence of Raised Intracranial Pressure
Authors: Nelson Richard J. , Roberts Jane , Rubin Caroline , Walker Valerie , Ackery Duncan M. , Pickard John D.
Published: April 2011

Hypovolemic patients are more likely to suffer delayed cerebral ischemia and infarction after a subarachnoid hemorrhage (SAH). Prompt recognition and correction of hypovolemia may improve the outcome. We have identified computed tomographic (CT) scan findings that increase the probability of a patient presenting with hypovolemia soon after an SAH. The plasma volume (PV) of 25 patients admitted within 96 hours of an SAH was measured using radioiodinated serum albumin. The normal PVs were measured in an outpatient setting 6 months later or predicted from their total body water. Nine patients (36%) were found to be hypovolemic, defined as a fall in PV exceeding 10% of the normal PV (mean fall, 18 ± 2%). Sixteen patients were normovolemic or hypervolemic (mean PV, + 9 ± 2%). The basal cisterns were compressed or obliterated on the CT scans of all hypovolemic patients compared with 12.5% of normovolemic patients (chi-square, 14.52; P < 0.01). The probabilities of a patient being hypovolemic if the CT scan indicated raised intracranial pressure were high: hydrocephalus, P = 0.80; compression of the basal cisterns, P = 0.82; and compression of the basal cisterns associated with intracerebral hematoma or midline shift, P = 1.00. Patients with an SAH and radiological evidence of raised intracranial pressure should be considered at particular risk for systemic hypovolemia.
Intracanalicular Acoustic Neurinomas
Authors: Samii Madjid , Matthies Cordula , Tatagiba Marcos
Published: April 2011

The cases of 16 patients with acoustic neurinomas confined to the intracanalicular area are presented. These represent 2.7% of the 600 patients with acoustic neurinomas consecutively operated upon at the Neurosurgical Clinic at Nordstadt Hospital during the last 8 years. The comparatively earlier onset of vestibular symptoms and signs was characteristic of this group and precipitated diagnosis. The diagnostic reliability of magnetic resonance imaging was at least equivalent to that of air computed tomographic cisternography. Complete tumor removal was accomplished via the suboccipital approach in all patients, with 100% preservation of facial nerve and facial function; the cochlear nerve was preserved anatomically in 100% of the patients and functionally in 57%. No recurrence has occurred during follow-up periods of up to 8 years in all 16 patients. A broad spectrum of the current literature is considered, and purely intracanalicular acoustic neurinomas are discussed with regard to clinical characteristics, diagnostic steps—including neuroradiological and neurophysiological approaches—and surgical treatment and results.
Long-Term Effects of Radiotherapy and Bromocriptine Treatment in Patients with Previous Surgery for Macroprolactinomas
Authors: Moberg Erik , af Trampe Eva , Wersäll Jan , Werner Sigbritt
Published: April 2011

The long-term effect of radiotherapy and bromocriptine treatment was retrospectively evaluated in 25 patients who had previously undergone transsphenoidal surgery for treatment of macroprolactinomas. Surgery had reduced the median serum prolactin (PRL) value from 613 Mg/l to 291 Mg/l, a reduction of 53%. Postoperative bromocriptine was administered to 21 of the 25 patients. In 14 of these patients, serum PRL values became normal or almost normal with medication. There were no radiological or ophthalmological signs of progressive tumor growth during bromocriptine treatment. Fourteen patients received postoperative radiotherapy. After withdrawal of bromocriptine in 13 of these patients an average of 7 years after radiotherapy, the median serum PRL value had further decreased by 95%. The PRL reduction was similar for all doses applied, 38 to 52 Gy. After withdrawal of bromocriptine in 8 patients not receiving radiotherapy an average of 7 years after operation, the median serum PRL level had further decreased by 75%. At follow-up, 18 additional instances of pituitary insufficiency had developed in the group receiving radiotherapy, compared with 8 cases of insufficiency in the group not receiving radiotherapy. Thus, because bromocriptine has a long-standing effect on prolactin secretion, and radiotherapy is associated with a notably high incidence of pituitary insufficiency, we propose that photon irradiation should be considered mainly for patients who are not candidates for surgical or medical treatment.
Pachymeningitis Associated with a Pulmonary Nodule
Authors: Adler John R. , Sheridan William , Kosek Jon , Linder Steven
Published: April 2011

The authors report a case of hypertrophic pachymeningitis, a rare cause of spinal cord compression. In this patient, dural inflammation was associated with a histologically identical pulmonary lesion. Such an association has not been described previously and supports the hypothesis that this disease is related to other connective tissue disorders.
Treatment of Cerebral Arteriovenous Malformations with a Combination of Preoperative Embolization and Surgery
Authors: Pasqualin Alberto , Scienza Renato , Cioffi Fabrizia , Barone Giovanni , Benati Aldo , Beltramello Alberto , Da Pian Renato
Published: April 2011

Forty-nine patients with cerebral arteriovenous malformations (AVMs) were treated with preoperative embolization followed by resection using a microsurgical approach. In 27 patients, the AVM was located in an eloquent area; in 32 patients, the volume of the AVM was over 20 cm3. Preoperatively, flow-directed embolization was performed in 10 patients (28 procedures), selective embolization with threads was performed in 35 patients (46 procedures), and a combination of flow-directed and selective embolization was performed in 4 patients (12 procedures). The percentage of reduction of the AVM volume averaged 36% after embolization. Five minor complications (transient neurological deficits, in 2 cases associated with ischemic areas on the CT scan) were observed after embolization. The interval between the last embolization and surgery was as follows: within 10 days in 7 patients; between 11 and 20 days in 3 patients; between 21 and 30 days in 10 patients; between 31 and 60 days in 11 patients; and 2 months later in 18 patients. The efficacy of this combined treatment (embolization plus surgery) was evaluated by the incidence of hyperemic complications and the clinical outcome. Hyperemic complications occurred more frequently in patients with an AVM volume greater than 20 cm3. When compared with flow-directed embolization, selective embolization was linked with decreased bleeding during surgery; postoperatively, the incidence of cerebral edema was also lower. Clinical outcome was better after selective embolization, with no occurrence of major deficits and no mortality. When the percentage of reduction of the AVM volume after embolization was 40% or more, the incidence of intraoperative hyperemic complications was lower; moreover, new permanent deficits were never observed in patients with this volume reduction. A retrospective clinical comparison of two groups of patients with similar AVM volumes (>20 cm3)—those given combined treatment (n = 32) versus those treated by direct surgery alone (n = 27)—showed that intraoperative bleeding appeared to decrease in patients treated by embolization; the incidence of postoperative hyperemic complications was not different in the two groups. New major deficits and deaths were less frequent in patients treated by embolization (P= 0.05 for the incidence of major deficits); postoperative epilepsy was also less common in these patients. In conclusion, combined treatment with selective preoperative embolization and direct surgery may help the neurosurgeon in the treatment of large, high-flow AVMs, reducing the risks connected with their surgical removal. (Neurosurgery 29:358-368, 1991)
Brachytherapy: A Viable Alternative in the Management of Basal Meningiomas
Authors: Kumar Pradeep P. , Patil Arun A. , Leibrock Lyal G. , Chu Wei-Kom , Syh Joseph , McCaul Gayle F. , Reeves Michael A.
Published: April 2011

Thirteen patients with intracranial meningiomas of the skull base were treated with one or more high-activity iodine-125 seeds. In 11 patients, the seeds were implanted stereotactically under local anesthesia. A minimum dose of 100 to 500 Gy was delivered to the tumor at a dose rate of 5 to 25 cGy/h. Indications for this procedure included recurrence after initial surgery or as the primary modality of treatment in patients who were not candidates for surgery. All 13 patients are alive at a median follow-up of 15 months. Nine of 11 patients (82%) without calcification in their meningiomas achieved complete response. The remaining 4 patients-2 with calcification and 2 without-achieved partial response. No early or late complications were observed. We conclude from our experience that both recurrent and primary meningiomas of the skull base can be treated effectively with permanent iodine-125 brachytherapy.
Continuous Monitoring of Cerebral Oxygenation in Acute Brain Injury: Assessment of Cerebral Hemodynamic Reserve
Authors: Cruz Julio , Miner Michael E. , Allen Steven J. , Alves Wayne M. , Gennarelli Thomas A.
Published: April 2011

A new index of cerebral hemodynamics, cerebral hemodynamic reserve (CHR), was evaluated in 12 comatose adults with severe, acute, traumatic, diffuse swelling of the brain, who underwent continuous monitoring with a fiberoptic catheter of the saturation difference in arteriojugular oxyhemoglobin. CHR was assessed as the ratio of changes in global cerebral oxygen extraction to changes in cerebral perfusion pressure (CPP) as a result of spontaneous increases in intracranial pressure (ICP). During the course of hyperventilation (Pco2 in the range of 20 mm Hg) for ICP control below 20 mm Hg. 34 observations were made over the initial 48 hours postinjury. Despite normal CPP. in 25 of the observations (73.5%). ICP elevations to the range of 20 mm Hg were associated with compromised CHR. as evidenced by decreases in jugular oxygenation directly attributed to the ICP increases. In the remaining nine observations (26.5%). CHR was preserved, as evidenced by no changes or increases in jugular oxygenation when ICP increased. The CHR improved on the second day. suggesting an improved tolerance of the cerebral hemodynamics to ICP increases. Before the ICP elevations, in most of the observations, the global cerebral blood flow was estimated as being optimally decreased (by hypocapnia). in relation to cerebral oxygen consumption. This was reflected by the occurrence of baseline normalized cerebral oxygen extraction. It is concluded that in this group of patients, under circumstances of profound hyperventilation. ICP elevations within the normal CPP range may result in decreased cerebral oxygenation, even when the normal CPP would imply otherwise. It is suggested that CHR assessment may provide information regarding the status of intracranial “tightness.” insofar as cerebral circulation and oxygenation are concerned.
Spinal Cord Compression Complicating Subarachnoid Infusion of Morphine: Case Report and Laboratory Experience
Authors: North Richard B. , Cutchis Protagoras N. , Epstein Jonathan A. , Long Donlin M.
Published: April 2011

The intraspinal administration of morphine has been employed increasingly in the management of intractable pain of malignant as well as benign origin. We have encountered a previously unreported clinical complication: spinal cord compression by an inflammatory tissue mass surrounding a subarachnoid infusion catheter administering morphine. leading to paraplegia. The patient was referred to our institution after catheter and pump implantation for chronic, intractable pain associated with pre-existing lumbar arachnoid fibrosis, after multiple myelograms and surgeries. The patient may. therefore, have had an underlying propensity to foreign body reactions. We have encountered a similar phenomenon, however, in a canine laboratory model. The pathological features in both our patient and our laboratory preparation, with inflammatory tissue masses around the tip of the catheter but not around proximal subarachnoid segments, suggest an effect related to infusion. as opposed to infection or the presence of the catheter. We review the pathological features in both settings and the pertinent literature.
Cerebrospinal Fluid Shunting for Hydrocephalus in the Adult: Factors Related to Shunt Revision
Authors: Puca Alfredo , Anile Carmelo , Maira Giulio , Rossi Gianfranco
Published: April 2011

Cerebrospinal fluid shunting procedures are widely employed in the treatment of hydrocephalus and other disturbances of the dynamics of cerebrospinal fluid. In spite of its popularity, this operation frequently requires surgical revision. A retrospective analysis of a series of 356 adults who underwent the insertion of a cerebrospinal fluid shunt between January 1970 and December 1988 was performed. The incidence of revision was analyzed, and an attempt was made to identify possible causal factors. The overall incidence of surgical revisions was 28.65%; the number of revisions in the same patient ranged between one and eight. The most frequent causes of revision were distal malposition, obstruction, and infection. A statistically significant difference (P < 0.05) was found in both the risk of revision in patients who had undergone previous operations and those who had not and in the incidence of revision before and after January 1985. Meticulous surgical technique as well as perioperative antibiotic prophylaxis appear responsible for the latter. The differences in the incidence of revision among patients treated with different types of shunts and valves, though remarkable, is not statistically significant.
Pregnancy in Patients with Cerebrospinal Fluid Shunts: Report of a Series and Review of the Literature
Authors: Wisoff Jeffrey H. , Kratzert Kristen J. , Handwerker Sara M. , Young Bruce K. , Epstein Fred
Published: April 2011

Hydrocephalic women with cerebrospinal fluid shunts are now surviving to reproductive age. Twenty-one pregnancies in 18 patients with shunts, including 11 from the present series and 10 from previous series, were analyzed for neurological, obstetrical, and perinatal outcome. Fourteen women had preexisting shunts, and 4 had the onset of symptomatic hydrocephalus and the placement of shunts during pregnancy. Neurological complications occurred in 13 of 17 (76%) pregnancies in patients with preexisting shunts, including symptoms of increased intracranial pressure (ICP) in 10 of 17 (59%) pregnancies, exacerbation of seizure disorder in 2 of 17 (12%) pregnancies, and severe headaches without increased ICD in 1 patient. In 7 of 11 (66%) of the symptomatic patients, symptoms spontaneously resolved postpartum. Four of 17 (23%) of these pregnancies were associated with shunt obstruction requiring antepartum or postpartum surgery. Four patients had a primary shunt placement, and one had a shunt revision during pregnancy without complications. There were no unusual obstetrical or perinatal complications in the series. The clinical management of pregnant patients with hydrocephalus should include preconception counseling and magnetic resonance imaging, as well as the use of serial antenatal magnetic resonance images, ICP monitoring, or the judicious use of radioisotope studies of shunt patency if signs of increased ICP appear. A cesarean section is recommended for the delivery of the neurologically unstable patient. For asymptomatic mothers, a vaginal delivery with a shortened second stage and prophylactic antibiotics are advised.
A Ventricular Infusion Technique for the Evaluation of Treated and Untreated Hydrocephalus
Authors: Morgan Michael K. , Johnston Ian H. , Spittaler Peter J.
Published: April 2011

Patients considered to have a possible disorder of the circulation of the cerebrospinal fluid (CSF) were prospectively randomized on clinical and computed tomographic grounds into one of four categories: low probability of a disorder of circulation of the CSF (n = 14); high probability of a disorder of the circulation of the CSF (n = 10); low probability of shunt malfunction (n = 10); and high probability of shunt malfunction (n = 9). Patients with possible disorders of the circulation of the CSF who did not meet the entry criteria for each of these categories were excluded from this study. A ventricular catheter connected to a subgaleal Rickham reservoir not in continuity with a shunt system (if this was present) either was inserted into each patient or was in place from previous surgery. Infusion studies were conducted by the infusion of 1 ml/min of normal saline through a 25-gauge needle inserted through the skin into the Rickham reservoir. A separate 25-gage needle was inserted into the Rickham reservoir for continuous recording of intracranial pressure. There were 43 infusion studies that were included in the four categories. Recordings of baseline intracranial pressure for a high probability of a disorder of the circulation of the CSF did not differ significantly from a low probability of a disorder of the circulation of the CSF. Baseline intracranial pressure for a high probability of shunt malfunction was significantly higher than the low probability of a disorder of the circulation of the CSF group and the low probability of shunt malfunction group; there was, however, marked overlap in values between these groups. On the other hand, resistance to infusion was no greater than 12 mm Hg ml-1/min-1for all patients with a low probability of a disorder of the circulation of the CSF and no less than 14 mm Hg ml-1/min-1in both the high probability of a disorder of the circulation of the CSF and the high probability of shunt malfunction. This result was significant. The results indicate that this test, which may be applied in an outpatient setting, could be a practical and useful addition to the current methods of the assessment of the circulation of the CSF.
Plasmacytoma of the Skull: Case Reports
Authors: Du Preez Jacomina H. , Branca Enrico P.
Published: April 2011

Two cases of solitary plasmacytoma of the skull are presented. Both patients underwent surgery, and the tumors were removed completely. The patients did not receive postoperative radiotherapy. After a follow-up period of 18 months, neither patient had a local recurrence, but one developed disseminated systemic myeloma.
Identification of piRNAs in the central nervous system
Authors: Lee Eun Joo , Banerjee Sourav , Zhou Hongjun , Jammalamadaka Aruna , Arcila Mary , Manjunath B.S. , Kosik Kenneth S.
Published: April 2011

Piwi-interacting RNAs (piRNAs) are small noncoding RNAs generated by a conserved pathway. Their most widely studied function involves restricting transposable elements, particularly in the germline, where piRNAs are highly abundant. Increasingly, another set of piRNAs derived from intergenic regions appears to have a role in the regulation of mRNA from early embryos and gonads. We report a more widespread expression of a limited set of piRNAs and particularly focus on their expression in the hippocampus. Deep sequencing of extracted RNA from the mouse hippocampus revealed a set of small RNAs in the size range of piRNAs. These were confirmed by their presence in the piRNA database as well as coimmunoprecipitation with MIWI. Their expression was validated by Northern blot and in situ hybridization in cultured hippocampal neurons, where signal from one piRNA extended to the dendritic compartment. Antisense suppression of this piRNA suggested a role in spine morphogenesis. Possible targets include genes, which control spine shape by a distinctive mechanism in comparison to microRNAs.
Do Large Effect QTL Fractionate? A Case Study at the Maize Domestication QTLteosinte branched1
Authors: Studer Anthony J , Doebley John F
Published: April 2011

Quantitative trait loci (QTL) mapping is a valuable tool for studying the genetic architecture of trait variation. Despite the large number of QTL studies reported in the literature, the identified QTL are rarely mapped to the underlying genes and it is usually unclear whether a QTL corresponds to one or multiple linked genes. Similarly, when QTL for several traits colocalize, it is usually unclear whether this is due to the pleiotropic action of a single gene or multiple linked genes, each affecting one trait. The domestication gene teosinte branched1 (tb1) was previously identified as a major domestication QTL with large effects on the differences in plant and ear architecture between maize and teosinte. Here we present the results of two experiments that were performed to determine whether the single gene tb1 explains all trait variation for its genomic region or whether the domestication QTL at tb1 fractionates into multiple linked QTL. For traits measuring plant architecture, we detected only one QTL per trait and these QTL all mapped to tb1. These results indicate that tb1 is the sole gene for plant architecture traits that segregates in our QTL mapping populations. For most traits related to ear morphology, we detected multiple QTL per trait in the tb1 genomic region, including a large effect QTL at tb1 itself plus one or two additional linked QTL. tb1 is epistatic to two of these additional QTL for ear traits. Overall, these results provide examples for both a major QTL that maps to a single gene, as well as a case in which a QTL fractionates into multiple linked QTL.
Focusing Forward Genetics: A Tripartite ENU Screen for Neurodevelopmental Mutations in the Mouse
Authors: Stottmann R W , Moran J L , Turbe-Doan A , Driver E , Kelley M , Beier D R
Published: April 2011

The control of growth, patterning, and differentiation of the mammalian forebrain has a large genetic component, and many human disease loci associated with cortical malformations have been identified. To further understand the genes involved in controlling neural development, we have performed a forward genetic screen in the mouse (Mus musculus) using ENU mutagenesis. We report the results from our ENU screen in which we biased our ascertainment toward mutations affecting neurodevelopment. Our screen had three components: a careful morphological and histological examination of forebrain structure, the inclusion of a retinoic acid response element-lacZ reporter transgene to highlight patterning of the brain, and the use of a genetically sensitizing locus, Lis1/Pafah1b1, to predispose animals to neurodevelopmental defects. We recovered and mapped eight monogenic mutations, seven of which affect neurodevelopment. We have evidence for a causal gene in four of the eight mutations. We describe in detail two of these: a mutation in the planar cell polarity gene scribbled homolog (Drosophila) (Scrib) and a mutation in caspase-3 (Casp3). We find that refining ENU mutagenesis in these ways is an efficient experimental approach and that investigation of the developing mammalian nervous system using forward genetic experiments is highly productive.
Diabetic Retinopathy Is Related to Both Endothelium-Dependent and -Independent Responses of Skin Microvascular Flow
Authors: Nguyen Thanh T. , Shaw Jonathan E. , Robinson Carol , Kawasaki Ryo , Wang Jie Jin , Kreis Andreas J. , Wong Tien Y.
Published: April 2011

OBJECTIVE

Endothelial dysfunction has been hypothesized as a possible pathogenic factor in the development of diabetic retinopathy (DR). We examined the relationship of DR to endothelium-dependent and endothelium-independent responses in skin microvascular flow.

RESEARCH DESIGN AND METHODS

Participants consisted of 224 individuals with diabetes: 85 with type 1 diabetes and 139 with type 2 diabetes. Sodium nitroprusside (SNP) and acetylcholine (ACh) were delivered across the skin by iontophoresis. Laser Doppler flowmetry was used to assess the skin microcirculation response to SNP (endothelium-independent response) and ACh (endothelium-dependent response). The presence and severity of DR were graded from retinal photographs using a standard protocol.

RESULTS

Of 224 participants, 64.3% had DR. After multivariable adjustment, participants with reduced responses to SNP or ACh were more likely to have DR, with an odds ratio (OR) of 2.33 (95% CI 1.09–5.01) for SNP and 2.20 (1.05–4.61) for ACh, comparing participants with responses below and above the median values. Participants with reduced responses (below the median) to both SNP and ACh were nearly four times more likely to have DR (OR 3.86 [1.45–10.3]) than those with SNP and ACh both above the median values.

CONCLUSIONS

The presence of DR was associated with a reduction in skin microcirculation responses to iontophoresis of both SNP and ACh, suggesting that vascular processes associated with both endothelial dysfunction and endothelial function-independent mechanisms may be pathogenically related to DR.