bluuebunny/crossref_metadata_2025 huggingface dataset:
Detection of Microemboli by Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage
Authors: Romano Jose G. , Forteza Alejandro M. , Concha Mauricio , Koch Sebastian , Heros Roberto C. , Morcos Jacques J. , Babikian Viken L.
Published: July 2004

OBJECTIVE:

To determine the frequency and characteristics of microembolic signals (MES) in subarachnoid hemorrhage (SAH).

METHODS:

Twenty-three patients with aneurysmal SAH were monitored with transcranial Doppler ultrasonography for the presence of MES and vasospasm. Each middle cerebral artery was monitored for 30 minutes three times each week. Patients were excluded if they had traumatic SAH or cardiac or arterial sources of emboli. Monitoring was initiated 6.3 days (1–16 d) after SAH and lasted 6.6 days (1–13 d). Eleven individuals without SAH or other cerebrovascular diseases who were treated in the same unit served as control subjects. Each patient underwent monitoring of both middle cerebral arteries a mean of three times; therefore, 46 vessels were studied (a total of 138 observations). Control subjects underwent assessment of each middle cerebral artery once, for a total of 22 control vessels.

RESULTS:

MES were detected for 16 of 23 patients (70%) and 44 of 138 patient vessels (32%) monitored, compared with 2 of 11 control subjects (18%) and 2 of 22 control vessels (9%) (P < 0.05). MES were observed for 83% of patients with clinical vasospasm and 54% of those without clinical vasospasm. Ultrasonographic vasospasm was observed for 71 of 138 vessels monitored; MES were observed for 28% of vessels with vasospasm and 36% of those without vasospasm. Aneurysms proximal to the monitored artery were identified in 38 of 138 vessels, of which 34% exhibited MES, which is similar to the frequency for vessels without proximal aneurysms (31%). Coiled, clipped, and unsecured aneurysms exhibited similar frequencies of MES.

CONCLUSION:

MES were common in SAH, occurring in 70% of cases of SAH and one-third of all vessels monitored. Although MES were more frequent among patients with clinical vasospasm, this difference did not reach statistical significance. We were unable to demonstrate a relationship between ultrasonographic vasospasm and MES, and the presence of a proximal secured or unsecured aneurysm did not alter the chance of detection of MES. Further studies are required to determine the origin and clinical relevance of MES in SAH.
Fatal Subarachnoid Hemorrhage, with Brainstem and Cerebellar Infarction, Caused by Aspergillus Infection after Cerebral Aneurysm Surgery: Case Report
Authors: Endo Toshiki , Tominaga Teiji , Konno Hidehiko , Yoshimoto Takashi
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Intracranial aspergillosis has been reported to cause subarachnoid hemorrhage (SAH) attributable to ruptured mycotic aneurysms. We describe a case of Aspergillus arteritis that caused SAH without aneurysm formation, followed by successive brainstem and cerebellar infarction.

CLINICAL PRESENTATION:

A 50-year-old woman experienced a sudden onset of headache. Computed tomography demonstrated SAH. After angiography revealed an aneurysm of the anterior communicating artery, a complete neck-clipping operation was performed, without neurological deterioration. However, the patient experienced another episode of SAH on the 26th postoperative day.

INTERVENTION:

We repeated the craniotomy and confirmed that the clip was still intact. A second angiographic evaluation did not reveal an aneurysm or any other cause of hemorrhage. On the 30th postoperative day, magnetic resonance imaging demonstrated cerebellar infarction in the territory of the anteroinferior cerebellar artery. The patient died on the 40th postoperative day, after another episode of SAH and progressive cerebellar and brainstem infarction. The postmortem examination revealed destruction of the basilar artery and occlusion of the basilar and vertebral arteries attributable to Aspergillus arteritis.

CONCLUSION:

When a patient presents with SAH of unknown origin followed by cerebral infarction, Aspergillus arteritis should be included in the differential diagnosis. Earlier recognition of this fungal infection improves the prognosis.
Endothelial Cell Activation after Subarachnoid Hemorrhage
Authors: Frijns Catharina J.M. , Rinkel Gabriël J.E. , Castigliego Domenico , van Gijn Jan , Sixma Jan J. , Fijnheer Rob
Published: July 2004

OBJECTIVE

Evidence from animal experiments suggests that endothelial cell activation plays a pathogenetic role in the development of cerebral ischemia after subarachnoid hemorrhage (SAH). We measured plasma concentrations of two markers of endothelial cell activation, i.e., ED1-fibronectin (ED1-fn) and von Willebrand factor (vWf), among patients with aneurysmal SAH. We analyzed the relationships of concentrations to initial clinical conditions, treatment modalities, and the occurrence of delayed cerebral ischemia.

METHODS

We collected 123 blood samples from 27 patients with aneurysmal SAH. Aneurysms were treated surgically in 19 cases, were treated endovascularly in 7 cases, and remained untreated in 1 case. Twelve patients developed symptomatic delayed cerebral ischemia.

RESULTS

Initial concentrations of ED1-fn (4.3 ± 3.7 μg/ml) and vWf (17.8 ± 8.2 μg/ml) were higher than the reference values (ED1-fn, 1.7 ± 0.9 μg/ml, P < 0.001; vWf, 11.5 ± 5.2 μg/ml, P = 0.003). Concentrations were higher among patients in poor clinical condition at admission, compared with patients in good clinical condition (mean difference, ED1-fn, 5.7 μg/ml, P = 0.04; vWf, 10.4 μg/ml, P = 0.02). Levels of both markers increased significantly after surgery (mean increase, ED1-fn, 7.5 μg/ml, P = 0.01; vWf, 13.2 μg/ml, P = 0.05) and after ischemic episodes (mean increase, ED1-fn, 8.3 μg/ml, P = 0.02; vWf, 5.0 μg/ml, P = 0.04).

CONCLUSION

Plasma concentrations of markers of endothelial cell activation were increased early after SAH and were significantly associated with the clinical condition at admission. We also observed a significant increase in concentrations after surgery and after ischemic episodes. Whether endothelial cell activation is a causal or indirectly related factor in the pathogenesis of delayed cerebral ischemia after SAH is still uncertain.
The Diagonal Ventricular Dimension: A Method for Predicting Shunt Malfunction on the Basis of Changes in Ventricular Size
Authors: Mesiwala Ali H. , Avellino Anthony M. , Ellenbogen Richard G.
Published: July 2004

OBJECTIVE

Serial computed tomographic and magnetic resonance imaging studies are critical in the evaluation of patients who present with symptoms and signs of recurrent hydrocephalus or possible ventricular shunt malfunction. Subtle changes in ventricular volume or complex variations in ventricular anatomy often make subjective assessment of changes in ventricular size difficult, and no previously described method relates these changes to intracranial pressure or shunt system function. The purpose of this study was to develop an objective, reproducible, simple linear method of detecting changes in ventricular size that provides an accurate reflection of shunt function on the basis of serial imaging studies.

METHODS

We developed a simple, linear estimate of ventricular volume—the diagonal ventricular dimension—to objectively assess changes in ventricular size on serial computed tomographic scans and magnetic resonance imaging scans. Serial imaging studies for 14 patients ages 1.6 to 71 years who underwent evaluation for shunt malfunction were used in this study. The sensitivity and specificity of this method in predicting shunt malfunction was compared with other well-established linear estimates of ventricular size as well as with a radiologist's interpretation of the same studies. The “gold standard” for measuring the status of ventricular shunt system function in this study was the measurement of intracranial pressure via shunt tap or surgical exploration results.

RESULTS

The sensitivity (100%) and specificity (100%) of the diagonal ventricular dimension in detecting changes in ventricular size consistent with shunt malfunction was superior to that of any other linear estimate and to a radiologist's interpretation of the same films.

CONCLUSION

The diagonal ventricular dimension provides an objective, simple linear method of assessing changes in ventricular size that correlates well with shunt system function in the context of a collaborative examination.
Schwannoma Arising from the Tentorium at an Unusual Location: Case Report
Authors: Oikawa Akihiro , Takeda Naoto , Aoki Nobuhiko , Takizawa Touichiro , Sakoma Takaaki
Published: July 2004

OBJECTIVE AND IMPORTANCE

We present a case of schwannoma attached to the tentorium.

CLINICAL PRESENTATION

A 41-year-old woman without evidence of neurofibromatosis presented with a 3-month history of headache, positional vertigo, and truncal ataxia. Magnetic resonance imaging revealed an extra-axial cystic mass lesion in the left anteromedial cerebellar region with a dural tail sign.

INTERVENTION

The tumor was removed completely by retrosigmoid craniotomy. Dense adhesion of the tumor to the inferior surface of the tentorium was confirmed during surgery. On light microscopic study, this neoplasm was composed of spindle cells and showed palisaded structures. Immunohistochemically, the tumor cells stained positive for S-100 protein and vimentin. Reticulin staining revealed a pericellular pattern of distribution of reticulin fibers. Electron microscopy confirmed the presence of a basement membrane encompassing the tumor cells. From these findings, the tumor was diagnosed as a schwannoma arising from the tentorium.

CONCLUSION

To our knowledge, this case report is the first to describe a schwannoma arising from the tentorium. Our case report indicates that schwannoma is a possible pathology in the differential diagnosis of dura-based tumors.
Acromegaly Caused by a Growth Hormone-releasing Hormone-secreting Carcinoid Tumor: Case Report
Authors: Altstadt Thomas J. , Azzarelli Biagio , Bevering Carl , Edmondson James , Nelson Paul B.
Published: July 2004

OBJECTIVE AND IMPORTANCE

We describe a patient with acromegaly and pituitary hyperplasia secondary to a growth hormone-releasing hormone-secreting gastrointestinal carcinoid tumor. This case report illustrates the importance of including this rare clinical syndrome in the differential diagnosis of acromegaly for patients with suspected or known neuroendocrine tumors.

CLINICAL PRESENTATION

A 19-year-old, Asian-American, male patient with a 2-year history of a nonresectable, metastatic, intestinal carcinoid tumor presented with complaints of headaches, arthralgias, sweats, and changing features. The examination revealed a young subject with acromegalic features, without visual field deficits. Magnetic resonance imaging revealed a diffuse sellar mass that extended suprasellarly to compress the optic chiasm. Endocrinological studies demonstrated a growth hormone level of more than 100 ng/ml and an inappropriately elevated growth hormone-releasing hormone level.

INTERVENTION

The patient underwent transsphenoidal resection of the pituitary mass for diagnostic and decompressive purposes. The pathological examination revealed pituitary hyperplasia, without evidence of an adenoma. Therapy with long-acting repeatable octreotide (Sandostatin LAR; Novartis AG, Basel, Switzerland) was initiated postoperatively, to further control the acromegaly and carcinoid tumor. The soft-tissue swelling resolved, and the patient remained free of headaches, arthralgias, and sweats at the 6-month follow-up examination.

CONCLUSION

Ectopic acromegaly is a rare syndrome that must be recognized by neurosurgeons because its treatment differs from that of classic pituitary acromegaly. We describe a patient for whom this syndrome was documented with magnetic resonance imaging, endocrinological testing, and pathological examinations.
Fourth Ventricle Central Neurocytoma: Case Report
Authors: Hsu Peng-Wei , Hsieh Tsung-Che , Chang Chen-Nen , Lin Tzu-Kang
Published: July 2004

OBJECTIVE AND IMPORTANCE

Central neurocytomas (CNs) are typically located in the lateral ventricle. Primary origins in the fourth ventricle are very rare. We discuss the clinical symptoms, imaging findings, and microscopic features of these rare tumors.

CLINICAL PRESENTATION

We report a case of a fourth ventricle CN in a 35-year-old male patient with the initial symptoms of progressive headaches and blurred vision for more than 2 months. Computed tomography and magnetic resonance imaging of the brain revealed a slightly enhanced tumor in the fourth ventricle, with obstructive hydrocephalus.

INTERVENTION

Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. The final definitive diagnosis as a CN was made after special immunohistochemical studies.

CONCLUSION

CNs located in the fourth ventricle are extremely rare. Immunohistochemical stains and transmission electron microscopy can provide useful diagnostic information. Total tumor excision is associated with favorable prognoses. Postoperative radiotherapy may be considered for cases of subtotal excision, anaplastic histological variants, or recurrent tumors.
A Craniocerebral Infectious Disease: Case Report on the Traces of Hippocrates
Authors: Viale Giuseppe L. , Deseri Sergio , Gennaro Sergio , Sehrbundt Elke
Published: July 2004

A MODERN CASE of complicated sinusitis, with osteitis of the cranium and intraorbital-intracranial empyema, closely corresponds to descriptions reported in the Hippocratic treatise Diseases II. The therapeutic measures suggested in that work can be regarded as suitable according to modern practice. An ancient physician who followed the Hippocratic doctrine probably would have been able to recognize this complicated disease and possibly save the patient.
Antiepileptic Effect of High-frequency Stimulation of the Subthalamic Nucleus (Corpus Luysi) in a Case of Medically Intractable Epilepsy Caused by Focal Dysplasia: A 30-month Follow-up: Technical Case Report
Authors: Benabid Alim Louis , Minotti Lorella , Koudsié Adnan , de Saint Martin Anne , Hirsch Edouard
Published: July 2004

OBJECTIVE AND IMPORTANCE

Currently, some forms of epilepsy are resistant to both pharmacological and surgical interventions. As a result, there is a need for new therapeutic strategies. Because the nigral system modulates neuronal excitability in animal models of epilepsy, we considered therapeutic high-frequency stimulation of the subthalamic nucleus (STN). We were encouraged by the known relationship between the STN and the nigral system, as well as by our experience with high-frequency stimulation of the STN in Parkinsonian patients.

CLINICAL PRESENTATION

A 5-year-old girl with pharmacologically resistant, inoperable epilepsy caused by focal centroparietal dysplasia underwent implantation with a permanent electrode in the left STN and was chronically stimulated. To date, we have followed up this patient for 30 months postoperatively.

TECHNIQUE

High-frequency stimulation of the STN induced a significant voltage-dependent reduction (by 80%) in the number and severity of seizures. In addition, consistent improvement in both motor and cognitive functions was noted as a result of reduced postictal states. The effect was more prominent for seizures occurring in clusters (89% reduction) and during the day (88% reduction) than for those that occurred during sleep (53% reduction).

CONCLUSION

This is the first report of epilepsy control using chronic high-frequency stimulation of the STN. Preliminary observations in three other operated patients (at 2, 12, and 18 mo) confirm these data. We think that high-frequency stimulation of the STN may hold significant future potential as a treatment for epilepsy, similar to its established role in the treatment of Parkinson's disease. This finding opens completely new experimental and therapeutic avenues for the treatment of surgically and medically intractable epilepsy.
Clinical and Radiographic Outcome in the Management of Posterior Circulation Aneurysms by Use of Direct Surgical or Endovascular Techniques
Authors: Ogilvy Christopher S. , Hoh Brian L. , Singer Robert J. , Putman Christopher M.
Published: July 2004

OBJECTIVE

Posterior circulation aneurysms can be difficult lesions to treat surgically, and they have potential for high morbidity and mortality, particularly in elderly patients or those in poor neurological condition. In an effort to improve outcomes, our combined neurosurgical and neuroendovascular unit has used both surgical clipping and endovascular coiling techniques to treat posterior circulation aneurysms. Patients considered at high risk for surgery were managed with endovascular treatment.

METHODS

From 1990 to 1998, 197 posterior circulation aneurysms in 189 patients were treated in our combined neurovascular unit. Of these aneurysms, 128 were ruptured, 63 were unruptured, and 6 had a distant history of rupture in patients who came to our center for delayed or repeat treatment. A total of 132 aneurysms were treated with surgical clipping (85 ruptured, 46 unruptured, and 1 with distant history of rupture) and 65 aneurysms were treated with endovascular coiling (43 ruptured, 17 unruptured, and 5 with distant history of rupture). Dissecting aneurysms of the vertebral or posteroinferior cerebellar arteries or aneurysms treated with proximal (Hunterian) occlusion were excluded from this analysis. Surgical risk was assessed using a previously described system (Massachusetts General Hospital [MGH] grade), which incorporates age, Hunt and Hess grade, size of lesion, and Fisher grade.

RESULTS

Overall clinical outcomes at 1 year of follow-up were 77.2% excellent or good, 10.2% fair, 4.1% poor, and 8.6% dead. Surgical treatment resulted in 95.6% complete aneurysm occlusion and 4.4% with residual aneurysm after surgical treatment, whereas endovascular treatment resulted in 32.3% complete occlusion, 26.2% with residual aneurysm, and 41.5% with partial occlusion. In most cases, however, treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA) was performed for palliation rather than complete radiographic occlusion. Outcome was closely associated with MGH grade with either treatment modality. Excellent/good outcomes were achieved in 96, 92.3, 82.9, 46.2, and 0% of surgically treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively. In comparison, excellent/good outcomes were achieved in 100, 84.2, 61.9, 0, and 50% of endovascularly treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively.

CONCLUSION

A combined surgical and endovascular approach to posterior circulation aneurysms can achieve good outcomes in high-risk surgical patients treated by use of coiling techniques.
Malignant Pineal Parenchymal Tumors in Adult Patients: Patterns of Care and Prognostic Factors
Authors: Lutterbach Johannes , Fauchon François , Schild Steven E. , Chang Susan M. , Pagenstecher Axel , Volk Benedikt , Ostertag Christoph , Momm Felix , Jouvet Anne
Published: July 2004

OBJECTIVE

The aim of our study was to analyze patterns of care and to identify prognostic factors in patients at least 18 years of age who received radiotherapy for malignant pineal parenchymal tumors.

METHODS

In a multicenter, retrospective study, we analyzed data for 37 previously published cases and 64 patients treated at the participating institutions.

RESULTS

A total of 56 patients received postoperative radiotherapy, and 45 patients received primary radiotherapy. Chemotherapy was administered to 34 patients. The median follow-up period was 38 months, and median overall survival was 100 months. The variables that significantly influenced overall survival were the extent of disease (localized versus disseminated; P = 0.0002), differentiation (pineal parenchymal tumor of intermediate differentiation versus pineoblastoma; P = 0.001), and residual disease (≥50% versus <50% reduction in size; P < 0.0001). In a multivariate analysis, the parameters turned out to be independent risk factors. The median survival in patients with local or spinal failure was 15 months. Local control was better in older patients (≥32 yr versus <32 yr; P = 0.02). Spinal control was more successful in patients with pineal parenchymal tumors of intermediate differentiation than it was in patients with pineoblastomas (P = 0.03). Nine of 45 treatment failures occurred later than 5 years after treatment.

CONCLUSION

Stage, histological characteristics, and response are independent risk factors in adults with malignant pineal parenchymal tumors. Late relapses are common.
Treatment of Chronic Pain with Spinal Cord Stimulation versus Alternative Therapies: Cost-effectiveness Analysis
Authors: Kumar Krishna , Malik Samaad , Demeria Denny
Published: July 2004

OBJECTIVE

There is limited available research measuring the cost-effectiveness of spinal cord stimulation (SCS), compared with best medical treatment/conventional pain therapy (CPT). The purpose of this study was to tabulate the actual costs (in Canadian dollars) for a consecutive series of patients treated with SCS in a constant health care delivery environment and to compare the costs with those for a control group treated in the same controlled environment.

METHODS

We present a consecutive series of 104 patients with failed back syndrome. Within this group, 60 patients underwent SCS electrode implantation, whereas 44 patients were designated as control subjects. We monitored these patients for a 5-year period and tabulated the actual costs incurred in diagnostic imaging, professional fees paid to physicians, implantation (including the costs for hardware), nursing visits for maintenance of the stimulators, physiotherapy, chiropractic treatments, massage therapy, and hospitalization for treatment of breakthrough pain. From these data, the cumulative costs for each group were calculated for a 5-year period. An analysis of Oswestry questionnaire results was also performed, to evaluate the effects of treatment on the quality of life.

RESULTS

The actual mean cumulative cost for SCS therapy for a 5-year period was $29,123/patient, compared with $38,029 for CPT. The cost of treatment for the SCS group was greater than that for the CPT group in the first 2.5 years. The costs of treating patients with SCS became less than those for CPT after that period and remained so during the rest of the follow-up period. In addition, 15% of SCS-treated patients were able to return to employment, because of superior pain control and lower drug intake. No patients in the control group were able to return to employment of any kind.

CONCLUSION

SCS is cost-effective in the long term, despite the initial high costs of the implantable devices.
Isolated, Giant Cerebellopontine Angle Craniopharyngioma in a Patient with Gardner Syndrome: Case Report
Authors: Link Michael J. , Driscoll Colin L.W. , Giannini Caterina
Published: July 2004

OBJECTIVE AND IMPORTANCE

We report the case of a 29-year-old man with Gardner syndrome and an isolated, giant cerebellopontine angle craniopharyngioma. Our description of this patient is only the second case report of a craniopharyngioma arising primarily in the cerebellopontine angle.

CLINICAL PRESENTATION

The patient presented with a 1-year history of progressive neurological impairment and headache. On the basis of the patient's history of multiple dermal fibromas, a cranial osteoma, familial adenomatous polyposis (FAP), a total abdominal colectomy, and an adenoma of the ampulla of Vater, we diagnosed the patient's condition as Gardner syndrome.

INTERVENTION

Magnetic resonance imaging showed a large cerebellopontine angle tumor, which was removed through a suboccipital retromastoid craniotomy. The pathological features were those of an adamantinomatous craniopharyngioma. The patient has done well postoperatively and has no new neurological deficits. A careful retrospective review of the preoperative imaging shows that this tumor was located exclusively in the posterior fossa and was not an extension of a sellar, suprasellar, or clival craniopharyngioma.

CONCLUSION

We present the second reported case of FAP and craniopharyngioma. There is no known genetic link between FAP and craniopharyngioma. Now that the patient has manifested a primary tumor of the central nervous system with FAP, it is unclear whether he should be classified as having Turcot syndrome. For this patient, we recommended vigilant follow-up imaging and forgoing external beam radiotherapy unless there is a documented recurrence of his craniopharyngioma.
Heterotopic Ossification of Peripheral Nerve (“Neuritis Ossificans”): Report of Two Cases
Authors: George David H. , Scheithauer Bernd W. , Spinner Robert J. , Buchler Ueli , Cronin Timothy E. , Reedy Michael T. , Arndt Byron C.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Heterotopic ossification (“neuritis ossificans”) is among the least frequently encountered reactive lesions in peripheral nerves. Only two cases have been described previously, one in the median nerve of a 34-year-old man, and the other in the ulnar nerve of an adult woman. The architecture of this lesion is distinctly zonal. Consisting of a central fibroblastic core, an intervening zone of osteoid production, and a peripheral layer of ossification, the pattern is remarkably similar to that of myositis ossificans. This similarity and the occurrence of the process in superficial nerves have led to speculation that trauma plays a role in its pathogenesis; this hypothesis remains unproved. We describe two additional cases of neuritis ossificans.

CLINICAL PRESENTATION

One patient, a 41-year-old man, experienced pain and numbness in the left leg for several months but had no history of local trauma. A mass was detected in the saphenous nerve. The second patient, a 16-year-old boy, noted subacute onset of pain in the popliteal fossa and decreased sensation in the distribution of the lateral sural cutaneous nerve. A mass was found within the tibial nerve at the knee level.

INTERVENTION

In each patient, resection of the mass required sacrifice of a segment of the nerve.

CONCLUSION

In each patient, the mass was composed of fibrovascular tissue with osteoid and bone deposition arranged in a zonal pattern. The ossifying process was intraneural but encased rather than directly involving nerve fascicles. These exceptionally intact examples of neuritis ossificans underscore its resemblance to myositis ossificans. Nerve-sparing resection of such masses is not always possible.
Role of Frameless Stereotaxy in the Surgical Treatment of Cerebral Arteriovenous Malformations: Technique and Outcomes in a Controlled Study of 44 Consecutive Patients
Authors: Russell Stephen M. , Woo Henry H. , Joseffer Seth S. , Jafar Jafar J.
Published: July 2004

OBJECTIVE

To describe a frameless stereotactic technique used to resect cerebral arteriovenous malformations (AVMs) and to determine whether frameless stereotaxy during AVM resection could decrease operative times, minimize intraoperative blood losses, reduce postoperative complications, and improve surgical outcomes.

METHODS

Data for 44 consecutive patients with surgically resected cerebral AVMs were retrospectively reviewed. The first 22 patients underwent resection without stereotaxy (Group 1), whereas the next 22 patients underwent resection with the assistance of a frameless stereotaxy system (Group 2).

RESULTS

The patient characteristics, AVM morphological features, and percentages of preoperatively embolized cases were statistically similar for the two treatment groups. The mean operative time for Group 1 was 497 minutes, compared with 290 minutes for Group 2 (P = 0.0005). The estimated blood loss for Group 1 was 657 ml, compared with 311 ml for Group 2 (P = 0.0008). Complication rates, residual AVM incidences, and clinical outcomes were similar for the two groups.

CONCLUSION

Frameless stereotaxy allows surgeons to 1) plan the optimal trajectory to an AVM, 2) minimize the skin incision and craniotomy sizes, and 3) confirm the AVM margins and identify deep vascular components during resection. These benefits of stereotaxy were most apparent for small, deep AVMs that were not visible on the surface of the brain. Frameless stereotaxy reduces the operative time and blood loss during AVM resection.
Evaluation of Traumatic Cervical Nerve Root Injuries by Intraoperative Evoked Potentials
Authors: Oberle Joachim , Antoniadis Gregor , Kast Erich , Richter Hans-Peter
Published: July 2004

OBJECTIVE

To evaluate intraoperative evoked potentials as a diagnostic tool in traumatic brachial plexus injuries.

METHODS

Thirteen patients with traumatic brachial plexus injuries were investigated by intradural nerve root inspection (n = 28 roots) via cervical hemilaminectomy to assess or rule out nerve root avulsion from the spinal cord. Two to 8 weeks later, evoked potentials from neck and scalp were recorded after direct electrical nerve root stimulation close to the vertebral foramen during operative brachial plexus repair via an anterior (supraclavicular and infraclavicular) approach. Recordings were performed without and after full muscle relaxation.

RESULTS

There was a clear relationship between the state of the root as documented by intradural root inspection and the result of intraoperative recording of evoked potentials: the absence of evoked muscle action potentials from neck muscles demonstrated a 100% sensitivity for anterior root lesions, whereas sensory evoked potentials from the scalp demonstrated a 100% sensitivity for posterior root lesions. Moreover, roots could be identified with preserved continuity that did not conduct, suggesting a nerve lesion in continuity.

CONCLUSION

Intraoperative evoked muscle action potentials and sensory evoked potentials after electrical nerve root stimulation allow selective functional evaluation of anterior and posterior nerve roots in patients with traumatic brachial plexus injuries. The high sensitivity and reliability of this test obviate the need for additional diagnostic surgery.
Review: Complications of Minimally Invasive Spinal Surgery
Authors: Perez-Cruet Mick J. , Fessler Richard G. , Perin Noel I.
Published: July 2004

COMPLICATIONS OF MINIMALLY invasive spinal surgery can be related to anesthesia, patient positioning, and surgical technique. The performance of successful minimally invasive spinal surgery is beset with several technical challenges, including the limited tactile feedback, two-dimensional video image quality of three-dimensional anatomy, and the manual dexterity needed to manipulate instruments through small working channels, which all account for a very steep learning curve. Knowledge of possible complications associated with particular minimally invasive spinal procedures can aid in their avoidance. This article reviews complications associated with minimally invasive spinal surgery in the cervical, thoracic, and lumbar spine by reviewing reported data of sufficient detail or with sufficient numbers of patients. In addition, possible complications associated with anesthesia use, patient positioning, and surgical techniques during thoracoscopic and laparoscopic spinal procedures are reviewed.
Anterior Cervical Microforaminotomy for Spondylotic Cervical Myelopathy: Part 2
Authors: Jho Hae-Dong , Kim Myung-Hyun , Kim Woo-Kyung
Published: July 2004

OBJECTIVE

Anterior microforaminotomy for spondylotic cervical myelopathy is reported with surgical results.

METHODS

A retrospective study was performed for 40 patients with spondylotic cervical myelopathy who had been surgically treated with anterior microforaminotomy at the University of Pittsburgh between April 1994 and June 1999. Age ranged from 32 to 74 years (median, 51 yr). Twenty-eight patients were men, and 12 were women. All had undergone magnetic resonance imaging (MRI) scans preoperatively. All underwent MRI scans and dynamic roentgenograms 6 weeks after the operation. The duration of follow-up ranged from 24 months to 86 months (median, 42 mo).

RESULTS

Twenty-eight patients (70%) had radiculopathy in addition to their myelopathy. Single-level operations were performed in 13 patients (32.5%), two-level operations in 19 patients (47.5%), three-level operations in 5 patients (12.5%), and four-level operations in 3 patients. Eleven patients (27.5%) had excellent results, 21 patients (52.5%) had good results, and 8 patients (20%) had unchanged results 6 weeks after the operation. Thirty-five patients (87.5%) were discharged the day of or the day after their operation. In all patients, MRI scans revealed good anatomic decompression, and dynamic roentgenograms revealed good stability. Postoperative complications included temporary deltoid weakness in one patient and temporary voice fatigue in another patient. In a final survey of 30 patients, 16 patients (53.3%) experienced excellent results, 11 patients (36.6%) experienced good results, and 3 patients (10%) experienced unchanged results. Final outcome survey with modified Japanese Orthopedic Association score is reported in 25 patients.

CONCLUSION

Anterior microforaminotomy provided good to excellent surgical results in 80% of the patients with minimal morbidities 6 weeks after the operation and in 90% of the patients at long-term follow-up. Spinal stability was well maintained in all patients.
Thoracic, Lumbar, and Sacral Spine Anatomy for Endoscopic Surgery
Authors: Pait T. Glenn , Elias Alexandre J.R. , Tribell Ron
Published: July 2004

WE DISCUSS THE anatomy of the thoracic, lumbar, and sacral levels of the spinal cord. Given the nature of endoscopic surgery, it is recommended that the surgeon have thorough knowledge not only of the bony architecture but also of important visceral and other soft tissue structures. It is essential to understand the normal anatomy to recognize the abnormal and anatomic variations. We present the so-called normal anatomic configurations and illustrate how these structures vary at the different levels of the spinal column.
Predictors of Successful Outcome for Lumbar Chemonucleolysis: Analysis of 3000 Cases during the Past 14 Years
Authors: Kim Young-Soo , Chin Dong-Kyu , Cho Yong-Eun , Jin Byung-Ho , Yoon Do-Heum
Published: July 2004

OBJECTIVE

Among numerous minimally invasive procedures for the treatment of herniated lumbar disc disease (HLD), chymopapain chemonucleolysis has the longest history of clinical usage. Long-term studies indicated good clinical results with a low risk for patients. However, much confusion still remains about the indications. This study was conducted to evaluate the predictors of successful outcome for chemonucleolysis and to firmly establish the proper indications for this procedure.

METHODS

Three thousand patients with HLD were treated with chemonucleolysis between 1984 and 1999. The clinical success rate in our series was 85%. The medical history and physical and radiological findings, including the type and direction of disc herniation, were analyzed retrospectively.

RESULTS

The patient group with the chief complaint of leg pain achieved a better clinical outcome than the patient group with low back pain (88% versus 59%, P < 0.05). A positive straight-leg-raising test was strongly correlated with good clinical outcome (< P < 0.05). Patients manifesting a soft, protruded disc had a better outcome than those manifesting diffuse bulging disc (< P < 0.05). Other prognostic factors favoring a good outcome were as follows: young age, short duration of symptoms, and no bony spur or calcification on radiological study.

CONCLUSION

Chymopapain chemonucleolysis is a safe and effective procedure. Proper selection of patients is important for the success of treatment. We propose the following three clinical criteria (Kim's triad) for selection of patients: chief complaint of leg pain rather than back pain, positive straight-leg-raising test, and soft protruded disc.
Microendoscopic Lumbar Discectomy: Technical Note
Authors: Perez-Cruet Mick J. , Foley Kevin T. , Isaacs Robert E. , Rice-Wyllie Lauri , Wellington Robin , Smith Maurice M. , Fessler Richard G.
Published: July 2004

OBJECTIVE

The microendoscopic discectomy (MED) technique was initially developed in 1997 to treat herniated lumbar disc disease. Since then, thousands of cases have been successfully performed at more than 500 institutions. This article discusses the technical aspects of this procedure and presents a consecutive case series.

METHODS

A total of 150 consecutive patients underwent MED. MED is performed by a muscle-splitting approach using a series of tubular dilators with consecutively increasing diameters. A tubular retractor is then inserted over the final dilator, and a specially designed endoscope is placed inside the tubular retractor. The microdiscectomy is performed endoscopically while the surgeon views the procedure on a video monitor.

RESULTS

Clinical outcomes were determined using a modified MacNab criteria, which revealed that 77% of patients had excellent, 17% had good, 3% had fair, and 3% had poor outcomes. The average hospital stay was 7.7 hours. The average return to work period was 17 days. Complications primarily included dural tears, which occurred in 8 patients (5%) and were seen early on in the patient series. Complication rates diminished as the surgeon's experience with this technique increased.

CONCLUSION

MED for lumbar herniated disc disease can be performed safely and effectively, resulting in a shortened hospital stay and faster return to work; however, there is a learning curve to this procedure.
Microsurgical Anterior Approaches to the Lumbar Spine for Interbody Fusion and Total Disc Replacement
Authors: Mayer H. Michael , Wiechert Karsten
Published: July 2004

OBJECTIVE

Anterior approaches to the lumbar spine for the treatment of various degenerative or postoperative abnormalities associated with low back pain have always been a matter of debate. They are known to be associated with considerable surgical trauma, high postoperative morbidity, and, occasionally, unacceptably high complication rates. In 1997, we inaugurated two new microsurgical modifications of conventional anterior approach techniques, which have been applied in anterior lumbar interbody fusion and more recently in total disc replacement. This article describes the results of microsurgical anterior interbody fusion in a consecutive series of 171 patients as well as preliminary results of these techniques for total disc replacement in 26 patients.

METHODS

The approaches are performed with the use of a surgical microscope. Lumbar segments L2–L5 are exposed through a lateral retroperitoneal approach. L5–S1 can be reached through a midline retroperitoneal or transperitoneal approach. Both approaches can be performed through a limited skin incision of 4 cm.

RESULTS

An independent observer evaluated results of anterior lumbar interbody fusion in 171 patients during a 2-year follow-up period. The clinical follow-up demonstrated low perioperative and postoperative morbidity with an average blood loss of less than 100 ml at the fusion site. Pseudoarthrosis rates were less than 5%, and clinical results, as evaluated in accordance with the scoring system developed by Prolo et al., did not differ significantly from conventional open techniques. Total disc replacement through a microsurgical anterior approach seems to be a promising alternative to fusion procedures with even less intraoperative and perioperative morbidity.

CONCLUSION

Microsurgical anterior approaches to the lumbar spine provide a reasonable surgical alternative to conventional approaches for anterior interbody fusion and total disc replacement.
Epidermal Nevus Syndromes: Clinical Findings in 35 Patients
Authors: Vidaurri‐de la Cruz Helena , Tamayo‐Sánchez Lourdes , Durán‐McKinster Carola , De La Luz Orozco‐Covarrubias María , Ruiz‐Maldonado Ramón
Published: July 2004

Abstract:  Of the patients with epidermal nevi, 10–18% may have disorders of the eye, nervous, and musculoskeletal systems. A predisposition to malignant neoplasms in ectodermal and mesodermal structures may also be found. There are six different epidermal nevus syndromes described so far: Proteus, congenital hemidysplasia with ichthyosiform nevus and limb defect syndrome, phakomatosis pigmentokeratotica, sebaceous nevus, Becker nevus, and nevus comedonicus. Thirty‐five patients with epidermal nevus syndrome seen at the National Institute of Pediatrics in Mexico City during a 31‐year period are described. This syndrome represented 7.9% of 443 patients with epidermal nevi; its relative frequency was 1 case per 11,928 pediatric patients and 1 case per 1080 dermatologic patients. Nine epidermal nevus syndrome patients (26%) had Proteus syndrome. Sebaceous nevus syndrome was found in six patients (17%), while the nevus comedonicus syndrome was found in three (8%). Two patients were diagnosed with phakomatosis pigmentokeratotica and one patient with congenital hemidysplasia with ichthyosiform nevus and limb defect syndrome. This is the first report of phakomatosis pigmentokeratotica and congenital hemidysplasia with ichthyosiform nevus and limb defect syndrome in Mexican patients. One patient had an inflammatory linear verrucous epidermal nevus with systemic involvement. Thirteen patients (37%) had keratinocytic nevi with systemic involvement. We propose the keratinocytic nevus syndrome to be defined as the association of a keratinocytic nevus with neuronal migration and/or musculoskeletal disorders in addition to a higher risk for mesodermal neoplasms.
Aleukemic Congenital Leukemia Cutis
Authors: Torrelo Antonio , Madero Luis , Mediero Imelda G. , Baño Antonio , Zambrano Antonio
Published: July 2004

Abstract:  A newborn girl had typical “blueberry muffin” skin lesions, which showed histopathologic features of myelomonocytic leukemia cutis. We could not demonstrate leukemic infiltration of bone marrow in four aspirates. Her course was complicated with primary pulmonary hypertension, which led to death at 7 months of age. We emphasize the persistence of skin lesions in the absence of bone marrow infiltration by leukemia throughout the course of the disease.
Miliary Neonatal Hemangiomatosis with Fulminant Heart Failure and Cardiac Septal Hypertrophy in Two Infants
Authors: O'Hagan A. H. , Irvine A. D. , Sands A. , O'Donaghue D. , Casey F. , Bingham E. A.
Published: July 2004

Abstract:  Miliary neonatal hemangiomatosis is a rare, life‐threatening condition associated with cutaneous and multiorgan involvement. We report two infants with this condition who had fulminant cardiac failure and cardiac septal hypertrophy. The first was a 5‐day‐old boy who presented with increasing numbers of cutaneous hemangiomata associated with worsening cardiac failure. Magnetic resonance imaging (MRI) showed extensive hepatic hemangioma. Despite treatment with systemic corticosteroids and subcutaneous interferon alfa‐2b his disease progressed. Hepatic artery embolization was unsuccessful. The infant died of congestive cardiac failure at 6 weeks of age. Postmortem examination showed a massively enlarged cardiac interventricular septum and biventricular hypertrophy. The second patient was a 1‐week‐old girl who also had cutaneous hemangioma and cardiac decompensation. MRI showed extensive intrahepatic involvement. She was treated early with corticosteroids and interferon α, which resulted in involution of the cutaneous and hepatic lesions. Cardiac septal hypertrophy did not persist at late follow‐up, and the association of miliary neonatal hemangiomatosis and cardiac septal hypertrophy has not yet been established.
Malignant Melanoma Associated with Lichen Sclerosus in the Vulva of a 10‐Year‐Old
Authors: Hassanein Ashraf M. , Mrstik Megan E. , Hardt Nancy S. , Morgan Linda A. , Wilkinson Edward J.
Published: July 2004

Abstract:  Malignant melanoma of the vulva in childhood is a rare neoplasm. Lichen sclerosus of the vulva in childhood is also a rare disease. The association of these two rare lesions in the vulva of young girls is extremely rare. We present a 10‐year‐old white girl with malignant melanoma associated with lichen sclerosus of the vulva. She had dark pigmentation of both the labia minora and posterior fourchette. The inner labia majora and fourchette showed whitish, glistening areas of skin. Histologic examination found mostly an in situ lentiginous/mucosal melanoma with focal invasion to a depth of 0.44 mm in the left upper labium majus. All specimens showed evidence of lichen sclerosus. Partial vulvectomy was performed, and no metastases were detected at the time of treatment. The patient has been disease free for the 12 months after treatment. It is critical for physicians to realize that melanoma can occur in children, and although rare, can occur in the vulva. We feel that lichen sclerosus in this instance may represent a pattern of host immune response to melanoma.
Elejalde Syndrome: Report of a Case and Review of the Literature
Authors: Cahali Juliana Burihan , Fernandez Solange Assuncion Villagra , Oliveira Zilda Najjar Prado , Machado Maria Cecília da Mata Rivitti , Valente Neusa Sakai , Sotto Mírian Nacagami
Published: July 2004

Abstract:  Elejalde syndrome is a rare autosomal recessive condition, with only 10 reported cases through 2001. It is characterized by silvery hair, pigment abnormalities, and profound central nervous system dysfunction. The differential diagnosis includes Griscelli and Chediak‐Higashi syndromes, which present with silvery hair, pigment abnormalities, central nervous system alterations, and severe immunologic dysfunction. We report a 6‐year‐old girl with Elejalde syndrome and review Elejalde, Griscelli, and Chediak‐Higashi syndromes.
Severe Monilethrix Associated with Intractable Scalp Pruritus, Posterior Subcapsular Cataract, Brachiocephaly, and Distinct Facial Features: A New Variant of Monilethrix Syndrome?
Authors: Erbagci Zulal , Erbagci Ibrahim , Erbagci Hulya , Erkılıc Suna , Tuncel A. Almila
Published: July 2004

Abstract:  Monilethrix is a rare developmental hair shaft defect characterized by small elliptical node‐like deformities with increased hair fragility resulting in partial or diffuse alopecia. The disorder is usually transmitted in an autosomal dominant fashion with incomplete penetrance and variable expressivity, but autosomal recessive inheritance has also been reported. It is thought to be without systemic involvement, whereas keratosis pilaris and follicular papules are almost invariably associated features.

We describe an instance of monilethrix in a 9‐year‐old boy from consanguineous parents, characterized by universal dystrophic alopecia associated with intractable scalp pruritus, diffuse keratosis pilaris, and bilateral posterior subcapsular cataracts. His disease was further characterized by physical underdevelopment and distinct features of hypertelorism, a wide‐based nose, long philtrum, relatively large mouth with thick lower lip, enlarged forehead, small, receding chin, short neck, and rounded (ultrabrachycranial) skull. The findings in our patient suggest that “monilethrix syndrome” is an appropriate term for defining the instances of monilethrix associated with other abnormalities. We conclude that our patient may represent a new and severe, autosomal recessive variant of monilethrix syndrome.