bluuebunny/crossref_metadata_2025 huggingface dataset:
Posterior Fossa Decompression and Clot Evacuation for Fourth Ventricle Hemorrhage after Aneurysmal Rupture: Case Report
Authors: Lagares Alfonso , Putman Christopher M. , Ogilvy Christopher S.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Massive intraventricular hemorrhage due to aneurysmal rupture is associated with a dismal prognosis. An intraventricular clot causing fourth ventricle dilation can cause compression to the brainstem similar to other posterior fossa masses such as cerebellar hemorrhage or infarction. The presence of fourth ventricle dilation carries a very high risk of death within 48 hours. Neither ventricular drainage nor fibrinolytic infusion has been successful in eliminating clots of the fourth ventricle. Posterior fossa decompression and direct evacuation of the clot could have good results in relieving brainstem compression caused by the clot.

CLINICAL PRESENTATION

A 45-year-old woman was admitted to our intensive care unit after experiencing an aneurysmal subarachnoid hemorrhage. The neurological examination at admission revealed that she was in Grade V according to the World Federation of Neurological Surgeons grading system, but brainstem reflexes were present. Computed tomographic scanning revealed a massive intraventricular hemorrhage, with fourth ventricle dilation caused by an intraventricular clot. Bilateral external ventricular drains were placed to relieve elevated intracranial pressure. Cerebral angiography revealed a 1-cm basilar tip aneurysm, which was embolized with Guglielmi detachable coils (Boston Scientific, Boston, MA) during the same procedure.

INTERVENTION

Given the patient's poor neurological condition, it was decided that brainstem compression should be relieved. A posterior fossa decompressive craniectomy was performed immediately after coil therapy, with direct evacuation of the intraventricular clot. The patient experienced a clear improvement in the level of consciousness and has achieved a good neurological result at early follow-up.

CONCLUSION

Dilation of the fourth ventricle by an intraventricular clot is a sign of brainstem compression that can be relieved by posterior fossa decompression and direct clot evacuation.
Microsurgical Removal of a Petrous Apex Meningioma after Stereotactic Radiation: Technical Case Report
Authors: Samii Madjid , Rosahl Steffen K. , Tatagiba Marcos S.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Stereotactic radiation is increasingly advocated as a primary treatment option for benign cranial base lesions. The clinical course of the patient reported herein raises questions regarding the rationale for initiation of radiotherapy to a petrous apex meningioma before microsurgery.

CLINICAL PRESENTATION

We report a 50-year-old woman who experienced medically refractory trigeminal pain. She was diagnosed with a meningioma around the petrous apex and treated by fractionated stereotactic radiation. After a short period of alleviation accompanied by hypesthesia, the pain returned in a previously unknown and violent fashion.

INTERVENTION

Complete tumor removal through a retrosigmoid intradural suprameatal approach resulted in immediate and permanent pain cessation.

CONCLUSION

Radiotherapy should be withheld for benign and accessible tumors of the cranial base until the option of radical microsurgical treatment has been explored.
Clinical Manifestations and Survival Rates among Patients with Saccular Intracranial Aneurysms: Population-based Study in Olmsted County, Minnesota, 1965 to 1995
Authors: Menghini Vanessa V. , Brown Robert D. , Sicks JoRean D. , O'Fallon W. Michael , Wiebers David O.
Published: July 2004

OBJECTIVE

To report presenting clinical symptoms, previous medical history, and survival rates for people with saccular intracranial aneurysms (IAs), in a defined population.

METHODS

The medical records of all residents of Olmsted County, Minnesota, with possible IAs were reviewed. Clinical manifestations at the time of diagnosis, previous medical history, demographic factors, and survival rates after diagnosis were determined.

RESULTS

Of 270 people with IAs detected between 1965 and 1995, 188 exhibited symptoms at the time of diagnosis, including 74% of women and 63% of men (P = 0.054). Intracranial hemorrhage (ICH) was the most common presenting symptom (60% of all patients and 86% of patients who exhibited symptoms), followed by cranial nerve palsy, transient ischemic attacks, and seizures. Survival rates after detection (with the exclusion of cases that were first detected during autopsies) were dependent on the occurrence of ICH; 23% of patients who presented with ICH died by 1 day after diagnosis, compared with 5% of those who did not exhibit symptoms or exhibited symptoms but without ICH at presentation. At 5 years, 44.7% of patients with hemorrhage had died, compared with 29.4% of patients with symptoms other than hemorrhage. After the first 24 hours after detection, survival rates did not differ significantly for those presenting with or without hemorrhage. Predictors of better survival rates also included lower age and later calendar year of presentation.

CONCLUSION

This study provides the first data on aneurysm characteristics, clinical symptoms, and survival rates among people with IAs in a defined population. During the study period, most aneurysms were detected in the context of an aneurysm-related symptom (particularly among women), with a large proportion of patients presenting with ICH. After the acute phase of hemorrhage, long-term survival rates among people with IAs were similar for those presenting with or without ICH.
Early Proactive Management of Vestibular Schwannomas in Neurofibromatosis Type 2
Authors: Brackmann Derald E. , Fayad Jose N. , Slattery William H. , Friedman Rick A. , Day John Diaz , Hitselberger William E. , Owens Robert M.
Published: July 2004

OBJECTIVE

The treatment of patients with neurofibromatosis Type 2 has always been challenging for neurosurgeons and neurotologists. Guidelines for appropriate management of this devastating disease are controversial.

METHODS

A retrospective study of 28 patients with neurofibromatosis Type 2 who underwent 40 middle fossa craniotomies for excision of their acoustic tumors is reported. Eleven patients underwent bilateral procedures. The study focused on hearing preservation and facial nerve results for this group of patients. The 16 male patients and 12 female patients ranged in age (at the time of surgery) from 10 to 70 years, with a mean age of 22.6 years. The mean tumor size was 1.1 cm (range, 0.5–3.2 cm), and the majority of tumors were less than 1.5 cm.

RESULTS

Measurable hearing was preserved in 28 ears (70%), with 42.5% being within 15 dB pure-tone average and 15% speech discrimination score of preoperative levels. In 55% of cases there was no change in the hearing class, as defined by the American Academy of Otolaryngology-Head and Neck Surgery. Of the 11 patients who underwent bilateral operations, 9 (82%) retained some hearing bilaterally. After 1-year follow-up periods (mean, 12.8 mo), 87.5% of patients exhibited normal facial nerve function (House-Brackmann Grade I).

CONCLUSION

Early surgical intervention to treat acoustic tumors among patients with neurofibromatosis Type 2 is a feasible treatment strategy, with high rates of hearing and facial nerve function preservation.
Long-term Outcome of 104 Patients after Lumbar Sequestrectomy According to Williams
Authors: Wenger Markus , Mariani Luigi , Kalbarczyk Andreas , Gröger Uli
Published: July 2004

OBJECTIVE

The authors report the late outcome of 104 consecutive patients after Williams' sequestrectomy for virgin lumbar disc herniation.

METHODS

The clinical records and the mailed questionnaires of 38 women and 66 men operated consecutively between March 1991 and November 1993 were analyzed retrospectively. In these 104 patients, 105 Williams' sequestrectomies were performed.

RESULTS

The mean age at operation was 50.5 years (range, 23.2–86.7 yr), and follow-up ranged from 4.1 to 6.9 years (mean, 5.3 yr). Success rates, including excellent, good, and fair results, were 92.5%, 94.7%, and 93.3% for lumbalgia, radicular pain, and neurological dysfunction, respectively. Only a few patients did not improve or presented with worsened symptoms. Three of four patients with cauda equina syndrome recovered immediately after the intervention. There were eight (7.7%) minor postoperative complications, which were treated conservatively. Three women and three men (5.8%) underwent a revision procedure for a recurrent lumbar disc herniation at the same level after 0.4 to 3.1 years (mean, 1.8 yr). Two (1.9%) of these patients underwent further operations because of reherniation, and they required internal instrumentation eventually because of failed back surgery syndrome.

CONCLUSION

Williams' conservative approach with sequestrectomy alone is a safe operative modality. It should be used whenever possible. As demonstrated in our series with a long follow-up time, the results are as favorable as or better than results after standard microsurgical lumbar discectomy with curettement of the interspace. Whether the incidence of failed back surgery syndrome can be reduced by this approach remains to be proved.
Middle Meningeal Origin of the Ophthalmic Artery
Authors: Liu Qingliang , Rhoton Albert L.
Published: July 2004

OBJECTIVE

To examine the microsurgical anatomy and clinical significance of an anomalous origin of the ophthalmic artery from the middle meningeal artery.

METHODS

In the course of an anatomic study of the cavernous sinus, an anomalous ophthalmic artery arising from the middle meningeal artery was found. To further define the anatomy of the region, five additional skulls, in which the arteries and veins were injected with colored latex, were dissected using 3× to 40× magnification.

RESULTS

The anomalous ophthalmic artery arose from the frontal branch of the middle meningeal artery, passed through the superior orbital fissure, and supplied the entire contents of the orbit, as well as giving rise to the central retinal artery. This study provides the first display of this anomaly in an anatomic dissection.

CONCLUSION

The ophthalmic artery may infrequently arise from the middle meningeal artery. This anomaly places the ophthalmic artery at risk during procedures in which the dura is elevated from the greater and lesser wings of the sphenoid or when the sphenoid ridge is removed and during embolization procedures involving the branches of the external carotid artery.
Isolated, Primary Extranodal Hodgkin's Disease of the Spine: Case Report
Authors: Citow Jonathan S. , Rini Brian , Wollmann Robert , Macdonald R. Loch
Published: July 2004

OBJECTIVE AND IMPORTANCE

To describe an unusual case of isolated, primary spinal Hodgkin's disease to draw attention to this disease as a possible diagnosis in patients with mixed inflammatory cell infiltrate lesions located in the spine.

CLINICAL PRESENTATION

A 54-year-old African American woman presented with back pain and progressive lower-extremity weakness as a result of spinal cord compression from Hodgkin's disease of the thoracic vertebrae.

INTERVENTION

The patient underwent decompressive surgery with stabilization, then was incorrectly treated with antituberculosis medication. When the disease progressed, later investigations revealed Hodgkin's disease, which responded to a course of radiation therapy. An extensive examination failed to detect lymphoma elsewhere.

CONCLUSION

Isolated, primary extranodal Hodgkin's disease of the spine is extremely rare. Seven other cases were reported in 1954. Although the Hodgkin's disease in these cases may arise in the bone of the spine, the possibility of origin in the paraspinous soft tissues also cannot be excluded.
Blood Clot Resolution in Human Cerebrospinal Fluid: Evidence of First-order Kinetics
Authors: Naff Neal J. , Williams Michael A. , Rigamonti Daniele , Keyl Penelope M. , Hanley Daniel F.
Published: July 2004

OBJECTIVE

To determine the kinetics of blood clot resolution in human cerebrospinal fluid.

METHODS

Computed tomographic scans of 17 adult patients with intraventricular hemorrhages were analyzed. Intraventricular clot volume was determined and analyzed over time to determine both a standardized percentage rate and an absolute rate of clot resolution. Results were analyzed by use of regression for cross sectional time-series data. To determine the kinetics of intraventricular clot resolution, the effect of the clot volume on the percentage rate of clot resolution, clot half-life, and absolute rate of clot resolution was analyzed. The potential effect of age, sex, type of hemorrhage, and treatment with external ventricular drainage on the percentage rate of clot resolution was assessed.

RESULTS

The percentage rate of clot resolution was 10.8% per day (95% confidence interval, 9.05–12.61%), and it was independent of initial clot volume, age, sex, type of underlying hemorrhage, and use of external ventricular drainage. The absolute rate of clot resolution varied directly with the maximal clot volume (R2 = 0.88;P < 0.001). The percentage clot resolution data are consistent with events during the first 24 to 48 hours that antagonize clot resolution.

CONCLUSION

These findings demonstrate that intraventricular blood clot resolution in patients with intraventricular hemorrhage follows first-order kinetics. The thrombolytic enzyme system responsible for intraventricular clot resolution seems to be saturated at 24 to 48 hours after the initial hemorrhage.
Successful Surgical Relief of Seizures Associated with Hamartoma of the Floor of the Fourth Ventricle in Children: Report of Two Cases
Authors: Delalande Olivier , Rodriguez Diana , Chiron Catherine , Fohlen Martine
Published: July 2004

OBJECTIVE AND IMPORTANCE

To discuss the physiopathology and surgical handling of seizures due to hamartoma of the floor of the fourth ventricle in two children.

CLINICAL PRESENTATION

Two girls aged 3 years at the time of their operations presented with seizures due to a lesion of the floor of the fourth ventricle. The seizures began within the first days of life and consisted of hemifacial contraction, then head deviation, blinking of the eyelids, and intermittent dysautonomic manifestations. The interictal neurological condition seemed normal in one patient and showed a slight development delay in the other. An ictal electroencephalogram showed slow waves in the posterior areas. A magnetic resonance imaging scan revealed a mass that remained unchanged on serial examinations bordering the fourth ventricle, with an isointense signal on T1-weighted sequences and high-intensity signals on T2-weighted sequences without gadolinium enhancement. An ictal single-photon emission computed tomographic scan showed hyperperfusion in the lesion in both girls.

INTERVENTION

The operation consisted of resection and disconnection of the lesion. An electrical recording was obtained in one patient during the operation while she was anesthetized; the recording, made by means of a depth electrode with five contacts inside the lesion, indicated that repetitive θ rhythmic discharges were present. Neuropathology was consistent with a hamartoma. In both girls, the seizures disappeared after their operations, and antiepileptic drugs were withdrawn (follow-up periods, 8 and 3 yr, respectively).

CONCLUSION

Considering the results of single-photon emission computed tomography, the intralesional electrical record, and the relief of seizures after the operation, we postulate that the seizures arose from inside the lesion. This particular kind of noncortical seizure is similar to gelastic seizure due to hypothalamic hamartoma.
Bilateral Resective Epilepsy Surgery in a Child with Tuberous Sclerosis: Case Report
Authors: Romanelli Pantaleo , Weiner Howard L. , Najjar Souhel , Devinsky Orrin
Published: July 2004

OBJECTIVE AND IMPORTANCE

Surgical intervention can reduce the burden of seizures in selected patients with tuberous sclerosis and medically refractory epilepsy.

CLINICAL PRESENTATION

A child presented with tuberous sclerosis and severe epilepsy beginning in the first month of life and delayed development before 1 year of age. Video-electroencephalographic monitoring at the age of 1 year revealed a left temporal seizure focus. Repeat video-electroencephalography at 2 years of age revealed a right posterior quadrant seizure focus. Bilateral subdural electrodes were placed, confirming independent seizure onsets from the right parietal area (overlying a tuber) and prominent interictal activity over the left superior temporal region.

INTERVENTION

The right parietal focus was resected, and electrodes were maintained over the left temporal focus. After right parietal resection, ictal discharges were recorded over the left temporal region; a corticectomy was performed 2 days later. No tonicoclonic or complex partial seizures have occurred during a follow-up period of more than 24 months. Simple partial motor seizures involving the right foot have been reduced by more than 80%, and other simple partial seizures have been eliminated. Postoperatively, there has been marked improvement in the patient's cognitive and motor developmental status.

CONCLUSION

In selected patients with bilateral seizure foci involving separate lobes, aggressive bilateral surgery can be safe and effective.
Dural Reconstruction with Fascia, Titanium Mesh, and Bone Screws: Technical Note
Authors: Sekhar Laligam N. , Sarma Sajjan , Morita Akio
Published: July 2004

OBJECTIVE

After the resection of cranial base tumors, there may not be enough free dural margin left for reconstruction after involved bone and dura have been removed. In such a situation, dural reconstruction becomes a problem. We propose a new technique of dural closure in such cases.

METHODS

A fascial graft is prepared from either fascia lata, abdominal fascia, pericranium, or temporal fascia and is trimmed to a size slightly larger than that of the dural defect. The fascial graft is placed over the dural defect and affixed to the underlying bone with a piece of titanium mesh, titanium screws, or both. The graft is then reinforced with fibrin glue.

RESULTS

This method of dural reconstruction has been used in five patients with basal meningiomas. Three were in the petromastoid area, and two were in the planum-ethmoid area. None of these patients experienced postoperative cerebrospinal fluid leak, and none experienced any complications related to the reconstruction.

CONCLUSION

This technique of dural reconstruction can be used in selected cases of basal tumors without enough free dural margin to sew into a fascial graft.
The Göteborg Cohort of Embolized Cerebral Arteriovenous Malformations: A 6-year Follow-up
Authors: Wikholm Gunnar , Lundqvist Christer , Svendsen Pål
Published: July 2004

OBJECTIVE

To present a follow-up of the results after endovascular treatment of cerebral arteriovenous malformations (AVMs) with acrylic glue. An initial follow-up was published in 1996.

METHODS

A cohort of 150 patients with cerebral AVMs underwent embolization between 1987 and 1993. Fifty-seven patients had supplemental stereotactic irradiation, and 13 had subsequent surgery. The follow-up was carried out clinically and radiologically.

RESULTS

The mean follow-up time was 6.2 years. Only four patients were lost to follow-up. If at least 90% of the AVM had been obliterated, the clinical course was stable and there were no new manifestations from the AVM. No recanalization occurred in any AVM that had been totally obliterated with glue. For patients in whom it was not possible to totally obliterate the AVM either with glue alone or glue supplemented with stereotactic irradiation or surgery, the long-term outcome was discouraging.

CONCLUSION

Obliteration of an AVM with acrylic glue seems to offer stability. If the AVM is totally obliterated, the patient had a stable clinical course. Patients with large AVMs with minor occlusion after embolization may have a worse clinical outcome than expected.
Rupture of Intracranial Aneurysms during Endovascular Coiling: Management and Outcomes
Authors: Levy Elad , Koebbe Christopher J. , Horowitz Michael B. , Jungreis Charles A. , Pride G. Lee , Dutton Kim , Kassam Amin , Purdy Phillip D.
Published: July 2004

OBJECTIVE

In this study, the incidence, etiologies, and management with respect to clinical outcome of patients with iatrogenic aneurysmal rupture during attempted coil embolization of intracranial aneurysms are reviewed.

METHODS

A retrospective analysis was conducted of 274 patients with intracranial aneurysms treated with Guglielmi detachable coils over a 6-year period from 1994 to 2000. Patient medical records were examined for demographic data, aneurysm location, the number of coils deployed preceding and after aneurysmal rupture, the etiology of the rupture, and the clinical status on admission and at the time of discharge.

RESULTS

Of 274 patients with intracranial aneurysms treated with coil embolization, six (2%) had an intraprocedural rupture. Of these six, two were women and four were men. The mean age was 67 years (range, 52–85 yr). Mean follow-up time was 8 months (range, 0–25 mo). Aneurysmal rupture resulted from detachment of the last coil in three patients, detachment of the third coil (of four) in one patient, and insertion of the first coil in another patient. In one patient, the aneurysmal rupture was a result of catheter advancement before detachment of the last coil. The Glasgow Outcome Scale score at last follow-up examination was 1 in two patients, 2 in two patients, and 5 in two patients.

CONCLUSION

The rate of rupture of aneurysms during coil embolization is approximately 2 to 4%. The clinical outcome may be related to the timing of the rupture and the number of coils placed before rupture. If extravasation of contrast agent is seen, which suggests intraprocedural rupture, further coil deposition should be attempted if safely possible.
Correlation between Magnetic Resonance Spectroscopy Imaging and Image-guided Biopsies: Semiquantitative and Qualitative Histopathological Analyses of Patients with Untreated Glioma
Authors: Croteau David , Scarpace Lisa , Hearshen David , Gutierrez Jorge , Fisher James L. , Rock Jack P. , Mikkelsen Tom
Published: July 2004

OBJECTIVE

Since intratumoral heterogeneity of gliomas is not adequately reflected in conventional magnetic resonance imaging (MRI), we sought to determine a correlation between different proton magnetic resonance spectroscopic imaging (1H MRSI) metabolic ratios and the degree of tumor infiltration in diffusely infiltrating gliomas. In this report, we describe the microscopic anatomy of gliomas on imaging.

METHODS

Image-guided biopsies with semiquantitative and qualitative histopathological analyses from a series of 31 untreated patients with low- and high-grade gliomas were correlated with multivoxel 1H MRSI referenced to the same spatial coordinates.

RESULTS

This series yielded 247 tissue samples and 307 observations. Choline-containing compounds using contralateral creatine and choline for normalization or ipsilateral N-acetylaspartate appear to correlate best with the degree of tumor infiltration. Similar correlations were present within each grade after stratification. Despite the interpatient overlap of metabolic ratios between normal tissue and mild tumor infiltration, preliminary analyses revealed that 1H MRSI appears more accurate than conventional MRI in defining the tumor boundary and quantifying the degree of tumor infiltration.

CONCLUSION

This is the first study showing histopathological validation of tumor boundaries using 1H MRSI. These results support the conclusion that 1H MRSI accurately reflects the extent of the disease in patients with gliomas. This has important diagnostic and therapeutic implications for more accurately assessing the burden of disease as well as for planning and assessing response to therapy.
Delayed Resolution of Residual Hemifacial Spasm after Microvascular Decompression Operations
Authors: Ishikawa Mami , Nakanishi Toru , Takamiya Yoshiaki , Namiki Jun
Published: July 2004

OBJECTIVE

After microvascular decompression to treat hemifacial spasm (HFS), resolution of the HFS is often gradual. We carefully investigated the course of the gradual resolution of HFS and examined the differences between patients with and without postoperative HFS.

METHODS

One hundred seventy-five patients with HFS were monitored, for observation of 1) whether postoperative HFS occurred, 2) when it occurred, and 3) when it disappeared after microvascular decompression. For two groups of patients, with (Group I) and without (Group II) postoperative HFS, we investigated age, sex, spasm side, preoperative facial nerve block (botulinum toxin treatment), decompression material, preoperative HFS period, offender (compressing vessel), temporary and permanent postoperative complications, and electromyographic findings.

RESULTS

In Group I (88 patients), postoperative HFS began within 4 days after surgery, a period that we have termed the silent period of postoperative HFS; the median value for the time to resolution was 28 days. The other 87 patients exhibited no postoperative HFS (Group II). There was a significantly higher incidence of postoperative facial weakness in Group II (Group II, 41.3%; Group I, 25.5%;P = 0.02 by logistic regression analysis). In Group I, there was no statistically significant relationship between the investigated parameters and the silent period or the postoperative HFS period, as determined by Cox proportional-hazards regression analysis, except for the number of preoperative facial nerve blocks. Electromyographic investigation of F waves revealed facial paresis during the silent period in a patient.

CONCLUSION

Approximately 50% of patients with HFS exhibited residual spasm postoperatively. An immediate postoperative silent period of 4 days without spasm was characteristic. One-quarter, one-half, and 90% of the residual spasm resolved by 1 week, 1 month, and 8 months after surgery, respectively.
Improving Clinical Outcomes from Acute Subdural Hematomas with the Emergency Preoperative Administration of High Doses of Mannitol: A Randomized Trial
Authors: Cruz Julio , Minoja Giulio , Okuchi Kazuo
Published: July 2004

OBJECTIVE

To evaluate clinical outcomes and postoperative physiological findings for comatose patients with acute subdural hematomas who received preoperative high-dose mannitol (HDM) versus conventional-dose mannitol treatment.

METHODS

One hundred seventy-eight adult patients with non-missile, traumatic, acute, subdural hematomas were prospectively and randomly assigned to receive emergency, preoperative, intravenous HDM treatment (91 patients), compared with a control group treated with a lower preoperative mannitol dose (87 patients).

RESULTS

Preoperative improvement of abnormal pupillary widening was significantly more frequent in the study group than in the control group of patients (P < 0.0001). Preoperative HDM treatment was also associated with significantly better clinical outcomes at 6-month follow-up evaluations (P < 0.01). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (relative cerebral hyperperfusion) in the control group, compared with the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was detected in 2.2 and 3.4% of the patients in the study and control groups, respectively.

CONCLUSION

Emergency preoperative HDM administration was associated with improved clinical outcomes for patients with acute subdural hematomas. Preoperative improvement of abnormal pupillary widening and better postoperative control of intracranial hypertension and associated relative cerebral hyperperfusion seemed to be relevant factors associated with improved outcomes.
Craniotomy Improves Outcomes for Cranial Subdural Empyemas: Computed Tomography-Era Experience with 699 Patients
Authors: Nathoo Narendra , Nadvi Syed Sameer , Gouws Eleanor , van Dellen James R.
Published: July 2004

OBJECTIVE

Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experience with 699 patients.

METHODS

Two analyses of the database (1983–1997) were performed. First, analysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed. Second, analysis of the composite database was performed. Outcomes were compared for possible outcome predictors by univariate analysis. Multivariate analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis.

RESULTS

Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the entire database (1983–1997) revealed a significant relationship between outcome and surgery type (P = 0.05). Pairwise comparison of limited procedures such as burr holes or craniectomies with wide-exposure surgical procedures such as primary craniotomies or procedures proceeding to full craniotomies indicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discriminant analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r2 = 0.034).

CONCLUSION

Craniotomy was determined to be the surgical procedure of choice for treatment of cranial SDEs, allowing complete evacuation of the pus and, more importantly, decompressing the underlying cerebral hemisphere. Limited procedures such as burr holes or craniectomies may be performed for patients in septic shock, for patients with parafalcine empyemas, or for children with SDEs secondary to meningitis.
Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery
Authors: Kelly Daniel F. , Oskouian R. Jamshid , Fineman Igor
Published: July 2004

OBJECTIVE

Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, “weeping” CSF leaks using collagen sponge is described.

METHODS

All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours.

RESULTS

During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage.

CONCLUSION

A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar drain placement.
Meningioma Radiosurgery: Tumor Control, Outcomes, and Complications among 190 Consecutive Patients
Authors: Stafford Scott L. , Pollock Bruce E. , Foote Robert L. , Link Michael J. , Gorman Deborah A. , Schomberg Paula J. , Leavitt Jacqueline A.
Published: July 2004

OBJECTIVE

To determine local control (LC) and complication rates for patients with intracranial meningiomas who underwent radiosurgery.

METHODS

One hundred ninety consecutive patients with 206 meningiomas underwent radiosurgery between 1990 and 1998. One hundred forty-seven tumors (77%) involved the cranial base. The median age at the time of radiosurgery was 58 years (range, 20–90 yr). There were 126 female patients (66%). One hundred twelve patients (59%) had undergone one or more previous operations (median, 1; range, 1–5). Twenty-two patients (12%) had either atypical (n = 13) or malignant (n = 9) tumors. The median prescription isodose volume was 8.2 cm3 (range, 0.5–50.5 cm3), and the median tumor margin dose was 16 Gy (range, 12–36 Gy). The median imaging and clinical follow-up periods were 40 and 47 months, respectively.

RESULTS

Overall survival rates for the entire cohort at 5 and 7 years were 82 and 82%, respectively; cause-specific survival rates at 5 and 7 years were 94 and 92%, respectively. The cause-specific survival rates at 5 years for patients with benign, atypical, and malignant tumors were 100, 76, and 0%, respectively (P < 0.0001). The 5-year LC rate was 89%, with 114 tumors (56%) decreasing in size. LC rates were correlated with tumor histological features (P < 0.0001); patients with benign tumors exhibited a 5-year LC rate of 93%, compared with 68 and 0% for patients with atypical or malignant meningiomas, respectively. No correlation was observed between radiation dose and LC rate. Twenty-four patients (13%) experienced treatment-related complications, including cranial nerve deficits (8%), symptomatic parenchymal changes (3%), internal carotid artery stenosis (1%), and symptomatic cyst formation (1%). Only six patients (3%) exhibited decreases in functional status that were directly related to radiosurgery. Tumor volume, tumor margin dose, or previous radiotherapy was not associated with the development of radiation-related complications.

CONCLUSION

Radiosurgery is an effective management strategy for many patients with meningiomas. Patients with atypical or malignant tumors exhibit high recurrence rates despite the use of radiosurgery, and these patients continue to exhibit worse cause-specific survival rates despite aggressive treatment, including surgery, external-beam radiotherapy, and radiosurgery. Further study is needed to determine the tumor control and complication rates 10 years or more after meningioma radiosurgery.
Outcomes after Aneurysm Rupture during Endovascular Coil Embolization
Authors: Tummala Ramachandra P. , Chu Ray M. , Madison Michael T. , Myers Mark , Tubman David , Nussbaum Eric S.
Published: July 2004

OBJECTIVE

Intracranial aneurysm rupture during placement of Guglielmi detachable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosurgical interventions to improve outcomes.

METHODS

We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The management and outcomes were recorded, and the pertinent literature was reviewed.

RESULTS

All 10 cases involved previously ruptured aneurysms. This complication occurred sporadically and was not observed in the first 100 cases. Perforation occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysms were located in the anterior circulation and three in the posterior circulation. Six of the 10 patients made good or fair recoveries; all three patients with posterior circulation lesions died immediately after rehemorrhage. Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly completed, and total or nearly total occlusion was achieved in all cases. Emergency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persistent dye extravasation after deployment of the first Guglielmi detachable coil, and persistent prolongation of contrast dye transit time (suggesting ongoing ICP elevation), were correlated with poor outcomes.

CONCLUSION

Previously ruptured aneurysms seem to be more susceptible to endovascular treatment-related perforation than are unruptured lesions. Worse prognoses are associated with iatrogenic rupture during coiling of posterior circulation lesions, compared with those in the anterior circulation. When perforation is recognized, the definitive treatment seems to be reversal of anticoagulation therapy and completion of Guglielmi detachable coil embolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.
Blood Transfusion during Aneurysm Surgery
Authors: Le Roux Peter D. , Elliott J. Paul , Winn H. Richard
Published: July 2004

INTRODUCTION

Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery.

METHODS

We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered.

RESULTS

A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1–17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 ± 0.35 units, whereas patients who did not have a rupture required 1.9 ± 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1–31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications.

CONCLUSION

Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.
Serum S100B Protein Levels Are Correlated with Subclinical Neurocognitive Declines after Carotid Endarterectomy
Authors: Connolly E. Sander , Winfree Christopher J. , Rampersad Anita , Sharma Ruchey , Mack William J. , Mocco J , Solomon Robert A. , Todd George , Quest Donald O. , Stern Yaakov , Heyer Eric J.
Published: July 2004

OBJECTIVE

Carotid endarterectomy (CEA) is an effective means of stroke prevention among appropriately selected patients; however, neuropsychometric testing has revealed subtle cognitive injuries in the early postoperative period. The purpose of this study was to establish whether serum levels of two biochemical markers of cerebral injury were correlated with postoperative declines in neuropsychometric test performance after CEA.

METHODS

Fifty-five consecutive patients underwent a battery of neuropsychometric tests 24 hours before and 24 hours after elective CEA. Two patients were excluded because of postoperative strokes. The pre- and postoperative serum levels of S100B protein and neuron-specific enolase for injured patients, defined as those who exhibited significant declines in neuropsychometric test performance (n = 12), were compared with the levels for uninjured patients (n = 41).

RESULTS

There were no significant differences in the baseline S100B levels for the two groups. Injured patients exhibited significantly higher S100B levels, compared with uninjured patients, at 24, 48, and 72 hours after surgery (P < 0.05). There were no significant differences in neuron-specific enolase levels for injured and uninjured patients at any time point.

CONCLUSION

These data suggest that subtle cerebral injuries after CEA, even in the absence of overt strokes, are associated with significant increases in serum S100B but not neuron-specific enolase levels. Analyses of earlier time points in future studies of subtle cognitive injuries and biochemical markers of cerebral injury after CEA may be revealing.
Infratentorial Supracerebellar Approach to the Colloid Cysts of the Third Ventricle
Authors: Konovalov Alexander N. , Pitskhelauri David I.
Published: July 2004

OBJECTIVE

The transcallosal and the frontal transcortical approaches are the most widely used methods in surgery of third ventricle colloid cysts. However, these approaches require traction of the frontal lobe and dissection of the corpus callosum or corticotomy and involve some postoperative consequences. The rationale of the proposed method is to remove the colloid cyst by the infratentorial supracerebellar approach and the posterior wall of the third ventricle without dissection of any neural structures.

METHODS

Five patients with a colloid cyst of the third ventricle were operated on by the proposed method. The first patient presented with several months' history of symptoms that included increased intracranial pressure and right-sided cerebellar signs, caused by a metastatic tumor of the right cerebellar hemisphere. The other four patients had symptoms including intracranial hypertension for an extended period of time without any other neurological deficits. In all patients, magnetic resonance imaging revealed a colloid cyst of the third ventricle without hydrocephalus.

TECHNIQUE

With the infratentorial supracerebellar approach, the arachnoid of the quadrigeminal cistern is dissected. The pineal body is separated and displaced from the internal vein medially, and the posterior velum interpositum is opened. Perforation of the inferior layer of the tela choroidea just above the suprapineal recess allows opening of the third ventricle cavity. A foraminal region is exposed after a slight lateral displacement of medial surfaces of the thalamus along the third ventricle roof.

CONCLUSION

The proposed approach through the infratentorial supracerebellar space and the posterior wall of the third ventricle may be used for removal of colloid cysts, especially in patients in whom the lateral ventricles are not enlarged.
Idiopathic Normal Pressure Hydrocephalus: A Systematic Review of Diagnosis and Outcome
Authors: Hebb Adam O. , Cusimano Michael D.
Published: July 2004

OBJECTIVE

Patient selection for cerebrospinal fluid diversion is difficult, because idiopathic normal pressure hydrocephalus (INPH) mimics other neurodegenerative disorders and no findings reliably predict outcome. The literature was reviewed to identify diagnostic criteria that predict shunt response and to formulate prognostic expectations.

METHODS

MEDLINE was searched, and 44 articles meeting predetermined criteria were included.

RESULTS

Clinical series were frequently retrospective with small patient numbers and unstandardized outcome evaluation. Clinical findings suggestive of shunt responsiveness were the complete triad (gait disturbance, urinary incontinence, and dementia) with early gait disturbance. Degree of hydrocephalus was not correlated with clinical improvement. Reduction of the subcortical low-blood flow area was correlated with improvement in three small studies. Clinical response to prolonged cerebrospinal fluid drainage predicted shunt outcome in all cases in two small series. Overall, 59% (range, 24–100%) of patients improved after shunting, and 29% (range, 10–100%) of patients experienced prolonged improvement. Complications occurred in 38% (range, 5–100%) of patients, additional surgery was required in 22% (range, 0–47%) of patients, and there was a 6% (range, 0–35%) combined rate of permanent neurological deficit and death.

CONCLUSION

Shunting INPH is associated with an approximately 29% rate of significant improvement and a 6% significant complication rate. Enlargement of the subcortical low-flow area and clinical improvement secondary to prolonged lumbar drainage may provide additive predictive value above clinical and computed tomographic criteria. A multicenter clinical trial that focuses on the value of ancillary tests, defines the clinical course of a patient with a ventriculoperitoneal shunt, and evaluates the cost effectiveness of shunting INPH is needed to better describe outcome from shunting in INPH.
Asymptomatic versus Symptomatic Infarcts from Vasospasm in Patients with Subarachnoid Hemorrhage: Serial Magnetic Resonance Imaging
Authors: Shimoda Masami , Takeuchi Masataka , Tominaga Jiro , Oda Shinri , Kumasaka Akira , Tsugane Ryuichi
Published: July 2004

OBJECTIVE

By use of serial magnetic resonance imaging (MRI), we prospectively investigated the incidence of and the risk factors associated with infarction caused by vasospasm with or without a delayed ischemic neurological deficit (DIND) in patients with subarachnoid hemorrhage (SAH).

METHODS

In 125 patients who underwent surgery for early aneurysms, postoperative MRI scans were obtained at four time points. We defined an infarct from vasospasm as a new lesion not present on the initial MRI within 3 days after SAH and therefore not attributable to primary brain damage or surgical complications.

RESULTS

Overall, symptoms of infarction (i.e., DIND) occurred in 38% of patients (48 of 125); DIND with a new infarct on MRI was evident in 34% (43 patients), whereas 4% (5 patients) showed no new lesion but had a DIND. However, 29 patients (23%) showed a new infarct but no DIND on MRI studies (asymptomatic infarction). Asymptomatic ischemic lesions due to vasospasm tended to involve noneloquent brain areas in the territory of intraparenchymal perforators. Multivariate analysis identified variables associated with symptomatic infarction to be of poor SAH grade, advanced age of the patient, angiographic findings of vasospasm, multiple cortical infarcts on MRI studies consistent with vasospasm, and chronic hydrocephalus.

CONCLUSION

Analysis of the data confirmed the occurrence of asymptomatic infarcts due to vasospasm. These infarcts often developed in noneloquent areas representing perforator territory. MRI investigation of vasospastic lesions referable to intraparenchymal vessels such as perforators complements the study of extraparenchymal major vessel vasospasm in patients with SAH by computed tomographic angiography.