bluuebunny/crossref_metadata_2025 huggingface dataset:
De novo formation of a central nervous system cavernous malformation: implications for predicting risk of hemorrhage
Authors: Detwiler Paul W. , Porter Randall W. , Zabramski Joseph M. , Spetzler Robert F.
Published: January 2008

The authors present a documented sporadic de novo cavernous malformation of the central nervous system in a patient undergoing follow-up magnetic resonance imaging after resection of an acoustic neuroma. The authors believe that this is the first report of a de novo cavernous malformation in a patient without a familial history of this disease or a history of treatment with cranial radiation. The occurrence of de novo lesions invalidates the common assumption that cavernous malformations are congenital lesions. The use of this assumption to calculate bleeding risks retrospectively in patients with cavernous malformations is likely to underestimate the risk of symptomatic hemorrhage significantly. Consequently, the de novo formation of cavernous malformations may be more common than appreciated and may explain the higher bleeding rates reported in prospective compared with retrospective studies of these lesions.
Molecular biological considerations in cerebral vasospasm following aneurysmal subarachnoid hemorrhage
Authors: Thomas Jeffrey E.
Published: January 2008

Chronic delayed cerebral vasospasm (CDCV) remains a serious and often fatal complication of aneurysmal subarachnoid hemorrhage (SAH). The current understanding of its fundamental mechanisms and molecular biological characterization is rudimentary. Two important vasoactive substances have been implicated in CDCV: endothelin-1 (ET-1) and nitric oxide (NO). A 21-amino acid vasoconstrictor peptide, ET-1 has generated interest as a possible important contributor to cerebral vasospasm on the basis of both clinical and experimental evidence suggesting abnormally enhanced production. Nitric oxide is a cell membrane-permeable free radical gas that accounts for the vasodilatory effect of endothelium-derived relaxation factor and is a physiological antagonist of ET-1. As with ET-1, abnormalities of NO production have been implicated in several pathological conditions including cerebral vasospasm. This brief report reviews some of the physiological and regulatory features of these two molecules and explores the possibility of their relationship to cerebral vasospasm.
Growth factors in central nervous system development and tumorigenesis
Authors: Lazio Barbara E. , Chin Lawrence S.
Published: January 2008

Growth factors play an important role in the development of the normal central nervous system as well as in the genesis of central nervous system tumors. Some of the more important growth factors and growth factor receptors, as they pertain to neurooncology, are reviewed in this article.
Current concepts of apoptosis
Authors: Harter David H. , Doherty Patrick F. , Chin Lawrence S.
Published: January 2008

Apoptosis is a carefully regulated process involved in developmental and immunological events. The alteration of apoptotic pathways is important in the establishment and progression of neoplasia. Apoptosis allows for the orderly removal of excess cells but, in contrast to necrosis, it is not an inflammatory process. Many of the molecular components and effectors of apoptosis have been described. In this review the authors briefly discuss the current understanding of apoptosis in the context of the two prevailing hypotheses, the “conflicting signal” and “dual signal” theories.
Surgical reconstruction of the musculocutaneous nerve in traumatic brachial plexus injuries
Authors: Samii Madjid , Carvalho Gustavo A. , Nikkhah Guido , Penkert Götz
Published: January 2008

Over the last 16 years, 345 surgical reconstructions of the brachial plexus were performed using nerve grafting or neurotization techniques in the Neurosurgical Department at the Nordstadt Hospital, Hannover, Germany. Sixty-five patients underwent graft placement between the C-5 and C-6 root and the musculocutaneous nerve to restore the flexion of the arm. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 54 patients: 1) time interval between injury and surgery; 2) choice of the donor nerve (C-5 or C-6 root); and 3) length of the grafts used for repairs between the C-5 or C-6 root and the musculocutaneous nerve.

The postoperative follow-up interval ranged from 9 months to 14.6 years, with a mean ± standard deviation of 4.4 ± 3 years. Reinnervation of the biceps muscle was found in 61% of the patients. Comparison of the different preoperative time intervals (1-6 months, 7-12 months, and > 12 months) showed a significantly better outcome in those patients with a preoperative delay of less than 7 months (p < 0.05). Reinnervation of the musculocutaneous nerve was demonstrated in 76% of the patients who underwent surgery within the first 6 months postinjury, in 60% of the patients with a delay of between 6 and 12 months, and in only 25% of the patients who underwent surgery after 12 months. Comparison of the final outcome according to the root (C-5 or C-6) that was used for grafting the musculocutaneous nerve showed no statistical difference.

Furthermore, statistical analysis (regression test) of the length of the grafts between the donor (C-5 or C-6 root) nerve and the musculocutaneous nerve displayed an inverse relationship between the graft length and the postoperative outcome.

Together, these results provide additional information to enhance the functional outcome of brachial plexus surgery.
Is routine transcranial Doppler ultrasound useful in the management of subarachnoid hemorrhage?
Authors: Wardlaw Joanna M. , Offin Ruth , Teasdale Graham M. , Teasdale Evelyn M.
Published: January 2008

In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were accurate when compared with those obtained on angiography. The authors conclude that a routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleened from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess this definitively.
The complement membrane attack complex and the bystander effect in cerebral vasospasm
Authors: Park Charles C. , Shin Moon L. , Simard J. Marc
Published: January 2008

Activation of complement results in formation of membrane attack complexes (MACs) that can insert themselves either into cells that initiate complement activation or into nearby (“innocent bystander”) cells. The MACs form large-conductance, nonspecific ion channels that can cause lytic or sublytic cell damage. The authors used a highly sensitive patch clamp technique to assess the contribution of the bystander effect to the pathophysiology of cerebral vasospasm. They compared the effect of complement activation by autologous aged versus fresh erythrocytes on the membrane conductance of freshly isolated rat cerebral artery smooth-muscle cells. In the presence of autologous serum, aged, but not fresh, erythrocytes caused a large increase in membrane conductance, an effect that was prevented by heat-inactivating the serum. Ethyleneglycol tetraacetic acid in the presence of Mg++ attenuated the effect, indicating that complement activation was taking place via the classic pathway. The effect was reproduced by zymosan-activated autologous serum, suggesting that such changes in conductance could result from insertion of MACs secondary to a bystander effect. Both C8- and C9-depleted heterologous sera produced minimal effects that were converted to full effect by addition of the missing complement component. Superoxide dismutase plus catalase did not attenuate the conductance changes produced by autologous serum plus aged erythrocytes. Autologous serum plus aged erythrocyte membrane ghosts that were free of lysate caused a typical increase in conductance. This study demonstrates that complement activation by aged erythrocytes can result in MAC insertion into innocent bystander smooth-muscle cell membranes and that this mechanism, heretofore undescribed, may contribute to development of vasospasm after subarachnoid hemorrhage.
Distribution and stability of antisense phosphorothioate oligonucleotides in rodent brain following direct intraparenchymal controlled-rate infusion
Authors: Broaddus William C. , Prabhu Sujit S. , Gillies George T. , Neal Jeffrey , Conrad William S. , Chen Zhi-Jian , Fillmore Helen , Young Harold F.
Published: January 2008

High-flow microinfusion is a novel technique for delivery of compounds directly into the brain parenchyma, bypassing the blood-brain barrier. The feasibility of this technique has been demonstrated with low-molecular-weight compounds, macromolecular dyes, and proteins. Delivery of antisense oligonucleotides into the brain parenchyma represents an additional potential application of this technique not previously described. In this report, the authors examined the distribution and disposition of phosphorothioate oligodeoxynucleotide (PS-ODN) infused for this reason. An 18-mer 35S-PS-ODN (molecular weight approximately 6000) was infused over 1 hour into the caudate putamen of Fischer 344 rats. At 1, 6, 12, 24, and 48 hours after beginning the infusion, the brains were extracted and analyzed using quantitative autoradiographic techniques. Cerebrospinal fluid (CSF) was also aspirated from the cisterna magna and analyzed for radioactivity and stability of the 35S-PS-ODN. At 1 hour, the infused ODN was uniformly distributed in brain tissue, with a maximum average concentration of 4806.5 ± 210.5 nCi/g. This represents a tissue concentration of 19.2 ± 0.84 μM. Extensive spread into surrounding parenchyma was observed over the ensuing 47 hours. The 35S-PS-ODN radioactivity peaked in the CSF at the end of the 1-hour infusion, containing 10% (50 ± 20 nCi) of the infused radioactivity. Activity then decayed exponentially over 11 hours, stabilizing at a lower CSF content of 0.2% (1 ± 0.1 nCi). The volume of distribution (Vd) was 105 ± 7.9 mm3 at 1 hour, representing a ratio of Vd/Vi (volume of infusion) of 5.2. The Vd increased to 443.4 ± 62.3 mm3 at the end of 48 hours, whereas the average minimum tissue concentration decreased from 15.2 to 3.2 μM. Undegraded 18-mer was seen throughout the 48-hour period using 20% polyacrylamide/7M urea gel electrophoresis. The animals tolerated the infusion without evidence of toxicity, and minimal structural changes in tissue were observed on histological examination. Thus, PS-ODN can be safely delivered in high concentrations to wide areas of the rat brain by using high-flow microinfusion, and the concentrations remain stable even after 48 hours in situ.
Activated lymph node T cells for systemic adoptive immunotherapy of malignant glioma
Authors: Plautz Gregory E. , Barnett Gene H. , Miller David W. , Cohen Bruce H. , Prayson Richard A. , Krauss John C. , Luciano Mark , Shu Suyu
Published: January 2008

Ten patients with progressive primary or recurrent malignant glioma received systemic adoptive immunotherapy to determine the feasibility, toxicity, and potential therapeutic benefits of this treatment. Adoptive immunotherapy, the transfer of immune T lymphocytes, is capable of mediating the regression of experimental brain tumors in animal models. A rich source of tumor-immune T cells are lymph nodes (LNs) draining the tumor vaccine site. In this clinical study, patients were inoculated intradermally with irradiated autologous tumor cells and granulocyte-macrophage colony stimulating factor as an adjuvant. Cells from draining inguinal LNs, surgically resected 7 days after vaccination, were stimulated sequentially with staphylococcal enterotoxin A and anti-CD3, and a low dose of interleukin-2 (60 IU/ml) was used to expand the stimulated cells. The maximum cell proliferation was 350-fold over 10 days of culture. The activated cells were virtually all T cells consisting of various proportions of CD4 and CD8 cells. These cells were given to patients by intravenous infusion at doses ranging from 9 X 108 to 1.5 X 1011. There were no Grade 3 or 4 toxicities associated with the treatment. Following T cell transfer therapy, radiographic regression that lasted at least 4 months was demonstrated in three patients with recurrent tumors, and four patients remain alive more than 11 months after surgery. The remaining patients had progressive disease, and three patients required intervention with corticosteroid agents or additional surgery approximately 1 month following cell transfer. These findings demonstrate that adoptive immunotherapy can be administered in patients with glioma without causing significant toxicity. It appears that this experimental regimen can provide therapeutic benefits for some patients.
Surgical treatment of craniopharyngiomas. Part I. Experience with 168 patients
Authors: Fahlbusch Rudolf , Honegger Jürgen , Paulus Werner , Huk Walter , Buchfelder Michael
Published: January 2008

The surgical management of 168 consecutive patients harboring craniopharyngiomas treated between January 1983 and April 1997 is described. In 148 patients undergoing initial (primary) surgery, the pterional approach was most frequently used (39.2%) followed by the transsphenoidal approach (23.6%). For large retrochiasmatic craniopharyngiomas, the bifrontal interhemispheric approach was used increasingly over the pterional approach and led to improved surgical results. Total tumor removal was accomplished in 45.7% of transcranial and 85.7% of transsphenoidal procedures. The main reasons for incomplete removal were attachment and/or infiltration of the hypothalamus, major calcifications, and attachment to vascular structures. The success rate in total tumor removal was inferior in the cases of tumor recurrence. The operative mortality rate in transcranial surgery was 1.1% in primary cases and 10.5% in cases of tumor recurrence. No patient died in the group undergoing transsphenoidal surgery. The rate of recurrence-free survival after total removal was 86.9% at 5 years and 81.3% at 10 years. In contrast, the 5-year recurrence-free survival rate was only 48.8% after subtotal removal and 41.5% after partial removal. Following primary surgery, the actuarial survival rate was 92.7% at 10 years, with the best results after complete tumor removal. At last follow up, 117 (79%) of 148 patients who underwent primary surgery were independent and without impairment.

Total tumor removal while avoiding hazardous intraoperative manipulation provides favorable early results and a high rate of long-term control in craniopharyngiomas.
Optimization of the operative corridor for the resection of craniopharyngiomas in children: the combined frontoorbitozygomatic temporopolar approach
Authors: Levy Michael L. , Khoo Larry T. , Day J. Diaz , Liker Mark , McComb J. Gordon
Published: January 2008

Complete extirpation of tumor remains the primary goal of neurosurgeons in treating intracranial craniopharyngiomas. The intimate relationship of these lesions with the structures of the skull base and the difficulties of obtaining adequate operative visualization often make total removal an elusive goal. The authors describe the use of a combined fronto-orbitozygomatic temporopolar craniotomy to maximize the operative corridor and thereby increase the probability of maximum tumor resection without morbidity and mortality. They applied this approach in four children with craniopharyngiomas that involved the sellar and parasellar, third ventricle, cavernous sinus, and interpeduncular fossa regions. The surgical results are summarized with a presentation of pre- and postoperative imaging from two illustrative cases. A detailed description of the operative procedure is provided with a comparison to other previously described surgical approaches.
Treatment of cystic craniopharyngiomas with yttrium-90 colloid solution.
Authors: Julow Jenö , Lányi Ferenc , Hajda Márta , Szeifert György T. , Bálint Katalin , Drasny Gábor , Pásztor Emil , Fedorcsák Imre , Borbély Katalin , Nyáry István
Published: January 2008

The authors analyzed long-term follow-up data to assess the value of intracavitary irradiation with stereotactically implanted beta-emitting radioisotope 90Y-silicate colloid for the treatment of craniopharyngiomas. Fifty-seven craniopharyngiomas in 42 patients were selected for retrospective analysis. The yttrium-90 was implanted intracavitally, using computerized tomography-guided and three-dimensional stereotactic treatment planning. The cumulative dose aimed at the inner surface of the cyst wall was 300 Gy.

An average of 75% shrinkage of the initial cyst volume was observed. In 18 cases the reduction was more than 91%, and the cyst disappeared totally in 11 cases.

A 50% decrease in cyst volume was usually apparent between the 2nd and 4th months. A 70% decrease in cyst volume was seen by the 5th and 6th months and an 80% reduction by the 7th and 8th months. Cysts that were unchanged remained so throughout the observation period. The time course of volume reduction could be expressed mathematically by the formula of 0.73 X e-0.62 X T + 0.27, where “e” is the basic number of natural logarithm and “T” is the time expressed in months. Mean survival duration after intracavitary irradiation was 9.4 years.

The shrinkage of the cyst was a consequence of fibrosis of the wall, as seen on histopathological examination. The neuroophthalmological prognosis was favorable only when the optic disc was normal or nearly normal at the time of the treatment. In the presence of preexisting optic atrophy, visual deterioration proved to be irreversible. The long-term results support the view that intracavitary90Y-irradiation is a noninvasive and very effective method of treatment for craniopharyngioma cysts. Because of the 1.1 mm half-life decay of beta irradiation, it cannot influence the solid part of the tumor; therefore, the best result can be expected in solitary cysts.
Ruptured giant intracranial aneurysms. Part I. A study of rebleeding
Authors: Khurana Vini G. , Piepgras David G. , Whisnant Jack P.
Published: January 2008

Object

The present study was conducted to estimate the frequency and timing of rebleeding after initial subarachnoid hemorrhage (SAH) from ruptured giant aneurysms.

Methods

The authors reviewed records of 109 patients who suffered an initial SAH from a giant aneurysm and were treated at the Mayo Clinic between 1973 and 1996. They represented 25% of patients with giant intracranial aneurysms seen at this institution during that 23-year period. Seven of the patients were residents of Rochester, Minnesota, and the rest were referred from other institutions. The aneurysms ranged from 25 to 60 mm in diameter, and 74% were located on arteries of the anterior intracranial circulation. The cumulative frequency of rebleeding at 14 days after admission was 18.4%. Cerebrospinal fluid drainage, cerebral angiography, and delayed aneurysm recurrence were implicated in rebleeding in some of the patients. Rebleeding was not precluded by intraaneurysm thrombosis. Among those who suffered recurrent SAH at the Mayo Clinic, 33% died in the hospital.

Conclusions

Rebleeding from giant aneurysms occurs at a rate comparable to that associated with smaller aneurysms, a finding that should be considered in management strategies.
Papillomas and carcinomas of the choroid plexus in children
Authors: Pencalet Philippe , Sainte-Rose Christian , Lellouch-Tubiana Arielle , Kalifa Chantal , Brunelle Francis , Sgouros Spiros , Meyer Philippe , Cinalli Giuseppe , Zerah Michel , Pierre-Kahn Alain , Renier Dominique
Published: January 2008

Object

Choroid plexus tumors are rare intraventricular tumors (1% of all intracranial tumors) that occur mainly in children. The physiopathological characteristics of associated hydrocephalus, surgical management, and oncological issues related to these tumors remain a matter of debate. To understand more about these tumors, the authors have reviewed their experience with the management of 38 children with choroid plexus tumors.

Methods

There were 25 cases of papilloma and 13 of carcinoma. The mean age of the patients at presentation was 22.5 months and one-half of the patients were younger than 2 years of age. Hydrocephalus was present in 33 patients and poorly correlated with the size, site, and pathological characteristics of the tumor. In nine children, a ventriculoperitoneal shunt was required after tumor excision, calling into question the notion that cerebrospinal fluid oversecretion is the only cause of hydrocephalus.

Complete excision was achieved in 96% of the cases of papilloma and 61.5% of the cases of carcinoma. These surgical procedures were complicated by the risks of perioperative hemorrhage, which proved to be fatal in two cases, and postoperative brain collapse, which led to subdural fluid collections requiring subdural shunt placement in six patients. Preoperative embolization was partially successful in four cases and significantly assisted surgery. Preoperative controlled drainage of excessively dilated ventricles and intraoperative gluing of the cortical incision have been used to address the problem of postoperative brain collapse.

Patients with carcinomas were treated postoperatively by chemotherapy alone (seven cases), radiotherapy (one case), or chemotherapy plus radiotherapy (one case). The overall 5-year survival rate was 100% for patients with papillomas and 40% for those with carcinomas.

Conclusions

Total surgical excision is curative in cases of papillomas. For carcinomas, the most effective treatment remains total surgical excision; however, adjuvant treatment in the form of chemotherapy in patients younger than 3 years, supplemented by radiation therapy in older children, can moderately reduce the risk of recurrence.
Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy
Authors: Gerszten Peter C. , Albright A. Leland , Johnstone Graham F.
Published: January 2008

Intrathecal baclofen infusion (IBI) is an effective treatment for spasticity secondary to cerebral palsy (CP). The authors retrospectively reviewed the need for orthopedic surgery of the lower extremities in 48 patients with spastic CP who were treated with IBI. Forty pumps were placed in patients suffering from spastic quadriplegia (84%) and eight (16%) in patients with spastic diplegia. The patients' ages ranged from 5 to 43 years (mean 15 years). The mean follow-up period was 53 months (range 22-94 months). The mean baclofen dosage was 306 μg/day (range 25-1350 μg/day). At the time of pump placement, subsequent orthopedic surgery was planned in 28 patients (58%); however, only 10 (21%) underwent orthopedic surgery after IBI therapy. In all 10 cases, the surgical procedure was planned at the time of initial evaluation for IBI therapy. In the remaining 18 patients, who did not subsequently undergo their planned orthopedic operation, it was believed that their lower-extremity spasticity had improved to the degree that orthopedic intervention was no longer indicated. In addition, although six patients had undergone multiple orthopedic operations before their spasticity was treated, no patient required more than one orthopedic operation after IBI treatment for their spasticity. The authors conclude that IBI for treatment of spastic CP reduces the need for subsequent orthopedic surgery for the effects of lower-extremity spasticity. In patients with spastic CP and lower-extremity contractures, spasticity should be treated before orthopedic procedures are performed.
Percutaneous lumbar discectomy with a working endoscope and laser assistance
Authors: Savitz Martin H. , Doughty Howard , Burns Paul
Published: January 2008

The authors describe percutaneous disc surgery performed via the unilateral monoportal method with a C-arm image intensifier, a working endoscope, and an yttrium-aluminum-garnet laser in 300 patients at three community hospitals over a 6-year period. Visualizing the area of the annulus to be fenestrated, verifying the status of the nerve root, inspecting the cavity created, and monitoring laser hemostasis and vaporization all contributed to patient safety. Fewer than 2% of the cases required a second surgery. The only postoperative sequelae recorded were one psoas hematoma, which resolved, and sympathetic mediated pain in 5% of the patients who responded to appropriate treatment. For treatment of a prolapsed lumbar disc, a 1-hour endoscopic procedure performed while the patient receives a neuroleptanalgesic continues to be a significant surgical alternative.
Recombinant human morphogenetic protein: its future role in spinal fusions
Authors: Chen Thomas C.
Published: January 2008

The marriage of basic scientific research and clinical application often leads to profound advances in our understanding of various disease processes and how they may be ameliorated. One such fortuitous combination has been the discovery of bone morphogenetic proteins (BMPs) and their potential application in spinal fusions. The goal of this article is to introduce the neurosurgeon to the basic biology of this protein family, current experimental data (in vitro and in vivo models) demonstrating their effectiveness in enhancing bony fusions, and preliminary clinical trials utilizing BMP in long bone fusions. Using this information, a proposal for the use of BMP in spinal fusions under various clinical scenarios will be discussed.
Vertebral artery injury in C1-2 transarticular screw fixation: results of a survey of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves
Authors: Wright Neill M. , Lauryssen Carl
Published: January 2008

Object

The 847 active members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Section on Disorders of the Spine and Peripheral Nerves were surveyed to quantitate the risk of vertebral artery (VA) injury during C1-2 transarticular screw placement.

Methods

This retrospective study elicited the number of patients treated with transarticular screws, the number of screws placed, the incidence of VA injury and subsequent neurological deficit, and the management of known or suspected VA injury.

Two hundred thirteen (25.1%) of the 847 surgeons responded. One hundred one respondents (47.4%) had placed a total of 2492 C1-2 transarticular screws in 1318 patients. Thirty-one patients (2.4%) had known VA injuries and an additional 23 patients (1.7%) were suspected of having injuries. However, only two (3.7%) of the 54 patients with known or suspected VA injuries exhibited subsequent neurological deficits and only one (1.9%) died from bilateral VA injury. Other iatrogenic complications included dural tears, screw fractures, screw breakout, fusion failure, infection, and suboccipital numbness.

Conclusions

Including both known and suspected cases, the risk of VA injury was 4.1% per patient or 2.2% per screw inserted. The risk of neurological deficit from VA injury was 0.2% per patient or 0.1% per screw, and the mortality rate was 0.1%. The choice of management of intraoperative VA injuries was evenly divided between placing the patient under observation and initiating immediate postoperative angiography with possible balloon occlusion.
Basilar invagination: a study based on 190 surgically treated patients
Authors: Goel Atul , Bhatjiwale Mohinish , Desai Ketan
Published: January 2008

Object

The authors analyzed the cases of 190 patients with basilar invagination that was diagnosed on the basis of criteria laid down in 1939 by Chamberlain to assess the appropriate surgical procedure.

Methods

Depending on the association with Chiari malformation, the anomaly of basilar invagination was classified into two groups. Eighty-eight patients who had basilar invagination but no associated Chiari malformation were assigned to Group I; the remainder of the patients, who had both basilar invagination and Chiari malformation, were assigned to Group II. The principal pathological characteristic was observed to be direct brainstem compression due to odontoid process indentation in Group I and a reduction in posterior cranial fossa volume in Group II.

Conclusions

Despite the anterior concavity of the brainstem in both groups, transoral surgery was the most suitable procedure for those patients in Group I and decompression of the foramen magnum was found to be appropriate for patients in Group II. After surgical decompression, a fixation procedure was found to be necessary in most Group I cases, but only in a small minority of Group II cases.
Three-dimensional image reconstruction for low-grade glioma surgery
Authors: Chabrerie Alexandra , Ozlen Fatma , Nakajima Shin , Leventon Michael E. , Atsumi Hideki , Grimson Eric , Jolesz Ferenc , Kikinis Ron , Black Peter McL.
Published: January 2008

Three-dimensional image reconstruction for preoperative surgical planning and intraoperative navigation for the resection of low-grade gliomas was performed in 20 patients. Thirteen of these surgeries were performed while the patient received a local anesthetic to allow for cortical mapping. Ninety percent of the patients were functionally intact postoperatively. The authors propose that the combination of the three-dimensional image reconstruction and surgical navigation, in conjunction with intraoperative cortical mapping, provides an additional means for surgeons to improve the safety and precision of the procedures.
Hereditary neurological tumor syndromes: clues to glioma oncogenesis?
Authors: Chen Thomas C.
Published: January 2008

The author reviewed five hereditary neurological tumor syndromes associated with gliomas: Li-Fraumeni cancer syndrome, neurofibromatosis type 1 (NF1) and type 2 (NF2), tuberous sclerosis (TS), and Turcot syndrome. In each case, clinical manifestation, genetic localization, and protein function were identified. Correlation with glioma oncogenesis demonstrated the following associations: 1) p53 mutation (Li-Fraumeni) with astrocytoma progression; 2) NF1 mutation (NF1) with pilocytic astrocytomas; and 3) NF2 mutation (NF2) with ependymoma formation. The role of the TS gene and the adenomatous polypopsis coli gene (Turcot syndrome) in glioma oncogenesis is not clear. Because tumorigenesis is a multistep process, it would be premature to equate a specific germline mutation with the multiple somatic mutations required for glioma formation. However, identification of specific germline genetic mutations provides a model for the multiple tumor suppressor genes involved in glioma pathogenesis.
Retention of an appropriate astrocytic response to retinoids by human brain tumors composed of predominantly glial fibrillary acidic protein-positive cells
Authors: Noll Elizabeth , Black Peter McL.
Published: January 2008

It has been demonstrated that glial fibrillary acidic protein (GFAP)-positive astrocyte precursors will differentiate in response to application of retinoic acid (RA), whereas GFAP/oligodendrocyte type 2-astrocyte progenitors will be inhibited from differentiating and continue to be mitotically active in the presence of RA. The authors sought to determine if cells taken from glial tumors that were GFAP positive retained the ability to differentiate following application of RA in vitro, as their normal astrocytic counterparts do. Primary cultures of seven astrocytic tumors were observed to have significantly fewer cells following 1 month of continuous exposure to 100 μM RA. Comparisons with sister control cultures indicated that in control conditions the tumor cells had undergone proliferation, whereas the number of cells in the RA-exposed cultures remained closer to the number of cells initially plated. This response to RA was demonstrated to be specific to the astrocytic tumors by virtue of the fact that cultures of normal brain and an anaplastic ependymoma both showed a strong proliferative response to retinoids.
Phase II study of carboplatin (CBDCA) in progressive low-grade gliomas
Authors: Moghrabi Albert , Friedman Henry S. , Ashley David M. , Bottom Krystal S. , Kerby Tracy , Stewart Elizabeth , Bruggers Carol , Provenzale James M. , Champagne Martin , Hershon Linda , Watral Melody , Ryan Janis , Rasheed Karima , Lovell Shelley , Korones David , Fuchs Herbert , George Timothy , McLendon Roger E. , Friedman Allan H. , Buckley Edward , Longee Darryl C.
Published: January 2008

In this study, the authors sought to investigate the response rate and toxicity of carboplatin in patients with progressive low-grade glioma (LGG). Thirty-two patients with progressive LGG were treated with carboplatin at a dosage of 560 mg/m2. Treatment was given at 4-week intervals and continued until the disease progressed, unacceptable toxicity supervened, or for 12 additional courses after achieving maximal response. Patients with stable disease were treated with a total of 12 cycles. All patients were treated as outpatients. Patients were evaluated for response to treatment and toxicity.

All patients received a minimum of two cycles of carboplatin, and were examined for response. A partial response was achieved in nine patients (28%) and a minimal response in two (6%), for an overall response rate of 34% (11 of 32 patients). Eighteen patients (56%) had stable disease. A partial response was achieved in the nine patients after a median of six cycles (range 4-11 cycles), a minimal response was achieved in the two patients after five cycles. Glioma progression was noted in three patients after three, five, and five cycles, respectively. The 11 patients in whom some response was achieved had either an optic pathway tumor or a juvenile pilocytic astrocytoma. Twenty-six of the 32 patients had those characteristics, making the response rate in that group 42% (11 of 26 patients). Thirty-two patients received a total of 387 cycles of chemotherapy. Hematological toxicity was moderate. Twenty-one patients developed thrombocytopenia (platelet count < 50,000/μl); three patients required one platelet transfusion each. Nine patients developed neutropenia (absolute neutrophil count < 500/μl); one developed fever and required administration of antibiotic agents. One dose adjustment in each of the patients prevented further thrombocytopenia and neutropenia. Two patients with stable disease died of respiratory complications. One patient developed Grade III ototoxicity after receiving five cycles, one patient developed hypersensitivity to carboplatin, and none developed nephrotoxicity.

Carboplatin given at a dosage of 560 mg/m2 every 4 weeks has activity in patients with progressive LGG. This drug regimen is relatively simple and well tolerated. Further investigation and longer follow-up study are warranted.
Long-term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study
Authors: Javid Manucher J. , Hadar Eldad J.
Published: January 2008

Object

Decompressive laminectomy for stenosis is the most common operation performed on the lumbar spine in older patients. This prospective study was designed to evaluate long-term results in patients with symptomatic lumbar stenosis.

Methods

Between January 1984 and January 1995, 170 patients underwent surgery for lumbar stenosis (86 patients), lumbar stenosis and herniated disc (61 patients), or lateral recess stenosis (23 patients). The male/female ratio for each group was 43:43, 39:22, and 14:9, respectively. The average age for all groups was 61.4 years. For patients with lumbar stenosis, the success rate was 88.1% at 6 weeks and 86.7% at 6 months. For patients with lumbar stenosis and herniated disc, the success rate was 80% at 6 weeks and 77.6% at 6 months, with no statistically significant difference between the two groups. For patients with lateral recess stenosis, the success rate was 58.7% at 6 weeks and 63.6% at 6 months; however, the sample was not large enough to be statistically significant. One year after surgery a questionnaire was sent to all patients; 163 (95.9%) responded. The success rate in patients with stenosis had declined to 69.6%, which was significant (p = 0.012); the rate for patients with stenosis and herniated disc was 77.2%; and that for lateral recess stenosis was 65.2%. Another follow-up questionnaire was sent to patients 1 to 11 years after surgery (average 5.1 years); 146 patients (85.9%) responded, 10 (5.9%) were deceased, and 14 (8.2%) were lost to follow-up review. At 1 to 11 years the success rate was 70.8% for patients with stenosis, 66.6% for those with stenosis and herniated disc, and 63.6% for those with lateral recess stenosis. Eleven patients who underwent reoperation were included in the group of patients whose surgeries proved unsuccessful, regardless of their ultimate outcome. There was no statistically significant difference in outcome between 1 year and 1 to 11 years with respect to stenosis, stenosis with herniated disc, and lateral recess stenosis.

Conclusions

In conclusion, long-term improvement after laminectomy was maintained in two-thirds of these patients.
Treatment options and time course for intramedullary spinal cord metastasis Report of three cases and review of the literature
Authors: Sutter Bernhard , Arthur Adam , Laurent Jeffrey , Chadduck James , Friehs Gerhard , Clarici Georg , Pendl Gerhard
Published: January 2008

Surgical treatment of intrameduallary spinal cord metastases (ISCM) has become increasingly effective in recent years. The advent of new imaging techniques combined with an enhanced understanding of the natural history of these tumors has improved the effectiveness of the available treatment options. The authors present three new cases of ISCM successfully treated with surgery. A review of 129 cases found in the literature is also discussed. Characteristic symptomology and presentation are reviewed with an eye toward improving diagnostic methodology. The natural history of ISCM is divided into three phases. Surgical intervention should be used early in phase 2.
Primary intramedullary melanoma
Authors: Salpietro Francesco M. , Alafaci Concetta , Gervasio Olga , La Rosa Giovanni , Tomasello Francesco , Baio Ambrogia , Francolini Dario Cavallini , Batolo Dario
Published: January 2008

Primary intramedullary melanoma is a very rare tumor, most frequently occurring in the middle or lower thoracic spinal cord. The authors present a new case of primary cervical cord melanoma that developed in a 62-year-old man whose tumor was surgically treated and subsequently received radiation therapy. Clinical and histogenetic features of this neoplasm, results of chemo-, radio-, and immunotherapy are reported. Both “disembryogenetic” and “mesodermal” hypotheses on the origin of primary spinal melanoma are discussed.
The impact of psychosocial need and needs resolution on quality of life in patients with brain tumors
Authors: Bunston Terry , Mings Deborah , Laperriere Normand , Malcolm Jacquey , Williams Dorothy
Published: January 2008

The diagnosis of cancer of the central nervous system (CNS) is often the diagnosis of an incurable, progressive disease with devastating effects on the physical, psychosocial, and cognitive functioning of patients. Because many of the treatment options are noncurative in nature, issues related to quality and quantity of life become paramount.

The purpose of the authors' research was to explore the prevalence of psychosocial needs in this cancer population and to determine whether these needs and their resolution impact on quality of life (QOL).

Telephone interviews were conducted with 75 patients in whom primary CNS cancer was diagnosed and who were able to pass the Mini-Mental Health Status Examination. Analysis of results indicated that the majority of patients (97.3%) had at least one concern; concerns over treatment side effects, controlling uncertainty, having a meaningful existence, self and body image, and family concerns were among the five most frequently cited need domains. Most patients (91.8%) received help. However, 75.3% reported needing additional help. The number of needs reported and the severity of fatigue most significantly impacted QOL.

The study identified the needs and experiences of the patient with CNS cancer. Quality of life and needs assessment information can be used to screen patients for distress and to measure the outcome of medical and psychosocial care and ultimately to ease the burden of illness.
Evidence-based review of the role of reoperation in the management of malignant glioma
Authors: Soults Clifford B. , Canute Greg S. , Ryken Timothy C.
Published: January 2008

Using an evidence-based approach to available clinical studies, the authors examined the role of reoperation in the management of malignant glioma. A review of 1270 Medline-referenced articles spanning the period from 1966 through March 1998 was undertaken using the key words “glioblastoma” and “astrocytoma.” Using an evidence-based four-tiered grading system, the authors found only 14 articles that met their inclusion criteria. Of these, 11 were graded as Class III (retrospective case series) and three as Class II (prospective nonrandomized studies). There were no Class I reports (randomized clinical trials), and all Class IV reports (opinion reports) were excluded. The authors of 10 Class III and one Class II articles supported the role of reoperation in increasing survival time or quality of life in selected patients; however, the results of multivariate analysis in two Class II and one Class III article did not support prolonged survival. The authors conclude that there was insufficient evidence to support either a standard or a guideline for reoperation in malignant glioma given the current status of the literature. Selection bias was a major factor in these studies. With continued interest in clinical trials for recurrent malignant glioma, the role of reoperation needs to be addressed in case-controlled or randomized fashion to establish either standards or guidelines on this commonly debated issue.
A proposed preoperative grading scheme to assess risk for surgical resection of primary and secondary intraaxial supratentorial brain tumors
Authors: Vorster Sarel J. , Barnett Gene H.
Published: January 2008

Although surgical resection of brain tumors has been performed for over a century, complications still occur with distressing frequency.

The authors propose a simple preoperative grading scheme to assess surgical risk for resection of primary and secondary intraaxial supratentorial brain tumors.

The authors retrospectively reviewed the clinical records, neuroimaging studies, and outcomes of 224 surgeries performed in 207 patients from January 1993 to December 1995 at the Cleveland Clinic Foundation Brain Tumor Center. Subsequently, they considered and statistically analyzed multiple variables related to the patients and their lesions. Surgical risk was defined as any complication occurring within 30 days postoperatively, and was divided into transient operative complications, transient medical complications, and new sustained neurological deficits. Length of stay was also recorded. The overall incidence of complications was 10.6% and the mortality rate was 2.7%, with a median hospital stay of 3 days. Patient age greater than 60 years (p < 0.001), preoperative Karnofsky Performance Scale scores of 50 or less (p < 0.03), previous irradiation (p < 0.001), tumor location in eloquent regions (p < 0.03), and depth of tumor invasion (p < 0.001) independently predicted complicated outcome or increased length of stay. Finally, the authors derived a simple five-tier grading scheme in which these patient risk factors are added together to obtain a grade of I to V that corresponds to outcome and length of hospital stay.

This grading scheme may be used to identify patients at higher risk and facilitate comparison of results between institutions and individual surgeons.
Diagnosis and outcome measures in trials for neoplastic meningitis: a review of the literature and clinical experience
Authors: Glantz Michael J. , Chamberlin Marc C. , Walters Beverly C.
Published: January 2008

Innovative approaches to the treatment of neoplastic meningitis are being widely tested. Unfortunately, research on diagnostic strategies and outcome measures on which any advances in treatment ultimately depend, has not been avidly pursued.

A critical review of the literature on neoplastic meningitis published since 1978 was undertaken by using MEDLINE and other English language databases. All articles addressing the issues of diagnostic or response criteria were included. Randomized clinical trials (RCTs) were emphasized. Prospectively collected data from the authors' institution correlating the results of cerebrospinal fluid (CSF) cytological examinations with Karnofsky Performance Scale (KPS) score are also discussed.

Twenty-six studies (representing 1208 patients) fulfilled search criteria. Only three were RCTs. Cerebrospinal fluid cytology was the sole diagnostic criterion in two-thirds of studies. The results of CSF cytological examination alone or in combination with other clinical or laboratory endpoints constituted the primary outcome measure in 85%. Few studies attempted to address known deficiencies in the reliability and validity of these measures, and correlation between measures was poor. Quality of life was never used as a primary outcome measure.

All currently available measurements, including CSF cytology, biochemistry, immunological, and molecular markers, neuroimaging studies, clinical examination, and survival, suffer from poor sensitivity and/or specificity, and often correlate poorly with each other. Although CSF cytological examination, performed according to a rigorous, research-supported protocol, may be the optimum diagnostic and outcome measure at this time, additional research is a prerequisite for any further advances in the clinical care of patients with neoplastic meningitis.
How well are we doing in caring for the patient with primary malignant brain tumor? Are we measuring the outcomes that truly matter? A commentary
Authors: Rosenberg Jay
Published: January 2008

Neurologists, neurosurgeons, and neuroconcologists have traditionally measured clinical information about the patient that includes descriptions of mortality, morbidity, time to progression, survival time, magnetic resonance imaging data, and laboratory evaluations. These measurements have been referred to as intermediate health outcomes. They are a reflection of what is happening to the patient but do not provide a direct measurement of total impact on the patient. This paper describes the traditional means of approaching patients with malignant brain tumor. A philosophical shift to a more functional alternative approach is offered. This emphasis on functional assessment and quality of life will help to focus not only on the disease but rather on the total impact of various treatment options on the patient.