bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of life in patients with brain tumor: what's relevant in our quest for therapeutic efficacy
Authors: Bampoe Joseph , Ritvo Paul , Bernstein Mark
Published: January 2008

Quality-of-life assessments in neurooncology are becoming more relevant with the proliferation of intensive research into brain tumors and their therapy. In this review, the authors examined several aspects and problems associated with the past, present, and future applications of quality-of-life assessments in neurooncology.

The inadequacy of the almost exclusive use of physical functioning assessments, image-documented tumor response to therapy, and patient survival time as endpoints when evaluating therapeutic regimens is becoming increasingly apparent. In therapies in which outcome using traditional endpoints are only marginally different, specific (neurological) toxicity and social and psychological outcomes must be evaluated as well to determine valid treatment options. Also becoming widely accepted is the consideration of patient values of specific health states in justifying treatment resources. There is ongoing research in brain tumor patients to address these issues.
Transthoracic vertebrectomy for metastatic spinal tumors
Authors: Gokaslan Ziya L. , York Julie E. , Walsh Garrett L. , McCutcheon Ian E. , Lang Frederick F. , Putnam Joe B. , Wildrick David M. , Swisher Stephen G. , Abi-Said Dima , Sawaya Raymond
Published: January 2008

Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region.

Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwent transthoracic vertebrectomy, decompression, reconstruction with methylmethacrylate, and anterior fixation with locking plate and screw constructs. Supplemental posterior instrumentation was required in seven patients with disease involving the cervicothoracic or thoracolumbar junction, which was causing severe kyphosis. After surgery, pain improved in 60 of 65 patients. This improvement was found to be statistically significant (p < 0.001) based on visual analog scales and narcotic analgesic medication use. Thirty-five of the 46 patients who presented with neurological dysfunction improved significantly (p < 0.001) following the procedure. Thirty-three patients had weakness but could ambulate preoperatively. Seventeen of these 33 regained normal strength, 15 patients continued to have weakness, and one patient was neurologically worse postoperatively. Of the 13 preoperatively nonambulatory patients, 10 could walk after surgery and three were still unable to walk but showed improved motor function. Twenty-one patients had complications ranging from minor atelectasis to pulmonary embolism. The 30-day mortality rate was 3%. The 1-year survival rate for the entire study population was 62%.

These results suggest that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.
Medical case management after laminectomy or craniotomy: do all patients benefit from admission to the intensive care unit?
Authors: Nitahara James A. , Valencia Malou , Bronstein Michael A.
Published: January 2008

To define severity of illness to identify most effectively patients for whom admission to the intensive care unit (ICU) is unnecessary, the authors performed a retrospective cost-effectiveness analysis. The authors studied the records of 113 patients who were admitted to the ICU after undergoing laminectomy (or other spinal cord surgery) or craniotomy for removal of neoplasm; the Acute Physiology and Chronic Health Evaluation III prognostic system had identified these patients as having a 10% or less risk of requiring intervention while in the ICU. No patient required active intervention during a mean stay of 3.26 days in the ICU. Combined use of a “step-down” postoperative care unit and ICU can optimize allocation of medical resources while providing high-quality care for some neurosurgical patients who are at low risk of requiring postoperative intervention.
Late-onset facial nerve degeneration after vestibular schwannoma surgery: incidence, putative mechanisms, and prevention
Authors: Sampath Prakash , Rhines Laurence D. , Holliday Michael J. , Brem Henry , Long Donlin M.
Published: January 2008

Delayed facial nerve dysfunction after vestibular schwannoma surgery is a poorly understood phenomenon that has been reported to occur in 15 to 29% of patients undergoing microsurgery. It is a condition characterized by spontaneous deterioration of facial nerve function in a patient who has otherwise normal or near-normal facial function in the immediate postoperative period. This delayed paralysis is generally reported to occur in the first few days postsurgery, with the majority of patients eventually recovering their immediate postoperative facial function. However, infrequently, it can also occur more than 1 week after surgery (so-called late-onset facial nerve palsy).

The authors reviewed facial nerve outcome in 611 patients who underwent microsurgery between 1973 and 1994. The facial nerve was anatomically preserved in 596 patients (97.5%), and 90% of patients had House-Brackmann[6] Grade 1 or 2 function 1 year after surgery. Late-onset facial dysfunction was seen in 13 patients (2.1%). All of these had significant deterioration in facial nerve function between 1 and 4 weeks postoperatively, and all showed improvement by 1 year. In this study, the focus on these patients who developed late-onset facial palsy. The incidence, treatment strategies, and outcomes will be discussed with emphasis on possible pathophysiological mechanisms that contribute to this relatively rare condition.
Decompression of the labyrinthine segment of the facial nerve in acoustic neuroma surgery: a consideration for minimizing postoperative delayed facial nerve dysfunction
Authors: Holliday Michael J. , Sampath Prakash
Published: January 2008

Delayed facial nerve palsy, a condition characterized by spontaneous deterioration of facial nerve function in patients who had otherwise normal or near-normal facial function in the immediate postoperative period, has been reported in 15 to 29% of patients undergoing microsurgical resection of vestibular schwannomas. One putative mechanism for its occurrence suggests that edematous entrapment of the facial nerve in the meatal foramen (the narrowest segment of the internal auditory canal) may lead to nerve ischemia or necrosis and subsequent facial nerve dysfunction. To assess whether meatal decompression may help reduce the incidence of delayed facial nerve palsy during microsurgical resection of acoustic tumors, we compared 25 patients undergoing translabyrinthine removal of acoustic neuromas who received prophylactic decompression of the labyrinthine segment of the facial nerve (Group 1) with 40 patients who did not receive facial nerve decompression (Group 2). No patients in Group 1 had a delayed progressive facial paralysis with degeneration. In contrast, when Group 2 patients with larger, average-sized tumors were reviewed, eight patients (20%) developed delayed degeneration. These findings suggest that decompression of the labyrinthine segment may be of value in acoustic tumor surgery in reducing delayed facial nerve dysfunction. Further study is indicated in this important area.
Endoscopic anatomy of the cerebellopontine angle: a study in cadaver brains
Authors: Chaynes Patrick , Deguine Olivier , Moscovici Jacques , Fraysse Bernard , Bécue Jean , Lazorthes Yves
Published: January 2008

The increasing trend toward performing minimally invasive neurosurgery may benefit from recent progress in using neuroendoscopic techniques to reduce trauma in patients who have undergone operations. Arterial and venous vessels, especially loops, may compress the central segment and cause hyperactive dysfunction of the nerves. Relationships of the anterior inferior cerebellar artery to the facial and vestibulocochlear nerves and the anterior inferior, and superior cerebellar arteries to the trigeminal nerve were studied. The authors report findings from an endoscopic study performed in cadaver heads via the retrosigmoid and retrolabyrinthine approaches. Arteries and veins were colored by injection of red and blue silicon rubber. The cerebellopontine angle (CPA) was examined using 2.7-mm and 4-mm-diameter rigid endoscopes at viewing angles of 0š, 30š, and 70š. Well-known structures could be identified endoscopically without prior dissection, and the entire CPA could be explored. However, with a retrosigmoid or a retrolabyrinthine approach, the cerebellum had to be retracted to some extent to view the CPA. Moreover, wide dural exposure was required to maneuver the endoscope freely in the CPA. Use of the rigid fiberoptic endoscope is not yet superior to standard surgical techniques for approaching and exploring the CPA.
Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery
Authors: Alleyne Cargill H. , Cawley C. Michael , Shengelaia George G. , Barrow Daniel L.
Published: January 2008

Object

The blood supply of the lower spinal cord is heavily dependent on the artery of Adamkiewicz, which characteristically originates from one of the thoracolumbar segmental arteries. The aforementioned artery is of enormous clinical, surgical, and radiological importance, and the goal of this study was to elucidate the course and branches of the segmental artery that gives rise to this important vessel.

Methods

In this cadaveric, microsurgical anatomical study, the authors investigate and describe the course and branches of the artery of Adamkiewicz and the segmental branch from which it ultimately originates. A review of the literature is provided.

Conclusions

By documenting the microsurgical anatomy of these important vessels, this study facilitates an understanding of the anatomy that will aid in treatment planning for surgery of various lesions in this area.
Early and aggressive treatment of medically intractable cerebral vasospasm with pentobarbital coma, cerebral angioplasty and ICP reduction
Authors: Armonda Rocco A. , Thomas Jeffrey E. , Rosenwasser Robert H.
Published: January 2008

The authors present the unique experience of one neurovascular service under the direct supervision of the senior author, for which surgical, endovascular, and intensive care treatments were conducted in a select group of 32 patients with aneurysmal subarachnoid hemorrhage who had medically intractable symptomatic vasospasm.

A protocol of early and aggressive treatment was instituted using pentobarbital coma, cerebral angioplasty, and intracranial pressure (ICP) reduction. The patient population consisted of 25 women and seven men, whose ages ranged from 34 to 60 years (average 47 years). The patients' Hunt and Hess grades on presentation were as follows: Grade 0 (one); Grade I (three); Grade II (two); Grade III (nine); Grade IV (10); Grade V (seven). Microsurgical clipping alone was performed in 15 of 32 patients, endosaccular occlusion was performed in 17 of 20 patients, and two patients underwent combined treatment. Subsequent angioplasty was performed in 26 of 32 patients. Additionally, all 32 patients underwent treatment of increased ICP with ventriculostomy placement, removal of the bone flap (11), evacuation of associated intracranial hematoma (five), and decompressive obectomy (four).

Twenty-one patients survived and 11 died. Of the 21 survivors, seven have returned to work, live independently, and have no neurological deficits; eight require minimal assistance at home; four are in rehabilitation with moderate deficits at 3 months; and two remain in a persistent vegetative state.

In this group of aggressively treated patients who received pentobarbital cerebral protection, successful treatment of medically intractable cerebral vasospasm was related to time of treatment (< 2 hours), expeditious reduction of elevated ICP, and angioplasty.
A novel approach to flow quantification in brain arteriovenous malformations prior to enbucrilate embolization: use of insoluble contrast (Ethiodol droplet) angiography
Authors: Wakhloo Ajay K. , Lieber Baruch B. , Rudin Stephen , Fronckowiak Mary Duffy , Mericle Robert A. , Hopkins L. Nelson
Published: January 2008

Successful therapeutic embolization of arteriovenous malformations (AVMs) of the brain with liquid polymers (glues) requires precise knowledge of highly variable AVM structure and flow velocities and transit times of blood through the AVM nidus. The goal of this study was to improve AVM flow measurement and visualization by the substitution of the insoluble Ethiodol (ethiodized oil) contrast agent for the soluble contrast media normally used in angiographic studies.

Before enbucrilate embolization of 24 AVM feeding pedicles in 13 patients, standard contrast medium was superselectively injected into each target pedicle, followed by infusion of 20 μl of Ethiodol microdroplets. Transport of contrast material was assessed using high-speed biplane pulsed digital subtraction angiography (DSA) operating at 15 frames per second.

The mean blood flow transit times through AVMs after administration of Ethiodol were found to be approximately half as long as in those measured after injection of soluble contrast materials (0.22 ± 0.10 seconds compared with 0.46 ± 0.19 seconds [mean ± standard deviation]; p < 0.0001). The discrete Ethiodol microdroplets travel with the core flow, more closely approximating the dynamic behavior of enbucrilate, allowing the AVM structure to be traced with high spatial and temporal resolution. There were no inadvertent vessel occlusions or pulmonary complications related to the use of Ethiodol for DSA.

Because of diffusion and convection, forces that decrease concentration, visualization of the contrast front is reduced, often resulting in deceptively long transit times when soluble contrast materials are used. Overestimation may prove dangerous when planning embolizations. The Ethiodol droplet DSA method provides accurate transit time measurements and precise, detailed, and dynamic AVM visualization. Further development of this method will improve the safety and precision of AVM treatments.
Results of the surgical treatment of perimedullary arteriovenous fistulas with special reference to embolization
Authors: Hida Kazutoshi , Iwasaki Yoshinobu , Goto Katsuya , Miyasaka Kazuo , Abe Hiroshi
Published: January 2008

This retrospective study was performed to evaluate the results of surgical treatment and the use of preoperative embolization in managing perimedullary arteriovenous fistulas (AVFs).

The authors studied 20 consecutive patients with perimedullary AVFs who underwent surgical treatment. Arteriovenous shunts were at the level of the cervical spine in five patients, the thoracic spine in 12, and the conus medullaris in three patients. Of the 20 AVFs, three were fed by the anterior spinal artery only, three by the posterior spinal artery, and 14 by both the anterior and posterior spinal arteries. Nine patients had varices that compressed the spinal cord. Eleven patients underwent surgery alone, and 9 patients underwent surgery combined with adjuvant preoperative embolization.

Preoperative embolization remarkably reduced the blood flow through AVFs and facilitated subsequent surgical procedures. Postoperative angiography revealed complete disappearance of the AVF in 16 patients. However, small fistulas persisted in the other four patients whose large lesions were fed by the anterior spinal artery. Neurological status was improved in 11 patients, unchanged in eight, and worse in one patient postsurgery.

Effective interruption of a spinal AV shunt was obtained by surgery in all cases, even when the anterior spinal artery was involved. For large and high-flow AVFs, embolization proved to be a useful adjunct to surgery.
Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow
Authors: Nakamura Mitsugu , Tamaki Norihiko , Kawaguchi Tetsuro , Fujita Shigekiyo
Published: January 2008

A transvenous embolization technique that spares normal cerebral venous drainage is described. Of 26 dural carotid-cavernous fistulas treated by the authors, in three cases the affected cavernous sinus was supplied by not only the shunt flow but also the sylvian venous drainage. Two patients presented with an abducent nerve palsy and one with an oculomotor nerve palsy in whom selective transvenous embolization of the fistulous portions of the affected cavernous sinus was achieved while preserving of the sylvian venous outflow. Posttransvenous embolization angiograms showed complete occlusion of the fistula in one patient and only small residual shunts in the other two; one underwent subsequent transarterial embolization, whereas the other was followed without additional treatment. The patients' symptoms disappeared between 1 and 2 months posttreatment. Follow-up angiograms revealed that the remnant shunt had disappeared and that the sylvian venous pathway had been preserved. The authors conclude that although the condition is uncommon it is important to recognize that a dural carotid-cavernous sinus fistula, which receives significant sylvian venous outflow, can be treated successfully by selective transvenous embolization of the fistulous compartments in an affected sinus.
Stent placement for vertebral artery occlusive disease: preliminary clinical experience
Authors: Fessler Richard D. , Wakhloo Ajay K. , Lanzino Giuseppe , Qureshi Adnan I. , Guterman Lee R. , Hopkins L. Nelson
Published: January 2008

Symptoms of vertebrobasilar insufficiency may precede neurological sequelae in up to 50% of patients. Although select patients may benefit from microsurgical revascularization, combined perioperative morbidity and mortality rates can be as high as 20%. The authors present their preliminary clinical experience using stent placement for symptomatic vertebral artery (VA) occlusive disease.

Six patients with clinical symptoms of vertebrobasilar insufficiency in whom VA stents were placed from 1995 to 1998 were identified. Diagnostic four-vessel cerebral angiography identified causative stenotic, atherosclerotic lesions in all cases. A transfemoral or transradial artery approach after the patient had undergone full heparinization was chosen for endovascular stenting. Guidewire placement across the lesion followed by urokinase infusion preceded stenting. Prestent angioplasty was performed in two patients. Following the procedure, all patients were maintained on daily antiplatelet therapy.

Patient age ranged from 45 to 76 years (average 63 years). Four patients were men and two were women. Angiography revealed greater than 95% stenosis in five patients and greater than 70% stenosis in one. Three patients had complete occlusion of the contralateral VA; in one other, the VA supplied only the posterior inferior cerebellar artery; and the remaining two patients had VAs with greater than 70% stenosis. Ten stents were placed in six patients for five VA origin lesions and one distal VA stenosis. A VA dissection occurring poststenting was treated by placement of three additional stents. One patient had transient double vision. All had resolution of their presenting symptoms. Follow up ranged from 1 to 24 months (average 8.4 months). Angiograms obtained in four patients at least 3 months postprocedure have revealed stent patency in all cases without evidence of restenosis.

Vertebral artery stent placement can be safely performed and is a viable treatment option for carefully selected patients with vertebrobasilar insufficiency.
Embolization of incidental cerebral aneurysms using the Guglielmi detachable coil system
Authors: Murayama Yuichi , Viñuela Fernando , Duckwiler Gary R. , Gobin Y. Pierre , Guglielmi Guido
Published: January 2008

Guglielmi detachable coil (GDC) technology is a valuable therapeutic alternative to the surgical treatment of ruptured or incidental intracranial aneurysms. The authors describe their technical and clinical experience in the utilization of the GDC technique in patients who underwent endovascular occlusion for the treatment of incidentally found intracranial aneurysms.

One hundred fifteen patients with 120 incidentally found intracranial aneurysms underwent embolization using the GDC endovascular technique. Ninety-one patients were female and 24 were male. Patient age ranged from 13 to 80 years. In 64 patients the incidental aneurysms were discovered when unrelated nonneurological conditions indicated the need for angiography or magnetic resonance angiography (Group 1). Twenty patients who presented with incidental aneurysms that were discovered during treatment for an acutely ruptured aneurysm were treated in the acute phase of subarachnoid hemorrhage (SAH) (Group 2). Sixteen patients with incidental aneurysms were treated during the chronic phase of SAH (Group 3). Group 4 included 15 patients who had incidental aneurysms associated with brain tumors or arteriovenous malformations.

Angiographic results showed complete or near complete occlusion in 109 aneurysms (91%) and incomplete occlusion in five aneurysms (4%). Unsuccessful GDC embolization was attempted in six aneurysms (5%). One hundred nine patients (94.8%) remained neurologically intact or unchanged from initial clinical status. Five patients (4.3%) deteriorated due to immediate procedural complications (overall immediate morbidity rate). All of these complications occurred in the first 50 patients treated earlier in this series. No clinical complications were observed in the last 65 patients. Follow-up cerebral angiograms were obtained in 77 patients with 79 aneurysms. The median clinical follow-up period was 16.3 months.

No recanalization was observed in the 52 completely occluded aneurysms. Of the 22 aneurysms with small neck remnants, eight (36%) showed further thrombosis, 7 (32%) remained anatomically unchanged, and seven (32%) showed recanalization due to compaction of the coils. In one patient, a partially embolized aneurysm ruptured 3 years postembolization. In Groups 1 and 3, the average length of hospitalization was 3.3 days.

The evolution of the GDC technology has proved to provide safe treatment of incidental aneurysms (a morbidity rate of 0% was achieved in the last 65 patients). The topography of the aneurysm and the clinical condition of the patient did not influence final anatomical or clinical outcomes. The GDC technology also confers a positive economical impact by decreasing hospital length of stay and by eliminating the need for postembolization intensive care unit care.
Therapeutic options for endovascular therapy for intracranial aneurysms
Authors: Armonda Rocco A. , Thomas Jeffrey E. , Rosenwasser Robert H.
Published: January 2008

Endovascular surgical technology is in the early stages of evolution. A critical phase of this development has been microcatheter technology, which has permitted sufficiently precise intravascular navigation to safely engage the lumen of the aneurysm itself. Digital subtraction angiography, rapid filming techniques and image acquisition, and simultaneous multiplanar imaging capability are indispensable tools that are constantly being refined in the setting of ever-improving computer technology. The marriage of these different technologies has allowed effective endovascular treatment of difficult-to-access aneurysms in medically compromised patients for whom open microsurgery has inherently higher risks.
Endovascular treatment for symptomatic cerebral vasospasm after subarachnoid hemorrhage: transluminal balloon angioplasty compared with intraarterial papaverine
Authors: Coenen Volker A. , Hansen Carolyn Apperson , Mstat  , Kassell Neal F. , Polin Richard S.
Published: January 2008

The authors retrospectively evaluated the short-term neurological improvement of 69 patients undergoing endovascular treatment for symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). The patient group observed here is a subset of patients enrolled in the multicenter North American Trial of Tirilazad in SAH. Thirty-one patients were treated with intraarterial administration of papaverine (IAP). Fourteen patients were only treated with transluminal balloon angioplasty (TBA), and 24 patients received a combination of angioplasty and papaverine.

The purpose of this study was to compare the effects of IAP and TBA on short-term clinical improvement of patients. Daily clinical staging with the modified Glasgow Coma Scale and every-other-day transcranial Doppler (TCD) measurements allowed for a close investigation of the clinical course. Furthermore, this study was designed to investigate the effects of treatment timing on short-term outcome.

Although TCD studies demonstrated a decrease in flow velocities in the middle cerebral artery in both treatment groups, indicating a vasodilating effect of both treatment modalities (dv = -18.4 cm/second for papaverine, dv = -26.04 cm/second for angioplasty; p = 0.5509), there was no significant difference in clinical improvement at Days 1 and 4 postprocedure (p = 0.1996). Neither of the two treatment forms showed an effect of therapy timing on neurological outcome.

Neither IAP nor TBA was correlated with a high percentage of short-term neurological improvement. The authors discuss reasons why those procedures may result in limited clinical change.
Multiple combined indirect procedure for the surgical treatment of children with moyamoya disease. A comparison with single indirect anastomosis with direct anastomosis
Authors: Matsushima Toshio , Inoue Takuya , Ikezaki Kiyonobu , Matsukado Koichiro , Natori Yoshihiro , Inamura Takanori , Fukui Masashi
Published: January 2008

Considering three different bypass procedures now in use, (single indirect nonanastomotic bypass procedure, multiple combined indirect (MCI) nonanastomotic procedure and direct anastomosis), the authors attempted to identify the most appropriate bypass procedure for treating ischemic-type moyamoya disease in children.

The authors performed three procedures (the original encephaloduroarteriosynangiosis [EDAS] alone, the frontotemporoparietal combined indirect bypass procedure, and the superficial temporal artery-middle cerebral artery [STA-MCA] anastomosis with encephalomyosynangiosis [EMS]) on 72 hemispheres in 50 patients with pediatric moyamoya disease. Analyses were then performed to compare postoperative collateral vessel formation found on angiograms, complications, and clinical improvements. Postoperative collateral formations were observed in more than two-thirds of the MCA distribution after the EDAS alone, the MCI procedure, and the direct anastomosis in 44%, 52%, and 74% of the surgically treated hemispheres, respectively. In addition, frontal encephalomyoarteriosynangiosis of the MCI bypass procedure formed collateral vessels of the anterior cerebral artery distribution in 94% of the treated hemispheres. Postoperatively, clinical symptoms resolved in 56%, 63%, and 74% of the treated sides 1 year after EDAS alone, MCI procedure, and the direct anastomosis, respectively. One patient suffered a minor stroke after EDAS alone, two patients developed epidural hematomas after the MCI procedure, and one patient suffered a major stroke and one patient a minor stroke after undergoing direct anastomosis.

The direct anastomosis procedure was found to result in the best postoperative collateral vessel formation and clinical improvement. However, the single and multiple combined indirect nonanastomotic bypass procedures were found to be safer than direct anastomosis. Furthermore, the frontotemporoparietal combined indirect bypass procedure caused the formation of collateral circulation not only in the MCA but also in the ACA distribution. Based on analysis of these findings, the authors recommend the MCI procedure as the appropriate surgical procedure in the treatment of children with moyamoya disease, although the best treatment is the STA-MCA anastomosis with EMS when feasible.
Long-term outcome after STA-MCA anastomosis for moyamoya disease
Authors: Miyamoto Susumu , Akiyama Yoshinori , Nagata Izumi , Karasawa Jun , Nozaki Kazuhiko , Hashimoto Nobuo , Kikuchi Haruhiko
Published: January 2008

A long-term assessment was performed to determine the posttreatment clinical course of 113 patients with moyamoya disease. All patients sustained cerebral ischemic attacks and underwent superficial temporal artery-middle cerebral artery anastomosis with or without temporal muscle grafting. The follow-up duration was 3 to 24 years (mean 14.4 ± 5.8 [standard deviation]). Complete cessation of the ischemic episodes was obtained in 110 of 113 patients. One hundred patients were able to return to independent acitvities of daily living. Intellectual delays prevented 24 patients from engaging in an independent social life. Although intracranial bleeding is one of the common manifestations in moyamoya disease, hemorrhage was not detected in the 113 patients who underwent cerebral revascularization.
Complications of carotid angioplasty and stenting
Authors: Théron Jacques , Guimaraens Léopoldo , Coskun Oguzman , Sola Thérésa , Martin Jean-Baptiste , Rüfenacht Daniel A.
Published: January 2008

The authors report the complications that occurred in their experience with performing recanalization procedures in the internal carotid artery and present their treatment strategies. The complications can be classified into those that were periprocedural and those that were postprocedural. The former include complications related to the vascular-approach access site of and those associated with the dilation and stenting procedure. Other complications observed included embolic events, dissection, vascular spasm, bradycardia, inappropriate dilation, occlusion of the external carotid artery, and rare, unusual complications such as the occurrence of iatrogenic cavernous carotid fistula. Postprocedure complications occurred in the hours and days following the procedure in the form of embolic and occlusive events, and hypotension and bradycardia were seen as late complications in the months following the procedure. The authors discuss how such complications occur and provide suggestions on how to avoid them. The role of stent placement and the potential use of protective devices are explored. Overall, adequate use of currently available systems allows for safe application of endovascular treatment techniques that avoid altogether or treat these potential complications. A reduced incidence of complications related to the initial individual learning curve may be obtained with preclinical training, in which use of invitro models should be considered. Surgical standby no longer seems required; however, early posttreatment surveillance in intensive care unit is mandatory to avoid the remaining primary complications.
Review of clinical trials of neuroprotection in acute spinal cord injury
Authors: Tator Charles H. , Fehlings Michael G.
Published: January 2008

In this paper the authors review the clinical trials of neuroprotection that have been performed for the treatment of acute spinal cord injury (SCI). The biological rationale for the selection of each treatment modality is discussed with reference to current knowledge of the principles in the management of acute SCI as well as the primary and secondary injury mechanisms identified by experimental and clinical studies of the pathophysiology of acute SCI. The trials are evaluated with regard to the availability and use of accurate clinical outcome measures, and the methodologies of the trials are critically evaluated with an emphasis on prospective randomized controlled studies. A detailed description and critical analysis are provided of the results of the 10 clinical trials conducted to date in which a randomized prospective controlled design has been used. The issue of the therapeutic time window in acute SCI is discussed. To date, methylprednisolone is the only effective neuroprotective agent that has been established for use in human SCI, and the only therapeutic time window established in human SCI is a maximum trauma-to-treatment time of 8 hours.
The parasellar region of human infants: cavernous sinus topography and surgical approaches
Authors: Weninger Wolfgang J. , Mülle Gerd B.
Published: January 2008

Object

In this study the authors analyze the peculiarities of the parasellar anatomy and the topography of surgical approaches to the parasellar region (PSR) in human infants.

Methods

Forty-nine specimens of the PSR obtained at autopsy were studied using microdissection and histological analysis. Important distances between anatomical landmarks were measured with the aid of a dissecting microscope. One serially sectioned specimen was three-dimensionally reconstructed and analyzed on the computer screen by using the authors' new episcopic reconstruction technique.

The anatomy of the infant PSR differs distinctly from that of the adult. The parasellar portion of the internal carotid artery (ICA) does not form a siphon, but takes a straight course, and the venous pathways as well as the cranial and sympathetic nerves have different topographical relationships. Analyses of surgical approaches demonstrate that, in young children, the anterolateral approach can be used to reach the pterygopalatine compartment, the superior ophthalmic vein, and those pathological processes that extend from the orbit into the PSR. The approach via Parkinson's triangle can be used in 45% of cases to access the pathological processes that occur in the voluminous space above and behind the posterior flexure of the parasellar ICA. Taking this route, sympathetic nerve fibers passing through the PSR are not at risk, but some arterial branches that run within the lateral wall of the sinus can complicate this approach.

Conclusions

This study presents a guideline that can assist radiologists and neurosurgeons in the planning and performance of interventions within the PSR of neonates and young children.
An evidence-based review of surgical decompression for acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies
Authors: Fehlings Michael G. , Tator Charles H.
Published: January 2008

The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI).

The experimental and clinical literature concerning the role of, and the biological rationale for surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class III (retrospective studies).

Studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early surgical decompression, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing of decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although there is good evidence from recent Class II trials that early decompressive surgery can be performed safely without added morbidity or mortality.

There is biological evidence from experimental studies in animals that early surgical decompression may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of surgical decompression for the treatment of acute SCI.
Current use and timing of spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study
Authors: Tator Charles H. , Fehlings Michael , Thorpe Kevin , Taylor Wayne
Published: January 2008

A multicenter retrospective study was performed in 36 participating North American centers to examine the use and timing of surgery in the treatment of acute spinal cord injury (SCI). The study was conducted to obtain information required for the planning of a randomized controlled trial of early compared with late decompressive surgery.

The records of all patients aged 16 to 75 years with acute SCI who were admitted to the 36 centers within 24 hours of injury over a 9-month period (August 1994 to April 1995) were examined to obtain data on admission variables, methods of diagnosis, use of traction, and surgical variables including type and timing of surgery.

A total of 585 patients with acute SCI or cauda equina injury were admitted to these centers, although approximately half were ultimately excluded because they did not meet inclusion criteria. Common causes for exclusion were late admission, age, gunshot wound, and an absence of spinal cord compression demonstrated on imaging studies. Thus, only approximately 50% of acute SCI patients would be eligible for inclusion in a study of acute decompressive procedures. Although 100% of patient underwent computerized tomography (CT) scaning, only 54% underwent magnetic resonance imaging, and CT myelography was performed in only 6%. Complete neurological injuries (American Spinal Injury Association Grade A) were present in 57.8%. Traction was applied in only 47% of patients with cervical injuries, of which only 42% demonstrated successful decompression by traction. Neurological deterioration occurred in 8.1% of patients after traction. Surgery was performed in 65.4% of patients. The timing of surgery varied widely: less than 24 hours in 23.5% of patients; 25 to 48 hours in 15.8%; 48 to 96 hours in 19.0%; and 5 days or longer in 41.7% of patients.

These data indicate that whereas surgery is commonly performed in patients with acute SCI, one-third of the cases are managed nonoperatively, and there is very little agreement on the optimum timing of surgical treatment. The results of this study confirm the need for a randomized controlled trial to determine the optimum timing of surgical decompressive procedures in patients with SCI.
Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach
Authors: Lanman Todd H. , Brackmann Derald E. , Hitselberger William E. , Subin Bill
Published: January 2008

Object

The choice of approach for surgical removal of large acoustic neuromas is still controversial. The authors reviewed the results in a series of patients who underwent removal of large tumors via the translabyrinthine approach.

Methods

The authors conducted a database analysis of 190 patients (89 men and 101 women) with acoustic neuromas 3 cm or greater in size. The mean age of these patients was 46.1 ± 15.6 years. One hundred seventy-eight patients underwent primary translabyrinthine surgical removal and 12 underwent surgery for residual tumor. Total tumor removal was accomplished in 183 cases (96.3%). The tumor was adherent to the facial nerve to some degree in 64% of the cases, but the facial nerve was preserved anatomically in 178 (93.7%) of the patients. Divided nerves were repaired by primary attachment or cable graft. Facial nerve function was assessed immediately after surgery, at the time of discharge, and at 3 to 4 weeks and 1 year after discharge. Excellent function (House-Brackmann facial nerve Grade I or II) was present in 55%, 33.9%, 38.8%, and 52.6% of the patients for each time interval, respectively, with acceptable function (Grades I–IV) in 81% at 1 year. Cerebrospinal fluid leakage that required surgical repair occurred in only 1.1% of the patients and meningitis occurred in 3.7%. There were no deaths.

Conclusions

Use of the translabyrinthine approach for removal of large tumors resulted in good anatomical and functional preservation of the facial nerve, with minimum incidence of morbidity and no incidence of mortality. The authors continue to recommend use of this approach for acoustic tumors larger than 3 cm and for smaller tumors when hearing preservation is not an issue.
Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding
Authors: Byrne James V. , Sohn Min-Joo , Molyneux Andrew J. , Chir B.
Published: January 2008

Object

During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed these cases to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding.

Methods

These cases were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual postal questionnaires.

Conclusions

Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.
Stereotactic radiosurgery in the management of acoustic neuromas associated with neurofibromatosis Type 2
Authors: Subach Brian R. , Kondziolka Douglas , Lunsford L. Dade , Bissonette David J. , Flickinger John C. , Maitz Ann H.
Published: January 2008

Object

Stereotactically guided radiosurgery is one of the primary treatment modalities for patients with acoustic neuromas (vestibular schwannomas). The goal of radiosurgery is to arrest tumor growth while preserving neurological function. Patients with acoustic neuromas associated with neurofibromatosis Type 2 (NF2) represent a special challenge because of the risk of complete deafness. To better define the tumor control rate and long-term functional outcome, the authors reviewed their 10-year experience in treating these lesions.

Methods

Forty patients underwent stereotactic radiosurgery at the University of Pittsburgh, 35 of them for solitary tumors. The other five underwent staged procedures for bilateral lesions (10 tumors, 45 total). Thirteen patients (with 29% of tumors) had undergone a median of two prior resections. The mean tumor volume at radiosurgery was 4.8 ml and the mean tumor margin dose was 15 Gy (range 12–20 Gy).

The overall tumor control rate was 98%. During the median follow-up period of 36 months, 16 (36%) tumors regressed, 28 (62%) remained unchanged, and one (2%) grew. In the 10 patients for whom more than 5 years of clinical and neuroimaging follow-up results were available (median 92 months), five tumors were smaller and five remained unchanged. Surgical resection was performed in three patients (7%) after radiosurgery; only one showed radiographic evidence of progression. Useful hearing (Gardner-Robertson Class I or II) was preserved in six (43%) of 14 patients and this rate improved to 67% after modifications made in 1992. Normal facial nerve function (House-Brackmann Grade 1) was preserved in 25 (81%) of 31 patients. Normal trigeminal nerve function was preserved in 34 (94%) of 36 patients.

Conclusions

Stereotactically guided radiosurgery is a safe and effective treatment for patients with acoustic tumors in the setting of NF2. The rate of hearing preservation may be better with radiosurgery than with other available techniques.
Intraoperative validation of functional magnetic resonance imaging and cortical reorganization patterns in patients with brain tumors involving the primary motor cortex
Authors: Fandino Javier , Kollias Spyros S. , Wieser Heinz Gregor , Valavanis Anton , Yonekawa Yasuhiro
Published: January 2008

The purpose of the present study was to compare the results of functional magnetic resonance (fMR) imaging with those of intraoperative cortical stimulation in patients who harbored tumors close to or involving the primary motor area and to assess the usefulness of fMR imaging in the objective evaluation of motor function as part of the surgical strategy in the treatment of these patients.

A total of 11 consecutive patients, whose tumors were near to or involving the central region, underwent presurgical blood oxygen level-dependent fMR imaging while performing a motor paradigm that required the patients to clench and spread their hands contra- and ipsilateral to the tumor. Statistical cross-correlation functional maps covering the primary and secondary motor cortical areas were generated and overlaid onto high-resolution anatomical MR images. Intraoperative electrical cortical stimulation was performed to validate the presurgical fMR imaging findings. In nine (82%) of 11 patients, the anatomical fMR imaging localization of motor areas could be verified by intraoperative electrical cortical stimulation. In seven patients two or more activation sites were demonstrated on fMR imaging, which were considered a consequence of reorganization phenomena of the motor cortex: contralateral primary motor area (nine sites), contralateral premotor area (four sites), ipsilateral primary motor area (two sites), and ipsilateral premotor area (four sites).

Functional MR imaging can be used to perform objective evaluation of motor function and surgical planning in patients who harbor lesions near or involving the primary motor cortex. Correlation between fMR imaging findings and the results of direct electrical brain stimulation is high, although not 100%. Based on their study, the authors believe that cortical reorganization patterns of motor areas might explain the differences in motor function and the diversity of postoperative motor function among patients with central tumors.