bluuebunny/crossref_metadata_2025 huggingface dataset:
Malignant Nerve Sheath Tumor of the Right Cerebral Peduncle: Case Report
Authors: Beauchesne Patrick , Mosnier Jean-François , Schmitt Thierry , Brunon Jacques
Published: August 2004

OBJECTIVE AND IMPORTANCE

Schwannomas occurring in the neuraxis are very rare. Usually, these tumors are benign. Primary malignant intracerebral nerve sheath tumors are extremely rare, with only five documented cases in the international literature. We report one case of a primary malignant intracerebral nerve sheath tumor occurring in the right cerebral peduncle of a 35-year-old man.

CLINICAL PRESENTATION

Magnetic resonance imaging revealed a heterogeneous peripherally enhancing mass of the right cerebral peduncle, surrounded by a small edema.

INTERVENTION

Unlike the five cases previously reported, this is the first time a stereotactic biopsy has been performed, and this is the only patient who responded to cranial radiation therapy for approximately 2 years. When the tumor recurred, a systemic chemotherapy treatment was prescribed. No positive response was seen, and the patient died 29 months after the initial diagnosis.

CONCLUSION

An accurate diagnosis and planned aggressive treatment seem to be the key elements in the management of the disease.
Hypertrophic Neuropathy of the Cauda Equina: Case Report
Authors: Kretzer Ryan M. , Burger Peter C. , Tamargo Rafael J.
Published: August 2004

OBJECTIVE AND IMPORTANCE

Hypertrophic neuropathy of the cauda equina (HNCE) is a rare form of peripheral neuropathy. The diagnosis is complicated by an insidious clinical presentation and complex radiographic images. We present a case of HNCE caused by chronic inflammatory demyelinating polyneuropathy with symptomatic improvement after decompressive lumbar laminectomy and dural expansion.

CLINICAL PRESENTATION

A 54-year-old woman with a history of back pain since she was in her 20s presented with low back and radicular pain that had increased during a period of 6 months, bilateral lower-extremity weakness, and sensory loss in the right thigh. Magnetic resonance imaging of the lumbosacral spine revealed multiple, poorly enhancing mass lesions and apparent intrathecal nerve root thickening from L1 to L5.

INTERVENTION

An L1-L5 decompressive laminectomy, performed with continuous somatosensory evoked potential and electromyographic monitoring, revealed multiple segmentally enlarged nerve roots. One nerve root that did not respond to high levels of stimulation was identified. This root was resected and submitted for pathological analysis. The dura was expanded with an 11-cm-long dural patch. The pathological examination revealed hypertrophic neuropathy, with extensive S-100-positive “onion bulb” formation. The patient's symptoms improved postoperatively.

CONCLUSION

HNCE is a rare disorder that can cause radicular pain and lower-extremity weakness, sensory loss, and hyporeflexia. One possible cause is demyelinating polyneuropathy. Although medical management is typically effective in the treatment of demyelinating polyneuropathy, it has little effect on compressive symptoms caused by intradural nerve root enlargement. As this case demonstrates, surgical management of symptomatic radiculopathy by lumbar laminectomy is a reasonable and effective approach to the treatment of HNCE.
Mini-Open Carpal Tunnel Decompression
Authors: Huang Jason H. , Zager Eric L.
Published: August 2004

CARPAL TUNNEL SYNDROME is the most common entrapment neuropathy, and it is caused by compression of the median nerve at the wrist. The authors describe the mini-open carpal tunnel technique for surgical release of the transverse carpal ligament. The success of the procedure depends on meticulous technique with attention to certain important anatomic details and careful avoidance of injury to the palmar cutaneous nerve and the recurrent motor branch.
Cavernous Sinus and Leptomeningeal Metastases Arising from a Squamous Cell Carcinoma of the Face: Case Report
Authors: Zhu Jay-Jiguang , Padillo Osvaldo , Duff John , Hsi Bae-Li , Fletcher Jonathan A. , Querfurth Henry
Published: August 2004

OBJECTIVE AND IMPORTANCE

Invasion of trigeminal and facial perineural spaces is a recognized complication of cutaneous malignancies. Centripetal spread along the trigeminal nerve axis and into the cavernous sinus and the gasserian ganglion is rare. Metastasis to the leptomeninges and cauda equina has not been reported. We report a unique case of perineural spread and central dissemination from an epithelial squamous cell carcinoma (SCC) associated with a tumor biomarker.

CLINICAL PRESENTATION

After excision of multiple cutaneous SCCs and basal cell carcinomas of the head and neck, a 70-year-old male patient developed successive, right-side, V1 and V2 trigeminal neuropathies and complete right cavernous sinus syndrome during a 5-year period. Concurrently, the right face became paralyzed. Left facial paresis developed during the latter half of this period. Two months before admission, subacute left lower-extremity radicular weakness resulted in falls. Serial magnetic resonance imaging scans obtained in the previous 4 years were unrevealing. At the time of admission, enhancing masses were found in the 1) right cavernous sinus and dura, foramina ovale and rotundum, and Meckel's cave, 2) right subtemporal region and orbital rectus muscles, and 3) cauda equina. Cerebrospinal fluid analysis demonstrated mild pleocytosis and rare carcinoma cells.

INTERVENTION

Biopsy of the right cavernous sinus mass confirmed moderately differentiated, metastatic SCC. Immunohistochemical staining and fluorescence in situ hybridization revealed epidermal growth factor receptor overexpression and genomic amplification.

CONCLUSION

The indolent progression of cranial nerve palsy among patients with resected cutaneous SCCs of the head and neck must raise clinical suspicion of perineural spread, even in the absence of radiological changes. Biomarkers predicting aggressive SCC behavior, illustrated here by epidermal growth factor receptor amplification and central invasion, have the potential to guide early therapy.
Analysis of Different Types of Resection for Pediatric Patients with Temporal Lobe Epilepsy
Authors: Clusmann Hans , Kral Thomas , Gleissner Ulrike , Sassen Robert , Urbach Horst , Blümcke Ingmar , Bogucki Jacek , Schramm Johannes
Published: August 2004

OBJECTIVE

Resection strategies for the treatment of temporal lobe epilepsy (TLE) are a matter of discussion. Few data on the significance of resection type are available for pediatric patients with TLE.

METHODS

Data for a series of 89 children who were surgically treated for TLE were analyzed. A first cohort of patients were mainly surgically treated with anterior temporal lobectomies. For a second cohort, resections were preoperatively “tailored” to the lesion and presumed epileptogenic area.

RESULTS

The follow-up period was 46 months (range, 14–118 mo). Seventy-seven patients (87%) attained satisfactory seizure control (82% Engel Class I and 5% Class II). For 12 patients (13%), seizure control was unsatisfactory (8% Class III and 5% Class IV). Anterior temporal lobectomies resulted in 94% satisfactory seizure control (33 patients), whereas the success rates were only 74% (20 patients) for amygdalohippocampectomy (AH) (P = 0.023) and 77% (13 patients) for lesionectomy plus hippocampectomy (not significant). All patients who underwent purely lateral temporal lesionectomies became seizure-free (14 patients). Logistic regression revealed the factors of AH (P = 0.021) and left-side surgery (P = 0.017) as significant predictors of unsatisfactory seizure control. Satisfactory seizure control was not dependent on the histopathological diagnoses. There was a low rate of verbal memory deterioration after left-side operations. Neuropsychological deterioration was rare after right temporal resections. Attentional and contralateral functions improved after surgery.

CONCLUSION

Surgery for the treatment of juvenile TLE is successful and safe, but the resection type may influence outcomes. Results after AHs were disappointing, probably because of difficulties in precise localization of the epileptogenic focus among children. Neuropsychological results demonstrated minimal rates of deterioration and significant improvements in contralateral functions. Surgical treatment of juvenile TLE should be encouraged, but the use of especially left AH should possibly be restricted.
Microsurgical Repair of the Sural Nerve after Nerve Biopsy to Avoid Associated Sensory Morbidity: A Preliminary Report
Authors: Schoeller Thomas , Huemer Georg M. , Shafighi Maziar , Gurunluoglu Raffi , Wechselberger Gottfried , Piza-Katzer Hildegunde
Published: August 2004

OBJECTIVE

The purpose of this article is to report our preliminary results regarding microsurgical repair of the sural nerve after nerve biopsy, in an attempt to reduce the well-described sensory morbidity and neuroma formation.

METHODS

Three patients with a suspected diagnosis of peripheral neuropathy underwent sural nerve biopsies to establish definitive diagnoses. A 10-mm segment of the sural nerve was resected with local anesthesia. After harvesting of the specimen, the proximal and distal nerve stumps were carefully mobilized and united with epineural suture techniques, under a surgical microscope. Sensory evaluations (assessing the presence of hypesthesia/dysesthesia or pain) of the lateral aspect of the foot, in regions designated Areas 1, 2, and 3, were performed before and 6 and 12 months after the biopsies. A visual analog scale was used for pain estimation.

RESULTS

The biopsy material was sufficient for histopathological examinations in all cases, leading to conclusive diagnoses (vasculitis in two cases and amyloidosis in one case). The early post-biopsy hypesthesia, which was present for 4 to 8 weeks, improved to preoperative levels as early as 6 months after the nerve repair. Sensory evaluations performed at 6- and 12-month follow-up times demonstrated that none of the patients complained of pain at the biopsy site or distally in the area innervated by the sural nerve. Ultrasonography performed at the 12-month follow-up examination revealed normal sural nerve morphological features, with no neuroma formation, comparable to findings for the contralateral site.

CONCLUSION

Microsurgical repair of the sural nerve after biopsy can eliminate or reduce sensory disturbances such as paraesthesia, hypesthesia, and dysesthesia distal to the biopsy site, in the distribution of the sensory innervation of the sural nerve, and can prevent painful neuroma formation. To our knowledge, this article is the first in the literature to report on microsurgical repair of the sural nerve after nerve biopsy. Decreased side effects suggest that this technique can become a standard procedure after sural nerve biopsy, which is commonly required to establish the diagnosis of various diseases, such as peripheral nerve pathological conditions, vasculitis, and amyloidosis. More cases should be analyzed, however, to explore the usefulness of the technique and the reliability of sural nerve biopsy samples in attempts to obtain conclusive diagnoses.
Intensity-modulated Stereotactic Radiotherapy of Paraspinal Tumors: A Preliminary Report
Authors: Bilsky Mark H. , Yamada Yoshiya , Yenice Kamil M. , Lovelock Michael , Hunt Margie , Gutin Philip H. , Leibel Steven A.
Published: August 2004

OBJECTIVE

Radioresistant paraspinal tumors may benefit from conformal treatment techniques such as intensity-modulated radiotherapy (IMRT). Local tumor control and long-term palliation for both primary and metastatic tumors may be achieved with IMRT while reducing the risk of spinal cord toxicity associated with conventional radiotherapy techniques. In this article, we report our initial clinical experience in treating 16 paraspinal tumors with IMRT in which the planning target volume was 2 mm or greater from the spinal cord.

METHODS

IMRT was administered by using a linear accelerator mounted with a multileaf collimator. Two immobilization body frames developed at Memorial Sloan-Kettering Cancer Center were used for patients with and without spinal implants. During a 30-month period, 16 patients underwent IMRT for metastatic and primary tumors. Eleven patients were treated for symptomatic recurrences after undergoing surgery and prior external beam radiotherapy, and one patient was treated after undergoing radiotherapy for a metastatic pancreatic gastrinoma with overlapping ports to the spine. Four patients with primary tumors were treated after primary resection that resulted in positive histological margins. Twelve patients were symptomatic with pain, functional radiculopathy, or both. Tumoral doses were determined on the basis of the relative radiosensitivity of tumors. Patients with metastatic tumors were administered a median tumoral dose of 20 Gy in four to five fractions and a spinal cord maximum dose of 6.0 Gy in addition to the full tolerance dose administered in previous radiation treatments. The primary tumors were delivered a median dose of 70 Gy in 33 to 37 fractions and a spinal cord maximum dose of 16 Gy. The median tumoral volume was 7.8 cm3.

RESULTS

Of the 15 patients who underwent radiographic follow-up, 13 demonstrated either no interval growth or a reduction in tumor size in a median follow-up period of 12 months (range, 2–23 mo). Two patients, one with a thoracic chondrosarcoma and one with a chordoma, showed tumor progression 1 year after undergoing IMRT. Pain symptoms improved in 11 of 11 patients, and 4 of 4 patients had significant improvement in their functionally significant radiculopathy and/or plexopathy. Pain relief was durable in all patients except the two with tumor progression. No patient showed signs or symptoms of radiation-induced myelopathy, radiculopathy, or plexopathy, including 12 patients with a median follow-up of 18 months.

CONCLUSION

IMRT was effective for treating pain and improving functional radiculopathy in patients with metastatic and primary tumors. Although long-term tumor control is not established in this study, high-dose tumoral irradiation can be performed without causing radiation myelopathy in more than 1 year of follow-up.
Rare Presentations of Delayed Radiation Injury: A Lobar Hematoma and a Cystic Space-occupying Lesion Appearing More Than 15 Years after Cranial Radiotherapy: Report of Two Cases
Authors: Lee Joshua K.L. , Chelvarajah Ramesh , King Andrew , David Karoly M.
Published: August 2004

OBJECTIVE AND IMPORTANCE

Radiation vasculopathy and radionecrosis, constituting delayed radiation injury, are rare but recognized complications of radiation therapy occurring at a peak incidence of 3 years after treatment. Little information is available about these complications occurring more than 15 years after radiotherapy and presenting as other than solid intracranial masses.

CLINICAL PRESENTATION

We describe two patients who presented with space-occupying cerebral lesions. Patient 1 presented as an emergency with a sudden loss of consciousness. Computed tomography revealed a large left intracerebral hemorrhage; cerebral angiography disclosed nothing abnormal, and a primary spontaneous hemorrhage was presumed. Twenty-seven years earlier, this patient had received adjuvant whole-brain and spine radiotherapy and concomitant chemotherapy after excision of a vermis medulloblastoma. Patient 2 presented with a left frontal cystic lesion (presumed malignant glioma) as the cause of personality and behavioral changes for some months. She had previously received external beam radiation for a basal cell epithelioma, which had been excised from her left forehead 19 years earlier.

INTERVENTION

Both patients recovered well after undergoing craniotomies and removal of their lesions; they were discharged home with no neurological deficit.

CONCLUSION

Even after long intervals after radiotherapy, it is important to consider radiation vasculopathy and radionecrosis as differential diagnoses of more common conditions. Histological confirmation of a delayed radiation injury in the absence of any evidence of neoplasia or vascular abnormality has allowed appropriate prognosis and management to be formulated with confidence in each of these patients.
Conservative Management of Asymptomatic Spinal Lipomas of the Conus
Authors: Kulkarni Abhaya V. , Pierre-Kahn Alain , Zerah Michel
Published: August 2004

OBJECTIVE

The natural history of spinal lipomas of the conus (SLCs) has not been well studied. Because of disappointing long-term results with early surgical treatment of asymptomatic children with SLCs, we have followed a protocol of conservative management for these patients. The results are presented in this report.

METHODS

Since 1994, all asymptomatic children with SLCs who were examined at Necker-Enfants Malades Hospital were subject to a protocol of conservative management. The records for those patients were reviewed, to determine the incidence and timing of neurological deterioration. The findings were compared with those for a previously reported historical cohort of asymptomatic patients who underwent early surgery at our institution.

RESULTS

Fifty-three asymptomatic children (35 girls and 18 boys) with SLCs were monitored, with conservative management. During a mean follow-up period of 4.4 years (range, 12 mo to 9 yr), 13 patients (25%) exhibited neurological deterioration. At 9 years, the actuarial risks of deterioration, as determined with the Kaplan-Meier method, were 33% for the conservatively treated patients and 46% for the surgically treated patients. With a Cox proportional-hazards model, there was no significant difference in the risks of neurological deterioration for patients who were treated conservatively and those who underwent early surgery.

CONCLUSION

The incidences and patterns of neurological deterioration seemed to be very similar, regardless of whether early surgery was performed. These results suggest that conservative treatment of asymptomatic patients is a reasonable option. A more definitive randomized study will be required to clarify the relative efficacy of early surgery for SLCs among asymptomatic patients.
Transcranial Motor Evoked Potential Recording in a Case of Kernohan's Notch Syndrome: Case Report
Authors: Binder Devin K. , Lyon Russ , Manley Geoffrey T.
Published: August 2004

OBJECTIVE AND IMPORTANCE

Compression of the cerebral peduncle against the tentorial incisura contralateral to a supratentorial mass lesion, the so-called Kernohan-Woltman notch phenomenon, can be an important cause of false localizing motor signs. Here, we demonstrate a case in which clinical, radiological, and electrophysiological findings were used together to define this syndrome.

CLINICAL PRESENTATION

A 21-year-old man sustained a left temporal depressed cranial fracture from a motor vehicle accident. Serial computed tomographic examinations demonstrated no evolution of hematomas or contusions, and he was managed nonsurgically with ventriculostomy for intracranial pressure control. Throughout his course in the neurosurgical intensive care unit, he displayed persistent left hemiparesis.

INTERVENTION

Further radiological and electrophysiological studies were undertaken in an attempt to explain his left hemiparesis. Brain magnetic resonance imaging demonstrated T2 prolongation in the central portion of the right cerebral peduncle extending to the right internal capsule. Electrophysiological studies using transcranial electrical motor evoked potentials revealed both a marked increase in voltage threshold, as well as a reduction in the complexity of the motor evoked potential waveform on the hemiparetic left side. This contrasted to significantly lower voltage threshold as well as a highly complex motor evoked potential waveform recorded on the relatively intact contralateral side.

CONCLUSION

This is the first time that clinical, radiological, and electrophysiological findings have been correlated in a case of Kernohan's notch syndrome. Compression of the contralateral cerebral peduncle against the tentorial incisura can lead to damage and ipsilateral hemiparesis. The anatomic extent of the lesion can be defined by magnetic resonance imaging and the physiological extent by electrophysiological techniques.
Unusual Presentations of Cerebral Solitary Fibrous Tumors: Report of Four Cases
Authors: Kim K. Anthony , Gonzalez Ignacio , McComb J. Gordon , Giannotta Steven L.
Published: August 2004

OBJECTIVE AND IMPORTANCE

Four rare cases of central nervous system solitary fibrous tumors (C-SoFTs) are described. This tumor has not previously been reported in children or in deep cortical structures. Three of these tumors occurred in the posterior fossa. Only four cases in the posterior fossa have been described previously. Nine years after its debulking from the posterior fossa, one tumor disseminated to the spine, lung, and liver. Only one such aggressive C-SoFT has been described previously.

CLINICAL PRESENTATION

A 7-year-old child had had 1 year of right-sided weakness at presentation. Magnetic resonance imaging scans revealed a left basal ganglia lesion. A 49-year-old woman and a 30-year-old man presented after experiencing headaches for months. Magnetic resonance imaging scans in these patients revealed a tumor in the fourth ventricle and right jugular foramen, respectively. A 55-year-old man had spinal, liver, and lung dissemination of a previous posterior fossa tumor at presentation.

INTERVENTION AND TECHNIQUE

All four patients underwent craniotomy for resection or subtotal removal of the tumor. Intraoperative observations noted solid well-encapsulated tumors. Immunohistochemistry confirmed C-SoFTs in all four cases.

CONCLUSION

C-SoFTs are rare central nervous system, typically dural-based, tumors. They frequently are overlooked in the differential diagnosis of solid central nervous system tumors. Our findings suggest that these tumors can occur at any age and in most locations, regardless of proximity to the meninges (basal ganglia and ventricle), suggesting that the cells of origin are not meningothelial, but rather the mesenchyme of the cerebral vasculature. T1- and T2-weighted magnetic resonance imaging was notable for areas of hypointensity and of hyperintensity best described as patchy or a ying-yang appearance in all cases. Delayed extracranial metastasis may be noted.
Surgical Management of a Ruptured Posterior Choroidal Intraventricular Aneurysm Associated with Moyamoya Disease Using Frameless Stereotaxy: Case Report and Review of the Literature
Authors: Ali M. Jafer , Bendok Bernard R. , Getch Christopher C. , Gottardi-Littell Numa R. , Mindea Stefan , Batjer H. Hunt
Published: August 2004

OBJECTIVE AND IMPORTANCE

Prevention of rebleeding is the most important aspect of the management of hemorrhagic moyamoya disease, because rebleeding causes significant morbidity and mortality.

CLINICAL PRESENTATION

A 26-year-old male patient with a history of moyamoya disease since the age of 3 years and multiple strokes was in a semicomatose state at presentation. He was found to have intraventricular and periventricular hemorrhages abutting the atrium of the right ventricle. His hospital course was complicated by a second hemorrhage. Both bleeding events were believed to be secondary to a ruptured right lateral posterior choroidal aneurysm.

INTERVENTION

The aneurysm was excised and revealed histopathology consistent with a true saccular aneurysm. Frameless stereotactic guidance was used during surgery to minimize damage to collateral vessels and to shorten the surgical corridor.

CONCLUSION

The management of hemorrhagic moyamoya disease should be modified based on the source of hemorrhage and its relation to a specifically located aneurysm. In the case of aneurysms arising from the choroidal artery, the general belief is that most of these represent pseudoaneurysms and have a tendency to regress spontaneously. Because of the rebleeding risk, we recommend early intervention in treating ruptured intracranial aneurysms using the least invasive surgical techniques.
Giant Vertebrobasilar Aneurysms: Endovascular Treatment and Long-term Follow-up
Authors: Lubicz Boris , Leclerc Xavier , Gauvrit Jean-Yves , Lejeune Jean-Paul , Pruvo Jean-Pierre
Published: August 2004

OBJECTIVE:

To report long-term imaging follow-up and clinical outcome of 13 patients with a giant vertebrobasilar aneurysm treated by parent artery occlusion (PAO).

METHODS:

From 1994 to 2000, 13 consecutive patients with a giant vertebrobasilar aneurysm were treated by PAO. Symptoms were related to mass effect in nine patients and to a subarachnoid hemorrhage in four. Endovascular treatment consisted of aneurysm trapping in nine patients and occlusion of one or both vertebral arteries in four. We assessed the clinical outcome and imaging findings in all patients during a 28-month period.

RESULTS:

Endovascular treatment resulted in clinical improvements in eight patients, worsening of symptoms in four, and death in one. One woman with a ruptured vertebral aneurysm died from a rebleeding after PAO without trapping. One man developed a brainstem infarction after lower basilar artery occlusion and incurred hemiparesis. In three patients, symptoms of mass effect increased after the procedure. Long-term follow-up revealed good or excellent clinical outcome in all patients and a sharp decrease in size of the thrombosed aneurysm in nine patients. One basilar aneurysm recanalized despite selective coiling and subsequent bilateral vertebral artery occlusion; one vertebral aneurysm and one basilar aneurysm did not decrease in size despite complete occlusion.

CONCLUSION:

Giant vertebrobasilar aneurysms are rare and challenging lesions for both neurosurgeons and neurointerventionalists. Their treatment by endovascular PAO remains safe and effective. Early clinical worsening may be observed, but long-term follow-up shows good or excellent results in most patients. This treatment can be carried out with minimal morbidity and mortality using clinical and angiographic monitoring.
Diagnosis and Management of Pineocytomas
Authors: Deshmukh Vivek R. , Smith Kris A. , Rekate Harold L. , Coons Stephen , Spetzler Robert F.
Published: August 2004

OBJECTIVE:

Pineocytomas are associated with the most favorable prognosis of all pineal tumors. However, a subset of pineocytomas may have a predilection for recurrence and therefore behave aggressively.

PATIENTS AND METHODS:

Records of nine patients (five men, four women; mean age, 44 yr; range, 24–63 yr) with histologically diagnosed pineocytomas consecutively treated between 1990 and 2003 were reviewed retrospectively to identify factors predictive of aggressiveness. Eight patients presented with hydrocephalus and four with tectal compression. Three patients underwent gross total resection, and six underwent subtotal resection or biopsy.

RESULTS:

Three local recurrences necessitated reoperation. One recurrence involved the obex of the fourth ventricle. The mean time to recurrence was 3.5 years (range, 1–7 yr). There was no correlation between histological features and tumor recurrence. Patients undergoing radiosurgery showed stable or attenuated local disease (mean follow-up, 19.3 mo; range, 6–36 mo). Mean radiographic follow-up was 34 months (range, 6 mo to 10 yr). Mean clinical follow-up was 36 months (range, 1 mo to 10 yr).

CONCLUSION:

A subset of pineocytomas demonstrates the potential for symptomatic recurrence. We advocate an attempt at gross total tumor resection for all symptomatic patients with tectal plate compression, reserving radiosurgery for small, subtotally resected, or recurrent lesions. Patients must be followed closely for recurrence. Radiosurgery seems to be beneficial for local tumor control. Further investigation is needed to identify histological markers for pineocytomas that behave aggressively.
The Unique Characteristics of “Upper” Lumbar Disc Herniations
Authors: Sanderson Scott P. , Houten John , Errico Thomas , Forshaw David , Bauman Joel , Cooper Paul R.
Published: August 2004

OBJECTIVE:

To compare the characteristics, presentation, and surgical outcome of patients with microdiscectomies at L1–L2 and L2–L3 with those we treated at L3–L4. We further sought to compare these results with those reported in the literature for discectomies at the L4–L5 and L5–S1 levels.

METHODS:

We reviewed the clinical data collected from 69 patients who had 72 L1–L2, L2–L3, and L3–L4 microdiscectomies performed from 1989 to 1999 at the New York University Medical Center. Patients who had surgery at L1–L2 or L2–L3 were grouped and compared with those treated at the L3–L4 level. Patients' charts were retrospectively reviewed at a mean of 12.9 months after surgery for presenting signs and symptoms, patient characteristics, and surgical outcome. Long-term follow-up via telephone interview was obtained at an average of 81.3 months after surgery.

RESULTS:

In the L1–L2 + L2–L3 group, 58% of the patients had previous lumbar disc surgery, compared with only 10% of those in the L3–L4 group, and 20% in the L1–L2 + L2–L3 group required a fusion during the procedure compared with only 10% in the L3–L4 group. These differences are both statistically significant. The short-term chart review demonstrates that only 58% and 53% of patients in the L1–L2 + L2–L3 group were improved with regard to radicular and back pain, respectively, whereas those in the L3–L4 group reported 94 and 87% rates of improvement in the same categories, both highly statistically significant findings. The long-term follow-up confirmed a highly statistically significantly worse outcome in the L1–L2 + L2–L3 group, with only 33% of patients reporting an improvement in their economic or functional status, compared with an 88% rate of improvement in the L3–L4 group. The outcome of our patients with L3–L4 herniations was similar to that reported in the literature for herniations at L4–L5 and L5–S1.

CONCLUSION:

Herniated discs at the L1–L2 or L2–L3 level are different entities from those at lower levels of the lumbar spine. The surgical outcome in terms of postoperative back and radicular pain is worse for herniated discs at L1–L2 and L2–L3 compared with those treated at L3–L4. Our patients with L1–L2 or L2–L3 surgically treated herniated discs were more likely to have had previous lumbar surgery and required a fusion more often than their counterparts with L3–L4 herniated discs.
Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Grafting for Cerebral Revascularization
Authors: Wanebo John E. , Zabramski Joseph M. , Spetzler Robert F.
Published: August 2004

SUPERFICIAL TEMPORAL ARTERY-to-middle cerebral artery bypass procedures are an important tool in the armamentarium of cerebrovascular surgeons for the treatment of carotid occlusion and revascularization for complex aneurysms and brain tumors. This article enumerates the essential steps in performing superficial temporal artery-to-middle cerebral artery bypass procedures. The nuances of this technique reflect the extensive experience of the senior authors (RFS, JMZ).
Trigeminal Neuralgia Caused by Venous Compression
Authors: Matsushima Toshio , Huynh-Le Phuong , Miyazono Masayuki
Published: August 2004

OBJECTIVE:

The purpose of this study is to clarify whether venous compression on the trigeminal nerve really causes trigeminal neuralgia or not, and to identify which veins are the offending veins.

METHODS:

We used microvascular decompression in operations on 121 patients with typical trigeminal neuralgia. We analyzed the intraoperative findings and surgical results in these 121 cases.

RESULTS:

In 7 of the 121 cases, only the vein was identified as a compressive factor on the trigeminal nerve. In 6 of these 7 cases, single venous compression was found, whereas the remaining case had two offending veins. The transverse pontine vein was most frequently found as the offending vein near Meckel's cave. All patients showed complete relief of trigeminal pain after decompression of the veins, but four of them developed facial numbness after surgery, which tended to be slight and did not require any treatment.

CONCLUSION:

Our surgical experiences showed that venous compression could cause trigeminal neuralgia by itself and that the transverse pontine vein should be carefully observed because it is most frequently the offending vein.
Comparison of Endovascular and Surface Cooling during Unruptured Cerebral Aneurysm Repair
Authors: Steinberg Gary K. , Ogilvy Christopher S. , Shuer Lawrence M. , Connolly E. Sander , Solomon Robert A. , Lam Arthur , Kassell Neal F. , Baker Christopher J. , Giannotta Steven L. , Cockroft Kevin M. , Bell-Stephens Teresa E. , Allgren Robin L.
Published: August 2004

OBJECTIVE:

To compare endovascular versus surface methods for the induction and reversal of hypothermia during neurosurgery in a multicenter, prospective, randomized study.

METHODS:

Patients undergoing elective open craniotomy for repair of an unruptured cerebral aneurysm (n = 153) were randomly assigned (2:1) to undergo whole-body hypothermia to 33°C, either with an endovascular cooling device placed in the inferior vena cava via the femoral vein (n = 92) or with a surface convective air blanket (n = 61). Active rewarming was accomplished using the same devices.

RESULTS:

Cooling rates in endovascular and surface blanket groups averaged 4.77 and 0.87°C/h, respectively (P < 0.001). When the first temporary arterial or aneurysm clip was placed, 99% of endovascular patients and 20% of surface blanket patients had reached the target of 33°C (P < 0.001). Obese patients were cooled efficiently with the endovascular approach (3.56°C/h). Rewarming rates averaged 1.88°C/h for endovascular patients and 0.69°C/h for surface blanket patients (P < 0.001). By the end of surgery, 89 and 53% of these patients, respectively, had rewarmed to at least 35°C (P < 0.001). On leaving the operating room, 14% of endovascular patients and 28% of surface blanket patients were still intubated (P = 0.035). The overall safety of the two procedures was comparable. No clinically significant catheter-related thrombotic, bleeding, or infectious complications were reported in the endovascular group.

CONCLUSION:

Endovascular cooling provided superior induction, maintenance, and reversal of hypothermia compared with the surface blanket, without an increase in complications. Endovascular cooling may have clinical benefit for patients undergoing cerebrovascular surgery, as well as patients with acute stroke, head injury, or acute myocardial infarction.
Volumetric Assessment of Glioma Removal by Intraoperative High-field Magnetic Resonance Imaging
Authors: Nimsky Christopher , Fujita Atsushi , Ganslandt Oliver , von Keller Boris , Fahlbusch Rudolf
Published: August 2004

OBJECTIVE:

To investigate the contribution of high-field intraoperative magnetic resonance imaging (iMRI) for further reduction of tumor volume in glioma surgery.

METHODS:

From April 2002 to June 2003, 182 neurosurgical procedures were performed with a 1.5-T magnetic resonance system. Among patients who underwent these procedures, 47 patients with gliomas (14 with World Health Organization Grade I or II glioma, and 33 with World Health Organization Grade III or IV glioma) who underwent craniotomy were investigated retrospectively. Completeness of tumor resection and volumetric analysis were assessed with intraoperative imaging data.

RESULTS:

Surgical procedures were influenced by iMRI in 36.2% of operations, and surgery was continued to remove residual tumor. Additional further resection significantly reduced the percentage of final tumor volume compared with first iMRI scan (6.9% ± 10.3% versus 21.4% ± 13.8%; P < 0.001). Percentages of final tumor volume also were significantly reduced in both low-grade (10.3% ± 11.5% versus 25.8% ± 16.3%; P < 0.05) and high-grade gliomas (5.4% ± 9.9% versus 19.5% ± 13.0%; P < 0.001). Complete resection was achieved finally in 36.2% of all patients (low-grade, 57.1%; high-grade, 27.3%). Among the 17 patients in whom complete tumor resection was achieved, 7 complete resections (41.2%) were attributable to further tumor removal after iMRI. We did not encounter unexpected events attributable to high-field iMRI, and standard neurosurgical equipment could be used safely.

CONCLUSION:

Despite extended resections, introduction of high-field iMRI in conjunction with functional navigation did not translate into an increased risk of postoperative deficits. The use of high-field iMRI increased radicality in glioma surgery without additional morbidity.
Predicting Stroke Risk in Pediatric Moyamoya Disease with Xenon-enhanced Computed Tomography
Authors: McAuley David J. , Poskitt Ken , Steinbok Paul
Published: August 2004

OBJECTIVE:

To determine whether estimates of regional cerebral blood flow (rCBF) using xenon computed tomography (XeCT) in children with moyamoya disease can predict stroke risk before and after treatment.

METHOD:

Seven patients with moyamoya disease underwent 22 serial Xe computed tomographic scans. Estimates of rCBF were obtained at three computed tomographic levels by use of a 5-minute inhalation of 28% Xe. Acetazolamide challenge was performed in eight scans. For comparison of abnormal vessel distribution and areas of infarction, 17 intra-arterial digital subtraction angiograms, 47 computed tomographic scans, and 15 magnetic resonance imaging scans were available. Follow-up exceeded 36 months in all patients. Mean follow-up for the interventional group was 65.2 months (n =5; range, 37–109 mo) and 38 months for the nonoperative patients (n =2; 36 and 40 mo).

RESULTS:

Of six Xe computed tomographic scans obtained at diagnosis, four revealed regions of oligemia, augmented vertebrobasilar flow, and regions of carotid steal after acetazolamide. In the delay between diagnosis and treatment, three patients had strokes in ischemic areas identified by XeCT. Of the 10 posttreatment scans obtained from 4 patients, 2 revealed improved tissue perfusion with angiography confirming successful encephaloduroangiomyosynangiosis. In 2 others, XeCT performed 6 months posttreatment revealed improved perfusion without angiographic change, and angiography at 1 year revealed failed encephaloduroangiomyosynangiosis and new native collaterals. None of the patients with improved rCBF had new strokes. Eleven of 14 Xe computed tomographic scans were obtained within 30 days of angiography. Comparison of these studies demonstrates that regions of oligemia were confined to areas associated with vessel stenosis and little neovascularity or collateral pathways.

CONCLUSION:

XeCT, particularly with acetazolamide challenge, objectively quantifies rCBF. Our preliminary data suggest that it may permit assessment of stroke risk in children with moyamoya disease and may predict surgical outcome earlier than angiography.
Correlation between Withdrawal Symptoms and Medication Pump Residual Volume in Patients with Implantable SynchroMed Pumps
Authors: Taha Jamal , Favre Jacques , Janszen Michele , Galarza Marcelo , Taha Assad
Published: August 2004

OBJECTIVE:

To investigate whether patients with implantable SynchroMed pumps (Medtronic, Inc., Minneapolis, MN) develop symptoms of drug withdrawal at residual medication volumes that exceed 2 ml (the alarm residual volume recommended by the manufacturer).

METHODS:

The data sheets of 88 patients with implantable SynchroMed pumps were retrospectively reviewed. The following parameters were analyzed: development of symptoms of drug withdrawal; drugs used in the pump; disease state; drug residual volume in the pump; intake of orally administered medications; time of development of withdrawal symptoms; drug flow volume through the pump; daily intrathecally administered drug dose; and drug concentration in the pump.

RESULTS:

Of 88 patients, 21 (24%) consistently developed symptoms of drug withdrawal 1 to 7 days before the drug residual volume reached a mean of 2.7 ml (range, 2.1–3.8 ml; median, 2.6 ml). Symptoms first developed 1 to 18 months after surgery. In all patients, symptoms of drug withdrawal subsided after pump refill and did not recur after the alarm volume was increased to 4 ml. Symptom development did not correlate with intake of orally administered medication, drug flow volume through the pump, intrathecally administered drug dose, drug concentration in the pump, drugs used in the pump, or disease state.

CONCLUSION:

Some patients develop symptoms of drug withdrawal at residual volumes that exceed 2 ml. We could not identify factors that predict this occurrence. Withdrawal symptoms did not recur when the alarm volume was increased to 4 ml.
Solitary Fibrous Tumor of the Spinal Cord: Case Report and Review of the Literature
Authors: Kawamura Mitsuhiro , Izawa Kazutaka , Hosono Noboru , Hirano Hiroshi
Published: August 2004

OBJECTIVE AND IMPORTANCE:

A solitary fibrous tumor (SFT) is a rare neoplasm of probable mesenchymal origin that was first reported in the pleura but can occur in different sites. Only six cases of SFT arising from the spinal cord have been reported.

CLINICAL PRESENTATION:

We report a case of primary SFT occurring in the thoracic spinal cord in a 64-year-old man with Brown-Séquard syndrome. Magnetic resonance imaging revealed an intradural mass at the level of T2–T3.

INTERVENTION:

Total T2–T3 laminectomies were performed. The tumor appeared to be adherent to the right lateral aspect of the cord but not attached to the meninges. On histological examination, the tumor exhibited spindle cell proliferation with abundant dense collagen but without a hemangiopericytomatous pattern. Immunohistochemically, the tumor cells were reactive with CD34 and vimentin only.

CONCLUSION:

We report a rare case of SFT occurring in the thoracic spinal cord. Histologically and immunohistochemically, we confirmed the diagnosis of SFT. Low signal intensity on T1- and T2-weighted images corresponded to the histological findings. When a spinal cord tumor exhibits a signal pattern similar to this, SFT should be included in the differential diagnosis. Because of the rarity of reports on this condition, the clinical manifestations and course of SFT of the spinal cord are unknown, and careful long-term follow-up is recommended.
Ventriculoperitoneal Shunt Dysfunction in Adults Secondary to Conditions Causing a Transient Increase in Intra-abdominal Pressure: Report of Three Cases
Authors: Miele Vincent J. , Bendok Bernard , Bloomfield Stephen M. , Ondra Stephen L. , Bailes Julian E.
Published: August 2004

OBJECTIVE AND IMPORTANCE:

Ventriculoperitoneal (VP) shunts function because of the pressure differential between the intracranial space and the peritoneal cavity. The pressure in the peritoneal cavity is the lower of the two in a properly functioning shunt; thus, cerebrospinal fluid flows distally. Although not reported in the literature, adult constipation, ileus, or small bowel obstruction can alter this pressure balance and cause dysfunction. If not recognized as a transient, easily treated phenomenon, patients may be subjected to unnecessary shunt revisions. This study analyzed the occurrence of shunt malfunction in three adults secondary to transient increases in intra-abdominal pressure.

CLINICAL PRESENTATION:

Three patients with clinical symptoms and radiographic evidence of VP shunt malfunction at presentation were found to have transient conditions causing a significant increase in intra-abdominal pressure. These patients' records were evaluated with an emphasis on risk factors, treatments, and outcomes.

INTERVENTION:

After resolution of the patients' abdominal issues, clinical signs and symptoms of VP shunt dysfunction resolved within 24 hours. Radiographic evidence of the resolution of shunt failure also was observed.

CONCLUSION:

Shunt malfunction or dysfunction consumes many person-hours and healthcare dollars. This study provides anecdotal evidence that transient and easily reversible increases in the intra-abdominal pressure of adults with VP shunts can result in dysfunction. Although it may not be practical to delay shunt revision while attempting to correct constipation, ileus, or small bowel obstruction, clinicians treating patients with these abdominal conditions should be aware that they could cause transient VP shunt failure. It would seem prudent that patients with VP shunts be started on a prophylactic bowel regimen before surgical procedures to decrease the risk of this somewhat preventable result.
Primary End-to-end Anastomosis of Anterior Cerebral Artery Dissecting Aneurysm: Technical Case Report and Review of The Literature
Authors: Al-Khayat Hisham , Kopitnik Thomas A.
Published: August 2004

OBJECTIVE AND IMPORTANCE:

Subarachnoid hemorrhage caused by an isolated dissection of the anterior cerebral artery (ACA) is an extremely rare problem. The optimal treatment for patients with this clinical scenario varies and is controversial in the literature. We report a patient with a hemorrhage from a distal ACA dissecting aneurysm at presentation 2 years after an arteriovenous malformation resection, who was treated effectively with excision of the diseased segment and direct revascularization of the ACA. We report this as the first case of delayed hemorrhagic arterial dissection after arteriovenous malformation resection treated with early revascularization. We review this rare topic and present our perspective on the method of treatment of ACA dissection.

CLINICAL PRESENTATION:

A 32-year-old woman was transferred to the University of Texas Southwestern Medical Center and admitted with subarachnoid and intraventricular hemorrhage. Angiography revealed the source of the hemorrhage to be a dissecting aneurysm of the pericallosal artery.

INTERVENTION:

The patient underwent surgery on the third day after hemorrhage for excision of the dissecting aneurysm and in situ primary anastomosis of the pericallosal artery. Exposure and anastomosis of the pericallosal artery was facilitated by partial resection of the genu of the corpus callosum.

CONCLUSION:

On the basis of our experience and review of the literature regarding this topic, an optimal treatment for a dissecting aneurysm with hemorrhage involving the pericallosal portion of the ACA at presentation is excision of the diseased segment followed by revascularization. This treatment should prevent rehemorrhage from the aneurysm and avoid iatrogenic ischemic complications to the ACA territory that would be likely with trapping of the aneurysm without revascularization.
Percutaneous Ventral Decompression for L4–L5 Degenerative Spondylolisthesis in Medically Compromised Elderly Patients: Technical Case Report
Authors: Lee Ho-Yeon , Ahn Yong , Kim Dong Yun , Shin Song-Woo , Lee Sang-Ho
Published: August 2004

OBJECTIVE AND IMPORTANCE:

To evaluate the efficacy of percutaneous ventral decompression for the treatment of elderly and medically compromised patients with degenerative lumbar spondylolisthesis (DLS).

CLINICAL PRESENTATION:

We present three cases of elderly and medically compromised patients with DLS. Each patient had one or more of the following disorders: diabetes, hypertension, or congestive heart failure. The mean age of the patients was 74.3 years (range, 66–84 yr). All three patients had compressive central canal stenosis on magnetic resonance imaging at the level of DLS. Their symptoms were bilateral buttock pain, leg pain, and back pain.

TECHNIQUE:

Percutaneous ventral decompression without violation of the posterior bony structure was performed under local anesthesia. After the surgery, the symptoms were relieved in all three patients. There was no further progression of spondylolisthesis or neurological complications during the follow-up period.

CONCLUSION:

Percutaneous ventral decompression is an alternative method of treating DLS in elderly and medically compromised patients, especially when general anesthesia is not recommended.