bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgery of the Subthalamic Nucleus: Use of Movement-related Neuronal Activity for Surgical Navigation
Authors: Starr Philip A. , Theodosopoulos Philip V. , Turner Robert
Published: August 2004

THE BASAL GANGLIA have important roles in somatic motor, oculomotor, limbic, and associative functions. These functions are represented in anatomically distinct territories in each basal ganglion nucleus. During surgery of the subthalamic nucleus for Parkinson's disease, the primary goal is to influence the physiology of the motor territory without affecting nonmotor areas. This article describes the use of movement-related cellular activity during single-unit microelectrode mapping to identify and to navigate within the motor territory of the subthalamic nucleus.
Dosimetric Comparison of CyberKnife with Other Radiosurgical Modalities for an Ellipsoidal Target
Authors: Yu Cheng , Jozsef Gabor , Apuzzo Michael L.J. , Petrovich Zbigniew
Published: August 2004

OBJECTIVE

To compare treatment plans obtained with the CyberKnife (CK) (Accuray, Inc., Sunnyvale, CA) with those of other commonly used radiosurgical modalities, such as the gamma knife (GK), linear accelerator multiple arcs, conformally shaped static fields, and intensity-modulated radiotherapy (IMRT).

METHODS

An ellipsoidal simulated target was chosen centrally located in a three-dimensional model of a patient's head acquired with magnetic resonance or computed tomographic imaging. It was 25 mm in diameter and 35 mm long. The aims of treatment plans were 100% target volume coverage with an appropriate isodose line, minimum radiation dose to normal tissue, and clinically acceptable delivery. These plans were evaluated by use of a dose-volume histogram and other commonly used radiosurgical parameters such as target coverage, homogeneity index, and conformity index.

RESULTS

All selected treatment modalities were equivalent in providing full target coverage. For dose homogeneity, all modalities except for multiple isocenter plans for GK (homogeneity index, 2.0) were similar (homogeneity index, ≅1.25). Dose conformity was essentially equivalent for all treatment plans except for IMRT, which had a slightly higher value (conformity index, ≅1.27). There was a substantial variation in the radiation dose to normal tissue between the studied modalities, particularly at the lower dose levels.

CONCLUSION

CK plans seemed to be more flexible for a given target size and shape. For a target of limited volume and essentially of any shape, one could obtain similarly good conformal dosimetry with CK and GK. For a regular-shaped but other than spherical target, homogeneous dose distribution could be obtained with all selected modalities except for multiple isocenters, linear accelerator multiple arcs, or GK. Both IMRT and conformally shaped static fields offered good alternative treatment modalities to CK, GK, or linear accelerator multiple arc radiosurgery, with slightly inferior dosimetry in conformity (IMRT).
Multiple Intracranial Arterial Stenoses around the Circle of Willis in Association with Graves' Disease: Report of Two Cases
Authors: Nakamura Kazuhiro , Yanaka Kiyoyuki , Ihara Satoshi , Nose Tadao
Published: August 2004

OBJECTIVE AND IMPORTANCE

The association of Graves' disease with multiple intracranial arterial stenoses is rare.

CLINICAL PRESENTATION

We report on two Japanese women who experienced the concurrence of Graves' disease and cerebral ischemia attributable to multiple intracranial arterial stenoses around the circle of Willis. Clinically, these patients demonstrated hyperthyroidism, goiter, ophthalmopathy, and ensuing ischemic strokes. Cerebral angiography demonstrated multiple intracranial arterial stenoses around the circle of Willis in both cases. These cases did not meet the full diagnostic criteria for moyamoya disease, in that there were no abnormal, net-like, collateral vessels, but the other clinical and angiographic findings were consistent with this condition.

INTERVENTION

After normalization of their hormonal conditions, the patients underwent cerebral revascularization procedures. Both patients achieved excellent recoveries and returned to normal daily life after treatment.

CONCLUSION

Multiple intracranial arterial stenoses and Graves' disease may occur simultaneously. Such cases may offer new insights into the pathogenesis of these two conditions. It is important to study more patients with this dual condition, to obtain more evidence of the relationship between genetic and immunogenic backgrounds.
Endoscopic Third Ventriculostomy with Cystoventricular Stent Placement in the Management of Dandy-Walker Malformation: Technical Case Report of Three Patients
Authors: Mohanty Aaron
Published: August 2004

OBJECTIVE AND IMPORTANCE

Dandy-Walker malformation has conventionally been managed with placement of cystoperitoneal or ventriculoperitoneal shunts. However, associated aqueductal obstruction requires simultaneous drainage of both the supratentorial and infratentorial compartments.

CLINICAL PRESENTATION

Three children with Dandy-Walker malformation and aqueductal obstruction were managed with endoscopic third ventriculostomy and placement of a stent from the third ventricle to the posterior fossa cyst.

INTERVENTION

After an endoscopic third ventriculostomy was performed, the stent was placed from the third ventricle to the posterior fossa cyst through the thinnest part of the posteroinferior wall of the aqueduct. There was no operative morbidity. In one patient, the stent was malpositioned, requiring a repositioning. The endoscopic third ventriculostomy was successful in two patients, whereas it failed in one, requiring a ventriculoperitoneal shunt placement.

CONCLUSION

Cystoventricular stent placement with endoscopic third ventriculostomy is a promising alternative in patients with Dandy-Walker malformation with aqueductal obstruction.
Surgical Management and Results of 135 Tibial Nerve Lesions at the Louisiana State University Health Sciences Center
Authors: Kim Daniel H. , Cho Yong-Jun , Ryu Stephen , Tiel Robert L. , Kline David G.
Published: August 2004

OBJECTIVE

This retrospective study presents 33 years of clinical and surgical experience with 135 tibial nerve lesions to review operative techniques and their results and to provide management guidelines for the proper selection of surgical candidates.

METHODS

Between 1967 and 1999, 135 patients with tibial nerve lesions at the knee level or below were managed surgically at the Louisiana State University Health Sciences Center. We reviewed these cases.

RESULTS

Of the 135 cases, traumatic injury accounted for 71, tarsal tunnel syndrome for 46, and nerve sheath tumor for 18. Of 22 lesions not in continuity, functional recovery of Grade 3 or better was achieved in 4 (67%) of 6 patients who required end-to-end suture repair and 11 (69%) of 16 patients who required graft repair. One hundred thirteen tibial nerve lesions in continuity underwent primarily external or internal neurolysis or resection of the lesions. A few received end-to-end suture or graft repair. Direct intraoperative recording of nerve action potentials guided case management decisions. Among the 113 patients with lesions in continuity, 76 (81%) of 94 patients receiving neurolysis, 5 (83%) of 6 receiving suture repair, and 11 (85%) of 13 receiving graft repair recovered function to Grade 3 or better. Repair results were best in patients with recordable nerve action potentials treated by external neurolysis. Results were poor in a few patients with very lengthy lesions in continuity and in reoperated patients with tarsal tunnel syndrome.

CONCLUSION

Surgical exploration and repair of tibial nerve lesions, including nerve sheath tumors and tarsal tunnel syndromes, achieved excellent outcomes.
Removal of an Anterior Spinal Dermoid Cyst with Fenestra Corpectomy in Klippel-Feil Syndrome: Technical Case Report
Authors: Kaya R. Alper , Türkmenoğlu Osman , Dalkılıç Türker , Aydın Yunus
Published: August 2004

OBJECTIVE AND IMPORTANCE

A spinal cord tumor occurring in association with Klippel-Feil syndrome is quite rare. The removal of an anteriorly located spinal cord tumor at the level of block vertebrae creates a surgical challenge.

CLINICAL PRESENTATION

A case of an intradural extramedullary dermoid cyst located anterior to the spinal cord and a syringomyelic cavity at the level of block vertebrae in a 43-year-old woman with Klippel-Feil syndrome is presented. She experienced pain and numbness in both shoulders and in her neck, and she had a slight weakness in both arms before the operation. Her weakness and the clinical symptoms completely disappeared after the operation, and the resolution of the syringomyelic cavity was observed at control magnetic resonance imaging.

INTERVENTION

An anterior approach creating a fenestra corpectomy to the block vertebrae was performed, and the tumor was removed totally. No fusion or fixation was performed.

CONCLUSION

To our knowledge, this is the first report of an anteriorly located intradural extramedullary cervical spine tumor in association with Klippel-Feil syndrome treated with this surgical technique. A three-dimensional computed tomographic control scan obtained 1 year after the operation did not show any instability.
Emergency Craniotomy for Intraparenchymal Massive Hematoma after Embolization of Supratentorial Arteriovenous Malformations
Authors: Iwama Toru , Yoshimura Kunikazu , Keller Emanuela , Imhof Hans-Georg , Khan Nadia , Leblebicioglu-Könu Dilek , Tanaka Michihiro , Valavanis Anton , Yonekawa Yasuhiro
Published: August 2004

OBJECTIVE

We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome.

METHODS

Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score ≤6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively.

RESULTS

Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed.

CONCLUSION

In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.
Poor-grade Aneurysmal Subarachnoid Hemorrhage: Outcome after Treatment with Urgent Surgery
Authors: Laidlaw John D. , Siu Kevin H.
Published: August 2004

OBJECTIVE

We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results.

METHODS

A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months.

RESULTS

Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05).

CONCLUSION

The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.
Cortical Areas Involved in Virtual Movement of Phantom Limbs: Comparison with Normal Subjects
Authors: Roux Franck-Emmanuel , Lotterie Jean-Albert , Cassol Emmanuelle , Lazorthes Yves , Sol Jean-Christophe , Berry Isabelle
Published: August 2004

OBJECTIVE

To demonstrate that amputees performing “virtual” movements of their amputated limb activate cortical areas previously devoted to their missing limb, we studied amputees with functional magnetic resonance imaging (fMRI) and positron emission tomographic (PET) scans and compared the results with those of normal volunteers performing imaginary movements during fMRI acquisitions.

METHODS

Ten amputees (age range, 33–92 yr; average age, 49 yr; six men and four women; eight upper-limb and two lower-limb amputations) able to move their phantom limb at will were studied by fMRI (all patients) and PET scan (seven patients). The time between amputation and fMRI and PET studies ranged from 1 to 27 years (average, 13 yr). Patients were asked to perform virtual movements of the amputated limb and normal movements of the contralateral normal limb according to the functional images acquisition procedure. Movements of the stump were also used to differentiate stump cortical areas from virtual movement-activated areas. Ten right-handed volunteers, age- and sex-matched to the amputees, were also studied by fMRI. All volunteers were asked to perform four tasks during their fMRI study: imaginary movements of their right arm (1 task) and foot (1 task) and real movements of their left arm (1 task) and foot (1 task).

RESULTS

In amputees, virtual movements of the missing limbs produced contralateral primary sensorimotor cortex activation on both fMRI and PET scans. These activation areas, different from the stump activation areas, were similar in location to contralateral normal limb-activated areas. Quantitatively, in two amputees who claimed to be able to perform both slow and fast virtual movements, regional cerebral blood flow measured by PET scan in the precentral gyrus increased significantly during fast movements in comparison with slow virtual movements. In normal subjects, significant differences between real versus imaginary fMRI activations were found (for both foot and hand movements); imaginary right hand and foot tasks activated primarily the contralateral supplementary motor areas, with no significant activation detected in the contralateral precentral or postcentral gyri.

CONCLUSION

Primary sensorimotor cortical areas can be activated by phantom-limb movements and thus can be considered functional for several years or decades after amputation. In this study, we found that the location of the activation of these areas is comparable to that of activations produced by normal movements in control subjects or in amputees.
Genetic Analysis of a Multifocal Glioblastoma Multiforme: A Suitable Tool to Gain New Aspects in Glioma Development
Authors: Krex Dietmar , Mohr Brigitte , Appelt Hella , Schackert Hans K. , Schackert Gabriele
Published: August 2004

OBJECTIVE

Multifocal glioblastomas constitute an increasingly diagnosed subgroup of glioblastoma multiforme, the most malignant primary brain tumor in adults. The molecular background of these lesions is unknown. However, the ability to study multiple lesions of one patient simultaneously could provide new aspects in glioma development.

METHODS

Short-term cell cultures were derived from three isolated glioblastoma lesions of one patient. Spectral karyotyping and interphase fluorescence in situ hybridization were used for cytogenetic analysis. Loss of heterozygosity was assessed in tumor tissues and cell lines for seven gene loci (p73, p21, p16, PTEN, p27, Rb, p53). In addition, sequence analysis of the PTEN and p53 loci was performed, epidermal growth factor receptor protein expression was assessed, and in vitro proliferation was assayed.

RESULTS

A balanced translocation [t(1;15)(p3?6;q2?5)] that has not been described previously in glioblastomas was identified in all cell lines. Primarily, the cell lines have a homozygous deletion of the p16 locus and inactivation of the PTEN gene by loss of heterozygosity and an identical mutation in common. Furthermore, the cell lines harbor a hemizygous (R175H) or two heterozygous (R175H, R213Q) mutations of the p53 gene or none at all. The occurrence of p53 mutations correlates with the size of the original tumors and in vitro proliferation.

CONCLUSION

The analysis of a multifocal glioma revealed three main aspects: 1) the combined cytogenetic and molecular analysis of this subgroup of glioblastoma multiforme is a suitable tool to gain new perspectives in glioma development, 2) the balanced translocation [t(1;15)(p3?6;q2?5)] might harbor a new genetic marker involved in glioma development, and 3) the pattern of p53 mutation suggests a role of p53 in the progression of malignancy, migration, and growth of this particular primary glioblastoma.
Cerebellar Liponeurocytoma with an Unusually Aggressive Clinical Course: Case Report
Authors: Jenkinson Michael David , Bosma Jark Jan Daniel , Du Plessis Daniel , Ohgaki Hiroko , Kleihues Paul , Warnke Peter , Rainov Nikolai G.
Published: August 2004

OBJECTIVE AND IMPORTANCE

Liponeurocytomas are rare cerebellar neoplasms in adults, with benign histological features and a favorable clinical prognosis. Current clinical opinion is based on a total of less than 20 published cases and suggests that gross total resection and long-term follow-up monitoring, with possible additional surgery and radiotherapy for treatment of recurrent tumors, represent the best treatment approach for this relatively benign tumor type.

CLINICAL PRESENTATION

A 51-year-old Caucasian woman presented with worsening unsteady gait and headaches, suggesting increased intracranial pressure.

INTERVENTION

The patient underwent subtotal resection of a cerebellar liponeurocytoma, followed by fractionated radiotherapy (total dose of 54 Gy). She experienced a local recurrence of the tumor 12 months later and underwent additional surgery for removal of the cerebellar mass. A second recurrent tumor was diagnosed on magnetic resonance imaging scans 3 months later and was surgically resected. The tumor histological findings were consistently devoid of atypical features, apart from leptomeningeal invasion noted in the first surgical specimen.

CONCLUSION

This unusual case demonstrated an atypical clinical course of a highly aggressive and radiation-resistant tumor, despite the consistent absence of aggressive histological features. Cerebellar liponeurocytomas may not be as benign as the current literature and typical low-grade cytological and histological features suggest.
Microvascular Decompression for Treatment of Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: Three Surgical Approach Variations: Technical Note
Authors: Hitotsumatsu Tsutomu , Matsushima Toshio , Inoue Tooru
Published: August 2004

OBJECTIVE

We have used three different approaches, namely, the infratentorial lateral supracerebellar approach, the lateral suboccipital infrafloccular approach, and the transcondylar fossa approach, for microvascular decompression for treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia, respectively. Each approach is a variation of the lateral suboccipital approach to the cerebellopontine angle (CPA); however, each has a different site of bony opening, a different surgical direction, and a different route along the cerebellar surface.

METHODS

The infratentorial lateral supracerebellar approach is used to access the trigeminal nerve in the superior portion of the CPA through the lateral aspect of the cerebellar tentorial surface. The lateral suboccipital infrafloccular approach is directed through the inferior part of the cerebellar petrosal surface to reach the root exit zone of the facial nerve below the flocculus. The transcondylar fossa approach is used to access the glossopharyngeal nerve in the inferior portion of the CPA through the cerebellar suboccipital surface, after extradural removal of the jugular tubercle as necessary.

RESULTS

In all three approaches, the cerebellar petrosal surface is never retracted transversely, that is, the cerebellar retraction is never directed parallel to the longitudinal axis of the VIIIth cranial nerve, dramatically reducing the risk of postoperative hearing loss.

CONCLUSION

The greatest advantage of the differential selection of the surgical approach is increased ability to reach the destination in the CPA accurately, with minimal risk of postoperative cranial nerve palsy.
Parallel Venous Channel as the Recipient Pouch in Transverse/Sigmoid Sinus Dural Fistulae
Authors: Caragine Louis P. , Halbach Van V. , Dowd Chris F. , Ng Perry P. , Higashida Randall T.
Published: August 2004

OBJECTIVE

The most common location for dural arteriovenous fistulae (AVFs) is the transverse/sigmoid sinus. We describe our prospective analysis of data for 10 patients with recipient fistulae parallel to the transverse/sigmoid sinus. Recognition of this entity allows embolization of the fistula with preservation of the parent sinus. This report reviews the presentation and angiographic characteristics of the “parallel venous channel” and the treatment results for this series of patients.

METHODS

Between 1995 and June 2002, at the medical center of the University of California, San Francisco, we identified 10 patients with a parallel venous channel as the recipient pouch for all arterial input into a transverse/sigmoid sinus AVF. The clinical presentations, angiographic features, endovascular treatments, and outcomes are described. Angiographic follow-up monitoring was performed for 1 to 6 years for all patients with cortical venous drainage (5 of 10 patients). Clinical follow-up periods ranged from 1 to 7 years.

RESULTS

All patients presented with pulsatile tinnitus disruptive to sleep. Other symptoms included severe headaches, papilledema and visual disturbances, hemiparesis, and mastoid pain. All 10 parallel venous channels communicated with the transverse or sigmoid sinus. Cortical venous drainage was present in 50% of cases. Endovascular ablative procedures, using either coils or ethanol, were performed for all patients. The parallel venous channel was successfully embolized, with preservation of the transverse/sigmoid sinus, for all 10 patients. There were no major complications. All patients experienced resolution of their symptoms, with no recurrence.

CONCLUSION

The existence of a parallel venous channel as the recipient pouch for all arterial inflow in a series of 10 transverse/sigmoid sinus AVFs is described. Endovascular obliteration of the parallel channel, with preservation of the parent sinus, was successfully performed for all 10 patients. Recognition of the parallel venous channel is clinically important for the treatment of transverse/sigmoid AVFs.
Evolution of Oculomotor Nerve Paresis after Endovascular Coiling of Posterior Communicating Artery Aneurysms: A Neuro-ophthalmological Perspective
Authors: Stiebel-Kalish Hadas , Maimon Shimon , Amsalem Jacob , Erlich Rita , Kalish Yuval , Rappaport Z. Harry
Published: August 2004

OBJECTIVE

Guglielmi detachable coil treatment is becoming an accepted alternative to microsurgical clipping for select intracerebral aneurysms. Resolution of oculomotor nerve paresis (ONP) after endovascular packing was claimed to be complete in two prior series, with three and six cases. We describe the evolution of ONP after Guglielmi detachable coil treatment of posterior communicating artery aneurysms, and we search for endovascular and patient factors correlated with the degree of functional nerve recovery.

METHODS

Twelve cases of ONP attributable to posterior communicating artery aneurysms were treated with Guglielmi detachable coils between 1999 and 2002. Eleven patients were available for follow-up monitoring. The degree of ONP was recorded at admission, at discharge, after 3 months, and at yearly intervals thereafter. The size of the aneurysm, the duration of ONP before coiling, the degree of coiling, age, and the presence of other microvascular risk factors were correlated with the degree of nerve recovery.

RESULTS

Complete resolution of ONP did not occur in any of the 11 cases in this series. However, residual oculomotor nerve deficits did not cause diplopia with primary gaze for 10 of 11 patients. Clinically significant ptosis did not persist for any of the patients. The pupil remained minimally affected in all cases.

CONCLUSION

Although mass effect remains after endovascular packing, oculomotor nerve dysfunction improves comparably to the recovery observed after surgical clipping. Contrary to previous reports, typical residual oculomotor nerve deficits persist. Older age and the presence of microvascular risk factors seem to be detrimental to ONP recovery.
Primary Intracerebral Hemorrhage in Izumo City, Japan: Incidence Rates and Outcome in Relation to the Site of Hemorrhage
Authors: Inagawa Tetsuji , Ohbayashi Naohiko , Takechi Akihiko , Shibukawa Masaaki , Yahara Kaita
Published: August 2004

OBJECTIVE

The aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage.

METHODS

The subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan.

RESULTS

The crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge.

CONCLUSION

Marked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.
Intraspinal Epidermoid Cyst Successfully Treated with Radiotherapy: Case Report
Authors: Bretz Anette , Van den Berge Dirk , Storme Guy
Published: August 2004

OBJECTIVE AND IMPORTANCE

Epidermoid cysts are benign lesions that account for 0.7% of all intraspinal tumors. Standard treatment is complete resection. The recurrence rate after surgery cannot be estimated from the scarce literature, but it has been acknowledged that, in some patients, curative surgery may be impossible and temporary relief of symptoms is the only aim.

CLINICAL PRESENTATION

In 1996, a 59-year-old woman presented with a 30-year history of a spinal epidermoid cyst, for which she had previously undergone eight operations. Spastic paraplegia of the lower limbs had been present from initial diagnosis, and the neurological level had moved upward to C6. At the time of presentation, paresthesia in her arms and hands had developed. A magnetic resonance imaging scan revealed typical sequelae of previous surgery and a fibrotic region starting at the level of C5–C6 with formation of a cyst that extended to the conus terminalis. The spinal cord could not be visualized caudally at C7.

INTERVENTION

Because both patient and surgeons did not want further surgical interventions that might comprise upper limb function, radiotherapy was performed. A dose of 46 Gy was delivered to the cervicothoracic spine (C4–T1) by opposing anteroposterior high-energy photon beams. The treatment was well tolerated, and after treatment, the patient's clinical symptoms improved slightly, without evolution on magnetic resonance imaging.

CONCLUSION

Irradiation was effective in stabilizing the patient's disease. Although radiotherapy is not established in the treatment of epidermoid cysts, it should be considered as an alternative to palliative surgery and in patients who cannot undergo operations.
One-stage Removal of Residual Intracanalicular Acoustic Neuroma and Hemihypoglossal-intratemporal Facial Nerve Anastomosis: Technical Note
Authors: Donzelli Renato , Motta Gaetano , Cavallo Luigi Maria , Maiuri Francesco , de Divitiis Enrico
Published: August 2004

OBJECTIVE AND IMPORTANCE

Incomplete removal of residual intracanalicular tumor and injury to the facial nerve are the main problems associated with surgery of large acoustic neuromas via the retromastoid suboccipital approach. In patients with residual or recurrent intracanalicular neuromas, the translabyrinthine approach is the preferred surgical route, allowing complete tumor removal; it may eventually also be used for exposure of the intratemporal portion of the facial nerve for a hemihypoglossal-facial nerve anastomosis when a postoperative facial palsy exists This one-stage procedure has not been described previously.

CLINICAL PRESENTATION

Three patients with postoperative facial palsy and residual intracanalicular tumor after surgical removal of a large acoustic neuroma via the retromastoid suboccipital approach underwent reoperation via the translabyrinthine approach and one-stage removal of the residual tumor and hemihypoglossal-facial nerve anastomosis. All three patients had a complete facial palsy of House-Brackmann Grade VI and a residual tumor of 8 to 12 mm.

TECHNIQUE

A classic translabyrinthine approach was used to open the internal auditory canal and remove the residual intracanalicular tumor. The facial nerve was exposed in its mastoid and tympanic parts, mobilized, and transected; then, the long nerve stump was transposed into the neck and used for an end-to-side anastomosis into the hypoglossal nerve. The operation resulted in variable improvement of the facial muscle function up to Grade III (one patient) and Grade IV (two patients).

CONCLUSION

Reoperation via the translabyrinthine approach is indicated for removal of residual intracanalicular acoustic neuroma and realization of a hypoglossal-facial nerve anastomosis in a single procedure. It is suggested that this type of anastomosis may also be used during the initial operation for acoustic neuroma removal when the facial nerve is inadvertently sectioned.
Paleopathological Features of the Cervical Spine in the Early Middle Ages: Natural History of Degenerative Diseases
Authors: Weber Jochen , Czarnetzki Alfred , Spring Axel
Published: August 2004

OBJECTIVE

Trauma and degenerative joint disease are the most common pathological conditions observed in archaeological skeletal remains. We describe the prevalence of different types of cervical bone diseases observed in the early Middle Ages (6th to 8th centuries AD).

METHODS

Human skeletons were excavated from Germanic row graves in southwestern Germany. One hundred ninety-six cervical spines thus obtained were examined for bone disease. The degenerative changes were classified into Grades 1 (marginal osteophytes), 2 (uneven joint surfaces), and 3 (osseous ankylosis). Cervical spinal canal stenosis was defined as anteroposterior diameters of <11 mm and intervertebral foraminal stenosis as <3.0 mm in the smallest diameter.

RESULTS

Of the skeletons, 27.5% demonstrated degenerative changes of the cervical spine. The mean age of the skeletons at the time of death was 33.4 years, compared with 43.7 years for those with degenerative disease. Degenerative changes of the vertebral bodies (usually Grades 1 and 2) were most common in the C5–C6 (12.4%, P < 0.05) and C6–C7 (15.3%, P < 0.05) segments. The medial (6.1%) and lateral (0.6%) atlantoaxial joints were rarely involved in degenerative disease. The facet joints from C3–C4 to C6–C7 demonstrated degenerative changes (usually Grades 1 and 2) in 8.0 to 11.8% of cases. The C2–C3 facet joints were significantly involved in degenerative disease in 19.7% of cases (P < 0.05), one-fourth of which demonstrated osseous ankylosis. We observed cervical spinal canal stenosis in 5 skeletons (2.6%) and osseous intervertebral foraminal stenoses in 12 (6.1%). Isolated cases of other pathological processes, i.e., spondylitis ankylopoietica, occipitalization of the atlas and axis, and an odontoid fracture with pseudoarthrosis, were also recorded.

CONCLUSION

In the early Middle Ages, the prevalence of degenerative cervical spine disease was the same as that observed today. The C2–C3 facet joints demonstrated high rates of degenerative disease.
Endovascular Coil Occlusion of 1811 Intracranial Aneurysms: Early Angiographic and Clinical Results
Authors: Henkes Hans , Fischer Sebastian , Weber Werner , Miloslavski Elina , Felber Stephan , Brew Stefan , Kuehne Dietmar
Published: August 2004

OBJECTIVE

We sought to evaluate the early angiographic and clinical outcomes of the first session of endovascular coil occlusion of a large number of patients with intracranial aneurysms treated by five neurointerventionalists during a decade at a single center.

METHODS

We performed retrospective analyses of pre- and postprocedural angiographic studies and early clinical outcomes. Enrolled patients underwent endovascular treatment of intracranial aneurysms with detachable coils.

RESULTS

A total of 1811 aneurysms in 1579 patients were treated with coil occlusion. Of these, 90 to 100% occlusion of 86.5% of the aneurysms was achieved. In 82.3% of the procedures, no complications occurred. The clinical outcome profile at primary discharge according to the Glasgow Outcome Scale was as follows: Grade V, 74.6%; Grade IV, 6.7%; Grade III, 11.1%; Grade II, 3.1%; and Grade I, 4.5%. In patients with large aneurysms with wide necks, a lower occlusion rate and an increased complication rate were encountered. The use of three-dimensional and fibered coils resulted in higher occlusion rates. Balloon remodeling and stent deployment increased the complication rate. Previous aneurysm rupture, procedural complications, and vasospasm correlated with poor outcome. Of the patients in poor grade after aneurysm rupture, 42% recovered to Glasgow Outcome Scale Grade IV or V, as opposed to 90% of patients who were treated for unruptured aneurysms. The ischemic complication rate was 9%, and the hemorrhagic complication rate was 3%. The early procedural morbidity rate was 5.3%, and the procedural mortality rate was 1.5%. The management mortality rate was 4.4%.

CONCLUSION

These data confirm the safety and efficacy of endovascular coil occlusion for patients with intracranial aneurysms.
Surgically Treated Aneurysms Previously Coiled: Lessons Learned
Authors: Veznedaroglu Erol , Benitez Ronald P. , Rosenwasser Robert H.
Published: August 2004

OBJECTIVE

Intravascular coil embolization of cerebral aneurysms has proved to be a safe and effective treatment in certain patient groups; however, this treatment is relatively new, and the long-term outcomes are unknown. One of the known complications is refilling of the aneurysm dome, which is seen in follow-up studies. This patient population poses unique technical difficulties for the neurosurgeon. We present a series of 18 patients who underwent surgery for residual aneurysms after coil remobilization.

METHODS

During a 5-year period, we performed surgery in 18 patients who had previously undergone coil embolization for their aneurysms. Of these aneurysms, four were in the anterior communicating artery, five were in the posterior communicating artery, three were in the internal carotid artery, three were in the posteroinferior cerebellar artery, and three were in the middle cerebral artery. One patient presented with rupture, one presented with acute IIIrd cranial nerve palsy, and the rest of the aneurysms were found on routine follow-up angiograms. Fifteen aneurysms were clipped, and in three patients, they were wrapped because the clip could not be placed adequately.

RESULTS

There were no major complications in any of the patients, and all had uneventful recoveries. The presence of coils in the aneurysm dome and/or neck made clipping and exposure of the aneurysm neck difficult, resulting in incomplete neck obliteration in three patients.

CONCLUSION

Operative clipping after previous coil embolization in aneurysms poses a unique problem for neurosurgeons. With the increasing use of coil embolization, this patient population will undoubtedly increase. The neurosurgeon should be aware of the difficulties and pitfalls encountered in these patients.
Endoscopic Exploration of the Brachial Plexus: Technique and Topographic Anatomy—A Study in Fresh Human Cadavers
Authors: Krishnan Kartik G. , Pinzer Thomas , Reber Friedemann , Schackert Gabriele
Published: August 2004

OBJECTIVE

The indications for and timing of brachial plexus exploration in closed injuries are controversial. The time-consuming surgery proves its worth in some cases, whereas spontaneous regeneration might have been possible in others. The differentiation is difficult, because no investigational method reveals the exact morphological correlates of the nerve lesions. Minimally invasive, direct observation of the structures is a possible solution. Here we describe our surgical technique and the anatomic features of the normal brachial plexus appreciated with the endoscope.

METHODS

Twenty-one brachial plexus in 11 fresh cadavers were investigated. Endoscopic exploration was performed at the supraclavicular and infraclavicular levels. The method involves insertion of an optic shaft-integrated retractor through a stab wound; retraction of landmark muscles produces a working space, into which other instruments are introduced for dissection. After completion of endoscopic surgery, open dissection was performed to verify the endoscopically identified structures and to assess iatrogenic injuries.

RESULTS

The omohyoid muscle is a reliable landmark in the supraclavicular region, beneath which the suprascapular nerve can be observed. Following the suprascapular nerve proximally leads to the plexus trunks. Infraclavicular exploration first reveals the axillary artery. The plexus and its nerves are traced around this artery. The anatomic features were constant in all cases, with variations in fat accumulation depending on the corporeal constitution. We detected iatrogenic injuries to the medial circumflex humeral vessels in two cases. No nerve injuries were observed.

CONCLUSION

The endoscopic technique combined with intraoperative nerve stimulation studies might provide important information on the type of morphological damage in closed brachial plexus injuries and thus might become an important tool for determination of the surgical treatment strategy. Clinical work is under way.
Detection of Intracranial Aneurysms with Two-dimensional and Three-dimensional Multislice Helical Computed Tomographic Angiography
Authors: Kangasniemi Marko , Mäkelä Teppo , Koskinen Seppo , Porras Matti , Poussa Kristiina , Hernesniemi Juha
Published: August 2004

OBJECTIVE

Computed tomographic angiography (CTA) has become a diagnostic method for the detection of intracranial aneurysms in cases of subarachnoid bleeding. We sought to evaluate the detection of aneurysms with CTA with a novel multislice helical computed tomographic scanner.

METHODS

Prospectively, 179 patients underwent multislice CTA, followed by digital subtraction angiography (DSA) of both carotid arteries with or without the posterior circulation, DSA of one carotid artery with or without the posterior circulation, or DSA of the posterior circulation alone. The total number of carotid arteries studied was 298, and the number of vertebrobasilar arteries studied was 124.

RESULTS

Of 178 aneurysms verified with DSA or intraoperatively, CTA failed to detect 7 aneurysms of 1 to 2 mm and 1 partially thrombosed, 4-mm aneurysm. The sensitivity and specificity of CTA for aneurysm detection were 0.96 and 0.97, respectively.

CONCLUSION

The first generation of multislice computed tomographic technology does not improve CTA to surpass DSA for the detection of small aneurysms of 1 to 2 mm. In practice, however, CTA is superior as a fast noninvasive method without complications.
Healing Process for Cerebral Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage
Authors: Mizutani Tohru , Kojima Hideaki , Asamoto Shunji
Published: August 2004

OBJECTIVE

This was a pathological study to investigate the healing process for cerebral dissecting aneurysms presenting with subarachnoid hemorrhage (SAH).

METHODS

Thirteen dissecting aneurysms that presented with SAH were obtained from 13 patients. Nine aneurysms arose from the vertebral artery, two arose from the anterior cerebral artery, one arose from the internal carotid artery, and one arose from the superior cerebellar artery. Eight aneurysm specimens were collected during autopsy and five were resected during surgery (trapping with or without bypass). The period between the onset of SAH and the time of specimen collection ranged from 6 hours to 35 days. All 13 aneurysms were pathologically examined with immunohistochemical staining, with a focus on the chronological healing process after SAH.

RESULTS

All dissecting aneurysms were generated with sudden widespread disruption of the internal elastic lamina and media. The healing process occurred with neointimal proliferation. The neointima, consisting mainly of newly synthesized smooth muscle cells and collagen fibers, extended from the disrupted ends of the media proper forward to the ruptured portion.

CONCLUSION

It is assumed that the healing process, with neointimal proliferation, begins after 1 week and may not be complete even after 1 month, depending on the extent of the wall injury.
The Value of Magnetic Resonance Imaging in the Evaluation of Fatty Filum Terminale
Authors: Bulsara Ketan R. , Zomorodi Ali R. , Enterline David S. , George Timothy M.
Published: August 2004

OBJECTIVE

To determine whether there are magnetic resonance imaging (MRI) characteristics of fatty fila that are correlated with neurological deficits, especially in the presence of a normal-level conus medullaris.

METHODS

Lumbosacral MRI scans were reviewed for patients with fatty fila who were treated at Duke University Medical Center during a 5-year period. The patients were divided into three groups. Group I patients (n = 5) had fatty fila that were incidentally detected during evaluations for metastases or infections. Group II patients (n = 16) exhibited isolated low back pain but were in neurologically intact condition. Group III patients (n = 15) exhibited neurological impairments consistent with distal spinal cord dysfunction. Several characteristics were measured on the MRI scans, including the location of the conus medullaris, the filum thickness, and the distance of fat from the conus. These results were assessed for statistically significant correlation with the presence of clinical symptoms.

RESULTS

The majority of patients in all three groups demonstrated the normal conus position (L2 or above) and thickened fila. The distance of fat from the conus was the only parameter that demonstrated a statistically significant difference among the groups.

CONCLUSION

The following findings were noted: 1) patients were likely to exhibit neurological deficits at a younger age (<22 yr in Group III versus 47 yr in Groups I and II); 2) a conus level below L2 was associated with neurological deficits (Group III); 3) filum thickness was not correlated with clinical presentation; 4) fat in the filum within 13 mm of the conus medullaris was most predictive of neurological deficits (Group III).
Does Intracisternal Thrombolysis Prevent Vasospasm after Aneurysmal Subarachnoid Hemorrhage? A Meta-analysis
Authors: Amin-Hanjani Sepideh , Ogilvy Christopher S. , Barker Fred G.
Published: August 2004

OBJECTIVE

Despite existing strategies for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage, vasospasm remains a persistent contributor to death and disability. The intracisternal application of thrombolytic agents to dissolve subarachnoid clot has been advocated. The goal of this analysis was to assess the currently available evidence regarding the effectiveness of this treatment.

METHODS

We conducted a systematic review of the published literature; all controlled trials were included. The outcomes of interest were delayed ischemic neurological deficits, poor Glasgow Outcome Scale scores, and death. A formal meta-analysis was performed with a random-effects model.

RESULTS

The search revealed nine trials or trial subgroups (only one of which was randomized), with a total enrollment of 652 patients. Pooled results demonstrated beneficial effects of treatment, with absolute risk reductions of 14.4% (95% confidence interval, 6.5–22.5%; P < 0.001) for delayed ischemic neurological deficits, 9.5% (95% confidence interval, 4.2–14.8%; P < 0.01) for poor Glasgow Outcome Scale scores, and 4.5% (95% confidence interval, 1.5–7.5%; P < 0.05) for death. Regression analysis revealed that treatment effects did not significantly differ among the studies on the basis of the type of thrombolytic agent used (tissue plasminogen activator versus urokinase) or the method of administration (intraoperative versus postoperative) (P > 0.10). Studies that enrolled only patients at high risk for vasospasm seemed to demonstrate greater treatment effects.

CONCLUSION

The meta-analysis suggests a clinically relevant and statistically significant beneficial effect of intracisternal thrombolysis. However, the results of the analysis are limited by the predominance of nonrandomized studies. Further randomized, blinded, placebo-controlled trials of high-risk patients would be justified.