bluuebunny/crossref_metadata_2025 huggingface dataset:
The Juxtaposition of a Capillary Telangiectasia, Cavernous Malformation, and Developmental Venous Anomaly in the Brainstem of a Single Patient: Case Report
Authors: Clatterbuck Richard E. , Elmacı İlhan , Rigamonti Daniele
Published: July 2004

OBJECTIVE AND IMPORTANCE

Capillary telangiectasias, cavernous malformations, and developmental venous anomalies are all vascular malformations that occur on the capillary-venous side of the cerebral circulation. The associations of capillary telangiectasias with venous malformations, cavernous malformations with venous malformations, and capillary telangiectasias with cavernous malformations have all been described; however, the association of all three lesions in a single patient is extremely rare.

CLINICAL PRESENTATION

A 52 year-old Caucasian woman presented to our clinic with an extended history of confusion, distorted visual perceptions, photophobia, neck pain, swallowing problems, and poor balance. The patient's examination was remarkable for difficulty concentrating, mild rotatory nystagmus, subtle decreased sensation over the left side of the face and body, and brisk reflexes. Review of the patient's magnetic resonance imaging examination demonstrated a cavernous malformation, a capillary telangiectasia, and a developmental venous anomaly located adjacent to one another in the brainstem.

INTERVENTION

Given the patient's complex constellation of symptoms and relatively mild neurological findings, it was difficult to ascribe any one of them to a specific vascular malformation. Conservative management of this patient's vascular malformations was decided upon.

CONCLUSION

Juxtaposition of these three different vascular lesions in the brainstem of an otherwise normal individual suggests a relationship among them. Although there are several theories that link similar associations through physiological mechanisms such as venous hypertension, we propose that a developmental event disrupting local capillary-venous pattern formation is a plausible alternative.
Successful Embolization of a Spinal Perimedullary Arteriovenous Fistula with Cellulose Acetate Polymer Solution: Technical Case Report
Authors: Sugiu Kenji , Meguro Toshinari , Nakashiama Hiroyuki , Ohmoto Takashi
Published: July 2004

OBJECTIVE AND IMPORTANCE

Spinal perimedullary arteriovenous fistulae are rarely reported in the literature and can be treated via both endovascular and direct surgical approaches. Coils, glues, and balloons have all been used to embolize these fistulae. Cellulose acetate polymer (CAP) solution is a liquid embolic material that was originally developed for thrombosis of cerebral aneurysms. This is the first report of CAP solution being used to treat a spinal perimedullary arteriovenous fistula, with changes in the viscosity of the solution.

CLINICAL PRESENTATION

A 15-year-old boy experienced spinal subarachnoid hemorrhage without any neurological deficits. A radiological examination revealed a spinal perimedullary arteriovenous fistula (Type 2) at the L1 level.

INTERVENTION

Transarterial embolization was performed with local anesthesia. The microcatheter was navigated through the anterior spinal artery to a site just proximal to the fistula. After provocative testing demonstrated negative results, CAP solution was injected and the fistula was completely closed, without complications. The patient experienced an uneventful postoperative course.

CONCLUSION

We describe the usefulness of CAP solution in the treatment of a spinal perimedullary arteriovenous fistula. This procedure must be performed for a larger series of patients for assessment of its long-term results.
Percutaneous Carotid Angioplasty and Stenting with the Use of Gadolinium in Lieu of Iodinated Contrast Medium: Technical Case Report and Review of the Literature
Authors: Amar Arun Paul , Larsen Donald W. , Teitelbaum George P.
Published: July 2004

OBJECTIVE AND IMPORTANCE

We describe a patient who underwent percutaneous transluminal carotid angioplasty and stent placement with the use of intra-arterial gadolinium (Gd-DTPA) instead of iodinated contrast medium. This represents one of the first published reports of the use of Gd-DTPA as an angiographic contrast agent for an interventional neuroradiological procedure.

CLINICAL PRESENTATION

A 75-year-old man with renal insufficiency and multiple comorbidities developed amaurosis fugax. Doppler examination revealed high-grade stenosis of the right internal carotid artery.

INTERVENTION

The patient underwent percutaneous transluminal balloon angioplasty with endovascular stent placement for 95% narrowing of the proximal right internal carotid artery. Because of his impaired renal function, the procedure was performed with the use of Gd-DTPA as the sole contrast agent. Approximately 60 ml of contrast medium (twice the volume typically used for a magnetic resonance imaging study) was used. There were no neurological, renal, or other complications.

CONCLUSION

Intra-arterially administered Gd-DTPA may be substituted for iodinated contrast agents in complex neuroendovascular procedures. This capacity expands the armamentarium for interventional neuroradiological procedures.
Peritoneography in the Assessment of Peritoneal Cerebrospinal Fluid Absorption Potential for Distal Ventriculoperitoneal Shunt Catheter Placement: Technical Case Report
Authors: McAuley David , Dick Alistair C. , Paterson Annie
Published: July 2004

OBJECTIVE AND IMPORTANCE

Distal ventriculoperitoneal shunt failure has been associated with absorption failure secondary to previous peritonitis. This assumption has caused surgeons to seek alternate sites for distal catheter placement. We propose that the absorptive potential of the peritoneal cavity should be assessed before that site is discounted for catheter placement.

CLINICAL PRESENTATION

The case of a 14-month-old male patient is presented, demonstrating multiple ventriculoperitoneal shunt placement procedures and a diagnostic dilemma with respect to distal shunt placement. Peritoneography was performed to demonstrate peritoneal fluid absorption, allowing subsequent placement of a new distal shunt catheter with good clinical results.

TECHNIQUE

Using aseptic technique, a 24-gauge spinal needle was inserted in the midline of the abdomen and water-soluble contrast material was instilled. Delayed radiographs delineated peritoneal adhesions and demonstrated renal excretion of the contrast material, confirming peritoneal absorption.

CONCLUSION

The peritoneal cavity remains the site of choice for distal shunt catheter placement. If failure of peritoneal cerebrospinal fluid absorption is suspected as a cause of shunt failure, then peritoneography with water-soluble contrast material may be safely used to demonstrate the adequacy of fluid absorption before a secondary site is chosen.
Intralesional Resection of Primary and Metastatic Sarcoma Involving the Spine: Outcome Analysis of 59 Patients
Authors: Bilsky Mark H. , Boland Patrick J. , Panageas Katherine S. , Woodruff James M. , Brennan Murray F. , Healey John H.
Published: July 2004

OBJECTIVE

Surgery plays an important role in achieving local tumor control and cure for primary and metastatic tumors of the spine. As has been established with regard to sarcomas at extraspinal sites, these goals may best be achieved by en bloc resection with negative histological margins. Unfortunately, sarcomas of the spine often present with tumor patterns that are amenable only to intralesional resection, if neurological preservation is a priority. This study is a retrospective analysis of the long-term outcomes of patients who had operations for sarcomas of the spine using modern surgical approaches, intralesional resections, and spinal instrumentation.

METHODS

Between 1985 and 1997, 59 patients had spinal operations for sarcoma involving the extrasacral spine. Data regarding tumor histology, grade, surgical indications, patterns of spinal tumor involvement, and neurological and functional outcomes were reviewed at presentation and at tumor recurrence.

RESULTS

Thirty-five patients underwent a single operation, and 24 patients required reoperation for locally recurrent tumors. At presentation, only nine patients (15%) had tumors that were amenable to marginal or wide resections. Functional outcomes after initial spinal surgery and after operations performed at first tumor recurrence showed that 95% of patients had maintained or regained ambulation. Intradural extension of tumor was seen in 5 of 12 patients who had three or more operations for locally recurrent disease. The median survival from first spine operation was 18 months, and the median event-free interval between the first and second spine operations was 13 months.

CONCLUSION

Surgery for sarcoma of the spine is useful for maintaining or improving neurological and functional outcomes, but local tumor recurrences are common. Because of the anatomy of the tumor at presentation and concern for neurological preservation, few patients are candidates for marginal or wide resections.
Reduced-dose Radiosurgery for Vestibular Schwannomas
Authors: Petit Joshua H. , Hudes Richard S. , Chen T. Timothy , Eisenberg Howard M. , Simard J. Marc , Chin Lawrence S.
Published: July 2004

OBJECTIVE

To evaluate tumor control and complications associated with low-dose radiosurgery for vestibular schwannomas.

METHODS

Between December 1993 and January 2000, 47 patients with vestibular schwannomas were treated at our center with gamma knife radiosurgery. The marginal tumor doses ranged from 7.5 to 14.0 Gy (median, 12.0 Gy) for patients treated after microsurgery and from 10.0 to 15.0 Gy (median, 12.0 Gy) for patients in whom radiosurgery was the primary treatment. The median maximum tumor diameter was 18 mm (range, 3–50 mm). Evaluation included audiometry, neurological examination, and serial imaging tests. A survey was conducted at the time of analysis.

RESULTS

Follow-up data were available for 45 patients and ranged from 1 to 7 years (median, 3.6 yr). In 43 patients (96%), tumor control (no radiographic progression or surgical resection) was observed. All 33 previously untreated patients had tumor control. Transient facial weakness, experienced in two patients (4%), had resolved completely within 6 months. No patient developed trigeminal neuropathy. Hearing was diminished from baseline in 12% of patients with useful hearing (Gardner-Robertson Class III). However, all patients with pretreatment hearing Gardner-Robertson Class I or II maintained testable hearing (Class I to III) at the most recent examination.

CONCLUSION

Low-dose radiosurgery in this series provided comparable local control and decreased incidences of complications in relation to other reports. Additional follow-up will allow more definitive conclusions to be reached regarding the ultimate rates of tumor control and hearing preservation. Nevertheless, the current dose used for vestibular schwannomas at the University of Maryland Medical Center is 12.0 Gy to the tumor periphery.
Delayed Cerebrovascular Complications of Intrathecal Colloidal Gold
Authors: Nussbaum Eric S. , Sebring Leslie A. , Neglia Joseph P. , Chu Ray , Mattsen Nancy D. , Erickson Donald L.
Published: July 2004

OBJECTIVE

Therapy with intrathecal colloidal gold has been used in the past as an adjunct in the treatment of childhood neoplasms, including medulloblastoma and leukemia. We describe the long-term follow-up period of a series of patients treated with intrathecal colloidal gold and emphasize the high incidence of delayed cerebrovascular complications and their management.

METHODS

Between 1967 and 1970, 14 children with posterior fossa medulloblastoma underwent treatment at the University of Minnesota. Treatment consisted of surgical resection, external beam radiotherapy, and intrathecal colloidal gold. All patients underwent long-term follow-up periods.

RESULTS

Of the 14 original patients, 6 died within 2 years of treatment; all experienced persistent or recurrent disease. The eight surviving patients developed significant neurovascular complications 5 to 20 years after treatment. Three patients died as a result of aneurysmal subarachnoid hemorrhage, and five developed ischemic symptoms from severe vasculopathy that resembled moyamoya disease.

CONCLUSION

Although therapy with colloidal gold resulted in long-term survival in a number of cases of childhood medulloblastoma, our experience suggests that the severe cerebrovascular side effects fail to justify its use. The unique complications associated with colloidal gold therapy, as well as the management of these complications, are presented. We recommend routine screening of any long-term survivors to exclude the presence of an intracranial aneurysm and to document the possibility of moyamoya syndrome.
Immediate Stiffness of the C5–C6 Segment after Discectomy with the Cloward Technique: An in Vitro Biomechanical Study on a Human Cadaveric Model
Authors: Maciejczak Andrzej , Ciach Michał , Radek Maciej , Radek Andrzej , Awrejcewicz Jan
Published: July 2004

OBJECTIVE

To determine whether the Cloward technique of cervical discectomy and fusion increases immediate postoperative stiffness of single cervical motion segment after application of interbody dowel bone graft.

METHODS

We measured and compared the stiffness of single-motion segments in cadaveric cervical spines before and immediately after interbody fusion with the Cloward technique. Changes in range of motion and stiffness of the C5–C6 segment were measured in a bending flexibility test (flexion, extension, lateral bending and axial rotation) before and after a Cloward procedure in 11 fresh-frozen human cadaveric specimens from the 4th through the 7th vertebrae.

RESULTS

The Cloward procedure produced a statistically significant increase in stiffness of the operated segment in flexion and lateral bending when compared with the intact spine. The less stiff the segment before the operation, the greater the increase in its postoperative flexural stiffness (statistically significant). The Cloward procedure produced nonuniform changes in rotational and extensional stiffness that increased in some specimens and decreased in others.

CONCLUSION

Our data demonstrate that Cloward interbody fusion increases immediate postoperative stiffness of an operated segment only in flexion and lateral bending in cadaveric specimens in an in vitro environment. Thus, Cloward fusion seems a relatively ineffective method for increasing the stiffness of a construct. This may add to discussion on the use of spinal instrumentation and postoperative management of patients after cervical discectomy, which varies from bracing in hard collars through immobilization in soft collars to no external orthosis.
Pseudomyasthenia Resulting from a Posterior Carotid Artery Wall Aneurysm: A Novel Presentation: Case Report
Authors: Tummala Ramachandra P. , Harrison Andrew , Madison Michael T. , Nussbaum Eric S.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Painful oculomotor palsy can result from enlargement or rupture of intracranial aneurysms. The IIIrd cranial nerve dysfunction in this setting, whether partial or complete, is usually fixed or progressive and is sometimes reversible with surgery. We report an unusual oculomotor manifestation of a posterior carotid artery wall aneurysm, which mimicked ocular myasthenia gravis.

CLINICAL PRESENTATION

A 47-year-old woman developed painless, intermittent, partial IIIrd cranial nerve palsy. She presented with isolated episodic left-sided ptosis, which initially suggested a metabolic or neuromuscular disorder. However, digital subtraction angiography revealed a left posterior carotid artery wall aneurysm, just proximal to the origin of the posterior communicating artery.

INTERVENTION

The aneurysm was successfully clipped via a pterional craniotomy. During surgery, the aneurysm was observed to be compressing the oculomotor nerve. The patient's symptoms resolved after the operation.

CONCLUSION

The variability of incomplete IIIrd cranial nerve deficits can present a diagnostic challenge, and the approach for patients with isolated IIIrd cranial nerve palsies remains controversial. Although intracranial aneurysms compressing the oculomotor nerve classically produce fixed or progressive IIIrd cranial nerve palsies with pupillary involvement, anatomic variations may result in atypical presentations. With the exception of patients who present with pupil-sparing but otherwise complete IIIrd cranial nerve palsy, clinicians should always consider an intracranial aneurysm when confronted with even subtle dysfunction of the oculomotor nerve.
Basilar Apex Aneurysms: Surgical Results and Perspectives from an Initial Experience
Authors: Lawton Michael T.
Published: July 2004

OBJECTIVE

To demonstrate that well-trained neurosurgeons can successfully treat patients with basilar apex aneurysms, to encourage young neurosurgeons in appropriate clinical environments to develop this expertise, and to describe a personal experience with an initial series.

METHODS

In a consecutive series of 500 aneurysms treated surgically over 3.5 years, 57 aneurysms in 56 patients were located at the basilar apex, 47% of which were large or giant in size.

RESULTS

Most aneurysms (77%) were treated by direct clipping through an orbitozygomatic-pterional transsylvian approach. The surgical mortality rate was 9%, and permanent neurological morbidity associated with treatment occurred in 5%. Good outcomes (Glasgow Outcome Scale score 5 or 4) were achieved in 84%. Good outcomes increased from 79% in the first half of the series to 90% in the second half, and the mortality rate decreased from 21 to 4%.

CONCLUSION

Young neurosurgeons can acquire technical proficiency with basilar apex aneurysms while achieving optimal patient outcomes. Young neurosurgeons with the right training, talent, and temperament are needed to deal with those patients with basilar aneurysms who require surgery and with a possible shortage of basilar aneurysm surgeons in the future. The learning curve is characterized by increased temporary clipping, better perforator dissection, and more sophisticated permanent clipping technique. The path to proficiency can be as demanding mentally as it is technically.
Coiling of Ruptured Pericallosal Artery Aneurysms
Authors: Menovsky Tomas , van Rooij Willem Jan , Sluzewski Menno , Wijnalda Douwe
Published: July 2004

OBJECTIVE

To assess the technical feasibility of treating ruptured pericallosal artery aneurysms with detachable coils and to evaluate the anatomic and clinical results.

METHODS

Over a period of 27 months, 12 patients with a ruptured pericallosal artery aneurysm were treated with detachable coils. A retrospective review was performed to assess the clinical and angiographic results. The three men and nine women had a mean age of 46.6 years (range, 35–75 yr). Seven patients presented in Hunt and Hess Grade II, three in Grade III, and two in Grade IV. Six patients had a concomitant intracerebral hematoma, and four had at least one additional aneurysm.

RESULTS

In all 12 patients, the pericallosal aneurysm could be reached with a microcatheter and the coils delivered. No procedure-related complications occurred. Angiography demonstrated that the initial occlusion was complete in 11 aneurysms and near-complete in 1. At follow-up angiography at 6 months, one aneurysm had become partially recanalized owing to coil compaction. At a mean clinical follow-up of 9.2 months, 11 patients had an excellent outcome and one patient had mild hemiparesis and aphasia.

CONCLUSION

Coiling of ruptured pericallosal artery aneurysms can be considered an alternative to surgical clipping.
Neurophysiological Refinement of Subthalamic Nucleus Targeting
Authors: Sterio Djordje , Zonenshayn Martin , Mogilner Alon Y. , Rezai Ali R. , Kiprovski Kiril , Kelly Patrick J. , Beric Aleksandar
Published: July 2004

OBJECTIVE

Advances in image-guided stereotactic surgery, microelectrode recording techniques, and stimulation technology have been the driving forces behind a resurgence in the use of functional neurosurgery for the treatment of movement disorders. Despite the dramatic effects of deep brain stimulation (DBS) techniques in ameliorating the symptoms of Parkinson's disease, many critical questions related to the targeting, effects, and mechanisms of action of DBS remain unanswered. In this report, we describe the methods used to localize the subthalamic nucleus (STN) and we present the characteristics of encountered cells.

METHODS

Twenty-six patients with idiopathic Parkinson's disease underwent simultaneous, bilateral, microelectrode-refined, DBS electrode implantation into the STN. Direct and indirect magnetic resonance imaging-based anatomic targeting was used. Cellular activity was analyzed for various neurophysiological parameters, including firing rates and interspike intervals. Physiological targeting confirmation was obtained by performing macrostimulation through the final DBS electrode.

RESULTS

The average microelectrode recording time for each trajectory was 20 minutes, with a mean of 5.2 trajectories/patient. Typical trajectories passed through the anterior thalamus, zona incerta/fields of Forel, STN, and substantia nigra-pars reticulata. Each structure exhibited a characteristic firing pattern. In particular, recordings from the STN exhibited an increase in background activity and an irregular firing pattern, with a mean rate of 47 Hz. The mean cell density was 5.6 cells/mm, with an average maximal trajectory length of 5.3 mm. Macrostimulation via the DBS electrode yielded mean sensory and motor thresholds of 4.2 and 5.7 V, respectively.

CONCLUSION

The principal objectives of microelectrode recording refinement of anatomic targeting are precise identification of the borders of the STN and thus determination of its maximal length. Microelectrode recording also allows identification of the longest and most lateral segment of the STN, which is our preferred target for STN DBS electrode implantation. Macrostimulation via the final DBS electrode is then used primarily to establish the side effect profile for postoperative stimulation. Microelectrode recording is a helpful targeting adjunct that will continue to facilitate our understanding of basal ganglion physiological features.
Elastance Correlates with Outcome after Endoscopic Third Ventriculostomy in Adults with Hydrocephalus Caused by Primary Aqueductal Stenosis
Authors: Tisell Magnus , Edsbagge Mikael , Stephensen Hannes , Czosnyka Marek , Wikkelsø Carsten
Published: July 2004

OBJECTIVE

To study prospectively the correlation between clinical outcome after endoscopic third ventriculostomy (ETV) and resistance to the outflow of cerebrospinal fluid (Rout) and elastance in adults with hydrocephalus caused by primary aqueductal stenosis (AS).

METHODS

Rout and elastance were measured in the subarachnoid space and intraventricularly before ETV in 15 consecutive patients. Three months after the ETV, the clinical effect was evaluated by standardized indices, and Rout and elastance were measured. If symptoms persisted and the ETV was patent, shunt surgery was offered. The effect of the shunt operation and Rout were measured after 3 months.

RESULTS

Four patients experienced excellent improvement, six improved slightly, and five had unchanged or deteriorated symptoms after ETV. Rout before ETV did not correlate with outcome. Rout decreased after ETV with correlation to the clinical effect; in the six patients who had shunt surgery, Rout decreased further. High preoperative elastance correlated strongly with a good outcome and reduction of ventricle size. Elastance did not change after ETV.

CONCLUSION

Rout intraventricularly and in the subarachnoid space could not predict the outcome of the ETV, but the reduction in Rout correlated positively with clinical improvement. Preoperative elastance correlated positively with clinical improvement, and elastance was unchanged after ETV. Clinical improvement correlated positively with reduction in ventricle size.
Inflammatory Mass Lesions Associated with Intrathecal Drug Infusion Catheters: Report and Observations on 41 Patients
Authors: Coffey Robert J. , Burchiel Kim
Published: July 2004

OBJECTIVE

Several reports have described inflammatory mass lesions at the tip of intraspinal drug administration catheters. We evaluated the number of patients reported with this condition and whether data support hypotheses that have been put forth regarding the cause of these lesions.

METHODS

Information that was reported in the medical literature, and by Medtronic, Inc., to the United States Food and Drug Administration as of November 30, 2000, was reviewed.

RESULTS

Forty-one cases were identified, including 16 from the literature and 25 that were not published previously in the literature. Because of voluntary reporting and other methodological limitations, the actual number of cases must be higher than reported. All of the patients had chronic pain. The mean duration of therapy was 24.5 months. Most masses were located in the thoracic region. Intrathecal drugs included morphine or hydromorphone, either alone or mixed with other drugs, in 39 of 41 cases. No masses were reported in patients who received baclofen as the only intrathecal medication. Thirty patients underwent surgery to relieve spinal cord or cauda equina compression. Eleven patients were nonambulatory at last follow-up, and one died of a pulmonary embolus. Surgical specimens revealed noninfectious chronic inflammation, granuloma formation, and fibrosis or necrosis.

DISCUSSION

The most plausible hypothesis with regard to the cause of intrathecal catheter tip mass lesions implicates the administration of relatively high-concentration or high-dose opiate drugs or the use of drugs and admixtures that are not labeled for intrathecal use.

CONCLUSION

Patients who require high-dose intraspinal opioid therapy and those who receive drugs or admixtures that are not approved for intrathecal use should be monitored closely for signs of an extra-axial mass or catheter malfunction. Prompt diagnosis and treatment may preserve neurological function.
Adaptation of Cerebral Circulation to Brain Arteriovenous Malformations Increases Feeding Artery Pressure and Decreases Regional Hypotension
Authors: Quick Christopher M. , Leonard Edward F. , Young William L.
Published: July 2004

PURPOSE

To determine how the adaptation of extranidal cerebral vessels affects feeding artery pressure, draining vein pressure, and regional hypotension due to the presence of brain arteriovenous malformations (BAVMs).

CONCEPT

BAVMs cause high flows in feeding arteries and draining veins and can induce profound hypotension in the neighboring vasculature. Despite the large difference in flow, endothelial shear stress (τ) observed in vessels ipsilateral to the BAVM is similar to τ in vessels contralateral to the BAVM, suggesting that the conductance vessels successfully adapt to keep τ constant. However, because BAVMs are discovered only after they are well developed, the natural history of the adaptation process in extranidal vessels is unknown.

RATIONALE

Currently, no way exists to determine experimentally the effects of adaptation of extranidal vessels in human patients. Therefore, a mathematical model of the cerebral vasculature is used to study adaptation in response to BAVMs. By comparing pressures and flows calculated before and after adaptation, the effect of adaptation of the conductance vessels on regional hemodynamics can be evaluated.

DISCUSSION

Structural adaptation of the extranidal circulation seems not only to reset τ, but also to ameliorate regional hypotension induced by BAVMs. However, this compensatory mechanism also increases feeding artery pressure and thus may increase the risk of hemorrhagic stroke.
Endovascular Administration after Intravenous Infusion of Thrombolytic Agents for the Treatment of Patients with Acute Ischemic Strokes
Authors: Suarez Jose I. , Zaidat Osama O. , Sunshine Jeffrey L. , Tarr Robert , Selman Warren R. , Landis Dennis M.D.
Published: July 2004

OBJECTIVE

To determine the feasibility of combined intravenous and intra-arterial thrombolytic therapy for acute ischemic strokes and to evaluate its associated risks, using magnetic resonance imaging as a triage tool. Intravenous treatment followed by intra-arterial infusion may increase the rate of recanalization and lead to better clinical results, with reduced frequency of intracranial hemorrhage.

METHODS

Our Brain Attack Team evaluated patients who presented within 3 hours after symptom onset. Patients who did not demonstrate improvement and exhibited no evidence of intracranial hemorrhage on head computed tomographic scans were treated with intravenously administered recombinant tissue plasminogen activator (0.6 mg/kg) and underwent emergency magnetic resonance imaging of the head. T2-weighted turbo-gradient and spin echo and echo-planar diffusion- and perfusion-weighted imaging scans were obtained. Patients with evidence of imaging abnormalities indicating acute cortical infarction underwent cerebral angiography. After determination of vessel occlusion, intra-arterially administered urokinase (up to 750,000 units) or intra-arterially administered recombinant tissue plasminogen activator (maximal dose, 0.3 mg/kg) was used to achieve recanalization.

RESULTS

We treated 45 patients with this protocol. The mean age was 67 ± 13 years, and 58% of the patients were women. There was a significant improvement in National Institutes of Health Stroke Scale scores after treatment. There was good correlation between abnormal perfusion-weighted imaging findings and cerebral angiographic findings (complete vessel occlusion). The incidence of symptomatic intracranial hemorrhage was 4.4% in this cohort. Seven patients died in the hospital, and the majority of survivors (77%) experienced good outcomes (Barthel index of ≥95) 3 months after treatment.

CONCLUSION

Our data demonstrate that this protocol is feasible and that combined intravenous and intra-arterial thrombolysis to treat acute ischemic strokes is sufficiently safe to warrant further evaluation.
Somatotopy of the Supplementary Motor Area: Evidence from Correlation of the Extent of Surgical Resection with the Clinical Patterns of Deficit
Authors: Fontaine Denys , Capelle Laurent , Duffau Hugues
Published: July 2004

OBJECTIVE

This study, which aimed to confirm or invalidate the somatotopic organization of the supplementary motor area (SMA), correlates the pattern of clinical symptoms observed after SMA removal with the extent of resection.

METHODS

Eleven patients with medial precentral glioma underwent partial or complete tumoral resection of the SMA. Seven patients underwent preoperative functional magnetic resonance imaging that incorporated speech and motor tasks. During the operation, the primary motor and speech areas and pathways (in the dominant side) were identified by use of intraoperative direct cortical or subcortical stimulation, and these areas were respected.

RESULTS

SMA resection resulted in motor deficits, language deficits, or both; the deficits were always regressive, and they corresponded to the SMA syndrome. The topography and severity of these deficits were correlated to the extent of the SMA resection. The location of the deficit corresponded to SMA somatotopy: the representations of the lower limb, the upper limb, the face, and language (in the left-dominant SMA) were located from posterior to anterior. This somatotopy was also observed with functional magnetic resonance imaging.

CONCLUSION

Correlation between clinical patterns of deficit and the extent of SMA resection, guided by means of pre- and intraoperative functional methods, provides strong arguments in favor of somatotopy in this area. This knowledge should allow clinicians to base preoperative predictions of the pattern of postsurgical deficit and recovery on the planned resection, thus allowing them to inform patients accurately before the procedure.
Biportal Thoracoscopic Sympathectomy: Surgical Techniques and Clinical Results for the Treatment of Hyperhidrosis
Authors: Han Patrick P. , Gottfried Oren N. , Kenny Kathy J. , Dickman Curtis A.
Published: July 2004

OBJECTIVE

To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis.

METHODS

Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires.

RESULTS

Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax.

CONCLUSION

Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.
Somatotopic Organization of the Facial Nucleus Is Disrupted after Lesioning and Regeneration of the Facial Nerve: The Histological Representation of Synkinesis
Authors: Choi David , Raisman Geoffrey
Published: July 2004

OBJECTIVE

After facial nerve repair, involuntary movement of part of the face during voluntary movement of another part of the face is common. We describe an animal model of facial nerve lesion, repair, and regeneration that demonstrates abnormal organization of the facial nucleus; this model may be used to study synkinesis.

METHODS

In 18 rats, the facial nerve was cut completely, proximal to the parotid gland, and immediately sutured end-to-end. After a period of regeneration of 1 to 10 months, retrograde fluorescence labeling of the distal branches of the facial nerve was performed. The distribution of the tracers in the facial nucleus was assessed in both the lesioned animals and in a nonlesioned group (n = 20).

RESULTS

In the control animals, muscle groups were somatotopically represented in the facial nucleus. After lesioning, repair, and regeneration, the somatotopy of the facial nucleus was disrupted. Axons projected from the facial nucleus to incorrect peripheral muscle groups, and aberrant branches were observed to simultaneously innervate different subdivisions of the facial nerve. The numbers of aberrant axons and branches did not change significantly during periods of regeneration ranging from 1 to 10 months.

CONCLUSION

Our model provides a clear demonstration of the failure of adult facial nerve axons to make correct connections with their distal targets during regeneration. This model may be used to assess strategies aimed at minimizing synkinesis and, by assessing histology together with behavior, provides a more robust model than those previously described.
Chondromyxoid Fibroma of the Cervical Spine: Case Report
Authors: Lopez-Ben Robert , Siegal Gene P. , Hadley Mark N.
Published: July 2004

OBJECTIVE AND IMPORTANCE

The clinical, pathological, and imaging findings in a patient with a chondromyxoid fibroma involving the C2 vertebra are reported. Seven cases that involve the cervical spine have previously been reported in the literature; the posterior vertebral body and posterior elements are the most frequently involved. To our knowledge, this is the first reported case of C2 involvement and craniocervical instability.

CLINICAL PRESENTATION

A 20-year-old man presented with intermittent neck pain resulting from a fall 4 years earlier. X-rays and magnetic resonance imaging demonstrated a lytic lesion in the body of C2, as well as instability at C1–C2.

INTERVENTION

Preoperative transcatheter angiography and embolization were performed. An expansile tumor of the C2 vertebral body was resected via a transoral approach. Because of craniocervical instability, fusion from the occiput to posterior elements of C1 through C4 was performed.

CONCLUSION

Chondromyxoid fibroma is a rare benign bone tumor that is uncommonly found in the spine and may mimic other lesions, particularly radiographically. We report the first known involvement of C2 by this tumor in the modern English-language literature. The patient has had excellent clinical and radiographic resolution of the prior instability with no neck pain, instability, or local recurrence.
C1–C2 Pedicle Screw Fixation with Rigid Cantilever Beam Construct: Case Report and Technical Note
Authors: Resnick Daniel K. , Benzel Edward C.
Published: July 2004

OBJECTIVE AND IMPORTANCE

Transarticular screw fixation of the C1–C2 complex provides immediate rigid fixation of the unstable spine. The technique is not feasible in a certain proportion of patients because of the position of the vertebral artery or the patient's body habitus.

CLINICAL PRESENTATION

The authors describe a rigid screw technique for the surgical treatment of a woman who was excluded as a candidate for C1–C2 transarticular screw fixation.

TECHNIQUE

C1–C2 pedicle screw fixation was achieved using a fixed moment arm cantilever beam system. This system provided immediate rigid fixation of the C1–C2 complex in a patient who was not a candidate for transarticular screw fixation.

CONCLUSION

This technique is technically more forgiving than posterior transarticular screw fixation and may be applied to a broader spectrum of patients.
Nonvestibular Schwannomas of the Brain: A 7-Year Experience
Authors: Sarma Sajjan , Sekhar Laligam N. , Schessel David A.
Published: July 2004

OBJECTIVE:

Nonvestibular schwannomas are uncommon tumors of the brain. Trigeminal nerve schwannomas are the most common of this group, followed by glossopharyngeal, vagal, facial, accessory, hypoglossal, oculomotor, trochlear, and abducens nerve schwannomas, in descending order of frequency. We present a series of nonvestibular schwannomas that were surgically treated during a 7-year period.

METHODS:

Forty-six patients with schwannomas of Cranial Nerves V (26 cases), VII (7 cases), IX, X, and XI (9 cases), XII (3 cases), and III (1 case) were microsurgically treated by the senior author (LNS) during a 7-year period, from 1993 to 2000. The clinical presentations, operative approaches, complications, and results were studied.

RESULTS:

Forty-five patients underwent gross total tumor resection in the first operation. One patient who had undergone subtotal tumor resection in the initial operation experienced a large recurrence after 4 years, and gross total tumor resection was achieved in the second operation. There were no postoperative deaths. Postoperative morbidity consisted of cerebrospinal fluid leaks for 5 patients (3 patients required a second operation to repair the leak, and 2 patients responded to lumbar drain placement), meningitis for 3 patients (2 cases were aseptic and 1 involved bacterial meningitis, which resolved with antibiotic therapy), vasospasm requiring angioplasty for 1 patient, temporary hemiparesis for 2 patients (who experienced good recoveries), and permanent hemiparesis for 1 patient. New cranial nerve deficits were observed for 24% of patients but were usually partial. The mean follow-up period was 33.3 months (range, 0.2–93 mo). No patient experienced tumor recurrence after complete tumor removal. The patient who experienced regrowth of the tumor did not exhibit recurrence after the second operation. The Karnofsky Performance Scale scores at the latest follow-up examination were 80 or more for 45 patients (98%) and 70 for 1 patient.

CONCLUSION:

Nonvestibular schwannomas can be treated via microsurgical excision, with excellent functional results. Recurrence is rare after total tumor excision, although much longer follow-up monitoring is required.
Tuberculoma of the Conus Medullaris: Case Report
Authors: Türeyen Kudret
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. This article describes an affected patient who presented with left leg paresis.

CLINICAL PRESENTATION:

A 46-year-old man presented with a 7-day history of left leg weakness. The patient's medical history included infection with pulmonary tuberculosis 15 years previously, at which time he had been treated with antituberculosis therapy. The neurological examination performed at admission revealed left leg paresis with Grade 2/5 power in all muscle groups. The patient reported no urinary or bowel problems.

INTERVENTION:

Surgery was performed with the patient in the prone position. The procedure involved laminectomies at T11, T12, and L1, followed by a midline myelotomy. The mass was excised completely. Histopathological examination revealed a granulomatous lesion that contained Langhans' giant cells, inflammatory cells, and evidence of caseating necrosis. The patient was prescribed a 6-month course of antituberculosis therapy with pyrazinamide, isoniazid, and rifampin.

CONCLUSION:

The outcome was favorable. Recently, a number of authors have reported success with medical management of intraspinal tuberculoma. Intraspinal tuberculoma produces a mass effect that can jeopardize spinal cord function. The optimal treatment is a combination of microsurgical resection and antituberculosis chemotherapy.
Intradural Hemangiopericytoma of the Lumbar Spine: Case Report
Authors: Betchen Simone , Schwartz Amit , Black Candice , Post Kalmon
Published: July 2004

OBJECTIVE AND IMPORTANCE:

Hemangiopericytoma is a rare tumor of the central nervous system, most often found supratentorially. Thirty-nine cases within the spinal column, of which five were intradural, have been reported. To date, no magnetic resonance imaging descriptions of intradural hemangiopericytomas have been published. This article is the first report of an intradural hemangiopericytoma of the lumbar spine and the first magnetic resonance imaging description of such a lesion.

CLINICAL PRESENTATION:

A 31-year-old man presented with progressive bilateral leg paresthesia and increased lower extremity cramping and fatigue during a period of several months. This progressed to urinary urgency, frequency, and sexual dysfunction. A neurological examination revealed no motor or sensory deficits. Gadolinium-enhanced magnetic resonance imaging of the lumbar spine revealed a centrally located intradural mass posterior to the L4 vertebral body.

TECHNIQUE:

The patient underwent a laminectomy of L4 and partial laminectomy of L3 with complete en bloc resection of the tumor. A discrete, intradural, red-appearing lesion was found and resected en bloc. Pathological findings were consistent with hemangiopericytoma.

CONCLUSION:

Intradural hemangiopericytomas, although rare, cannot be differentiated from other, more benign tumors. Spinal hemangiopericytomas ideally should be resected en bloc to reduce operative blood loss and potentially increase disease-free survival time. Despite total surgical resection of these benign-seeming lesions, the high recurrence rate mandates close follow-up and consideration of adjuvant therapy.
There Is No Transmantle Pressure Gradient in Communicating or Noncommunicating Hydrocephalus
Authors: Stephensen Hannes , Tisell Magnus , Wikkelsö Carsten
Published: July 2004

OBJECTIVE:

To examine whether a transmantle pressure gradient exists in adult patients with communicating and noncommunicating hydrocephalus.

METHODS:

Ten patients participated in the study. The mean patient age was 57 ± 18 years (range, 20–80 yr); seven patients had communicating hydrocephalus, and three had noncommunicating hydrocephalus. Microsensors were used to measure the intracranial pressure (ICP), for 17 to 24 hours during sleeping and waking periods, in the right lateral ventricle (ICPIV) and in the subarachnoid space (ICPSAS) over the right cerebral convexity simultaneously. Patient activities and body positions were documented. The hydrostatic pressure difference between the two sensors was calculated from cranial x-rays for four basic body positions and compared with the actual body positions of the patients and the measured difference between the two sensors. For three 10-minute periods, the exact transmantle pressure gradient was calculated for each patient as ICPIV − ICPSAS, adjusted for the hydrostatic pressure difference.

RESULTS:

The measured pressure difference between the two sensors was always within the limits of the maximal possible hydrostatic pressure difference, and it correlated well with the expected difference for the various body positions: mean correlation coefficient, 0.79 ± 0.10 (range, 0.65–0.92). The exact mean transmantle pressure was −0.01 ± 0.24 mm Hg (range, −0.4 to 0.4 mm Hg). ICP waves caused by cardiac pulse, respiration, and B waves were identical in both spaces.

CONCLUSION:

This study demonstrates no factual support for existence of a transmantle pressure gradient in nonacute communicating or noncommunicating hydrocephalus.
Surgical Resection of Grade II Astrocytomas in the Superior Frontal Gyrus
Authors: Peraud Aurelia , Meschede Magnus , Eisner Wilhelm , Ilmberger Josef , Reulen Hans-Jürgen
Published: July 2004

OBJECTIVE:

Surgery in the superior frontal gyrus partially involving the supplementary motor area (SMA) may be followed by contralateral transient weakness and aphasia initially indistinguishable from damage to the primary motor cortex. However, recovery is different, and SMA deficits may resolve completely within days to weeks. No study has assessed the distinct postoperative deficits after tumor resection in the SMA on a homogeneous patient group.

METHODS:

Twenty-four patients with World Health Organization Grade II astrocytomas in the superior frontal gyrus consecutively treated by surgery were studied. Degree and duration of postoperative deficits were evaluated according to tumor location and boundaries via magnetic resonance imaging scans, intraoperative neuromonitoring results, and extent of tumor resection.

RESULTS:

Postoperatively, motor deficits were evident in 21 of 24 and speech deficits in 9 of 12 patients. Motor function quickly recovered in 11 and speech function in 3 patients. None of the 12 patients in whom the posterior tumor resection line was at a distance of more than 0.5 cm from the precentral sulcus experienced persistent motor deficits. Eight of these patients developed typical SMA syndrome with transient initiation difficulties. Seven of 12 patients in whom the tumor extended to the precentral sulcus still had motor deficits at the 12-month follow-up assessment.

CONCLUSION:

Surgery for Grade II gliomas in the superior frontal gyrus is more likely to result in permanent morbidity when the resection is performed at a distance of less than 0.5 cm from the precentral gyrus or positive stimulation points. Therefore, cortical mapping of motor and speech function, in critical cases under local anesthesia with the patient as his or her own monitor, is recommended; resection should be tailored to obtain good functional outcome and maintain quality of life.