bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical management of epilepsy associated with cerebral arteriovenous malformations
Authors: Yeh Hwa-Shain , Kashiwagi Shiro , Tew John M. , Berger Thomas S.
Published: May 2009

✓ Between 1982 and 1986, 27 patients with seizure disorders due to cerebral arteriovenous malformation (AVM) were surgically treated by the authors. These patients had no history or clinical manifestation of intracranial hemorrhage. All were treated with anticonvulsant agents by their neurologists but became disabled due to inadequate control of seizures by medication, side effects of the anticonvulsant drugs, or the effects on their professional lives of even infrequent seizures. The age of the patients ranged from 13 to 61 years. There were 13 males and 14 females. The AVM's were smaller than 2 cm in four patients, between 2 and 4 cm in five, and larger than 4 cm in 18. The most frequent location of the AVM's was in the temporal lobe, followed by the frontal, parietal, and occipital lobes. All patients had preoperative electroencephalography (EEG) and intraoperative electrocorticography. Intraoperative recording of the amygdala and the hippocampus by depth electrodes was performed if the AVM's were located in the temporal lobe. Superficial or posterior temporal lobe AVM's often have remote seizure foci that involve the amygdala and hippocampus. All patients underwent craniotomy and total excision of their AVM's. Surgery was carried out under local anesthesia to allow localization by electrical stimulation if the AVM involved the speech area or the sensorimotor cortex. Based on the EEG findings, excision of the epileptogenic lesion in addition to the AVM was performed in 18 patients. In seven patients with AVM's located in the temporal lobe, remote seizure foci were identified and excised. The remote epileptic activity was particularly prominent in AVM's in the temporal lobe and usually involved mesial temporal structures.

Microscopic study of excised seizure foci showed gliosis in 26 cases, hemosiderin deposits in 10, and focal hemorrhage in four. There were no operative deaths. Two patients developed a hemiparesis and three suffered temporary dysphasia after surgery. Two patients had visual field deficits. The results of postoperative seizure control during the average follow-up period of 3 years 11 months were excellent in 21 patients, good in three, fair in two, and poor in one. The latter patient, whose epileptic lesion was not completely excised because of its location in the motor cortex, had poor seizure control postoperatively. Another patient required a second operation to remove a remote seizure focus.

In this series, proposed mechanisms of seizure associated with cerebral AVM include focal cerebral ischemia secondary to arteriovenous shunting, gliosis of the surrounding brain, and a secondary epileptogenesis in the temporal lobe. Successful seizure control can be obtained with wide excision of the epileptogenic foci surrounding the AVM's. In some circumstances, seizure foci remote from the vascular malformation must be excised.
Effect of clot removal on cerebral vasospasm
Authors: Inagawa Tetsuji , Yamamoto Mitsuo , Kamiya Kazuko
Published: May 2009

✓ The effect of clot removal on cerebral vasospasm was studied in 104 patients with aneurysmal subarachnoid hemorrhage (SAH). The series included patients who fulfilled all of the following criteria: operation was performed by Day 3 after the ictus; the patient's preoperative clinical grade was between Grades I and IV; there was no rebleeding; computerized tomography (CT) showed only SAH; and carotid angiograms were performed by Day 2 and repeated between Days 7 and 9. Both the degree of SAH on CT and angiographic vasospasm were graded from 0 to III. The relationship of the SAH grade in the basal frontal interhemispheric fissure (IHF) to the presence of vasospasm at the A2 segments of the anterior cerebral artery and the relationship of the SAH grade in the sylvian stems to the presence of vasospasm at the M1 segments of the middle cerebral artery were analyzed.

Correlation of preoperative and postoperative SAH grades with the angiographic vasospasm grades, with the incidence of symptomatic vasospasm, and with the low-density area on CT could be found in the A2 and M1 territories. Decrease of cisternal blood measured by CT after the operation did not relate directly to the reduction of vasospasm. When the SAH was Grade II or III in the basal frontal IHF, the angiographic vasospasm grades at the A2 were significantly lower in patients with surgery via the interhemispheric approach than in those with surgery via the pterional approach. Symptomatic vasospasm occurred in two of the eight cases operated on by the interhemispheric approach compared with 11 of the 22 cases approached via the pterional route. In patients with a pterional approach, there was no significant difference in severity of vasospasm in the M1 territory between the side of approach and the opposite side. No consistent relationship could be found between the time interval from SAH to operation and the severity of vasospasm. While clot removal may ameliorate cerebral vasospasm, its effect per se does not seem to be significant.
The effect of fetal mesencephalon implants on primate MPTP-induced parkinsonism
Authors: Bankiewicz Krzysztof S. , Plunkett Robert J. , Jacobowitz David M. , Porrino Linda , di Porzio Umberto , London William T. , Kopin Irwin J. , Oldfield Edward H.
Published: May 2009

✓ Parkinsonism or hemiparkinsonism was induced by administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in four rhesus monkeys, which then received homologous fetal mesencephalon implants into the caudate nuclei. Cavities were prepared in the medial caudate nucleus 2 to 5 weeks before the fetal grafts were implanted. Control studies were conducted in unoperated MPTP-treated animals. Significant behavioral improvement, which occurred within weeks of implantation of fetal mesencephalon, was sustained for up to 7 months. No recovery was seen in the unoperated control animals. Histological examination revealed numerous surviving tyrosine hydroxylase (TH)-immunoreactive cell bodies. In addition to the graft, abundant TH-immunoreactive fibers were observed in the host caudate nucleus ventral to the region of the implanted and the nonimplanted cavities. Since TH-immunoreactive cell bodies of the substantia nigra compacta (A-9 cells) were destroyed by MPTP treatment and the ventral tegmental area (A-10) remained intact, it is concluded that sprouting of remaining host dopaminergic fibers occurs. These newly formed fibers appeared to emanate from the mesolimbic projection to the striatum. It is likely that the newly sprouted dopaminergic fibers account for the motor improvement elicited by precavitation and fetal mesencephalon implantation.

These results suggest that the mechanism of recovery of parkinsonian primates after implantation of fetal dopaminergic tissue into the caudate nucleus is by stimulation of sprouting from host neurons. They also suggest that, with identification of the factors responsible for the formation of the new dopaminergic neuronal processes and with further development, tissue implantation may be an effective therapy for Parkinson's disease in humans.
Capillary permeability factor secreted by malignant brain tumor
Authors: Ohnishi Takanori , Sher Peter B. , Posner Jerome B. , Shapiro William R.
Published: May 2009

✓ Conditioned media from two human malignant gliomas, C6 rat glioma, Walker 256 carcinosarcoma, and normal human glia were concentrated 50-fold to create a culture supernatant (SUP-C). The effect of SUP-C on rat brain capillary permeability was investigated by measuring the entry of 14C-aminoisobutyric acid (14C-AIB) by means of quantitative autoradiography. The SUP-C contained proteins with a molecular weight of 10 kD or greater. The SUP-C from all tumor cells markedly increased brain capillary permeability, indicating the presence of a permeability factor, whereas that from normal glial cells did not. Glioma cells produced more factor after incubation for 20 hours than 4 hours. The activity of capillary permeability factor in the SUP-C was inhibited by pretreatment of animals with BW755C (lipoxygenase inhibitor), but not with indomethacin (cyclo-oxygenase inhibitor). Pretreatment of animals with dexamethasone prior to intracerebral infusion of tumor SUP-C significantly reduced the factor-induced increase in capillary permeability. On the other hand, coincubating glioma cells with dexamethasone produced SUP-C with a permeability activity that was about one and a half times greater than that without dexamethasone. These results indicate that glucocorticoids produce their anti-edema effects by directly acting on capillary endothelial cells, possibly through the inhibition of phospholipase A2 activity, resulting in a decrease of lipoxygenase rather than cyclo-oxygenase products. The production of capillary permeability factor by tumor cells was not inhibited, but rather enhanced, by administration of glucocorticoids.
Pro-opiomelanocortin gene expression in silent corticotroph-cell adenoma and Cushing's disease
Authors: Nagaya Takashi , Seo Hisao , Kuwayama Akio , Sakurai Tsuyoshi , Tsukamoto Nobuhiro , Nakane Toshichi , Sugita Kenichiro , Matsui Nobuo
Published: May 2009

✓ The silent corticotroph-cell adenoma (SCCA) is characterized by the presence of immunoreactive adrenocorticotropic hormone (ACTH) in the tumor tissue in patients without symptoms of Cushing's disease. To elucidate the pathophysiology of SCCA, the expression of pro-opiomelanocortin (a ACTH precursor) genes was studied in a patient with SCCA and in three patients with Cushing's disease. Pro-opiomelanocortin messenger ribonucleic acid (mRNA) was found in the SCCA tissue to a greater degree than in the adenomas of the patients with Cushing's disease. Northern blot analysis revealed that the size of pro-opiomelanocortin mRNA present in the SCCA tissue was indistinguishable from that in the adenomas associated with Cushing's disease. A ribonuclease mapping study indicated that there were no point mutations in the coding sequence of pro-opiomelanocortin mRNA present in the SCCA tissue. Because of the presence of pro-opiomelanocortin mRNA and immunoreactive ACTH in the adenoma tissue, it is proposed that translation of the mRNA and subsequent accumulation of ACTH precursor occurred in the SCCA. Thus, the absence of Cushing's disease symptoms in this SCCA could not be caused by abnormality in the coding sequence of the pro-opiomelanocortin gene or in ribonucleic acid processing. The occurrence of abnormality at or after the translational steps was strongly suggested.
Immunohistochemical demonstration of DNA polymerase α in human brain-tumor cells
Authors: Kunishio Katsuzo , Mishima Nobuya , Matsuhisa Takashi , Tsuno Kazuyuki , Matsumi Nobuhiko , Satoh Toru , Matsumoto Kengo , Furuta Tomohisa , Nishimoto Akira , Shiraishi Tetsuya
Published: May 2009

✓ The proliferative capacity of brain-tumor cells was analyzed in vitro and in situ using monoclonal antibody (MAb) against deoxyribonucleic acid (DNA) polymerase α. For the in vitro studies, two cultured human glioma cell lines were investigated using MAb against DNA polymerase α, the MAb Ki-67, a serum against proliferating cell nuclear antigen (PCNA/cyclin), bromodeoxyuridine (BUdR), and an anti-BUdR MAb. During exponential growth of the cells, the percentage of polymerase α-positive cells (the “polymerase α score”) ranged from 72.0% to 77.1%, the Ki-67-positive cells (the “Ki-67 score”) ranged from 43.4% to 59.4%, the PCNA/cyclin-positive cells from 30.9% to 41.4%, and the BUdR labeling index from 28.6% to 39.3%.

For the in situ studies, tissue from 60 human brain tumors and from two normal human brains was investigated and the polymerase α scores and Ki-67 scores were compared. In normal brain tissue, no immunostaining was found by either method. In brain tumors, both the polymerase α scores and the Ki-67 scores correlated with the histological grade of malignancy. Polymerase α scores were generally higher than Ki-67 scores in the same specimen, especially in malignant brain tumors.

These findings suggest that immunostaining of DNA polymerase α is a convenient and important new method by which to estimate the cellular proliferation rate of brain tumors. Polymerase α scores may be closer to the growth fraction of the individual tumor than the MAb Ki-67 or other scores.
Nerve root compression by herniated intradiscal gas
Authors: Ricca Gregory F. , Robertson James T. , Hines Robert S.
Published: May 2009

✓ Intervertebral disc degeneration of any etiology may be associated with the formation of spaces or clefts within the disc. Gas collects within these spaces and can be seen roentgenographically. A case is presented in which intradiscal gas herniated into a connective tissue capsule, displacing the left S-1 nerve root and producing symptoms and signs identical to those of a herniated nucleus pulposus. The pathophysiology of gas within a disc space and the possibility that it may herniate much like the nucleus pulposus is discussed.
Optic nerve degeneration caused by supraophthalmic carotid artery infusion with cisplatin and ACNU
Authors: Shimamura Yutaka , Chikama Masanori , Tanimoto Takaho , Kawakami Yasuto , Tsutsumi Akira
Published: May 2009

✓ A 28-year-old woman with a left frontoparietal anaplastic astrocytoma was treated postoperatively with a combination of cisplatin and 1-(4-amino-2-methylpyrimidine-5-yl) methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU). The drugs were infused via the left supraophthalmic internal carotid artery in an attempt to avoid ocular toxicity. The patient subsequently developed blindness in the left eye and a right temporal hemianopsia from marked degeneration of the left optic nerve and tract. It is apparent that the placement of a catheter into the supraophthalmic carotid artery does not exclude visual complications.
Basilar artery migraine
Authors: McDonald Joseph V.
Published: May 2009

✓ The case of a 40-year-old woman with a 24-year history of basilar artery migraine is described. She was admitted to the hospital after suffering a large cerebellar infarction causing hydrocephalus and deep stupor during an attack of migraine. She recovered after ventricular shunting and removal of the infarct.
Foreign-body granuloma as a complication of wrapping and coating an intracranial aneurysm
Authors: Haisa Toshihiko , Matsumiya Korehito , Yoshimasu Norio , Kuribayashi Nobuo
Published: May 2009

✓ A rare case is presented in which a foreign-body granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an internal carotid artery aneurysm. The importance of avoiding the use of muslin, especially close to the optic nerve and chiasm, is emphasized.
Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine
Authors: Maroon Joseph C. , Kopitnik Thomas A. , Schulhof Larry A. , Abla Adnan , Wilberger James E.
Published: May 2009

✓ Lumbar-disc herniations that occur beneath or far lateral to the intervertebral facet joint are increasingly recognized as a cause of spinal nerve root compression syndromes at the upper lumbar levels. Failure to diagnose and precisely localize these herniations can lead to unsuccessful surgical exploration or exploration of the incorrect interspace. If these herniations are diagnosed, they often cannot be adequately exposed through the typical midline hemilaminectomy approach. Many authors have advocated a partial or complete unilateral facetectomy to expose these herniations, which can lead to vertebral instability or contribute to continued postoperative back pain.

The authors present a series of 25 patients who were diagnosed as having far lateral lumbar disc herniations and underwent paramedian microsurgical lumbar-disc excision. Twelve of these were at the L4–5 level, six at the L5–S1 level, and seven at the L3–4 level. In these cases, myelography is uniformly normal and high-quality magnetic resonance images may not be helpful. High-resolution computerized tomography (CT) appears to be the best study, but even this may be negative unless enhanced by performing CT-discography. Discography with enhanced CT is ideally suited to precisely diagnose and localize these far-lateral herniations. The paramedian muscle splitting microsurgical approach was found to be the most direct and favorable anatomical route to herniations lateral to the neural foramen. With this approach, there is no facet destruction and postoperative pain is minimal. Patients were typically discharged on the 3rd or 4th postoperative day. The clinical and radiographic characteristics of far-lateral lumbar-disc herniations are reviewed and the paramedian microsurgical approach is discussed.
Correlation of motor cortex brain mapping data with magnetic resonance imaging
Authors: Berger Mitchel S. , Cohen Wendy A. , Ojemann George A.
Published: May 2009

✓ Brain maps derived intraoperatively from patients undergoing tumor resection were correlated retrospectively with magnetic resonance (MR) images with respect to the precise localization of the motor cortex in an attempt to identify useful preoperative MR imaging landmarks that correspond to functional brain regions. Superior axial T2-weighted MR images consistently localized the central sulcus, whereas parasagittal and far-lateral sagittal images readily identified the rolandic (sensorimotor) cortex, as a functional unit, based on the cingulate-marginal sulcus and insula, respectively. It is therefore concluded that multiplanar MR images may serve as a useful preoperative planning aid prior to removing intrinsic brain tumors within or adjacent to the motor cortex.
Effects of intrathecal baclofen on voluntary motor control in spastic paresis
Authors: Latash Mark L. , Penn Richard D. , Corcos Daniel M. , Gottlieb Gerald L.
Published: May 2009

✓ Intrathecal baclofen injections were given to six patients with long-standing spastic paresis resistant to any nondestructive treatment, including oral baclofen. Attempts by the patients at voluntary muscle activation before intrathecal administration of baclofen led to considerable uncontrolled coactivation of antagonist and distant muscles. After the injection, dramatic suppression of the spastic signs was accompanied by more selective voluntary muscle activation. Tonic coactivation of the antagonists and distant muscle groups during voluntary contractions was decreased while the agonist level on electromyography (EMG) was not affected (three cases) or only slightly reduced (three cases). Furthermore, in one patient with sufficient residual motor control function, there was a considerable increase in the speed of fast isotonic movements, accompanied by the emergence of the ability to generate phasic muscle bursts on EMG that were characteristic of normal motor patterns. The results suggest that baclofen exerts different effects upon reflex pathways and descending motor pathways. This therapy appears to be a promising way for improving residual motor control in patients with increased muscle tone and/or reflexes.
Cryptic vascular malformations of the spinal cord: diagnosis by magnetic resonance imaging and outcome of surgery
Authors: Barnwell Stanley L. , Dowd Christopher F. , Davis Richard L. , Edwards Michael S. B. , Gutin Philip H. , Wilson Charles B.
Published: May 2009

✓ The cases of seven patients with intramedullary, cryptic vascular malformations of the spinal cord are reported. In all patients, the clinical course was progressive; a Brown-Séquard syndrome was the most common presenting symptom complex. Magnetic resonance (MR) imaging was performed in all patients. The pattern seen most often was a focus of high signal (on both T1- and T2-weighted MR images) surrounded by a larger zone of low signal (best seen on T2-weighted images), and was remarkably similar for all patients. Six patients underwent surgical exploration; removal of the lesions halted the progression of symptoms in five patients, and one patient had worsened sensory function after surgery. Motor function did not decrease postoperatively in any patient. The one patient who refused surgery has continued to decline neurologically. Histopathological examination of surgical specimens showed a cavernous malformation in one patient, a venous malformation in one, venous varices in two, and organizing hematomas in two; these findings are markedly different from those in previously reported cases of cryptic vascular malformations.
Prediction of stability of cervical spine fracture managed in the halo vest and indications for surgical intervention
Authors: Sears William , Fazl Mahmood
Published: May 2009

✓ A retrospective study was made of 173 cases of acute cervical spine injury with halo vest management to compare initial injury features with outcome. The object was to determine whether a mathematical model could be developed enabling a prediction to be made at the time of the initial assessment as to the probability of success or failure of conservative management using the halo vest alone, and thus perhaps avoid lengthy, unsuccessful treatment.

Patients with facet joint dislocation were found to form a distinct subgroup of the injury population. Of the 70 patients in this subgroup, 44% achieved stability with the halo vest alone, but half of these had a “poor anatomical result.” No mathematical model or associated injury features could be found to assist in the outcome prediction in this subgroup. Of the 103 patients without facet joint dislocation, 70% achieved stability with the vest alone and over 75% of these had a “good anatomical result.” A useful model of outcome prediction was found for this subgroup by logistic regression analysis; the two most important predictors in the model were the amount of subluxation and the degree of angulation in the sagittal plane.
Induction of cytotoxicity in human T cells coated with anti-glioma × anti-CD3 bispecific antibody against human glioma cells
Authors: Nitta Taizo , Sato Kiyoshi , Okumura Ko , Ishii Shozo
Published: May 2009

✓ A bifunctional hetero-F(ab′)2 antibody fragment was developed that contained the Fab portions from anti-CD3 and anti-glioma monoclonal antibodies. The antibody simultaneously recognized two different molecules, the CD3 complex on effector T cells and a human glioma-associated antigen; thus, it could cross-link effector and target cells. This bispecific F(ab′)2 fragment induced peripheral blood mononuclear cells (PBMC's) from healthy donors to lyse cells of the human glioma cell line, U251MG, which are resistant to natural killer cell-mediated cytolysis. The effect of the bispecific antibody on lymphokine-activated killer (LAK) cell activity was tested in patients suffering from malignant glioma. For this study, PBMC's from these patients were preactivated with recombinant interleukin-2 and their killer activity against U251MG cells was investigated in vitro with and without the bispecific antibody. The LAK cell activity of the PBMC's from patients with malignant gliomas was found to be suppressed compared with those of healthy donors. However, after preincubation with bispecific antibody, the patients' LAK cells exhibited marked cytolytic activity against U251MG cells. These findings suggest that this bispecific antibody may be a useful addition to anti-glioma immunotherapy.
Evaluation of a fiberoptic intracranial pressure monitor
Authors: Crutchfield J. Stuart , Narayan Raj K. , Robertson Claudia S. , Michael Lloyd H.
Published: May 2009

✓ The fiberoptic device is a relatively new type of intracranial pressure (ICP) monitor which appears to offer certain advantages over conventional monitoring systems, particularly its ability to measure brain parenchymal pressures. This study was undertaken to analyze the accuracy and drift characteristics of the fiberoptic device and to compare pressures in the subdural, intraparenchymal, and intraventricular compartments. The device was accurate to ± 3 mm Hg over a 0- to 30-mm Hg range in vitro. The maximum daily drift was ± 2.5 mm Hg, with an average daily drift of ± 0.6 mm Hg and an average drift over a 5-day period of ± 2.1 mm Hg. In vivo, the pressures and waveform characteristics obtained with the fiberoptic device and with a strain-gauge transducer connected to a ventriculostomy were very similar. Alterations in ICP were induced by various therapeutic and pathological manipulations, and the pressures in the three intracranial compartments were compared. Changes in ICP appeared to be reflected simultaneously and equally in all three compartments. Furthermore, changes in ICP secondary to a unilateral mass lesion were identical in both supratentorial parenchymal compartments when measured simultaneously. It is concluded that the fiberoptic device is an accurate and reliable system for ICP monitoring; the pressures recorded in the subdural, intraparenchymal, and intraventricular compartments paralleled each other in all of the physiological and pathological states tested. Although the drift associated with this device is less than that reported for previously available systems, its maximal cumulative drift over a 5-day period of ± 6 mm Hg is significant. Since the fiberoptic device cannot be recalibrated in situ, it is suggested that the device be replaced if monitoring is to be continued for periods longer than 5 days.
Osteolytic skull lesions secondary to trauma
Authors: Hornig Gregory W. , Beatty Robert M.
Published: May 2009

✓ Two patients with posttraumatic osteolytic skull lesions are presented and discussed. One was operated on, and pathological examination confirmed an inflammatory reactive process within the bone lesion.
Modulation of blood flow following excision of a high-flow cerebral arteriovenous malformation
Authors: Tamaki Norihiko , Lin Tingkai , Asada Masahiro , Fujita Katsuzo , Tominaga Shogo , Kimura Mitsuru , Ehara Kazumasa , Matsumoto Satoshi
Published: May 2009

✓ The authors present a case in which a large high-flow arteriovenous malformation was totally excised. The success of the operation was in part attributed to the prevention of hyperperfusion breakthrough phenomena by the use of Selverstone clamps on the cervical carotid artery. Monitoring of cortical blood flow during surgery was found to be helpful.
Retrograde thrombosis of feeding arteries after removal of arteriovenous malformations
Authors: Miyasaka Yoshio , Yada Kenzoh , Ohwada Takashi , Kitahara Takao , Endoh Masataka , Saito Motoyoshi , Kurata Akira , Ohtaka Hirotoshi
Published: May 2009

✓ Five cases of retrograde thrombosis of former feeding arteries after removal of an arteriovenous malformation (AVM) are reported. The clinical features of these patients were studied and compared to those of 71 patients without this complication. The following characteristics were found to correlate with retrograde thrombosis: 1) advancing age of the patient; 2) large AVM size; and 3) markedly dilated and elongated feeders. It is suggested that the slow flow in the former feeding arteries that was observed immediately after AVM removal and pathological changes in these vessels due to long-standing hemodynamic stresses contributed to the development of retrograde thrombosis. Neurological manifestations related to retrograde thrombosis were noted in three of the five cases. Although infrequent, this complication should be considered as a serious possibility following removal of an AVM.
Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency
Authors: Ausman James I. , Diaz Fernando G. , Vacca Dante F. , Sadasivan Balaji
Published: May 2009

✓ Eighty-three patients underwent 85 intracranial to extracranial pedicle bypass anastomosis procedures to the posterior circulation. There were 15 patients with occipital artery (OA) to posterior inferior cerebellar artery (PICA) anastomosis, 20 patients with OA to anterior inferior cerebellar artery (AICA) anastomosis, and 50 patients with superficial temporal artery (STA) to superior cerebellar artery (SCA) anastomosis. All patients had transient ischemic attacks (TIA's) suggestive of vertebrobasilar ischemia. Twenty-seven patients had crescendo TIA's or stroke in evolution and were considered to be clinically unstable. All patients had severe bilateral distal vertebral artery or basilar artery disease. Twenty-two patients had bilateral vertebral artery occlusion and three had basilar artery occlusion. In this series, 69% had complete resolution of symptoms; the mortality rate was 8.4% and the morbidity rate 13.3%. Clinically stable patients did better than unstable patients. The STA-SCA anastomosis was well tolerated and technically less demanding than the OA-PICA or OA-AICA anastomosis procedures. Patients with symptomatic severe bilateral vertebral or basilar artery disease have a grave prognosis and the option of a surgical arterial pedicle revascularization procedure should be offered to them.
The significance of morphological changes in cerebral arteries after subarachnoid hemorrhage
Authors: Mayberg Marc R. , Okada Tomohisa , Bark Don H.
Published: May 2009

✓ A porcine model was developed to allow quantitative assessment of morphological changes in cerebral arteries after subarachnoid hemorrhage and to determine the significance of structural changes in producing arterial narrowing. Whole blood was selectively applied to the middle cerebral artery (MCA) of seven pigs. After 10 days, vessels were perfusion-fixed and examined by light and transmission electron microscopy and immunohistochemistry. The MCA's exposed to whole blood for 10 days showed prominent luminal narrowing associated with profound ultrastructural changes affecting all layers of the vessel wall. Morphometric analysis, however, demonstrated that significant reductions in the luminal cross-sectional area (−55.8% ± 12.5%, p < 0.005) and increases in radial wall thickness (75.1% ± 10.5%, p < 0.005) were associated with only minimal increase in the cross-sectional area of the vessel wall (12.5% ± 15%,p < 0.025). By stereological analysis, the volume density of individual components of the arterial wall was unchanged in MCA's exposed to blood. Vessels exposed to blood showed a 44% reduction in smooth-muscle cell immunoreactive actin and increased collagen in the extracellular matrix of the vessel wall. These data suggest that structural changes in cerebral arteries after subarachnoid hemorrhage do not directly contribute to vessel narrowing through increases in wall mass. Nevertheless, such changes may reflect pathological mechanisms which act to augment prolonged vasoconstriction or inhibit the maintenance of normal vascular tone.
The role of hemoglobin in arterial narrowing after subarachnoid hemorrhage
Authors: Mayberg Marc R. , Okada Tomohisa , Bark Don H.
Published: May 2009

✓ A porcine model for subarachnoid hemorrhage has been developed to allow the selective application of blood and its components to cerebral arteries. Whole blood was centrifuged to produce two fractions consisting of washed erythrocytes (red blood cells, RBC's) and white blood cells (WBC) plus platelet-rich plasma (PRP); the RBC fraction was subsequently separated into hemoglobin (Hb)-containing cytosol and erythrocyte membranes. Each fraction was selectively applied to the middle cerebral artery (MCA) of pigs for 10 days; after which, vessels were perfusion-fixed and examined by light and transmission electron microscopy and immunohistochemical studies. By morphometric analysis, a marked reduction in the MCA lumen cross-sectional area was observed after selective application of RBC's or Hb/cytosol but not of WBC/PRP or erythrocyte membranes. In both RBC- and Hb/cytosol-treated vessels, luminal narrowing was associated with a differential increase in vessel wall thickness of the ventral (subarachnoid) compared to the dorsal (brain) aspect of the artery, but no significant change in cross-sectional area of the vessel wall. After 10 days of exposure to RBC's or Hb/cytosol, there was a spectrum of ultrastructural changes in the vessel wall comparable to those seen after periadventitial application of whole blood. Selective application of commercially available Hb to MCA produced similar structural and morphometric changes. The degree of luminal narrowing after exposure to whole blood or RBC's was proportional to the volume of the erythrocyte mass adjacent to the vessel at sacrifice. These data suggest that arterial narrowing after SAH is mediated by mechanisms related to prolonged exposure of the vessel wall to hemoglobin or its catabolites from lysing subarachnoid erythrocytes.
Dorsal midbrain encephalitis caused by Propionibacterium acnes
Authors: Camarata Paul J. , McGeachie Robert E. , Haines Stephen J.
Published: May 2009

✓ A syndrome of dorsal midbrain dysfunction in association with a central nervous system anaerobic diphtheroid infection is described. Two cases of infection with Propionibacterium acnes manifested as shunt malfunctions with a clinical dorsal midbrain syndrome. Magnetic resonance images showed increased signal in the midbrain tectum which has decreased slowly over time. The evidence suggesting that this syndrome represents bacterial midbrain encephalitis is discussed.
Clivus epidural hematoma
Authors: Kurosu Akihiro , Amano Keiichi , Kubo Osami , Himuro Hiroshi , Nagao Takeki , Kobayashi Naoki , Kakinoki Yoshio , Kitamura Koichi
Published: May 2009

✓A rare case of epidural hematoma of the clivus is reported in an 11 -year-old girl involved in a traffic accident which caused a severe hyperextension injury. Only one similar case has been reported in the literature. The mechanism for the formation of the hematoma of this region is discussed.
Intradural granulocytic sarcoma presenting as a lumbar radiculopathy
Authors: Kim Fred S. C. , Rutka James T. , Bernstein Mark , Resch Lothar , Warner Ellen , Pantalony Dominic
Published: May 2009

✓ Granulocytic sarcoma usually occurs in the setting of leukemia and myeloproliferative disorders. Rarely, it can occur in isolation at various anatomical sites without hematological evidence of leukemia. The unique case of an elderly man presenting with right L2–3 radiculopathy is described. Intradural granulocytic sarcoma of the L-2 and L-3 nerve roots with extradural extension was found at surgery and he was treated with incomplete resection and antileukemic chemotherapy. Local recurrence at 3 months was treated with irradiation. Granulocytic sarcoma is frequently misdiagnosed and invariably progresses to acute leukemia. The chloroacetic acid esterase, granulocytic immunohistochemical markers, and electron microscopy appearance can aid in diagnosis. The prognosis is improved with initial aggressive antileukemic chemotherapy and local irradiation.
Aneurysms of the ophthalmic segment
Authors: Day Arthur L.
Published: May 2009

✓ The clinical, radiographic, and anatomical features in 80 patients with ophthalmic segment aneurysms were reviewed, and were categorized according to a presumed origin related to the ophthalmic (41 cases) or superior hypophyseal (39 cases) arteries. There was a marked female predominance (7:1) and high incidence of multiple aneurysms (45%) within this population. Clinical presentations included subarachnoid hemorrhage in 23 cases (29%) and visual deficits in 24 (30%); five patients exhibited both hemorrhage and visual loss. Twenty-eight aneurysms were incidentally identified.

Ophthalmic artery aneurysms arose from the internal carotid artery (ICA) just distal to the ophthalmic artery, pointed superiorly or superomedially, and (when large) deflected the carotid artery posteriorly and inferiorly, closing the siphon. Abnormalities relating to vision were not identified until the aneurysm realized giant proportions. The optic nerve was typically displaced superomedially, which restricted contralateral extension until late in the clinical course; unilateral nasal field loss was seen in 12 patients. Nine patients had bilateral ophthalmic artery aneurysms which were often clipped via a unilateral craniotomy.

Superior hypophyseal artery aneurysms arose just above the dural ring from the medial bend of the ICA, at the site of perforator origin to the superior aspect of the hypophysis, and had no direct association with the ophthalmic artery. The carotid artery was usually located lateral or superolateral relative to the aneurysm. These lesions could extend medially beneath the chiasm (suprasellar variant), producing a clinical and computerized tomography picture similar to a pituitary adenoma, or they could extend ventrally to burrow beneath the anterior clinoid process (paraclinoid variant).

Preoperative categorization of these lesions according to their likely branch of origin provides excellent correlation with visual deficits and operative findings, and has allowed the author to clip 52 of 54 lesions, with very low operative or visual morbidity.
Stereotactic resection of occult vascular malformations
Authors: Davis Dudley H. , Kelly Patrick J.
Published: May 2009

✓ Angiographically occult vascular malformations can be identified on computerized tomography and magnetic resonance imaging. Surgical excision, when possible, is the treatment of choice in symptomatic lesions. Because these malformations are usually small and can be located in surgically treacherous areas of the brain, stereotactic resection should be considered. Stereotactic resection of a pathologically verified occult vascular malformation was performed in 26 patients in this series (13 females and 13 males, mean age 30 years). Seventeen patients presented with a seizure disorder, four with an intracerebral hemorrhage, and four with a progressive neurological deficit; one patient was asymptomatic. Sixteen patients had normal neurological examinations, nine had neurological signs referable to their lesion, and one had a visual field deficit related to a previous temporal lobectomy. In six patients evidence of acute hemorrhage was found on imaging studies or at surgery, and 11 patients had evidence of previous hemorrhage on imaging studies, determined at surgery or by histological examination. Three patients had evidence of both acute and previous hemorrhage and six patients had no evidence of hemorrhage. Lesions were located in cortical or subcortical areas in 21 patients, in the thalamus or basal ganglia in three, and in the posterior fossa in two. Following stereotactic resection, 24 patients were improved, one patient was unchanged, and one patient was worse. Without stereotaxis or intraoperative ultrasound studies, localization of these lesions at conventional craniotomy can be difficult. A stereotactic craniotomy is ideally suited to the treatment of these benign circumscribed, but potentially devastating lesions.
Hypermetabolism in the acute stage of hemorrhagic cerebrovascular disease
Authors: Touho Hajime , Karasawa Jun , Shishido Hisashi , Morisako Toshitaka , Yamada Keisuke , Shibamoto Keiji
Published: May 2009

✓ Oxygen consumption carbon dioxide production , urinary nitrogen excretion, respiratory quotient, resting energy expenditure (REE), %REE, and the consumption rates of carbohydrate, fat, and protein (%CHO, %Fat, %Prot, respectively) were determined pre- and postoperatively by indirect calorimetry in 13 patients with ruptured intracranial aneurysms and 11 patients with hypertensive intracerebral hemorrhage in the acute stage. The preoperative urinary nitrogen excretion, respiratory quotient, REE, and %REE were, respectively (mean ± standard deviation): 171 ± 46 ml/min, 203 ± 56 ml/min, 10.3 ± 1.7 gm/day, 0.84 ± 0.01, 1397 ± 389 Cal/day, and 129% ± 8%. The values for REE, and %REE were all increased above normal levels. The %Prot was increased to 26.1% ± 9.1%. In the postoperative period, the urinary nitrogen excretion, REE, and %REE significantly increased to: 186 ± 44 ml/min, 229 ± 56 ml/min, 14.8 ± 2.9 gm/day, 1557 ± 384 Cal/day, and 141% ± 21%, respectively. The %Fat and %Prot also increased significantly, but the %CHO significantly decreased. Preoperatively, in the patients with ruptured intracranial aneurysms, there was a greater increase in %Prot in eight patients classified (according to Fischer) as having a Group 3 or 4 subarachnoid hemorrhage (SAH) on computerized tomography than in five patients classified as having a Group 1 or 2 SAH.

In summary, increased metabolic expenditure, especially increased catabolism of protein and fat, is characteristic of accompanying hemorrhagic cerebrovascular disease, and there is an increase in consumption of fat and protein in the postoperative period. Lack of precise knowledge about the cause and consequences of these metabolic responses makes it impossible at present to judge the optimal extent of nutritional replacement. The hypermetabolic state should be taken into consideration when caring for these patients as it may cause weight loss, poor wound healing, and susceptibility to infection.
The disposition of TCNU (tauromustine) in human malignant glioma: pharmacokinetic studies and clinical implications
Authors: Whittle Ian R. , MacPherson Janet S. , Miller J. Douglas , Smyth John F.
Published: May 2009

✓ Tauromustine (TCNU), 130 mg/sq m, was administered intraoperatively by nasogastric tube to 10 patients with malignant glioma (seven glioblastomas and three anaplastic astrocytomas). High-performance liquid chromatography analysis of 32 tumor specimens for TCNU revealed that tissue concentrations ranged from 0 to 554 ng/gm; TCNU was not detected in necrotic regions of the tumor. Levels of TCNU in brain adjacent to tumor were similar to those recorded within the gliomas (range 0 to 635 ng/gm). The variability in the tissue level of TCNU was partly attributable to variable absorption of the drug, since peak plasma TCNU levels ranged from 164 to 3333 ng/ml. There were close quantitative and temporal relationships between the times of peak plasma levels (median 456 ng/ml at 45 minutes after administration), peak tumor levels (median 250 ng/gm tissue at 55 minutes), and brain adjacent to tumor levels (median 256 ng/gm tissue at 50 minutes). Linear regression analysis of the ratio between tissue and plasma TCNU levels at particular times after drug administration suggest that plasma concentrations can be used to estimate tissue concentrations. This study demonstrates that TCNU enters malignant glioma. In view of the activity of TCNU against a range of tumors, a full clinical evaluation of this new nitrosourea in malignant glioma seems justified.
Experience in the management of myelomeningocele in Puerto Rico
Authors: Brau Ricardo H. , Rodríguez Rafael , Ramírez Mayra Vera , González Rosario , Martínez Virginia
Published: May 2009

✓ The medical records of 128 children with myelomeningocele who were treated at the Pediatric University Hospital, Puerto Rico Medical Center, from January, 1980, to July, 1985, were reviewed retrospectively. The medical and surgical management during the first hospitalization of these children was studied in detail for predefined parameters. The average age at the time of myelomeningocele repair was 6.6 days. Statistical analysis showed that repair of the myelomeningocele defect before 48 hours of age did not reduce the occurrence of ventriculitis. The incidence of ventriculitis secondary to the management of the myelomeningocele lesion was 12.5%. Complications after repair of the myelomeningocele (including skin flap necrosis, cerebrospinal fluid leaks, and wound infection) were present in 43.8% of the patients who developed ventriculitis and in 19.0% of those who did not. This observation is statistically significant (p = 0.03) and indicates that complications of healing after myelomeningocele repair represent the most significant risk factor for the development of ventriculitis.
Reduction in radiation-induced brain injury by use of pentobarbital or lidocaine protection
Authors: Oldfield Edward H. , Friedman Robert , Kinsella Timothy , Moquin Ross , Olson Jeffrey J. , Orr Kathryn , DeLuca Anne Marie
Published: May 2009

✓ To determine if barbiturates would protect brain at high doses of radiation, survival rates in rats that received whole-brain x-irradiation during pentobarbital- or lidocaine-induced anesthesia were compared with those of control animals that received no medication and of animals anesthetized with ketamine. The animals were shielded so that respiratory and digestive tissues would not be damaged by the radiation. Survival rates in rats that received whole-brain irradiation as a single 7500-rad dose under pentobarbital- or lidocaine-induced anesthesia was increased from between from 0% and 20% to between 45% and 69% over the 40 days of observation compared with the other two groups (p < 0.007). Ketamine anesthesia provided no protection. There were no notable differential effects upon non-neural tissues, suggesting that pentobarbital afforded protection through modulation of ambient neural activity during radiation exposure.

Neural suppression during high-dose cranial irradiation protects brain from acute and early delayed radiation injury. Further development and application of this knowledge may reduce the incidence of radiation toxicity of the central nervous system (CNS) and may permit the safe use of otherwise “unsafe” doses of radiation in patients with CNS neoplasms.
Persistent high lactate level as a sensitive MR spectroscopy indicator of completed infarction
Authors: Houkin Kiyohiro , Kwee Ingrid L. , Nakada Tsutomu
Published: May 2009

✓ Serial proton (1H) and phosphorus-31 (31P) magnetic resonance (MR) spectroscopy of cerebral infarction was performed in rats to assess the sensitivity of these techniques for use in clinical cerebral infarction. In this experimental chronic infarction model, 31P spectroscopy tended to return to a “normal” pattern within 24 hours after induction of infarction in spite of pathologically proven completed infarction and, therefore, appeared not to be sensitive enough for clinical application. On the other hand, proton spectroscopy invariably showed persistent high lactate levels and was capable of distinguishing completed infarction from reperfused recovered brain. Persistent high lactate levels appear to be a good MR spectroscopic indicator of completed infarction.
Evidence of the role of hemolysis in experimental cerebral vasospasm
Authors: Peterson John W. , Roussos Lawrence , Kwun Byung-Duk , Hackett John D. , Owen Christopher J. , Zervas Nicholas T.
Published: May 2009

✓ The short-term (≤ 72-hour) reaction to subarachnoid injections of various blood components was determined in a canine model of cerebral vasospasm. Platelet-rich plasma (PRP) formed durable clots in the basal cistern surrounding the basilar artery and provoked no vascular reaction in 72 hours or more. Freshly isolated autologous erythrocytes resuspended in PRP likewise provoked no vasoconstriction in 72 hours, although a second injection of fresh erythrocytes in PRP induced significant reaction, as in the conventional “double subarachnoid hemorrhage (SAH)” canine model. Hemolysate of fresh erythrocytes led to a severe immediate vascular reaction after introduction into the basal cistern using PRP as the carrier/clotting medium, as did the injection of intact erythrocytes incubated ex vivo for 72 hours. Resolution of the initial reaction was rapid for hemolysate, but slow and (depending on hematocrit) incomplete for intact “aged” erythrocytes. In vitro measurements of erythrocyte lysis in these media and histological examination indicate that the production of erythrocyte lysate was responsible for the vascular reaction observed, suggesting that the rate of lysis of erythrocytes in the subarachnoid clot is a major factor in the genesis of vasospasm after SAH.