bluuebunny/crossref_metadata_2025_split huggingface dataset:
Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system
Authors: Khanna Rohit K. , Malik Ghaus M. , Qureshi Nuzhat 
Published: June 2009

✓ Surgical treatment of unruptured aneurysms is gaining increased support owing to the recently defined poor long-term natural history of these aneurysms. The benefit of treatment ultimately depends on the relative risk of subsequent aneurysm rupture in untreated patients versus the risk of surgery. To identify those patients at a higher risk from surgery, the authors reviewed the management of 172 patients with unruptured intracranial aneurysms treated at their institution. The size of the aneurysms ranged from 3 to 45 mm (mean 13.7 mm). Twenty-two patients (12.8%) had aneurysms in the posterior circulation, and 32 (18.6%) of these were giant aneurysms. Major morbidity occurred in 12 patients (6.9%) and five patients (2.9%) died. Multivariate logistic analysis of several risk factors revealed that aneurysm size and location had an independent correlation with surgical outcome and that patient age approached statistical significance. Patients presenting with ischemic cerebrovascular disease, in particular, did not have a higher risk of a poor outcome.
A simple classification for predicting patients at high risk from surgical morbidity and mortality is proposed. Preoperative grading is based on the size and location of the aneurysm and patient's age. The lowest grade is given to young patients with small anterior circulation aneurysms, and the highest grade includes elderly patients with complex giant posterior circulation aneurysms. A retrospective analysis of this classification demonstrated a strong correlation with postoperative outcome. The incidence of poor outcome progressively increased with a higher grade, ranging from 0% in Grade 0 to 66.6% in Grade VI. An analysis of this classification on 50 consecutive surgically treated patients with unruptured aneurysms not included in the analysis also validated the predictive value of this system. Along with predicting outcome, this classification should provide a standardized format for comparison of results from different clinical centers as well as different therapeutic techniques (surgical vs. endovascular) without omission of significant risk factors found to influence outcome.
Treatment of large and giant fusiform intracranial aneurysms with Guglielmi detachable coils
Authors: Gobin Y. Pierre , Viñuela Fernando , Gurian John H. , Guglielmi Guido , Duckwiler Gary R. , Massoud Tarik F. , Martin Neil A. 
Published: June 2009

✓ Results in nine patients with large or giant fusiform intracranial aneurysms that were treated with Guglielmi detachable coils (GDCs) are reported. There were six males and three females between the ages of 12 and 63. Four patients presented with subarachnoid hemorrhage (SAH) and four with mass effect; in one patient the aneurysm was asymptomatic and located in an arterial feeder of an arteriovenous malformation. Five aneurysms were supratentorial and four were in the posterior fossa. Five were giant and four were large. Selective occlusion with preservation of the parent artery was attempted in three cases, and complete occlusion of the aneurysm and the parent artery was performed in six patients. The tolerance to parent artery occlusion was assessed by angiography, balloon test occlusion, and amytal testing. Six aneurysms were permanently occluded and two partially recanalized. In one case, GDC embolization was not possible.
The four patients who presented with SAH made an excellent clinical recovery. Three of the four patients presenting with mass effect recovered completely and one remained unchanged. The patient with an incidental aneurysm remained asymptomatic. There were no permanent complications. In conclusion, GDCs were useful for the occlusion of large and giant intradural fusiform aneurysms. Occlusion of the aneurysm and the parent artery afforded the greatest opportunity for a complete cure. Advantages of GDCs compared to balloons include: occlusion of a shorter segment of normal artery, no traction on the parent vessel, and safer and easier catheterization techniques.
Intraoperative endovascular surgery for cerebral aneurysms
Authors: Sinson Grant , Philips Matthew F. , Flamm Eugene S. 
Published: June 2009

✓ The application of a number of procedures that can be considered intraoperative endovascular neurosurgery has enhanced our ability to treat cerebral aneurysms from the abluminal surface. This study identifies a role for these techniques in the management of difficult aneurysms. A review of the last 1202 aneurysms undergoing direct clipping by the authors disclosed that these methods were used in 62 cases. Of these aneurysms, 36 arose from the internal carotid artery, 12 from the middle cerebral artery, eight from the vertebrobasilar distribution, and six from the anterior cerebral artery.
The indications for applying these methods were large size (12–60 mm), intraluminal thrombus, broad neck, plaque at the neck, the potential compromise of branches at the base of the aneurysm, or a combination of these problems. The most frequently chosen intraoperative technique was suction decompression with direct removal of plaque and thrombus using suction, dissection, and/or ultrasonic aspiration. The application of temporary clips was required in all cases in which the aneurysm was opened before definitive clipping. No special pharmacological cerebral protective regimen was used. In one case in which a greater occlusion time was anticipated, cardiopulmonary bypass with profound hypothermia was performed.
A favorable outcome was achieved in 73% of these difficult cases. An increased neurological deficit after surgery was seen in 11%, and the mortality rate was 8%. These methods should be considered and can be anticipated before surgery for unusual aneurysms. Many cases now being considered for embolization may be more suitable for definitive surgical obliteration.
Relationship between transcranial Doppler-determined pulsatility index and cerebrovascular resistance: an experimental study
Authors: Czosnyka Marek , Richards Hugh K. , Whitehouse Helen E. , Pickard John D. 
Published: June 2009

✓ Clinical studies with transcranial Doppler suggest that the pulsatility of the flow velocity (FV) waveform increases when the distal cerebrovascular resistance (CVR) increases. To clarify this relationship, the authors studied animal models in which the resistance may be decreased in a controlled manner by an increase in arterial CO2 tension, or by a decrease in cerebral perfusion pressure (CPP) in autoregulating animals. Twelve New Zealand white rabbits were anesthetized, paralyzed, and ventilated. Transcranial Doppler basilar artery FV, laser Doppler cortical blood flow, arterial pressure, intracranial pressure, and end-tidal CO2 concentration were measured continuously. Cerebrovascular resistance (CPP divided by laser Doppler cortical flux) and Gosling Pulsatility Index (PI, defined as an FV pulse amplitude divided by a timed average FV) were calculated as time-dependent variables for each animal.
Four groups of animals undergoing controlled manipulations of CVR were analyzed. In Group I, arterial CO2 concentration was changed gradually from hypocapnia to hypercapnia. In Group II, gradual hemorrhagic hypotension was used to reduce CPP. In Group III, the short-acting ganglion blocking drug trimetaphan was injected intravenously to induce transient hypotension. Intracranial hypertension was produced by subarachnoid saline infusion in Group IV. During the hypercapnic challenge the correlation between the cortical resistance and Doppler flow pulsatility was positive (r = 0.77, p < 0.001). In all three groups in which cerebral perfusion pressure was reduced a negative correlation between pulsatility index and cerebrovascular resistance was found (r = −20.84, p < 0.001). The authors conclude that PI cannot be interpreted simply as an index of CVR in all circumstances.
Significance of proliferating cell nuclear antigen in predicting recurrence of intracranial meningioma
Authors: Cobb Mark A. , Husain Muhammad , Andersen Bruce J. , Al-Mefty Ossama 
Published: June 2009

✓ It is well known that the histological appearance of meningiomas often fails to predict accurately the clinical behavior of the tumor. Therefore, attention has turned from tumor histology to tumor biology. Proliferating cell nuclear antigen (PCNA), a cell cycle-regulated protein, has been recently characterized as the cofactor of DNA polymerase-δ, an enzyme required for DNA replication. The rate of synthesis of PCNA directly correlates with the proliferative state of cells. Immunohistochemical labeling of this antigen is now possible with monoclonal antibodies that allow for its demonstration in routinely fixed, paraffin-embedded specimens.
In this study, the PCNA labeling index (LI) was determined for 83 meningiomas, including tumors with both benign and malignant clinical courses and with benign, atypical, and malignant histologies, apparent after total or subtotal resections. No statistical difference was found between the LI on recurrence and that found at initial presentation. In addition, stepwise multivariate regression analysis failed to identify any combination of factors (age, gender, race, age of specimen, tumor histology, Simpson grade of resection) that contributes to the predictive strength of the PCNA LI for tumor recurrence.
However, for LIs less than 2%, only one of 26 gross totally resected tumors recurred (mean follow up 53 months); for LIs more than 7%, five of 13 gross totally resected tumors recurred (mean follow up 55 months). The difference in recurrence rates between gross totally resected meningiomas with PCNA LIs less than 2% and those with PCNA LIs more than 7% achieved statistical significance with a Fisher's exact probability equaling 0.011. The authors conclude that quantitative PCNA labeling of meningiomas is a promising technique that can provide meaningful prognostic information.
William Macewen and the treatment of brain abscesses: revisited after one hundred years
Authors: Canale Dee J. 
Published: June 2009

✓ The year 1993 marked the centennial of the publication of Sir William Macewen's monograph, Pyogenic Infective Diseases of the Brain and Spinal Cord, and its accompanying volume, Atlas of Head Sections. As Harvey Cushing noted, the text on pyogenic diseases of the brain was a landmark in surgery of the nervous system. At the time of its publication, Macewen's work was the most comprehensive study of pyogenic brain diseases.
In this paper the author reviews the state of knowledge of brain abscess existing in the 19th and 20th centuries, with particular emphasis on the late 19th century, and elucidates factors contributing to Macewen's remarkable success. His thorough knowledge of the natural history of pyogenic diseases of the temporal bone and nasal sinuses, in addition to his clear description of cranial anatomy, as illustrated in his Atlas of Head Sections, were especially important in developing his successful treatment of brain abscess. The x-ray had not yet been discovered; Macewen's diagnosis was based on clinical findings superbly illustrated by his three clinical stages of brain abscess development. His clinical observations are as relevant today as when he described them 100 years ago.
Macewen recorded 25 cases of brain abscess. Nineteen of these patients came to his attention in time to undergo surgery, resulting in 18 recoveries. All five of his patients with extradural abscess recovered. These results were achieved in the era known as “the most glorious period in British surgery.” Neurosurgery was in its infancy; nevertheless, even as the 20th century closes, Macewen's results still have not been surpassed.
Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils
Authors: McDougall Cameron G. , Halbach Van V. , Dowd Christopher F. , Higashida Randall T. , Larsen Donald W. , Hieshima Grant B. 
Published: June 2009

✓ Preliminary experience using electrolytically detachable coils to treat basilar tip aneurysms in 33 patients is described. The most frequent presentation was subarachnoid hemorrhage (SAH) in 23 patients. All patients were referred after neurosurgical assessment and exclusion as candidates for surgical clipping of their aneurysms. At the time of initial treatment complete aneurysm occlusion was achieved in seven (21.2%) of 33 patients. In 17 of the patients (51.5%), greater than 90% but less than 100% aneurysm occlusion was achieved. Angiographic follow up (mean 11.7 months) was available in 19 patients. At follow-up angiography four (21%) of 19 aneurysms were 100% occluded and 12 (63.2%) of 19 were more than 90% but less than 100% occluded.
The mean clinical follow-up time in treated patients surviving beyond the initial treatment period is 15 months. One patient suffered major permanent morbidity from thrombosis of the basilar tip region a few hours after coil placement. One patient treated following SAH experienced further hemorrhage 6 months later. No other patient suffered direct or indirect permanent morbidity as a consequence of this method of treatment.
The authors believe that this technique is a reasonable alternative for patients who are not candidates for conventional surgical treatment or in whom such treatment has failed. This study's follow-up period is brief and greater experience with long-term follow-up study is mandatory.
Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis
Authors: Barker Fred G. , Ogilvy Christopher S. 
Published: June 2009

✓ The authors report findings from a metaanalysis of all published randomized trials of prophylactic nimodipine used in patients who have experienced subarachnoid hemorrhage (SAH). Seven trials were included with a total of 1202 patients suitable for evaluation. Eight outcome measures were examined, including good versus other outcome, good or fair outcome versus other outcome, overall mortality, deficit and/or death attributed to vasospasm, infarction rate as judged by computerized tomography (CT), and deficit and/or death from rebleeding.
Nimodipine improved outcome according to all measures examined. The odds of good and of good plus fair outcomes were improved by ratios of 1.86:1 and 1.67:1, respectively, for nimodipine versus control (p < 0.005 for both measures). The odds of deficit and/or mortality attributed to vasospasm and CT-assessed infarction rate were reduced by ratios of 0.46:1 to 0.58:1 in the nimodipine group (p < 0.008 for all measures). Overall mortality was slightly reduced in the nimodipine group, but the trend was not statistically significant. The rebleeding rate was not increased by nimodipine. A metaregression yielded findings indicating that the treatment effect of nimodipine in individual trials was positively correlated with the severity of SAH in enrolled patients.
Although the majority of individual trials examined did not have statistically significant results at the p < 0.01 level according to most outcome measures, the metaanalyses confirmed the significant efficacy of prophylactic nimodipine in improving outcome after SAH under the conditions used in these trials.
Central nervous system medulloepithelioma: a series of eight cases including two arising in the pons
Authors: Molloy Patricia T. , Yachnis Anthony T. , Rorke Lucy B. , Dattilo James J. , Needle Michael N. , Millar William S. , Goldwein Joel W. , Sutton Leslie N. , Phillips Peter C. 
Published: June 2009

✓ Medulloepithelioma is an uncommon childhood tumor of the central nervous system (CNS) whose histopathological appearance has been confused with medulloblastoma and other childhood primitive neuroectodermal tumors (PNETs), but which has a vastly different clinical course. The authors have reviewed the clinical features and treatment responses of eight children with these rare tumors, the largest series to date.
In this series, the medulloepitheliomas were equally distributed between supratentorial and infratentorial primary sites. Four patients underwent gross- or near-total resections, one patient's tumor was partially resected, and one patient had biopsy only. Biopsy and ablative surgery were not attempted in two children with pontine tumors. Treatment included both radiation and chemotherapy (four patients), radiation alone (one patient), chemotherapy alone (one patient), and no postoperative treatment (two patients). Six patients died with a mean survival of 10 months and two are disease free with neurological impairment. Both long-term survivors underwent gross-total resections of their tumors. Postmortem examination revealed diffuse CNS tumor dissemination in four patients.
Medulloepithelioma, often confused with less aggressive PNETs, can mimic intrinsic brainstem glioma, responds poorly to treatment, and is prone to CNS dissemination at the time of tumor progression.
Ovine pericardium as a new material for duraplasty
Authors: Pařízek Jan , Husěk Zdeněk , Měřička Pavel , Téra Josef , Němeček Stanislav , Spaček Josef , Němečková Jana , Šuba Petr 
Published: June 2009

✓ The authors report on their 2 1/2-year clinical experience using a dural substitute, ovine pericardium, stabilized with 0.3% glutaraldehyde, flat freeze-dried, and sterilized with γ-irradiation.
Packaging of the ovine pericardium in double-plastic transparent bags allows simple storage in operating rooms and the opportunity for the surgeon to choose an ideal graft according to its shape, size, and plasticity.
The ovine pericardia were examined histologically and by transmission and scanning electron microscopy in their native, freeze-dried, and irradiated forms. The final product is composed solely of pericardium fibrosum interwoven with artificially formed extracellular microcavities that serve as natural pores for the ingrowth of host tissue. The surfaces of the grafts appear smooth on the inner and rough on the outer sides.
Sixteen grafts were examined macroscopically at autopsy and four of these were also examined histologically to illustrate their successful healing with no adhesion to the underlying brain.
As a new dural substitute, ovine pericardium proved to be superior to bovine and allogeneic pericardia because of its workability, flexibility, and reduced thickness. In a study of 120 grafts, all but one healed without complications.
Comparison of syringopleural and syringosubarachnoid shunting in the treatment of syringomyelia in children
Authors: Vernet Olivier , Farmer Jean-Pierre , Montes José L. 
Published: June 2009

✓ Case records from the Montreal Children's Hospital containing the diagnosis of shunted syringomyelia were retrospectively reviewed. From 1984 to 1994, 31 patients had their syrinx treated by either syringopleural (19 cases, Group A) or syringosubarachnoid (13 cases, Group B) shunting. One patient was included in both groups.Associated diagnoses included: in Group A, two cases of Chiari I and 14 of Chiari II malformations, 14 cases of shunted hydrocephalus, 13 cases of spina bifida aperta, and three cases of spina bifida occulta; Group B, four cases of Chiari I and two of Chiari II malformations, four cases of shunted hydrocephalus, two cases of spina bifida aperta, and five cases of spina bifida occulta. Eight Group A and six Group B patients had undergone prior posterior fossa decompression. Motor deficits predominated in both groups and arachnoiditis was a uniform operative finding.Neurological follow-up examinations showed 11 Group A patients improved and eight stabilized, whereas on magnetic resonance imaging, 12 cavities appeared to have collapsed, five were markedly reduced, and one had increased. One patient underwent reoperation for pleural effusions and one for shunt displacement. In Group B, one patient improved, eight stabilized, three worsened neurologically, and one was lost to follow-up review. Radiologically, one cavity appeared to have collapsed, six were significantly reduced, two were unchanged, and three had enlarged.The authors conclude that syringopleural shunting is a valuable option for controlling syringomyelia in patients without Chiari malformation or in patients who have previously undergone a craniovertebral decompression or are otherwise asymptomatic from their Chiari malformation.
Loss of nitric oxide synthase immunoreactivity in cerebral vasospasm
Authors: Pluta Ryszard M. , Thompson B. Gregory , Dawson Ted M. , Snyder Solomon H. , Boock Robert J. , Oldfield Edward H. 
Published: June 2009

✓ To determine the distribution of nitric oxide synthase (NOS) in the primate cerebral artery nervi vasorum and to examine the potential role of NOS in cerebral vasospasm after subarachnoid hemorrhage (SAH) in primates, the distribution of NOS immunoreactivity (NOS-IR) in the major cerebral arteries was examined immunohistochemically in cynomolgus monkeys by the use of whole, mounted preparations of the circle of Willis. In four normal monkeys, NOS-IR was localized to the endothelial and adventitial layers of the large cerebral arteries. On the abluminal side, NOS-IR staining was densely concentrated in perivascular nerve fibers (nervi vasorum) of the anterior circulation. Staining was less prominent in the posterior circulation. In six monkeys with vasospasm on Day 7 after placement of preclotted arterial blood to form an SAH around the right middle cerebral artery (MCA) (42% ± 8.3% decrease of MCA area, mean ± standard deviation), NOS-IR was virtually absent in nerve fibers around the spastic right MCA but was normal on the contralateral side. In five monkeys in which vasospasm resolved by Day 14 after SAH (36% ± 14% decrease of right MCA area on Day 7, and 5% ± 14% decrease on Day 14), NOS-IR was also absent in the right MCA adventitial nerve fibers and remained normal in the left MCA. Adventitial NOS-IR was also normal in cerebral vessels of a sham-operated, nonspastic monkey.These findings provide further evidence that nitric oxide (NO) functions as a neuronal transmitter to mediate vasodilation in primates and indicate a role for adventitial NO in the pathogenesis of cerebral vasospasm after SAH in humans.
Percutaneous endoscopic treatment of suprasellar arachnoid cysts: ventriculocystostomy or ventriculocystocisternostomy?
Authors: Decq Philippe , Brugières Pierre , Le Guerinel Caroline , Djindjian Michel , Kéravel Yves , Nguyen Jean-Paul 
Published: June 2009

✓ The use of an endoscope in the treatment of suprasellar arachnoid cysts provides an opening of the upper and lower cyst walls, thereby allowing the surgeon to perform a ventriculocystostomy (VC) or a ventriculocystocysternostomy (VCC). To discover which procedure is appropriate, magnetic resonance (MR)—imaged cerebrospinal fluid (CSF) flow dynamics in two patients were analyzed, one having undergone a VC and the other a VCC using a rigid endoscope. Magnetic resonance imaging studies were performed before and after treatment, with long-term follow-up periods (18 months and 2 years). The two patients were reoperated on during the follow-up period because of slight headache recurrence in one case and MR—imaged CSF flow dynamics modifications in the other. In each case surgery confirmed the CSF flow dynamics modifications appearing on MR imaging.
In both cases, long-term MR imaging follow-up studies showed a secondary closing of the upper wall orifice. After VCC, however, the lower communication between the cyst and the cisterns remained functional.
The secondary closure of the upper orifice may be explained as follows: when opened, the upper wall becomes unnecessary and tends to return to a normal shape, leading to a secondary closure. The patent sylvian aqueduct aids this phenomenon, as observed after ventriculostomy when the aqueduct is secondarily functional.
The simplicity of the VCC performed using endoscopic control, which is the only procedure to allow the opening in the cyst's lower wall to remain patent, leads the authors to advocate this technique in the treatment of suprasellar arachnoid cysts.