[Show abstract][Hide abstract] ABSTRACT: Objective To illustrate a unique instance of Ehlers-Danlos syndrome type VIII (EDS VIII) with blood blister-like aneurysm of the middle cerebral artery. Design This is a single patient case report. Setting University of Wisconsin-Madison Hospital. Participants A 42-year-old woman with diagnosis of EDS VIII presented with a sudden onset severe headache and altered mental status. She was diagnosed with Hunt and Hess grade IV subarachnoid hemorrhage. Angiography demonstrated a blood blister-like aneurysm of the left middle cerebral artery. After an unsuccessful coiling attempt in another facility, the patient was operated on with the intention to perform extracranial to intracranial bypass and trapping of the diseased segment of the artery. Results The patient's neurologic condition remained poor after surgery. On postoperative day 2, her neurologic examination unchanged, and care was withdrawn per the family's request. Conclusions Individuals with EDS VIII may be at risk for catastrophic vascular events.
Journal of neurological surgery reports. 12/2014; 75(2):e210-e213.
[Show abstract][Hide abstract] ABSTRACT: Background and Study Aim To enhance the visualization of the intracranial vasculature of cadavers under gross examination with a combination of imaging modalities. Material and Methods A total of 20 cadaver heads were used to test two different perfusion techniques. First, fixed cadaver heads were perfused with water; second, fresh cadavers were perfused with saline and 10% formalin. Subsequently, brains were removed and fixed. The compounds used were silicone rubber, silicone rubber mixed with powdered barium sulfate, and silicone rubber mixed with tantalum dioxide prepared by the first perfusion technique and gelatin mixed with liquid barium prepared with the second technique. Conventional X-ray imaging, computed tomography (CT), dynamic computed tomography (dCT), and postprocessing three-dimensional (3D) images were used to evaluate all the heads. Results Gelatinized barium was better visualized when compared with tantalum dioxide in conventional X-ray images. The blood vessels injected with either tantalum dioxide or gelatinized barium demonstrated a higher enhancement than the surrounding soft tissues with CT or dCT. The quality of the 3D reconstruction of the intracranial vasculature was significantly better in the CT images obtained from the gelatinized barium group. Conclusions Radiologic examinations of the heads injected with gelatinized barium facilitates the 3D understanding of cerebrovascular anatomy as an important tool for neuroanatomy training.
Journal of neurological surgery. Part B, Skull base. 12/2014; 75(6):435-444.
[Show abstract][Hide abstract] ABSTRACT: Blood blister-like aneurysms (BBAs) pose a significant challenge to neurosurgeons and neuro-interventionalists. These fragile broad-based aneurysms have a propensity to rupture with minimal manipulation during surgical or endovascular explorations because, unlike saccular aneurysms, they lack all layers of the arterial wall. Aneurysm trapping with extracranial-intracranial (EC-IC) bypass is a safe and durable treatment for BBAs.
[Show abstract][Hide abstract] ABSTRACT: Although configurations of the posterior cerebral artery (PCA) and posterior communicating artery (PComA) have been extensively studied, reported rates of adult (AC), fetal (FC) and transitional configurations (TC) vary widely due to techniques used. A histological technique was applied to measure the circumference of the arteries and this was compared with caliper measurements taken from the same arteries. Ninetyfive brains were examined. The external diameters of all precommunicating, postcommunicating PCAs and PComAs were measured under operating microscope with a micrometer caliper. After measurements, all arteries were prepared for histology, sections were stained with Verhoff's elastic technique and the circumferences were measured using the light microscope. In the caliper group, AC was found in 77.2%, FC was found in 17.3% and TC was found in 5.5% of the right hemispheres, while on the left AC was found in 81.7%, FC in 18.3% and no TC was found. In the histology group, AC was found in 78.3% and FC was found in 21.7% of the right, while on the left AC was found in 81.7% and FC was found in 18.3% of cases. No TC was found in any hemisphere. There was no statistical significance between the two groups. Results of the present study reveal several important findings. When the PComA was absent in one hemisphere, the PComA was FC on the contralateral hemisphere. Transitional configuration was found in a very small number of cases in the caliper group compared to previous studies, and no TC was found in the histology group.
Journal of neurosurgical sciences 03/2014; · 0.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The retrosigmoid approach is a work-horse approach to the cerebellopontine angle (CPA), providing access from the foremen magnum to the tentorium. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of vertebrobasilar system, vascular decompression of cranial nerves (V, VII, IX, X), cranial nerve neurectomies, and intrinsic lesions of the cerebellum and brainstem. In this video, we demonstrate the use of retrosigmoid craniotomy for resection of a large CPA meningioma, delineating all steps including positioning, mapping. The video can be found here: http://youtu.be/kISkYS16Brk .
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to better define the microsurgical anatomy of the supra/parasellar region and describe variations of the anterior clinoid process (ACP). MATERIAL and METHODS: Fifteen formalin-fixed cadaver heads and 25 dry skulls were used to define the microsurgical anatomy of the ACP and related structures. The presence of the caroticoclinoid foramen (CaCF) as well as other relevant measurements were all noted. Radiological examination of the CaCF was also demonstrated on dry skulls.
[Show abstract][Hide abstract] ABSTRACT: In adolescents and young adults, ependymomas are the most common intramedullary tumors in the spinal cord.These tumors arise from ependymal cell lining the ventricles and spinal canal. The clinical presentation of intramedullary ependymomas are variable and nonspecific. They usually present with diffuse back or neck pain as a chief complaint. Upper and lower motor neuron deficits, numbness which typically progresses from distal to proximal, are other common symptoms. Gross total resection of ependymomas can achieve long-term tumor control with preservation of function. Here we present a 29-year old man who presented with progressive weakness of the left leg, bowel and bladder incontinence. During surgery, somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were used and we achieved gross total resection while preserving the spinal cord. The patient made excellent recovery and all of his preoperative deficitis improved completely. He returned to work on postoperative 2-month.
[Show abstract][Hide abstract] ABSTRACT: The pupose of this study is to assess the long-term outcome and toxicity of fractionated stereotactic radiation therapy (FSRT) and stereotactic radiosurgery (SRS) for 100 vestibular schwannomas treated at a single institution. From 1993 to 2007, 104 patients underwent were treated with radiation therapy for vestibular schwannoma. Forty-eight patients received SRS, with a median prescription dose of 12.5 Gy for SRS (range 9.7-16 Gy). For FSRT, two different fraction schedules were employed: a conventional schedule (ConFSRT) of 1.8 Gy per fraction (Gy/F) for 25 or 28 fractions to a total dose of 45 or 50.4 Gy (n = 19); and a once weekly hypofractionated course (HypoFSRT) consisting of 4 Gy/F for 5 fractions to a total dose of 20 Gy (n = 37). Patients treated with FSRT had better baseline hearing, facial, and trigeminal nerve function, and were more likely to have a diagnosis of NF2. The 5-year progression free rate (PFR) was 97.0 after SRS, 90.5 % after HypoFSRT, and 100.0 % after ConFSRT (p = NS). Univariate analysis demonstrated that NF2 and larger tumor size (greater than the median) correlated with poorer local control, but prior surgical resection did not. Serviceable hearing was preserved in 60.0 % of SRS patients, 63.2 % of HypoFSRT patients, and 44.4 % of ConFSRT patients (p = 0.6). Similarly, there were no significant differences in 5-year rates of trigeminal toxicity facial nerve toxicity, vestibular dysfunction, or tinnitus. Conclusions:Equivalent 5-year PFR and toxicity rates are shown for patients with vestibular schwanoma selected for SRS, HypoFSRT, and ConFSRT after multidisciplinary evaluation. Factors correlating with tumor progression included NF2 and larger tumor size.
Journal of Neuro-Oncology 10/2013; · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:: Primary central nervous system posttransplantation lymphoproliferative disorder (PCNS-PTLD) is a rare complication after solid organ transplantation (SOT). With increasing rates of SOT, PCNS-PTLD incidence is increasing. OBJECTIVE:: To describe the characteristics of PCNS-PTLD patients requiring neurosurgical intervention. METHODS:: From 2000 to 2011, 10 patients with prior SOT underwent biopsy for evaluation of brain lesions and were diagnosed with PCNS-PTLD. Data collected included imaging characteristics, pathology, treatments administered, and survival outcomes. RESULTS:: All patients had kidney transplantation, and 3 had concurrent pancreas transplantation. Median age at diagnosis was 49 years, with a median of 4.5 years from SOT to diagnosis (range, 1.8-11.4 years). Presenting symptoms most often included focal neurological deficits (n = 6), although several patients had nonspecific symptoms of headache and altered mental status. Brain lesions were generally multiple (n = 7), supratentorial (n = 8), and lobar or periventricular in distribution with ring enhancement. Diagnosis was established by stereotactic (n = 4) and open surgical (n = 6) biopsy. Treatments most frequently administered included reduction of immunosuppression (n = 10), dexamethasone (n = 10), rituximab (n = 8), high-dose methotrexate (n = 3), and whole-brain radiotherapy (n = 6). Six patients remain alive without PCNS-PTLD relapse, including 4 patients who have sustained remissions beyond 2 years from diagnosis of PCNS-PTLD. Of 4 observed deaths, 1 was related to progressive PCNS-PTLD. CONCLUSION:: PCNS-PTLD must be considered in the differential diagnosis of any patient with prior SOT presenting with an intracranial lesion. Histological diagnosis with brain biopsy is imperative, given the risk for opportunistic infections that may have similar imaging findings and presentation. Prognosis is variable, although long-term survival has been reported. ABBREVIATIONS:: EBER, Epstein-Barr virus--encoded RNAEBV, Epstein-Barr virusPCNS-PTLD, primary central nervous system posttransplantation lymphoproliferative disorderSOT, solid organ transplantation.
[Show abstract][Hide abstract] ABSTRACT: Background Laminoplasty in the case of intramedullary spinal tumor requires care to avoid neurologic injury. The harmonic bone scalpel provides a method of laminoplasty that can be done safely and quickly for this and other indications.Patients Five cases are presented, each of which required operative intervention, namely laminoplasty. The pathologies presented are one cervical intramedullary tumor, one thoracic intramedullary spinal mass, one lumbar extramedullary intradural tumor, and two cases of multiple lower brachial plexus nerve root avulsions requiring dorsal root entry zone (DREZ) lesion.Results These five patients underwent laminoplasty for either tumor resection or DREZ lesion. The laminotomies were performed using the BoneScalpel™ (Misonix Inc., Farmingdale, NY, USA), which is a harmonic bone scalpel instrument. This obviated the need to place any instrument under the intact lamina. Kerrison punches and various instruments were still used, but for purposes other than the bony removal of the laminoplasty.Conclusion These cases demonstrate that the BoneScalpel™ can be used to facilitate the laminar cuts while still allowing a safe and effective operation, even in cases as delicate as an intramedullary thoracic spinal cord tumor. The mechanism of action of the harmonic bone scalpel allows osteotomies without cutting or penetrating soft tissue and also leaves minimal bony defect.
Journal of neurological surgery. Part A, Central European neurosurgery. 03/2013;
[Show abstract][Hide abstract] ABSTRACT: True hemodynamic assessment of the posterior communicating artery (PComA) by preoperative angiography in terms of its perforators and configuration (adult vs. fetal vs. transitional) can be challenging in the surgical treatment of aneurysms involving the PComA, posterior cerebral artery, and basilar artery. Indocyanine green videoangiography (ICG-VA) is a widely accepted new technique in the surgical treatment of intracranial aneurysms to assess the patency of the parent artery, branches, and residual flow within the aneurysm after clipping.
Here we report two cases in which ICG-VA was utilized to assess either the direction of flow in the PComA or preservation of the PComA perforators with temporary clip application before dividing the PComA.
Our experience is that ICG-VA can be used to assess the main trunk, and perforating branches of the PComA providing real-time, dynamic intraoperative information of the surgical field. Therefore we suggest that ICG-VA may increase the safety of surgical treatment of aneurysm involving PComA.
Surgical Neurology International 01/2013; 4:122. · 1.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Isolated Blastomyces dermatitidis infection of the central nervous system is an uncommonly encountered entity. If left untreated it can be fatal; thus accurate diagnosis in a timely manner is critical. A 37-year-old white male presented with a severe headache. An MRI scan revealed a rightsided enhancing cerebellopontine angle mass with extension into the internal acoustic canal and diffuse basilar enhancement. After thorough assessment of the patient, an open surgical biopsy of the lesion was performed for pathological evaluation. The biopsy demonstrated broadbased budding yeasts. The cerebrospinal fluid antigen enzyme immunoassay (EIA) (MVista®) for Blastomyces dermatitidis was also positive with a level of 4.28 EIA units.
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Indocyanine green video angiography (ICG-VA) has been recently introduced into neurovascular surgery and gained a role in assessing vessel patency and obliteration of intracranial aneurysms (IA) after clipping. Although its correlation with intra-postoperative angiography was demonstrated in previous studies, difficulties in evaluating aneurysm obliteration have not been reported. We report reliability and accuracy of ICG-VA in 109 clipped aneurysms with attention given to five cases in which ICG-VA evaluation resulted in false indication that aneurysms were secure in terms of complete obliteration. MATERIALS AND METHODS: A retrospective chart review was performed of IAs surgically treated by a single surgeon from January 2009. In all cases, aneurysm obliteration was confirmed by a combination of microdoppler ultrasonography (MUSG), ICG-VA, and post-operative angiography. RESULTS: ICG-VA appropriately assessed vessel patency and aneurysm obliteration in 93.5% of aneurysms clipped. In four cases (3.6%), puncturing the dome of the aneurysm after satisfactory clipping revealed persistent flow within the aneurysm despite ICG-VA showing no flow after clipping. In one case (0.9%), ICG-VA showed persistent flow within the aneurysm and MUSG did not, and puncture of the dome confirmed no flow within the aneurysm. In one case (0.9%), ICG-VA failed to demonstrate residual neck. CONCLUSION: ICG-VA is a simple and safe procedure and an important adjunct to microsurgical clipping of aneurysm. Although ICG-VA assesses vessel patency and obliteration of aneurysms in most cases, applying the principles of microsurgery in aneurysm clipping remains a main tool for obtaining the complete obliteration of aneurysm along with preservation of the normal vasculature.
Clinical neurology and neurosurgery 09/2012; · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Of the presigmoid approaches, the translabyrinthine approach is often used when a large exposure is needed to gain access to the cerebellopontine angle but when hearing preservation is not a concern. At the authors' institution, this approach is done with the aid of ENT/otolaryngology for temporal bone drilling and exposure. In the present article and video, the authors demonstrate the use of the translabyrinthine approach for resection of a large cystic vestibular schwannoma, delineating the steps of positioning, opening, temporal bone drilling, tumor resection, and closure. Gross-total resection was achieved in the featured case. The patient's postoperative facial function was House-Brackmann Grade II on the side ipsilateral to the tumor, although function improved with time. The translabyrinthine route to the cerebellopontine angle is an excellent approach for masses that extend toward the midline or anterior to the pons. Although hearing is sacrificed, facial nerve function is generally spared.
[Show abstract][Hide abstract] ABSTRACT: To report 3 unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol.
Clinical capsule report.
Three tertiary academic referral hospitals.
Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, whereas the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits after SSE.
One patient with isolated complete cranial nerve VII palsy demonstrated partial return of function at 8 months. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within 1 week but failed to demonstrate mobility of the ipsilateral true vocal fold.
We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that the use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.
Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 07/2012; 33(7):1270-5. · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before. OBJECTIVE: For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH. METHODS: We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n=338) or naSAH (n=46) on clinical and radiological criteria. PMH (n=32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared. RESULTS: Aneurysmal SAH occurred most often from 6am to 12pm (p<0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p=0.008) and smoking (p=0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p=0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p<0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p=0.0159). CONCLUSION: Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.
Clinical neurology and neurosurgery 07/2012; · 1.30 Impact Factor