Surgical Neurology

Published by Elsevier
Print ISSN: 0090-3019
The present study was undertaken to evaluate 10% hydroxyethyl starch (HES 200/0.5) with regard to its clinical outcome and safety in the treatment of severe head injury. Retrospective review of patient data from a prospectively designed standard treatment protocol for severe head injury. The standard protocol included (1) cerebral perfusion pressure higher than 60 mm Hg, (2) colloid solution (10% HES 200/0.5) 1000 mL/d in combination with crystalloid solution, (3) stepwise management of intracranial hypertension. Renal function, coagulation function, and electrolytes were evaluated every other day. The data of intracranial pressure, mean arterial pressure, cerebral perfusion pressure, intake, output, mannitol, complications, and outcome were recorded and analyzed. There were 78 patients, aged 45.61 +/- 21.80 years, in this study. The initial Glasgow Coma Scale score was 6.35 +/- 1.38. Seventy-three patients received operations with intracranial pressure monitoring. Blood transfusion was surgery related (days 1 and 2); otherwise, it was rarely used (P<.05). Prolonged prothrombin time was shown only 7 (2.65%) times of 234 of blood sampling. There was no anaphylactic reaction, pulmonary complications, or renal function deterioration in the course of our observation. The chart review of the patients at 6 months revealed the following: favorable outcome, 55.1%; unfavorable outcome, 33.3%; and mortality, 11.6%. The 10% HES (200/0.5) can be used in the treatment protocol of severe head injury. There is no definite bleeding complications documented by current dosage of HES. Besides, balanced fluid management can be achieved without causing serious pulmonary complications. However, a further randomized, prospective study is needed to define the actual benefit of HES in fluid management and clinical outcome.
Modern cranial base approaches to the clivus and foramen magnum may threaten the stability of the cranio-cervical junction. This necessitates stabilization and fusion in some cases. We studied occipitocervical fusion after extreme lateral transcondylar approaches. Twenty-seven patients underwent an extreme lateral transcondylar approach over a 2-year period. Two patients were excluded because of prior occipitocervical fusion. The pathological diagnosis was meningioma in ten patients, chordoma in six patients, neurofibroma in two, and 10 patients had other tumoral and nontumoral pathologies. Eight patients required occipitocervical fusion and stabilization. Five of six patients with chordomas required fusion, whereas no patient with a meningioma underwent fusion. All the patients who were fused had more than 70% resection of their occipital condyle. No patient with resection of less than 70% of the occipital condyle required fusion. Significant interference of the surgical construct with follow-up imaging was seen only in the patient in whom a stainless steel Steinman pin was used. One third of patients will require fusion after extreme lateral transcondylar approaches. Most patients with less than 70% resection of the condyle remain stable without need for surgical intervention, whereas complete resection necessitates fusion in most cases.
In order to examine the functional changes in the vascular smooth muscle, the effects of a thromboxane A2 synthetase inhibitor (OKY-046) and a calcium channel blocker (diltiazem) on vessels following subarachnoid hemorrhage, and the contractile activity of cerebral vessels with various vasoactive agents, were investigated by studying isometric tension recordings in rings of cat basilar artery. The maximum contractile activities of the vessels in response to noradrenalin and adrenaline during the course of subarachnoid hemorrhage were significantly less than those in the control group. On the other hand, the maximum contractile activity of the vessels in response to prostaglandin F2 alpha on the seventh day following subarachnoid hemorrhage was significantly augmented compared with that in the control group. A significant decline in the relaxation of responsiveness to diltiazem during the course of subarachnoid hemorrhage was observed compared with that of diltiazem in the control group. This responsiveness to vasoactive agents was not influenced by the application of OKY-046. The present study reveals functional changes in vascular smooth muscle exposed to subarachnoid hemorrhage in response to vasoactive agents and a calcium entry blocker. Thromboxane A2 may not be a significantly influential factor in the present results. It is suggested that cerebral vasospasm may well be related to functional changes of the arterial wall, which appear to be associated with derangement of the mechanisms of smooth muscle constriction and dilatation based on organic changes.
Clinical analysis of postoperative complications was made in 1,000 cases of intracranial saccular aneurysm. Psychological symptoms, motor disturbances, and aphasia were observed in 107 cases (11.5%), 74 cases (7.1%) and 20 cases (2.1%), respectively, in 939 discharged cases. Water and electrolyte disturbances and gastro-intestinal bleeding were found in 60 cases (6.0%) and 19 cases (1.9%), respectively, in 1,000 surgically treated patients including those that died during hospitalization. Psychological symptoms were most apt to develop in cases of vertebrobasilar artery aneurysm, multiple aneurysms and anterior communicating aneurysm. It appeared that the poorer the preoperative grade, the higher the incidence of psychological symptoms. These developed most frequently in patients operated on the third to seventh days after the subarachnoid hemorrhage. The postoperative psychological symptoms improved in 63% of 107 cases. The occurrence rates of other complications were also studied.
A case of disseminated intravascular coagulation is reported. This was thought to be a complication of chemotherapy with 1,3-bis(2-chlorethyl)-nitrosourea for a malignant astrocytoma of the brain. This is the first report of this condition due to this chemotherapeutic agent.
In a clinical trial, 10 patients with malignant gliomas underwent partial resection of their tumors and were treated by intraarterial 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) chemotherapy. The drug was given at least 1 month after the completion of postoperative radiotherapy in total doses of 270-280 mg/m2 in two sessions separated by a 48-hour interval (the two sessions with interval were equal to one course). This therapy was repeated every 8-10 weeks. Four patients had three courses and the other six patients had two courses of chemotherapy. This therapy was the only antitumor chemotherapy for this group of patients. Our preliminary results demonstrate the safety of this new procedure and suggest that intraarterial BCNU chemotherapy may be more effective, and has a better tolerance and less toxicity, than intravenous BCNU chemotherapy. Furthermore, it was demonstrated that, in the case of one patient, higher antitumor activity resulted from intraarterial BCNU chemotherapy as compared to intravenous BCNU therapy.
Primary palmar hyperhidrosis (PH) is very common, and can be disabling. Various surgical methods for endoscopic sympathectomy have been advocated. We present a simple and effective method of treating PH by means of transthoracic endoscopic sympathectomy (TES). From July 1994 to May 1998, a total of 1,360 patients with hyperhidrosis palmaris underwent TES. There were 544 males and 816 females with a mean age of 23.1 years old (range, 5 to 60 years). All patients were placed in a half-sitting position under single-lumen intubational anesthesia. We performed the ablation of the T2 ganglion using either a 6- or 8-mm, 0-degree thoracoscope (Karl Storz Company, Germany) In these 1,360 patients, 2,715 sympathectomies were performed. TES was usually accomplished within 15 min. Surgical complications were minimal: six cases of pneumothorax (0.44%), four cases of segmental collapse of lung (0.29%), and two wound infections (0.15%). There was no surgical mortality. The mean postoperative follow-up period was 27.8 months. A total of 1,292 patients (95%) had highly satisfactory results, although 1,140 patients (84%) have developed compensatory sweating of the trunk and lower limbs. The affected area was the axillae, back, abdomen, lower limbs (16%, 82%, 52%, and 78%, respectively). The recurrence rates of PH were 0.4% in the first year, 0.6% in the second year, and 1.1% in the third year. TES is a simple, safe, and effective method of treating PH.
Considering that the 1.32-microns Nd-YAG laser should have physicothermal properties close to those of the CO2 laser, a series of experiments were conducted on rat cortex (N = 51). Three laser wavelengths were compared: CO2 laser (10.6 microns), 1.06-microns Nd-YAG, and 1.32-microns Nd-YAG lasers. For each shot, temperature measurements were recorded with an infrared thermographic videocamera. The digitized signals were figured as thermal profiles and temperature developments. Ninety-five shots were correctly studied and analyzed: CO2, N = 29; 1.06-microns Nd-YAG, N = 20; 1.32-microns Nd-YAG, N = 46. The histological lesions produced by these three lasers were compared on animals killed 24 hours (N = 20), 8 days (N = 20), and 30 days (N = 5) after the laser impacts. For equivalent densities of energy, the depth of cortical necrosis was comparable for the CO2 laser (200-250 microns) and the 1.32-microns Nd-YAG laser (210-260 microns) whatever the date of death; the 1.06-microns Nd-YAG laser shots were responsible for much more important damage (400-550 microns). Because of its important absorption in water and nervous tissue, the authors consider the 1.32-microns Nd-YAG laser most suitable for neurosurgery, particularly because it is conducted through optic fibers, and therefore is easy to handle during neurosurgical procedures.
Poor results after lumbar spinal surgery have been recorded in compensation cases throughout the world medical literature. It seems that psychosocial factors play an important role in the delay in returning to gainful employment but that chronic postoperative lumbar and lower extremity pain is blamed for this state of affairs. The present series of late outcomes is based on actual physical examination by independent neurosurgical and orthopedic experts appointed by the Workman's Compensation Board, providing an impartial opinion as to the discrepancy between objective findings and failure to reintegrate into the work force. One thousand workmen's compensation patients who had undergone lumbar spinal surgery were divided into two groups, one of 600 patients with single operations, evaluated on average 51 months after surgery, and the second of 400 with multiple operations, evaluated on average 38 months postoperatively. Seventy-one percent of the single operation group had not returned to work more than 4 years after the operation, and 95% of the multiple operations group. In none of these cases was there a neurological deficit that precluded gainful employment, the failure to return to work being blamed on chronic postoperative pain. Although motivational (that is, psychosocial) factors undoubtedly play a role in failure to return to work, the role of chronic pain cannot be ignored. Increased attention must be devoted to ascertaining the etiology of this pain and ways to prevent it.
Wide experience over a 20-year period with 1000 interventions for radiculomyelopathy caused by cervical arthrosis is reported. The results are analyzed according to clinical signs, surgical methods, timing of operation, influence of pathogenic phenomena, age, and preexisting illness. Intra- and postoperative problems and accidents are covered.
One thousand consecutive head injuries were evaluated in a 14-month period. Computerized tomography (CT) was performed in 316 patients and 200 (63%) were scanned within 72 hours of injury. Fifty-one percent of patients had abnormal scans. The yield of abnormal scans varied with the neurological state at the time of the scan: alert and normal neurologically, 13%; alert and focal deficit, 50%; impaired consciousness and no lateralizing findings, 35%; impaired consciousness and lateralizing findings, 85%; deep coma or posturing, 56%. Thirty-eight percent of patients had multiple lesions. Repeat scans were done in 103 patients, 52% developed new lesions or deterioration in known lesions, and 31% required subsequent surgery. Ten patients developed delayed onset subdural hygromas noted six to 46 days after injury. Two of eight operated patients improved markedly. The CT scan appearance of subdural lesions may be independent of the time from injury depending upon initial composition and rebleeding episodes. Thus, subdural lesions should not be labeled "acute," "subacute," or "chronic" on the basis of CT morphology alone. Seven patients had subdural lesions with the same density as brain (isodense). Arteriography aided diagnosis in six patients. The CT scan readily shows what proportion of a parenchymal lesion is intracerebral hematoma, contusion, or edema, rather than nonspecific arteriographic mass effect, and allows precise surgical decisions. Eighteen of 40 patients (45%) with "brain stem contusion" harbored surgical lesions, including five cases of delayed subdural hygroma.
Intraspinal meningiomas are less frequent in occurrence as compared with their intracranial counterparts. Typical presentation is onset of new spinal pain followed by other deficits in the sixth decade of life. Although total surgical removal is the optimum treatment, various tumor- and patient-related factors can determine the aggressiveness of the surgical endeavor. We present our experience of diagnosis and management of cervical intraspinal meningioma in the oldest reported patient (101 years) with an atypical clinical presentation and remarkable dissociation between clinical and radiologic findings. The patient, a 101-year-old woman, experienced progressive weakness in her legs. Motor examination revealed no definite weakness. There was stocking type sensory loss to just below the knees bilaterally. The MRI of the cervical spine showed an enhancing mass anterolateral to the cord at the region C7 through T1. It markedly compressed the cord. The tumor was removed in total, and the dural attachment was thoroughly coagulated. The presented experience supports the belief that, in spinal meningiomas, a good clinical outcome can be expected even in patients who may be less than perfect candidates for an aggressive surgical approach.
The authors highlight the neurosurgical contributions of an Arabic surgeon by the name of Abul-Qasim Al-Zahrawi, known in Western literature as Abulcasis. This man lived during the Middle Ages from 936 to 1013 AD and wrote a 30-volume treatise on medicine. A significant part of his work on surgery consists of early descriptions of neurosurgical diagnosis and treatment, including the surgical treatment of head injuries and skull fractures, spinal injuries and dislocations, hydrocephalus and subdural effusions, headache, and many other medical afflictions. He described neurosurgical instruments such as cranial drills that avoided puncture of the dura mater. Abulcasis is known for his concepts of pain as a symptom and his emphasis on anatomy of the skull and brain in relation to the neurosurgical operations of that period. Because his works were translated from Arabic to Latin, Hebrew, and Turkish with only recent or limited translation into the modern occidental languages, the historic role played by this man has been largely unknown by neurosurgeons who are not fluent in these languages.
Outcomes for elderly patients undergoing craniotomy for evacuation of subdural hematoma (SDH) have been reported to be poor with high mortality rates. We present the case of a patient who underwent craniotomies at the age of 102 years, and again at the age of 103 years, for acute SDHs with good recovery to her premorbid neurologic condition. A 102-year-old woman presented after falling to the floor, and underwent a left-sided craniotomy for evacuation of a large, left hemispheric acute SDH. She recovered from that event and returned home. Six months later, she presented after falling again and was found to have a large, right hemispheric acute SDH. A right-sided craniotomy was performed and again she made good recovery with return to her neurologic baseline. We report this unique case of good recovery after 2 separate craniotomies for acute SDH in a patient older than 100 years. Implications of acute SDH in the elderly are discussed, as relevant to this case, with a review of the literature. Although the morbidity and mortality of acute SDH are high, particularly in elderly patients, there is potential for good recovery and excellent outcome in appropriately selected patients.
Peri-orbital puncture wounds by sharp wooden objects are not rare, but can be dangerous when there is intracranial penetration by and retention of the wooden foreign body. Days to years after an apparently trivial initial wounding, serious intracranial complications can occur. The authors have reviewed 42 case reports from the literature. Morbidity-defined as permanent neurologic sequelae-occurred in 74% of the cases. Intracranial suppuration was the major complication, with brain abscess having occurred in nearly one-half of the cases. Mortality occurred in 25% of 28 cases occurring in the post-antibiotic era. The qualities of wood which make it especially hazardous as a wounding agent and foreign body are discussed. The role of orbital anatomy in affording easy access to the cranial contents is described. Surgical exploration in all those cases in which there is a reasonable suspicion of intracranial injury is recommended.
The common occurrence of chronic subdural hematoma (CSDH) in older patients raises some diagnostic and therapeutic difficulties. Despite general agreement about the indication of operation, the extent of surgery is still discussed controversially. We have, therefore, reviewed operative findings and outcome in 104 patients with CSDH. Retrospective analysis was performed by differentiating age < or = 60 years (n = 28) versus age > 60 years (n = 76) and burr hole craniostomy with a size range from 12-30 mm (n = 94) versus larger craniotomy (n = 10). All patients received closed-system drainage of the subdural space for 2-4 days. Four patients older than 60 years died within 30 days after surgery, two in each operative group. Excluding these postoperative deaths, 17 out of 92 patients (18.5%) after burr hole trepanation and one out of eight patients (12.5%) after craniotomy required reoperation due to rebleeding (n = 6), residual subdural fluid (n = 4), and residual thick hematoma membranes (n = 8). Eight patients, who had been initially treated by burr hole craniostomy despite preoperative detection of neomembranes by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), recovered without further intervention. Clinical outcome was good in both operative groups. The percentage of patients without or with only mild neurologic deficits at the time of discharge from the hospital was 72.3% in the burr hole and 70.0% in the craniotomy group, respectively. The clinical data of the present study suggest that burr hole craniostomy with closed-system drainage should be the method of choice for the initial treatment of CSDH, even in cases with preoperative detection of neomembranes. Craniotomy should be carried out only in patients with reaccumulating hematoma or residual hematoma membranes, which prevent reexpansion of the brain.
Colloid cyst of the third ventricle is a relatively rare intracranial tumor. It generates tremendous interest for the neurosurgeon because of its benign nature, deep location, and an excellent prognosis when diagnosed early and excised. A retrospective analysis of 105 cases of third ventricle colloid cyst treated between 1967 to 1998 was conducted. The clinical presentation, radiological findings, different surgical approaches, and outcome were analyzed. The transcallosal and transcortical-transventricular approaches were predominantly used. Memory and psychological assessment were carried out both pre- and postoperatively. A computerized tomography (CT) scan was performed during follow-up. The male to female ratio was 1.5:1. The age of the patients ranged from 10 to 68 years. Headache was the most common symptom. Papilledema and short-term memory disturbances were the most common signs. In 5 patients the colloid cyst was detected incidentally. Surgery for colloid cyst was performed in 93 patients. Transcallosal and transcortical-transventricular approaches were performed in 62 and 30 patients, respectively. In 1 patient the cyst was excised through the subfrontal lamina terminalis approach. Total excision was achieved in 90 patients, while partial cyst excision was done in three patients. Moderate to severe lateral ventricular enlargement was found in 76 patients at presentation. A ventriculoperitoneal shunt was the only surgical procedure performed in 7 patients. In 16 patients colloid cyst excision was conducted after cerebrospinal fluid (CSF) diversion via a shunt. No surgical treatment of any kind was performed in 5 patients. Five patients died. Eighty-six patients came for follow-up, with a range from 1 month to 25 years (average 3 years and 8 months). Postoperatively, transient recent memory deficits occurred in 14 patients, while a permanent recent memory loss was noted in 2 patients. There was no incidence of postoperative disconnection syndrome or behavioral disturbance. A CT scan was performed in 44 patients during follow-up. Recurrence was detected in 1 patient in whom the cyst had been partially excised. Colloid cyst, although a benign tumor, is surgically challenging because of its deep midline location. Early detection and total excision of the colloid cyst carries an excellent prognosis.
Delay in the diagnosis of meningiomas of the tuberculum sellae and planum sphenoidale is detrimental to the patient in terms of visual recovery, morbidity and mortality. Early accurate diagnosis of these tumors is possible through the use of computed tomography which is recommended for all patients with unexplained impairment of vision. In this article 105 cases of meningiomas of the planum sphenoidale and tuberculum sellae are reviewed. In only five cases was the diagnosis made within three months of the onset of the symptoms.
We surveyed computed tomographic findings after 1074 intracranial operations to determine the incidence and etiology of postoperative intracerebral hemorrhages. Medium or large hemorrhages occurred after 42 operations (3.9%). Larger hemorrhages, hemorrhages in the suprasellar region, and hemorrhages associated with other types often preceded a poor outcome. Major etiologies underlying postoperative intracerebral hemorrhages were uncontrolled bleeding from a blind area, difficult dissection of a tumor from the brain, retraction injury, vessel injury from a needle, bleeding from a residual tumor, local hemodynamic changes after removal of a tumor, premature rupture of an aneurysm, and hypertensive putaminal hemorrhage. Hypertension during recovery from anesthesia was another important factor.
The clinical response to ETV of adult patients with noncommunicating hydrocephalus may differ from that of children because of such factors as chronicity of hydrocephalus, physiologic differences in CSF dynamics, and changes in brain viscoelastic properties. We sought to determine which factors might predict clinical success and failure. A retrospective single-surgeon case series analysis was performed. This was a consecutive case series for which the goal of the ETV procedures was shunt independence. One hundred ten ETV procedures were performed in 108 adult patients (mean, 48 years; range, 17-88 years). There were 52 cases of idiopathic aqueductal stenosis, 47 cases of mass lesions causing noncommunicating hydrocephalus, plus 9 other miscellaneous obstructive etiologies. Long-term shunt independence was achieved in 77% of patients. Two additional patients, who initially failed, later achieved success after reoperation and remained shunt free for the duration of their follow-up. Therefore, after reoperation, shunt independence was achieved in 79% of patients. Of the patients who ultimately failed, 11 failed within 1 month. Therefore, 52% who ultimately failed had more than 1 month of shunt-free existence (mean, 10 months). There were 6 surgical complications, including 2 deaths related to intracranial hemorrhage from brain tumors (not directly related to ETV per se), and 10 medical complications. The median hospital length-of-stay was 3 days. The median follow-up was 8 months (range, 0-95 months). Endoscopic third ventriculostomy is an effective treatment option for adult patients with noncommunicating hydrocephalus. Although most procedures resulted in long-term shunt independence, more than half of the eventual failures were delayed, and therefore, appropriate follow-up is required.
The angioarchitectures of traumatic indirect CCFs and the effectiveness and safety of transarterial liquid adhesive embolization for these fistulas remain to be evaluated. A total of 276 consecutive patients with traumatic craniofacial arteriovenous fistula were referred for embolization in the past 15 years. Eleven had traumatic indirect CCFs and were managed with transarterial liquid adhesive embolization. This group was composed of 8 men and 3 women ranging from 15 to 46 years of age. The most frequently observed symptoms were neuro-ophthalmic, followed by bruit and headache. All lesions were single fistula and fed exclusively by meningeal artery. The accessory meningeal artery was involved most often (n = 7), followed by the middle meningeal artery (n = 4). Venous drains were the ophthalmic vein (n = 11) and/or inferior petrous sinus (n = 8). No cortical vein drainage was observed. Liquid adhesives (60%) were used to obliterate all fistulas; 2 patients were also treated with detachable coils. All fistulas were totally occluded with resolutive fistula-related symptoms. Asymptomatic migration of liquid adhesives into the nearby arterial branch was observed in 1 patient. One patient had partial ocular choroidal infarction. No recurrent or residual fistula was found upon clinical follow-up. Angioarchitecture and treatment of traumatic indirect CCFs differed from the spontaneous type of fistulas. By transarterial liquid adhesive embolization, treatment of all fistulas was safe, with effective occlusion and associated low peri-procedural risk. This procedure may be considered as the primary treatment for these traumatic fistulas.
Interleukin (IL) 11 is a multipotential cytokine with anti-inflammatory and fibrogenic properties. It is released into the peripheral blood from damaged brain tissue. The objective of this study was to determine plasma and cerebral spinal fluid (CSF) levels of IL-11 in patients with spontaneous intracerebral hemorrhage (ICH) and to correlate IL-11 with survival, related edema of the brain, volume of hematoma, and hydrocephalus. Forty-three patients with spontaneous ICH were included. Twenty-three were male, and 20 were female. The mean age of the patients was 64.3 years. Plasma and CSF samples were collected on the first, second, third, and fourth days after spontaneous ICH onset. The levels of IL-11 in CSF (123.9 +/- 107 pg/mL) were 5 times higher than those in plasma (25.5 +/- 18.0 pg/mL) on the first day (P = .001 by paired t test) in our spontaneous ICH patients, and this significant difference persisted up to the third day of ICH. Plasma IL-11 levels in the nonsurvival group (41.2 +/- 18.9 pg/mL) were significantly higher than those in the survival group (22.2 +/- 15.2 pg/mL) on the second day of ICH onset (P = .024 by Mann-Whitney U test), and the significant difference extended to the fourth day. Plasma IL-11 levels of the hydrocephalus group were higher than those of the nonhydrocephalus group in the first 4 days of ICH, but the difference was not statistically significant. IL-11 was highly associated with mortality caused by spontaneous ICH and correlated with the hydrocephalus occurring after ICH onset. It is our belief that IL-11 can be a useful clinical marker for spontaneous ICH patients.
Approximately 5% to 10% of intracranial germinomas arise from the basal ganglia or thalamus. Diagnosis is usually made by stereotactic biopsy, and precise location of the biopsy target is crucial because germinoma in these sites is potentially curable. We herein describe a case with germinoma in the basal ganglia that showed nonspecific clinical and radiological findings. The usefulness of MET-PET in locating an optimal biopsy target and monitoring treatment efficacy in this case is presented. A 9-year-old boy presented with a 4-month history of dystonia in his left upper extremity. Magnetic resonance imaging of the brain showed abnormal signal intensity in the right basal ganglia, internal capsule, and corona radiata without mass formation and enhancement effect. He had been treated as having multiple sclerosis without improvements on clinical and radiological findings. The MET-PET study showed increased tracer uptake in the areas of abnormal signal intensity on the MR images, and the MRI-PET co-registered images exhibited the highest tracer uptake in the anterior limb of the internal capsule. A stereotactic biopsy targeting the highest tracer uptake lesion was performed with histologic verification of germinoma. He was intensively treated with combined chemotherapy and radiotherapy according to the MR images and MET-PET findings. After the treatment, the area of abnormal signal intensity significantly reduced in size on the follow-up MRI and lesional tracer uptake was also decreased on MET-PET images. The MET-PET study is very useful for locating a precise biopsy target and provides useful information in monitoring treatment efficacy in the basal ganglia germinoma that showed nonspecific radiological findings.
The treatment of intracranial NGMGCTs is generally based on chemotherapy and radiotherapy. To avoid the potential of tumor recurrence, we normally have the residual mass lesion removed after adjuvant therapy. However, since 1988 we have treated 15 patients with NGMGCT and pathologically evaluated 12 such patients after adjuvant therapy by a new method we have developed and found viable tumor cells in 4 (33%) of 12 patients. Based on our experience, therefore, we feel we have been able to develop a reliable diagnostic tool for confirming the presence or absence of viable tumor cells in residual mass after adjuvant therapy for patients with NGMGCT. We describe here 2 patients with NGMGCTs who underwent MET-PET. Patient 1 was an 11-year-old boy with immature teratoma. On gadolinium (Gd)-enhanced magnetic resonance imaging (MRI), a high-intensity area was found in his right cerebellar hemisphere and a high uptake in MET-PET was confirmed in the same region. We judged it as the recurrence of the tumor. Finally, he died and was autopsied. Patient 2 was a 16-year-old girl with an NGMGCT who received combined chemo- and radiotherapy that led to a reduction in the volume of the tumor. Her serum beta-HCG and HCG levels also returned to the reference range. However, the mass did not disappear and another MRI scan disclosed a residual Gd-enhanced lesion. To assess whether there were residual viable tumor cells, MET-PET was performed, and it demonstrated no hyper-uptake region in the residual mass. We, therefore, did not surgically remove the mass and kept the patient under observation. There has not been any tumor recurrence in this patient for more than 2 years. In these 2 cases, the increased MET uptake was more specific of tumor tissue and more accurate than MR Gd enhancement. MET-PET may be a useful diagnostic tool for predicting viable tumor cells after adjuvant therapy in patients with NGMGCT, thus allowing further surgical intervention.
Lhermitte-Duclos disease is a cerebellar lesion, characterized by an overgrowth of cerebellar ganglion cells, which replace granular cells and Purkinje cells. Lhermitte-Duclos disease may be a manifestation of Cowden syndrome (multiple hamartoma-neoplasia syndrome). The nature of LDD, whether neoplastic, dysplastic, or hamartomatous, is still not exactly understood. Metabolic imaging of the amino acid metabolism using PET could be useful for noninvasive characterization of these lesions. To define the Meth-PET imaging characteristics of these lesions, we undertook a Meth-PET study in 4 patients with LDD after obtaining informed consent. All 4 patients had clinical signs of Cowden syndrome. In 2, the diagnosis was made with MRI; in 2, it was confirmed histologically. Using Meth-PET, the cerebellar lesions had a high methionine uptake, except in the subtotally resected lesion. The uptake of the lesions was markedly higher than that of the contralateral normal regions. The mean L/C ratio was 2.07. 11C-methionine positron emission tomography visualizes the lesion of Lhermitte-Duclos disease as a high uptake area. This amino acid hypermetabolism may be related to the slow growth of the lesions, and is an argument to suggest that patients with LDD should be followed up carefully to detect progression of the cerebellar lesion.
Earlier studies suggested that the use of high-dose IV MP was the gold standard of care for the treatment of ASCI, but this has been debated. This study aims to identify the effects of high-dose MP in treatment of cervical SCI and how the treatment might be improved. The medical records of 138 patients with cervical spinal injury secondary to blunt injuries were retrospectively reviewed to determine the steroid administration protocol, effects, and complications. The findings on admission were compared with those at discharge and at the most recent outpatient follow-up visit. Significant neurologic improvement was defined as increase in at least 1 clinical grade according to the Frankel classification system. Significantly more motor and sensory recovery was noted (complete ASCI, 69% vs 0; incomplete ASCI, 70% vs 50%) in patients treated with surgery and MP than in patients without such treatment. Moreover, 87% (14/16) of patients with complete ASCI (unlike patients with incomplete [8/28, 28.6%] and mild [2/14, 14.3%] ASCI) treated with MP had steroid-related complications, and 1 patient died from sepsis related to a perforated peptic ulcer. Mean hospitalization was significantly shorter for the patients who underwent tracheostomy (49 days, ranged from 22 to 110 days) vs nontracheostomy(94 days, ranged from 28-268 days). Early intervention with surgery and MP is critical. Although treatment with MP for 24 or 48 hours significantly improves motor and sensory function of patients with ASCI, harmful side effects limit its functional efficacy in patients with complete ASCI. Early tracheostomy can shorten hospital stay in patients with complete ASCI.
Although there has been great development in the anatomical understanding and operative techniques for skull base tumors, controversy still exists regarding the optimal surgical strategies for the FMMs. We report clinical and radiologic features as well as the surgical findings and outcome for patients with FMM treated at our institution over the last 15 years. We reviewed 114 consecutive cases of FMM operated between May 1993 and June 2008 in the neurosurgery department at Beijing Tiantan Hospital. There were 68 female and 46 male patients (mean age, 52.3 years; range, 28-76 years). Foramen magnum meningiomas were classified as anterior (80 cases), anterolateral (24 cases), and posterolateral (10 cases). Mean duration of symptoms was 11.7 months (ranging from 1.5 to 240 months). Cervico-occipital pain (80.7%) and headache and dizziness (42.1%) were the most common presenting symptoms. The preoperative KPS was 72.5 +/- 8.3. Mean maximum diameter of the tumors on MRI was 3.35 cm (range, 1.5-4.7 cm). Posterior midline approach was performed in 10 cases, far-lateral retrocondylar approach in 97 cases, and extended far-lateral approach in 7 cases. Gross total resection was achieved in 86.0% of patients and subtotal resection in 14.0%. Surgical mortality was 1.8%. Follow-up data were available for 93 patients, with a mean follow-up of 90.3 months (range, 1-180 months), of which 59 (63.4%) lived a normal life (KPS, 80-100). Our experience suggests that most anterior and anterolateral FMMs can be completely resected by a far-lateral retrocondylar approach without resection of the occipital condyle. Complete resection of the tumor should be attempted at the first operation. Postoperative management of FMM is important for the prognosis.
The aim of the study is to analyze the nature, extensions, and dural relationships of hormonally inactive giant pituitary tumors. The relevance of the anatomic relationships to surgery is analyzed. There were 118 cases of hormonally inactive pituitary tumors analyzed with the maximum dimension of more than 4 cm. These cases were surgically treated in our neurosurgical department from 1995 to 2002. Depending on the anatomic extensions and the nature of their meningeal coverings, these tumors were divided into 4 grades. The grades reflected an increasing order of invasiveness of adjacent dural and arachnoidal compartments. The strategy and outcome of surgery and radiotherapy was analyzed for these 4 groups. Average duration of follow-up was 31 months. There were 54 giant pituitary tumors, which remained within the confines of sellar dura and under the diaphragma sellae and did not enter into the compartment of cavernous sinus (Grade I). Transgression of the medial wall and invasion into the compartment of the cavernous sinus (Grade II) was seen in 38 cases. Elevation of the dura of the superior wall of the cavernous sinus and extension of this elevation into various compartments of brain (Grade III) was observed in 24 cases. Supradiaphragmatic-subarachnoid extension (Grade IV) was seen in 2 patients. The majority of patients were treated by transsphenoidal route. Giant pituitary tumors usually have a meningeal cover and extend into well-defined anatomic pathways. Radical surgery by a transsphenoidal route is indicated and possible in Grade I-III pituitary tumors. Such a strategy offers a reasonable opportunity for recovery in vision and a satisfactory postoperative and long-term outcome. Biopsy of the tumor followed by radiotherapy could be suitable for Grade IV pituitary tumors.
Lesions of the pineal region are histopathologically heterogeneous but often accompanied with severe progression of clinical signs. Surgical treatment remains challenging because of the close vicinity of the deep venous system and the mesencephalo-diencephalic structures in this region. We present the surgical approaches and techniques in a consecutive series of 119 patients treated by the senior author (J.H.) between 1980 and 2007 at 2 different neurosurgical university centers in Kuopio and Helsinki, Finland. Of the included patients, 107 (90%) presented with pineal region tumors and 12 (10%) with vascular malformations. The ITSC route was used for removal of the lesion in 111 (93%) patients and the OIH approach in 8 (7%) patients. All except one patient were operated on in a sitting position. We reviewed all clinical data and radiographic images and analyzed all surgical videos. The pineal lesions were removed completely in most cases (88%). There was no surgical mortality. Twenty-two (18%) of the patients had complications in the postoperative period; these included 1 epidural hematoma, 9 transient Parinaud syndrome, 2 meningitis, 3 wound infections, 2 transient memory disturbances, 2 mild hemiparesis, 1 CSF fistula, and 2 cranial nerves palsies (IV and VI). During a 3.5-year follow-up, 12 patients with malignant lesions died; all patients with benign tumors survived. The ITSC route is a safe and effective surgical approach, associated with low morbidity, complete lesion removal, and definitive histopathologic diagnosis. Considering risk vs benefit, we therefore believe that the surgical treatment can be offered in most cases as the first treatment option for pineal tumors.
The authors report a series of 120 cerebellar medulloblastomas. All patients were operated on between 1953 and 1982. Among them, 88 completed the treatment with radiotherapy, and 32 had additional chemotherapy. The operative mortality was 22.5%. The 5-year survival rate was 30% in the whole series. Recurrences occurred in 35 patients, associated with supratentorial or spinal metastasis in 60% of cases.
Eleven patients with occlusive cerebrovascular diseases were imaged with N-isopropyl-p-I-123 iodoamphetamine. Preoperative and postoperative single-photon emission computed tomography was performed in 10 patients undergoing extracranial-to-intracranial bypass procedures. New images were reconstructed from the two images obtained on the different days by superimposition and division in each pixel to get the ratio of cerebral perfusion change. All patients with bypass procedures had an increase in cerebral blood flow in the affected areas, and nine of 10 had an increase in cerebral blood flow in the contralateral cortex. There was no increase in cerebral blood flow in one case with no operation. Neither our procedure nor the results in this small series prove that recovery of function is due to an increase in blood flow, but we believe this is the case.
We quantified the rCBF and regional vascular reserve (CVR) in adult patients with moyamoya disease before and after surgery using IMP I 123 SPECT. The patient population included 5 adult patients with ages at presentation ranging between 23 and 42 years. One patient had stroke, whereas 4 patients had transient ischemic attacks. Before surgery, the mean resting rCBF and mean CVR in the frontal, parietal, and temporal lobes of the surgically treated hemisphere were 40.09, 39.50, and 36.9 mL/100 g per minute and 15.39%, 27.09%, and 28.92%, respectively. After surgery, the rCBF increased significantly (P = .0002, .0005, and .0062), but in a CVR evaluation, only the frontal lobe increased significantly (P = .0055). In the unaffected hemispheres, the mean resting rCBF significantly increased only in the frontal lobe (P = 038) and no significant increase in the CVR was observed after surgery. In 2 patients who showed steal phenomenon induced by acetazolamide administration, CVR significantly increased not only in the frontal lobe but also in the parietal and temporal lobe after surgery, although the CVR in these areas significantly decreased both before and after surgery in comparison to the mean CVR in all patients. The frontal lobe showed severe hemodynamic ischemia. The cerebral hemodynamics in patients with moyamoya disease improved after surgical intervention, especially in severely damaged patients. Split-dose (123)I-IMP SPECT was therefore found to be a useful diagnostic modality for quantifying the hemodynamics of moyamoya disease.
Central benzodiazepine (BZD) receptor imaging is effective to evaluate neuron density in the pathological brain cortex. This study used BZD receptor imaging to evaluate neuronal damage in adult ischemic moyamoya disease. Single photon emission computed tomography and a novel tracer, 123I-iomazenil, were used to measure BZD receptor density in the brain. Evaluation of early and late images was performed in three asymptomatic, unoperated patients, and six mildly symptomatic, operated patients. Uptakes in the frontal, parietal, and occipital lobes of symptomatic patients were significantly lower (p<0.05) than those of asymptomatic patients. The late image/ early image count ratios (L/E ratios) of asymptomatic patients were relatively constant (mean, 0.571; range, 0.550-0.581) in all regions of interest. In contrast, the L/E ratios of symptomatic patients were not uniform. The neuron density was preserved in adult asymptomatic patients despite harboring moyamoya disease. In contrast, the neuronal density was decreased in symptomatic patients even though their symptoms were mild and they had undergone revascularization.
During the past decade there has been increasing use of omental transposition to the brain of patients who experienced neurologic sequelae after a cerebral infarction. This paper reports the long-term neurologic effects seen in a patient who underwent omental transposition 31 months after a stroke. Her postoperative follow-up period has been 13 years. The patient had an expressive aphasia, a right hemiparesis and the inability to read which occurred immediately after her stroke. After surgery she demonstrated subjective and objective improvement in her speech and mobility. She also regained her ability to read shortly after surgery. The patient demonstrated that omental transposition to the brain can improve neurologic function in the presence of a long-standing cerebral infarction and that the clinical improvement can be maintained over an extended period.
A 40-year-old man presented with cavernous sinus syndrome due to a giant aneurysm in the cavernous sinus. After a course of 13 years, he died of a subarachnoid hemorrhage (SAH). The finding in this case suggest that radical operation should be considered for nonruptured giant cavernous sinus aneurysms, depending on the location and development of the lesion.
Top-cited authors
James I Ausman
  • University of California, Los Angeles
Juha Hernesniemi
  • University of Helsinki
Tetsuji Inagawa
  • Araki Neurosurgical Hospita
Fady T Charbel
  • University of Illinois at Chicago
Manuel Dujovny
  • Wayne State University