PURPOSE To evaluate stable xenon-enhanced CT cerebral blood flow with balloon test occlusion as a predictor of stroke risk in internal carotid artery sacrifice. METHODS Abrupt internal carotid artery occlusion was performed by surgical or endovascular means below the origin of the ophthalmic artery in 31 normotensive patients who were assessed preoperatively by a 15-minute clinical balloon test occlusion followed by an internal carotid artery-occluded xenon CT cerebral blood flow study. RESULTS One patient, who passed the clinical test occlusion but exhibited regions of cerebral blood flow less than 30 mL/100 g per minute on the occlusion xenon CT cerebral blood flow study went on to have a fatal stroke corresponding exactly to the region of reduced blood flow. Thirty patients passed both components of the preoperative stroke-risk assessment. Neuroimaging demonstrated possible flow-related infarctions, which subsequently developed in three patients. Two patients were asymptomatic, and one patient was left with a mild residual hemiparesis. CONCLUSIONS Our protocol provided a statistically significant reduction in subsequent infarction rate and infarction-related death rate when compared with a control group of normotensive abrupt internal carotid artery occlusion patients who did not undergo any preoperative stroke-risk assessment (reported in the literature). The estimated false-negative rate for our preoperative assessment protocol ranged from 3.3% to 10% depending on the assessment of the cause of the three potentially flow-related infarctions. Although life-threatening major vascular territory infarctions have been avoided, our protocol is less sensitive to changes predicting smaller, often minimally symptomatic, vascular border zone infarctions and does not predict postoperative thromboembolic strokes.

http://www.ajnr.org/content/ajnr/15/5/829.full.pdf

Stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced CT.

• Objective. —A retrospective study was performed to delineate the clinical characteristics of symptomatic unruptured aneurysms. Design. —Patient histories, operative reports, and angiograms in 111 patients with 132 unruptured aneurysms were reviewed. Setting. —Tertiary care university hospital. Patients. —One hundred eleven patients with 132 unruptured intracranial aneurysms were studied. There were 85 women and 26 men, with a mean age of 51.2 years (age range, 11 to 77 years). Many patients were referred by community neurologists and neurosurgeons for further evaluation and neurosurgical management. Results. —Fifty-four symptomatic patients were identified. Group 1 (n=19; mean aneurysm diameter, 2.1 cm) had acute symptoms: ischemia (n=7), headache (n=7), seizure (n=3), and cranial neuropathy (n=2). Group 2 (n=35; mean aneurysm diameter, 2.2 cm) had chronic symptoms attributed to mass effect: headache (n=18), visual loss (n=10), pyramidal tract dysfunction (n=4), and facial pain (n=3). Group 3 (n=57; mean aneurysm diameter, 1.1 cm) had asymptomatic aneurysms. Conclusions. —Acute severe headache, comparable to subarachnoid hemorrhage headache, but without nuchal rigidity, was associated with the following mechanisms: aneurysm thrombosis, localized meningeal inflammation, and unexplained. Unruptured aneurysms may be misdiagnosed as optic neuritis or migraine, or serve as a nidus for cerebral thromboembolic events. Internal carotid artery and posterior circulation aneurysms were more likely to cause focal symptoms from mass effect than were anterior cerebral artery and middle cerebral artery aneurysms. Weeks to years may elapse before their diagnosis. The absence of subarachnoid blood does not exclude an aneurysm as a cause for acute or chronic neurologic symptoms.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=neur&articleId=592230&pdfFileName=archneur_50_3_010.pdf

The Clinical Spectrum of Unruptured Intracranial Aneurysms

Surgery of tumors invading the cavernous sinus

Juvenile active ossifying fibroma is a rare lesion seldom seen by neurosurgeons. It originates in the paranasal sinuses during childhood, grows slowly, and encroaches on adjacent orbital and cranial compartments. In the past 3 years, four patients with this lesion were seen (three men and one woman; mean age 28 years). The clinical presentations were different with each patient: sinusitis, meningitis, periorbital pain, and a unique case of a juvenile active ossifying fibroma presenting with high-grade internal carotid artery stenosis and ischemic symptoms. Three patients were treated by transfacial approaches: two with a transfrontal-nasal approach and one with a transfrontal-nasoorbital approach. Two open resections resulted in gross-total excision and no recurrence as of the 2-year follow-up review. In the third patient, the tumor-encased carotid artery was preserved at the expense of a complete resection; that patient underwent superficial temporal artery-middle cerebral artery bypass and remains without ischemic symptoms or tumor recurrence at 2 years. The fourth patient underwent three subtotal endoscopic resections and is also without symptomatic recurrence at 2 years. Three points must be made concerning these lesions. First, the clinical and radiographic characteristics of juvenile active ossifying fibroma may not be easily recognized by neurosurgeons, which could lead to misdiagnosis and mismanagement of these lesions. Second, this tumor can encase the carotid artery and cause severe stenosis or occlusion. Third, complete resection of the tumor is required to effect a cure, and transfacial approaches, which give wide exposure of the sinuses, appear to yield better, more radical resections than endoscopic procedures.

Juvenile active ossifying fibroma Report of four cases

Background/Aims: The purpose of the present article is a systematic review of the proposed medical or surgical treatments in patients in chronic vegetative state (VS) or minimally c

/pdf/vegetative-state-and-minimally-conscious-state-a-review-of-1zme531nw6.pdf

Vegetative state and minimally conscious state: a review of the therapeutic interventions.

Objectives. The problem of treating patients in a vegetative state remains grossly unresolved, and spinal cord stimulation (SCS) had seemed promising in some studies, suggesting, to us, further study.



Materials and Methods.  A prospective uncontrolled and nonrandomized observational study for 20 consecutive years (1986–2005) was performed on the effect of SCS in 214 patients in persistent vegetative state (PVS) that resulted from global anoxia and/or, stroke and/or head injury. After confirming the condition of PVS, a spinal cord stimulator, at the C2–C4 level, was implanted, stimulating according to a protocol of 15-min on/15-min off during daytime only. The results were evaluated using an efficacy scale designed by us for our study, detecting signs of awareness of self and surrounding.



Results.  Excellent and positive results were obtained in 109 of 201 patients (54%), but better in those patients below the age of 35, those of PVS of traumatic origin and those patients with regional cerebral blood flow over 20 mL/100 g/min.



Conclusions.  These findings, though inconclusive of actual benefit of SCS for PVS, indicate to us that further evidence-based, randomized controlled trials are needed to confirm efficacy of the treatment and define those who are going to benefit from this treatment method.

Dorsal column stimulation in persistent vegetative state.

Dorsal column stimulation has been used in four patients who were in a persistent vegetative state. There was improvement of the EEG in four patients and clinical improvement in three patients. Stimulation was for 12 hours per day at 100 Hz, 5 to 8 volts, and with a pulse width of 0.12 msec. The mechanism of improvement may involve changes in cerebral blood flow.

Neurostimulation for patients in vegetative status.

Bilateral giant intracavernous aneurysms technique of unilateral operation

UNLABELLED Developments in the diagnostic procedures, microsurgical techniques, intensive care, and the social rescue system have lowered the mortality in cerebrovascular diseases, head injuries and other emergencies of neurology and neurosurgery. However, this decreased mortality has given rise to a new social and medical problem i.e. vegetative status, which is an increase in the number of people who live on with mild or severe residual neurological deficits. During the last two years, we have used dorsal column stimulation (DCS) for improving spasticity of hemiplegics. While doing so, we incidentally found an improvement in the EEG in some of the cases. This led us to use dorsal column stimulation in cases of vegetative status. In this paper, we describe methodology and our experience with ten cases of vegetative status. All cases satisfied the definition of "vegetative status" and had received medical treatment for more than 3 months prior to DCS without showing any clinical improvement. A neurostimulator made by "Medtronic Neuro" was used. The neurostimulator was implanted in epidural space, in midline, at C-2 level under general anaesthesia. Video recording of clinical conditions, EEG, rCBF and catecholamine metabolism in CSF at regular intervals were monitored to see the efficacy of this treatment. RESULT 1) There was an improvement in the EEG in nine cases out of ten cases after neurostimulation. This was in the form of appearance of more wide spread alpha-waves, and was noticed between 3 to 14 days after starting the neurostimulation. 2) Four of these cases showed good clinical improvement. In the other four cases there was slight clinical improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of neurostimulation on the reversibility of neuronal function: experience of treatment for vegetative status].

A rare case of an ossifying fibroma that developed in the sylvian fissure is reported here. During surgery, branches of the middle cerebral artery were encased in osseous tumor. The encased branches were divided and reanastomosed after the mass was removed. Postoperative angiograms demonstrated patency of the anastomosed arteries and a postoperative magnetic resonance imaging scan revealed no infarction distal to the arterial anastomoses. The authors recommend division and anastomosis of the encased arteries rather than partial removal of tumor from around the encased arteries, resulting in residual tumor being left behind.

Yoshifumi Kamei

Papers

Dorsal column stimulation in persistent vegetative state.

Neurostimulation for patients in vegetative status.

Bilateral giant intracavernous aneurysms technique of unilateral operation

[Effects of neurostimulation on the reversibility of neuronal function: experience of treatment for vegetative status].

Ossifying fibroma in the sylvian fissure: case report.