Showing papers in "Acta Neurochirurgica in 2006"
TL;DR: In this article, the authors describe epidemiological factors from European studies largely published in the last 20 years, and describe the impact of these factors on traumatic brain injury (TBI) outcomes.
Abstract: Background. The world’s literature on traumatic brain injury (TBI) grows annually including new reports on epidemiologic findings from many regions. With the wide variety of reports emphasizing various factors it is useful to compile these findings, hence the objective of this report. Thus, we describe epidemiological factors from European studies largely published in the last 20 years.
1,092 citations
TL;DR: Current thought considers TAI a progressive process evoked by the tensile forces of injury, gradually evolving from focal axonal alteration to ultimate disconnection, while discussing the potential diversity of pathological processes observed within various injured fibers.
Abstract: Traumatic brain injury (TBI) evokes widespread/diffuse axonal injury (TAI) significantly contributing to its morbidity and mortality. While classic theories suggest that traumatically injured axons are mechanically torn at the moment of injury, studies in the last two decades have not supported this premise in the majority of injured axons. Rather, current thought considers TAI a progressive process evoked by the tensile forces of injury, gradually evolving from focal axonal alteration to ultimate disconnection. Recent observations have demonstrated that traumatically induced focal axolemmal permeability leads to local influx of Ca2+ with the subsequent activation of the cysteine proteases, calpain and caspase, that then play a pivotal role in the ensuing pathogenesis of TAI via proteolytic digestion of brain spectrin, a major constituent of the subaxolemmal cytoskeletal network, the “membrane skeleton”. In this pathological progression this local Ca2+ overloading with the activation of calpains also initiates mitochondrial injury that results in the release of cytochrome-c, with the activation of caspase. Both the activated calpain and caspases then participate in the degradation of the local axonal cytoskeleton causing local axonal failure and disconnection. In this review, we summarize contemporary thought on the pathogenesis of TAI, while discussing the potential diversity of pathological processes observed within various injured fiber types. The anterograde and retrograde consequences of TAI are also considered together with a discussion of various experimental therapeutic approaches capable of attenuating TAI.
494 citations
TL;DR: Malignant glioma patients treated with BCNU wafers at the time of initial surgery in combination with radiation therapy demonstrated a survival advantage at 2 and 3 years follow-up compared with placebo.
Abstract: Objective. Adjuvant systemic chemotherapy increases survival of primary malignant glioma patients beyond 12–18 months. The only interstitial chemotherapy treatment approved for malignant glioma is Gliadel® wafer containing carmustine (BCNU) placed in the resection cavity at surgery. Analysis of a large trial by Westphal and colleagues (n = 240) showed a 29% risk reduction (P = 0.03) in the BCNU wafer-treated group over the course of the 30-month trial. Long-term follow-up of these patients was undertaken to determine the survival benefit at 2 and 3 years.
408 citations
TL;DR: In this article, several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection, and the authors propose a method to identify the most important factors.
Abstract: Background. Several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection.
276 citations
TL;DR: The presence of IVH and hydrocephalus are independent predictors of poor outcome in spontaneous ICH and early surgery is of some benefit in those with IVH.
Abstract: Introduction
Intraventricular hemorrhage (IVH), either independent of or as an extension of intracranial bleed, is thought to carry a grave prognosis. Although the effect of IVH on outcome in patients with subarachnoid hemorrhage has been extensively reviewed in the literature, reports of spontaneous intracerebral hemorrhage (ICH) in similar situations have been infrequent. The association of hydrocephalus in such situations and its influence on outcome is also uncertain.
254 citations
TL;DR: The integration of 3D US with neuronavigation technology has created an efficient and inexpensive tool for intra-operative imaging in neurosurgery and has so far mostly been applied to improve surgery of tumours in brain tissue.
Abstract: In recent years there has been a considerable improvement in the quality of ultrasound (US) imaging. The integration of 3D US with neuronavigation technology has created an efficient and inexpensive tool for intra-operative imaging in neurosurgery. In this review we present the technological background and an overview of the wide range of different applications. The technology has so far mostly been applied to improve surgery of tumours in brain tissue, but it has also been found to be useful in other procedures such as operations for cavernous haemangiomas, skull base tumours, syringomyelia, medulla tumours, aneurysms, AVMs and endoscopy guidance.
251 citations
TL;DR: The concept of decompressive craniectomy in traumatic brain injury and the rationale and protocol of the RESCUEicp study are described.
Abstract: The RESCUEicp (Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure) study has been established to determine whether decompressive craniectomy has a role in the management of patients with traumatic brain injury and raised intracranial pressure that does not respond to initial treatment measures. We describe the concept of decompressive craniectomy in traumatic brain injury and the rationale and protocol of the RESCUEicp study.
250 citations
TL;DR: It is not clear, however, whether the incidence of vascular injury has been reduced significantly in all procedures of spine surgery, and emerging new techniques, such as microendoscopic discectomy and lumbar disc arthroplasty, seem to be promising, but the authors need to keep in mind their safety issues.
Abstract: Vascular injury is an uncommon, but not rare complication of spine surgery. The consequence of vascular injury may be quite devastating, but its incidence can be reduced by understanding the mechanisms of injury. Properly managing vascular injury can reduce mortality and morbidity of patients. A review of the literature was conducted to provide an update on the etiology and management of vascular injury and complication in neurosurgical spine surgery. The vascular injuries were categorized according to each surgical procedure responsible for the injury, i.e., anterior screw fixation of the odontoid fracture, anterior cervical spine surgery, posterior C1-2 arthrodesis, posterior cervical spine surgery, anterolateral approach for thoracolumbar spine fracture, posterior thoracic spine surgery, scoliosis surgery, anterior lumbar interbody fusion (ALIF), lumbar disc arthroplasty, lumbar discectomy, and posterior lumbar spine surgery. The incidence, mechanisms of injury, and reparative measures were discussed for each surgical procedure. Detailed coverage was especially given to vascular injury associated with ALIF, which may have been underestimated. The accumulation of anatomical knowledge and advanced imaging studies has made complex spine surgery safer and more reliable. It is not clear, however, whether the incidence of vascular injury has been reduced significantly in all procedures of spine surgery. Emerging new techniques, such as microendoscopic discectomy and lumbar disc arthroplasty, seem to be promising, but we need to keep in mind their safety issues, including vascular injury and complication.
182 citations
TL;DR: Pure MVD offers patients affected by Trigeminal Neuralgia due to vascular compression a long-lasting cure in three-fourths of the cases, view in contrast to the classical view that an atypical presentation has an adverse effect on outcome after surgery.
Abstract: Background. Few publications on primary Trigeminal Neuralgia treated by Micro-Vascular Decompression (MVD) report large series, with long-term follow-up, using Kaplan-Meier (K-M) analysis. None was specifically directed to the comparative study of MVD effectiveness on Trigeminal Neuralgia with typical (i.e., with paroxysmal pain only) and atypical features (i.e., with association of a permanent background of pain).
157 citations
TL;DR: It is suggested that MMP-9 may contribute to BBB disturbance and subsequent brain edema after traumatic brain injury.
Abstract: Matrix metalloproteinases (MMPs) are associated with blood-brain opening and may be involved in the pathophysiology of acute brain injury. Previous research demonstrated that knockout mice de- ficient in MMP-9 subjected to transient focal cerebral ischemia had reduced blood-brain barrier (BBB) disruption and attenuated cerebral infarction.
150 citations
TL;DR: A variety of monitoring techniques and devices are available, each offering advantages and disadvantages as mentioned in this paper, but the analysis of large populations has never been performed, which is a limitation of large-scale ICP monitoring.
Abstract: Background. Intracranial pressure (ICP) monitoring has become standard in the management of neurocritical patients. A variety of monitoring techniques and devices are available, each offering advantages and disadvantages. Analysis of large populations has never been performed.
TL;DR: DBS on STN and ATN demonstrated their clear efficiency and relative safety comparable or superior to previous studies during long term follow-up, and warrant the further increase of the knowledge about antiepileptic effect of DBS.
Abstract: Objectives
Experimental data and case reports of intractable epilepsy patients treated with deep brain stimulation (DBS) of the internal nuclei suggest a considerable anticonvulsant effect. We intended to describe the results of DBS on subthalamic nuclei and anterior thalamic nuclei (STN and ATN) from our patients and to evaluate the long-term efficiency and safety of DBS for controlling intractable epilepsy.
TL;DR: New evidence indicates that chemokines (chemoattractant cytokines) do not merely direct leukocytes to areas of injury, but have direct and indirect effects on the BBB leading to BBB disruption, facilitating entry of leukocyte into brain, and inducing vasogenic brain edema formation.
Abstract: Brain edema is associated with a variety of neuropathological conditions such as brain trauma, ischemic and hypoxic brain injury, central nervous system infection, acute attacks of multiple sclerosis, and brain tumors. A common finding is an inflammatory response, which may have a significant impact on brain edema formation. One critical event in the development of brain edema is blood-brain barrier (BBB) breakdown, which may be initiated and regulated by several proinflammatory mediators (oxidative mediators, adhesion molecules, cytokines, chemokines). These mediators not only regulate the magnitude of leukocyte extravasation into brain parenchyma, but also act directly on brain endothelial cells causing the loosening of junction complexes between endothelial cells, increasing brain endothelial barrier permeability, and causing vasogenic edema. Here we review junction structure at the BBB, the effects of pro-inflammatory mediators on that structure, and focus on the effects of chemokines at the BBB. New evidence indicates that chemokines (chemoattractant cytokines) do not merely direct leukocytes to areas of injury. They also have direct and indirect effects on the BBB leading to BBB disruption, facilitating entry of leukocytes into brain, and inducing vasogenic brain edema formation. Chemokine inhibition may be a new therapeutic target to reduce vasogenic brain edema.
TL;DR: Two patients who developed hypomania following STN-DBS but were unaware of their mood disturbance were described, and readjusting the stimulation parameters resolved the hypomanic behaviour with continued motor benefits.
Abstract: Mania following subthalamic nucleus (STN) deep brain stimulation (DBS) is well described and obvious to both the patient and their physician. The authors describe two patients who developed hypomania following STN-DBS but were unaware of their mood disturbance. Two Parkinson’s patients with no previous mood disorders received bilateral STN electrodes. Both experienced dramatic improvement in their motor function and neither complained of any side effects. Their families reported detrimental hypomanic behaviour. Readjusting the stimulation parameters resolved the hypomania with continued motor benefits. The authors draw attention to potential adverse effects of STN-DBS that might be neglected by patients.
TL;DR: Overall the results demonstrated that decompressive craniectomy, when applied as part of protocol-driven therapy, yields a satisfactory rate of favorable outcome.
Abstract: Although decompressive craniectomy following traumatic brain injury is an option in patients with raised intracranial pressure (ICP) refractory to medical measures, its effect on clinical outcome remains unclear. The aim of this study was to evaluate the outcome of patients undergoing this procedure as part of protocol-driven therapy between 2000–2003. This was an observational study combining case note analysis and follow-up. Outcome was assessed at an interval of at least 6 months following injury using the Glasgow Outcome Scale (GOS) score and the SF-36 quality of life questionnaire. Forty-nine patients underwent decompressive craniectomy for raised and refractory ICP (41 [83.7%] bilateral craniectomy and 8 [16.3%] unilateral). Using the Glasgow Coma Scale (GCS), the presenting head injury grade was severe (GCS 3–8) in 40 (81.6%) patients, moderate (GCS 9–12) in 8 (16.3%) patients, and initially mild (GCS 13–15) in 1 (2.0%) patient. At follow-up, 30 (61.2%) patients had a favorable outcome (good recovery or moderate disability), 10 (20.4%) remained severely disabled, and 9 (18.4%) died. No patients were left in a vegetative state. Overall the results demonstrated that decompressive craniectomy, when applied as part of protocol-driven therapy, yields a satisfactory rate of favorable outcome. Formal prospective randomized studies of decompressive craniectomy are now indicated.
TL;DR: The data indicate that “tailored” resective surgery for temporo-mesial epilepsy can be performed with a low rate of morbidity, and is highly efficacious, with the use of invasive presurgical investigation (SEEG).
Abstract: Background We studied the surgical outcome, and the complications in a group of 100 consecutive adult patients with medically refractory epilepsy arising from the temporo-mesial structures
TL;DR: PEEK cages appear to be safe and efficient for anterior cervical fusion (ACF), and preliminary impressions studies on larger series with long term follow-up are warranted.
Abstract: Study design. Retrospective analysis of 36 cases of degenerative disc disease treated by interbody fusion with polyetheretherketone (PEEK) cages.
TL;DR: Use of iMRI during surgery for intracranial gliomas permits to attain aggressive tumour resection with good functional outcome, and surgical experience with the iMRI system, establishment of treatment algorithm, and improvement of image quality are of paramount importance for optimal results.
Abstract: Background. Radical resection of gliomas can increase patient’ s survival. There is known concern, however, that aggressive tumour removal can result in neurological morbidity. The objective of the present study was to evaluate the usefulness of low magnetic field strength (0.3 Tesla) open intraoperative magnetic resonance imaging (iMRI) for complete resection of glioma with emphasis on functional outcome.
TL;DR: A comprehensive review about spinal extradural arachnoid cysts is made including the author’s own case of a 59-year-old woman with a 6-month history of progressive back pain radiating to both legs.
Abstract: Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. They usually present with progressive signs and symptoms caused by spinal cord compression if they enlarge. A comprehensive review about spinal extradural arachnoid cyst is made including the author's own case of a 59-year-old woman with a 6-month history of progressive back pain radiating to both legs. Key points concerning the possible pathogenesis including symptomatology, diagnosis, and the implications for treatment are highlighted. Surgical treatment is curative and this rare clinical entity should be considered in the differential diagnosis of spinal extradural lesions.
TL;DR: Arthroplasty using the Bryan disc appears to be safe and provided a favorable preliminary clinical and radiological outcome, and future studies will need to address the association between postoperative kyphosis, clinical outcome and adjacent segment disease.
Abstract: Background. This was a retrospective study of clinical and radiological results of cervical arthroplasty using the Bryan cervical disc prosthesis to evaluate the efficacy of arthroplasty in clinical applications.
TL;DR: Posterior bisegmental transpedicular correction/fixation and staged anterior corpectomy and titanium cage implantation is a safe and reliable surgical treatment option in unstable TL junction burst fractures.
Abstract: Background. Controversy exists about the best treatment of unstable thoraco-lumbar (TL) burst fractures. Kyphosis correction and canal decompression in case of a neurological deficit are recognized treatment objectives, and various conservative and surgical strategies have been proposed. This prospective observational study evaluates the benefits and risks of a posterior bisegmental transpedicular correction/fixation and staged anterior corpectomy and titanium cage implantation in unstable TL junction burst fractures.
TL;DR: In this paper, a retrospective analysis of the clinical presentation, radiological studies and operative findings in 77 patients surgically treated for symptomatic lumbar synovial cysts at their institution is presented.
Abstract: Background. Synovial cysts represent an uncommon and probably underestimated pathological entity of the degenerative lumbar spine. The authors report a retrospective analysis of the clinical presentation, radiological studies and operative findings in 77 patients surgically treated for symptomatic lumbar synovial cysts at their institution.
TL;DR: The multimodal protocol for awake craniotomy provides for tumour resection under general anaesthesia in selected patients using functional neuronavigation and is a useful tool for preserving function in patients undergoing surgery of the language cortex while reducing the operative risk on an individual basis.
Abstract: Background. Intra-operative neurophysiological language mapping has become an established procedure in patients operated on for tumours in the area of the language cortex. Awake cranial surgery has specific risks and patients are exposed to an increased physical and mental stress. The aim of the study was to establish an algorithm that enables tailoring the neurosurgical and anaesthetic techniques to the individual patient.
TL;DR: In this one-year material, mean wave Amplitudes were elevated in 60% of iNPH patients, and in those with elevated mean wave amplitudes who were treated with shunt, 91% had a significant clinical response.
Abstract: Background. It was previously reported that the intracranial pulse pressure amplitudes were elevated in idiopathic normal pressure hydrocephalus (iNPH) patients responding to shunt surgery. In this study, pulse pressure amplitudes were determined in all patients referred for tentative iNPH, and patients were selected for shunt surgery based on the determination of their threshold levels of intracranial pulse pressure amplitudes.
TL;DR: The investigation suggests that the existence of subdural hematoma is a major cause of brain swelling following sports-related, repetitive head injury, and second impact syndrome is thought to occur because of loss of autoregulation of cerebral blood flow, leading to vascular engorgement, increased intracranial pressure, and eventual herniation.
Abstract: Introduction
The most common head injury in sports is concussion, and repeated concussions occurring within a short period occasionally can be fatal. Acute subdural hematoma is the most common severe head injury and can be associated with severe neurologic disability and death in sports. We investigated severe brain damage resulting from repetitive head injury in sports, and evaluated the pathophysiology of sports-related repetitive injury.
TL;DR: Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome, and early surgery and single bleeding were associated with better surgical results.
Abstract: Background. The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome.
TL;DR: Only M1 stimulation was effective for pain reduction in 10 of 20 patients, and seemed to be higher in cases of pain with spinal cord and peripheral origins, while it was lower in Cases of post-stroke pain.
Abstract: The stimulation of the primary motor cortex (M1) has proved to be an effective treatment for intractable deafferentation pain. This treatment started in 1990, and twenty-eight studies involving 271 patients have been reported so far. The patients who have been operated on were suffering from post-stroke pain (59%), trigeminal neuropathic pain, brachial plexus injury, spinal cord injury, peripheral nerve injury and phantom-limb pain. The method of stimulation was: a) epidural, b) subdural, and c) within the central sulcus. Overall, considering the difficulty in treating central neuropathic pain, trigeminal neuropathic pain and certain types of refractory peripheral pain, the electrical stimulation of M1 is a very promising technique; nearly 60% of the treated patients improved with a higher than 50% pain relief after several months of follow-up and sometimes of a few years in most reports. The mechanism of pain relief by the electrical stimulation of M1 has been under investigation. Recently, repetitive transcranial magnetic stimulation (rTMS) of M1 has been reported to be effective on deafferentation pain. In the future, rTMS may take over from electrical stimulation as a treatment for deafferentation pain.
TL;DR: Non-smoking, a low pain level and normal rating on DRAM were the best preoperative predictors of a good outcome in ACDF.
Abstract: Background. Predictive factors for a low arm and neck pain, and good health after anterior cervical decompression and fusion (ACDF) with a cervical carbon fibre intervertebral fusion cage (CIFC) are still lacking.
TL;DR: While the pre-operative mean ICP was similar between outcome groups, themean ICP wave amplitude was significantly higher in iNPH patients improving clinically after shunt treatment as compared to the non-responders.
Abstract: Background. Although the mean intracranial pressure (ICP) is normal in patients with idiopathic normal pressure hydrocephalus (iNPH), there could possibly be alterations in their single ICP waves.
TL;DR: High ICP and low PRx are strongly associated with fatal outcome and there is a considerable heterogeneity amongst patients; optimization of care depends upon observing the time-trends for the individual patient.
Abstract: Objective
To investigate the relationships between long-term computer-assisted monitoring of intracranial pressure (ICP) and indices derived from its waveform versus outcome, age, and sex.