Showing papers in "Journal of Neurosurgery in 1976"

Anatomy of the cavernous sinus. A microsurgical study.

Abstract: ✓ Fifty cavernous sinuses from cadavers were studied in detail using magnification, with special attention to the relationships important in surgical approaches on the intracavernous structures, and to understanding arterial contributions to arteriovenous fistulas involving the cavernous sinus. Significant findings were: 1) The three main branches of the intracavernous portion of the carotid artery were the meningohypophyseal artery, present in 100% of the specimens, the artery of the inferior cavernous sinus (84%), and McConnell's capsular arteries (28%). In addition, the ophthalmic and dorsal meningeal arteries arose from the carotid artery within the cavernous sinus in 8% and 6%, respectively. The three main branches of the meningohypophyseal trunk were the tentorial artery, present in 100%, the dorsal meningeal (90%), and the inferior hypophyseal (80%). 2) The carotid artery was separated from the trigeminal nerve just proximal to the sinus by only dura in 84% of the specimens, and the artery was expo...

Microsurgical anatomy of the anterior cerebral-anterior communicating-recurrent artery complex

Abstract: ✓ The microvascular relationships important to surgery of aneurysms in the anterior communicating region were defined in 50 cadaver brains. The recurrent artery of Heubner was frequently exposed before the A-1 segment in defining the neck on anterior cerebral aneurysms because it commonly courses anterior to A-1. It arose from the A-2 segment of the anterior cerebral artery (ACA) in 78% and most commonly terminated in the area of the anterior perforated substance, and lateral to it in the Sylvian fissure. The anterior communicating artery (ACoA) frequently gave rise to perforating arteries which terminated in the superior surface of the optic chiasm and above the chiasm in the anterior hypothalamus. This finding contrasts with previous reports that no perforating branches arise from the communicating artery. The proximal half of the A-1 segment was a richer source of perforating arteries than the distal half. The A-1 branches most commonly terminated in the anterior perforated substance, the optic chiasm,...

Fluid-percussion model of mechanical brain injury in the cat

Abstract: ✓ Mechanical brain injury was produced in 36 cats with a fluid-percussion model in which brain damage or dysfunction is produced by a single, brief, hydraulically-induced pressure transient that is conducted through the brain. Fluid-percussion injury induces elastic deformation of the brain resembling the brain deformation known to occur following head impact. Physiological responses and pathological changes following injury were expressed as a function of peak pressure. Macroscopic central nervous system lesions concentrated at the pontomesencephalic junction, cervicomedullary junction, and in the cerebellar tonsils were consistently observed at and above 2.6 atmospheres (atm). At higher levels of injury (≥ 3.2 atm) there was extensive basal subarachnoid hemorrhage. At very high levels of injury (>4.0 atm) hemorrhagic contusions were noted at the cerebral hemisphere impact site. A spectrum of neuronal alterations was identified in the damaged areas. Computer analysis showed correlation of electroencephal...

Postoperative hypertension in the management of patients with intracranial arterial aneurysms

Abstract: Elevation of systemic arterial pressure in seven patients with intracranial arterial aneurysms has been shown to be effective in alleviating ischemic symptoms attributed to cerebral vasospasm. Autoregulation is at least partially lost in patients with cerebral hemodynamic crisis. Blood volume expansion was used to augment vasopressors in maintenance of systemic hypertension. The management of these cases is discussed. Caution in the use of this technique is advised, since the regimen is not without risk.

Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine

Abstract: ✓ The lateral extracavitary approach to the spine was used for resection of displaced bone and disc located anterior to the dura in 62 patients with traumatic lesions of the thoracic and lumbar spine. Fifty-two patients had closed vertebral fractures and 10 had gunshot wounds. The spinal cord was involved in 44 patients, and the cauda equina in 18. A spinal subarachnoid block was demonstrated in 17 of 57 preoperative gas myelograms. Evoked potential recordings, although related to perception of joint rotation, tended to reflect the overall neurological condition and had some prognostic value. Significant improvement followed surgery in 46 patients with incomplete neurological lesions, and one was transiently worse. Before operation 18 patients were able to walk; nine with assistance and nine without. After operation 47 patients were able to walk; 12 with assistance and 35 without. Adequate bladder function was present in 17 patients before surgery, and in 44 after surgery. A laminectomy had been done prev...

Clinical and pathological study of 24 cases of gliosarcoma

Abstract: ✓ The authors review the clinical and pathological features of 24 patients with gliosarcoma. The study revealed the following findings. Gliosarcoma occurs more frequently than is indicated in the literature, and in our series was present in 8% of all cases of glioblastoma multiforme. The presenting features are not significantly different from those of glioblastoma multiforme. The lesion often presents itself at surgery as a firm, well circumscribed mass within the temporal lobe, and at surgery it is commonly mistaken for a meningioma. There is an increased likelihood of metastasis compared to that of glioblastoma. The prognosis is no worse than that of glioblastoma, in spite of the addition of sarcomatous elements.

Physiopathogenesis of subdural hematomas: Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man

Abstract: The dorsal subcutaneous injection in rats of 12 ml or more of autologous hemolyzed whole blood clotted in situ induced the formation of sterile, hemispheric lesions, 47% of which showed an initial decrease in volume followed by a progressive enlargement. The behavior, histology, and biochemical characteristics of the liquid contents of these lesions were found to be remarkably similar to those of subdural hematomas in man. To evaluate the role of the various blood components that may have influenced the formation and growth of these lesions, more than 150 clots composed of human platelet-free plasma, autologous hemolyzed blood, or autologous whole blood were implanted subcutaneously in rats by either surgical or injection techniques. The in vitro behavior of the different clots used was also assessed. This systematic approach led to the following conclusions: 1) the composition and volumes of the clots are critical variables; 2) plasma-fibrin provides the matrix shape of the lesions; 3) the breakdown products derived from erythrocytes, hemoglobin, leukocytes, and other solid blood elements induce neomembrane formation and contribute to the lesion's subsequent growth; and 4) inflammation mechanisms appear to be essential, while cerebrospinal fluid plays no discernable role in this process.

Body position and cerebrospinal fluid pressure. Part 2: clinical studies on orthostatic pressure and the hydrostatic indifferent point.

Abstract: Lumbar cerebrospinal fluid (CSF) pressure was recorded in 116 adult neurosurgical patients in the lateral and sitting positions The level of zero CSF pressure while in the sitting position (ZPS) and hydrostatic indifferent point (HIP) for lateral and sitting positions were determined and referred to the craniospinal axis In control patients ZPS was located mainly at the upper cervical region, and showed nearly the same variation and frequency distribution as CSF pressure in the lateral position when efforts were made to reduce sources of error and there was no orthostatic change in CSF filling pressure Under these circumstances ZPS may be used as a variable comparable from one subject to another In control patients the HIP was located between C-6 and T-5 In 25 hydrocephalic patients, shunting resulted in a mean caudal shift of ZPS of 244 mm, and a mean pressure fall of 126 mm H2O in the lateral position This difference was due to a caudal shift of HIP on shunting A caudally located ZPS was found in patients with complete cervical subarachnoid block Prevention and treatment of CSF leakage cranial to HIP is discussed

Review of the effect of spinal cord trama on the vessels and blood flow in the spinal cord.

Abstract: The effect of spinal cord trauma on the vasculature and blood flow of the spinal cord is reviewed. Both quantitative and nonquantitative studies are critically discussed and reasons sought for some of the major controversies that have arisen. Differences in methodology, species variation, and variation in the degree and type of cord injury may all be important factors in producing the conflicting results reported in the literature. In general, it can be said that trauma has a profound effect on the vasculature and blood flow in the cord and that severe compression injury of the cord causes marked ischemia in the gray and white matter.

Laminotomy and total reconstruction of the posterior spinal arch for spinal canal surgery in childhood

Abstract: ✓ Kyphosis, anterior subluxation, and instability of the spine are reported as postoperative complications of multiple level laminectomies in children. The surgical procedure of multiple level laminotomies is proposed as an alternative. Indications in infants and children, the surgical technique, and the postoperative management are presented. The goal is preservation of the normal architecture of the spine in patients who are still developing.

Anterior cervical discectomy with and without interbody bone graft.

Abstract: ✓Fifty-one patients with symptomatic cervical disc disease refractory to conservative management were allocated at random to one of two treatment groups. The standard anterior approach devised by Cloward was used for 25 patients, and radical discectomy and foraminotomy for the other 26. All patients were followed for 6 months or longer with interview, physical examination, and radiographic evaluation. There was no difference in the success rate between the two groups. The large majority (92%) of patients in both groups were pleased with results of their operation. Because of technical factors related to operative exposure of the spinal canal and nerve roots, we prefer the Cloward procedure for patients symptomatic from advanced spondylosis and reserve discectomy without bone graft insertion for those with minimal spondylosis or soft disc herniations.

Role of local hyperfibrinolysis in the etiology of chronic subdural hematoma.

Abstract: ✓ The authors describe studies performed on material aspirated from chronic subdural hematomas. Patients were given 51Cr-labeled red cells prior to aspiration, and it was possible to demonstrate that the mean daily hemorrhage into the hematoma space amounted to 10.2% of its volume. Immunoelectrophoresis of the aspirated hematoma fluid by monospecific anti-human fibrinogen revealed the presence of fibrin and fibrinogen degradation products that, measured by hemagglutination-inhibition immunoassay techniques, varied between 5.0 and 10,500 µg/ml with an average of 2604 µg/ml in 18 cases. The tissue activator was demonstrated by Todd's histological localization in the outer membrane of the chronic subdural hematoma in 11 cases, but not in the inner membrane. These results indicate that if a clot in the subdural space causes the formation of neomembrane, and excessive fibrinolysis occurs, the subdural clot would not only liquefy, but also enlarge by continuous hemorrhage from the neomembrane. Therefore, local ...

Clinical experience with extra-intracranial arterial anastomosis in 65 cases.

Abstract: Clinical results of an extra-intracranial arterial bypass (EIAB) procedure for cerebral ischemia are assessed in 65 patients The 5-year-study suggests that the EIAB procedure has a protective effect against further clinically significant cerebrovascular accidents in properly selected patients Correlation with angiography and regional cerebral blood flow (rCBF) studies are discussed It is felt that rCBF measurements offer the best diagnostic test to determine which patients are suitable for surgery by revealing if an ischemic or relative ischemic focus is present The surgical procedure is contraindicated in acute cerebral ischemia and when the rCBF study reveals general reduction of cerebral blood flow as opposed to a localized ischemic focus

Experience with Arnold-Chiari malformation, 1960 to 1970

Abstract: A retrospective study of 60 adult patients with Arnold-Chiari malformation revealed that certain presenting clinical syndromes, although not pathognomonic, seemed to have definite prognostic significance. Surgical management by suboccipital decompression led to remarkable and enduring improvement in 65% of patients followed for as long as 14 years. In some patients, however, the initial postoperative benefit tended to fade into an insidious progression of neurological deficit. Despite operation, 18.6% of patients eventually experienced progressive neurological deterioration. Patients who presented with paroxysmal intracranial hypertension or cerebellar dysfunction had the best prognosis. Evidence of central cord involvement was the single most detrimental factor to neurological recovery.

Effect of acute spinal cord compression injury on regional spinal cord blood flow in primates.

Abstract: Spinal cord blood flow (SCBF) was measured in 24 rhesus monkeys after injury to the cord produced by the inflatable circumferential extradural cuff technique. Measurement of regional blood flow in the white and gray matter of the cord in areas of 0.1 sq mm was achieved with the 14C-antipyrine autoradiographic technique and a scanning microscope photometer. After moderate cord injury (400 mm Hg pressure in the cuff maintained for 5 minutes), which produced paraplegia in 50% of animals and moderate to severe paresis in the other 50%, mean white matter SCBF was significantly decreased for up to 1 hour. White matter blood flow then rose to normal levels by 6 hours posttrauma and was significantly increased by 24 hours posttrauma. Gray matter SCBF was significantly decreased for the entire 24-hour period posttrauma. After severe cord injury (150 mm Hg pressure in the cuff maintained for 3 hours), which produced total paraplegia in almost all animals; SCBF in white and hours), which prodced total paraplegia in almost all animals, SCBF in white and gray matter was reduced to extremely low levels for 24 hours posttrauma. In addition, focal decreases in SCBF were seen in white and gray matter for considerable distances proximal and distal to the injury site. It is concluded that acute compression injury of the spinal cord is associated with long-lasting ischemia in the cord that increases in severity with the degree of injury.

Anatomical observations of the subarachnoid cisterns of the brain during surgery.

Abstract: Subarachnoid cisterns and their contents are described briefly in the light of observations made during microsurgical explorations. The concept of intracranial surgery in terms of moving from one cistern to another is presented here with particular emphasis on the cisterns in surgical approaches to intracranial vessels and nerves for the treatment of aneurysms, arteriovenous malformations, and for surgery of basal tumors.

Surgical anatomy of the proximal anterior cerebral artery

Abstract: ✓ The authors present this study of proximal anterior cerebral arteries in the normal human to provide a clearer basis for strategy in aneurysm surgery. They describe patterns of origin of branches, their subarachnoid course, and parenchymal distribution. Branches that originate from the anterior cerebral artery at the internal carotid bifurcation perfuse the genu and contiguous posterior limb of the internal capsule and the rostral thalamus. Proximal 4-mm branches supply the anterior limb of the internal capsule, the neighboring hypothalamus, anteroventral putamen, and pallidum. The remaining anterior cerebral artery proximal to the communicating artery sends branches to the optic chiasm, the adjacent hypothalamus, and the anterior commissure. Heubner's artery arises directly opposite the anterior communicating artery to supply much of the striatum and internal capsule rostral to the anterior commissure. The anterior communicating artery branches supply the fornix, corpus callosum, septal region, and ant...

Peripheral nerve stimulation in the treatment of intractable pain.

Abstract: ✓ Peripheral nerve stimulating devices were implanted for pain control in 33 patients with a variety of disabling chronic pain conditions, which had persisted despite usual medical and surgical therapy. The implants were placed on major nerves innervating the area of the patient's pain. Records were obtained of each patient's stated relief from pain produced by nerve stimulation, along with assessments of narcotic withdrawal, ability to return to work, sleep pattern, and relief from depression. Based on these five criteria 17 patients were judged to be treatment failures, while eight patients had excellent results, and seven had intermediate results. Twelve of the failures were in patients with either low back pain with sciatica, or pain from metastatic disease. The most dramatic successes occurred in patients with peripheral nerve trauma. The incidence of complications has been low, and two patients have used the stimulator for 5 years without adverse effects. Techniques of peripheral stimulator implanta...

Body position and cerebrospinal fluid pressure. Part 1: clinical studies on the effect of rapid postural changes.

Abstract: Cerebrospinal fluid (CSF) pressure was recorded in 149 patients and arterial blood pressure (BP) in 11 patients while moving between lateral and sitting positions. Rapid tilting initiated waves in BP and CSF filling pressure. The postural CSF pressure wave manifested itself either as a transient or as a stationary wave similar to a plateau wave. When patients sat up, transient waves had amplitudes up to 550 and stationary waves up to 1000 mm H2O. When they lay down, transient waves had amplitudes up to 800 mm H2O. Stationary waves were found only among patients with elevated intracranial pressure and a diseased brain. The waves were mainly caused by changes in cerebral blood volume probably reflecting the postural BP wave and brain autoregulation. Most patients with stationary and large transient waves also manifested clinical symptoms. These symptoms were aggravated when a craniospinal block developed in the sitting position, and were reduced or avoided when the tilting was performed slowly over 2 to 3 minutes.

Metastasis via ventriculoperitoneal shunt in patients with medulloblastoma

Abstract: ✓ The authors have routinely inserted a ventriculoperitoneal shunt in all patients with a posterior fossa tumor and hydrocephalus some 7–10 days prior to craniotomy. Forty-one patients with medulloblastoma were treated in this fashion and of these, four metastasized through the shunt and died of systemic metastases without evidence of recurrent tumor in their central nervous system. A millipore filter which can be incorporated in the shunt has been used by the authors during the past 18 months in an effort to prevent metastatic spread through the shunt.

Dynamic changes in regional CBF, intraventricular pressure, CSF pH and lactate levels during the acute phase of head injury.

Abstract: ✓ The authors measured regional cerebral 133xenon (133Xe) blood flow (rCBF), intraventricular pressure (IVP), cerebrospinal fluid (CSF) pH and lactate, systemic arterial blood pressure (SAP), and arterial blood gases during the acute phase in 23 comatose patients with severe head injuries. The IVP was kept below 45 mm Hg. The rCBF was measured repeatedly, and the response to induced hypertension and hyperventilation was tested. Most patients had reduced rCBF. No correlation was found between average CBF and clinical condition, and neither global nor regional ischemia contributed significantly to the reduced brain function. No correlation was found between CBF and IVP or CBF and cerebral perfusion pressure (CPP). The CSF lactate was elevated significantly in patients with brain-stem lesions, but not in patients with “pure” cortical lesions. The 133Xe clearance curves from areas of severe cortical lesions had very fast initial components called tissue peaks. The tissue peak areas correlated with areas of ea...

Glioblastoma multiforme in children.

Abstract: Of 488 children with central nervous system neoplasms, 43 (8.8%) had glioblastomas, 22 of which were in the cerebral hemispheres, 16 in the brain stem, two in the cerebellum, and three in the spinal cord. The male to female ratio was 3:2. Glioblastoma multiforme of the cerebral hemispheres occurred at a mean age of 12.7 years, and the frontal lobe was the most commonly involved. Main presenting symptoms included headache (85%), nausea or vomiting (65%), and seizures (35%). Papilledema (45%) was the most common physical finding. The longest survivals were achieved by a combination of operation and radiation (22 months). Brain stem glioblastomas occurred at a mean age of 6.7 years, with the pons as the most frequent site. Nausea or vomiting (50%) and headache (36%) were the main presenting symptoms; the major physical findings were ataxia (43%), cranial nerve palsies (28%), and paresis (28%). The length of survival was greatest with radiation alone (10.5 months). The period of survival of children with glioblastoma multiforme was significantly increased with steroid therapy. Glioblastoma multiforme behaves similarly in children and adults. Intracranial glioblastomas have a more rapidly fatal course than that of other similarly situated gliomas in childhood.

Ependymomas and ependymoblastomas in children

Abstract: The authors analyze histologically verified cases of ependymoma and ependymoblastoma (malignant ependymoma) occurring in children in Connecticut from 1935 to 1973. Of the 488 central nervous system tumors diagnosed in that period, 44 (9%) of the 467 intracranial neoplasms and five (24%) of the 21 intraspinal tumors were of ependymal origin. An increase in the incidence of ependymomas was noted since the mid-1950's. The mean ages at diagnosis of ependymomas and ependymoblastomas were 5.6 and 5.0 years respectively. The male to female ratio was 0.6:1 for ependymomas and 1.7:1 for ependymoblastomas. Epencymomas were found above and below the tentorium with similar frequency; however, viturally all of the epencymoblastomas occurred supratentorially. Presenting symptoms and physical findings were reviewed. A significant difference (p less than 0.05) was noted in the seizure rates of supratentorial ependymomas (9%) and ependymoblastomas (38%). A significantly increased survival (p less than 0.05) was associated with supratentorial ependymal neoplasms relative to infratentorial from 42 months following diagnosis onward. Contrary tp the reports of no clinical difference between ependymomas and ependymoblastomas, children with supratentorial ependymomas were noted to have a significantly longer survival (p less than 0.05) than those with similarly situated ependymoblastomas, with the difference noted from 18 months following diagnosis onward. The children treated by operation and irradiation had a significantly greater survival (p less than 0.05) than those treated by other methods; furthermore, with this treatment, longer survivals were noted in the ependymoma patients as compared to those with epencymoblastomas. This difference became significant (p less than 0.05) at 27 months after diagnosis. Operative mortality decreased from 40% to 17% in the last decade of the study as compared to the previous decade. Steroid therapy may have contributed to this decreased operative mortality, but it had no statistically significant effect on length of survival. The clinical course of intracranial ependymal neoplasms in adults and children was compared and appeared to be essentially the same.

Physiopathogenesis of subdural hematomas

Abstract: ✓ A previously described experimental hematoma model, achieved by the subcutaneous injection of 12 ml of autologous hemolyzed blood clotted in situ, was made in 33 rats. Seventeen animals served as controls; the other 16 received daily intramuscular injections of dexamethasone. After an initial decrease in size, 47% of the lesions in the control animals enlarged to a mean weight of 12.1 ± 2.5 gm, while the lesions in the 16 steroid-treated rats weighed 3.2 ± 0.70 gm (p < 0.01). Histologically, lesions from the steroid group showed absence of neomembrane formation. These data offer further support to the theory that the neomembrane development and subsequent enlargement of subdural hematomas is due to inflammatory reactions of tissues in contact with large blood clots.

Lateral canthal advancement of the supraorbital margin: A new corrective technique in the treatment of coronal synostosis

Abstract: In coronal synostosis, in addition to fusion of the coronal suture, the frontosphenoidal and frontoethmoidal sutures are usually closed A linear craniectomy along the coronal sutures does not affect the synostotic process at the base of the skull The facility with which the supraorbital margin could be mobilized in Tessier's method of craniofacial repair suggested to us that we could easily modify our approach to coronal synostosis and advance the supraorbital margin, creating an artificial suture at the base of the skull and allowing for proper correction of this disorder During the past 3 years, we have treated 15 patients with coronal synostosis by this technique, which we have termed lateral canthal advancement The method of this form of surgical management and its results are discussed

Trans-unco-discal approach. A combined anterior and lateral approach to cervical discs.

Abstract: ✓ A series of 40 patients with degenerative discopathy was effectively treated by means of a trans-unco-discal approach, which is a combined anterior and lateral approach to cervical discs. Interbody fusion is not performed except for special cases such as significant kyphosis and unstable cervical spine. Twenty patients who had this approach without interbody bone graft have been followed clinically and radiographically for 9 to 36 months. The author describes the surgical technique, complications, and results.

Late results of cervical disc surgery

Abstract: ✓ Late results of cervical disc surgery have been reported and statistically studied in 383 cases; 83% were lateral discs, 13% were central spondylosis discs, and 4% central soft discs. Central spondylosis occurred at a higher spinal level, and caused cord compression with or without weakness of the hands, but no pain. A posterior approach was used in all lateral discs, and either an anterior or a posterior approach, with or without fusion, for central discs. Preoperative myelography was always done and is recommended postoperatively in central disc surgery to evaluate the results. Our results were good to excellent in 95% of lateral discs, in 64% of central spondylosis discs, and in an unexpected 91% of 11 cases of central soft discs. There were no recurrences and no serious complications, although 20% developed other cervical or lumbar disc herniations.

Infections complicating the use of external ventriculostomy.

Abstract: ✓ The use of external ventriculostomy at our institution has been retrospectively analyzed to determine the incidence of cerebrospinal fluid sepsis. Placement of 65 ventriculostomies over a 2-year period resulted in three cases of complicating meningitis and ventriculitis (4.5%). Duration of ventriculostomy placement did not seem related to the rate of infection but the method of placement, the prophylactic antibiotics used, and the monitoring and collecting system employed may be important.

Selection of patients for extra-intracranial arterial bypass surgery based on rCBF measurements.

Abstract: ✓ Extracranial intracranial arterial anastomosis is gaining acceptance as a form of treatment in selected cases with ischemic cerebrovascular disease. To establish indications for this operation and to provide an objective assessment of postoperative results, regional cerebral blood flow (rCBF) studies were performed in 110 patients with cerebrovascular insufficiency considered for extra-intracranial bypass surgery. The 133Xe intracarotid injection method with 16 externally placed detectors was used for measuring rCBF. Postoperatively, rCBF was measured in 40 patients. From these results our present criteria for surgery have evolved. The probability of a good postoperative result is best in patients who showed focal cerebral ischemia or a moderate general reduction of CBF with an additional ischemic focus. The operation is contraindicated in patients with either normal or severely reduced CBF values (less than 60% of normal).

Angiographic study of the growth of intracranial aneurysms.

Abstract: ✓ The authors have attempted to assess whether there is any standard rate of growth of intracranial aneurysms. Angiographic studies were performed on 67 patients with 82 aneurysms with intervals between angiograms ranging from a few days to 10 years. Examination of these records showed no consistent rate of change in size, possibly partly because of inherent inaccuracies in the method, which are discussed. The clinical reasons for the repeat studies are briefly mentioned. It is concluded that it is unwise to wait and see what may happen to any but perhaps the smallest aneurysm.