Showing papers in "Journal of Neurosurgery in 1998"
TL;DR: The incidence of craniopharyngioma in the United States was estimated from two population-based cancer registries that include brain tumors of benign and borderline malignancy and Los Angeles county and information on additional pediatric tumors was available from the Greater Delaware Valley Pediatric Tumor Registry.
Abstract: Object In this report the authors describe the epidemiology of craniopharyngioma. Methods The incidence of craniopharyngioma in the United States was estimated from two population-based cancer registries that include brain tumors of benign and borderline malignancy: the Central Brain Tumor Registry of the United States (CBTRUS) and the Los Angeles county Cancer Surveillance Program. Information on additional pediatric tumors was available from the Greater Delaware Valley Pediatric Tumor Registry (GDVPTR). The overall incidence of craniopharyngioma was 0.13 per 100,000 person years and did not vary by gender or race. A bimodal distribution by age was noted with peak incidence rates in children (aged 5-14 years) and among older adults (aged 65-74 years in CBTRUS and 50-74 years in Los Angeles county). Survival information was available from GDVPTR and the National Cancer Data Base (NCDB), a hospital-based reporting system. In the NCDB, the 5-year survival rate was 80% and decreased with older age at diagnosis. Survival is higher among children and has improved in recent years. Conclusions Craniopharyngioma is a rare brain tumor of uncertain behavior that occurs at a rate of 1.3 per million person years. Approximately 338 cases of this disease are expected to occur annually in the United States, with 96 occurring in children from 0 to 14 years of age.
563 citations
TL;DR: A retrospective review of patients with melanoma treated at a single institution was undertaken to identify demographic factors associated with the development of clinically significant brain metastases and to determine the factors influencing the prognosis of this population to permit more informed recommendations regarding surgical therapy.
Abstract: Brain metastases are a common and devastating complication in patients with malignant melanoma. Therapeutic options for these patients are limited, and the prognosis is usually poor. Object. A retrospective review of 6953 patients with melanoma treated at a single institution was undertaken to identify demographic factors associated with the development of clinically significant brain metastases in 702 of these patients and to determine the factors influencing the prognosis of this population to permit more informed recommendations regarding surgical therapy. Methods. Factors found to be associated with the development of brain metastases included male gender, primary lesions located on mucosal surfaces or on the skin of the trunk or head and neck, thick or ulcerated primary lesions, and histological findings of acral lentiginous or nodular lesions. The overall median survival time of all patients with brain metastases was 113.2 days, and these metastases contributed to the death of 94.5% of the patients ...
512 citations
TL;DR: Improvements in diagnostic and treatment procedures since the mid-1970s have resulted in improved survival rates for patients diagnosed as having medulloblastoma, oligodendroglioma, and astrocytoma, controlling for age at diagnosis.
Abstract: Object. The authors present population-based survival rate estimates for patients with malignant primary brain tumors based on an analysis of 18 years of data obtained from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. Methods. Estimates of survival rates at 2 and 5 years after diagnosis for patients with specific histological tumor types were categorized by patient's age at diagnosis (≤ 20 years, 21–64 years, and 65 years or older) and by the time period in which the patients were diagnosed (1973–1980, 1981–1985, 1986–1991). Where appropriate, survival estimates were adjusted for changing patterns in the mean age at diagnosis. Conclusions. The authors observed a pattern of declining survival rates in patients with increasing age of the patient at diagnosis for most histological groups and overall improvements in survival rates of patients across these time periods adjusting for age at diagnosis. There were improvements in 2- and 5-year survival rates ove...
474 citations
TL;DR: The structures of the visual pathways (the optic nerve, chiasm, and tract) exhibit a much higher sensitivity to single-fraction radiation than other cranial nerves, and their particular dose-response characteristics can be defined.
Abstract: As the number of patients treated with stereotactic radiosurgery increases, it becomes particularly important to define with precision adverse effects on distinct structures of the nervous system. Object. This study was designed to assess the dose—response tolerance of the visual pathways and cranial nerves after exposure of the cavernous sinus to radiation. Methods. A total of 66 sites in the visual system and 210 cranial nerves of the middle cranial fossa were investigated in 50 patients who had undergone gamma knife treatment for benign skull base tumors. The mean follow-up period was 40 months (range 24–60 months). Follow-up examinations consisted of neurological, neuroradiological, and neuroophthalmological evaluations. The actuarial incidence of optic neuropathy was zero for patients who received a radiation dose of less than 10 Gy, 26.7% for patients receiving a dose in the range of 10 to less than 15 Gy, and 77.8% for those who received doses of 15 Gy or more (p < 0.0001). Previously impaired visi...
469 citations
TL;DR: The authors evaluated the role of EEAs in human traumatic brain injury in patients who have suffered severe head injury by placing a microdialysis probe into the gray matter along with a ventriculostomy catheter or an intracranial pressure monitor for 4 days.
Abstract: Object. Recent animal studies demonstrate that excitatory amino acids (EAAs) play a major role in neuronal damage after brain trauma and ischemia. However, the role of EAAs in patients who have suffered severe head injury is not understood. Excess quantities of glutamate in the extracellular space may lead to uncontrolled shifts of sodium, potassium, and calcium, disrupting ionic homeostasis, which may lead to severe cell swelling and cell death. The authors evaluated the role of EEAs in human traumatic brain injury. Methods. In 80 consecutive severely head injured patients, a microdialysis probe was placed into the gray matter along with a ventriculostomy catheter or an intracranial pressure (ICP) monitor for 4 days. Levels of EAAs and structural amino acids were analyzed using high-performance liquid chromatography. Multifactorial analysis of the amino acid pattern was performed and its correlations with clinical parameters and outcome were tested. The levels of EAAs were increased up to 50 times normal...
465 citations
TL;DR: A randomized double-blind clinical trial was conducted to compare neurological and functional recovery and morbidity and mortality rates 1 year after acute spinal cord injury in patients who had received a standard 24-hour methylprednisolone regimen with those in whom an identical MP regimen had been delivered for 48 hours.
Abstract: Object. A randomized double-blind clinical trial was conducted to compare neurological and functional recovery and morbidity and mortality rates 1 year after acute spinal cord injury in patients who had received a standard 24-hour methylprednisolone regimen (24MP) with those in whom an identical MP regimen had been delivered for 48 hours (48MP) or those who had received a 48-hour tirilazad mesylate (48TM) regimen. Methods. Patients for whom treatment was initiated within 3 hours of injury showed equal neurological and functional recovery in all three treatment groups. Patients for whom treatment was delayed more than 3 hours experienced diminished motor function recovery in the 24MP group, but those in the 48MP group showed greater 1-year motor recovery (recovery scores of 13.7 and 19, respectively, p = 0.053). A greater percentage of patients improving three or more neurological grades was also observed in the 48MP group (p = 0.073). In general, patients treated with 48TM recovered equally when compared ...
461 citations
TL;DR: The number of patients treated with transarticular screws, the number of screws placed, the incidence of VA injury and subsequent neurological deficit, and the management of known or suspected VA injury were surveyed to quantitate the risk of vertebral artery injury during C1-2 transartsicular screw placement.
Abstract: Object. The 847 active members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Section on Disorders of the Spine and Peripheral Nerves were surveyed to quantitate the risk of vertebral artery (VA) injury during C1–2 transarticular screw placement. Methods. This retrospective study elicited the number of patients treated with transarticular screws, the number of screws placed, the incidence of VA injury and subsequent neurological deficit, and the management of known or suspected VA injury. Two hundred thirteen (25.1%) of the 847 surgeons responded. One hundred one respondents (47.4%) had placed a total of 2492 C1–2 transarticular screws in 1318 patients. Thirty-one patients (2.4%) had known VA injuries and an additional 23 patients (1.7%) were suspected of having injuries. However, only two (3.7%) of the 54 patients with known or suspected VA injuries exhibited subsequent neurological deficits and only one (1.9%) died of bilateral VA injury. Other iatrogen...
452 citations
TL;DR: The hypothesis that apoptosis occurs in human SCIs and is accompanied by the activation of caspase-3 of the cysteine protease family is supported and may have important clinical implications for the further development of protease inhibitors to prevent programmed cell death.
Abstract: Object. Apoptosis is a form of programmed cell death seen in a variety of developmental and disease states, including traumatic injuries. The main objective of this study was to determine whether apoptosis is observed after human spinal cord injury (SCI). The spatial and temporal expression of apoptotic cells as well as the nature of the cells involved in programmed cell death were also investigated. Methods. The authors examined the spinal cords of 15 patients who died between 3 hours and 2 months after a traumatic SCI. Apoptotic cells were found at the edges of the lesion epicenter and in the adjacent white matter, particularly in the ascending tracts, by using histological (cresyl violet, hematoxylin and eosin) and nuclear staining (Hoechst 33342). The presence of apoptotic cells was supported by staining with the terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate nick-end labeling technique and confirmed by immunostaining for the processed form of caspase-3 (CPP-32), a member of t...
439 citations
TL;DR: Arterial aneurysms associated with cerebral AVMs may be classified as intranidal, flow-related, or unrelated to the AVM nidus, and have a high correlation with hemorrhagic clinical presentation and a risk of bleeding during the follow-up period that considerably exceeds that which would be expected in their absence.
Abstract: Object. The goal of this study was to develop a classification system for aneurysms associated with arteriovenous malformations (AVMs) based on their anatomical and pathophysiological relationships and to determine the incidence and bleeding rates for these aneurysms as well as the effects of AVM treatment on their natural history. Methods. Of 632 patients with AVMs, intranidal aneurysms were found in 35 (5.5%) and flow-related aneurysms in 71 (11.2%). Patients with intranidal aneurysms presented more frequently with hemorrhage (72% compared with 40%, p < 0.001) and had a 9.8% per year risk rate of bleeding during follow-up review. Twelve (17%) of the patients with flow-related aneurysms associated with an AVM presented with hemorrhage from an aneurysm, whereas 15 (21%) bled from their AVM. Seventeen patients underwent angiography after AVM treatment (mean 2.25 years). Of 23 proximal aneurysms, 18 (78.3%) were unchanged, four (17.4%) were smaller, and one (4.3%) had disappeared, whereas four (80%) of five...
362 citations
TL;DR: It is suggested that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.
Abstract: Object. Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region. Methods. Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwe...
360 citations
TL;DR: The fusion rate and donor-site morbidity for rib autograft compare favorably with those for iliac crest when used in posterior cervical constructs, and the largest series to date in which the safety and efficacy of using autogeneic bone graft materials in spinal surgery are critically analyzed.
Abstract: Object. Autogeneic bone graft is often incorporated into posterior cervical stabilization constructs as a fusion substrate. Iliac crest is used frequently, although donor-site morbidity can be substantial. Rib is used rarely, despite its accessibility, expandability, unique curvature, and high bone morphogenetic protein content. The authors present a comparative analysis of autogeneic rib and iliac crest bone grafts, with emphasis on fusion rate and donor-site morbidity. Methods. A review was conducted of records and radiographs from 600 patients who underwent cervical spinal fusion procedures in which autogeneic bone grafts were used. Three hundred patients underwent rib harvest and posterior cervical fusion. The remaining 300 patients underwent iliac crest harvest (248 for an anterior cervical fusion and 52 for posterior fusion). The analysis of fusion focused on the latter subgroup; donor-site morbidity was determined by evaluating the entire group. Fusion criteria included bony trabeculae traversing t...
TL;DR: RBCs play a potentially important role in delayed edema development after ICH and that RBC lysis and hemoglobin toxicity may be useful targets for therapeutic intervention.
Abstract: Object. The mechanisms of brain edema formation following spontaneous intracerebral hemorrhage (ICH) are not well understood. In previous studies, no significant edema formation has been found 24 hours after infusion of packed red blood cells (RBCs) into the brain of a rat or pig; however, there is evidence that hemoglobin can be neurotoxic. In this study, the authors reexamined the role of RBCs and hemoglobin in edema formation after ICH. Methods. The experiments involved infusion of whole blood, packed RBCs, lysed RBCs, rat hemoglobin, or thrombin into the right basal ganglia of Sprague—Dawley rats. The animals were killed at different time points and brain water and ion contents were measured. The results showed that lysed autologous erythrocytes, but not packed erythrocytes, produced marked brain edema 24 hours after infusion and that this edema formation could be mimicked by hemoglobin infusion. Although infusion of packed RBCs did not produce dramatic brain edema during the first 2 days, it did indu...
TL;DR: Analysis of cases of 190 patients with basilar invagination diagnosed on the basis of criteria laid down in 1939 by Chamberlain found transoral surgery was the most suitable procedure for those patients in Group I and decompression of the foramen magnum was found to be appropriate for patients in Groups II.
Abstract: Object. The authors analyzed the cases of 190 patients with basilar invagination that was diagnosed on the basis of criteria laid down in 1939 by Chamberlain to assess the appropriate surgical procedure. Methods. Depending on the association with Chiari malformation, the anomaly of basilar invagination was classified into two groups. Eighty-eight patients who had basilar invagination but no associated Chiari malformation were assigned to Group I; the remainder of the patients, who had both basilar invagination and Chiari malformation, were assigned to Group II. The principal pathological characteristic was observed to be direct brainstem compression due to odontoid process indentation in Group I and a reduction in posterior cranial fossa volume in Group II. Conclusions. Despite the anterior concavity of the brainstem in both groups, transoral surgery was the most suitable procedure for those patients in Group I and decompression of the foramen magnum was found to be appropriate for patients in Group II. A...
TL;DR: The authors describe the microelectrode recording and stimulation techniques used for localizing the caudal sensorimotor portion of the globus pallidus internus (GPi) and nearby structures (internal capsule and optic tract) in patients undergoing GPi pallidotomy in idiopathic Parkinson's disease and other movement disorders.
Abstract: Object. The authors describe the microelectrode recording and stimulation techniques used for localizing the caudal sensorimotor portion of the globus pallidus internus (GPi) and nearby structures (internal capsule and optic tract) in patients undergoing GPi pallidotomy. Methods. Localization is achieved by developing a topographic map of the abovementioned structures based on the physiological characteristics of neurons in the basal ganglia and the microexcitable properties of the internal capsule and optic tract. The location of the caudal GPi can be determined by “form fitting” the physiological map on relevant planes of a stereotactic atlas. A sensorimotor map can be developed by assessing neuronal responses to passive manipulation or active movement of the limbs and orofacial structures. The internal capsule and optic tract, respectively, can be identified by the presence of stimulation-evoked movement or the patient's report of flashes or speckles of light that occur coincident with stimulation. The...
TL;DR: The pattern of predominantly local relapse and the important influence of residual tumor or the extent of resection on PFS duration confirms a prevailing impression that local disease control is the major factor in the prediction of outcome of ependymoma.
Abstract: Object. Ependymomas in children continue to generate controversy regarding their histological diagnosis and grading, optimal management, and possible prognostic factors. To increase our knowledge of these tumors the authors addressed these issues in a cohort of children with prospectively staged ependymomas treated with radiotherapy and chemotherapy. Methods. Children between the ages of 2 and 17.3 years harboring an intracranial ependymoma confirmed by a central review of the tumor's pathological characteristics were treated according to Children's Cancer Group Protocol 921 from 1986 to 1992. Treatment following surgery and postoperative tumor staging (including brain computerized tomography or magnetic resonance [MR] imaging, spinal MR imaging or myelography, and cerebrospinal fluid cytological investigation) included craniospinal irradiation with a local boost to the primary tumor and patient randomization to receive adjuvant chemotherapy with either 1) CCNU, vincristine, and prednisone, or 2) the eigh...
TL;DR: Given the potential injury-induced uncoupling of cerebral blood flow and metabolism after TBI, these increases in extracellular glutamate may reflect a degree of enhanced cellular crisis, which in severe head injury in humans appears to last up to 9 days.
Abstract: Increase in extracellular glutamate caused by reduced cerebral perfusion pressure and seizures after human traumatic brain injury: a microdialysis study
TL;DR: Subgroup analysis suggested that tirilazad mesylate may be effective in reducing mortality rates in males suffering from severe head injury with accompanying treatment with a novel aminosteroid.
Abstract: Object. The authors prospectively studied the efficacy of tirilazad mesylate, a novel aminosteroid, in humans with head injuries. Methods. A cohort of 1120 head-injured patients received at least one dose of study medication (tirilazad or placebo). Eighty-five percent (957) of the patients had suffered a severe head injury (Glasgow Coma Scale [GCS] score 4–8) and 15% (163) had sustained a moderate head injury (GCS score 9–12). Six-month outcomes for the tirilazad- and placebo-treated groups for the Glasgow Outcome Scale categories of both good recovery and death showed no significant difference (good recovery in the tirilazad-treated group was 39% compared with the placebo group in which it was 42% [p = 0.461]; death in the tirilazad-treated group occurred in 26% of patients compared with the placebo group, in which it occurred in 25% [p = 0.750]). Subgroup analysis suggested that tirilazad mesylate may be effective in reducing mortality rates in males suffering from severe head injury with accompanying t...
TL;DR: The demonstration of a survival advantage provided by radical resection should prompt neurosurgeons to treat malignant pediatric astrocytomas with aggressive surgical resection prior to initiation of radiotherapy or adjuvant chemotherapy.
Abstract: Object. One hundred seventy-two children with high-grade astrocytomas were treated by members of the Children's Cancer Group in a prospective randomized trial designed to evaluate the role of two chemotherapy regimens. Seventy-six percent of the patients (131 children) in whom a diagnosis of either anaplastic astrocytoma or glioblastoma multiforme was confirmed by central pathological review are the subject of this report. Methods. Patients were stratified according to the extent of tumor resection (biopsy [ 90%], and total resection) as determined by surgical observation and postoperative computerized tomography scanning. Information on contemporary neurosurgical management was obtained from the patient's operative records and standardized neurosurgical report forms. The vast majority of tumors were supratentorial: 63% (83 tumors) in the superficial cerebral hemisphere, 28% (37 tumors) in the deep or midline cerebrum,...
TL;DR: This study quantified intraoperative brain distortion, determined the different behavior of tumors in four pathological groups, and identified preoperative predictors of shift with which the reliability of neuronavigation may be estimated.
Abstract: Object. This prospective study was conducted to quantify brain shifts during open cranial surgery, to determine correlations between these shifts and image characteristics, and to assess the impact of postimaging brain distortion on neuronavigation. Methods. During 48 operations, movements of the cortex on opening, the deep tumor margin, and the cortex at completion were measured relative to the preoperative image position with the aid of an image-guidance system. Bone surface offset was used to assess system accuracy and correct for registration errors. Preoperative images were examined for the presence of edema and to determine tumor volume, midline shift, and depth of the lesion below the skin surface. Results were analyzed for all cases together and separately for four tumor groups: 13 meningiomas, 18 gliomas, 11 nonglial intraaxial lesions, and six skull base lesions. For all 48 cases the mean shift of the cortex after dural opening was 4.6 mm, shift of the deep tumor margin was 5.1 mm, and shift of ...
TL;DR: The use of endoscopically assisted strip craniectomies and barrel-stave osteotomies to treat infants with sagittal suture synostosis is safe; decreases blood loss, operative time, and hospitalization costs; and provides excellent early surgical results.
Abstract: Object. The authors sought to minimize scalp incisions, blood loss, and operative time by using endoscopically assisted strip craniectomies and barrel-stave osteotomies to treat infants with sagittal suture synostosis. Methods. Four patients, aged 2, 4, 9, and 12 weeks, who presented with scaphocephaly underwent endoscopic midline craniectomies through small midline scalp incisions. The mean operative time for the procedure was 1.68 hours (range 1.15–2.8 hours); the mean blood loss was 54.2 ml (range 12–150 ml). Three patients did not require blood transfusions and were discharged within 24 hours. Postoperatively, all patients were fitted with custom cranial molding helmets. Follow-up evaluation ranged between 8 and 15 months. All patients had successful correction of their scaphocephaly with no mortalities, morbidities, or complications. Conclusions. The use of endoscopic techniques for early correction of sagittal synostosis is safe; decreases blood loss, operative time, and hospitalization costs; and p...
TL;DR: This series shows, based on IFGF-I measurements and strict GH suppression criteria to define remission, that transsphenoidal surgery provides an excellent chance for long-term cure in patients with microadenomas.
Abstract: Object. The results of surgical therapy for acromegaly were assessed using carefully conducted endocrinological testing in 115 patients who underwent transsphenoidal surgery from 1981 to 1995. Methods. Ninety-nine of the 115 patients could be contacted for follow-up review; in 57 of the patients an endocrinological assessment was performed by the authors. Biochemical cure was strictly defined as a normalization of the insulin-like growth factor(IGF)—I level (obtained in 100 patients) and/or a basal or glucose-suppressed growth hormone (GH) level of 2 ng/ml or less. The mean length of follow up from transsphenoidal surgery to laboratory testing was 5.4 years with a maximum of 15.7 years. After transsphenoidal surgery alone, 61% of the patients achieved a biochemical remission; the remission rate was 88% for patients with microadenomas and 53% for those with macroadenomas. Tumor size and preoperative GH level tended to correlate negatively with outcome of surgery. Early postoperative GH level tended to corr...
TL;DR: The authors suggest the use of stereotactic radiosurgery as the preferred treatment for recurrent acromegaly resulting from unsuccessfully resected tumors.
Abstract: Object. The authors tested the assumption that gamma knife radiosurgery is more effective than fractionated radiotherapy for the treatment of patients with acromegaly who have undergone unsuccessful resective surgery. Untreated and uncured acromegaly causes illness and death. Acromegalic patients in whom growth hormone and, particularly, insulin-like growth factor I are not normalized must undergo further treatment. Methods. After unsuccessful operations, 16 patients suffering from recurrent and uncured acromegaly underwent stereotactic radiosurgery (25 Gy to the tumor margin, 50 Gy maximum), the outcome of which was compared with the result obtained in 50 patients who received fractionated radiotherapy (40 Gy). The cumulative distribution functions of the two groups (Kaplan—Meier estimate) differed significantly (p < 0.0001 in the log-rank test of Mantel). The mean time to simultaneous normalization of both parameters was 1.4 years in the group treated with the gamma knife and 7.1 years in the group trea...
TL;DR: Hearing preservation postsurgery by tumor type was as follows: 1A, 92; 1B, 88%; 1C, 100%; 2A, 83%; 2B, 92%; and 3, 57%.
Abstract: Object. The authors studied the relationships between tumor size, location, and topographic position relative to the intact facial nerve bundles in acoustic neurinomas to determine the influence of these factors on hearing preservation postoperatively. Consistent topographic relationships were found. Methods. Four hundred fifty-two patients with acoustic neurinoma treated via a retrosigmoid approach were analyzed with respect to hearing preservation and facial nerve function. One hundred fifteen tumors were identified as small and were categorized as Grades I and II. Patients with Grade I tumors, that is, purely intracanalicular lesions, all had good hearing preoperatively, defined by a less than 50-dB pure tone average and 50% speech discrimination score. All 14 Grade I tumors were removed, resulting in preservation of the patient's hearing by these criteria. There were no particular topographic anatomical relationships associated with these tumors that affected hearing preservation. Grade II tumors, def...
TL;DR: A novel method for intraoperative monitoring of spinal motor conduction that is safe, sensitive and specific to motor pathways, and compatible with anesthesia requirements is developed, and allows monitoring of spontaneous and/or nerve root stimulus-evoked electromyography.
Abstract: Numerous methods have been pursued to evaluate function in central motor pathways during surgery in the anesthetized patient. At this time, no standard has emerged, possibly because each of the methods described to date requires some degree of compromise and/or lacks sensitivity. Object. The goal of this study was to develop and evaluate a protocol for intraoperative monitoring of spinal motor conduction that: 1) is safe; 2) is sensitive and specific to motor pathways; 3) provides immediate feedback; 4) is compatible with anesthesia requirements; 5) allows monitoring of spontaneous and/or nerve root stimulus—evoked electromyography; 6) requires little or no involvement of the surgical team; and 7) requires limited equipment beyond that routinely used for somatosensory evoked potential (SSEP) monitoring. Using a multipulse electrical stimulator designed for transcranial applications, the authors have developed a protocol that they term “threshold-level” multipulse transcranial electrical stimulation (TES)....
TL;DR: Aggressive treatment including both surgical decompression and radiation therapy improves the quality of life in patients suffering from symptomatic pituitary metastasis.
Abstract: Object. The diagnosis and treatment of metastasis to the pituitary gland can be difficult to determine. The goal of this study was to analyze the clinical presentation, treatment, and prognosis of patients who presented with symptomatic pituitary metastasis. Methods. The cases of 36 patients with symptomatic pituitary metastases were reviewed. The most common primary cancers were breast (33%) and lung (36%). The presenting symptoms included diabetes insipidus, anterior pituitary insufficiency, and retroorbital pain. The overall median length of patient survival following diagnosis of pituitary metastasis was 180 days. In 20 patients (56%), symptoms stemming from pituitary metastasis were the first manifestation of illness. Local control of tumor was associated with significant improvement in survival times (p < 0.05) and amelioration of disabling symptoms including painful ophthalmoplegia and visual field deficits. Conclusions. Aggressive treatment including both surgical decompression and radiation thera...
TL;DR: The findings suggest that the pain control afforded by MC stimulation requires neuronal circuits that are maintained by the presence of intact corticospinal tract neurons originating from the MC.
Abstract: Object. The goal of this study was to identify the neurological characteristics of patients with poststroke pain who show a favorable response to motor cortex (MC) stimulation used to control their pain. Methods. The neurological characteristics of 31 patients treated by MC stimulation were analyzed. In 15 patients (48%), excellent or good pain control (pain reduction > 60%) was achieved for follow-up periods of more than 2 years by using MC stimulation at intensities below the threshold for muscle contraction. Satisfactory pain control was achieved in 13 (73%) of 18 patients in whom motor weakness in the painful area was virtually absent or mild, but in only two (15%) of the 13 patients who demonstrated moderate or severe weakness in the painful area (p < 0.01). Muscle contraction was inducible in the painful area in 20 patients when stimulated at a higher intensity. No such muscle response was inducible in the remaining 11 patients, no matter how extensively the authors attempted to determine appropriat...
TL;DR: It was possible to achieve relief of noncommunicating hydrocephalus, tumor resections, and even complete tumor removals by using endoscopic techniques, and the authors believe that endoscope techniques should be considered in the treatment of selected intraventricular lesions.
Abstract: Object The purpose of this study was to determine the efficacy of endoscopic treatment in patients with intraventricular tumors. Methods A series of 30 patients with endoscopically treated intraventricular lesions is reported. The lesions included seven colloid cysts, six astrocytomas, three subependymomas, two ependymomas, and one each of the following: pineoblastoma, pineocytoma/pineoblastoma (intermediate type), epidermoid cyst, pineal cyst, medulloblastoma, arteriovenous hemangioma, cavernoma, choroid plexus papilloma, pituitary adenoma, craniopharyngioma, melanoma, and germinoma. Total tumor resections, partial resections, biopsies, stent implantations, septostomies, and third ventriculostomies were performed. In two cases (two subependymomas > 2 cm in diameter), piecemeal endoscopic resection was ineffective because of the very firm consistency of the tumors. Therefore the endoscopic procedure was discontinued and the tumors were removed microsurgically. In the remaining cases the procedures were co...
TL;DR: Detachable platinum coil embolization is a promising treatment for ruptured basilar tip aneurysms that are not surgically clippable; in selected patients it offers lower incidences of morbidity and mortality compared with conservative medical management.
Abstract: Object. To assess the safety and efficacy of aneurysm embolization performed using Guglielmi detachable coils (GDCs), the authors reviewed the results of a cohort of 150 patients with either ruptured (83 patients) or unruptured (67 patients) basilar tip aneurysms treated with these detachable platinum coil devices in the early part of the United States multicenter GDC clinical trial that led to Food and Drug Administration approval for the device. Methods. The most common presentation in this cohort of patients was headache (53%). All patients were entered into the trial after neurosurgical assessment excluded them as candidates for surgical clipping of their aneurysms. Greater than 90% coil packing was achieved in 75% of the patients. For those patients in whom follow-up information was available, the mean angiographic and clinical evaluation follow-up time for 61 patients with ruptured aneurysms was 13.7 months (range 0–43 months) and that for the 49 patients with unruptured aneurysms was 9.8 (range 0–4...
TL;DR: The review of the surgical experience with the implantation of movable stainless-steel joints in 20 patients treated for cervical myelopathy, cervical radiculopathy, and severe pain indicated that the procedure is safe and well tolerated and does preserve cervical joint motion in most patients over an extended period of observation.
Abstract: Object. To assess the effectiveness of Cummins' artificial cervical joint, the authors reviewed the cases of 20 patients in whom the joint had been placed. Methods. A review of patients' medical records and reexamination of 18 patients were performed. The review of the surgical experience with the implantation of movable stainless-steel joints in 20 patients treated for cervical myelopathy (16 patients), cervical radiculopathy (three patients), and severe pain (one patient) indicated that the procedure is safe and well tolerated and does preserve cervical joint motion in most patients over an extended period of observation. To date, adjacent segmental symptomatic degenerative changes leading to further surgical treatment have been avoided. The joint has been placed in patients with advanced congenital and acquired cervical fusion and has been demonstrated to be stable, mobile, and biomechanically and biochemically compatible; it has shown no subsidence into adjacent bone. Wear debris has not occurred. Con...
TL;DR: The clinical course of patients with this lesion is summarized to clarify the nature of the small hemispherical bulge from the anterior wall of the internal carotid artery (ICA), which may be confused with a tiny berry aneurysm although the clinical features are distinctly different.
Abstract: Object. An aneurysm arising from the anterior wall of the internal carotid artery (ICA) is a poorly understood entity. A small hemispherical bulge from the anterior wall of the ICA, which is called a “blood blisterlike aneurysm” (BBA), may be confused with a tiny berry aneurysm although the clinical features are distinctly different. This paper summarizes the clinical course of patients with this lesion to clarify the nature of the BBA. Methods. Six patients with BBAs who presented with subarachnoid hemorrhage (SAH) are described. In all patients, the initial angiogram obtained soon after SAH showed only a small bulge from the anterior wall of the ICA. In three of the six patients this bulge had progressed to a saccular appearance within a few weeks. The wall of the lesion was so thin and fragile that the aneurysm ruptured at the base during clipping or within a few hours after clipping in two patients. Conclusions. From the authors' experience, as well as a review of the literature, which includes an aut...