World Neurosurgery

A Marvelous Landscape: The Endoscopic Universe

Michael L.J. Apuzzo — 2011-12-26

Charles Lutwidge Dodgson was a nineteenth century English mathematician, logician, Anglican deacon, and photographer. Dodgson was born into a Northern English, conservative, Anglican family of clergymen and army officers. A gifted mathematician, he attained first class in the Final Honors School of Mathematics at Christ Church, Oxford, holding the Mathematical Lectureship at that institution for 26 years. Deaf in one ear, he was troubled by a speech stammer, a hesitation that he acquired in early life. In addition, it is said that he suffered from migraines and episodes of syncope—being evaluated for epilepsy at the Radcliff Infirmary.

Neuroendoscopy: A Modern Perspective

Paolo Cappabianca — 2012-01-13

From among the many different evolving fields of our specialty, the choice to write a supplement to WORLD NEUROSURGERY on endoscopy comes from the Editor-in-Chief himself, who gave me the task of coordinating a group of experts from all over the world to provide a current update and “moving” inspection on this technique. And I feel deeply indebted for such an honor being assigned to me by Dr. Apuzzo, because he has been shown to be a master of science and a talented artist, with a global vision and long-distance perspective of what is and will be going on in the six continents covered by WORLD NEUROSURGERY. As a matter of fact, endoscopy represents, for the surgeon, the possibility to gain an intrusive view close to the relevant target area by means of what is not only a technical device, but rather an evolving philosophy projected toward a better vision, aimed at performing a safer procedure. The concept behind the action realized through the endoscope is the enrichment of knowledge and details enabling all the community involved in the operating room's daily activities to get the direct information about the surgical gesture. This is a matter of striving toward perfection, care for detail, active democracy, and a team approach.

Nanostructural Changes of Intervertebral Disc After Diode Laser Ablation

2011-11-15

Disc herniation remains a challenge for modern society. Laser decompression of the disc nucleus is one minimally invasive approach for the treatment of disc herniations. A diode laser with a wavelength of 810–1024 nm and emission power of 6–30 watts was used in this study. Despite good clinical results in some cases, the microstructural mechanisms of disc changes are still under investigation now. A team of neurosurgeons and scientists from Irkutsk, Russia, are applying the comparatively new method of atomic-force microscopy (AFM) for the investigation of nanostructure changes of intervertebral disc material after laser vaporization.

Direct Conversion of Fibroblasts to Functional Neurons

M. Yashar, S. Kalani, Nikolay Martirosyan — 2011-11-15

The application of stem cells to neurological diseases has experienced a great setback due to poor results from several clinical trials over the past 30 years. The shortcomings of many of these trials have stemmed from our lack of knowledge about the actual potential and biology of cell populations used, the heterogeneity of the patients who have had cell transplants, and the lack of a patient-specific and abundant source of cells for transplantation. The advent of induced pluripotency (iPS) revolutionized the field of regenerative medicine by allowing for generation of patient- and disease-specific stem cell populations from the skin of patients. This technology allows for the conversion of committed cell types into a quasi-embryonic stem cell state that can then be programmed into different cell types by using growth factor cocktails. A major roadblock to the application of this technology for transplantation has been the theoretical problem with uncontrolled and non–lineage-restricted growth of these cells. Three papers () in the latest issue of Nature demonstrate that this shortcoming can be remedied via the direct conversion of fibroblasts to functional neurons using transcription factors and small RNAs (). These papers provide a major advance in the field of regenerative medicine and stem cell biology. The technique of direct conversion of one cell type into another without going through an embryonic stem cell state prevents the formation of teratomas or cancerous growth of other tissue types when these cells are transplanted into their intended organ. These results further enrich our understanding of the fluidity of cellular identity and the signals necessary to change what was once believed to be a fixed state. Although far from clinical application, the ability of direct cellular conversion of fibroblasts to neurons has greatly advanced the likelihood that these cells may one day be used as therapeutics.

Human Oocytes Reprogram Somatic Cells to a Pluripotent State

Ryan D. Smith, Alexa Reeves, Abiodun Azeez, Michael L. Levy — 2011-11-15

Human embryonic stem cells (hESC) have long been known to carry the potential to make up any cell in the human body, from pluripotent cells of the blastula to terminally differentiated, specific tissue cells. Conceptually inherent in current approaches is that within the cellular substrate lies the algorithm to progress from an oocyte into every potential tissue type, both healthy and diseased. This allows not only for the immense possibility of defining the exact etiology of many diseases, but also to address the potential for a cure. Conceptually, replacing the genome of a somatic cell with that of an oocyte could result in the derivation of pluripotent stem cells that could address numerous degenerative disease states.

A Better Source of Therapeutic Stem Cells

Tobias A. Mattei, Andrew J. Tsung — 2011-11-15

The initial development of methods for generating induced pluripotent stem cells (iPSCs) through the reprogramming of differentiated adult cells has greatly stimulated the scientific community because such techniques seem to provide an alternative source of pluripotential cells that bypasses the ethical issues related to embryonic stem cell (ESC) research. Nevertheless, three original articles recently published in Nature () provide a significant alert to the scientific community that such reprogramming processes and subsequent in vitro culture of iPSCs may result in several genetic and epigenetic abnormalities.

Issam A. Awad — 2011-11-09

Neuroethics resides at the intersection of two fields of philosophy and science, the ethics of neuroscience and the neuroscience of ethics. The first deals with matters of morality (e.g., concepts such as good and evil, right and wrong, virtue and vice, justice) arising from alterations of the mind, including the effects of illness, injury, pharmaceutical, and surgical interventions. The second, the neuroscience of ethics, deals with questions of moral development and the theories of free will, and aims to define the neural substrate of conscience, goodness, values, and in a broader sense, the human mind, in the scientific context (empiric observations, experimental modification, reductionist and systems biology concepts).

Michael Y. Wang — 2011-11-09

Advancements in the field of minimally invasive spinal surgery (MISS) have occurred rapidly during the past decade. The need for such developments has been obvious to neurosurgeons, as the significant soft-tissue disruption associated with accepted open surgical procedures has many untoward immediate and delayed consequences for the patient. However, during this renaissance in minimally invasive surgery, documentation of the advances in the peer-reviewed literature has been sporadic. This has been in part attributable to the paucity of high-quality clinical studies in which investigators document the successes and failures of MISS. This shortage of peer-reviewed reports does not, however, indicate the success or failure of MISS procedures, and it is becoming increasingly understood that a multitude of neurosurgeons use some variations of MISS in their practices with highly successful, and likely superior, clinical results.

Upcoming Events

2012-01-01

WFNS Educational Course:

Development of Neurosurgery in Germany: Comparison of Data Collected by Polls for 1997, 2003, and 2008 Among Providers of Neurosurgical Care

Hans J. Steiger, Michael Krämer, Hans J. Reulen — 2011-11-09

Objective: To deduce structural trends in neurosurgery in Germany by comparison of data derived from polls conducted by the Deutsche Gesellschaft für Neurochirurgie (DGNC) in 1997, 2003 and 2008. Methods: The questionnaires of the different polls probed a comparable set of issues. The data from the responding sample were extrapolated to the nationwide average or sum and compared between the different time periods. Results: The number of identified neurosurgical departments increased from 146 to 201 during the years 1997–2008 largely as a result of the new foundation of numerous private groups. Nationwide total neurosurgical bed capacity and intensive care unit bed capacity increased modestly over the time period. The extrapolated total number of neurosurgical operations increased from 196,341 to 319,295. Although cranial and spinal neurosurgery remain the dominant subspecialties, the number of functional neurosurgical procedures and operations for pain increased more than proportionally. Outpatient procedures were established during the time period and corresponded in 2008 to a substantial proportion of the surgical volume. The total number of residents and board-certified neurosurgeons increased during the period 1997–2008 from 1513 to 1961. The proportion of residents decreased during 1997–2003 and then increased again. Conclusions: The number of neurosurgical operations increased in Germany proportionally to the economic growth of other service branches over the time period. Private organizations developed more than neurosurgical departments at university and other general hospitals. Work density measured as operations per physician increased during the period 1997–2008.

An American Medical Student's Experience in Global Neurosurgery: Both in Their Infancy

Jordan Magarik, Joseph Kavolus, Robert Louis — 2011-11-14

There are only three fully trained neurosurgeons to care for Tanzania's population of more than 41 million people. Madaktari was founded in 2006 to serve as a physician training partnership to establish more self-sufficient health care through education and training. Medical students play a valuable role in Madaktari as they are primarily responsible for collecting postneurosurgical outcome data on operations performed by Tanzanian physicians trained by our organization. In addition, medical students represent the future of global medicine. Thus, it is important to determine the extent that Madaktari has affected student interest in global health. Our purpose in this article is to explore one student's experience working in global neurosurgery while working with Madaktari. In addition we attempted to determine the effect Madaktari may play on the future medical careers of eight medical student volunteers. To determine that effect we conducted a six-question online survey of medical student volunteers. We received responses from four of our eight medical student volunteers, all of whom stated they had a good or excellent experience volunteering with Madaktari and that their experience further increased their desire to incorporate global health into their careers. After working with Madaktari nearly half of the medical student volunteers have pursued or will be pursuing year-long funded global health research during their medical school careers. Madaktari is not only pioneering a path toward increased and more independent neurosurgical capabilities in Tanzania, but it is also helping foster increased interest and participation among U.S. medical students in global neurosurgery.

Expanding Neurosurgical Care in Northwest Tanzania: The Early Experience of an Initiative to Teach Neurosurgery at Bugando Medical Centre

2011-11-14

Objective: Tanzania suffers from a severe lack of health practitioners trained in neurosurgical procedures. To address this problem, we have implemented an initiative, modeled after the experience of other pioneers in international neurosurgery, to establish cost-effective and sustainable neurosurgical care by teaching fundamental neurosurgical skills to local surgeons. In this report we describe our early experience in Northwest Tanzania and discuss the potential for this training model to improve neurosurgical care to a region in need. Methods: Between September 2009 and October 2010, three residents and two attendings from our institution spent a total of 15 weeks at Bugando Medical Centre in Mwanza, Tanzania. During this time, we focused on teaching neurosurgical techniques, intraoperative decision-making, and clinical management skills to two local surgeons. The emphasis of our presence was on teaching and providing sustainable neurosurgical care. Results: During this period, we performed 41 neurosurgical procedures with one of two local surgeons. The most common procedures performed were ventriculoperitoneal shunts (22%), myelomeningocele repairs (22%), and cranial trauma cases (17%). Five (12%) cases required the placement of spinal instrumentation. Thirty-nine (95%) patients remained stable or improved at discharge. There were 2 (5%) perioperative deaths. Conclusion: Although numerous challenges remain, our experience demonstrates the potential of this teaching model in providing sustainable neurosurgical care in Northwest Tanzania.

Delayed Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Riikka Tulamo, Mika Niemelä, Juha Hernesniemi — 2012-01-01

Delayed vasospasm is a devastating consequence of subarachnoid hemorrhage (SAH), affecting critically the outcome of individuals that suffer from rupture of an intracranial aneurysm. Of patients with symptomatic vasospasm or ischemic deficit 30% die, and 34% are left with permanent neurological deficit (). In addition to the triple-H therapy (hypertension, hypervolemia, and hemodilution), the common practice is to treat patients preventively with calcium antagonists (e.g., nimodipine) to prevent the obvious cause of vasospasm—the contraction of smooth muscle cells of the arterial wall (). Also some evidence support the use of magnesium in prevention of delayed vasospasm (). However, regardless of the current preventive therapy, the outcome of patients remains still poor. According to a meta-analysis one additional good outcome should occur for every seventh patient treated with nimodipine ().

The Sitting Position for Neurosurgery: Yet Another Case Series Confirming Safety

Andrew H. Kaye, Kate Leslie — 2012-01-01

A debate has raged since the introduction of the sitting position for neurosurgery about its benefits and risks. Numerous case series report the incidence of venous air embolism (VAE) and other complications, detected using a range of monitoring modalities, and during a variety of intracranial and cervical spine procedures (). However, some key questions about the safety of the sitting position remain unanswered.

The Art of Neuroanatomy

Katharine Cronk, Robert F. Spetzler — 2012-01-01

Although aneurysms of the posterior cerebral artery (PCA) are rare and represent only 1% of all intracranial aneurysms, the complex anatomy of the PCA itself and the surrounding tissue represents a particular challenge to the skull base surgeon. The surgical approach and dissection of the PCA are technically challenging because of the complexity of its perforating branches and their intimate relationship with the cranial nerves and upper brainstem. Arterial venous malformations that arise from branches of the PCA are also rare but also illustrate that both of these lesions require a thorough understanding of the anatomy of the PCA and the surrounding tissue for treatment. Although our current treatment paradigms may include surgery or endovascular techniques or a multimodality combination of these two treatments, any of these choices still requires a precise knowledge of the segmental anatomy of the PCA and its branches when these approaches are planned.

Erythropoietin for Subarachnoid Hemorrhage: Is There a Reason for Hope?

Giovanni Grasso, Francesco Tomasello — 2011-11-14

Subarachnoid hemorrhage (SAH) associated with a ruptured cerebral aneurysm remains a source of significant morbidity and mortality, not only from the initial hemorrhage but also from the delayed complications, such as cerebral vasospasm often severe enough to induce irreversible changes in cerebral perfusion. Several drugs have been developed that have the potential to limit cerebral vasospasm and delayed ischemic neurologic deficit, thus improving outcome for patients. However, although numerous agents that can prevent arterial narrowing and/or block the excitatory cascade of events leading to ischemic neuronal death in experimental conditions, there is still no pharmacologic agent that has been shown conclusively to improve the outcome in the clinical practice. Because the SAH-induced cerebrovascular dysfunction is a multifactorial process, the available pharmacologic therapies are addressed to counteract the main causative processes. The main therapeutic interventions used are limited to manipulation of systemic blood pressure, alteration of blood volume or viscosity, and control of arterial carbon dioxide tension.

Chronic Subdural Hematomas: Current Treatment

Faiz U. Ahmad, M. Ross Bullock — 2011-11-09

In their article, Nayil et al., from Sheri-Kashmir Institute of Medical Sciences, Kashmir, India, have presented their experience with chronic (CSDH) and subacute subdural hematomas. This series represents one of the largest series published to date on this topic. They have retrospectively analyzed 1347 subdural collections in 1181 patients with CSDH and subacute subdural hematomas operated on in a span of 4 years and reported their demographic profiles, clinicoradiologic features, surgical treatment, and outcomes. A major achievement! Sixty percent of the patients had history of previous head injury. Headache was the most common presenting symptom and hemiparesis was the most common neurological finding. The collection was bilateral in roughly one-fourth of the patients. Two burr holes and closed subdural drainage was performed in the majority of patients. The postoperative complication rate was 7.5% and mortality was a very low 3.1%. Their recurrence rate was also relatively low (6%). However, follow-up scans were done only in symptomatic patients and the final follow-up was reported at 3 months—both of which could be reasons to underestimate the actual recurrence rate. Perioperative seizure prophylaxis was not routinely used with very low seizure rate. Overall the results of the study are consistent with the literature, patients presenting in poor neurological grade did worst and higher recurrence rates occurred for those with a bleeding diathesis and multiloculated membranes.

Types of Postoperative Drainage for Chronic Subdural Hematoma: To Do it on the Table or Under?

Marco C.L. Kwan, David T.F. Sun, Wai S. Poon — 2011-11-16

The clinical features, etiology, and treatment options of symptomatic chronic subdural hematoma (CSH) has been described since the 1857 publication of the essay entitled “pachymeningitis haemorrhagica interna” by Virchow (). Its annual incidence, at 5 per 100,000 in the general population (), can be as high as 58 per 100,000 in the older age group (>70 year old) (). As the aging population reflects improving global health, it also raises special challenges for neurosurgeons to treat this sometimes vexing lesion. Although a small number of CSH may be secondary to coagulopathies and overdrainage of cerebrospinal fluid shunting, the majority are regarded as the result of an episode of undiagnosed trivial head injury.

The Abducens Nerve and Skull Base Surgery

Dirk De Ridder — 2011-11-16

Since the development of skull base surgery in the 1990s and the advance of highly skilled skull base centers, the detailed surgical anatomy of cranial nerves has become of more interest, and has forced neurosurgeons, anatomists, and neurologists to reevaluate undisputed knowledge of some cranial nerves. One of the cranial nerves that has come into focus is the abducens nerve.

Management of Supratentorial Intracerebral Hemorrhage—Still a Controversy?

Ludwig Benes, Christopher Nimsky — 2011-11-16

Spontaneous intracerebral hemorrhages (ICHs) bear a high mortality risk and are responsible for 10% to 30% of all stroke admissions to hospitals. The mortality rate of ICH accounts for 30% to 50%, and 20% of the patients involved are disabled after hemorrhage and mostly incapable of leading an independent, unsupported life (). Although there are some therapeutic advances, the treatment of ICH is still controversially discussed in the pertinent literature. On the one hand, there is advocacy for a conservative treatment option because some people have the opinion that a surgical therapy is presumably worsening a patient's outcome. This appraisal is referred to the first prospective randomized study from McKissock et al., published in 1961 (), and was the code of best practice for a few years. One should keep in mind that this was the pre–computed tomography (CT) era, with limited surgical skills and restricted therapy in intensive care units. On the other hand, there is the concept of classical surgical therapy by evacuating spontaneous intracerebral hematomas microsurgically via craniotomy. A multitude of studies were performed and published dealing with these different concepts of ICH management, demonstrating controversial results. A subsequent publication on this topic described the opposite observation to what McKissock et al. have described in terms of a patient's outcome after surgery (). These surgically treated patients with superficially located hemorrhages had a favorable outcome. They were treated by endoscopic hematoma evacuation. This trial was the onset of minimal invasive surgery for intracerebral hematoma evacuation. This minimally invasive technique was later supplemented by stereotactical CT-guided hematoma aspiration by using catheters placed into the hematoma with subsequent application of recombinant tissue plasminogen activator (rtPA).

Intracerebral Hemorrhage: The Pot Continues to Be Stirred

Sanju Lama, Garnette R. Sutherland — 2011-11-09

Primary intracerebral hemorrhage (ICH) constitutes approximately 15% of all strokes. Among caucasians, incidence is approximately 25 in 100 000 people per year, but this number is higher among other ethnicities, reaching up to 55 in 100 000 people within Asian populations (). Pathology is primarily localized to the arterioles and of a hypertensive etiology in the central aspect of the brain, while being more often associated with amyloid deposition in the neo-cortex (). Poor clinical outcome, with a 30-day mortality of more than 40%, has been observed, with only 20% of survivors gaining functional recovery by six months.

Bringing the Endovascular Neurosurgeon into the Neuro-oncology Treatment Team

Pierpaolo Peruzzi, E. Antonio Chiocca — 2011-11-16

Recurrence after radiation therapy and temozolomide defines the terminal stage of glioblastoma multiforme (GBM) and has been historically associated with a mean overall survival (OS) of 8-9 months (). Despite great efforts to find new therapeutic strategies, this outcome has been substantially unchanged for the past few decades. Recently, bevacizumab, a humanized antibody against the vascular endothelial growth factor (VEGF) that had already shown substantial survival benefit in patients with colorectal (), lung (), and renal cancers (), was approved by the U.S. Food and Drug Administration for treatment of recurrent GBM, in light of the results of two phase III clinical trials showing objective radiographic response (decrease of gadolinium-enhancing tumors on MRI, an imperfect correlate of glioma) in 25.9% and 19.6% of patients, and mean progression-free survival (PFS) of 4.2 and 3.9 months, respectively (). Friedman et al. () have recently reported an OS of 9.2 months in 85 patients with tumor recurrence treated with intravenous (IV) bevacizumab only. The rationale behind the use of bevacizumab derives from laboratory evidence that VEGF is a critical driver of angiogenesis, the tumor-driven process whereby cancer cells “recruit” endothelial-like cells to form new fragile and disorganized blood vessels that are essential for tumor growth (). VEGF receptors are localized both in the luminal and interstitial sides of endothelial cells lining blood vessels (). In the presence of an intact or only partially disrupted blood–brain barrier (BBB), bevacizumab can still exert an antiangiogenic effect by preventing activation of luminal receptors but cannot diffuse into the tumor and consequently has no effect on interstitial VEGF (). It has thus been hypothesized that bevacizumab could be even more effective if it did cross the BBB (). In this issue of WORLD NEUROSURGERY, Burkhardt et al. report their analysis of PFS and OS in 14 patients with recurrent GBM who received superselective, intra-arterial carotid injection of bevacizumab after mannitol-induced disruption of BBB, in addition to the standard biweekly regimen of 10 mg/kg IV bevacizumab.

Ventriculostomy Infections and Complications: Surely We Should Be Doing Better?

James R. Van Dellen — 2011-11-09

Cerebrospinal fluid (CSF) volume and its relationship to intracranial pressure can be a very challenging, and often very urgent, circumstance in clinical practice. The alteration of CSF volume is a means by which increases in normal and abnormal components in the intracranial volume can be rapidly, or slowly, accommodated to maintain normal intracranial pressure according to the Monro-Kellie equation. The presences of abnormal, or excesses of normal, components in the usually crystal clear, aqueous fluid may further alter the manner in which it behaves.

Lumbar Juxtafacet Cysts: Simply an Extension of the Lumbar Degenerative Process

Edward C. Benzel — 2011-11-16

In their article, Bashir and Ajani have clearly and concisely outlined the pathology and management of lumbar juxtafacet cysts (LJFCs). Using their large case series as a foundation for discussion, they have provided a well-constructed review of the literature. They point out the heterogenic nature of LJFCs, with the common characteristic being their adjacent location to the lumbar facet joint. They point out that the broad definition of LJFC includes cysts arising from the ligamentum flavum, synovial cysts (with a synovial lining, suggesting an existing or prior communication with the synovial joint with xanthrochromic fluid contained within), and ganglion cysts (no synovial lining with mucinous degeneration and proteinaceous fluid contained within). It appears, as they state, that “the histological differentiation does not appear to bear clinical significance, as one type of cyst could evolve into another.” They go on to reference the terminology “cystic formations of the mobile spine” as a catch-all term for all cystic lesions of the parafacet joint region in the lumbar spine. Regardless, they all appear to be related in some way (often by direct connection) to the lumbar facet joint.

Surgical Strategies in the Management of Sequestrated Disc Herniations in the Lumbar and Cervical Spines

Hiroshi Nakagawa, Koji Saito, Tohru Mitsugi — 2011-11-09

Orief et al. have reported six cases of sequestrated disc herniation, five in the lumbar spine and one in the cervical spine, which regressed in the follow-up magnetic resonance imaging (MRI) corresponding to neurological improvement. We also experienced the same kind of cases of cervical and lumbar disc herniations in the repeated MRI several months after the initial study. With their thorough review of the literature, they concluded that the possible mechanism of resorption of the sequestrated disc was dehydration and inflammation-mediated resorption as a foreign body in the vascular-rich epidural space, which seemed to be quite reasonable.

Spontaneous Disappearance of Large Herniated Disk Fragments

Konstantin V. Slavin — 2011-11-16

Examples of spontaneous resolution of neurosurgical conditions are rare. With the exception of intracranial hemorrhages that resorb over time and distal bacterial aneurysms that may heal without surgery, most anatomical and functional problems that come to attention of neurosurgeons remain stable or worsen during follow-up. Gradual worsening is pretty much expected whenever one talks about neoplasms, degenerative conditions, chronic infections, or vascular stenosis, particularly if they are not aggressively treated. Similarly, even with appropriate medical management, symptomatic spondylosis deteriorates over time and frequently requires surgical intervention when symptoms become refractory to conventional treatment or disabling.

Lumbar and Cervical Disc Herniations: A Common Problem, Many Solutions

Volker K.H. Sonntag — 2012-01-01

Lumbar and cervical disc herniation is most likely the most common entity that neurosurgeons treat throughout their career. A common presentation associated with a herniated disc, whether lumbar or cervical, is radiculopathy. A lumbar disc herniation is the most common cause of sciatica in working adults with an estimated annual incidence of 5 per 1000 adults ().

Is There a Benefit of Using Artificial Cerebrospinal Fluid for Irrigation?

Peter Siesjö — 2011-11-18

Routine evacuation of cerebrospinal fluid (CSF) has been a standard procedure in operative neurosurgery since its beginnings with the purpose to reduce intracranial pressure and increase surgical access. During surgery, newly produced CSF is continually evacuated to allow for continuing spatial access to deeper structures. With an estimated production of 10–15 mL/hr, the evacuated volume is soon replaced “as the water in a stream instantly fills up the space of a withdrawn fist.” Nevertheless, neurosurgeons routinely “fill up” the operative cavity with artificial fluids, most commonly saline or lactated Ringer's solution, mainly to avoid trapping of air in the operative area. Most neurosurgeons also advocate a strategy to keep the brain surface moist with rinsing fluid, be it of intuitive knowledge that the brain tissue could be damaged or more easily infected by “drying up” or only a routine that they learned from their tutors. Prolonged irrigation is also performed to remove liquefied hematomas, prototypically in surgery for chronic subdural hematomas through a burr hole.

Surgical Treatment of Blister-Like Aneurysms

Mark Garrett, Robert F. Spetzler — 2011-11-16

Dissecting or “blood blister–like” aneurysms of the supraclinoid internal carotid artery (ICA) are particularly difficult lesions to treat successfully. Located at nonbranching points along the ICA, these aneurysms are often described by their anatomic orientation on the ICA, such as dorsal, distal medial, superior, and internal carotid anterior wall. These lesions are challenging to treat because they typically have thin, fragile walls and poorly defined necks that are difficult to clip primarily. Because of their fragile nature, these aneurysms are at an increased risk for preoperative and intraoperative rupture. Various methods for treating these aneurysms, including direct clipping, clip wrapping, ICA trapping with or without bypass, and endovascular treatment, have been proposed.

Greater Superficial Petrosal Nerve: A Pole Star to Sail Into the Middle Cranial Fossa

Francesco F. Tomasello, Filippo Flavio Angileri, Salvatore Cardali — 2011-11-09

The greater petrosal superficial nerve (GSPN) is an anastomotic branch connecting the facial nerve to the vidian nerve. It contains sensory and parasympathetic fibers to the lacrimal gland and the nasal and palatal mucosa. In its course into the distal sphenopetrosal groove it is usually, but not always, covered by a bony ledge and dense endosteum (). Distally, it crosses the V3 branch of the fifth nerve.

How to Decrease the Incidence of Dysphagia After Anterior Cervical Surgery

Hiroshi Nakagawa, Koji Saito, Tohru Mitsugi — 2011-11-03

In this issue of WORLD NEUROSURGERY, Kalb et al. report a well-organized paper on risk factors for the development of dysphagia after anterior cervical surgery. In 27 (10.8%) of 249 patients who developed dysphagia, the authors found that older age (55 vs 50 years), longer surgical levels (2.2 vs 1.8 levels), and more operative time (186 vs 169 minutes) were more common compared with nondysphagic patients. However, they found no statistical differences in two groups in terms of sex, race, cigarette smoking, side and type of surgery, previous anterior cervical surgery, use and type of anterior plate, or use of postoperative collars.

Retethering After Filum Cutting

John R.W. Kestle — 2011-11-16

Dividing the filum terminale for “tethered cord” is a fairly common pediatric neurosurgical procedure, often done in the setting of a low conus and urologic abnormalities. The definition of a low conus is not precise; there is a range of normal for termination of the conus. As a result, surgical series sometimes include patients with the conus in the normal range. Furthermore, faced with a child with intractable urinary incontinence, abnormal (neurogenic) urodynamic testing, and a clearly normal conus termination, some surgeons will divide the filum.

If You Want to Learn New Things, Read Old Books: Cutdown Techniques Are Well Described in the Old Literature

Shady Jahshan, L. Nelson Hopkins — 2011-11-18

In 1927, the Portuguese neurologist Egas Moniz and his co-worker Almeida Lima performed the first successful cerebral angiogram (). This was performed in a 20-year-old patient with a pineal tumor. The procedure was done by surgical exposure of the carotid artery. Initially, most clinicians favored surgical exposure of the carotid artery rather than percutaneous injection. Later, the percutaneous approach became the standard route for angiographic injection as a part of the diagnostic imaging work-up for intracranial lesions, until the introduction of computed tomography in the 1970s.

How Can We Manage Difficult Access for Neuroendovascular Procedures?

Giuseppe Lanzino — 2011-11-18

Improvements in endovascular techniques have widened the range of lesions amenable to this therapy. Because it is perceived to be less invasive, endovascular therapy is offered to elderly patients and to patients with coexistent vasculopathies in an increasing number of cases. These factors have created new challenges because in many patients, despite continuous improvement of devices, catheters, and wires, access to the lesion is often the most difficult portion of the procedure. The tortuosity of the proximal vasculature in elderly patients and in patients with coexistent vasculopathies makes access challenging and sometimes impossible from the traditional and more familiar (to most endovascular surgeons) transfemoral route. In such cases, alternative access routes must be considered.

Direct Percutaneous Puncture Approach Versus Surgical Cut Down Technique for Intracranial Neuroendovascular Procedures

Peter A. Rasmussen, Alejandro Spiotta — 2011-11-18

Dorfer et al. report their experience with methods of approaching the intracranial vasculature from an endovascular standpoint that circumvent the conventional percutaneous transfemoral route. From a moderate-volume center (894 neurointerventions over a 15-year period), they describe the approach taken in 23 procedures (2%) in which the traditional transfemoral route was not accessible. Alternate approaches were devised to perform a wide spectrum of therapeutic interventions including aneurysm coil embolization, internal carotid occlusion, and arteriovenous malformation and carotid–cavernous fistula embolization. Femoral artery occlusion and difficult arch and/or cervical anatomy precluding access to the lesion were the scenarios in which unconventional alternate access was necessary. In other cases, the lesion was accessed, but stable microcatheter position was not possible via a transfemoral approach. In twelve patients, a surgical cut down was performed and in nine a direct percutaneous puncture was employed.

Inflammatory Pseudotumor: A Rare Intracranial Lesion

Christopher Nimsky, Malgorzata Kolodziej — 2011-11-09

An inflammatory pseudotumor is a tumor-like mass lesion, a non-neoplastic process of unknown etiology. This process is characterized by an unregulated growth of inflammatory cells, including the capacity for local invasion, rapid growth, recurrence, and even sarcomatous transformation. This kind of tumor is histologically characterized by a proliferation of fibroblasts, myofibroblasts, plasma cells, eosinophilis, lymphocytes, and histocytes. Mitotic figures can be present, but no abnormal mitotic figures are found.

Old-School Techniques Meet New-School Technology: 3D Fluoroscopy in Percutaneous Rhizolysis

Oren Sagher — 2011-11-09

In this issue of WORLD NEUROSURGERY, Olivero et al. describe a technique in which three-dimensional fluoroscopy is used as a way to enhance capabilities during the performance of percutaneous trigeminal balloon compressions. The cannulation of the foramen ovale is a key step common to all of the percutaneous approaches to the trigeminal nerve. It has been classically performed by the use of standard surface landmarks and biplane fluoroscopy. As the authors point out, this step can be sometimes challenging because it is occasionally difficult to visualize foramen ovale. Because individual anatomical variations can make it difficult to cannulate, the authors propose the use of three-dimensional fluoroscopic imaging to augment the standard biplane views to help both plan the trajectory and assess needle position along the way. The authors describe doing this in a three-dimensional neuro-angiography suite, which has the required hardware and software for doing these procedures. One could also envision doing this in the operating room with a three-dimensional isocentric fluoroscopy unit. Three-dimensional fluoroscopy, usually used in the performance of spine surgery, has started to make its way to other surgeries, including skull-base approaches, sinus surgery, pituitary surgery, and occasional functional procedures. Its use in percutaneous trigeminal procedures makes sense in this regard.

“Through the Looking Glass”: Optical Physics, Issues, and the Evolution of Neuroendoscopy

Gabriel Zada, Charles Liu, Michael L.J. Apuzzo — 2011-11-07

Although the concept of endoscopy has existed for centuries, a practical, working neuroendoscopic system did not emerge until last century, as a result of numerous contributions and refinements in optical technology, illumination sources, and instrumentation. Modern neuroendoscopy would not be a flourishing field, as it is today, without the dedication, innovation, and implementation of emerging technology by key contributors including Maximilian Nitze, Walter Dandy, and Harold Hopkins. Despite several inherent and unique limitations, neuroendoscopic surgery is now performed for a variety of intraventricular, skull base, and spinal operations. In this review, the history of neuroendoscopy, key players who envisioned how the inner workings of the human body could be visualized “through the looking glass,” and current state and future potential for neuroendoscopic surgery are discussed. Future directions of neuroendoscopic surgery will likely be guided by further miniaturization in camera and optical technology, innovations in surgical instrumentation design, the introduction of robotics, multi-port minimally invasive surgery, and an enhanced ability to perform bimanual microdissection.

Subdural Hematomas: An Analysis of 1181 Kashmiri Patients

2012-01-01

Background: We endeavored to analyze patients of subacute and chronic subdural hematomas studied in a 4-year period at the Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India. Methods: The study was a retrospective analysis of 1181 patients of subdural hematomas. Demographic characteristics, clinico-radiologic features, operative modalities, and outcome were studied. Acute subdural hematomas were excluded from the study. Results: The mean age was 60.4 ± 12.4 and males outnumbered females. Chronic subdural collections were more common than subacute subdural hematomas and left side predominated. Two burr holes with closed-system drainage was used in most patients. Incidence of postoperative seizures is very low. Overall recurrence rates were low; however, multilocular hematomas had the highest incidence of recurrence. Morbidity and mortality were 7.53% and 2.96%, respectively. Preoperative neurologic grade correlated with outcome. Conclusions: Subdural hematomas are common in elderly males. Preoperative neurologic grade dictates the outcome. Multilocular hematomas have a higher chance of recurrence. Craniotomy should be reserved for recurrent hematomas, and there may be a scope of craniotomy for multilocular chronic subdural hematomas at the outset. Antiepileptic prophylaxis is not routinely recommended.

Subdural Drainage versus Subperiosteal Drainage in Burr-Hole Trepanation for Symptomatic Chronic Subdural Hematomas

2011-11-16

Background: Symptomatic chronic subdural hematoma (scSDH) is one of the most frequent diseases in neurosurgical practice, and its incidence is increasing. However, treatment modalities are still controversial. Object: The aim of this retrospective single-center study is to compare for the first time two surgical methods in the treatment of subdural hematoma that have been proven to be efficient in previous studies in a direct comparison. Methods: We analyzed the data of 143 scSDHs in 113 patients undergoing surgery for subdural hematoma with placement of subperiosteal or subdural drainage after double burr-hole trepanation for hematoma evacuation. Results: Overall, there were no statistically significant differences regarding general patient characteristics, preoperative and postoperative symptoms, postoperative hematoma remnant, rates of recurrences, mortality, complications, and outcome at discharge and at 3-month follow up between the groups. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage system. Conclusions: Our study shows for the first time a direct comparison of two mainly used surgical techniques in the treatment of scSDH. Both methods proved to be highly effective, and general patient data, complications, outcome and mortality of both groups are equal or superior compared with previously published series. Because there is a clear tendency to less mortality and fewer serious complications, treatment with double burr-hole trepanation, irrigation, and placement of subperiosteal drainage is our treatment of choice in patients with predictable high risk of complications.

Dorello Canal Revisited: An Observation that Potentially Explains the Frequency of Abducens Nerve Injury After Head Injury

2011-11-16

Objective: The abducens nerve is frequently injured after head trauma and some investigators have attributed this to its long intracranial course. The present study aimed to elucidate an additional mechanism to explain this phenomenon. Methods: Twelve fresh adult cadavers underwent dissection of Dorello canal using standard microsurgical techniques. In addition, traction was applied to the nerve at its entrance into this canal before and after transection of Gruber ligament to observe for movement. Results: In all specimens, a secondary tunnel (i.e., tube within a tube) was found within Dorello canal that exclusively contained the abducens nerve. This structure rigidly fixated the abducens nerve as it traversed Dorello canal, thereby not allowing any movement. Transection of Gruber ligament did not detach the nerve, but after release of the inner tube, the nerve was easily mobilized. Conclusions: Rigid tethering of the abducens nerve with a second tube within Dorello canal affords this nerve no ability for movement with motion of the brainstem. We hypothesize that this finding is a main factor in the high incidence of abducens nerve injury after head trauma.

Stereotactic Aspiration Plus Subsequent Thrombolysis for Moderate Thalamic Hemorrhage

2011-11-11

Objective: This study aimed to evaluate the efficacy and safety of stereotactic aspiration combined with subsequent thrombolysis in treating moderate thalamic hemorrhage (TH). Methods: A total of 105 patients with TH were nonrandomly assigned to the conservative treatment group (n = 60) or to the aspiration group (n = 45). Patients in the aspiration group were treated with stereotactic aspiration plus subsequent thrombolysis for removal for their hematomas. Results: The 30-day mortality in the conservative group was significantly higher than that in the aspiration group (28.3% (17/60) vs. 11.2% (5/45), P = 0.032). The rank of the 30-day Glasgow outcome scale in the conservative group was significantly lower than that in the aspiration group (P = 0.041), and the mean 30-day National Institutes of Health Stroke Scale score of the survivors in the conservative group was significantly higher than that in the aspiration group (16.5 ± 4. 2 vs. 14.2 ± 3.9, P = 0.012). There were a greater reduction in TH volume in the aspiration group than in the conservative group from day 1 to day 3 (-0.24% and 39.28%, respectively, P < 0.0001) and from day 1 to day 7 (26.58% and 63.26%, respectively, P < 0.0001). The rank of 90-day Glasgow outcome scale was significantly lower in the conservative group than that in the aspiration group (P = 0.015). Eighteen of 60 patients (30.0%) had a favorable outcome in the conservative group, whereas 23 of 45 patients (51.1%) had a favorable outcome in the aspiration group, and this difference was significant (P = 0.028). The 90-day cumulative mortality rate in the conservative group was significantly higher than that in the aspiration group (33.3% (20/60)) vs. 15.6% (7/45), P = 0.039). Conclusions: Stereotactic aspiration plus subsequent thrombolysis is effective and safe for moderate TH.

Intra-Arterial Delivery of Bevacizumab after Blood-Brain Barrier Disruption for the Treatment of Recurrent Glioblastoma: Progression-Free Survival and Overall Survival

2011-11-23

Background: This prospective, single-center study assesses progression-free survival (PFS) and overall survival (OS) in patients with recurrent glioblastoma multiforme (GBM) treated with a single dose of superselective intra-arterial cerebral infusion (SIACI) of bevacizumab (BV) after blood-brain barrier disruption (BBBD). Patients were initially enrolled in our phase I study, for which the primary end point was to determine the safety and maximum tolerated dose of SIACI BV. Methods: Fourteen patients with recurrent GBM were recruited between August 2009 and November 2010 after failing the standard treatment with radiation therapy and temozolomide. None of these patients were previously treated with BV. After receiving a single dose of IA BV (2 to 15 mg/kg), standard IV BV chemotherapy was continued in 12 of 14 patients (86%). The recently updated Response Assessment in Neuro-Oncology Working Group (RANO) criteria were used to evaluate PFS, and the Kaplan-Meier estimator was used to evaluate PFS and OS. Results: Using RANO criteria, the median PFS in these patients was 10 months. The median OS estimation for this cohort was 8.8 months. The OS was less than the PFS because 4 patients died without progressing. Toxicity attributed to the IA BV treatment was present in 2 patients (wound dehiscence and rash). Another patient suffered from seizures 1 week after the SIACI procedure; however, this patient had epilepsy before and seizure type/frequency were similar before and after therapy. Conclusions: Our study shows that for patients naïve to BV, a single dose of SIACI BV after BBBD followed by IV BV offers an encouraging outcome in terms of PFS when compared with previous trials using IV BV with and without concomitant irinotecan (CPT-11). Larger phase II trials are warranted to determine whether repeated IA BV alone is superior to IV BV for recurrent GBM.

Factors Contributing to Ventriculostomy Infection

2011-11-17

Objective: Catheter-related infection remains a cause of morbidity in the use of external ventricular drains (EVDs). The aim of this retrospective single-center study was to assess the rate and factors related to ventriculostomy infections in the setting of the published literature. Methods: Patients that underwent EVD placement in a single-center were retrospectively reviewed. Diagnosis, treatment, hospital course, and infection-related data were collected and analyzed in reference to ventriculitis rates. The protocols for EVD placement and maintenance were reviewed. Results: Of 343 patients, 12 acquired an EVD infection. No significant differences existed between those with and without ventriculitis for age, sex, underlying diagnosis, or concomitant systemic infection. Although not significant, concomitant systemic infection existed in 4.7% of patients with ventriculitis versus 1.5% without. There was a significant difference in length of EVD placement in patients with ventriculitis (20.9 ± 15.3 days) versus those without (12.1 ± 18.2; P = 0.005). Coagulase-negative Staphylococcus and Staphylococcus aureus represented the most commonly associated pathogens. With an overall cumulative incidence of 3.5%, our rate compared favorably to the published literature (cumulative incidence 9.5%; range, 3.9%-23.2%). Conclusions: Catheter-related infection remains an important complication of EVD placement. Of factors evaluated, length of time of catheter placement has the most notable relationship to infection incidence, suggesting that early drain removal should be a goal whenever medically appropriate.

Management of Lumbar Spine Juxtafacet Cysts

El Fatih Bashir, Olufemi Ajani — 2012-01-01

Objective: We review a series of 21 patients with lumbar juxtafacet cysts (LJFCs) treated in two institutions. Methods: The charts of 21 patients with a diagnosis of LJFCs during a 6- year period, January 2001 to December 2006, treated at Hamad Hospital, Doha, Qatar, and El Ribat University Hospital, Khartoum, Sudan, were reviewed. Demographic data, clinical and imaging findings, management, and outcome were reviewed. Results: Twenty-one patients with 23 LJFCs were identified (14 men, 7 women) with a mean age of 54 years. All presented with back pain and radicular symptoms. Ten patients presented with neurogenic claudication due to spinal canal stenosis. All had magnetic resonance imaging and dynamic spine radiographs. Fourteen LJFCs were found at L4-5 level, 8 at L5-S1 level, and 1 at L3-4 level. Three patients had sustained improvement with conservative treatment and 17 patients underwent surgical management, mainly through a microsurgical approach. Nine of 10 patients with lumbar canal stenosis underwent decompressive laminectomy; one patient refused treatment. One patient with bilateral LJFCs and mobile spondylolisthesis underwent spinal fusion. All patients, except one, were followed up for a period of 12–72 months. Conclusions: LJFCs may lead to symptoms similar to degenerative disc disease. Surgery is reserved for symptomatic patients who do not improve satisfactorily with conservative treatment. The microsurgical approach is our preferred surgical method and spinal fusion should be reserved for patients with spinal instability. Long-term outcome with surgical treatment appears satisfactory.

Spontaneous Resorption of Sequestrated Intervertebral Disc Herniation

Tamer Orief, Yasser Orz, Walid Attia, Khaled Almusrea — 2011-11-18

Objective: The aim of this study is to describe six cases with spontaneous resorption of sequestrated intervertebral disc herniation observed using magnetic resonance imaging. In addition, the possible mechanisms, predictive factors of spontaneous disappearance of the sequestrated disc herniation, and the proper surgical timing were discussed and reviewed in literature. Methods: All the studied cases experienced acute radicular pain due to sequestrated intervertebral disc herniation; they refused surgery and were treated conservatively, and they were followed up neurologically and radiologically in the outpatient clinic in regular visits. Results: The studied cases included five cases with lumbar disc herniation (three at level L4-5 and two at level L5-S1) and one case with cervical disc herniation at level C5-6. All patients recovered from their radicular pain within 3 to 6 weeks, and it was correlated with resorption of their sequestrated intervertebral disc herniation as documented in their follow-up magnetic resonance imaging at 4 to 9 months. Conclusions: We found that sequestrated disc herniation has potential for regression, which can be clearly demonstrated by magnetic resonance imaging, because of having higher water content, and therefore, may regress through both dehydration and inflammation-mediated resorption. We suggest conservative treatment in the initial course of the sequestrated type of disc herniation for at least 2 months before recommending surgical intervention unless severe neurologic deterioration takes place.

Imaging Mass Spectrometry Evaluation of the Effects of Various Irrigation Fluids in a Rat Model of Postoperative Cerebral Edema

2011-11-18

Background: Using imaging mass spectrometry (IMS), we investigated the cerebral protective effect of an artificial cerebrospinal fluid (CSF), ARTCEREB (Artcereb, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan), as an irrigation and perfusion solution for neurosurgical procedures in a rat craniotomy model. Methods: Wounds created in the rat cerebral cortex were continuously irrigated with Artcereb, normal saline, or lactated Ringer's solution at a steady rate for 4 hours, after which brain tissue was collected. Brain slices were prepared and analyzed using IMS. Results: In tissue surrounding the injury, the signal intensity for Na adduct ions to phosphatidylcholine was high and that for K adduct ions to phosphatidylcholine was low. This is thought to reflect the level of water retention in brain cells and to be a change accompanying edema. The signal intensity with Na adduct ions to phosphatidylcholine was significantly lower in the Artcereb group than in the physiological saline or lactated Ringer's solution groups. Conclusions: IMS analysis in a rat craniotomy model indicated that the level of water retention in brain cells, calculated from the signal intensity of Na-adducted phosphatidylcholine around the wound area, was lowest in the Artcereb group, suggesting that artificial CSF that has similar composition and properties to human CSF can minimize edema in the brain surrounding the surgical wound.

A Case for Further Investigating the Use of Controlled Lumbar Cerebrospinal Fluid Drainage for the Control of Intracranial Pressure

Ali Murad, Samer Ghostine, Austin R.T. Colohan — 2011-11-17

Objective: Increased intracranial pressure (ICP) that is refractory to medical measures and ventriculostomy placement after severe traumatic brain injury or aneurysmal rupture is associated with high mortality. In some recent reports, authors have described the use of lumbar cerebrospinal fluid drainage in these patients. We report the results of a prospective study involving the use of lumbar drainage in 15 patients with elevated ICP that was refractory to medical management and ventriculostomy placement. Methods: A prospective study was designed to enroll patients at Loma Linda University Medical Center. Ten patients with traumatic brain injury and five patients with ruptured aneurysms were enrolled. Medical management included maintaining serum Na >150 mEq/L, mild hyperventilation, deep sedation, and maintenance of normothermia. A lumbar drain was placed when ICP was >20 mm Hg for an average of 3 hours despite the optimization of the aforementioned parameters. Results: After lumbar drain placement, ICP was reduced from a mean of 28.2 ± 6.5 mm Hg to 10.1 ± 7.1 mm Hg (P <0.001). Requirements for hyperosmolar therapy, sedatives, and paralytics were also significantly decreased (P < 0.05) after lumbar drain placement. One patient had unilateral papillary changes four hours after lumbar drain placement. The pupil returned to its normal state after decompressive craniectomy. There was no incidence of CSF infection. Three of the 15 patients died during the study period. Conclusions: This study shows the beneficial role of lumbar cerebrospinal fluid drainage as an effective and safe treatment modality for elevated ICP.

Ischemic Complications after Radial Artery Grafting and Aneurysmal Trapping for Ruptured Internal Carotid Artery Anterior Wall Aneurysm

2011-11-21

Objective: Treatment of ruptured internal carotid artery anterior wall (ICAW) aneurysms presents a surgical challenge because limitations and difficulties are encountered with either clipping or endovascular treatment. The present study examined clinical outcomes after aneurysmal trapping followed by radial artery grafting for management of these difficult lesions. Methods: Radial artery grafting was followed immediately by parent artery occlusion in five sides of five patients with acute ruptured ICAW aneurysm (3 men, 2 women; mean age 55.2 years). All patients underwent postoperative angiography and computerized tomography to assess graft patency and ischemic complications including vasospasm. Results: Of the five patients, only one had a poor outcome. However, temporary ischemic complications due to vasospasm developed in four (80%) of the five patients. Long-term results of radial artery grafting and internal carotid trapping for acute stage ruptured ICAW were satisfactory, but detailed analysis indicated a high risk of ischemic complications. Conclusions: The long-term result was satisfactory, but there was a high rate of acute stage ischemic complications due to delayed vasospasm and low perfusion from the radial artery graft. Based on these results, the investigators recommend that, in addition to intraoperative anticoagulation therapy, in cases where the cerebral blood flow study in the early postoperative period indicates low cerebral perfusion or in cases with World Federation of Neurological Societies grade III-V, the patients should be placed under the highest level of intensive care to detect ischemic complications.

Microsurgical Anatomy of the Greater Superficial Petrosal Nerve

Yong-Xiang Shao, Xin Xie, Hong-Sheng Liang, Jie Zhou, Meng Jing, En-Zhong Liu — 2011-11-03

Objective: To clarify the orientation, classification, and relationships of the greater superficial petrosal nerve (GSPN), and to provide a detailed description on the microsurgical anatomic features and some landmarks to its identification. Methods: A microsurgical anatomic dissection of the GSPN was studied in 40 specimens obtained from 20 adult cadaveric heads fixed in formalin. The course of the GSPN and its relationship to neighboring anatomic structures were observed. Results: The GSPN could be divided into four segments: intrapetrosal, suprapetrosal, of foramen lacerum, and of pterygoid canal. About 17.5% (7/40) of GSPNs had communication with the glossopharyngeal nerve (GN). According to communication between the GSPN, internal carotid plexus, and GN, the segment of the foramen lacerum could be divided into five types. The middle meningeal artery and internal maxillary artery were the major blood suppliers of the GSPN. The GSPN usually ran parallel with the lesser petrosal nerve, but sometimes they were at angle to each other. Conclusions: The relationships between the GSPN and its surrounding structures were studied. The vulnerability of the GSPN is attributed to diverse factors. We confirmed the communication branches between the GSPN and the GN. Our study is important to the understanding of the relationship of the GSPN with adjacent structures and will improve further information during skull base operations.

Dysphagia After Anterior Cervical Spine Surgery: Incidence and Risk Factors

2011-11-17

Objective: To evaluate risk factors for the development of dysphagia after anterior cervical surgery. Methods: The records of 249 patients who underwent anterior cervical surgery were reviewed. The presence and severity of dysphagia were assessed with the Dysphagia Disability Index 6 weeks and 3, 6, and 12 months after surgery. Age; sex; ethnicity; cigarette smoking; previous cervical surgeries; reoperation for same pathology; type of procedure, incision, and instrumentation; number and levels involved; side of procedure, length of surgery; and use of postoperative bracing were analyzed. Results: During the first 6 months after surgery, 27 (10.8%) patients developed dysphagia. From these patients the presence of dysphagia at 6 weeks and at 3 and 6 months was 88.8%, 29.6%, and 7.4%, respectively. By 12 months, dysphagia had resolved in all cases. The mean age of patients with dysphagia was 55 years (SD 12.98) and 50 years (SD 12.07) in patients without dysphagia (P = 0.05). Dysphagic patients had an average of 2.2 (SD 1.15) levels operated compared with 1.84 (SD 0.950) in nondysphagic patients (P = 0.05). Patients who developed dysphagia were most often treated at C4-5 (67%) and C5-6 (81%: P < 0.001). Although mean operative time was slightly longer in patients with dysphagia (186 minutes) compared with those without (169 minutes), the difference was not significant. Conclusions: In our patients, the incidence of dysphagia was low, and it had completely resolved at 12 months in all cases. Risk factors for dysphagia were multilevel procedures, involvement of C4-5 and C5-6, and age.

Outcome, Reoperation, and Complications in 99 Consecutive Children Operated for Tight or Fatty Filum

Lauren R. Ostling, Karin S. Bierbrauer, Charles Kuntz — 2011-11-21

Objective: Recent studies have suggested that retethering in patients operated for a tight or fatty filum is higher than previously predicted. In this retrospective review, outcome, complications, and risk of reoperation for recurrent tethered cord syndrome (TCS) at our own institution were investigated. Methods: The medical records of 100 consecutive children who underwent initial division of the filum terminale at Cincinnati Children's Hospital Medical Center (November 1995–May 2006) for a tight or fatty filum were reviewed. One patient was excluded due to previous spinal surgery at an outside institution. Presenting symptoms/signs, magnetic resonance imaging findings, complications, postoperative symptoms/signs, and need for reoperation were recorded. Mean follow-up for 97 of the 99 patients was 33 months; 80 were followed for 6 months or more and 68 were followed for 12 months or more. Results: The most common presenting symptoms were bladder and/or bowel dysfunction, followed by gait abnormality, back pain, and spasticity. At last follow-up, 85 patients were improved or stable, whereas 12 patients had at least one symptom or sign that had worsened. Five children required a second operation for recurrent TCS. Mean time to reoperation was 58 months (range 22–73 months). Arachnoid adhesions accounted for the retethering in four of five patients. There were a total of 12 complications in 9 patients including 5 wound infections, 4 cerebrospinal fluid leaks, 1 pseudomeningocele, 1 stitch abscess, and 1 transient headache. Conclusions: Division of a tight or fatty filum, in this consecutive series of pediatric patients, resulted in improved or stable neurological symptoms in 88% of patients. However, the complication and reoperation rate for recurrent TCS were not insignificant. Future studies aimed at reducing complications and retethering in this population may be warranted.

Direct Percutaneous Puncture Approach versus Surgical Cutdown Technique for Intracranial Neuroendovascular Procedures: Technical Aspects

2011-11-18

Objective: To present the authors' experience with a direct transcervical or transbrachial puncture approach in neuroendovascular procedures in which cranial access via the commonly used percutaneous transfemoral route was impossible because of tortuous upstream angioarchitecture. Methods: During 1992-2007, 23 neuroendovascular procedures were performed in 21 patients via a direct puncture approach. In 12 patients, surgical cutdown (SCD) and cannulation of the targeted artery (carotid, n = 8; vertebral, n = 4) were done. A direct percutaneous puncture (PP) of either the carotid (n = 5) or the brachial (n = 4) artery was done in nine patients. Treated pathologies were as follows: 10 ruptured and 6 unruptured cerebral aneurysms including two stent-assisted coiling and one internal carotid artery (ICA) balloon occlusion, four brain arteriovenous malformations (AVMs) and one carotid cavernous fistula (CCF). Results: Of 21 patients, 19 (90.5%) had a direct puncture introduction of the microcatheter and successful endovascular procedure. No complications related to the technique were encountered either in the PP or in the SCD group. Conclusions: Transcervical or transbrachial direct puncture accomplished with PP or by SCD is an effective and safe access route in patients in whom neuroendovascular interventions cannot be done transfemorally. In cases where extensive perioperative anticoagulation is mandatory, bleeding at the puncture site may be a serious problem and can be controlled more effectively through an open surgical approach than by percutaneous maneuvers.

Aneurysm of a Duplicate Middle Cerebral Artery

2011-11-21

Background: Anatomic middle cerebral artery (MCA) anomalies are rare, but each of the described variants (eg, duplicate, fenestrated, accessory) can be of clinical significance. Case Description: A 34-year-old man with a history of left hemispheric stroke was found to have an aberrant, early-arising duplicate left M1 segment of the MCA with an associated asymptomatic fusiform aneurysm. The patient was treated with a superficial temporal artery (STA) to distal MCA bypass followed by surgical trapping of the aneurysm. Results: Intraoperative and follow-up angiography performed postoperatively at 3 months showed complete isolation of the aneurysm from the circulation and patency of the bypass graft. The postoperative course was uneventful with the exception of a craniotomy flap infection, which was effectively managed with intravenous antibiotics, flap removal, and subsequent use of a fabricated replacement. Conclusions: This rare case is presented and used as a framework for a brief discussion of the literature regarding both variant MCA anatomy and treatment considerations for these anomalies when associated with an aneurysm.

Endovascular Treatment of a Bilateral Dural Carotid-Cavernous Fistula Using an Unusual Unilateral Approach Through the Basilar Plexus

2011-11-21

Background: Indirect carotid-cavernous fistulae are dural arteriovenous shunts between dural branches of the internal and/or external carotid arteries and the cavernous sinuses. Methods: We present an uncommon case of bilateral dural carotid-cavernous fistula with aggressive angioarchitectural features that was successfully treated with bilateral coil embolization using an unusual unilateral transvenous approach through the basilar plexus. Conclusions: This route should be considered for similar cases, and also for unilateral fistulae when the ipsilateral petrosal sinus cannot be accessed.

Neuroendocrine Tumor of Unknown Origin Metastasizing to a Growth Hormone-Secreting Pituitary Adenoma

Farshad Nassiri, Michael Cusimano, Fabio Rotondo, Eva Horvath, Kalman Kovacs — 2011-11-09

Background: Metastasis of a neuroendocrine tumor to the anterior pituitary is extremely rare. Methods: A 55-year-old woman presented with features suggestive of acromegaly and bone and joint pain. A bone scan suggested metastatic disease. A biopsy of the lumbar spinal lesions revealed a neuroendocrine tumor. Magnetic resonance imaging of the sella demonstrated a lesion with parasellar and suprasellar extensions. Given the need for tissue diagnosis and optic compression, the sellar lesion was removed via transsphenoidal hypophysectomy. Results: Histology of the biopsy indicated two different tumors in close association. One showed histological features of a pituitary adenoma, whereas the other was a neuroendocrine carcinoma. The pituitary adenoma was immunopositive for growth hormone (GH), whereas the neuroendocrine carcinoma was immunopositive for serotonin and bombesin and immunonegative for GH. Conclusions: This is the first report of a serotonin and bombesin immunopositive neuroendocrine tumor of unknown primary origin metastatic to a GH-secreting pituitary adenoma, resulting in acromegaly.

Inflammatory Pseudotumor of the Cerebellum in a Patient with Crohn's Disease

2011-11-21

Background: Inflammatory pseudotumors are ubiquitous lesions characterized by a polymorphous inflammatory infiltrate containing plasma cells and lymphocytes. In the central nervous system, this pathological condition is rare and the association with Crohn's disease has never been described. Case Description: A 31-year-old woman with a history of Crohn's disease was referred to our department for progressive headaches and nausea. Neurological examination was normal. Magnetic resonance imaging showed an irregular heterogeneous enhanced mass infiltrating the left cerebellar hemisphere. Total resection was performed and pathological examination led to the conclusion of an inflammatory pseudotumor. Conclusion: To our knowledge, this case is the first describing an intra-cerebral inflammatory pseudotumor associated with an inflammatory bowel disease. The diagnosis of an extradigestive location of Crohn's disease was excluded by pathological examination. Although the precise cause of this association remains unknown, it could be hypothesized that the intra-cranial lesion could be the result of the immunosuppressive therapy given for Crohn's disease, or, more likely, could be a part of a systemic dysimmune process.

Percutaneous Balloon Rhizotomy for Trigeminal Neuralgia Using Three-Dimensional Fluoroscopy

William C. Olivero, Huan Wang, Richard Rak, Matthew F. Sharrock — 2011-11-21

Background: Percutaneous balloon rhizotomy is one of the standard techniques for the treatment of trigeminal neuralgia. However, there have been well-reported complications from cannulating the foramen ovale (FO). We describe a novel technique for cannulating the FO using 3-dimensional (3D) rotational fluoroscopy. Methods: Three-dimensional rotational fluoroscopy is used to reconstruct the skull base. The optimal working projection is thus generated to best visualize the FO. When the optimal working projection is not anatomically feasible, for example, in a patient with severe cervical spondylosis, further rotational fluoroscopic data acquisition can assess the position of the needle to determine its relationship to the foramen. Furthermore, while inflated, the balloon position can also be verified with the same rotational technique. Results: Three-dimensional rotational fluoroscopy allows quick, safe, and easy cannulation of the FO. The equipment is readily available in the biplanar fluoroscopy suite. Its use should decrease the incidence of complications reported with the standard fluoroscopic technique. Conclusions: Three-dimensional rotational fluoroscopy allows real-time visual guidance to cannulate the FO and determine the optimal position of the inflated balloon. We believe that this is an important adjunct for treating trigeminal neuralgia via percutaneous techniques.

Extradural En-Plaque Spinal Meningioma with Intraneural Invasion

Jayshree Tuli, Dan Michael Drzymalski, Hart Lidov, Sagun Tuli — 2011-11-21

Background: Extradural spinal meningiomas are rare. Our understanding of purely extradural spinal meningiomas is incomplete because most reports rarely differentiate purely extradural meningiomas from extradural meningiomas with an intradural component. Occasionally, reports have described involvement of the adjacent nerve root, but there has never been a description of an extradural meningioma that actually infiltrates the nerve root. Case Description: A 42-year-old woman presented with progressive lower extremity weakness and numbness below T3 during the span of 4 months with imaging evidence of an extradural lesion compressing the cord from T4 through T6. Surgical resection revealed an extradural mass extending through the foramen at T5-6 and encompassing the cord and T5 root on the left. Pathologically, the lesion was a World Health Organization grade I meningioma with nerve root invasion and a concerning elevated mindbomb homolog 1 (MIB-1) of 9.4%. Conclusions: Purely extradural meningiomas are rare, and our case is one of the first to describe a patient with an extradural meningioma that actually infiltrates the nerve root. Extradural spinal meningiomas are usually not adherent to the dura, but only appear to be adherent or invade (as in our patient) the adjacent nerve root. They are easily mistaken preoperatively and grossly intraoperatively for malignant metastatic tumors and can change the proposed surgical treatment. The long-term prognosis remains uncertain, but our patient's last follow-up suggests a favorable prognosis.

Validation of the Intra-Operative Use of 5-Aminolevulinic Acid (5-ALA) in Patients With Suspected High Grade Glioma in the Two Belgian Gliolan® Training Centres

2012-01-01

The extent of surgery is one of the significant, independent prognostic factors in patients with HGG. Gliolan® has been registered as a real-time intra-operative tool to enhance the extent of resection.

Narciclasine, A Plant Growth Modulator, Shows Anti-Tumoral Activity in Vitro and In Vivo in Human Preclinical Models of Primary and Secondary Brain Tumors

F. Lefranc, V. Mathieu, G. Van Goietsenhove, R. Kiss — 2012-01-01

Cell motility and resistance to apoptosis characterize glioblastoma growth and malignancy. Narciclasine extracted from Daffodil, an Amaryllidaceae isocarbostyril controlling plant growth by means of actin cytoskeleton modulation could represent a powerful new weapon targeting the Achilles' heel of brain tumors.

Four-Hand Endonasal Endoscopic Surgery for Anterior Skullbase Pathology: Our Lessons Learned Over 40 Cases

T. Van Havenbergh, T.H. Somers, D. Berghmans, K. De Smedt, R. Van Paesschen — 2012-01-01

To present the pitfalls and surgical difficulties we experienced performing the first 50 cases of endoscopic endonasal procedures for anterior skull base lesions. We collected all data concerning pathology, surgical procedure and surgical results. The treated pathology consisted of pituitary tumors (28), Rathke cleft cyst (1), craniopharyngeoma (1), meningioma (2), metastases (2), juvenile angiofibroma (3), chordoma (2) and chondroma (1). We focused on the peroperative difficulties encountered such as exposure, handling space, bleeding, surgery duration and complication management.

Endovascular and Surgical Treatment of Intracranial Aneurysms in A Non-Academic Centre: A Retrospective Analysis On Safety, Clinical Outcome And Costs

J. Cotens, E. Gielen, Y. Palmers, M. Vandersteen, J. Wuyts, L. Stockx — 2012-01-01

This study validates the results of endovascular embolisation and neurosurgery treatment of intracranial aneurysms in an observative and retrospective way. Aim of the study was to evaluate morbidity, mortality and hospital costs of each technique for treatment of aneurysmal subarachnoid hemorrhage (aSAH) and unruptured aneurysms.

Recanalization and SAH Recurrence After Treatment By Endovascular Coiling or Surgical Clipping of Ruptured Intracranial Aneurysms

E. Costa, G. Vaz, C. Raftopoulos — 2012-01-01

To analyze the risk of recanalization and subarachnoidal haemorrhage (SAH) recurrence after treatment by endovascular coiling (EVC) or surgical clipping (SC) of ruptured intracranial aneurysms (RIA).

Intraoperative Assessment of Incomplete Clipping of An Aneurysm and of Vascular Patency in The Surrounding Vessels By a Near-Infrared Indocyanine Green Video-Angiography-Integrated Microscope

J. Van Oostveldt, J. Wuyts, F. Weyns, K. Engelborghs, D. Peuskens — 2012-01-01

First described in 2003 the application of microscope-integrated near-infrared (NIR) indocyanine green video-angiography (ICG VA) is a relatively new technique of blood-flow measurement that may help to improve the final result of cerebrovascular surgery.

Evaluation of The Treatment Using a Clip-Reinforced Wrapping Technique With Collagen-Impregnated Dacron for Intracranial Aneurysms Without Favorable Characteristics for Embolisation or Surgical Clipping

G. Vaz, M. Di Santo, M.-A. Doquier, C. Raftopoulos — 2012-01-01

The treatment of the intracranial aneurysms (ICA) is either by coil embolisation or by surgical clipping. However there are aneurysms without ideal characteristics for these two techniques. We present our experience to treat these particular ICA by a clipreinforced wrapping technique.

Multiple Subpial Transections and MRI-Imaging

P. Finet, C. Grandin, G. Vaz, C. Raftopoulos — 2012-01-01

The use of multiple subpial transections (MST) in the treatment of epilepsy refractory to medical treatment with the epileptogenic zone in an eloquent area is known since 1989. However, there are very few data of the impact of this surgical technique in MRI-imaging. what we suggest to report.

Incorporation of Navigated Transcranial Magnetic Stimulation Data in Preoperative Navigation Planning

H. Colle, B. Noens, G. Alessi, B. D'Haen, L. De Waele, C. van der Linden — 2012-01-01

Transcranial magnetic stimulation can be used for functional location of motor cortex; when this technique is used in combination with preoperative MRI-anatomy (Navigated Transcranial Magnetic Stimulation, NTMS), a precise localisation of eloquent areas in the precentral gyrus can be obtained in preoperative navigation planning, regardless of distortion by presence of tumour.

Is Paralysing Lumbar Disc Herniation a Surgical Emergency?

2012-01-01

Foot drop from lumbar disc herniation (LDH): what and when to do? Our objective is to evaluate the prognostic factors of motor recovery in case of paralysing LDH. 30 charts were retrospectively reviewed of patients suffering of LDH with motor deficit. We excluded LDH with cauda equina syndrome.

Early Individualized Physical Therapy After First-Time Lumbar Microdiscectomy and the Effect on Proprioceptive Postural Control, Disability and Pain: A Pilot RCT

2012-01-01

Despite the high success rate of first-time lumbar microdiscectomy (LMDT), residual functional complaints are not infrequent. We investigated whether individualized physical therapy (PT) after LMDT compared to a control group improves proprioceptive postural control and functional outcome.

Spinal Metastases. A Retrospective Analysis of The Experience in UZ Leuven

P.h. De Vloo, J. Goffin, B. Depreitere — 2012-01-01

Spinal metastases and associated spinal cord compression and spinal instability are considered to be incapacitating, though underrecognised and undertreated complications of cancer. Several treatment modalities are being used, with difficulties arousing in decision making, even more since the Patchell RCT.

Posterior Osteosynthesis of the Atlas for Non-Consolidated Jefferson Fractures: A New Surgical Technique

L. Abeloos, O. De Witte, M. Walsdorff, I. Delpierre, M. Bruneau — 2012-01-01

The two surgical techniques reported until now for stabilizing atlas burst fractures are associated with important drawbacks. Posterior C0–C2 or C1–C2 fixations reduce significantly head rotation while the transoral C1 lateral masses osteosynthesis can be associated with oropharyngeal and neurological complications, such as cerebrospinal fluid leaks, meningitis, neurological deficits, and pseudo-meningocele. We propose a new surgical technique, that can be applied in some conditions for the treatment of unstable Jefferson fractures, aimed at avoiding these problems by reconstructing selectively the atlas from a posterior approach.

Dynamic Cervical Implant. Alternative Between Cage Fusion and Total Disc Replacement

G. Matgé — 2012-01-01

Although cervical total disc arthroplasty (TDA-C) has shown equivalence or superiority over anterior cervical discectomy and fusion (ACDF), potential problems include non-physiologic motion which may accelerate degeneration of the facet joints, particulate wear, and compromise of the endplate mechanical integrity during device fixation. Cervical stabilization with DCI is a motion-preserving concept that facilitates controlled, limited flexion and extension, but prevents axial rotation and lateral bending, thereby reducing motion across the facet joints.

Cervical Laminoplasty for Spondylotic Myelopathy. A Study of 15 Patients

2012-01-01

The treatment of cervical spondylotic myelopathy (CSM) entails a variety of techniques: anterior cervical discectomy with or without fusion, anterior cervical corpectomy with fusion, laminectomy, laminectomy with fusion and laminoplasty. There is level III evidence that all techniques lead to improved functional outcome but laminectomy appears to be associated with late deterioration caused by postoperative kyphosis. Laminectomy with fusion as an alternative to prevent postoperative kyphosis, compromises mobility. Laminoplasty is a less destabilizing alternative while preserving mobility.

O-Arm Guided Balloon Kyphoplasty: Prospective Monocenter Case Series of 54 Consecutive Patients

F. Schils, J. Lenaerts, T. Guillaume — 2012-01-01

Balloon kyphoplasty is now widely used to treat vertebral compression fractures. Procedure outcome and safety is directly linked to precise radiological imaging, requiring one or two C-arm to allow correct visualization throughout the procedure. This minimally invasive spinal surgery is associated with radiation exposure for both patient and surgeon.

Transdiscal L5-S1 Screws as an Adjunct Fixation Method in Instrumented Posterolateral Fusion in Patients With Severe Dysplastic Spondylolisthesis

S. De Muynck, J. Goffin, B. Depreitere — 2012-01-01

No consensus exists on the best surgical strategy in symptomatic high grade lumbosacral spondylolisthesis. Attempts to reduce high-grade slippage carry a risk for L5 root injuries. Bohlman and Abdu reported new methods for in situ transfixation using transdiscal fibular strut grafts/pedicle screws. We report on 3 patients with high grade L5-S1 spondylolisthesis in whom instrumented posterolateral fusion was supplemented with transdiscal traction screws.

An Unusual Case of Dural Plasmacytoma

J. Duerinck, K. Van Rompaey, M. Moens, A. Michotte, R. Schots, J. D'Haens — 2012-01-01

Dural plasmacytoma is a rare entity that can present as a solitary extramedullary plasmacytoma, which is often considered a separate disease from multiple myeloma. In cases of multiple myeloma, however, plasmacytomas can also form throughout the body, including the dura, in which case prognosis is worse. Rarely, dural plasmacytoma is the presenting feature, leading to the diagnosis of multiple myeloma. Differential diagnosis between solitary extramedullary plasmacytoma and multiple myeloma is important since treatment and prognosis are radically different.

Central Nervous System Tumours Mimicking Schwannoma: “Things Are Not Always What They Seem”

2012-01-01

When treating patients with central nervous system tumours a thorough preoperative differential diagnosis is of the upmost importance. Imaging should be complete and precise to obtain details about the nature of a lesion. Unfortunately things are not always what they seem.

Intraparenchymal Cerebrospinal Fluid Collections After Translabyrinthine Resection of Acoustic Neuroma: A Rare Complication

T. Van Havenbergh, T.H. Somers, D. Berghmans, K. De Smedt, R. Van Paesschen — 2012-01-01

We present 2 patients with a parenchymal cerebro-spinal fluid collection causing neurological symptoms after trans-labyrinthine removal of acoustic neuroma. Patient 1 was operated through a translab approach with complete resection of a medium size acoustic neuroma. Patient made an uneventful recovery with discharge on the 5th postoperative day. He presented eight days after surgery with a severe confusion. CT and MRI of the brain showed a large cyst in the temporal lobe at the side of the schwannoma resection. Patient 2 underwent a complete resection of a left sided medium sized acoustic neuroma with initially a normal recovery. On the ninth postoperative day she presented a deterioration of consciousness and cerebellar signs. CT of the brain demonstrated a large intracerebellar cystic lesion on the side of the surgery.

Haemangiopericytoma of the Central Nervous System: A Rare Tumour Often Mimicking Meningioma. Four Illustrative Cases and a Short Review of the Literature

R. Rasschaert — 2012-01-01

Intracranial haemangiopericytomas are rare tumours of the brain with a high recurrence rate and have the potential to metastasize outside the central nervous system. Radiologically and intra-operative they resemble meningiomas, but histological they are different tumours.

L'Hermitte-Duclos Disease: An Aunt Minnie Diagnosis On MR Imaging

S. Bamps, J. Ceuppens, F. Van Calenbergh, J. Goffin, S. De Vleeschouwer — 2012-01-01

The dysplastic gangliocytoma of the cerebellum or L'hermitte-Duclos disease (LDD) is a rare, benign condition of the cerebellum. The striated appearance on MR imaging is pathognomonic.

Cerebral Metastasis of a Follicular Dendritic Reticulum Cell Sarcoma: Description of the First Case in the Literature

S. De Vleeschouwer, R. Sciot, J. Menten, G. Wilms, H. Dumez — 2012-01-01

A follicular dendritic (reticulum) Cell Sarcoma (FDCS) is a very rare entity, especially in an extranodal head and neck location. It is being categorized as one of the five groups of rare dendritic cell neoplasms by the WHO. Radical surgery of the primary tumor site, even without adjuvant treatment is considered curative in 2/3 of cases. Thusfar, no cerebral metastasis has been reported from an extranodal FDCS in the medical literature.

Acute Posterior Fossa Syndrome Caused by Tension Pseudomeningocele: Report of Two Cases

2012-01-01

Pseudomeningocele is a relatively frequent com-plication after posterior fossa surgery which is usually not clinically significant. Very rarely however, an acute posterior fossa syndrome can arise as a result of tension pseudomeningocele.

Modulation of Intratumoral Galectin-1 Expression To Improve Efficacy of DC-Mediated Immunotherapy For Malignant Glioma

2012-01-01

Glioblastoma multiforme (GBM) is the most aggressive type of primary brain tumor in humans with a dismal prognosis in spite of multimodal treatment. Active specific immunotherapy is considered as a promising concept that aims at increasing the antitumoral immune response. However, the success of immunotherapeutic strategies to promote tumor regression is counteracted by tumor-mediated immune suppressing mechanisms. In this regard, intratumoral targeting of Galectin-1 (Gal-1), a glycan-binding protein with immune modulating functions, whose expression is upregulated in GBM, might strengthen the efficacy of current immuno-therapeutic strategies.

Primary Central Nervous System Melanocytic Tumors: Report of 4 Cases

2012-01-01

Primary melanocytic tumors of the CNS form a rare entity (1/1000000/yr), that is histologically and clinically distinct from metastatic cutaneous or retinal malignant melanoma. These neoplasms have a spectrum ranging from well differentiated melanocytoma to an overtly malignant tumor.

Multiple Metastases of A C2 Chordoma. Case Report

M. Thys, P. Thys, E. Urbain, T. Boulanger, R. Duhem, C. Ide, V. Tonnelle — 2012-01-01

Chordomas are known benign tumor with aggressive local comportment. Metastasis are rare but described, commonly intradural or in skin and lungs. A male patient, 73 years old, present himself in 2004 with intense cervicalgia. C2 dens was invaded by an osteolytic tumor. Chordoma was confirmed by biopsy. A resection was realised by transoral approach after posterior stabilisation, but residue was left in lateral right vertebral joint. Surgical field and residue were treated by IMRT Novalis radiation therapy. A 2.6 cm lateral right recurrence was controlled by a new IMRT radiation therapy in 2007. 6 years after diagnosis he developed a right lower limb paresis. Cerebral CT and MR scan showed 8 metastatic lesions. Two had an hemorrhagic component. Simultaneous cutaneous lesions appeared in cranial, frontal, scapular and lumbar skin. one big and four small metastasis were found in lungs, with a mass that invades the superior lobar vein, with an endo-vasular tumoral nodule, probably the source of last rapidly growing tumors.

STA-MCA Revisited: Treatment of Limb-Shaking TIA

J. van Loon, G. Wilms, V. Thijs — 2012-01-01

Limb shaking TIA is a rare feature of severe carotid artery stenosis. It is caused by hemodynamic compromise of cerebral blood flow, and consists of hyperkinetic phenomena often followed by paresis. The large EC-IC Bypass Study showed no benefit of surgery to prevent stroke in patients with carotid artery stenosis. However, several studies have suggested that EC-IC bypass surgery may be of benefit in a subgroup of patients with impaired cerebral perfusion.

Recurrent Chiasma Cavernoma

G. Matgé — 2012-01-01

A 40 year-old-female presented recently in emergency with chiasmal apoplexy: headache, retroorbital pain, reduced vision and worsening hemianopia. Twelve years ago, she underwend elsewhere a frontolateral approach for chiasmal cavernoma, without logterm follow-up.

Rupture of Anterior Communicating Artery Aneurysms During Angio-CT: Description of the Pathway for Intraseptal and Iintraventricular Haemorrhage

F. Scholtes, F. Signorelli, M.W. Bojanowski — 2012-01-01

Intraventricular haemorrhage is common after rupture of anterior communicating artery aneurysms. The anatomical pathway has not been described. Knowledge of the mechanism of haemorrhage may enhance understanding of its prognosis.

Traumatic Aneurysm of the Distal Anterior Cerebral Artery in the Adult. Case Report Describing an Anatomical Explanation

A. Henroteaux, F. Scholtes, D. Martin — 2012-01-01

5% of intracranial aneurysms involve the distal anterior cerebral artery (dACA), most commonly at the origin of the callosomarginal artery. Aneurysms due to either closed or penetrating head injury are rare in the adult (<1%), but more common in children (30%). The close spatial relationship of traumatic dACA aneurysms with the free edge of the falx cerebri has been implicated in their pathogenesis.

Subarachnoid Haemorrhage From a Notochordal Lesion of The Clivus

F. Scholtes, F. Bing, A. Weil, F. Lavigne, M.W. Bojanowski — 2012-01-01

Clival lesions of notochordal origin comprise ecchordosis physaliphora and chordoma. Subarachnoid haemorrhage (SAH) from these lesions is rare. We report the second case of survival after SAH from a clival notochordal mass.

Twiddler's Syndrome Complicating Neuromodulation Systems For Chronic Pain

M. Moens, A. De Smedt, J. Duerinck, J. D'Haens, R. Brouns — 2012-01-01

Voluntary or unvoluntary manipulation of a implanted pulse generator can lead to migration of the transducer wires and permanent malfunction of the device. This socalled Twiddler's syndrome has been described for pacemakers, implantable cardioverter-defibrillators and deep brain stimulators. Twiddler's syndrome can be expected at any subcutaneously implanted device accessible for patient manipulations. We report 2 cases, one treated with a spinal cord stimulator and the other with an implantable intrathecal infusion pump, presenting with Twiddler's syndrome.

Technical Challenges and Pitfalls in the Implementation Of Multimodality Monitoring in Neurocritical Care

G. Van der Steen, B. Feyen, S. Sener, A.I.R. Maas — 2012-01-01

Multimodality monitoring in neurocritical care offers opportunities to better target neurocritical care to the needs of an individual patient. The implementation of multimodality monitoring in the “dirty” setting of the intensive care environment can be challenging. We recently implemented extensive neuromonitoring in the context of a prospective study aimed at personalizing management approaches.

The Cingulum: New Insights In Cerebral Asymmetry

J. Dejaegher, S. Sunaert, J. Goffin, J. van Loon — 2012-01-01

Current research of the cingulum suggests a relationship between disruption of this fiber tract and psychiatric diseases such as schizofrenia and cognitive deficits. Recent studies have assessed this tract in these conditions. However, descriptions of normal anatomy are scarce and data concerning asymmetry conflicting. The purpose of this study is to describe and quantify the cingulum in healthy subjects.

”Codubix”, Polypropylene-Polyester Knit Used for Cranioplasty of Significant Skull Defect

J. Strzelecki, G. Miekisiak, M. Lekan, L. Rozycki — 2012-01-01

Many different materials are used to perform alloplastic cranioplasties all having some advantages and disadvantages. Used materials vary from methyl methacrylate OR-prepared, titanium, to customised fabricated polyetheretherketone (PEEK) implants. This is technical note about the use of the polypropylene-polyester knit as a cranioplasty material.

A Large Intracerebral Aneurysm In a 15-Year-Old Boy, Mimicking an Intrinsic Brain Tumor: A Typical Presentation of An Infrequent Condition

2012-01-01

Pediatric aneurysms are rare, have different presenting symptoms compared to their adult counterparts and are complex and challenging to treat. We report the case of a 15-year old boy referred with signs of increased intracranial pressure. Imaging showed a mass lesion between the frontal horns of both lateral ventricles suggestive of an intrinsic tumor. Intra-operatively the contours of a large, partially thrombosed aneurysm were noted, confirmed by intraoperative ultrasound and Doppler flow measurements. The aneurysm of 2×1×1cm of the second segment of the ACA with distal reinjection of the pericallosal artery was confirmed by a fourvessel angiography (DSA). An important collateral vessel network from the ipsilateral MCA was noticed. In an awake procedure, endovascular test-occlusion was successfully performed and followed by parent vessel occlusion using two occlusive coils positioned proximally in the right CA2 segment before the origin of the aneurysm. There was no post-procedural neurological deficit. MRA three months later showed the thrombosed aneurysm, excluded from the cerebral vascular circulation. Because the boy had bilateral diffuse subependymal periventricular heterotopy on MRI and hyperlaxity of his joints, mutations in filamin A were verified because of their known link with Ehlers-Danlos disease.

C1-2 Fusion for OS Odontoideum With Universal Clamp: Preliminary Experience

J. Ceuppens, M. Verfaillie, P. Moens, F. Van Calenbergh — 2012-01-01

There is emerging consensus on the traumatic etiology of os odontoideum rather than a congenital anomaly. We discuss 2 symptomatic children in whom os odontoideum was diagnosed and who were surgically treated by C1-2 fusion using Universal Clamp.

Management of Cervical Spine Chordomas. Case Report

B. Depreitere, V. Vander Poorten, J. Vranckx, S. Pans, J. Menten, G. Goitein — 2012-01-01

While most chordomas are situated in the skull base and sacrum, the cervical spine is the third most frequent chordoma location. Given that it is often impossible to perform radical en bloc excision, their treatment constitutes a surgical challenge. We report a case of a large C3\en\C6 chordoma, that was treated with complete intracapsular resection and proton irradiation.

Use of Peek Cervical Prosthesis

H. Colle, B. Noens, G. Alessi, B. D'Haen, L. De Waele — 2012-01-01

The advantages of mobile cervical prosthesis have been well established in the last decade. However, with the use of metal prosthesis, postoperative imaging is disturbed by artefacts, precluding precise postoperative diagnosis.

2012-01-01

Editorial Board

2012-01-01

Global Associates

2012-01-01

Subscription Information

2012-01-01

Member Societies

2012-01-01

Editor's Choices

2012-01-01