Ventriculoperitoneal (VP) shunts are among the most frequently performed operations in the management of hydrocephalus. Hepatic cerebrospinal fluid (CSF) pseudocyst is a rare but important complication in patients with a VP shunt insertion. In addition to presenting our own case, we performed a PubMed search to comprehensively illustrate the predisposing factors, clinical picture, diagnostic methods, and surgical treatment. This article represents an update for this condition.
A 40-year-old male was admitted to a hospital complaining of fever, abdominal distention, and pain. He had undergone a VP shunt for communicating hydrocephalus caused by a head trauma one year earlier. Laboratory studies showed liver enzymes alterations, and imaging studies demonstrated a well-defined intraaxially hepatic cyst with the shunt catheter placed inside. Staphylococcus epidermis was cultured via CSF. After removing the VP shunt and an adequate antibiotic treatment, the complication of hepatic CSF pseudocyst was resolved.
Hepatic CSF pseudocyst is a rare complication of a VP shunt. Once the diagnosis is verified and if the CSF is sterile, just simply remove the peritoneal catheter and reposition a new one in the abdomen. We believe that it is not necessary to remove or aspirate the hepatic intraaxial pseudocyst, because of the risk of bleeding. In case of CSF infection, the VP shunt can be removed and/or an external derivation can be made, and after treatment with antibiotics, a new VP shunt is placed in the opposite side of the peritoneum.
Cerebrospinal fluid pseudocyst; hepatic pseudocyst; hydrocephalus; ventriculoperitoneal shunt complication
Extramedullary hematopoiesis is defined as the formation of blood cells outside the bone marrow. It is a common manifestation of many chronic hemolytic anemias, and typically involves the liver, spleen, and lymph nodes. Only rarely is the spinal epidural space involved.
We describe a 25-year-old male, known to have thalassemia intermedia, who presented with a 1-month history of stiffness and weakness in both lower extremities. On physical examination, he had palpable splenomegaly accompanied by spinal tenderness at the D5 level, weakness in both lower extremities, hyperactive bilateral Patellar and Achilles reflexes with bilateral Babinski responses, and a graded sensory loss to pin appreciation below D5.
The magnetic resonance (MR) study revealed a posterior, isointense and soft tissue epidural mass extending from D2 to D12 on both the T1- and T2-weighted images. These findings were consistent with the diagnosis of “red marrow,” and long-segment spinal epidural extramedullary hematopoiesis.
Although extramedullary hematopoiesis is rarely encountered within the spinal canal, it should be considered among the differential diagnoses when a posterior compressive thoracic lesion contributes to myelopathy in a patient with a history of thalassemia intermedia and the accompanying chronic hemolytic anemia.
Extramedullary hematopoiesis; epidural; thalassemia
Dimethylfumarate (DMF), a drug used in the treatment of psoriasis and multiple sclerosis, has been shown to limit the growth of melanoma cells. The ability of DMF to inhibit the Rel protein has been used to explain the antioncogenic properties of this drug. Studies analyzing the effect of DMF in gliomas are limited. Therefore, we investigated the potential antitumor effects of DMF by assessing its effects on proliferation, cell death, and differentiation in gliomas in several glioma models.
Mouse glioma Gl261, human glioblastoma A172 and human glioblastoma cells from patients were exposed to DMF at therapeutic concentrations (100 μM) and supratherapeutic concentrations (300 μM) and studies to assess proliferation, cellular lysis, and differentiation undertaken. The 5-bromo-2’-deoxyuridine (BRDU) proliferation assay and lactate dehydrogenase LDH cell lysis assay were used. Immunocytochemistry was used to assess differentiation: CD133 (stem cell marker), Nestin (progenitor marker), Sox2 (progenitor marker), β-tubulin III (neuronal marker), glial fibrillary acidic protein (astrocytic marker), and myelin basic protein (oligodendrocytic marker). We also assessed cellular expression of nuclear factor kappa B (NF-κB) via immunocytochemistry.
Proliferation significantly decreased and tumor cell lysis significantly increased in all tumor cell lines after exposure to DMF. The human glioblastoma cells expressed the Neuronal Stem Cell marker CD133, Progenitor Cell markers, Neuronal and Astrocytic Cell Markers in vitro. When exposed to DMF, a drastic decline in CD133 expression was observed in addition to a decrease in the expression of NF-κB.
DMF appears to have a promising role in the treatment of malignant brain neoplasms. DMF reduced proliferation rate, generated cell lysis, decreased the expression of NF-κB, and restricted the growth of CD133 cells in gliomas. This suggests that DMF may be considered for further antitumor studies, and provide a new treatment modality for brain tumors.
Astrocytes; dimethylfumarate; glioma; glioblastoma; NF-κB
Various vascular, neoplastic, and epileptogenic pathologies occur in the mediobasal temporal region. A transsylvian translimen insula (TTI) approach can be used as an alternative to temporal transcortical approach to the mediobasal temporal region. The aim of this study was to demonstrate the surgical anatomy of the TTI approach, including the gyral, sulcal, and vascular anatomy in and around the limen insula. The use of this approach is illustrated in the resection of a complex arteriovenous malformation.
The TTI approach to the mediobasal temporal region was performed on three silicone-injected cadaveric heads. The gyral, sulcal, and arterial anatomy of the limen insula was studied in six formalin-fixed injected hemispheres.
The TTI approach provided access to the anterior and middle segments of the mediobasal temporal lobe region as well as allowing access to temporal horn of the lateral ventricle. Using this approach we were able to successfully resect an arteriovenous malformation of the dominant medial temporal lobe.
The TTI approach provides a viable surgical route to the region of mediobasal temporal lobe region. This approach offers an advantage over the temporal transcortical route in that there is less risk of damage to optic radiations and speech area in the dominant hemisphere.
Arteriovenous malformation; mesial temporal sclerosis; mesial temporal lobe; transinsular; translimen insula; transsylvian; uncus
Cavernous sinus tuberculomas are extremely rare, but the increasing incidence worldwide of central nervous system (CNS) tuberculosis, mostly due to human immunodeficiency virus and poor sanitary conditions, and the ability of tuberculomas to mimic a brain neoplasm makes cavernous sinus tuberculomas a suspicious pathologic finding in the differential diagnosis of a brain space-occupying lesion.
We present an immunocompetent patient with no signs of systemic tuberculosis and an isolated right cavernous sinus space-occupying lesion. A skull base approach was performed and tumor resection achieved. The postoperative course was uneventful. Pathologic findings consisted of a tuberculoma and antituberculous treatment was immediately begun with total tumor regression after a 12-month regimen. After reviewing the literature, we propose suggestions to orient the diagnosis and a treatment algorithm for tuberculomas in rare locations.
Tuberculomas in rare locations, as the cavernous sinus, are a challenging pathology as they have the ability to mimic a brain neoplasm. Although first line treatment are antituberculous therapy (4 drugs for at least 12 months) and adjuvant steroids, in inconclusive cases, surgical biopsy or excision is recommended for histopathologic confirmation and to reduce the mass effect, always following with antituberculous therapy and adjuvant steroids.
Brain tumor; cavernous sinus; meningioma; skull base; tuberculoma; tuberculosis
Autograft bone provides an excellent substrate for multilevel arthrodesis after anterior discectomy and is inexpensive. However, the use of tricortical bone could increase the discomfort for the patient.
We reviewed cases of cervical disc diseases operated on by a single neurosurgeon (AS), within the period June 2000-December 2011. A total of 221 patients were considered for the present study; 109 female, 112 male, averaging 49 years of age. Only patients who could be followed up for at least one year were included in the present study. The grafts obtained with the technique described are bi- (and not tri-) cortical, and always of sufficient size in order to fit two spaces if necessary.
The technique is not associated with long-term significant donor site pain except for a striking minority of patients, it shortens the hospital stay, it offers comparable results to the published surgical series in which cage and/or modern implants are used.
Autograft bone can be reasonably considered as one of the possible alternatives to be used in the surgical management of cervical disk disease.
Autograft; anterior cervical approach; cervical cage; donor site pain
Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported.
We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position.
A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment.
Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.
Infratentorial; pineal; surgery; supracerebellar
Dolichoectasia is a rare disorder of the cerebral vasculature consisting of vascular elongation, widening, and tortuosity, usually involving the vertebral and basilar arteries. Its neurological symptoms and signs are highly variable.
We present a case of dolichoectasia of the vertebrobasilar system in a patient with a long standing history of multiple falls. Repeat neuroimaging revealed an increase in size of the dolichoectatic segment. In addition, a new fusiform dilatation of the contralateral petrous segment of the internal carotid artery and isolated ventriculomegaly had developed.
Vertebrobasilar dolichoectasia can cause multiple clinical manifestations, with hydrocephalus being less common. In addition, having dolichoectasia of both posterior and anterior circulation is extremely rare.
Carotid artery; hydrocephalus; vertebrobasilar dolichoectasia
A wide range of results have appeared in the literature for intercostal nerve transfers in brachial plexus patients. Oriental countries generally have a lower body mass index (BMI) than their occidental counterparts. We analyzed published series of intercostal nerve transfers for elbow reinnervation to determine if a difference in outcomes exists between Eastern and Western series that could be inversely related to BMI.
A PubMed search was conducted. Inclusion criteria were: (1) time from trauma to surgery <12 months, (2) minimum follow-up one year, (3) intercostal to musculocutaneous nerve transfer the only surgical procedure performed to reestablish elbow flexion, and (4) males comprising more than 75% of cases. Two groups were created: Series from western countries, including America, Europe, and Africa; and series from Asia. Pearson correlation analysis was performed to assess for the degree of correlation between percent responders and mean national BMI.
A total of 26 series were included, 14 from western countries and 12 from Eastern countries, encompassing a total of 274 and 432 surgical cases, respectively. The two groups were almost identical in mean age, but quite different in mean national BMI (26.3 vs. 22.5) and in the percentage of patients who achieved at least a Medical Research Council (MRC) level 3 (59.5% vs. 79.3%). Time from trauma to surgery was slightly shorter in Eastern (3.4 months) versus Western countries (5.0 months).
The percentage of responders to intercostal to musculocutaneous nerve transfer was inversely correlated with the mean national BMI among male residents of the country where the series was performed.
Brachial plexus injury; body mass index elbow flexion; intercostal nerve transfer
The simultaneous occurrence of multiple intracranial neoplasms has been reported, especially in genetic familial syndromes and after cranial irradiation. In the absence of these etiologic factors, some reports showed simultaneous occurrence of glioblastoma and meningioma but the association between gliosarcoma and meningioma is unknown.
We report a case of a 51-year-old woman with synchronous gliosarcoma and meningioma in whom extensive immunohistochemical characterization and molecular profile was performed. The gliosarcoma recurred 21 months after the first resection, reaching 3 years of overall survival. A molecular characterization of all three lesions was performed. None of the lesions showed the presence of mutations in TP53 and BRAF genes. MGMT analysis showed the presence of loss of expression associated with promoter hypermethylation in both gliosarcoma lesions. EGFR overexpression and gene amplification was found only in the recurrent gliosarcoma.
The immunohistochemistry and molecular data of this unique case, suggest the distinct clonal origin of meningioma and gliosarcoma lesions, and the association of MGMT methylation with the presumable favorable prognosis observed.
EGFR; gliosarcoma; long survival; MGMT; meningioma; synchronous
We analyzed factors associated with worsened paresis in a large series of patients with brain lesions located within or near the primary motor area (M1) to establish protocols for safe, awake craniotomy of eloquent lesions.
We studied patients with brain lesions involving M1, the premotor area (PMA) and the primary sensory area (S1), who underwent awake craniotomy (n = 102). In addition to evaluating paresis before, during, and one month after surgery, the following parameters were analyzed: Intraoperative complications; success or failure of awake surgery; tumor type (A or B), tumor location, tumor histology, tumor size, and completeness of resection.
Worsened paresis at one month of follow-up was significantly associated with failure of awake surgery, intraoperative complications and worsened paresis immediately after surgery, which in turn was significantly associated with intraoperative worsening of paresis. Intraoperative worsening of paresis was significantly related to preoperative paresis, type A tumor (motor tract running in close proximity to and compressed by the tumor), tumor location within or including M1 and partial removal (PR) of the tumor.
Successful awake surgery and prevention of deterioration of paresis immediately after surgery without intraoperative complications may help prevent worsening of paresis at one month. Factors associated with intraoperative worsening of paresis were preoperative motor deficit, type A and tumor location in M1, possibly leading to PR of the tumor.
Awake surgery; brain tumor; complication; failure; neurological deficit; primary motor area
Extracranial aneurysms of the posterior inferior cerebellar artery (PICA) are rare, with only 22 reported cases in the English literature. For saccular extracranial distal PICA aneurysms not amenable to coiling, a surgically placed clip is not protected by the cranium postoperatively, and can be subject to movement in the mobile cervical region. Furthermore, fusiform or complex aneurysms cannot be clipped primarily. Resection and primary reanastomosis is a useful surgical approach not previously described for these extracranial lesions.
We report three cases of extracranially located distal PICA aneurysms successfully treated with this surgical strategy at our center. One patient harboring a broad necked saccular aneurysm originally underwent successful primary clipping of the aneurysm but sustained a second subarachnoid hemorrhage (SAH) on postoperative day 25 due to clip dislodgement from vigorous neck movement. The other two patients were found to have fusiform and complex aneurysms, respectively. All three patients were ultimately treated with resection and end-to-end PICA anastomosis, which successfully obliterated their aneurysms.
Resection and primary reanastomosis of extracranial distal PICA aneurysms averts the risk of clip dislodgement due to neck movement and/or compression by soft tissues in the upper cervical region. It is a safe and efficacious technique, which we propose as the preferred management strategy for these rare vascular lesions.
Anastomosis; aneurysm; PICA; resection; subarachnoid hemorrhage
Bow Hunter's syndrome/stroke is defined as symptomatic, vertebrobasilar insufficiency provoked by physiologic head rotation. It is a diagnostically challenging cause of posterior circulation stroke in children. While there have been prior reports of this rare disorder, we describe an exceptional case of pediatric Bow Hunter's stroke resulting from a near complete occlusion the right vertebral artery (VA) secondary to an anomalous spur emanating from the right occipital condyle. Surgical and endovascular options and approaches are also detailed herein.
A 16-year-old male presented with multiple posterior circulation ischemic strokes. A dynamic computerized tomography angiogram performed with the patient's head in a rotated position revealed a near complete occlusion of the V3 segment of the right VA from a bone spur arising from his occipital condyle. The spur caused a focal dissection of the distal right VA with associated thrombus. He was initially managed with a cervical collar, antiplatelet therapy with aspirin 81 mg and anticoagulation with coumadin (INR goal 2-3) for 3 months. Despite the management plan, he had a subsequent thromboembolic event and a right VA sacrifice with coil embolization was then performed. At the 3-month follow-up, the patient was doing well with no reports of any subsequent strokes.
We report the first reported pediatric case of Bow Hunter's stroke due to dynamic right VA occlusion from an occipital condylar bone spur. The vascular compression from this spur led to a right VA dissection and thrombus formation and ultimately caused multiple posterior circulation thromboembolic strokes. Endovascular treatment options including vessel sacrifice should be considered in cases that have failed maximal medical management.
Bow Hunter's syndrome; coil embolization; endovascular surgery; stroke; vertebral artery
Craniopharyngiomas (CPs) are slow growing tumors with an incidence of between 1.2% and 4.6%, having a bimodal age distribution typically peaking in childhood and in adults between 45 and 60 years. Recurrences occur even after documented gross total resections necessitating a combination of therapeutic strategies. Obtaining a cure of this tumor in adults without producing major side effects continues to remain elusive.
We describe our results in 11 patients with CP treated in a minimally invasive fashion using a combination of techniques like burr hole aspiration, Ommaya reservoir placement, ventriculo-peritoneal (VP) shunting and focal radiation (Gamma Knife stereotactic radiosurgery/Intensity modulated radiotherapy [GKRS/IMRT]).
Visual function remained intact in all patients; endocrine status remained stable with two patients developing new postoperative diabetes insipidus. There was no periprocedural morbidity or mortality, with hospital stays for any in-patient procedure being 48 hours or less.
Minimally invasive techniques such as cyst aspiration, insertion of a catheter with Ommaya reservoir, when combined with stereotactic radiosurgery/IMRT is an effective and safe option for management and long-term control of adult CPs. We believe the Ommaya catheter by itself could act as a stent, creating a tract allowing gradual drainage of cyst fluid and stabilization without necessitating any further interventions in selected cases.
Craniopharyngioma; focal radiotherapy; minimally invasive; radiosurgery
The purpose of this article is to explain the anatomy of the pterygopalatine ganglion (PPG), its location in the pterygopalatine fossa (PPF) in the skull, and the relationship it has to the Vidian nerve terminal branches and the fifth cranial nerve. An overview of the neuro-anatomical/clinical correlations, a spectrum of pathologies affecting the seventh cranial nerve and some therapies both medical and surgical are noted. The focus is the pterygopalatine region with discussion of the proximal courses of the seventh and fifth cranial nerves and their pathological processes. The ganglion is used as an example of neuro-anatomical model for explaining cluster headaches (CH). Radiological correlation is included to clarify the location of the PPF and its clinical importance.
Cluster headaches; facial paresis; greater superficial petrosal nerve; pterygopalatine fossa; pterygopalatine ganglion; radiosurgery; treatment of cluster headaches; seventh cranial nerve
The glomus jugulare tumor is a slowly growing benign neoplasm originating from neural crest. There is a high morbidity associated with surgical resection of glomus jugulare. Radiosurgery play a relevant role as a therapeutic option in these tumors and its use has grown in popularity. The authors describe a retrospective series of 15 patients and reviewed the literature about the glomus jugulare tumors.
We reviewed retrospectively the data of 15 patients treated with stereotactic linear accelerator stereotactic radiosurgery (LINAC) radiosurgery between 2006 and 2011.
The average tumor volume was 18.5 cm3. The radiation dose to the tumor margin ranged between 12 and 20 Gy. The neurological status improved in three patients and remained unchanged in 12 patients. One patient developed a transient 7th nerve palsy that improved after clinical treatment. All tumors remained stable in size on follow-up with resonance magnetic images.
The radiosurgery is a safe and effective therapy for patients with glomus jugulare tumor. Despite the short follow-up period and the limited number of patients analyzed, we can infer that radiosurgery produce a tumor growth control with low morbidity, and may be used as a good option to surgical resection in selected cases.
Chemodectoma; glomus jugulare tumor; radiosurgery
This report focuses on the overall survival and complications associated with treatment of cerebral metastases with surgical resection followed by stereotactic radiosurgery (SRS). Management and complications of corticosteroid therapy are underreported in the literature but represent an important source of morbidity for patients.
Fifty-nine consecutive patients underwent surgical resection of a cerebral metastasis followed by SRS to the cavity. Patient charts were reviewed retrospectively to ascertain overall survival, local control, surgical complications, SRS complications, and corticosteroid complications.
Our mean follow-up was 14.4 months (median 12.0 months, range 0.9-62.9 months). Median overall survival in this series was 15.25 months and local control was 98.3%. There was a statistically significant survival benefit conferred by Radiation Therapy Oncology Group recursive partitioning analysis Classes 1 and 2. The surgical complication rate was 6.8% while the SRS complication rate was 2.4%. Corticosteroid complications are reported and dependence at 1 month was 20.3%, at 3 months 6.8%, at 6 months 1.7%, and at 12 months no patients remained on corticosteroid therapy.
Overall survival and local control with this treatment paradigm compare well to the other published literature. Complications associated with this patient population are low. A corticosteroid tapering protocol is proposed and demonstrated lower rates of steroid-related complications and dependence than previously reported.
Cerebral metastases; corticosteroids; stereotactic radiosurgery
Putative changes of cognition after deep brain stimulation (DBS) in patients with Parkinson's disease (PD) are a matter of debate. The aim of this study was to assess cognitive abilities before and following bilateral subthalamic nucleus (STN) DBS and to review the available literature.
Twenty patients underwent bilateral DBS of the STN. Cognitive skills were assessed in a standardized fashion before and at least at 12 months after the surgical intervention.
There was a significant decline of both semantic and phonematic verbal fluency and a mild trend for a deterioration of verbal memory after DBS. Mood, general cognitive screening, and visospatial abilities remained unchanged.
STN DBS in the treatment of PD has resulted in a significant reduction of motor symptoms and improved independence and quality of life in appropriately selected patients. However, it may have isolatable effects on verbal fluency and related function. Case series in the literature reported similar findings. Potential candidates for DBS should be counseled about the risk of mild cognitive declines.
Cognitive decline; deep brain stimulation; memory; Parkinson's disease; subthalamic nucleus; verbal fluency
A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option?
We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge.
Five of the eight “stereotactic cases” had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine “neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery.
Conventional craniotomy isn’t indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these treatment modalities for CCGSI.
Bullet/pellet extraction; craniocerebral gunshot wound; craniocerebral injury; gunshot injury; neuronavigation; stereotactic surgery
Sclerosteosis is a rare bone disorder characterized by a progressive craniotubular hyperostosis. The diagnosis of sclerosteosis is based on characteristic clinical and radiographic features and a family history consistent with autosomal recessive inheritance. The skull overgrowth may lead to lethal elevation of intracranial pressure, distortion of the face, and entrapment of cranial nerves, resulting in recurrent facial palsy or secondary trigeminal neuralgia.
The authors reported cases of two siblings who were diagnosed with familial sclerosteosis and presented with secondary trigeminal neuralgia. The patients were 28 and 40-year-old and presented with pain in the right V2-V3 and V3 distributions, respectively. The facial pain was resistant to medications and was treated with percutaneous techniques. The foramen ovale puncture was complicated initially and the difficulty increased over the years due to stenosis of the foramen.
The treatment of the trigeminal neuralgia secondary to hyperostosis and resistant to medications presents a dilemma. The narrowing of the foramen oval and difficulty in the identifying and approaching of the foramen makes the percutaneous technique a challenge for the neurosurgeon in patients harboring sclerosteosis. Microvascular decompression should not be considered since the primary cause of the trigeminal neuralgia is the nerve entrapment by the narrowing of neurovascular foramina and not the neurovascular conflict related to essential trigeminal neuralgia. Stereotactic radiosurgery may be a good treatment option, but there is a lack of published data supporting the use of this method in cranial hyperostosis.
Percutaneous balloon compression; pain control; sclerostesosis; trigeminal neuralgia
Some cases of paradoxical mesial temporal lobe epilepsy (MTLE) are shown to be bilateral MTLE (BMTLE) by intracranial electrodes. The treatment for BMTLE is difficult, which poses several questions. Can corticoamygdalohippocampectomy (CAH) be applied to treat BMTLE? What are the long-term therapeutic effects if CAH is performed in BMTLE patients?
Four patients were shown to have BMTLE through bilateral intracranial electrode implantation. CAH was performed on the side with relatively more seizure originations. These patients were followed-up at 6 months, 1 year, 2 years and longer, in some cases, after the CAH. The postoperative seizure frequency was recorded. Preoperative and postoperative clinical memory tests and a postoperative 4-hour video electroencephalography (EEG) were conducted in the hospital at different follow-up times. The average seizure frequencies and memory quotient scores were analyzed.
The average seizure frequency significantly decreased by 80.8%, 83.5%, and 84.3% at different postoperative times. Although no patient was seizure free, the intensity of the seizures was reduced in all cases. The postoperative average memory quotient score was moderately decreased by 15.8%, 11.7%, and 16.6% at different postoperative times. Both the average values of the postoperative seizure frequency (5.5, 4.75, and 4.5 per month) and the average values of the postoperative memory quotient (73.7, 77.3, and 73) at different postoperative times were approximately the same.
CAH reduced the seizure frequency and intensity in these BMTLE patients. Mild hypomnesis occurred in every case. We observed the long-term treatment effects at 6 months after the CAH and showed that the effects did not change at that time or over the next few years.
Mesial temporal lobe epilepsy; corticoamygdalohippocampectomy; long-term therapeutic effect; memory
Traditional stainless steel retractors can interfere with electromagnetic neuronavigation and intraoperative magnetic resonance imaging (ioMRI). In such cases, titanium instruments are frequently used; however, they often shift during the procedure. The authors describe a simple technique, illustrated with intraoperative photographs, for securing titanium cerebellar retractors into place to keep both the retractors and tissues in their desired locations throughout a craniotomy.
Titanium retractors were used by our institute's neurosurgical service during operations utilizing electromagnetic neuronavigation or ioMRI. Once the retractor was in the desired position, a 2-0 silk suture was placed around a retractor tong and tied outside the skin. Two sutures were placed on either side of the titanium retractor in the same fashion.
Retractors were subsequently noted to remain in their desired position throughout the operative procedure.
The authors describe a technique for securing titanium cerebellar retractors into their desired position during a craniotomy to minimize their movement during the procedure. This simple technique can help to eliminate a potential frequent source of surgeon frustration, and has proven to be quick to perform, safe, and practicable.
Cerebellar; intraoperative; magnetic resonance imaging; retractor; titanium
Hemangioblastomas are associated with Von Hippel-Lindau disease (VHLD) in 10-40% of cases. Based upon a literature review we state the core features the neurosurgeon should be aware of.
We performed a selective literature (Cochrane and Medline) search for hemangioblastoma, both sporadic and VHL associated. We reviewed general characteristics (epidemiology, symptomatology, diagnosis, and management) and focused on follow-up as well as screening modalities for sporadic and VHL associated lesions.
Based upon our literature search, we established guidelines for screening and follow-up in both sporadic and VHL associated hemangioblastoma patients.
Screening for retinal angiomas, abdominal masses, and pheochromocytomas as well as genetic analysis is recommended for every patient with a newly diagnosed hemangioblastoma. Follow-up is by magnetic resonance imaging (MRI) of the clinical neuronal region at 6 and at 12-24 months postoperatively. For VHL-associated hemangioblastomas yearly investigation for craniospinal hemangioblastoma by MRI and yearly screening and follow-up for retinal angiomas is recommended. Annual abdominal ultrasound with triennial computed tomography (CT) imaging for abdominal masses is postulated. Annual audiometry is to be performed for possible endolymphatic sac tumor, detailed radiographic imaging of the skull base should be performed upon abnormality in auditory testing. Investigations for cystadenomas of the epidydimis and broad ligament only are mandatory on indication. Annual investigation for pheochromocytoma is recommended.
Diagnosis; follow-up; hemangioblastoma; Von Hippel-Lindau disease; work-up