Treatment and outcomes of acute intracranial vertebrobasilar artery occlusion: one institution’s experience.
J Neurosurg. 2012 Feb 3;
Authors: Webb S, Yashar P, Kan P, Siddiqui AH, Hopkins LN, Levy EI
Abstract
Object The treatment of acute intracranial vertebrobasilar artery occlusion (VBO) has been described but often with poor results. The authors of this study set out to evaluate their institution’s outcomes following multimodal treatment of VBO. Methods They retrospectively reviewed their endovascular database for all patients treated for acute intracranial VBO between December 2004 and June 2010. Twenty-four patients were identified. Two patients were excluded from evaluation-one because of incomplete medical records and one because the etiology was basilar stenosis and not stroke. Occlusion location, hypercoagulable causes, time to endovascular treatment, time to revascularization, comorbidities, devices used, procedural anticoagulation, and outcomes were analyzed. Results Among the 22 eligible study patients, the mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15.3. The mean time from presentation to initiation of the endovascular procedure was 4.77 hours. The mean time for recanalization from the start of angiography was 1.63 hours. In 16 patients (73%), revascularization was successful (Thrombolysis in Myocardial Infarction [TIMI] score of 2 or 3). Thirteen (59%) of the 22 patients were discharged to home or a rehabilitation facility. One patient was transferred to a chronic care facility. The overall survival rate was 64%. The average NIHSS score for the 14 surviving patients at discharge was 3.9. At the follow-up (average 14.5 months, range 1-58 months), 10 patients (71%) had achieved good outcomes (modified Rankin Scale [mRS] score ≤ 2) and 4 (29%) had poor outcomes (mRS Score 3-6). Conclusions Published case series have historically shown poor outcomes and high mortality rates in association with the treatment of acute VBO, prompting surgeons to be less aggressive in the treatment of this disease than they might be otherwise. Data in this series show that the revascularization of posterior circulation occlusions is feasible and that good outcomes and lower mortality rates with newer endovascular technologies are possible, and thus more prompt and aggressive treatment of this disease may be warranted.
PMID: 22304447 [PubMed - as supplied by publisher]
Crocodile tears syndrome after vestibular schwannoma surgery.
J Neurosurg. 2012 Feb 3;
Authors: Nakamizo A, Yoshimoto K, Amano T, Mizoguchi M, Sasaki T
Abstract
Object Crocodile tears syndrome (CTS) is a lacrimal hypersecretion disorder characterized by excessive tearing with gustatory stimulation while eating, drinking, or smelling food. Surgeons tend to overlook CTS after vestibular schwannoma (VS) surgery because its symptoms are less obvious compared with facial paralysis. The authors aim to elucidate the precise incidence and the detailed natural course of CTS after VS surgery. Methods This study included 128 consecutive patients with unilateral VSs resected via a retrosigmoid, lateral suboccipital approach. Clinical information on the patients was obtained by retrospective chart review. The presence of, time of onset of, and recovery of patients from CTS were obtained from the chart or evaluated from the most recent outpatient visit. Results A total of 14 patients (10.9%) developed CTS. Motor function of the facial nerve at discharge was statistically related to the occurrence of CTS (p < 0.001). The odds ratio of House-Brackmann Grade 4 compared with Grade 1 was 86.4 (p < 0.001). A bimodal distribution of CTS onset was observed, with a mean onset of 6.1 ± 4.0 months after resection. The CTS improved in 10 patients (71%) at various intervals, whereas CTS resolved in only 7 patients (50%) at a mean interval of 10.9 ± 7.9 months. The mean interval to recovery in the early-onset group was 9.7 ± 7.9 months, and it was 18 months in the late-onset group; the mean is given ± SD throughout. Conclusions The occurrence of CTS following VS surgery was more common than expected; however, a surgical procedure intended to protect the functioning of the facial nerve appears to be conducive to reduction of the occurrence of CTS. To reduce the distress caused by CTS, all patients should be given sufficient information and provide their informed consent prior to surgery.
PMID: 22304448 [PubMed - as supplied by publisher]
A novel technique of multiple-site epidural blood patch administration for the treatment of cerebrospinal fluid hypovolemia.
J Neurosurg. 2012 Feb 3;
Authors: Ohtonari T, Ota S, Nishihara N, Ota T, Tanaka Y, Sekihara Y, Tanaka A
Abstract
Object An epidural blood patch (EBP) is a widely accepted standard procedure to treat CSF hypovolemia, especially when the epidural CSF leak is detected by spinal MRI or CT myelography (CTM). In quite a few cases, however, the leaked CSF is spread over a large area along the spinal epidural space, making it difficult for the surgeon to clearly identify the true leakage points. In such cases, autologous blood can be infused at multiple spinal levels with multiple entries. In this paper, the authors have devised a new multiple-site EBP method with a single lumbar entry point by way of using an intravenous catheter as a slidable device for continuous infusion. In this report, they introduce this new, single-entry, continuous multiple-site EBP administration technique and report some of the results that they have obtained. Methods An EBP was applied via an epidural catheter in 5 patients with spontaneous CSF hypovolemia (3 men and 2 women; mean age 47.2 years, range 34-65 years). The detection of an epidural CSF leak was based on MRI and/or CTM findings. In all cases, however, the leakage sites could not be identified clearly. The main symptoms of these patients were recurrent spontaneous chronic subdural hematoma with orthostatic headache (3 patients) and orthostatic headache only (2 patients). All patients underwent surgery in the prone position on an angiography table, and biplane fluoroscopy was used for accurate manipulation. After administration of a local anesthetic, the authors inserted a 4-Fr short sheath (which is standard in angiography) through the lumbar interlaminar window and placed it in the dorsal epidural space. They then introduced a 4.2-Fr straight catheter through the sheath and navigated it upward along a 35-gauge guidewire whose tip was moved upward beyond the cranial end of the detected CSF leakage. Blood was obtained from each patient from a previously secured venous entry on the forearm, and it was injected slowly into the epidural catheter. Each time, the authors tried to infuse as much autologous blood as possible into the epidural space, while moving the catheter gradually in the caudal direction in response to the patient’s expression of pain. Results In all 3 cases of chronic subdural hematoma, its recurrence was prevented. In 1 patient, the orthostatic headache disappeared completely, and it was relieved in the other 4 patients. Conclusions An efficient treatment option for CSF hypovolemia is provided by the new application method of EBP with the aid of an intravenous catheter as a slidable device, which enables infusion of a sufficient amount of autologous blood into multiple epidural areas with a single lumbar entry point.
PMID: 22304449 [PubMed - as supplied by publisher]
Rates and predictors of long-term seizure freedom after frontal lobe epilepsy surgery: a systematic review and meta-analysis.
J Neurosurg. 2012 Feb 3;
Authors: Englot DJ, Wang DD, Rolston JD, Shih TT, Chang EF
Abstract
Object Frontal lobe epilepsy (FLE) is the second-most common focal epilepsy syndrome, and seizures are medically refractory in many patients. Although various studies have examined rates and predictors of seizure freedom after resection for FLE, there is significant variability in their results due to patient diversity, and inadequate follow-up may lead to an overestimation of long-term seizure freedom. Methods In this paper the authors report a systematic review and meta-analysis of long-term seizure outcomes and predictors of response after resection for intractable FLE. Only studies of at least 10 patients examining seizure freedom after FLE surgery with postoperative follow-up duration of at least 48 months were included. Results Across 1199 patients in 21 studies, the overall rate of postoperative seizure freedom (Engel Class I outcome) was 45.1%. No trend in seizure outcomes across all studies was observed over time. Significant predictors of long-term seizure freedom included lesional epilepsy origin (relative risk [RR] 1.67, 95% CI 1.36-28.6), abnormal preoperative MRI (RR 1.64, 95% CI 1.32-2.08), and localized frontal resection versus more extensive lobectomy with or without an extrafrontal component (RR 1.71, 95% CI 1.26-2.43). Within lesional FLE cases, gross-total resection led to significantly improved outcome versus subtotal lesionectomy (RR 1.99, 95% CI 1.47-2.84). Conclusions These findings suggest that FLE patients with a focal and identifiable lesion are more likely to achieve seizure freedom than those with a more poorly defined epileptic focus. While seizure freedom can be achieved in the surgical treatment of medically refractory FLE, these findings illustrate the compelling need for improved noninvasive and invasive localization techniques in FLE.
PMID: 22304450 [PubMed - as supplied by publisher]
Coexistence of intracranial aneurysm in 800 patients with surgically confirmed pituitary adenoma.
J Neurosurg. 2012 Feb 3;
Authors: Oh MC, Kim EH, Kim SH
Abstract
Object The purpose of this study was to assess factors associated with intracranial aneurysm (IA) in patients with pituitary adenoma (PA). In addition, these patients were compared with a control group from the general patient population in terms of the age-matched prevalence rate and the pattern of distribution of IA. Methods The authors retrospectively reviewed 800 patients who received transsphenoidal surgery for PA and 3850 control patients from the general patient population who were evaluated for routine health care at the authors’ institution between 2004 and 2010. All patients underwent MR imaging and MR angiography. Hormone assessment and pathological examination performed using immunohistochemical (IHC) staining were completed for patients with PA. Results Coexistence of IA in patients with PA was detected in 18 patients (2.3%). Multivariate analysis showed that age (p = 0.04) and cavernous sinus invasion (p < 0.001) were correlated with the increased incidence of IA, but hormone type, IHC staining, and sex were not associated. An age-matched comparison of the prevalence of IA showed an increased prevalence in patients with PA compared with the controls (p = 0.014), and when categorized according to age by decade, the 6th decade was significantly different (p = 0.039). However, the intracranial distribution pattern of IA did not demonstrate a significant difference. Conclusions Older age and the existence of a cavernous sinus invasion were correlated with increased incidence of IA in patients with PA. An age-matched comparison showed an increased incidence of IA in patients with PA than in the controls.
PMID: 22304451 [PubMed - as supplied by publisher]
Utility of presurgical navigated transcranial magnetic brain stimulation for the resection of tumors in eloquent motor areas.
J Neurosurg. 2012 Feb 3;
Authors: Krieg SM, Shiban E, Buchmann N, Gempt J, Foerschler A, Meyer B, Ringel F
Abstract
Object Navigated transcranial magnetic stimulation (nTMS) is a newly evolving technique. Despite its supposed purpose (for example, preoperative central region mapping), little is known about its accuracy compared with established modalities like direct cortical stimulation (DCS) and functional MR (fMR) imaging. Against this background, the authors performed the current study to compare the accuracy of nTMS with DCS and fMR imaging. Methods Fourteen patients with tumors in or close to the precentral gyrus were examined using nTMS for motor cortex mapping, as were 12 patients with lesions in the subcortical white matter motor tract. Moreover, preoperative fMR imaging and intraoperative mapping of the motor cortex were performed via DCS, and the outlining of the motor cortex was compared. Results In the 14 cases of lesions affecting the precentral gyrus, the primary motor cortex as outlined by nTMS correlated well with that delineated by intraoperative DCS mapping, with a deviation of 4.4 ± 3.4 mm between the two methods. In comparing nTMS with fMR imaging, the deviation between the two methods was much larger: 9.8 ± 8.5 mm for the upper extremity and 14.7 ± 12.4 mm for the lower extremity. In 13 of 14 cases, the surgeon admitted easier identification of the central region because of nTMS. The procedure had a subjectively positive influence on the operative results in 5 cases and was responsible for a changed resection strategy in 2 cases. One of 26 patients experienced nTMS as unpleasant; none found it painful. Conclusions Navigated TMS correlates well with DCS as a gold standard despite factors that are supposed to contribute to the inaccuracy of nTMS. Moreover, surgeons have found nTMS to be an additional and helpful modality during the resection of tumors affecting eloquent motor areas, as well as during preoperative planning.
PMID: 22304452 [PubMed - as supplied by publisher]
Recanalization with subsequent near-total occlusion of an internal carotid artery aneurysm after immediate thrombotic occlusion using a flow-diverting stent.
J Neurosurg. 2012 Jan 6;
Authors: Wong GK, Yu SC, Siu DY, Poon WS
Abstract
A flow-diverting stent is placed in the parent artery to reduce blood flow in the aneurysm sac to facilitate progressive thrombosis and neointimal remodeling while maintaining outflow in the side branches and perforators. All international multicenter registries have reported on the progressive occlusion of aneurysms with time and have implied that an occluded aneurysm would not recanalize given the protective effect of the altered hemodynamics. Recanalization of an occluded aneurysm after placement of a flow-diverting stent has not been reported in the literature. The authors here describe a case of aneurysm recanalization after immediate thrombotic occlusion of the aneurysm with a flow-diverting stent. A 46-year-old male chronic smoker with chronic hypertension and hypercholesterolemia had a recurrent internal carotid artery aneurysm 1 year after embolization. Immediate thrombotic occlusion of the aneurysm and cessation of blood flow to the posterior communicating artery (PCoA) occurred immediately after activating a flow-diverting stent, with corresponding ischemic complications. However, 3 months after insertion of the stent, follow-up MR angiography showed recanalization of the aneurysm as well as of the PCoA. Additional angiography studies at 6 months showed near-total occlusion of the aneurysm with the restoration of blood flow to the PCoA.
PMID: 22224783 [PubMed - as supplied by publisher]
Transnasal excerebration surgery in ancient Egypt.
J Neurosurg. 2012 Jan 6;
Authors: Fanous AA, Couldwell WT
Abstract
Ancient Egyptians were pioneers in many fields, including medicine and surgery. Our modern knowledge of anatomy, pathology, and surgical techniques stems from discoveries and observations made by Egyptian physicians and embalmers. In the realm of neurosurgery, ancient Egyptians were the first to elucidate cerebral and cranial anatomy, the first to describe evidence for the role of the spinal cord in the transmission of information from the brain to the extremities, and the first to invent surgical techniques such as trepanning and stitching. In addition, the transnasal approach to skull base and intracranial structures was first devised by Egyptian embalmers to excerebrate the cranial vault during mummification. In this historical vignette, the authors examine paleoradiological and other evidence from ancient Egyptian skulls and mummies of all periods, from the Old Kingdom to Greco-Roman Egypt, to shed light on the development of transnasal surgery in this ancient civilization. The authors confirm earlier observations concerning the laterality of this technique, suggesting that ancient Egyptian excerebration techniques penetrated the skull base mostly on the left side. They also suggest that the original technique used to access the skull base in ancient Egypt was a transethmoidal one, which later evolved to follow a transsphenoidal route similar to the one used today to gain access to pituitary lesions.
PMID: 22224784 [PubMed - as supplied by publisher]
Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution’s success.
J Neurosurg. 2012 Jan 6;
Authors: Titsworth WL, Hester J, Correia T, Reed R, Williams M, Guin P, Layon AJ, Archibald LK, Mocco J
Abstract
Object To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate. Methods All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted. Results The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r(2) = 0.79, p < 0.0001). Conclusions This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.
PMID: 22224785 [PubMed - as supplied by publisher]
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