Background: Although the added value of increasing extent of glioblastoma resection is still debated, multiple technologies can assist neurosurgeons in attempting to achieve this goal. Intraoperative magnetic resonance imaging (iMRI) might be helpful in this context, but to date only one randomized trial exists. Methods: We included 14 adults with a supratentorial tumor suspect for glioblastoma and an indication for gross total resection in this randomized controlled trial of which the interim analysis is presented here. Participants were assigned to either ultra-low-field strength iMRI-guided surgery (0.15 Tesla) or to conventional neuronavigation-guided surgery (cNN). Primary endpoint was residual tumor volume (RTV) percentage. Secondary endpoints were clinical performance, health-related quality of life (HRQOL) and survival. Results: Median RTV in the cNN group is 6.5% with an interquartile range of 2.5-14.75%. Median RTV in the iMRI group is 13% with an interquartile range of 3.75-27.75%. A Mann-Whitney test showed no statistically significant difference between these groups (P =0.28). Median survival in the cNN group is 472 days, with an interquartile range of 244-619 days. Median survival in the iMRI group is 396 days, with an interquartile range of 191-599 days (P =0.81). Clinical performance did not differ either. For HRQOL only descriptive statistics were applied due to a limited sample size. Conclusion: This interim analysis of a randomized trial on iMRI-guided glioblastoma resection compared with cNN-guided glioblastoma resection does not show an advantage with respect to extent of resection, clinical performance, and survival for the iMRI group. Ultra-low-field strength iMRI does not seem to be cost-effective compared with cNN, although the lack of a valid endpoint for neurosurgical studies evaluating extent of glioblastoma resection is a limitation of our study and previous volumetry-based studies on this topic.
This paper presents a comprehensive numerical investigation on a self-centering eccentrically braced frame (SEBF) with a vertical link member consisting of inner and outer link components. These components are respectively bolted to floor beam and Chevron braces using shape memory alloy bolts, which provide self-centering driving forces. When a lateral load is applied, the inner link component freely slides inside the outer one to shorten the length of the vertical link member to prevent additional forces and deformations in the floor beam and braces. The seismic input energy is dissipated through the superelastic deformations of the shape memory alloy bolts and the friction between the link components. To prove the efficiency of the proposed self-centering system, a comprehensive finite element analysis is carried out using Abaqus software. In this regard, first, the numerical modeling results are validated using the existing experimental studies in the literature. Then, the effect of key design parameters on the cyclic behavior of the proposed SEBF is investigated. The proposed self-centering system demonstrated stable hysteresis behavior with almost no residual drifts. The proposed system also offered moderate energy dissipation with equivalent viscous damping of up to 15%.
Background: Pneumocephalus is commonly seen after neurosurgical procedures and is usually of little consequence. When an anatomical I-way valve develops, there can be significant air entrapment, known as tension pneumocephalus. In cases of craniofacial resection, an iatrogenic ball-valve mechanism involving the nasopharynx can be created.Case Description: In this case of craniofacial resection, we find that a tension pneumocephalus developed after surgery, resulting in a change in the patient's mental status. A latissimus dorsi muscle flap, which had been created during surgery, was found to pulsate with the patient's respirations. This flap, along with the patient's nasopharynx, created a ball valve mechanism which led to entrapment and accumulation of intracranial air. This case demonstrates the use of endotracheal intubation as a means of bypassing a 1-way valve of this nature.Conclusion: Endotracheal intubation in conjunction with twist drill hole aspiration effectively resolves the pneumocephalus by both providing an outlet for trapped air and by removing the ball-valve mechanism from the circuit. Endotracheal intubation should be considered along with twist drill hole aspiration in the emergent management of tension pneumocephalus secondary to a nasopharyngeal ball-valve mechanism. (c) 2009 Elsevier Inc. All rights reserved.
BACKGROUND:The authors describe the rationale of cervical spine lateral approach technique to manage spondylotic myeloradiculopathy with its advantages, disadvantages, complications, and pitfalls. METHODS:The cervical lateral approach could be indicated to treat spondylotic myeloradiculopathy where anterior compression is predominant and the spine is straight or kyphotic without instability. RESULTS:Using the present approach the lateral aspect of the cervical spine is easily reached and the vertebral artery is well controlled. The lateral part of the pathological intervertebral discs, uncovertebral joints, vertebral bodies and posterior longitudinal ligament are removed as necessary and decompression tailored to each patient to completely free the nerve roots and/or spinal cord. CONCLUSION:The cervical lateral multilevel corpectomy/foraminotomy technique allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression preserving spinal stability and physiological spinal motion.
Background: Chiari III malformation (CM3) is rare among Chiari malformations (I-TV). Its definition has been expanded to include caudal medullary displacement and hindbrain herniation into encephaloceles in lower occipital and high cervical regions. Prognosis is recorded as dismal, with respect to survival and functional outcome.Methods: We describe the presentation, radiologic evaluation, and repair of this malformation using methyl-methacrylate cranioplasty and an occipital scalp rotation flap for closure. Outcome after surgery is addressed.Results: Adequate closure of the defect and protection of underlying structures was achieved without undue stress at incision site.Conclusions: This method of closure can be considered in cases of large occipital and cervical encephaloceles with poor skin cover and added osseous anomalies around the foramen magnum. (C) 2009 Elsevier. Inc. All rights reserved.
In ancient times, awake craniotomy was used for trepanation to treat seizures and remove a variety of morbid conditions or even to permit the escape of evil air. In modern times, this technique was initially used for removal of epileptic foci with simultaneous application of brain mapping with electrical current. Further developments brought this technique into use for resection of tumors involving functional cortex. Recently, awake craniotomy has been described as an approach for removal of supratentorial tumors nonselectively, regardless of the involvement of eloquent cortex. It has been used in North America since the 1980s, then Europe, and recently has spread into Asia. Its spread to Asia could have significant impact based on the large population of patients and the low resource utilization associated with awake craniotomy.
Background: The frequency of spontaneous CSF rhinorrhea in macroprolactinoma patients is poorly documented and was previously thought to be a very rare occurrence.Methods: Thirty patients with macroprolactinomas (>1.0 cm diameter) identified from the Swansea neuroendocrine database were studied retrospectively.Results: At presentation, the median serum prolactin was 28 354 (range, 1844 to >6 000 000) mU/L; radiologically, 4 adenomas were invading the cavernous sinus, one the sphenoid sinus and 5 both the cavernous and sphenoid sinus. After commencement of medical therapy, 4 subjects developed CSF rhinorrhea requiring surgical correction; all 4 had tumors invading both the cavernous and sphenoid sinus and an initial serum prolactin more than 75 000 mU/L. One subject. developed an acute psychosis, and a man who presented with delayed puberty committed a serious sexual offense.Conclusions: Serious adverse effects are not uncommon in medically treated macroprolactinoma patients. Subjects with adenomas invading the sphenoid sinus have a high risk of developing CSF rhinorrhea that requires neurosurgical intervention. (C) 2009 Elsevier Inc. All rights reserved.
Background: Although various bypass options for the surgical treatment of middle cerebral artery aneurysms have been described, little has been reported about similar options for complex aneurysms of the anterior cerebral artery.Case description: We report the case of a 15-year-old adolescent girl, in whom a giant A1 segment aneurysm was successfully treated with aneurysm resection followed by saphenous vein interposition grafting.Conclusion: Recognizing the option for a bypass call be the key to success in the surgical management of complex intracranial aneurysms. A potential donor vessel of appropriate size (either arterial of venous) should be prospectively identified. Interposition grafting is technically feasible for proximal anterior cerebral artery aneurysms, although technically demanding. (C) 2009 Elsevier Inc. All rights reserved.
BACKGROUND:We describe the development of a prototype neurosurgical robotic system called NISS. The aim is to implement a robotic system capable of achieving accurate registration of robotic coordinate systems based on CT images, so that it can be used in clinical application. This system has been refined with a better level of predictability, reliability, and robustness sufficient for animal trial evaluation in stereotactic biopsy of brain lesions. METHODS:Point accuracy evaluation of NISS began with an in vitro study. The in vitro robotic application accuracy result was 0.1 +/- 0.05 mm and absolute needle-to-target deviation was 0.3 +/- 0.2 mm. An in vivo experiment approach of using steel balls of 1.56-mm-diameter as targets inside the brain of an anaesthetized dog was used to evaluate the performance accuracy of NISS stereotactic probe placement. Five dogs underwent surgical insertion of steel balls into the brain, and the steel balls were served as targets to be reached by a core needle (1.56-mm-diameter). The experiment was carried out by precise manipulation of the needle to reach the steel ball using frameless stereotactic localization principles. RESULTS:A total of 9 needle results were collected from procedures involving 5 dogs. In the first 5 procedures on 3 dogs, the results were less than 1.9 mm, with an average of 1.3 +/- 0.5 mm. The remaining 4 procedures on 2 dogs yielded results of less than 0.7 mm, with an average of 0.3 +/- 0.2 mm. CONCLUSION:The in vitro and in vivo studies represent the first approach toward evaluating targeting accuracy of a robotic surgery system by using stereotactics biopsy application in a living subject.
Background: Spinal intramedullary cysticercosis is a very uncommon manifestation of NCC, which is caused by the larvae of Taenia solium.Case Description: We report a case of spinal intramedullary cysticercosis who presented subacutely. Magnetic resonance imaging dorsal spine and CSF ELISA clinched the diagnosis. Eight weeks of medical therapy resulted in complete clinicoradiological cure.Conclusion: Surgery used to be the mainstay treatment for spinal intramedullary cysticercosis; however, early diagnosis and medical therapy with albendazole and dexamethasone can obviate the need for surgery in many patients. (C) 2009 Elsevier Inc. All rights reserved.
BACKGROUND:Postoperative intracerebral hemorrhage is a rare complication after surgical revascularization for moyamoya disease, and its mechanism is totally undetermined. CASE DESCRIPTION:A 47-year-old woman with moyamoya disease, experiencing crescendo transient ischemic attack on her left hand, underwent STA-MCA anastomosis on the right hemisphere. Postoperative MR imaging 1 day after surgery demonstrated asymptomatic vasogenic edema without ischemic change at the subcortex under the site of the anastomosis that expanded the next day, and STA-MCA bypass was apparently patent with the strong high signal by MR angiography. N-isopropyl-p-[(123)I]iodo-amphetamine single-photon emission CT showed marked increase in the CBF on the hemisphere operated on. Four days after surgery, the patient complained of sudden headache and experienced severe monoparesis in her left hand due to the intracerebral hemorrhage at the corresponding lesion to the prior vasogenic edema. Edema around hematoma was prolonged for as long as a month; while intensive blood pressure control and the use of adrenocorticosteroid gradually relieved her symptoms. The patient completely recovered from her symptoms 2 months later, and she was discharged without neurologic deficit. Her transient ischemic attacks completely disappeared postoperatively. CONCLUSION:Early increase in CBF associated with vasogenic edema formation at the site of the anastomosis could be the warning sign for subsequent hemorrhagic complication, and intensive blood pressure control is warranted in such patients. Alternatively, it would be necessary to elucidate the biochemical mechanism of the deleterious cascade during reperfusion in moyamoya disease to avoid this rare complication.
Background: Rapid spontaneous resolution of posttraumatic intracranial ASDH has been reported in the literature since 1986. We report a case to demonstrate that redistribution of hematoma to the spinal subdural space is a mechanism for file rapid spontaneous resolution of posttraumatic intracranial ASDH.Case Description: A 73-year-old woman with a slipped-and-fell injury had a worst GCS score of 8/15. Computerized tomography of the brain demonstrated a large intracranial ASDH with mass effect. Conservative management was decided because of her poor premorbid general condition. Rapid clinical improvement was observed within 5 hours after the CT. Progress CT of the brain at 45 hours postinjury showed that the size of the intracranial ASDH was markedly diminished. The CT findings apparently demonstrated a caudal distribution of the intracranial ASDH over the tentorium and then into the Posterior fossa. To investigate this further, all MRI of the spine was performed. which showed that there was spinal SDH in the cervical and thoracic spine.Conclusion: This is the first report demonstrating that redistribution of posttraumatic intracranial ASDH to the spinal subdural space is one of the mechanisms behind the rapid spontaneous resolution of posttraumatic intracranial ASDH in the acute phase. (C) 2009 Elsevier Inc. All rights reserved.
Background: Spinal cord herniation through a dural defect is a cause of myelopathy and BSS that may be underdiagnosed. It may occur spontaneously, after trauma, or after surgery.Case Description: We present the case of a 47-year-old woman who presented with low back pain, progressive myelopathy, right proximal LEW, several episodes of falling, sensory changes below the lower part of the chest wall, and pathologic reflexes. Magnetic resonance imaging of the thoracic spine showed kinking of the spinal cord anteriorly at the level of T6-7. Posterior laminoplasty and intradural exploration revealed an anteriorly displaced spinal cord that was herniating through a ventral dural fold. The defect was repaired, and the spinal cord abnormality was reduced. Postoperatively, the patient's strength, gait, and sensation improved immediately.Conclusions: We discuss the successful surgical treatment of a thoracic spinal cord tethering from herniation through a ventral dural defect and review the literature regarding the proposed pathogenesis, surgical repair options, and reported outcomes. (c) 2009 Elsevier Inc. All rights reserved.
Background: Giant cell tumors are benign tumors of the bone that most commonly occur at the ends of the long bones; they are rarely found in the spine above the sacrum. The management of patients with giant cell tumors of the spine represents a challenge, and the clinical approach to this problem continues to evolve with improvements in surgical and adjunctive therapies.Case Description: A 19-year-old woman with localized back pain and a spinal compression deformity was found to harbor a giant cell tumor of the T7 vertebral body. The patient was first treated with arterial embolization of the hypervascular region observed on angiography. Subsequently, the patient underwent a one-stage transthoracic T7 corpectomy followed by anterior spinal reconstruction and stabilization. Postoperatively, the patient's kyphotic deformity was corrected. To optimize local disease control, the patient underwent IMRT delivered to the site of tumor resection. She remains neurologically intact at 1 year postoperatively without evidence of disease recurrence.Conclusion: The literature and approaches to the management of spinal giant cell tumors are reviewed. (C) 2009 Elsevier Inc. All rights reserved.
